EMPIRICAL STUDIES doi: 10.1111/scs.

12733

Falls in hospital: a case–control study

Gudrun Cathrine Lindgren de Groot MS (Physical therapist)1 , Ahmad Al-Fattal MD (Physician,

Geriatrician)1 and Irene Sandven MPH, PhD2
1
Department of Medicine, Telemark Hospital, Skien, Norway and 2Oslo Centre of Biostatistics and Epidemiology, Research Support
Services, Oslo University Hospital Sogn Arena, Oslo, Norway

Scand J Caring Sci; 2019 men (OR = 1.82, 95% CI: 1.24–2.68), and 50%
increased probability of fall with every 10 year increase
Falls in hospital: a case–control study
of age (OR = 1.51, 95% CI: 1.34–1.69). Furthermore,
the patients who fell were more likely to use antidepres-
Aims: Falls among inpatients are common. The method sant drugs (OR = 3.85, 95% CI: 1.09–13.63), antipsy-
used by The Norwegian Patient Safety Campaign to mea- chotic drugs (OR = 3.27, 95% CI: 1.94–5.51),
sure the adverse events is the Global Trigger Tool, which anxiolytic/hypnotic drugs (OR = 1.80, 95% CI: 1.22–
does not look at the causation for falls. This study was 2.67) and antiepileptic drugs (OR = 1.13, 95% CI: 1.11–
aimed at investigating major risk factors for falls in the 4.06) than patients who did not fall.
hospital setting. Conclusions: During hospital stay, patients who fell had a
Methods: This retrospective case–control study was con- higher risk profile than patients who did not fall. Clini-
ducted at Telemark Hospital in Norway, in the period cians should work to improve patients’ safety and reduce
from September 2012 to August 2014. A total of 842 the risk of falls by accurately assessing balance and
patients from three wards were included, whereof 172 mobility as a form of primary prevention. We recom-
cases had experienced one or more fall(s) during hospi- mend that a review of the patient medications should be
talisation and 670 random controls had not fallen. Data conducted upon falling, as a form of a secondary preven-
were analysed according to a pragmatic strategy. tive strategy against falls.
Results: Compared with patients who did not fall,
patients who fell were 21 times more likely to have Keywords: falls, drugs, antidepressants, hospital,
poor balance (OR = 21.50, 95% CI: 10.26–45.04) and balance.
19 times more likely to have very poor balance
(OR = 19.62, 95% CI: 9.55–40.27), twice as likely to be Submitted 5 November 2018, Accepted 2 June 2019

in hospitals, although subgroup analysis suggests this may

Introduction
apply mostly to a subacute setting, but the evidence for
Falls among inpatients are common, and the incidence risk of falling was uncertain (3). Effective interventions
varies from 3, 4 cases per bed annually in the acute reha- are important to detect, because they will have significant
bilitation of stroke patients to an average fall rate of 4.8 health benefits for older people.
falls per 1000 patient days in acute hospitals (1,2). Falls in In 2012, Telemark Hospital was selected to be a pilot
the elderly may cause loss of independence, injuries and project in the Norwegian Patient Safety Program, ‘In safe
sometimes death as a result of the injury (3). In 2017, hands,’ and therefore started the registration of all acci-
falls accounted for 13.7% of all adverse events reported dental falls (7). In a two-year period, 172 falls were regis-
from Norwegian hospitals (4). Most frequent were falls tered in three hospital wards (Neurology, Respiratory
due to loss of balance, falls out of bed or in connection medicine and Acute Geriatric medicine). The hospital
with going to the toilet (4). Risk factors for falls are well quality assurance register suggested that these three
documented (5). Still, there is inconclusive evidence for wards had the highest number of falls registered among
the effectiveness of most preventive strategies (1,6). There elderly patients between the ages of 76 and 85 years. An
is evidence that multifactorial interventions reduce falls earlier study demonstrated an extensive use of drugs
given in hospitals, where the average drug consumption
was over seven drugs per patient (8). Central nervous
Correspondence to:
system (CNS) active drugs, such as neuroleptics, benzodi-
Gudrun Cathrine Lindgren de Groot, Department of Medicine,
azepines and antidepressants, appear to be the most com-
Telemark Hospital, Postboks 2900 Kjørbekk, 3710 Skien, Norway.
E-mail: cathrine.degroot@sthf.no
mon drugs associated with falls (5). It is claimed that the

© 2019 The Authors. 1

Scandinavian Journal of Caring Sciences published by John Wiley & Sons Ltd on behalf of Nordic College of Caring Science.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License,
which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and
no modifications or adaptations are made.
2 G.C.L. de Groot et al.

use of drugs is one of the most modifiable fall risks in sex, balance, chronic diseases, renal function and drugs.
hospital (5). Based on this evidence, one might assume Increased inpatient fall risk has been associated with older
that a medication review is a key factor to preventing age and poor health status (1), and therefore, the diagno-
falls in the acute hospital setting. It may, however, prove sis and the number of chronic diseases were registered.
difficult to change a patient’s medication in the hospital Patients with previous history of falls, reduced balance
setting. An Irish study from 2014 demonstrated a higher and poor gait are at an increased risk for future falls (11).
possibility for change of on-demand drugs as compared The information on balance was clinically assessed to be
with regular medication (9). either of good balance (patient was able to walk without a
From 2010 to 2012, the proportion of adverse events walking aid), or of poor balance (patient was walking
reported from Norwegian hospitals decreased from 16 to unsteadily but had no documented walking aid) or of very
13.9% at the national level (10). Since then, the propor- poor balance (patient was walking unsteadily and had a
tions have been stable, but the risk of moderately serious documented walking aid). Patients with poor renal func-
patient injury has probably increased (10). The method tion are less able to excrete drugs. Rowe (12) cited in
used to measure these numbers is the Global Trigger Tool, Rochon (13) claims that decreased drug clearance may also
which does not look at the causation between these result from the natural decline in renal function with age,
adverse events (10). By improving our knowledge about even in the absence of renal disease. This increases the risk
today’s clinical situation, we will have a better under- that the patient is being exposed to a higher dosage of the
standing of how to weigh interventions in order to reduce drug, as compared to a patient with normal renal function
the number of falls. Therefore, we see the need for more (14). The renal function was measured as good (glomerular
knowledge with regard to clinical practice in relation to filtration rate (GFR) >60), moderate (GFR 30–60) or poor
evidence-based practice. Consequently, this study was (GFR <30). Polypharmacy is also a known risk factor asso-
aimed at investigating which major risk factors had the ciated with falls (13). Each medication was therefore regis-
strongest association with the falls that have occurred. tered upon admission, during hospital stay and at
discharge. The following six CNS active drug groups were
considered potential risk factors for falls: antidepressants,
Material and methods
cardiovascular and antihypertensives, opioids, antiepilep-
A retrospective case–control study was conducted at Tele- tics, antipsychotics, and anxiolytic and hypnotic drugs.
mark Hospital in Norway. Eligible for inclusion were Registration of patient data was based on information
adults, 18 years or older, admitted to the hospital from from (1) the pilot project, (2) the hospital’s safety system
September 2012 to August 2014. Participants were Total Quality Management (TQM) and (3) the patient’s
recruited from three wards: Neurology, Respiratory medi- medical records. A case report form (CRF) was developed
cine and Acute Geriatric medicine. From the total num- and a database built in EPIDATA ENTRY version 3.1 (The Epi-
ber of patients admitted to these three wards during the Data Association, att. Jens Lauritsen, Denmark, Europe).
study period (source population), we included all the Sample size estimation was performed considering
patients registered with one or more falls (cases) during antidepressant drugs as a potential risk factor for falls.
hospitalisation and a random sample of patients who did Based on an estimated prevalence of antidepressant use
not fall (controls). The procedure of random controls was among stroke patients of 30% (15) and users being 1.68
to remove 172 cases from the total 5957 patients at the times more likely to fall compared with non-users (16),
three wards during the study period leaving 5785 not we would need a minimum of 167 cases and 668 con-
with falls. Weighting was done according to the total trols considering four controls per case, a type I error of
number of patients at the three wards: Respiratory medi- 5% and power of 80%.
cine (2585), Neurology (3058) and Acute Geriatric medi- We analysed the data according to a pragmatic strat-
cine (142). Considering four controls per case, we egy, which means that the priority was not given to a
estimated the number of controls needed from each specific hypothesis. The association between potential
ward. The random sample was generated in STATA version risk factors and falls was quantified by the odds ratio
11.0 (Statacorp, College Station, TX, USA) with sampling (OR) and its 95% confidence interval (CI). We explored
fractions at the Respiratory medicine ward, the Neurol- the importance of patients’ age by stratifying age accord-
ogy ward and the Acute Geriatric medicine ward of 11.7, ing to the 25, 50 and 75% percentiles, and estimated the
11.7 and 11.9%, respectively. association and gradient effect of each risk factor along
Fall was defined as ‘an event resulting in a person com- the four age groups by a chi-square test for trend. To
ing to rest inadvertently on the ground, floor or other identify the independent risk factors for falls, we per-
lower level, whether there is any damage caused by the formed a manual backward stepwise elimination proce-
fall’ (7). The major risk factors for falls were considered dure using the logistic regression model (22).
most relevant for an acute hospital setting based on the Multivariable analyses were preceded by the estimation
earlier mentioned pilot project. These factors include age, of correlations between variables. The criteria for

© 2019 The Authors.

Scandinavian Journal of Caring Sciences published by John Wiley & Sons Ltd on behalf of Nordic College of Caring Science.
 Falls in hospital 3

sequential elimination of candidate risk factors were vari- summarised in Table 2. With increasing age, there was
ables’ strength and significance on the association with an increasing frequency of patients with poor balance,
fall, and optimal calibration and discrimination of the poor renal function, multiple chronic diseases, use of car-
model. The predictive accuracy of the model was evalu- diovascular/antihypertensive drugs and anxiolytic/hyp-
ated by calibration and discrimination. Calibration mea- notic drugs. The frequency of men and the use of
sures the ability of the model to assign the appropriate antiepileptic drugs decreased with increasing age. All
risk and was evaluated by the Hosmer and Lemeshow these associations showed a gradient effect with highly
(H-L) goodness-of-fit test. A statistically nonsignificant H- significant test for trend. There was no association
L result (p-value > 0.05) suggests that the model predict between the use of opioids, antipsychotic drugs and
accurately on average. Discrimination measures the mod- antidepressant drugs with increasing age.
el’s ability to differentiate between patients who fall and The final analysis, in order to highlight the indepen-
not fall and was evaluated by the analysis of the area dent risk factors for falls, is shown in Table 3. Due to the
under the ROC curve. If the area under the curve is association between age and the presence of poor or very
greater than 0.7, it can be concluded that the model has poor balance, poor renal function, chronic diseases, male
an acceptable discriminatory capability. sex and the use of cardiovascular/antihypertensive drugs,
anxiolytic/hypnotic drugs and antiepileptic drugs, two
multivariate models were needed to avoid collinearity
Results
problems. Model A shows that the patients who fell had
A total of 842 patients were included in the study, whereof 21 times (OR = 21.50, 95% CI: 10.26–45.04) the preva-
172 fallers (cases) and 670 nonfallers (controls). The clini- lence of poor balance and 19 times (OR = 19.62, 95% CI:
cal profile and the distribution of potential risk factors are 9.55–40.27) the prevalence of very poor balance as com-
presented in Table 1. Compared with controls, cases were pared to the patients who did not fall. Furthermore, this
12 years older (median age 78 vs. 66), more frequently group was twice as likely to consist of men (OR = 1.82,
males (58.7% vs. 46.7%), with poor balance (39.0% vs. 95% CI: 1.24–2.68), and using/receiving the following
15.5%) or very poor balance (54.1% vs. 23.7%), having drugs: anxiolytic/hypnotic drugs (OR = 1.80, 95% CI:
multiple chronic diseases (60.5% vs. 50.1%) and getting 1.22–2.67), antiepileptic drugs (OR = 1.13, 95% CI:
the following drugs: antidepressants (2.9% vs. 1.0%), car- 1.11–4.06) and antipsychotic drugs (OR = 2.01, 95% CI:
diovascular/antihypertensive drugs (22.7% vs. 12.2%), 1.15–3.51). Model B informs us that the probability of
opiates (32.0% vs. 22.4%), antiepileptic drugs (13.4% vs. falling increased with 50% with every 10-year increase
5.2%), antipsychotic drugs (19.2% vs. 6.4%) and anxi- of age (OR = 1.51, 95% CI: 1.34–1.69). Furthermore, the
olytics/hypnotic drugs (47.1% vs. 25.2%). patients who fell used three times more antipsychotics
Our results showing the association between the differ- (OR = 3.27, 95% CI: 1.94–5.51) and antidepressant drugs
ent age groups and the different risk factors are (OR = 3.85, 95% CI: 1.09–13.63) than the patients who

Table 1 Clinical profile of patients with fall (cases) vs. no fall (controls)

Casesn = 172 (%) Controlsn = 670 (%) OR (95% CI) p-Value

Age in years, median (IQR) 78 (68–85) 66 (49–79) 0.001

Men 101 (58.7) 313 (46.7) 1.62 (1.16–2.28) 0.005
Balancea
Good 9 (5.2) 353 (52.7) (reference)
Poor 67 (39.0) 104 (15.5) 25.27 (12.18–52.40) 0.001
Very poor 93 (54.1) 159 (23.7) 22.94 (11.29–46.63) 0.001
Poor renal function 47 (27.3) 189 (28.2) 0.96 (0.66–1.39) 0.818
Multiple chronic diseases 104 (60.5) 336 (50.1) 1.52 (1.08–2.14) 0.016
Drugs
Antidepressants 5 (2.9) 7 (1.0) 2.84 (0.89–9.05) 0.078
Cardiovascular/Antihypertensive 39 (22.7) 82 (12.2) 2.10 (1.37–3.22) 0.001
Opiates 55 (32.0) 149 (22.4) 1.64 (1.14–2.38) 0.008
Antiepileptics 23 (13.4) 35 (5.2) 2.80 (1.61–4.88) 0.001
Antipsychotics 33 (19.2) 43 (6.4) 3.46 (2.12–5.65) 0.001
Anxiolytics/Hypnotic 81 (47.1) 169 (25.2) 2.64 (1.87–3.73) 0.001
Polypharmacy 78 (45.3) 170 (25.4) 2.44 (1.69–3.49) 0.001

CI, confidence interval; IQR, interquartile range; OR, odds ratio.

a
Missing 57 (6.7%).

© 2019 The Authors.

Scandinavian Journal of Caring Sciences published by John Wiley & Sons Ltd on behalf of Nordic College of Caring Science.
4 G.C.L. de Groot et al.

did not fall. The H-L goodness-of-fit test was nonsignifi- This indicates a useful goodness of fit for the two models
cant for model A with five risk factors (p-value = 0.6486) and that they predict accurately on average and suitable
and model B with three risk factors (p-value = 0.9763). for use in low- to high-risk patients. Additionally, model

Table 2 Gradient effect of age interval by quartiles and frequency of risk factors

Age (years)

≤51 52–68 69–80 ≥81 Total p-Value trend

Fall
Yes (cases) 13 37 56 66 172 0.0001
No (controls) 198 181 156 135 670
Total 211 218 212 201 842
Frequency (%) 6.2 17.0 26.4 32.8 20.4
OR (95% CI) 1.0 3.1 (1.6–6.0) 5.5 (2.9–10.4) 7.4 (4.0–14.0)
Sex
Male 101 130 95 88 414 0.0037
Female 110 88 117 113 428
Total 211 218 212 201 842
Frequency 52.1 47.9 59.6 44.8 43.8
OR (95% CI) 1.0 1.6 (1.1–2.4) 0.9 (0.6–1.3) 0.8 (0.6–1.3)
Balance
Poor 62 98 142 178 480 0.0001
Good 149 120 70 23 362
Total 211 218 212 201 842
Frequency (%) 29.4 45.0 67.0 88.6 57.0
OR (95% CI) 1.0 2.0 (1.3–2.9) 4.9 (3.2–7.4) 18.6 (11.0–31.5)
Renal function
Poor 29 35 68 104 236 0.0001
Good 182 183 144 97 606
Total 211 218 212 201 842
Frequency (%) 13.7 16.1 32.1 51.7 28.0
OR (95% CI) 1.0 1.2 (0.7–2.0) 3.0 (1.8–4.8) 6.7 (4.2–10.9)
Chronic diseases
≥4 45 103 140 152 440 0.0001
<4 166 115 72 49 402
Total 211 218 212 201 842
Frequency (%) 21.3 47.2 66.0 75.6 52.3
OR (95% CI) 1.0 3.3 (2.2–5.0) 7.2 (4.6–11.1) 11.4 (7.2–18.1)
Cardiovascular/Antihypertensive drugs
Yes 7 22 44 48 121 0.0001
No 204 196 168 153 721
Total 211 218 212 201 842
Frequency (%) 3.3 10.1 20.8 23.9 14.4
OR (95% CI) 1.0 3.3 (1.4–7.8) 7.6 (3.4–17.4) 9.1 (4.0–20.8)
Anxiolytic/Hypnotic drugs
Yes 30 58 82 80 250 0.0001
No 181 160 130 121 592
Total 211 218 212 201 842
Frequency (%) 14.2 26.6 38.7 39.8 29.8
OR (95% CI) 1.0 2.2 (1.3–3.6) 3.8 (2.4–6.1) 4.0 (2.5–6.4)
Antiepileptic drugs
Yes 19 19 17 3 58 0.0241
No 192 199 195 198 784
Total 211 218 212 201 842
Frequency (%) 9.0 8.7 8.0 1.5 6.9
OR (95% CI) 1.0 1.0 (0.5–1.9) 0.9 (0.4–1.7) 0.2 (0.04–0.5)

© 2019 The Authors.

Scandinavian Journal of Caring Sciences published by John Wiley & Sons Ltd on behalf of Nordic College of Caring Science.
 Falls in hospital 5

Table 2 (Continued)

Age (years)

≤51 52–68 69–80 ≥81 Total p-Value trend

Opioids
Yes 56 40 56 52 204 0.1383
No 155 178 156 149 638
Total 211 218 212 201 842
Frequency (%) 26.5 18.3 26.4 25.9 24.2
OR(95% CI) 1.0 0.6 (0.4–1.0) 1.0 (0.6–1.5) 1.0 (0.6–1.5)
Antipsychotics
Yes 20 14 16 26 76 0.1115
No 191 204 196 175 766
Total 211 218 212 201 842
Frequency (%) 9.5 6.4 7.5 12.9 9.0
OR (95% CI) 1.0 0.7 (0.3–1.3) 0.8 (0.4–1.5) 1.4 (0.8–2.6)
Antidepressants
Yes 3 7 2 0 12 0.2168
No 208 211 210 201 830
Total 211 218 212 201 842
Frequency (%) 1.4 3.2 0.9 0.0 1.4
OR (95% CI) 1.0 2.3 (0.6–9.0) 0.7 (0.1–4.0) –

CI; confidence interval; OR; odds ratio.

A demonstrated an excellent discriminatory capability benefit from preventive interventions. Personal assistance
(AUC = 0.8306) and model B demonstrated an accept- or a walking aid can in many cases prevent a fall, but
able discriminatory capability (AUC = 0.7164). these resources were not investigated in the current
study. In clinical practice, we often see that the injury
caused by a fall is often treated without assessing balance
Discussion
or investigating other possible causes of the fall (5). A
Results from this study suggest that antiepileptic drugs, reason for this could be that these investigations often
antipsychotic drugs, anxiolytic/hypnotic drugs and consume a longer time than to treat the injury itself.
antidepressant drugs could be important risk factors for Another reason could be lack of knowledge among the
falls during hospital stay along with well-known risk fac- staff. Hence, based on our findings, we suggest a greater
tors such as age, sex and balance. need for accurately assessing balance and mobility. This
Among the risk factors for falls investigated in this can help clinicians identify early signs of functional
study, the most clinically important identified risk factor decline and assist with the individual’s interventions goal
was balance. The prevalence of poor balance and very setting, and also with discharge planning. The latter is
poor balance was high (39.0 and 54.1%) among patients especially important considering that exercise improving
who experienced a fall during hospital stay. We know strength and balance is known to prevent falls among
from earlier studies that intrinsic factors such as sensory community-dwelling older adults (20,21).
input, muscle activation patterns, lower extremity func- The drugs with the highest association to a fall were
tion and gait speed are all factors known to decline due not unexpectedly the antidepressants drugs (OR = 3.85)
to old age and thus reduce balance and mobility (17,18). and the antipsychotic drugs (OR = 3.27). This association
Acute illness in combination with sedentary behaviour is well known (22). However, we found that the fre-
among older patients during hospital stay reduces bal- quency was very low for use of antidepressants (1.4%)
ance and mobility even further. A study investigating the and relatively low for the antipsychotics (9%). This could
characteristics and circumstances of falls in a hospital set- indicate that clinicians had been wisely cautious in pre-
ting found lost balance to be the most common adverse scribing these drugs in old age.
event reported in connection to falls and ambulation to The prevalent use of medication was highest for anxi-
be the most common performed activity at the time of olytic/hypnotic drugs (29.8%). These drugs were given
the fall (19). Results from our study indicate a high risk to 47% of the fallers and 25% of the nonfallers. Look-
of falling on both clinically assessed levels of impaired ing through the patients’ medical records, we found that
balance, which may help identify patients most likely to the anxiolytic/hypnotic drugs are a widely prescribed

© 2019 The Authors.

Scandinavian Journal of Caring Sciences published by John Wiley & Sons Ltd on behalf of Nordic College of Caring Science.
6 G.C.L. de Groot et al.

Table 3 Risk factors differentiating patients with fall versus no fall using the multivariate logistic model

Risk factors Level OR (95% CI) p-Value

Model A
Male sex Yes/no 1.82 (1.24–2.68) 0.002
Balance Good (reference)
Poor 21.50 (10.26–45.04) 0.001
Very poor 19.62 (9.55–40.27) 0.001
Anxiolytics/Hypnotic drugs Yes/no 1.80 (1.22–2.67) 0.003
Antiepileptic drugs Yes/no 1.13 (1.11–4.06) 0.022
Antipsychotic drugs Yes/no 2.01 (1.15–3.51) 0.014
Model B
Age 10 year increase 1.51 (1.34–1.69) 0.001
Antipsychotic drugs Yes/no 3.27 (1.94–5.51) 0.001
Antidepressants Yes/no 3.85 (1.09–13.63) 0.037

CI, confidence interval; OR, odds ratio.

Two-model presentation was used to avoid the problem of collinearity between the risk factors of fall

group of drugs before and during hospital stay, and considered. Therefore, we argue that age, in itself, is still
often in unsuitable combination with other drug groups. a factor that always needs to be considered when aiming
This puts an important emphasis on the careful and pre- to prevent falls, and especially in relation to poor balance
cautious administration of these drugs, especially in the and mobility.
presence of other risk factors such as old age and poor As for the other risk factors considered in our study,
balance. Browne et al. (9) concluded that 80% of the fall kidney function, chronic diseases and opioids, they were
risk medications suitable for intervention came from four not significantly associated with falls, had minimal con-
drug classes: anti-emetics, opioid analgesics, anti-choliner- founding effect and did not change the model’s predictive
gic agents acting on the bladder and benzodiazepines/ and discriminatory ability. Given the utility for clinical
hypnotics (9). Among six groups of central nervous sys- practice, we excluded these variables from the model pre-
tem (CNS) active drugs investigated in the current study, sented, keeping those regarded most clinically relevant.
four groups were identified as independent risk factors Strengths of the study include minor probability of
for falls. All four drug groups fall within these four selection bias as all patients registered with falls (cases),
classes. To prevent falls in the hospital setting, we suggest and a random sample of controls were selected from the
a more targeted fall risk medication review, with a par- same source population during the same time period.
ticular focus on antidepressants, antiepileptics, antipsy- Limitations include the possibility of information bias
chotics and anxiolytic/hypnotic drugs. because case status and risk factor status were assessed in
From the time of hospital admission to discharge, we retrospect from medical records. However, the resident
observed that the number of drugs administered during physicians were masked to our research questions, and
that period was higher and increased more during hospital the potential misclassification would be nondifferential
stay, for the fallers as compared to the nonfallers. This is creating a bias towards the null effect (24). Due to the
of a great concern knowing that the interaction of drugs lack of information in the medical records, there is a pos-
themselves can lead to falls. Thus, we see the need for a sibility of unmeasured risk factors such as poor vision,
more organised, targeted and systematic cooperation con- dizziness and cognitive status of the patient. Elderly
cerning medication prescribed during hospital stay and the adults are particularly dependent on vision to maintain
discontinuation of medications upon discharge (23). postural stability (25). Dizziness is a known reported
The association between old age and falls is long cause to falls in the elderly and a well-known adverse
known, but in the clinical setting, age limit is still dis- effect of medications (1,26). Cognitive impairment con-
cussed when considering fall risk. In the literature, an tributes to falls in the hospital setting (1). On the other
increased fall risk is described among community-dwell- hand, and since poor vision, dizziness and cognitive
ing people 65 years or older, and Hitcho et al. found an impairment are all associated with impaired balance, and
average age of 63 among hospital fallers (5,19). In the we argue that this has been taken into account by con-
present study, the median age of the patients was sidering the balance factor (1,25,26). A further limitation
69 years, and patients who fell were on average 12 years in our study is the difficulty in establishing a correct tem-
older than those with no fall. We further observed a gra- poral relationship between the risk factors and fall
dient association between patient’s age and fall, and that events. This is also the experience from one hospital,
age was associated with the majority of risk factors which raises the question of generalizability, but the

© 2019 The Authors.

Scandinavian Journal of Caring Sciences published by John Wiley & Sons Ltd on behalf of Nordic College of Caring Science.
 Falls in hospital 7

sample of patients, both cases and controls, was taken

Conflict of interest
from three different wards.
The authors report no conflicts of interest in this work.
In the preparations of this manuscript, all tips for pub-
Clinical implications
lishing ethics are followed.
Clinicians should work to improve patient’s safety and
reduce the risk of falls by accurately assessing balance and
Author contribution
mobility among older patients as a form of primary pre-
vention. We recommend that a review of the patient med- The authors worked together to perform the case–control
ications should be conducted upon falling, as a form of a study. The first author was mainly responsible for prepar-
secondary preventive strategy against falls. While at the ing the manuscript. The second author was vital in the
same time prompting a more robust and pragmatic pri- gathering of the clinical and medical data, and had an
mary preventive strategy against falls, even before the fall expertise in the field of medical care for the elderly. The
happening, including a more dynamic approach to the third author was responsible for the accuracy of the anal-
patient medications upon hospital admission,under hospi- ysis and interpretation of the results. The authors report
tal stay, and upon discharge, especially in the presence of no conflicts of interest in this work. The three authors G.
one or more of the important risk factors for falls. Cathrine L. de Groot, Ahmad Al-Fattal and Irene Sand-
More clinical studies, preferably prospective studies, are ven meet the Scandinavian Journal of Caring Sciences
needed to be done with regard to the clinicians approach criteria for contribution to authorship.
to the patients’ medications before and after falls as a form
of primary and secondary prevention strategy accordingly.
Ethical approval
This study was registered at the Norwegian Social Science
Acknowledgement
Data Services (NSD) on 3 June 2015, with the registra-
An acknowledgement page is not included, since there tion number 43162. Enrolment of patients started in
has been no state founding or support in the form of February 2016. No ethical approval typical for empirical
grants given to this study. studies was needed.

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