ISSN: 1981-8963 DOI: 10.5205/reuol.11138-99362-1-SM.

1111sup201707

Oliveira DU de, Ercole FF, Melo LS de et al. Evaluation of falls in hospitalized elderly.

ORIGINAL ARTICLE
EVALUATION OF FALLS IN HOSPITALIZED ELDERLY
AVALIAÇÃO DE QUEDAS EM IDOSOS HOSPITALIZADOS
EVALUACIÓN DE CAÍDAS EN ANCIANOS HOSPITALIZADOS
Danilo Ulisses de Oliveira¹, Flávia Falci Ercole², Laís Samara de Melo³, Selme Silqueira de Matos 4, Camila
Cláudia Campos5, Eduardo Andrey Marques Fonseca6
ABSTRACT
Objective: to evaluate the occurrence of falls in hospitalized elderly patients who presented high risk for the
event. Method: a quantitative, concurrent cohort study, with 96 elderly individuals at risk of falling, using the
Fall Risk Score scale. The data was released in the EpiInfo, program version 3.5.1, and performed double
typing. Results: 53.13% were female; age between 60 and 95 years; of 24 days, and the incidence of falls
during the hospitalization of the 96 elderly was 13.54%. After the final adjustment of the model, the factors
associated with the occurrence of falls in the studied sample were: to present cognitive deficits, to have a
diagnosis of depression and to use some type of orthosis. Conclusion: the falls are directly linked to the
patient's safety indicators, requiring a multidisciplinary and interdisciplinary approach, assessing the risk
factors to which the hospitalized elderly are exposed in order to adopt preventive strategies for health
maintenance. Descriptors: Patient Safety; Accidental Falls; Aged; Nursing.
RESUMO
Objetivo: avaliar a ocorrência de queda nos pacientes idosos internados que apresentavam alto risco para o
evento. Método: estudo quantitativo, tipo coorte concorrente, com 96 idosos em risco de queda, utilizando a
escala Fall Risk Score. Os dados foram lançados no programa EpiInfo, versão 3.5.1, e realizada dupla
digitação. Resultados: 53,13% eram do sexo feminino; idade entre 60 e 95 anos; média de internação de 24
dias, e a incidência de queda durante a internação dos 96 idosos foi de 13,54%. Após o ajuste final do modelo,
os fatores associados à ocorrência de quedas na amostra estudada foram: apresentar déficit cognitivo, ter
diagnóstico de depressão e utilizar algum tipo de órtese. Conclusão: as quedas estão ligadas diretamente aos
indicadores de segurança do paciente, sendo necessária uma abordagem multiprofissional e interdisciplinar,
avaliando os fatores de risco a que os idosos hospitalizados estão expostos para que sejam adotadas
estratégias preventivas para a manutenção da saúde. Descritores: Segurança do Paciente; Acidentes por
Quedas; Idoso; Enfermagem.
RESUMEN
Objetivo: evaluar la ocurrencia de caída en los pacientes ancianos internados que presentaban alto riesgo
para el evento. Método: estudio cuantitativo, tipo cohorte concurrente, con 96 ancianos en riesgo de caída,
utilizando la escala Fall Risk Score. Los datos fueron lanzados en el programa EpiInfo, versión 3.5.1, y
realizada doble digitación. Resultados: 53,13% eran del sexo femenino; edad entre 60 y 95 años; promedio de
internación de 24 días, y la incidencia de caída durante la internación de los 96 ancianos fue del 13,54%.
Después del ajuste final del modelo, los factores asociados a la ocurrencia de caídas en la muestra estudiada
fueron: presentar déficit cognitivo, tener diagnóstico de depresión y utilizar algún tipo de ortesis.
Conclusión: las caídas están ligadas directamente a los indicadores de seguridad del paciente, siendo
necesaria un abordaje multiprofesional e interdisciplinario, evaluando los factores de riesgo a los que los
ancianos hospitalizados están expuestos para que se adopten estrategias preventivas para el mantenimiento
de la salud. Descriptores: Seguralidad del Pacient; Accidentes por Caídas; Anciano; Enfermería.
¹Nurse, Master in Nursing, Federal University of Minas Gerais / UFMG. Belo Horizonte (MG), Brazil. E-mail: daniloulisses@yahoo.com.br;
²Nurse, Professor, PhD, Federal University of Minas Gerais / UFMG, Belo Horizonte (MG), Brazil. E-mail: flavia.ercole@gmail.com; ³Nurse,
Master in Nursing, Federal University of Minas Gerais / UFMG. Belo Horizonte (MG), Brazil. E-mail: laisdtna@yahoo.com.br; 4Nurse,
Professor, PhD, Federal University of Minas Gerais / UFMG. Belo Horizonte (MG), Brazil. E-mail:: selmesilqueira@gmail.com; 5Nurse,
Doctorate, Federal University of Minas Gerais / UFMG. Belo Horizonte (MG), Brazil. Email: camilacbh@hotmail.com; 6Nursing Academic,
Newton Paiva University. Belo Horizonte (MG), Brazil. E-mail: dudubh132@yahoo.com.br

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INTRODUCTION
Population aging is a worldwide
phenomenon. The increase in the proportion
of the elderly population occurs rapidly and
abruptly, especially, in developing countries.
In Brazil, those individuals who are 60 years of
age or older are considered elderly, and
estimates indicate that, in 2025, they will be
one of the countries with the largest number
of elderly people in the world.1-2
However, the increase of the elderly
population in the country results, in a change
in the profile of health needs, since the
diseases that affect elderly people are, in
most cases, chronic degenerative diseases,
mental disorders, cardiovascular diseases,
cancer and stress.3 Thus, they have had an
important impact in all levels of health care,
among them, the tertiary level, due to
hospital admissions of elderly patients.
Although hospitalization is necessary in
cases of acute or chronic decompensated
disease, it can result in a series of
complications unrelated to the initial reason
for hospitalization, such as adverse events.
Adverse events can be defined as
unintentional injuries due to health care, not
related to the natural evolution of the
underlying disease that cause measurable
lesions, in the affected patients, associated to
the prolongation of hospitalization and / or
death. Among the adverse events, were
highlighted, the falls of hospitalized patients,
which can be considered as a problem that
presents a high incidence in the hospital
environment, but are, underreported.4
Fall prevention is linked directly to patient
care, especially, when it comes to the elderly
because it involves knowledge, feelings,
behaviors and attitudes of nurses and staff. In
this sense, surveillance for the prevention of
falls should also be one of the priorities of
Nursing care at the moment of the patient's
hospitalization at the health institution. From
the identification of the risk of the fall, the
nurse can formulate an action plan and, then,
evaluate the results of the care provided.
To formulate a consistent plan of care,
nurses need to know the factors that are
related to the occurrence of falls in
hospitalized elderly individuals, such as
environmental, cognitive, physiological
factors, use of certain drugs and age. 5
In the search for the quality of care and,
above all, the safety of hospitalized patients,
it is necessary to know the risk factors to
which the patient is exposed, in order to
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DOI: 10.5205/reuol.11138-99362-1-SM.1111sup201707
Evaluation of falls in hospitalized elderly.
minimize the occurrence of falls and avoid the
complications resulting from this event.
The national and international literature
has been working on this problem in basic
health care and with elderly people in the
general community.6
In view of the increasing number of
hospitalized elderly people, and considering
the biopsychosocial repercussions caused by
falls, as well as the lack of investigation of
this issue in the hospital environment, it is
important to identify the elderly who are at
high risk for falls and the main factors of risk
of occurrence of this event in the hospital
setting, with the purpose of preventing them.
OBJECTIVE
● To evaluate the occurrence of falls in
elderly patients, at high risk for the event,
hospitalized in a large hospital in Belo
Horizonte - MG.
METHOD
A quantitative, concurrent cohort study,
carried out in hospitalization units of a private
hospital and Grande Porte, Belo Horizonte,
MG, Brazil, considered a referral hospital in
high complexity care in which consultations
and hospitalizations are performed in several
specialties.
The study population consisted of 96
elderly people who were admitted to the
study hospital from March to September 2014,
after applying the "Fall Risk Score" scale to
identify the high risk for fall. This instrument,
developed by Dowton (1993),7-8 was adapted
and validated in Brazil by Shiavetto (2008).9
The project was approved by the
Departmental Chamber of the Basic Nursing
Department of the Nursing School of UFMG
and COEP - UFMG (CAAE
27925114.6.0000.5149), in addition to the
acceptance of the patient / responsible in
participating in the study by signing the Free
and Informed Consent Term (FICT), respecting
the ethical aspects contained in Resolution
466/12, of the National Health Council (NHC),
which deals with research and testing with
human beings. The project was authorized by
the Nursing Management and Technical
Department of the hospital involved.
Data collection was performed by the
researcher and by a Nursing student previously
trained to apply the instruments used in the
study. The elderly, who had a score of three
or more on the risk scale for "Fall Risk Score"
(high risk of fallas), were followed during
hospitalization to estimate the incidence of
falls in the period.
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To do this, daily, the researcher and / or
academic visited the beds in which the
patients of the study were to evaluate if there
was the occurrence of fall. The fall was
identified by the nurses of the sector through
the presence of the event or report by the
companion or own patient and passed on to
the researcher.
The information extracted from the
instruments (Socio-demographic Data, Mini
Mental, Fall Risk Score) were launched in the
program EpiInfo, version 3.5.1, and performed
double typing. Subsequently, the data were
exported to the STATA Program 12 (Stata
Corp, College Station, TX).
For the descriptive analysis of the data, we
used the simple frequency distribution, the
central tendency measures (mean and
median), as well as the measures of variability
(standard deviation).
For the analysis of the association of
possible risk factors with the occurrence of
falls, in hospitalized elderly, univariate and
bivariate analyzes were used for the variables
studied, from Logistic Regression and Odds
Ratio (OR) analysis, considering Confidence
Interval (CI) of 95% and p-value less than or
equal to 0.05. To identify which variables
were simultaneously associated to produce
the fall outcome, the Logistic Regression
model was used.
The explanatory or independent variables
that presented a minimal relation with the
outcome fall, at a significance level of 0.25 in
the bivariate models, were selected for
multivariate analysis. Then, the stepwise
method was used. The variables selected in
this step, that presented p-value greater than
0.05, were withdrawn one by one until the
definition of the best set of explanatory
variables of the event surveyed.
RESULTS
Regarding sex, among the 96 elderly, 45
(46.88%) are males and 51 (53.13%) are
females. The patients' age ranged from 60 to
95 years, with a mean of 74, 81 years, median
of 75 years and standard deviation (SD) of
87.9 years.
As can be seen in table 1, 20 elderly
(20.83%) had ages ranging from 80 to 84 years
and only five (05) elderly were 90 years or
older.

Table 1. Distribution of age frequency by age group and sex of patients followed from
March to September 2014. Belo Horizonte (MG), Brazil, 2014.
Age groups Female Male Total
N % N % N %

60 – 64 years 8 15,69 5 11,11 13 13,54

65 – 69 years 5 9,80 11 24,44 16 16,67
70 – 74 years 8 15,69 9 20 17 17,71
75 – 79 years 7 13,7 10 22,22 17 17,71
80 – 84 years 14 27,4 6 13,33 20 20,83
85 – 89 years 7 13,7 1 2,22 8 8,33
90 years or more 2 3,92 3 6,67 5 5,21
Total 51 100 45 100 96 100

Of the 96 elderly people who participated (44.79%) had eight or more years of study. The
in the study, 54 (56.25%) were married and 43 table below (Table 2).
Table 2. Distribution of years of study and marital status of patients according to sex. Belo
Horizonte (MG), Brazil, 2014.
Variables Sex Total
Male % Female % N %
Years of Illiterate 6 13,33 6 11,76 12 12,5
education
1 to 7 years 16 35,56 25 49,02 41 42,71
8 or more 23 51,11 20 39,22 43 44,79
Marital Single 3 6,67 6 11,76 9 9,38
Status
Married 35 77,78 19 37,25 54 56,25
Divorced 3 6,67 2 3,92 5 5,21
Widow 4 8,89 24 47,06 28 29,17
Total 51 100 45 100 96 100

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The length of hospital stay ranged from one

to 177 days, with an average of 24 days,
median of 18 days and SD of 24.73.
Most admission medical diagnoses are
related to diseases of the circulatory system
(32.29%), followed by diseases of the
gastrointestinal system (18.75%). Among the
diseases of the circulatory system, the most
frequent cause of hospitalization was
Congestive Heart Failure (CHF), accounting for
11 (11.46%) hospitalizations.
Among the 96 researched, 13 elderly had a
registered fall in their hospitalization in the
studied institution, during the study period.
The incidence of fall was 13.54%.
The evaluation of the possible association
between the risk factors studied and the
occurrence of falls was performed using the
bivariate analysis through Logistic regression.
Data on the association of fall occurrence
with independent variables, Odds Radio (OR),
Confidence Interval (95% CI) and p-value, are
shown in Table 3.

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Table 3. Bivariate analysis of the independent variables in relation to the fall from March to September 2014. Belo
Horizonte (MG), Brazil, 2014.
Independent variables Fall incidence
No Yes OR IC 95% P Value
N % N %
Sex Female 44 86,27 7 13,73
Male 39 86,67 6 13,33 0,96 0,29 – 3,12 0,955
Young elderly 26 89,66 3 10,34
Age Elderly 46 85,19 8 14,81 1,50 0,36 – 6,18 0,569
Very elderly 11 84,62 2 15,38 1,57 0,23 –10,78 0,643

Single 7 77,78 2 22,22

Marital status Married 48 88,89 6 11,11 0,43 0,73 – 2,60 0,396
Divorced 5 100 0 0 - - -
Widow 23 82,14 5 17,86 0,80 0,59 – 1,37 0,118
8 or more 40 93,02 3 6,98
Education (years) 1 to 7 years 33 80,49 8 19,51 3,23 0,79 –13,16 0,129
Illiterate 10 83,33 2 16,67 2,66 0,39 –18,16 0,316
Time of
hospitalization 22,50 35,69 1,01 0,99 – 1,02 0,104
(day)
No 36 92,31 3 7,69
Use of tranquilizer Yes 47 82,48 10 17,54 2,55 0,65 – 9,96 0,177

Use of diuretic No 46 82,14 10 17,86

Yes 37 92,50 3 7,50 0,37 0,11 – 1,52 0,155
Use of anti No 25 83,33 5 16,67
hipertensive Yes 58 87,88 8 12,12 0,68 0,20- 2,31 0,548

Use of Anti No 73 86,9 11 13,10

Parkinsonian Yes 10 83,33 2 16,67 1,32 0,25 – 6,87 0,736
Use of No 73 90,12 8 9,88
antidepressant Yes 10 66,67 5 33,33 4,56 1,24 –16,71 0,022
No 25 100 0 0
Difficulty walking Yes 58 81,69 13 18,31 - - -
Post operative No 78 90,70 8 9,30
Yes 5 50,0 5 50,00 9,75 2,31 –41,04 0,002
Psychological State No 66 95,65 3 4,35
(Depression) Yes 17 62,96 10 37,04 12,44 3,20 –52,24 0,000
Impaired balance No 32 96,97 1 3,03
Yes 51 80,95 12 19,05 7,52 0,93 –60,71 0,058
Sedentary lifestyle No 7 77,78 2 2,22
Yes 76 8,736 11 12,64 0,57 0,13 – 2,57 0,463
Incontinence No 62 87,32 9 12,68
(urinary-intestinal) Yes 21 84,00 4 16 1,31 0,36 – 4,70 0,677

Hypotension No 65 90,28 7 9,72

Postural Yes 18 75 6 26 3,09 0,92 – 10,36 0,067
Environmentally No 2 100 0 0
Appropriate Yes 81 86,17 13 13,83 - - -
Lighting

Room fittings No 13 76,47 4 23,53

Yes 70 88,61 9 11,39 0,41 0,11 – 1,56 0,194
Absence Of No 14 100 0 0
Handrail Yes 69 84,15 13 15,85 - - -
Presence of No 32 80 8 20
Obstacles Yes 51 91,07 5 8,93 0,39 0,11 -1,30 0,127
Use of orthoses No 92 95,38 3 4,62
Yes 21 67,74 10 32,26 9,84 2,47 –39,19 0,001
Cognitive deficit No 66 92,96 5 7,04
(MEEM) Yes 17 68 8 32 6,21 1,80 – 21,42 0,004
Impaired Vision No 67 89,33 8 10,67
Yes 16 76,19 5 23,81 2,61 0,75 – 9,07 0,129
Hearing Impaired No 73 89,02 9 10,98
Yes 10 71,43 4 28,57 3,24 0,84 – 12,52 0,088
History of falls No 28 80 7 20
Yes 55 90,16 6 9,84 0,43 0,13 – 1,42 0,169
Being in the postoperative period, having It was analyzed that the mean age did not
difficulty walking, using some type of bracing, vary between the elderly who fell and those
presenting with cognitive deficits and having a who did not fall. The length of hospital stay
diagnosis of depression was statistically was higher in the group that fell (Table 4).
associated with falls.
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Table 4. Association of fall with age and length of hospital stay, Belo Horizonte
(MG), Brazil, 2014.
Characteristic
Yes
Average
Age 75,4
Time of 34,9
hospitalization
To identify which covariables, among the
respondents, influenced the occurrence of
fall, the logistic regression model was used.
The first step was to determine the
relationships between each of the
characteristics and the outcome event. As
previously described, bivariate logistic
regression models, were constructed and
characteristics whose significance probability
The table below (Table 5) shows the association between the risk and fall factors that were
significant after Logistic regression.
Table 5. Result of the final adjustment of the Logistic Regression model with the
covariates for the occurrence of fall. Belo Horizonte (MG), Brazil, 2014.
Variables OR
Psychological State 22,1
(Depression)
Use Orthoses 27,5
Cognitive deficit 6,8
At the end of the multivariate model, the
variables considered as risk factors were
psychological state (depression), use of
orthoses and cognitive deficit.
DISCUSSION
Among the 13 elderly people who fell
during the study, 13.73% were female, with a
mean age of 74.4 years. The higher incidence
in females corroborates with some studies,
since, it demonstrates greater physiological
loss of muscle mass in this group, which
increases its fragility. In addition, there is a
reduction in mobility in women, that has a
tendency to activate more distal muscle
groups, that are unable to guarantee postural
stability increasing the chance of fall.10,12
The mean age of the patients who fell, in
this study, was 75.40 years, which
corroborates with that found in the literature,
since it is demonstrated that falls occur in
older people due to their fragility and
functional disability in this population.13
Fragility has been used, in practice, to
designate among the elderly population, those
with clinical characteristics attributed to
aging, associated with the existence of
comorbidities, predisposing to factors that
lead to a greater risk of adverse events, such
as falls.14 Fragility is associated although it is
not exclusively the result of the aging process,
since the elderly do not necessarily become
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DOI: 10.5205/reuol.11138-99362-1-SM.1111sup201707
Evaluation of falls in hospitalized elderly.
Fall follow up P-value
No
Stadard Average Stadard
deviation deviation
7,3 74,7 9,0 0,744
28,5 22,6 23,7 0,232
(p-value) were less than or equal to 0.25 were
chosen for the multivariate model.
Although they did not give a significant p-
value, it was also chosen to select, the
variable gender, age, gait difficulty and
urinary / intestinal incontinence because they
are frequently, referred to as risk factors for
drop occurrence.10-2
IC 95% Value of p
3,3 – 146,7 0,001
3,6 – 211,7 0,001
1,22 – 39,70 0,033
fragile.15 However, there was no statistically
significant association between age and the
event falling in this study (p = 0.744).
Although there was no significant
difference, it can be observed that patients
who suffered falls were those with one to
seven years of study (61, 53%). Schooling does
not interfere with the pathophysiology of
frailty and the risk of falls in the elderly, but,
it may be considered an indirect connection,
because it is related to the individual's style,
and quality of life, which are factors that may
predispose the occurrence of this outcome.10
The mean time of hospitalization of
patients who had a fall was 34.90 days. This
finding was greater than that found in other
studies, ranging from eight to 15 days of
hospitalization.16,17
Prolonged hospitalization of the elderly
may trigger a series of events, such as
infections, ulcers, falls, among others, which,
often, lead to decreased functional capacity
and quality of life, which may increase the
morbidity and mortality rate, worsen
prognosis and predisposition to the embryo
process.18
Among the medical diagnoses presented by
patients at admission, diseases of the
circulatory system were the most prevalent,
affecting 32.29% of the patients. This
prevalence corroborates with other studies,
which say that the most frequent reasons for
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Oliveira DU de, Ercole FF, Melo LS de et al.
hospitalization in the elderly are diseases of
the circulatory system (28.6% to 30.1%),
followed by respiratory diseases (20.4% to
18.7%) and of the digestive tract (9.0 to 11%)
.18 Diseases and physical disabilities in the
elderly contribute to the occurrence of falls.
Thus, the greater the number of existing
morbidities, the greater the risk of falls.19
In this study, considering the 96 elderly
patients followed up, there was an incidence
of 13.54% of falls, with a confidence interval
ranging from 7.41% to 22.04%, an incidence
greater than that of 12.4% found in a study
performed with 97 neurosurgical patients over
18 years of age at the neurosurgery unit and
neurosurgery ICU of Hospital São Paulo from
February to August 2006.20 A retrospective
cohort, performed in southern Brazil with
adult patients (> 18 years) , hospitalized in a
private hospital of high complexity, found an
incidence of 15.4% .21
When analyzing 284 falls of all the patients
of an inpatient unit in a private hospital,
between January of 2005 and December of
2008, they observed that there was a great
monthly oscillation in the occurrence of fall,
ranging from 0.00 to 2.97 falls / 1000 patients
/ day, with a mean of 1.45 falls / 1000
patients / day.22-3
It is important to emphasize that the
incidence studies compared were performed
with adult patients in general. Thus, it is
necessary to carry out other studies in the
elderly and hospitalized population to better
estimate the incidence of falls.
The variable psychological state
(depression) is a predisposing factor (p value =
0.001), indicating a risk condition for the
elderly. Depression has a high frequency and
negative consequences in the life of the
affected individuals. Studies indicate that the
population with depression is about 2.2 times
more likely to fall when compared to the
elderly who do not have this diagnosis.24-5
The presence of depressive symptoms is an
important factor for falls, due to the effect of
antidepressant medications, decline in
functional capacity, low self-confidence,
indifference to the environment, seclusion
and inactivity.
Regarding the association between the use
of orthotics and fall, studies show that this
correlation is due to the inadequate use of
these devices.26 The use of equipment to aid
in walking facilitates the activities of the
elderly, but, when used incorrectly or without
orientation may have an opposite-to-expected
effect and lead the elderly to fall.
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J Nurs UFPE on line., Recife, 11(Suppl. 11):4589-97, Nov., 2017
DOI: 10.5205/reuol.11138-99362-1-SM.1111sup201707
Evaluation of falls in hospitalized elderly.
In relation to the cognitive deficit,
evaluated through the MiniMental in this work,
a significant association with the occurrence
of fall was found. The use of MiniMental was
adequate to evaluate the presence of
cognitive deficits in other studies.27
Cognitive deficit is associated, in studies,
as a strong risk factor for the occurrence of
falls.19,26-7. Elderly people with cognitive
deficits find it difficult to assess their actual
situation (hospitalized and frail), leading them
to misjudge their abilities and predisposing
them to the occurrence of the fall.
CONCLUSION
The findings of this study showed that, the
majority of females had a fall, with a mean
age of 74.81 years. Psychological status, use
of bracing and cognitive deficit were
identified as risk factors for falls in
hospitalized elderly.
The falls in elderly hospitalized patients
cause physical, psychological trauma, loss of
independence and even death risk. Thus, it is
imperative that Nursing professionals are
aware of the risk factors for the occurrence of
this event, in order to perform quality care
based on the prevention of falls in the
hospital environment.
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Submission: 2016/01/26
Accepted: 2017/09/22
Publishing: 2017/11/15
Corresponding Address
Flávia Falci Ercole
Universidade Federal de Minas Gerais/UFMG
Escola de Enfermagem
Avenida Professor Alfredo Balena, 190, Sala 23
Bairro Santa Efigênia
CEP: 30130-100 – Belo Horizonte (MG), Brasil
English/Portuguese
J Nurs UFPE on line., Recife, 11(Suppl. 11):4589-97, Nov., 2017 4597
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