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Breaking the fall: Preventing fractures after discharge

From the January ACP Hospitalist, copyright © 2009 by the American College of Physicians

By Jan Bowers

Sidebar: Eight steps to preventing falls

Recent research suggests that hospitalization is a risk factor for post-discharge fracture in elderly patients, prompting some hospitalists to consider what measures they can take to reduce fracture risk before these patients leave the hospital.

The prospective study included 3,075 white and black women and men, age 70 to 79 years, in relatively good health (for example, they had no reported difficulty walking a quarter of a mile or performing activities of daily living). During the followup period of 6.6 years, participants who had any hospitalization had a twofold increased risk of fracture (95% confidence interval [CI], 1.57 to 2.57), and the risk increased with multiple hospitalizations. Three or more hospital stays indicated a 3.66- fold increased relative hazard for hip fracture (95% CI, 1.78 to 7.53).

“Our results weren’t unexpected,” said Rebekah Gardner, ACP Member, assistant professor of medicine at the Warren Alpert Medical School at Brown University and lead author of the study published in Archives of Internal Medicine (2008;168(15):1671-1677). “We hypothesized that hospitalization would put this population at higher risk for fracture for a variety of reasons, including a decrease in neuromuscular function or bone mass after a hospital stay.”

The findings highlight an opportunity for hospitalists to take a preventive approach before elderly patients are discharged, said Dr. Gardner.

“While we have to be sensitive to asking hospitalists to do even more in the hospital setting,” she said, “this is certainly an opportunity to begin the evaluation of patients who may be at higher risk, such as a woman who has been hospitalized several times.”

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In-house efforts

The many causes of geriatric falls can seem overwhelming, leading physicians to suffer “possibility paralysis” and do nothing, said Ethan Cumbler, ACP Member, assistant professor of internal medicine and director of the Acute Care for the Elderly (ACE) service at the University of Colorado Hospital. But “if you look at the things that are in the toolbox for hospitalist physicians (to prevent falls and fractures), it’s a manageable list,” he said.

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Check for sensory aids, such as glasses and hearing aids, before patients leave the hospital.

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“By trying to get our hospitalist residents to focus on just eight things they can do to reduce the risk of both subsequent falls and subsequent injury from falls, then you’ve lowered the barrier to action,” Dr. Cumbler observed (see sidebar).

Dr. Gardner suggested several interventions physicians can undertake during hospitalization, including:

• test the level of vitamin D and begin supplementation if indicated,
• coordinate with a caseworker to arrange for in-home physical therapy
• facilitate a home safety evaluation
• communicate the patient’s elevated risk of fracture to the primary care physician, and
• recommend post-discharge instructions.

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Elderly patients hospitalized for falls may need ambulation and gait aids.

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Most hospitalists would take preventive measures that relate to the admitting diagnosis, but “it’s less common for hospitalists to think about prevention that does not directly relate to the reason for hospitalization,” Dr. Gardner said. “The next step to consider is testing interventions to see if we can prevent fractures in this elderly population, now that we’ve identified a very high-risk group.”

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Collaborative effort

Teamwork among hospitalists, geriatricians, nurses, physical therapists and other providers is an essential component of the fall prevention effort. At Beth Israel Deaconess Medical Center (BIDMC) in Boston, nurses screen all patients on admission to determine their risk of falling in the hospital, said Melissa Mattison, ACP Member, a geriatrics hospitalist at BIDMC.

"The hospital setting affords an opportunity for nurses, physicians and physical therapy to work together to identify the most vulnerable patients." —Melissa Mattison, ACP Member

“The hospital setting affords an opportunity for nurses, physicians and physical therapy to work together to identify the most vulnerable patients,” said Dr. Mattison. “We frequently don’t discharge patients until they have a physical therapy assessment in-house because we just don’t know if they can manage at home or not.”

At the University of California, Irvine School of Medicine, the recent Archives study prompted a discussion within the hospitalist program as to whether to routinely incorporate a fracture risk assessment for elderly patients, said Michael Wang, ACP Member, a hospitalist and geriatrician at UC Irvine.

“My recommendations to my hospitalist colleagues included more frequently checking vitamin D levels in the inpatient setting and getting patients to a recommended dose of vitamin D and calcium,” Dr. Wang said, adding that he routinely reviews elderly patients’ medications and asks if they have fallen in the last year— easy steps to take. He checks the patient’s orthostatics as well, particularly if he is adjusting the patient’s blood pressure medication, or if the patient’s blood pressure is in the low-normal range.

“To be more comprehensive in the fall risk assessment and bone health assessment, that gets more complicated and takes a lot more time,” Dr. Wang said. “When the patient has multiple issues, and the details increase for after-hospital care, the hospitalist has to spend extra time to ensure good communication with the primary care physician.”

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Bridging the communication gap

Even with the best intentions on both sides, lack of clear communication during the handoff from hospitalist to primary care physician can hamper the effort to prevent falls and fractures.

For example, “we might say to a patient’s primary care physician that the patient needs a DEXA scan because she’s at risk for osteoporosis, and we would recommend a bisphosphonate if the DEXA scan is consistent with osteoporosis,” Dr. Wang said. “But it’s one thing to put it in the discharge summary and communicate it to the primary care physician—along with 10 other things. It’s another to support the whole system so that the intervention is done and the recommendations made are successful. Communication is not as streamlined or effective as we’d like it to be.”

Dr. Cumbler said that he frequently has difficulty reaching physicians outside the University of Colorado health system. “Transitions are the single biggest challenge that we have as hospitalists. We do a great job of getting the right diagnosis, getting the right therapies in place, but far too often it’s the discharge part where our plans fall apart,” he said. “The solution is to figure out how to make the system work more efficiently so that we can lower the barriers to clear, two-way communication.”

Jan Bowers is a freelance writer based in Evanston, Ill.

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Eight steps to preventing falls

Ethan Cumbler, ACP Member, recommends eight in-house reviews that can prevent falls after discharge. These measures target patients who are hospitalized as the result of a fall and are not screening tools or interventions for patients who have been admitted with another diagnosis.

• Physical therapy/occupational therapy evaluation, with orders for home therapy if indicated,
• Sensory aids such as glasses and hearing aids,
• Ambulation and gait aids such as four-prong canes and walkers, when appropriate,
• Review of the medication list for problematic medications that can contribution to confusion or loss of balance. These could include blood pressure medications that cause orthostasis, benzodiazepines, psychotropics, anticholinergic medications and alpha antagonists. While these medications may be discontinued while the patient is hospitalized, “We have to be careful about changing people’s outpatient medication lists because sometimes we don’t know the full story behind why a medicine has been started,” said Dr. Cumbler. “When you communicate with the primary care physician and suggest a medication change that is less likely to cause falls, my experience has been they’re generally very receptive to that.”
• Hydration, if hypovolemia is suspected to have contributed to a previous fall.
• Bed alarms in patients who have dementia with impulsivity (in a supervised environment).
• A home safety evaluation by an occupational therapist, with an eye to hazards such as rugs and cords that can cause tripping, poor lighting and unsteady staircase rails. Appropriate supplementation of vitamin D and calcium, and prescription of bisphosphonate for elderly patients hospitalized with fracture.

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© 2010 ACP Hospitalist and American College of Physicians

ACP Hospitalist provides news and information for internists about the practice of medicine and reports on the policies, products and activities of ACP. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated