What is the appropriate management for a hospice patient who has fallen three times in the past few days?

Management of Recurrent Falls in a Hospice Patient

For a hospice patient with three falls in recent days, prioritize immediate safety through environmental modification, medication review focusing on deprescribing fall-risk drugs, and symptom management rather than aggressive diagnostic workup, as the goal shifts from fall prevention to comfort and quality of life in the final weeks to days of life. 1

Immediate Safety Assessment

• Evaluate the patient's current life expectancy (weeks to days versus months), as this fundamentally determines the intensity and type of interventions appropriate for this hospice patient 1

• Assess whether falls are related to progressive weakness from advancing disease, delirium, medication side effects, or treatable conditions like orthostatic hypotension that could be managed with minimal burden 1, 2

• Determine if the patient has altered mental status or delirium, which may represent a reversible condition (infection, medication toxicity, metabolic derangement) worth treating even in hospice if it improves comfort 1, 3

Medication Management (Priority Intervention)

• Conduct an immediate medication review focusing on deprescribing rather than adding interventions, specifically targeting psychotropic medications, sedative/hypnotics, opioids causing oversedation, antipsychotics, diuretics causing orthostasis, and any vestibular suppressants 1, 2, 3

• Reduce polypharmacy if the patient is taking ≥4 medications, as this independently increases fall risk even in hospice patients 2, 3

• Consider whether opioid doses need adjustment if the patient is oversedated, as appropriate pain management should not cause excessive sedation leading to falls 1

Environmental Modifications (Low-Burden, High-Impact)

• Implement immediate home safety measures including removing loose rugs and floor clutter, ensuring adequate lighting throughout the home (especially pathways to bathroom), placing the bed in the lowest position, and keeping frequently needed items within easy reach 1, 2, 4

• Install grab bars in the bathroom and ensure a bedside commode is available if the patient has difficulty reaching the bathroom safely 1, 4

• Arrange for occupational therapy home assessment with direct intervention if the patient's prognosis is weeks to months, as this can reduce fall risk without adding treatment burden 1, 4

Assistive Devices and Mobility Support

• Prescribe an appropriate assistive device (walker or rollator) if the patient has sufficient strength and life expectancy (weeks to months) to benefit, using ICD-10 codes Z91.81 (history of falls), R26.9 (abnormality of gait), and R42 (dizziness) for insurance coverage 2

• Ensure the device is properly fitted and the patient receives training to prevent the assistive device itself from becoming a fall hazard 2

• Consider whether the patient would benefit from 24-hour supervision or caregiver assistance with transfers and ambulation, as this may be more appropriate than assistive devices for patients with very limited life expectancy 1, 2

Symptom-Specific Interventions

• Screen for benign paroxysmal positional vertigo (BPPV) using the Dix-Hallpike maneuver, as BPPV affects 9% of geriatric patients and can be treated with the canalith repositioning procedure (Epley maneuver) even in hospice if it improves quality of life 1, 4

• Assess for orthostatic hypotension with supine and upright blood pressure measurements, and if present, consider reducing or discontinuing diuretics and vasodilators rather than adding fludrocortisone 1, 2, 3

• Evaluate whether fluid overload or dehydration is contributing to falls, adjusting enteral or parenteral fluids accordingly and considering low-dose diuretics only if fluid overload is causing distressing symptoms 1

Counseling and Goals of Care Discussion

• Counsel the patient and family that falls place the patient at risk for injury, particularly fractures, and discuss whether the patient's goals prioritize mobility and independence versus safety and comfort 1, 2

• Provide anticipatory guidance about the natural progression of weakness in terminal illness, helping the family understand that increasing fall risk may signal disease progression rather than a problem requiring aggressive intervention 1

• Discuss the risk-benefit ratio of continued ambulation versus accepting increased dependence with wheelchair or bed-bound status if falls continue despite interventions 1, 2

What NOT to Do in Hospice Patients

• Avoid aggressive diagnostic workup such as extensive imaging, polysomnography, or referral to multiple specialists unless findings would change management in a way that improves comfort 1

• Do not prescribe vitamin D supplementation or initiate bone-strengthening medications for fracture prevention in patients with life expectancy of weeks to days, as these interventions require months to show benefit 1, 3

• Avoid adding medications that increase fall risk (such as benzodiazepines for anxiety) unless the symptom burden outweighs the fall risk, and always start at the lowest possible dose 1, 2

Monitoring and Reassessment

• Reassess fall risk daily and adjust interventions based on the patient's changing functional status and proximity to death 1

• If falls continue despite interventions, consider consultation with specialized palliative care services to help balance safety concerns with quality of life and patient autonomy 1

• Document whether falls are causing distress to the patient or family, as this should guide the intensity of interventions rather than the falls themselves 1

Critical Pitfall to Avoid

The most common error is applying standard geriatric fall prevention protocols to hospice patients without considering life expectancy and goals of care. A patient with days to weeks to live does not benefit from exercise programs, comprehensive geriatric assessment, or DEXA scans—these interventions add burden without improving quality of life in the final phase of illness. 1 Instead, focus on simple environmental modifications, medication deprescribing, and ensuring the patient can access comfort measures (bathroom, pain medications) safely with caregiver assistance. 1, 2, 4