Iam an NP, but I am also a patient with a disability. I have earned the right to call myself an expert on falls—not because of my professional background, but because of my medical history, which includes a perplexing neurologic condition called chronic inflammatory demyelinating polyneuropathy, which is best described as a chronic Guillain–Barré syndrome.
If there were a track event for falls, I'd be a star. I've performed them all: falls with injury, falls without injury, falls with idiocy involved (why was I standing on that chair anyway?), and falls that simply happened. As a result, I have arrived at the same conclusion as various health care institutions: no matter how well researched fall prevention may be, it remains mystifying to nurses, patients, and administrators. Why is this?
For years, health care has focused on extrinsic fall risk factors (hospital equipment, slippery floors, access to bathroom facilities, types of slippers). More recently, the focus has shifted to also include the study of intrinsic risk factors (hyponatremia, vitamin D deficiency, disequilibrium, motor or sensory weakness, polyneuropathy, and a myriad of potential precursors to falls, including the effects of some medications).
Over the course of time, I have had numerous physicians ask why I fell. From an insider's viewpoint, I can answer that most patients do not know. Falls happen—suddenly and unexpectedly. No patient awakens in the morning and thinks “this is a fabulous day to take a fall.” Falls hurt, even without significant injury. They can be fatal or leave a victim with lasting disability.
Fall risk increases with age, at least in part because muscle mass, particularly in the lower extremities, diminishes over time. Most patients and health care providers are unaware of the significance of this finding. Until I suffered from repetitive falls, I was as well. A rehabilitation assessment was pivotal in providing a comprehensive depiction of my functional status. The specialists were able to assess underlying mobility factors such as gait disturbance, balance, coordination, proprioception, and intrinsic muscle strength. The education and instruction I received helped me understand why someone who appeared healthy could still be at risk for falls.
It has also been useful to me to stay in the “rehab loop,” no matter where I am in the system. Outpatient classes geared to building muscle mass, improving balance and coordination, and refocusing my energy as much on safety as independence have helped me avoid further episodes. Nurses are taught to be independent. But was it really worth it, I had to ask myself, to clean the highest kitchen cupboards myself?
Over time, I've learned that fostering the patient's independence should include encouraging a realistic sense of limitations. This was fully reinforced the day I performed a face-plant in the driveway after a light snow inspired me with an insurmountable desire to start shoveling. Had I focused on what the rehab specialists taught me, I would have remembered the risk involved. Patients, especially nurses who are fall “veterans,” need support and reinforcement in learning to choose safety whenever possible.
Hospital programs typically focus on bed alarms, booties, hourly rounding, and patient signatures on fall prevention guidelines. These only scratch the surface of a complex, multidimensional issue. To examine only extrinsic risk factors means overlooking the link between disease and disease management. Patients don't want to fall any more than you want them to, yet, as my experience shows, patients may be “experienced” in the art of falling, yet ultimately clueless about practical steps they can take, such as sitting a few minutes longer before standing; staying hydrated; maintaining adequate nutrition, with enough protein; and keeping active.
As further research examines intrinsic as well as extrinsic risk factors, a more distinct picture of why we fall may begin to emerge. This research should include the study of fall “insiders” such as myself. In the meantime, I strongly encourage patients at risk to be assessed and reassessed by rehabilitation services as frequently as possible.