Falls in older adults hospitalized in tertiary centers in Colombia. Clinical description and complications

Abstract

Objective

The incidence of falls in elderly patients in the hospital environment is three times higher than that in the community. The aim was to determine the characteristics of patients who suffered in-hospital falls and their complications.

Methods

This was a cross-sectional study with patients older than 64 years of age, admitted between 2018 and 2020 to four clinics in Colombia who presented a fall during their stay. Clinical data, reasons for the fall, complications and use of drugs with a known risk for causing falls and with an anticholinergic load were reviewed.

Results

A total of 249 patients were included. The mean age was 77.5 ± 7.4 years, and there was a predominance of males (63.9%). The patients were hospitalized mainly for community-acquired pneumonia (12.4%) and heart failure (10.4%). Falls occurred most frequently in hospitalization wards (77.1%) and emergency departments (20.9%). Falls were related to standing alone (34.4%) and on the way to the bathroom (28.9%), with 40.6% (n = 102) of falls resulting in trauma, especially to the head (27.7%); the incidence of fractures was low (3.2%). Ninety-two percent of patients had polypharmacy (≥5 drugs), 88.0% received psychotropic drugs, and 37.3% received drugs with an anticholinergic load ≥3 points.

Conclusions

Hospitalized adults over 65 years of age suffered falls, mainly in hospitalization wards and emergency departments, especially during the process of solitary ambulation. Most had received psychotropic drugs and medications with a high anticholinergic load. These results suggest that it is necessary to improve risk prevention strategies for falls in this population.

Resumen

Introducción

La incidencia de caídas en pacientes ancianos dentro del ambiente hospitalario es tres veces superior a las que se presenta en la comunidad. Se planteó el objetivo de determinar las características de pacientes que sufrieron caídas intrahospitalarias y sus complicaciones en cuatro clínicas de Colombia.

Métodos

Estudio transversal con pacientes mayores de 65 años de edad, ingresados entre 2018 y 2020 en cuatro clínicas de Colombia, que presentaron una caída durante su estancia. Se revisaron datos clínicos, motivos de la caída, complicaciones y uso de medicamentos de riesgo conocido para generar caídas y con carga anticolinérgica.

Resultados

Se identificaron 249 pacientes, con edad media de 77,5 ± 7,4 años y predominio masculino (63,9%), internados principalmente por neumonía adquirida en comunidad (12,4%) y falla cardiaca (10,4%); las caídas ocurrieron más frecuentemente en los servicios de hospitalización (77,1%) y urgencias (20,9%). Se relacionaron con procesos de bipedestación en solitario (34,4%), y movilización al baño (28,9%), con traumatismo en 40,6% (n = 102), especialmente de cabeza (27,7%), y baja incidencia de fracturas (3,2%). El 92% de casos tenían polifarmacia ≥5 medicamentos, el 88% recibieron psicofármacos y 37,3% medicamentos con carga anticolinérgica ≥ 3 puntos.

Conclusiones

Los adultos mayores de 65 años internados sufrieron caídas, principalmente en los servicios de hospitalización y urgencias, en especial durante el proceso de deambulación en solitario. La mayoría habían recibido psicofármacos y medicamentos con alta carga anticolinérgica. Estos resultados sugieren que es necesario mejorar las estrategias de prevención de riesgo de este tipo de eventos.

What is known

The incidence of falls in elderly patients in the hospital environment is three times higher than that in the community.

What it contributes

This study identified the frequency of falls in older patients that occurred during their stay in four high-complexity hospitals in Colombia, information previously not available for this population of the country. Some of the outcomes associated with falls were reported, as were the main reasons for falls, an aspect that could be useful for designing strategies focused on their prevention.

Introduction

In Colombia, according to the last census carried out in 2018 by the National Administrative Department of Statistics (DANE), 9.8% of the population was older than 65 years,¹ and by 2020, 12.6% of Colombians were expected to be over 60 years of age.² This is important when recognizing a growing population, with a high prevalence of diseases related to aging, including alterations in nutrition, daily physical activity and frailty.³

Frailty has been defined as a multicausal syndrome characterized by a decrease in strength, endurance and some physiological functions, leading to an increase in vulnerability to greater dependence or death.⁴ Frailty can lead to complications such as falls, which are a very important geriatric syndromes. It has been estimated that up to 30% of older adults require medical attention for an outpatient fall and that 10% suffer fractures and other complications resulting from falls.⁵ These complications are explained by the aging process and fragility itself, which implies instability, muscular weakness and physical deconditioning (caused by pain, prolonged rest due to an acute or chronic pathology or a lack of exercise and physical activity), situations that are also related to falls themselves and worse outcomes and survival in these patients.^6,7

In addition to the characteristics of aging, the consumption of certain medications, especially psychotropics such as benzodiazepines and opioids, among other that have a confirmed anticholinergic load, for example, antidepressants, antipsychotics, and drugs for urinary problems or gastrointestinal diseases, increase the probability of falls and even fractures because these drugs can cause different neurological alterations, producing dizziness, blurred vision, cognitive dysfunction, ataxia or sleep disturbances.^8–10

Studies carried out with older adults outside the hospital environment in Colombia identified an increased probability of falls with hip fracture between (OR: 1.97; 1.19–3.27) for drugs with an anticholinergic load and (OR: 4.49; 2.72–7.42) for opioids.^11,12 Additionally, comorbidities such as diabetes mellitus in older patients increase the risk of falls, especially in insulin users because of the risk of developing severe hypoglycemia (OR: 1.27; 95% CI: 1.06–1.52).¹³ In hypertensive patients, there is a risk of falls from symptomatic hypotension when adding a new antihypertensive, especially in the first 24 h after the change in dose or in the first 21 days after starting a diuretic.¹⁴

The incidence of falls in patients within the hospital environment is three times higher than that in the community, and for older people, who are especially vulnerable during hospitalization due to acute illness, the need for permanent monitoring and decreased mobility, up to 25% may suffer injuries that require additional medical attention, as well as other complications described as mild to severe trauma, fractures, wounds and sometimes death.^15,16 Multiple risk factors associated with falls in hospitalized patients have been identified that are related to medical and nursing care (quantity and quality of training of the nursing staff); the hospital center; patient age, condition, clinical characteristics, comorbidities, capacity for mobility, and family support; architectural barriers; and medications received during hospitalization.^17–19 Currently, in Colombia, there is insufficient evidence regarding the clinical characteristics of patients who suffer falls within the hospital environment and a lack of knowledge of the mechanisms of falls. Therefore, the objective of this study was to identify the characteristics of older adult patients with in-hospital falls and secondary complications in four clinics in Colombia between 2018 and 2020.

Materials and methods

Design and patients

This was a retrospective cross-sectional study that included patients 65 years of age or older of either sex admitted to hospital care between January 1, 2018, and December 31, 2020, in four different high-complexity hospitals (care of medical specialties and emergency care, surgery, intensive care unit) in southwestern Colombia (Departments of Risaralda, Quindío, Valle del Cauca and Cauca). As of December 2020, the four centers had an availability of 855 beds and treated a total of 530,097 patients over the 4 years.

All the patients who presented a fall during their hospital stay were identified from the mandatory notification registry for falls, which includes sociodemographic information related to the fall, such as the reason, a description of the incident, location and other related data.

Inclusion and exclusion criteria

As an inclusion criterion, in addition to age, all patients with falls who had data in the mandatory notification registry from each hospital center were considered. There were no exclusion criteria. Once a patient was identified, information was obtained from the patient’s medical history and drug dispensing records during hospitalization; this information was collected for all included patients in a dataset, and the confidentiality of the patients was not compromised. By including all patients with reports that met the inclusion, no sampling was used.

A fall was defined as an event in which the person lost his or her balance and hit the floor or some ground or firm object that stopped him or her; a report was made by the nursing staff of the department where said event occurred (Patient Safety Record²⁰). During care within the hospital, the following variables were collected from the medical history:

• -

  Sociodemographic data: age, sex, city of residence, and hospital;

• -

  Clinical data: admission diagnosis and comorbidities (International Classification of Diseases version 10 (ICD-10));

• -

  Fall: date and location of the fall (emergency department, hospital ward (internal medicine and surgical), surgery room, intensive care unit (ICU), radiology and other), reasons for the fall (walking to the bathroom, during a stay in the bathroom, mobilization in a wheelchair, problems with railings/stretcher) being alone or accompanied, associated trauma, need for care, and presence of fracture and other complications;

• -

  Medications: name and pharmacological group of medications prescribed during hospitalization and frequency and proportion of use, not including antimicrobials;

• -

  Anticholinergic load: calculated using the anticholinergic risk scale (ARS),²¹ with 0 points indicating no load, 1 point indicating a low load, 2 points indicating a moderate load, and 3 or more points indicating a high load; and

• -

  Polypharmacy: five or more simultaneous medications (Supplementary Table 1 shows the load of each medication based on the ARS).

Statistical analysis

The collected variables were recorded in a data file in Microsoft Excel with closed fields, and the information recorded from each of the data sources was validated in search of outliers and inconsistent data, which were confirmed in the original sources. Univariate analyses were performed, and the results are presented a frequencies and proportions for categorical variables and measures of central tendency, position and dispersion for quantitative variables. The statistical package SPSS 28.0 for Windows was used for the analyses.

Bioethics statement

Endorsement from the Bioethics Committee of the Universidad Tecnológica de Pereira was obtained; the study was classified as research “without risk” as established by Resolution 8430 of 1993 of the Ministry of Health of Colombia. The principles of justice, beneficence, nonmaleficence and confidentiality of information established by the Declaration of Helsinki were respected.

Results

During the observation period, 249 patients with a fall within the four different clinics in Colombia in the cities of Pereira (n = 103, 41.4%), Cali (n = 77, 30.9%), Popayán (n = 43, 17.3%) and Armenia (n = 26, 10.4%) met the inclusion criteria. The average age of the patients was 77.5 ± 7.4 years, with a predominance of males (n = 159; 63.9%). In 2018, 11 falls were recorded (4.4%), in 2019 a total of 121 (48.6%) and in 2020 a total of 117 (47.0%).

The main reason for admission of the patients was community-acquired pneumonia, followed by decompensated heart failure, systemic infections such as sepsis, and cancer. Table 1 shows the sociodemographic variables, admission diagnoses and comorbidities of the identified patients. Most of the falls occurred in hospitalization wards (medical and/or surgical), followed by emergency departments. Most falls were related to standing alone, without the help of a family member or nursing staff, walking to the bathroom or being in the bathroom itself. In addition, 102 patients (40.6%) presented identifiable associated trauma, mainly to the head, requiring additional medical attention for more than half of the patients (52.6%), the most frequent being radiographs of the trauma site. Table 2 shows the characteristics associated with falls, reasons for falls, trauma, medical attention, presence of fracture and other complications related to falls.

Table 1.

Sociodemographic variables, admission diagnoses and comorbidities in 249 older patients with in-hospital falls in 4 high-complexity centers.

Variables	n = 249	%
Age (years: mean; SD)	77.5 ± 7.4
65−69 years	39	15.5
70−79 years	108	43
≥ 80 years	104	41.4
Male sex	159	63.9
Admission Diagnoses (ICD-10^a)
Community-acquired pneumonia	31	12.4
Heart failure	26	10.4
Systemic infection	26	10.4
Cancer	25	10.0
COVID-19	21	8.4
Acute coronary syndrome	20	8.0
Other admission diagnoses	18	7.2
Ischemic cerebrovascular event	14	5.6
Scheduled surgery	14	5.6
Traumatic fracture	14	5.6
Urinary tract infection	14	5.6
Chronic kidney disease	7	2.8
Cognitive decline/dementia	6	2.4
Major bleeding	6	2.4
Diabetic foot	4	1.6
Hepatic cirrhosis	3	1.2
Comorbidities
Arterial hypertension	160	64.3
Type 2 Diabetes mellitus	63	25.3
Chronic kidney disease	54	21.7
Chronic obstructive pulmonary disease	52	20.8
Heart failure	44	17.7
Coronary heart disease	41	16.5
Hypothyroidism	34	13.7
Dementia	16	6.4
Active cancer	16	6.4
Stroke	11	4.3
Dizziness	10	4.0
Urinary incontinence	6	2.4
Parkinson’s disease	3	1.2
Epilepsy/Seizures	3	1.2

a

International Classification of Diseases 10th Revision.

Table 2.

Information related to falls and associated comorbidities in 249 older patients with in-hospital falls in 4 high-complexity centers.

Variables	n = 249	%
Place of the fall
Hospitalization	192	77.1
Emergency care	52	20.9
Critical Care	3	1.2
Radiology	2	0.8
Reason/Situation associated with the fall
Standing alone ^a	113	34.4
Mobilization to the bathroom	72	28.9
Being in the bathroom	47	18.9
Railings Down/Jumping Rails	75	30.1
Wheelchair	9	3.6
Associated trauma	102	40.6
Head	69	27.7
Lumbar/Pelvis	20	8.0
Upper extremity	17	6.8
Lower extremity	7	2.8
No data	11	4.4
Required additional attention	131	52.6
X-rays	53	21.3
Head CT scan	32	12.9
Specialized medicine assessment	31	12.4
Wound Healing/Suture	13	5.2
Other paraclinical	5	2.0
Surgery	7	2.8
Fracture	8	3.2
Hip/femur	3	1.2
Distal ulna	3	1.2
Ulna + Radius	1	0.4
Bone of the nose	1	0.4
Other complications
Face/scalp hematoma	9	3.6
Altered state of consciousness	2	0.8
Subdural hematoma	2	0.8
Hemodynamic instability	2	0.8

a

Standing alone was defined as walking or attempting to walk without the accompaniment of a family member or hospital staff.

The drugs most frequently used during hospitalization in the group of patients who fell were antihypertensives (88.0%), proton pump inhibitors (72.2%), nonopioid analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) (69.9%), lipid-lowering drugs (61.8%), partial (59.4%) and total (53.0%) agonists, antiplatelet drugs (46.8%) and psychotropic drugs such as antipsychotics (30.8%), antidepressants (28.0%) and antiepileptics (25.2%) (Table 3). Of the drugs used, the antimuscarinic load was estimated using the ARS scale (supplementary table), and the mean anticholinergic load score was 2.26 ± 2.25 points. On average, the patients used 11.8 drugs (nonantimicrobial) during the hospital stay, and an estimated 92% had polypharmacy, reaching up to 29.7% with 15 or more medications. A total of 37.3% of the patients had three or more points for anticholinergic load (Table 4).

Table 3.

Medications used during hospitalization in 249 older patients with in-hospital falls in 4 high-complexity centers.

Medication used	(n = 249)	%
Cardiovascular use
Antihypertensives	219	88.0
ARB^a	147	59.0
ASA diuretics	141	56.6
Calcium antagonists	123	49.4
Beta Blockers	119	47.8
ACEi^b	62	24.9
Mineralocorticoid receptor antagonists	52	20.9
Thiazides	37	14.9
Alpha 1 and central blockers	35	14.1
Central origin antihypertensives	35	14.1
ARNI^c	5	2.0
Others for cardiovascular use
Atropine	41	16.5
Other antiarrhythmics	27	10.8
Methyldigoxin	8	3.2
Lipid-lowering drugs	154	61.8
Statins	154	61.8
Fibrates	2	0.8
Hematic system and others
Acetylsalicylic acid	114	45.8
Clopidogrel and other antiplatelet agents P2Y12i	60	24.1
Direct oral anticoagulants	14	5.6
Warfarin	1	0.4
Digestive, Respiratory and Endocrine Use
Digestive
Proton Pump Inhibitors	181	72.7
Hyoscine butylbromide	87	34.9
Anti H2 (ranitidine)	4	1.6
Respiratory (at least one)
Inhaled anticholinergics	99	39.8
B2 agonists	77	30.9
Theophylline	3	1.2
Antihistamines	38	15.3
1st generation antihistamines	29	11.6
2nd generation antihistamines	10	4.0
Endocrinological
Levothyroxine	34	13.7
Some Antidiabetic	57	22.9
Fast-acting insulin	45	18.1
Long-acting insulin	27	14.9
Metformin	20	8.0
DPP-4 inhibitors^d	10	4.0
SGLT-2 inhibitors^e	5	2.0
Sulfonylurea	0	0.0
GLP-1 agonists^f	0	0.0
Antiparkinsonians
Pyridostigmine/neostigmine	13	5.2
Biperiden	3	1.2
Levodopa	3	1.2
Use in Central Nervous System, Inflammation and Pain
Some psychotropic drug	219	88.0
Antiepileptics	75	30.1
Conventional antipsychotics	63	25.3
Memantine	5	20.0
Atypical antipsychotics	36	14.5
Amantadine	2	0.8
Benzodiazepines and Z Drugs	99	39.6
Some antidepressant	70	28.0
Trazodone	42	16.9
Selective Serotonin Reuptake Inhibitors	34	13.7
Atypica	4	1.6
Tricyclics	4	1.6
Selective Serotonin + Norepinephrine Reuptake Inhibitors	1	0.8
Some analgesic	211	84.7
Non-Steroidal Anti-Inflammatory Drugs	174	69.9
Acetaminophen	110	44.2
Dipyrone	83	33.3
Some Opioid	190	76.3
Partial agonist opioids	148	59.4
Full agonist opioids	132	53.0
Inflammation and others
Systemic corticosteroids	98	39.4
Conventional DMARDs^g	7	2.8
Biological DMARDs	1	0.4
Anti-gout and muscle relaxants	0	0.0
Antimigraine drugs	0	0.0

a

ARB: angiotensin receptor blockers.

b

ACEi: Angiotensin-converting enzyme inhibitors.

c

ARNI: angiotensin receptor neprilysin inhibitor.

d

DPP-4 Dipeptidyl Peptidase 4 inhibitors.

e

SGLT-2: Sodium-glucose cotransporter-2 inhibitors.

f

GLP-1: Glucagon-like Peptide-1 Receptor Agonists.

g

DMARD: Disease Modifying Antirheumatic Drugs.

Table 4.

Polypharmacy, frequency of use of drugs with a higher risk of falls and anticholinergic load using the ARS scale for 249 older patients with in-hospital falls in 4 high-complexity centers.

Variables	n = 249	%
Quantity of drugs - hospitalization (days, mean; SD)	11.8 ± 1.1
Polypharmacy (5 or more drugs)	229	92
Drug frequency distribution
Between 0–4 medications	20	8
Between 5–9 medications	78	31.3
Between 10–14 medications	77	30.9
Between 15–19 medications	50	20.1
Between 20 and more medications	24	9.6
Medications with risk of falls
Antihypertensives (n, mean; SD^b)	2.9 ± 1.9
Use of at least one antihypertensive	219	88
Antidiabetics (n, mean; SD)	0.4 ± 0.9
Use of at least one antidiabetic	57	22.9
Antidepressants (n, mean;SD)	0.3 ± 0.6
Use of at least one antidepressant	70	28.1
Psychotropic drugs^a(n, mean;SD)	2.5 ± 0.3
Use of at least one psychotropic drug a	219	88