Article

Risk factors for geriatric patient

falls in rehabilitation hospital
settings: a systematic review

Clinical Rehabilitation
25(9) 788799
! The Author(s) 2011
Reprints and permissions:
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DOI: 10.1177/0269215511400639
cre.sagepub.com

Edgar Ramos Vieira1, Rosalie Freund-Heritage2

and Bruno R da Costa3

Abstract
Objective: To review the literature to identify and synthesize the evidence on risk factors for patient falls
in geriatric rehabilitation hospital settings.
Data sources: Eligible studies were systematically searched on 16 databases from inception to
December 2010.
Review methods: The search strategies used a combination of terms for rehabilitation hospital patients,
falls, risk factors and older adults. Cross-sectional, cohort, case-control studies and randomized clinical
trials (RCTs) published in English that investigated risks for falls among patients 65 years of age in
rehabilitation hospital settings were included. Studies that investigated fall risk assessment tools, but did
not investigate risk factors themselves or did not report a measure of risk (e.g. odds ratio, relative risk)
were excluded.
Results: A total of 2,824 references were identified; only eight articles concerning six studies met
the inclusion criteria. In these, 1,924 geriatric rehabilitation patients were followed. The average age
of the patients ranged from 77 to 83 years, the percentage of women ranged from 56% to 81%,
and the percentage of fallers ranged from 15% to 54%. Two were case-control studies, two were
RCTs and four were prospective cohort studies. Several intrinsic and extrinsic risk factors for falls
were identified.
Conclusion: Carpet flooring, vertigo, being an amputee, confusion, cognitive impairment, stroke, sleep
disturbance, anticonvulsants, tranquilizers and antihypertensive medications, age between 71 and 80,
previous falls, and need for transfer assistance are risk factors for geriatric patient falls in rehabilitation
hospital settings.

Keywords
Falls, elderly, rehabilitation, safety, predictors
Received: 30 August 2010; accepted: 23 January 2011

Introduction
Patient falls are the predominant patient safety
issue in hospitals, accounting for up to 32% of

1
Department of Physical Therapy, Florida International
University, Miami, FL, US
2
Glenrose Rehabilitation Hospital, Edmonton, Alberta, Canada
3
Division of Clinical Epidemiology and Biostatistics, Institute of
Social and Preventive Medicine, University of Bern,
Finkenhubelweg, Bern, Switzerland

Corresponding author:
Bruno R da Costa, Division of Clinical Epidemiology and
Biostatistics, Institute of Social and Preventive Medicine,
University of Bern, Finkenhubelweg 11, 3012 Bern, Switzerland
Email: bdacosta@ispm.unibe.ch

Vieira et al.

all reported patient safety incidents.1 In total,

35% of patients that fall suer physical harm,
including death.1 Falls in hospitals may also
cause a fear of falling, leading to decreased
mobility resulting in muscle weakness, contracture, postural hypotension, and thrombogenic
events.2,3 Fall-related complications lead to prolonged hospitalization periods and increased
healthcare costs.4,5 It is estimated that in the
UK, patient falls in acute hospitals cost approximately 92 million pounds/year.6 These values
may actually be higher as falls are frequently
under-reported.1
Older adults (65 years of age) in rehabilitation hospital settings are particularly susceptible
to this problem. The rate of falls in general rehabilitation settings is approximately 13%,5,7 and
the rate of falls in geriatric rehabilitation hospitals is approximately 2.5 times higher
(2430%).8,9 This fact points out that the risk
factors for falls in geriatric rehabilitation hospital settings may dier and/or be more prevalent
among these patients. Geriatric rehabilitation
hospital settings and patients have characteristics distinct from other settings which may
explain the higher fall rate.
Falls are related to more than 90% of all hip
fractures in older adults, and 20% of older
adults that suer hip fractures die within a
year.10 Hospitalized older adults present an
increased risk of falls due to the complex interaction between intrinsic and extrinsic factors in
an unfamiliar environment.11 It is crucial to
identify the intrinsic and extrinsic factors that
contribute to the occurrence of falls in geriatric
rehabilitation hospital settings so that more
eective falls prevention interventions can be
designed and implemented to lessen the human
and economic burden.
Previous systematic reviews have investigated
risk factors for patient falls in hospitals.1214
However, none of these previous reviews
focused on patient falls in general geriatric rehabilitation hospital settings. Such specicity is
central to the identication of modiable risk
factors, and the development of successful

789

prevention strategies specic for this population

and setting. For these reasons, we conducted a
systematic review of the literature to identify
and synthesize the evidence on risk factors that
may contribute to patient falls in geriatric rehabilitation hospital settings.

Methods
To identify eligible trials we undertook a systematic search of the following databases:
MEDLINE, EMBASE, CINAHL, SCOPUS,
Web of Science, Rehab data, and CIRRIE
Database of International Rehabilitation
Research from inception to December 2010.
The search strategy included a combination of
terms for rehabilitation hospital patients, falls,
risk factors and older adults (Appendix 1). The
terms included text words, keywords and subject
headings specic to each database. Similar strategies were used to identify previously published
systematic reviews in the following databases:
Cochrane Database of Systematic Reviews,
OTseeker, and PEDro from inception to
December 2010. In addition, we searched
ProQuest Dissertations for unpublished studies
(inception to December 2010), searched conference proceedings on OCLC ProceedingsFirst
(inception to December 2010), screened reference lists of all included papers and contacted
authors and experts in the eld. Finally, we
searched four clinical trial registers to identify
ongoing trials: Current Controlled Trials
(www.controlled-trials.com); ClinicalTrials.gov
(www.clinicaltrials.gov);
Australian
New
Zealand Clinical Trials Register (www.actr.
org.au), and UK Clinical Research Network
Study Portfolio (http://public.ukcrn.org.uk/
search/) Our search strategies were derived
from review of a relevant Cochrane systematic
review,15 guidelines for eective searching15,16
and consultation with a medical rehabilitation
librarian.
We included observational studies that 1)
investigated risks for falls among patients

790

65 years of age with any diagnosis admitted to

rehabilitation hospital settings, 2) had a crosssectional, cohort or case-control design, and 3)
were published in English. Randomized clinical
trials that reported a measure of risk (e.g.
odds ratio, relative risk) for potential fall
risk factors were also included. We excluded
studies that 1) investigated the psychometric
properties of prediction tools for falls in rehabilitation hospital settings but did not investigate
risk factors for falls in rehabilitation hospital
settings, or 2) did not report a measure of risk
(e.g. odds ratio, relative risk). We did not apply
any restrictions regarding length of follow-up.
One reviewer screened titles and abstracts of
all initially identied reports for eligibility;
screening was independently checked by a
second reviewer.
Data on clinical outcomes were extracted by
one reviewer and independently checked by
another. Data regarding participants characteristics, exposure and outcome variables, main
ndings, and study limitations were extracted
and tabulated. When necessary, means and measures of dispersion were approximated from gures in the reports.
The following methodological quality components (associated with bias in therapeutic
research) of the selected papers were assessed:
prospective design; enrolment of consecutive
patients admitted to a geriatric rehabilitation
ward; whether investigators of fall occurrence
and data collection were blinded regarding the
objectives of the study; adjustment for confounders (matching cases and controls regarding main confounders or RCT design implies
yes for this item); completeness of data analysis (i.e. all screened patients included also
included in the analysis), and reporting of a
clear denition for a fall event. Finally,
when authors dichotomized a continuous exposure variable to create two exposure groups
(e.g. group of patients above or below 80
years of age), we assessed whether selection
of threshold for dichotomization was conducted a priori.

Clinical Rehabilitation 25(9)

Results
We identied 2,824 references in our literature
search and considered 2,309 to be potentially
eligible (Figure 1). After full text screening,
eight articles concerning six studies met our
inclusion criteria.1724 Most of the studies
excluded during full-text screening, were
excluded either because the studies were not conducted in a rehabilitation setting or because
patients were not exclusively 65 years of age or
older. The median year of publication was 2005
(range: 1999 to 2009).
Overall, 1,924 geriatric patients in rehabilitation hospital settings were followed for the
investigation of fall risk factors (Table 1).
In general, patients were going through rehabilitation for neurological or orthopaedic conditions. Only three studies did not report to
which medical subspecialty patients were treated
under. The average age of the patients ranged
from 77 to 83 years, the percentage of women
ranged from 56% to 81%, and the percentage of
fallers ranged from 15% to 54%. All included
studies were longitudinal; two were case-control
studies,17,18 two were RCTs19,20 and four were
prospective cohort studies.2124
All studies presented potential biases
(Table 2). Five had prospective designs, four
enrolled patients consecutively or adjusted their
results for potential confounders, and all studies
provided clear fall event denitions. On the
other hand, only in two studies were the investigators blinded regarding the studies objectives.
Potential biases could not be assessed for some
items in all studies due to incomplete reporting of
the methods employed.
The factors identied as signicant risks for
falls (eect ratios and lower boundary of condence intervals higher than 1) were: carpet ooring (as opposed to vinyl ooring), vertigo, being
an amputee, confusion (three studies), cognitive
impairment, stroke, sleep disturbance, some
medications (i.e. anticonvulsants, tranquilizers
and
antihypertensive
in
two
studies),
age (7180), previous falls, and need for

Vieira et al.

791

Potentially relevant studies

screened:
EMBASE 1,262
MEDLINE 776
CINAHL 227
SCOPUS 186
WEB OF SCIENCE 232
REHAB DATA 111
CIRRIE 30
515 duplicates
2,309 articles
2,214 not eligible
after abstract and
title screening
95 articles

12 articles
could not be
retrieved

83 articles were retrieved in full

text for review
75 not eligible
8 articles concerning 6 studies
investigating risk factors for falls in
geriatric rehabilitation

Figure 1. Stages of this systematic review of studies investigating risk factors for geriatric patient falls in rehabilitation hospital settings.

transfer assistance. Use of antipsychotics

(among patients requiring this medication),
and use of walkers reduced the risk of falls
(eect ratios and higher boundary of condence
intervals lower than 1). The factors identied as
non-signicant risks for falls (eect ratios close
to and/or condence intervals crossing 1) were:
use of diuretics, lower limb abnormalities, and
visual impairments. Finally, the factors that
require further investigation (eect ratios indicate a relationship, but the condence intervals
crossed 1 to both sides signicantly) were:
poor patient and therapist communication,
use of a wheelchair, hearing impairment, and

some medications (i.e. antidepressants and

antiparkinsonian).

Discussion
This systematic review identied eight articles
concerning six studies investigating falls risk
factors for geriatric patients in rehabilitation
hospital settings. Studies identied in this
review indicate that the following are signicant
risk factors: carpet ooring, vertigo, being an
amputee, confusion, cognitive impairment,
stroke, sleep disturbance, anticonvulsants,

17

Barr 199918

Aizen 2007

Ref.

Design

n*

-Three case groups: Nested case- 168

control
stroke rehabilitation; hip
surgery rehabilitation;all other
rehabilitation
patients.
-Control groups
were non-fallers
matched by
gender, age,
functional disability, and medical condition
Case-cohort 174
Patients over 65
years of age who
are medically
stable and
expected to
achieve functional gain during
their rehabilitation stay in a 22bed aged care
rehabilitation
unit within a
120-bed rehabilitation facility.

Medical condition

77

71

56

Mean %
Age ,

Medical records
and incident
reports.

Interview; medical
records; functional tests.

Measurement of
exposure, patient
characteristics,
and falls

100

# falls

Table 1. Overview of included studies showing studies characteristics and summary of findings

Unclear

84 (54)

Main findingsy

Unclear

Amputee: OR
5.15 (2.15
12.45)
Stroke: OR 2.71
(1.734.24)
Patients requiring assistance
with transfers:
OR 1.74 (1.21
2.5)
Confused: OR
5.18 (2.839.49)
Antipsychotics:
OR 0.35 (0.16
0.79)

Vertigo:
OR 5.25
(1.0725.9)
 Antihypertensive: OR 2.4
(1.135.1)

133 falls per 100  Age 71-80:

patient-years
OR 2.22
(1.174.2)

Fall
incidence rate,
length of
# fallers (%) follow-upz

792
Clinical Rehabilitation 25(9)

Patients of a met- RCT

ropolitan geriatric rehabilitation
hospital receiving orthopaedic,
neurological, or
general geriatric
rehabilitation.
Patients from reha- Prospective
cohort
bilitation wards
in four general
hospitals receiving orthopaedic,
neurological, or
general geriatric
rehabilitation.

Haines
200620

Izumi 200221

Geriatric rehabilita- RCT

tion unit
patients.

Donald
200019

277

226

54

83

83

58

67

81

11

Standardized risk
assessment tool;
fall incident
report.

Medical records

Unclear

Unclear

39 (17)

8 (15)

13 months
follow-up

8 falls per 100

patient-years

21 falls per 100

patient-years

Anticonvulsants:
OR 2.22 (1.08
4.58)
Previous falls:
OR 1.75 (1.19
2.56)
Sleep disturbance: OR 2.39
(1.653.48)
Carpet floor vs.
vinyl floor: RR
8.3 (0.9573)
(favoring vinyl
floor)
Poor patient
and therapist
communication:
RR 1.21 (0.68
2.14)

(continued)

Use of a walker:
OR 0.22 (0.05
1.01)
 Use of a wheelchair: OR 1.22
(0.403.70)


Vieira et al.
793

Patients considered Prospective

cohort
having an unsafe
gait from three
rehabilitation
wards of a nonacute geriatric
hospital.

Vassallo
2004**22

Design

Medical condition

Ref.

Table 1. Continued

599

n*
82

136 (23)

# falls # fallers (%)

67 Fall incident report; 224

Unclear how
patient characteristics and
exposure were
registered;
Patients were
considered confused if
Hodkinson
Abbreviated
Mental Test
score <7/10; A
patient was considered visually
impaired if registered blind or
having a visual
acuity of 6/60 or
less on a Snellen
chart; A hearing
defect was
defined as the
inability to
follow a
conversation.

Mean %
Age ,

Measurement of
exposure, patient
characteristics,
and falls
Unclear

Previous fall:
OR 2.05 (1.22
3.44)
Visual impairment: OR 1.18
(0.721.93)
Hearing impairment: OR 1.39
(0.922.10)
Lower limb
abnormality: OR
1.07 (0.701.65)
Confusion: OR
3.77 (3.525.65)
Use of diuretics: OR 0.85
(0.571.24)
Antidepressants: OR 1.22
(0.702.12)
Antihypertensive: OR 1.31
(0.881.96)
Antiparkinsonian: OR 1.69
(0.823.47)
Tranquilizers:
OR 1.52 (0.99
2.34)

Fall
incidence rate,
length of
follow-upz
Main findingsy

794
Clinical Rehabilitation 25(9)

Patients from three Prospective

cohort
rehabilitation
wards of a nonacute geriatric
hospital.

Vassallo
2009**24
825

1,025

83

82

64 Fall incident report; 253

Unclear how
patient characteristics and
exposure were
registered;
Patients were
considered confused if
Hodkinson
Abbreviated
Mental Test
score <7/10.
64 Fall incident report:
Patients characteristics were
measured routinely in all
patients admitted to the hospital, but unclear
how; Patients
with score of
less than 7/10 in
an abbreviated
mental test
score were considered cognitively impaired.
150 (18)

173 (17)

25.6 days

16.8 days

 Cognitive
impairment: OR
3.75 (2.585.45)

 Non-confused
patients: OR
0.38 (0.290.49)
 Patients not on
tranquilizers: OR
0.63 (0.490.82)

*N of interest to our review. **Study population of Vassallo et al.2224 derived from the same patient cohort (confirmed through contact with the author).
y Effect measures based on faller or non-faller classification. Unclear whether fall occurrence in Izumi21 was considered >1/per patient.
z When available. Fall rate standardized to 100 patient-years to facilitate interpretability.

Patients from three Prospective

cohort
rehabilitation
wards of a nonacute geriatric
hospital receiving orthopaedic,
neurological, or
general geriatric
rehabilitation.

Vassallo
2006**23

Vieira et al.
795

Yes
Yes
Yes
Yes
Yes
No
Yes
No
Aizen 200717
Barr 199918
Donald 200019
Haines 200620
Izumi 200221
Vassalo 200422
Vassalo 200623
Vassalo 200924

ya priori selection of threshold for dichotomization of continuous predictive factors.

Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Unclear
Yes
Unclear
Unclear
Unclear
Unclear
Yes
Unclear
No
Unclear
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes

Study

Yes
Unclear
Yes
Unclear
Yes
Yes
Yes
Yes

Clear definition
of fall provided
Completeness
of data analysis
Adjustment
for confounders
Blinding of
investigator
Consecutive
enrolment
Prospective
design

Table 2. Findings of the assessment of the included studies in relation to risk of bias

Unclear
Unclear
Not applicable
Unclear
Unclear
Unclear
Unclear
Unclear

Clinical Rehabilitation 25(9)

Selection
of threshold
a priori y

796

tranquilizers and antihypertensive medications,

age (7180), previous falls, and need for transfer
assistance are risk factors for geriatric patient
falls in rehabilitation hospital settings.
Other factors were either not investigated in
these studies or were not identied as signicant
risk factors.
Many risk factors have been reported as possible causes for patients falls in hospitals in general.13,14,25 The most commonly reported are:
older age, mobility issues, visual and/or hearing
impairment, cognitive impairment or confusion,
culprit drugs, postural hypotension, vertigo,
urinary incontinence, fear of falling, previous
falls, special toileting needs, some specic diagnosis (e.g. Parkinsons, stroke, dementia), use
of bed rails, improper bed height, type of
oor surface, and poor lighting. We did not
identify previous systematic reviews which investigated possible risk factors for patient falls in
rehabilitation hospital settings. Thus, we compared our ndings with those of previous systematic reviews of risk factors for falls in acute
hospitals.
Findings of previous systematic reviews of
risk factors for falls among patients in acute hospitals agree with our ndings of risk factors for
geriatric patient falls in rehabilitation hospital
settings. There seems to be no unique features
among geriatric rehabilitation patients. Thus,
the higher rates of falls in this setting may be
related to a higher prevalence of known risk factors for falls among these patients. Future studies comparing geriatric patients in rehabilitation
and other settings are required to test this
hypothesis.
Evans12 reported that confusion was the
factor most commonly associated with falls in
acute hospitals. Oliver14 also identied confusion as one of the main risk factors for falls in
acute care hospitals. Our ndings corroborate
those of these previous studies because confusion was one of the three factors commonly
identied across studies as a risk factor for geriatric patients in rehabilitation hospital settings.
A previous fall was another factor identied in
previous reviews, as well as in our present

Vieira et al.

review, as a risk factor for falls in hospitals.

Gaebler26 reported that 58% of patients
having multiple falls repeat the type of fall,
and 64% repeat the location in subsequent
falls. Culprit drugs were also consistently
associated with falls in hospitals. We also
found in the present review some evidence supporting this association. More specically,
patients taking drugs that act on the central nervous system, such as sedatives, tranquillizers,
and benzodiazepines, and patients receiving
three or more psychoactive drugs are at
increased risk for falls.
Presenting a mobility problem was another
commonly reported risk factor for falls. In our
review, lower limb abnormality was associated with falls in geriatric rehabilitation hospital settings. Mobility problems were consistently
identied as a risk factor for falls in systematic reviews with dierent populations and settings. However, this is not the case when
prediction tools are used to identify those with
a high risk of falling.14 Thus, established risk factors may be more reliable than prediction
tools when designing and implementing interventions to prevent falls due to their consistency across dierent studies with dierent
populations and settings.14 Nevertheless, risk
factors that predict falls may not be the ones
causing falls. Because of this, risk factors that
may predict falls should be investigated
prospectively.
The strengths of our review include the
extensive search of seven general and eldspecic databases with a highly sensitive search
strategy and thorough assessment of the methodological quality of the included studies. Due
to our extensive search, it is unlikely that we
overlooked important studies investigating
risk factors for geriatric patient falls in rehabilitation hospital settings. On the other hand, our
ndings are limited by the quality of the
included studies. All studies identied had
some methodological or reporting issues.
It was unclear in four studies whether the
results were adjusted for confounders. It
is important to adjust the eect estimates of

797

observational studies for known confounding

factors. Moreover, blinding regarding the study
objectives of investigators responsible for
the adjudication of fall occurrence and data collection is required to avoid detection bias.
That is, investigators that are aware of the objective of the studies may be more likely to identify studied risk factors in patients who
have fallen. The same investigators may also
subconsciously adjudicate occurrence of fall
events in those patients presenting potential
risk factors disproportionately.
The results reported (falls prevalence from
15% to 54%) may underestimate the actual
rate of falls in geriatric rehabilitation hospital
settings because falls tend to be reported inconsistently and underreporting is frequent.27 It is
unclear to us, however, whether this possible
inconsistent falls reporting aects the ratio of
fall occurrence proportions between exposure
groups. Also, it has been reported that falls
are more common at certain times of the day
than others which could also aect the documentation of falls.27 Again, it is not clear to us
whether this may aect the ratio of fall occurrence proportions between exposure groups.
In addition, there was considerable heterogeneity between studies regarding risk factors
investigated, clinical characteristics of patients,
and study design, which made interpretation of
the results dicult and a meta-analysis unfeasible. Finally, the included studies had dierent
lengths of follow-up. Longer follow-up periods
may result in a higher number of fallers/falls
observed, limiting direct comparisons of fall
incidence across studies.
Additional studies investigating potential
risk for falls in geriatric rehabilitation settings
are suggested. The factors identied in this
review as signicant risks for geriatric patient
falls in rehabilitation hospital settings were
carpet ooring, vertigo, being an amputee, confusion, cognitive impairment, stroke, sleep disturbance, anticonvulsants, tranquilizers and
antihypertensive medications, age between 71
and 80, previous falls, and need for transfer
assistance.

798

Clinical messages
. Falls in geriatric rehabilitation settings are
common; from 15% to 54% of these
patients fall during hospitalization.
. Carpet ooring, vertigo, being an amputee, confusion, cognitive impairment,
stroke, sleep disturbance, anticonvulsants,
tranquilizers and antihypertensive medications, age between 71 and 80, previous
falls, and need for transfer assistance are
risk factors for geriatric patient falls in
rehabilitation hospital settings.
. There seems to be no unique features
among geriatric rehabilitation hospital
patients. Thus, the higher rates of falls in
this setting may be related to a higher
prevalence of known risk factors for falls
among these patients.

Acknowledgements
The authors would like to acknowledge the Glenrose
Rehabilitation Hospital Research and Nursing oces
for their support. We would like to thank Daniel Holt
for his help formatting this paper, and we would like
to thank and to acknowledge the other members of
the Glenrose fall reduction group (Colleen Berean,
Debra Paches, Penny Caveny, Doris Yuen and
Lauralee Ballash) for their input and suggestions on
early drafts of this paper.

Funding
This work was supported by the Alberta Health
Services.

Competing interests
None declared.

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