Inpatient falls and injuries in older patients

treated for femoral neck fracture

Michael Stenvall a,*, Birgitta Olofsson a,b, Maria Lundstrom a,Olle Svensson b, Lars Nyberg c, Yngve Gustafson a

a Department of Community Medicine and Rehabilitation, Geriatric Medicine,

Umea University, SE-901 87 Umea, Swedenb Department of Surgical and Perioperative Sciences, Orthopedics, Umea University,

SE-901 87 Umea, Swedenc Department of Health Sciences/Physiotherapy Unit, Lulea University of Technology,

SE-961 36 Boden, Sweden

Received 29 August 2005; received in revised form 19 January 2006; accepted 20 January 2006

Available online 15 March 2006

Abstract

A prospective inpatient study was performed at the Orthopedic and Geriatric Departments at the

Umea University Hospital, Sweden, to study inpatient falls, fall-related injuries, and risk factors for

falls following femoral neck fracture surgery. Ninety-seven patients with femoral neck fracture aged

70 years or older were included, background characteristics, falls, injuries, and other postoperative

complications were assessed and registered during the hospitalization. There were 60 postoperative

falls among 26/97 patients (27%). The postoperative fall event rate was 16.3/1000 Days (95% CI

12.2–20.4). Thirty two percent of the falls resulted in injuries, 25% minor, and 7% serious ones. In

multiple regression analyses, delirium after Day 7, HRR 4.62 (95% CI 1.24–16.37), male sex 3.92

(1.58–9.73), and sleeping disturbances 3.49 (1.24–9.86), were associated with inpatient falls. Forty-

five percent of the patients were delirious the day they fell. Intervention programs, including

prevention and treatment of delirium and sleeping disturbances, as well as better supervision of male

patients, could be possible fall prevention strategies. Improvement of the quality of care and

rehabilitation, with the focus on fall prevention based on these results, should be implemented in

postoperative care of older people.

# 2006 Elsevier Ireland Ltd. All rights reserved.

Keywords: Falls of aged; Hip fracture; Rehabilitation of elderly; Hospital care of elderly

www.elsevier.com/locate/archger

Archives of Gerontology and Geriatrics 43 (2006) 389–399

* Corresponding author. Tel.: +46 90 785 87 55; fax: +46 90 13 06 23.

E-mail address: michael.stenvall@germed.umu.se (M. Stenvall).

0167-4943/$ – see front matter # 2006 Elsevier Ireland Ltd. All rights reserved.

doi:10.1016/j.archger.2006.01.004

1. Introduction

Nearly all hip fractures occur as a result of a fall (Nyberg et al., 1996; Fuller, 2000), and

the risk of a subsequent fracture after an osteoporotic fracture is high soon after the event

(Johnell et al., 2004). The hip fracture patient is thus a person with high fall risk; a fact that

cannot entirely be explained by pre-fracture risk factors (Colon-Emeric et al., 2003). In a

study of relatively healthy individuals living independently before the fracture, 12% fell

during the inpatient rehabilitation (Pils et al., 2003). The highest fall risks were in the

second week after admission to a sub-acute rehabilitation ward.

The etiology of falls in older people is complex and multifactorial with several fall risk

factors such as co-morbidity, functional disability, previous falls and medication intake

(Tinetti et al., 1988; Gluck et al., 1996; Kallin et al., 2002, 2004; Lawlor et al., 2003; Van

Doorn et al., 2003; Vassallo et al., 2003; Oliver et al., 2004; Salgado et al., 2004) as well as

aging (Luukinen et al., 1994; Halfon et al., 2001), and among the oldest, male sex (Sadigh

et al., 2004).

Acute diseases such as infections and delirium have been identified as important

precipitating factors for falls (Gluck et al., 1996; Jensen et al., 2002; Vassallo et al., 2003;

Kallin et al., 2004; Oliver et al., 2004; Salgado et al., 2004). Among hip fracture patients,

delirium is a common complication (Gustafson et al., 1988; Edlund et al., 1999;

Marcantonio et al., 2000). In particular, males run an increased risk to develop delirium

after hip fracture surgery (Gustafson et al., 1991; Edlund et al., 2001; Edelstein et al.,

2004). One non randomized delirium intervention study found that by reducing the

delirium incidence and duration, fewer serious injurious falls occurred in the intervention

group (Gustafson et al., 1991). This may indicate that delirium is an important risk factor

for postoperative falls and injuries in hip fracture patients.

Knowledge lacks about falls during hospital stay following hip fracture surgery,

especially including persons from residential care, chronically diseased, and those with

cognitive impairment. Therefore, the aim was to study inpatient falls, fall-related injuries,

and risk factors for falls following femoral neck fracture surgery.

2. Methods

2.1. Study sample

This study consists of the control group from a larger intervention study including

patients with femoral neck fracture aged 70 years or older, consecutively admitted to the

Orthopedic Department at the Umea University Hospital, Sweden, between May 2000 and

December 2002. Exclusion criteria were: rheumatoid arthritis, severe hip osteoarthritis,

severe renal failure, pathological fracture, and bedridden before the fracture. These

exclusion criteria were applied due to the operation methods used in the study.

In the emergency room the patients were asked both in writing and orally if they were

willing to participate in the study. The next of kin were also asked in the case of those

patients with cognitive impairment. Two hundred and fifty eight patients fulfilled the

inclusion criteria, and 59 patients refused or did not participate in the study for other

M. Stenvall et al. / Archives of Gerontology and Geriatrics 43 (2006) 389–399390

reasons. Twenty-one of them had suffered their fractures in the hospital (8%). The final

study sample consisted of 199 patients. One hundred and two patients were randomized to

the intervention group, and 97 were randomized to the control group. The 97 patients from

the control group were analyzed in this study (Table 1). They were treated at the Orthopedic

M. Stenvall et al. / Archives of Gerontology and Geriatrics 43 (2006) 389–399 391

Table 1

Basic characteristics of the study group

Total (n = 97) Fallers (n = 26) Non-fallers (n = 71)

Sociodemographic

Age (mean � S.D.) years 82.0 � 5.9 81.9 � 5.0 82.1 � 6.2

Females 74 (76%) 15 (58%) 59 (83%)

Independently living before fracture 60 (62%) 18 (69%) 42 (59%)

Health and medical problems

Cardiovascular disease (n = 24/69) 53 (57%) 16 (67%) 37 (54%)

Stroke (n = 24/69) 20 (22%) 6 (25%) 14 (20%)

Dementia 36 (37%) 11 (42%) 25 (35%)

Depression (n = 26/69) 45 (47%) 13 (50%) 32 (46%)

Diabetes 17 (18%) 4 (15%) 13 (18%)

Previous hip fracture (n = 26/70) 14 (15%) 1 (4%) 13 (19%)

Falls during last month (n = 23/67)a 25 (28%) 9 (39%) 16 (24%)

Sensory impairments

Impaired hearing (n = 24/58) 34 (41%) 8 (33%) 26 (45%)

Impaired vision (n = 19/55) 27 (36%) 7 (37%) 20 (36%)

Functional performance before fracture

Staircase of ADL, median (IQR) (n = 25/63) 5 (0.25–7) 5 (4–7) 4 (0–8)

Walked independently outside 47 (48%) 11 (42%) 36 (51%)

Walked without walking aids inside 56 (58%) 16 (62%) 40 (56%)

S-COVS walking ability, median (IQR) (n = 25/69) 5.5 (5–7) 5 (5–7) 6 (5–7)

Medications on admission

Antidepressants 45 (46%) 14 (54%) 31 (44%)

Benzodiazepines 25 (26%) 5 (19%) 20 (28%)

Neuroleptics 8 (8%) 1 (4%) 7 (10%)

Hospital stay, inpatient complications and assessments during hospitalization

Length of hospital stay in days, median (IQR) 27 (11–55) 57 (43–96) 13 (10–41)

Delirium postoperatively 73 (75%) 25 (96%) 48 (68%)

Delirium after Day 7 (n = 26/61) 45 (52%) 23 (88%) 22 (36%)

Number of delirious days (mean � S.D.) 7.7 � 12.3 15.1 � 20.0 5.0 � 6.2

Sleeping disturbances 44 (45%) 21 (81%) 23 (32%)

Depression during hospital stay 53 (55%) 15 (58%) 38 (54%)

Nutritional problems 37 (38%) 14 (54%) 23 (32%)

Urinary tract infection (n = 26/70) 49 (51%) 16 (62%) 33 (47%)

Urinary retention 18 (19%) 5 (19%) 13 (18%)

Decubital ulcers (n = 26/69) 21 (22%) 5 (19%) 16 (23%)

Anemia (n = 26/70) 79 (82%) 24 (92%) 55 (79%)

Inpatient mortality 7 (7%) 2 (8%) 5 (7%)

MMSE score (mean � S.D.) (n = 24/66) 15.7 � 9.1 14.6 � 7.2 16.1 � 9.8

GDS (mean � S.D.) (n = 20/48) 4.5 � 3.5 5.2 � 3.8 4.2 � 3.4

OBS scale, mean � S.D., (n = 24/66) 12.5 � 11.4 13.2 � 9.4 12.2 � 12.1

a Except for the fall that resulted in the hip fracture.

Department, and if a longer rehabilitation period was necessary they were transferred to a

Geriatric Rehabilitation ward.

2.2. Data collection

Two registered nurses assessed the patients in the project. In addition, one of the nurses

worked 50% at the control group’s ward, which facilitated the data collection during the

hospital stay. Medical and social data were collected from the patients, relatives, staff, and

medical records on admission. Inpatient complications, including falls, length of stay,

morbidity and mortality, were systematically registered.

The occurrence of falls was collected and registered from the medical and nursing

records. Nurses are obliged by law to document all falls in the records (The Swedish Code

of Statutes, 1985). A fall was defined as an incident when the patient unintentionally came

to rest on the floor and included syncopal falls. Numbers of falls and time lapse to first fall

after admission were calculated. A physician assessed the patients soon after every fall if

any injuries were suspected. The Abbreviated Injury Scale (AIS) (1990), was used to

classify the injuries resulting from a fall into a hierarchical level of severity, with AIS

scores ranging from one (minor) to six (maximum). The maximum injury (MAIS)

connected with each incident was recorded.

Three to five days following surgery, patients were assessed and interviewed using the

Mini Mental State Examination (MMSE) (Folstein et al., 1975), to assess the patient’s

cognitive status, scoring from 0 to 30. A score of less than 24 indicates cognitive

impairment (Tombaugh and McIntyre, 1992). Delirium was assessed by the modified

Organic Brain Syndrome Scale (OBS-Scale) (Jensen et al., 1993), consisting of two main

parts: the disorientation subscale, a questionnaire containing 12 items, and the

confusions subscale, an observation schedule covering 21 clinical features. The

disorientation subscale measures the patient’s orientation to time, place, and their own

identity with a maximum score of 36 (higher score = poorer test result). The confusion

subscale includes various assessments of cognitive, perceptual, emotional, and

personality changes, as well as fluctuations in the clinical states. In addition, it is

based on observations and interviews with the patients as well as interviews with the

caregivers. The OBS Scale has been compared with other assessment scales and has

shown good concurrent validity (Jensen et al., 1993). It has also been compared to the

Confusion Assessment Method (CAM) and showed 100% agreement regarding the

diagnosis of delirium (Eriksson et al., 2002). Mental state changes and numbers of

delirious days for each patient were also registered from medical records. The symptoms

of delirium during the first 8 postoperative hours were viewed as immediate effects of

pre-medication and/or of other anesthetic agents, and were not registered as delirium.

Preinjury depression was diagnosed following an evaluation of earlier documented

diagnoses in the records, and current treatment with antidepressants. Depression during

hospitalization was diagnosed due to current treatment with antidepressants and

depression screened using the Geriatric Depression Scale (GDS-15) (Sheikh and

Yesavage, 1986) in combination with depressive symptoms observed and registered by

the OBS-Scale. The patients’ vision and hearing were assessed by their ability to read

3 mm block letters with or without glasses, and their ability to hear a normal speaking

M. Stenvall et al. / Archives of Gerontology and Geriatrics 43 (2006) 389–399392

voice from a distance of 1 metre. The functional status of performing Activities of Daily

Living (ADL) prior to the fracture was measured using the Staircase of ADL (Sonn,

1996). This includes both personal ADL (PADL) (bathing, dressing, toileting, transfer,

continence, and feeding) and instrumental ADL (IADL) (cleaning, shopping,

transportation, and cooking). The ADL score consist of 10 parts; scoring is from 0

to 10, with higher score indicating more ADL dependence. An item from the Swedish

version of Clinical Outcome Variables (Seaby and Torrence, 1989) (S-COVS)

(Hasselgren-Nyberg et al., 1997) was used to assess the participants’ walking ability.

The item has seven levels, one indicating no functional walking ability and seven

indicating normal function including outdoor obstacles and gait speed.

Finally, a geriatrician analyzed all assessments and documentation including all

patients’ medical and nursing records to decide if the patients fulfilled the DSM-IV criteria

(American Psychiatric Association, 1994) for delirium, dementia, and depression.

2.3. Ethical considerations

The Ethical Committee of the Faculty of Medicine at Umea University approved the

study (§ 00-137).

2.4. Statistics

Univariate Cox regression analyses, including hazard rate ratio (HRR) and 95%

confidence intervals, were calculated between known and potential fall risk variables and

the time lapse to the occurrence of first fall. Multiple regression analyses were performed

including those variables that were significantly associated with falls in the univariate

analyses using the Cox regression forward stepwise (Ward) function. Mann–Whitney U-

test was performed to analyze differences in in-hospital stay and Pearson’s x2 test was used

to describe difference between falls during a day with delirium and the total number of

delirious days among all postoperative days.

3. Results

3.1. Falls and injuries

During hospitalization there were 60 postoperative falls among 26/97 patients (27%).

The postoperative fall event rate was 16.3/1000 days (CI 12.2–20.4). Sixteen fell more than

once, mean 2.3 � 2.1 times (range 1–11). Time lapse to first fall varied between Days 2 and

79, median 18 days after surgery. The falls were most common in the second and fourth

week (Fig. 1), and between 12:00 and 22:00, with a peak between 20:00 and 22.00. The

majority (67%) of the falls took place in the patient’s room or in the bathroom.

Injuries were reported in 32% of the falls and four of them (7%) were serious injuries

(AIS 3), including two hip fractures, one rib fracture with pneumothorax, and one with

multiple skull fractures. Finally, there were 15 minor injuries (AIS 1) (25%) such as

bruises, contusions, and wounds according to the AIS injury scale.

M. Stenvall et al. / Archives of Gerontology and Geriatrics 43 (2006) 389–399 393

The median hospital stay was 27.0 (IQR 11.0–55.0) with a range of 2–208 days. There

was a significant difference in in-hospital stay between fallers and non-fallers ( p < 0.001)

(Table 1). Among those 10 with the longest postoperative in-hospital stays (93–206 days)

there were eight fallers and two of them had new fractures. The mean in-hospital stay

among those four with new fractures was 101 days.

3.2. Fall risk factors

Univariate Cox regressions showed a significant association between time lapse to first

fall and males, history of falls, postoperative delirium after Day 7, number of delirious

days, and sleeping disturbances during hospital stay (Table 2). In the multiple Cox

M. Stenvall et al. / Archives of Gerontology and Geriatrics 43 (2006) 389–399394

Fig. 1. Fall incidence/1000 days and number of falls each postoperative week. Postoperative week number.

Table 2

Potential fall risk factors analyzed by univariate Cox regression, dependent variable time lapse to first fall

Variable HRR 95% CI

Delirium after Day 7 (n = 26/61) 6.77 1.97–23.24

Delirium postoperatively 6.22 0.83–46.42

Sleeping disturbances 4.05 1.51–10.85

Males 3.57 1.53–8.31

Dementia 2.08 0.90–4.86

Falls during last month (n = 23/67) 2.04 1.01–4.15

Nutritional problems 1.42 0.64–3.16

Cardiovascular disease (n = 24/69) 1.36 0.57–3.21

Anemia (n = 26/70) 1.29 0.30–5.52

Diabetes 1.17 0.40–3.44

Stroke (n = 24/69) 1.16 0.43–3.13

Impaired vision (n = 19/55) 1.05 0.39–2.82

Use of antidepressants 1.02 0.46–2.26

Number of delirious days (mean � S.D.) 1.02 1.01–1.04

Depression (n = 26/69) 1.00 0.46–2.21

Age (mean � S.D.) 0.98 0.91–1.06

Walking with walking aids inside 0.95 0.43–2.12

Urinary tract infection (n = 26/70) 0.87 0.38–2.01

Walking independently outside 0.65 0.29–1.48

regression analyses, delirium after Day 7, male sex, and sleeping disturbances remained

significant (Table 3). We did not find any associations between any of the functional

variables or use of any medications.

Patients were registered as delirious during 746 out of the 3685 observation days (20%)

but 27/60 (45%) of all falls occurred during a day when the patients were delirious

( p < 0.001).

4. Discussion

This study shows that postoperative delirium, male sex and sleeping disturbances are

associated with an increased fall risk during inpatient rehabilitation. Nearly half of the falls

occurred during a day when the patients were delirious.

We found a higher incidence of postoperative falls among hip fracture patients than

previously reported (Pils et al., 2003). However, that study included ‘‘healthier’’ hip

fracture patients than in this study. We included a large proportion of patients with co-

morbidities such as dementia, and many were admitted from institutions. When compared

with non-hip fracture samples, our fall incidence remains high (Nyberg et al., 1997; Halfon

et al., 2001). The fall incidence is as high as found at a psycho-geriatric ward among people

with dementia (Nyberg et al., 1997). A large proportion of hip fracture patients are

demented (Van Balen et al., 2001; Huusko et al., 2002). In the present study there was 37%

with a dementia diagnosis.

The only study found analyzing inpatient falls in hip fracture patients did not present

figures on injuries, except three new hip fractures among 935 hip fracture patients (Pils

et al., 2003). The high proportion of falls resulting in injuries in the present study is more

in accordance with studies in residential care facilities (Nyberg et al., 1997; Jensen et al.,

2002; Kallin et al., 2002). In-hospital postoperative falls in hip fracture patients is clearly

a serious and common problem, which also appears to increase length of hospital stay

and thereby costs.

Males were at higher risk for falls during the in-hospital rehabilitation following a hip

fracture, as reported previously (Pils et al., 2003). It can be speculated that males are more

ill and frailer than women when they suffer a hip fracture and that they have lower

threshold for complications such as delirium. Males are also associated with poorer

rehabilitation outcome and higher mortality after a hip fracture (Lieberman et al., 1996;

Forsen et al., 1999; Cree et al., 2000; Fransen et al., 2002). In contrast to Pils et al. (2003)

we did not find any age differences.

M. Stenvall et al. / Archives of Gerontology and Geriatrics 43 (2006) 389–399 395

Table 3

Multiple Cox regression analyses using forward stepwise (Wald) between significant HRR in the univariate

analyses

Variable HRR 95% CI

Delirium after Day 7 4.62 1.24–16.37

Males 3.92 1.58–9.73

Sleeping disturbances 3.49 1.24–9.86

Dependent variable was time lapse to first fall.

Delirium was associated with falls during the hospital stay, which is supported by other

studies both in hospitals and in residential care facilities (Gluck et al., 1996; Vassallo et al.,

2003; Kallin et al., 2004). Associations between delirium and males, and delirium and

dementia has been reported earlier (Gustafson et al., 1991; Edlund et al., 1999, 2001;

Edelstein et al., 2004). We found a high prevalence of delirium (75%) compared with other

studies (Williams et al., 1985; Gustafson et al., 1988; Marcantonio et al., 2000). Nearly all

fallers were delirious at some point during the hospital stay, and almost half of the falls

occurred during a day when it was recorded that the patients were delirious. Studies with a

lower incidence of delirium have often excluded patients with dementia, or patients with

signs of cognitive impairment or delirium on admission. This inevitably results in a lower

incidence of delirium (Williams et al., 1985; Marcantonio et al., 2000). Delirium during

hospitalization has also been reported to be associated with poor functional recovery

following a hip fracture (Marcantonio et al., 2000), and new injuries along with other

complications which may contribute to this.

Fewer patients fell during the first week despite that the largest proportions are delirious

during the first postoperative week (data not shown). This is most likely because they are

less mobile and more strictly supervised early following surgery.

Similar to other studies (Gluck et al., 1996; Vassallo et al., 2003; Kallin et al., 2004;

Oliver et al., 2004; Salgado et al., 2004), we found an association between inpatient falls

and at least more than one previous fall. In the multiple regression analyses, however, those

associations did not remain significant.

The association between falls and sleeping disturbances in hip fracture cases is not clear.

But since nighttime falls resulting in hip fractures are associated with hypoxemia (Nyberg

et al., 1996), it could be speculated that this association could be due to sleep-apnea

syndrome, which results in hypoxemia, an entity found to be associated with delirium in

old stroke patients (Sandberg et al., 2001). In the present study, association between sleep

disturbances and falls could at least partly be mediated by the prevalent occurrence of

delirium. A study among community dwelling older people (Brassington et al., 2000)

found that sleeping disturbances are risk factors for falls even when controlling for other

known fall risk factors; they had not however controlled for delirium. The fall peak

between 20:00 and 22:00 may be associated with the use of sleeping medication

administered before the fall. However, we have not registered the time the patients took

their sleeping pills.

We believe that we had few, if any, missing falls. For one thing, the nurses were focused

on fall registration; for another, hip fracture surgery patients can hardly get up from floor

without assistance after a fall.

The care and rehabilitation should concentrate on regaining the physical ability, as well

as preventing complications. The most important complications to prevent appears to be

delirium and sleeping disturbances because those complications seem to be connected to an

increased risk of falling during hospital stay as shown in this study. There are studies that

have shown successful results of preventing and treating delirium during the in-hospital

stay with multifactorial, multidisciplinary efforts and geriatric consultations (Lundstrom

et al., 1998; Marcantonio et al., 2001). In addition, one intervention study resulted in fewer

inpatient injuries when delirium was reduced after a femoral neck fracture surgery

(Gustafson et al., 1991).

M. Stenvall et al. / Archives of Gerontology and Geriatrics 43 (2006) 389–399396

We conclude that the high incidence of inpatient falls and injuries was independently

associated with postoperative delirium, males, and sleeping disturbances. Falls and injuries

cause suffering, prolong hospitalization, and increase costs. Intervention programs,

including prevention and treatment of delirium and sleeping disturbances, as well as better

supervision of male patients, could be possible fall prevention strategies. Improvement of

the quality of care and rehabilitation, with the focus on fall prevention based on these

results, should be implemented in postoperative care of older people.

Acknowledgements

The authors wish to thank all the patients and the staff at the Orthopedic and Geriatric

Departments at the Umea University Hospital. The authors also wish to thank Eva Elinge

Reg. OT, Undis Englund and Bengt Borssen MD for their cooperation. The study was

supported by the ‘‘Vardal Foundation’’, the Joint Committee of the Northern Health Region

of Sweden (Visare Norr), the JC Kempe Memorial Foundation, the Foundation of the

Medical Faculty, University of Umea and the County Council of Vasterbotten (‘‘Dagmar’’,

‘‘FoU’’ and ‘‘Aldre Centrum Vasterbotten’’) and the Swedish Research Council, Grant

K2005-27VX-15357-01A.

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