ABSTRACT

Objective

To identify the risk of falls of older adults in a hospital in the Trairi region in Rio Grande do Norte, Brazil, and to describe the relationship between risk of falls and the sociodemographic characteristics of the participants.

Method

A descriptive, transversal, and quantitative study conducted in a regional hospital, respecting the ethical principles in force. The Morse Scale was adopted for data collection, which took place in July and August 2018, and adapted with sociodemographic questions. A descriptive and inferential statistical analysis was performed.

Results

There were 46 participants in the study, most of whom were women with low education, and the most frequent reasons for hospitalization were surgical treatment and lung disease. More than half had a high risk of falling (54.35%), followed by moderate (32.61%) and low (13.04%). There was an association between high risk of falls, having lung disease as a reason for hospitalization and diabetes as a comorbidity. The high risk of falls was less frequent among older adult patients hospitalized for surgical treatment.

Conclusion

The high risk of falls was found in more than half of the older adults, which varied according to the reason for hospitalization and comorbidities, being more frequent in those hospitalized for lung disease and in those who had Diabetes.

Aged; Hospitalization; Accidental Falls; Patient Safety; Geriatric Nursing

RESUMO

Objetivo

Identificar o risco de quedas em idosos em um hospital da região do Trairi, no Rio Grande do Norte; descrever a relação entre risco de quedas e as características sociodemográficas dos participantes.

Método

Estudo descritivo, transversal, quantitativo, realizado em um hospital regional, respeitando os princípios éticos vigentes. Para a coleta, ocorrida em julho e agosto de 2018, foi adotada a Escala de Morse, adaptada com questões sociodemográficas. Realizada análise estatística descritiva e inferencial.

Resultados

O estudo teve 46 participantes, dos quais a maioria era formada por mulheres, com baixa escolaridade e os motivos de internação mais frequentes foram tratamento cirúrgico e doença pulmonar. Mais da metade apresentou risco alto de sofrer quedas (54,35%), seguido de moderado (32,61%) e baixo (13,04%). Houve associação entre risco alto de quedas, ter doença pulmonar como motivo de internação e diabetes como comorbidade. O risco alto de quedas foi menos frequente entre idosos internados para tratamento cirúrgico.

Conclusão

O risco alto para quedas foi encontrado em mais da metade dos idosos, o que variou de acordo com o motivo de internação e comorbidades, sendo mais frequentes naqueles internados por doença pulmonar e que apresentavam Diabetes.

Idoso; Hospitalização; Acidentes por Quedas; Segurança do Paciente; Enfermagem Geriátrica

RESUMEN

Objetivo

Identificar el riesgo de caídas en ancianos en un hospital de la región del Trairi, en Rio Grande do Norte; describir la relación entre riesgo de caídas y las características sociodemográficas de los participantes.

Método

Estudio descriptivo, transversal, cuantitativo, realizado en un hospital regional, respetando los principios éticos vigentes. Para la recolección de datos, ocurrida en julio y agosto de 2018, fue adoptada la Escala de Morse, adaptada con cuestiones sociodemográficas. Realizado análisis estadística descriptiva y inferencial.

Resultados

El estudio tuve 46 participantes, de los cuales la mayoría era formada por mujeres, con baja escolaridad y los motivos de internamiento más frecuentes fueran tratamiento quirúrgico y enfermedad pulmonar. Más de la mitad presento riesgo alto de sufrir caídas (54,35%), seguido de moderado (32,61%) y bajo (13,04%). Hubo asociación entre riesgo alto de caídas, tener enfermedad pulmonar como motivo de internamiento y diabetes como comorbilidad. El riesgo alto de caídas fue menos frecuente entre ancianos internados para tratamiento quirúrgico.

Conclusión

El riesgo alto para caídas fue encontrado en más de la mitad de los ancianos, lo que varió de acuerdo con el motivo de internamiento y comorbilidades, siendo más frecuentes en los internados por enfermedad pulmonar y que presentaban Diabetes.

Anciano; Hospitalización; Accidentes por Caídas; Seguridad del Paciente; Enfermería Geriátrica

INTRODUCTION

According to the World Health Organization (WHO), the concept of Patient Safety refers to reducing the risk of unnecessary harm associated with healthcare to an acceptable minimum(¹1. Organização Mundial da Saúde; Direção-Geral de Saúde. Estrutura conceitual da classificação internacional sobre segurança do doente [Internet]. Lisboa: OMS; 2011 [citado 2018 mar. 09]. Disponível em: https://proqualis.net/sites/proqualis.net/files/Estrutura%20Conceitual%20da%20Classifica%C3%A7%C3%A3o%20Int%20Seguran%C3%A7a%20do%20Paciente.pdf
https://proqualis.net/sites/proqualis.ne... ). This issue is important in preventing injuries to patients by encouraging basic measures such as correct patient identification, hand hygiene, and the use of institutional protocols, among others.

The World Alliance for Patient Safety, launched in 2004 by WHO, aims to facilitate the development of policies and practices for patient safety. Brazil has taken an important step in this direction by instituting the National Patient Safety Program through the Ministry of Health(²2. Rede Brasileira de Enfermagem e Segurança do Paciente. Estratégias para a segurança do paciente: manual para profissionais da saúde [Internet]. Porto Alegre: REBRAENSP; 2013 [citado 2018 mar. 08]. Disponível em: https://www.rebraensp.com.br/images/publicacoes/manual_seguranca_paciente.pdf
https://www.rebraensp.com.br/images/publ... ).

The Brazilian Network of Nursing and Patient Safety (REBRAENSP - Rede Brasileira de Enfermagem e Segurança do Paciente) prepared a manual in 2013 with 12 strategies based on the global challenges formulated by the World Alliance for Patient Safety, aimed at preventing damage and promoting health. Thus, the strategy which addresses falls prevention is highlighted in this study(²2. Rede Brasileira de Enfermagem e Segurança do Paciente. Estratégias para a segurança do paciente: manual para profissionais da saúde [Internet]. Porto Alegre: REBRAENSP; 2013 [citado 2018 mar. 08]. Disponível em: https://www.rebraensp.com.br/images/publicacoes/manual_seguranca_paciente.pdf
https://www.rebraensp.com.br/images/publ... ).

Ordinance No. 2.095, of September 24, 2013, approved the basic patient safety protocols in Brazil, with the Fall Prevention Protocol among them, and determines the need to assess all patients regarding the risk of this event, followed by an elaboration and prescription of preventive measures according to the risk of each individual(³3. Brasil. Ministério da Saúde; Agência Nacional de Vigilância Sanitária. Programa Nacional de Segurança do Paciente. Protocolo Prevenção de Quedas [Internet]. Brasília; 2013 [citado 2018 mar. 10]. Disponível em: https://www20.anvisa.gov.br/segurancadopaciente/index.php/publicacoes/category/diversos
https://www20.anvisa.gov.br/segurancadop... ).

Falling is defined as involuntary displacement of the body to a level lower than the initial position, being caused by multiple factors, and resulting or not in harm to the patient. The fall can occur from the height itself, from a stretcher/bed or from seats such as wheelchairs, armchairs, chairs, bathtub, or toilet seat(³3. Brasil. Ministério da Saúde; Agência Nacional de Vigilância Sanitária. Programa Nacional de Segurança do Paciente. Protocolo Prevenção de Quedas [Internet]. Brasília; 2013 [citado 2018 mar. 10]. Disponível em: https://www20.anvisa.gov.br/segurancadopaciente/index.php/publicacoes/category/diversos
https://www20.anvisa.gov.br/segurancadop... -⁴4. Sociedade Brasileira de Geriatria e Gerontologia. Projeto diretrizes: quedas em idosos: prevenção [Internet]. São Paulo: SBGG; 2008 [citado 2018 mar. 08]. Disponível em: https://www.projetodiretrizes. org.br/projeto_diretrizes/082.pdf
https://www.projetodiretrizes. org.br/pr... ).

The occurrence of falls for older adults in a hospital environment may be associated with factors such as continuous use of medications, sensory deficits (visual, auditory, tactile), the use of glasses and mobility aids such as a cane, wheelchair or walker(⁵5. Vaccari E, Lenardt MH, Willig MH, Betiolli SE, Andrade LAS. Patient safety and falls in the hospital environment. Cogitare Enferm. 2016;21(n.spe):1-9. DOI: http://dx.doi.org/10.5380/ce.v21i5.45562
http://dx.doi.org/10.5380/ce.v21i5.45562... ).

A falls event can have more serious repercussions on the health of the older adult, since the natural process of human aging causes a reduction in bone density, muscle mass and physical strength. These parameters impact posture, walking, balance and factors which increase the risk of falls(⁶6. Gasparotto LPR, Falsarella GR, Coimbra AMV. Falls in elderly: basics concepts and updates of research in health. Rev Bras Geriatr Gerontol [Internet]. 2014 [cited 2018 Mar 10]; 17(1): 201-9. Available from: http://www.scielo.br/pdf/rbgg/v17n1/1809-9823-rbgg-17-01-00201.pdf
http://www.scielo.br/pdf/rbgg/v17n1/1809... ).

Fall accidents are the main cause of non-fatal injuries and death in older adults, and therefore constitute a serious public health problem(⁷7. Cuevas-Trisan R. Balance problems and fall risks in the elderly. Phys Med Rehabil Clin N Am. 2017;28(4):727-37. DOI: 10.1016/j.pmr.2017.06.006
https://doi.org/10.1016/j.pmr.2017.06.00... ) whose impacts not only deserve greater attention in the scope of research, but also in healthcare and public policies. Other authors have found that some health professionals reduce attention to the occurrence of falls, considering them only as inevitable consequences of aging(⁸8. Morsch P, Myskiw M, Myskiw JC. Fall’s problematization and risk factors identification through older adults narrative. Ciênc Saúde Coletiva. 2016;21(11):3565-74. DOI: 10.1590/1413-812320152111.06782016
https://doi.org/10.1590/1413-81232015211... ).

In this sense, surveillance to prevent the occurrence of falls should also be one of the priorities of nursing care when the patient is admitted to a health institution. Identifying the risk of falls provides fundamental information for formulating care plans which are more adequate to the individual needs of each patient, providing support for implementing the Systematization of Nursing Care(⁹9. Oliveira DU, Ercole FF, Melo LS, Matos SS, Campos CC, Fonseca EAM. Evaluation of falls in hospitalized elderly. Rev Enferm UFPE on line. 2017;11(11):4589-97. DOI: 10.5205/reuol.11138-99362-1-SM.1111sup201707
https://doi.org/10.5205/reuol.11138-9936... ).

There were 941,923 hospitalizations with secondary diagnosis associated with falls among older adults in Brazil in the period from 1996 to 2012. In addition, hospitalization rates in this age group remain high, and therefore not only the physical repercussions, but also the biopsychosocial consequences caused by falls must be noted(¹⁰10. Abreu DROM, Novaes ES, Oliveira RR, Mathias TAF, Marcon SS. Internação e mortalidade por quedas em idosos no Brasil: análise de tendência. Ciênc Saúde Coletiva. 2018; 23(4): 1131-1141. DOI: http://dx.doi.org/10.1590/1413-81232018234.09962016.
http://dx.doi.org/10.1590/1413-812320182... ), which include suffering, hospitalization, and isolation, thus raising questions which may lead to elaborating proposals to prevent this event in this population. Furthermore, falls are one of the most important indicators for patient safety, therefore the Ministry of Health and the National Patient Safety Program include assessing the risk of falls as one of the most effective interventions in preventing this adverse event.

Accordingly, this study sought to answer the following research question: What is the risk of accidents due to falls in older adult patients admitted to a hospital in the Trairi region in the State of Rio Grande do Norte in Brazil?

Given the above, the study had the following objectives: to identify the risk of falls in older adults in a hospital in the Trairi region in Rio Grande do Norte, and to describe the relationship between risk of falls and the sociodemographic characteristics of the participants.

METHOD

STUDY DESIGN

A descriptive study with a cross-sectional design using quantitative approach.

SCENARIO

The study was conducted in a hospital in the Trairi region, located in the municipality of Santa Cruz, in the state of Rio Grande do Norte, Brazil.

This hospital has 40 beds, being considered small, and serves patients from 11 municipalities in the Trairi region. The location was chosen due to its importance in general and emergency clinical care in the region for all clientele, especially for older adult patients, in addition to being located in a city which has the presence of Universidade Federal do Rio Grande do Norte campus with four undergraduate courses in the health area, namely nursing, physiotherapy, nutrition and psychology.

The hospital serves as a field for practical activities in the discipline of semiology and semiotechnics and supervised internship for the nursing course, providing opportunities for developing important skills and competencies for training nursing professionals. The hospital currently does not have a patient safety center, which is an extremely important service to promote the prevention, control and mitigation of incidents, in addition to integrating sectors, promoting the articulation of work processes and information which impact risks to the patient.

SELECTION CRITERIA

Inclusion criteria for this study were: being 60 years of age or older; being admitted to the medical or surgical clinic sectors of the abovementioned hospital during the collection period; and being able to understand the instrument questions. Those with communication difficulties which prevented them from responding to the instruments or those whose health status was severe and/or unstable were excluded to avoid discomfort during collection.

The number of hospitalizations of the older adults occurring in the months of July and August 2017 was taken into account for the sample definition, considering that it corresponded to the same period in which data collection would be conducted in 2018. Thus, the sample calculation considered a population of 52 older adults, a 95% confidence interval and an estimated frequency of 52%, which was the percentage of older adults at high risk of falls in a study conducted with older adults in Belém/Pará state(¹¹11. Sarges NA, Santos MIPO, Chaves EC. Evaluation of the safety of hospitalized older adults as for the risk of falls. Rev Bras Enferm [Internet]. 2017;70(4):860-7. DOI: http://dx.doi.org/10.1590/0034-7167-2017-0098
http://dx.doi.org/10.1590/0034-7167-2017... ). Thus, the sample calculated for this study was 46 older adults.

DATA COLLECTION

The data collection technique was a structured interview using the Morse Scale as the instrument, which contains closed questions which address the history of falls, secondary diagnoses, aid in walking, use of intravenous therapy/saline or heparinized intravenous device, gait and mental state. The version of the instrument translated and validated by other authors(¹²12. Urbanetto JS, Pasa TS, Bittencout HR, Franz F, Rosa VPP, Magnago TSBS. Analysis of risk prediction capability and validity of Morse Fall Scale Brazilian version. Rev Gaúcha Enferm. [Internet]. 2016 [cited 2019 Apr 19];37(4):e62200. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1983-14472016000400414&lng=en.
http://www.scielo.br/scielo.php?script=s... ) was used, in which the scale score can vary from 0 to 125 points, with 0 to 24 points being considered Low Risk, from 25 to 44 points as Moderate Risk, and ≥ 45 points is considered High Risk.

Some questions were inserted in the header of this instrument regarding the participants’ sociodemographic data such as gender, age group, education (in years), reason for hospitalization, length of stay (in days) and self-reported diseases. These sociodemographic questions were obtained from consulting the individual medical records of the older adults. Information was also taken from the medical record to complete items 1 and 2 of the Morse Scale; the other items of the scale were evaluated with the participant in the ward where they were hospitalized and registered in the research form.

DATA ANALYSIS AND PROCESSING

The database was built in an EXCEL spreadsheet, version 2017; the Statistical Package for the Social Sciences (SPSS®) version 25.0 software was used to perform the descriptive tables and apply statistical tests.

Descriptive statistics of trend and data dispersion measures were analyzed for the quantitative variables evaluated in the study, such as: minimum, maximum, mean and standard deviation. A descriptive analysis was performed for qualitative variables by distributions of absolute and relative frequencies (%), with a value of p ≤ 0.05.

The Chi-squared statistical test was applied when comparing the risk of falling classification from Morse regarding the general profile of the patient with the categorized variables. A significance level of 5% was considered when performing all statistical tests, adopting a p-value ≤ 0.05.

ETHICAL ASPECTS

The research respected all the ethical principles of Resolution No. 466/2012 of the National Health Council. The research protocol was evaluated and approved by the Research Ethics Committee of the Faculty of Health Sciences of Trairi/ Universidade Federal do Rio Grande do Norte, through Opinion No. 2.715.284/2018. All had access to the Informed Consent Form (ICF) and those who agreed to participate in the study signed the form before starting the data collection procedures.

RESULTS

The average age of the participants was 75.02 years, with a standard deviation of 10.08 years, ranging from 60 to 104 years of age. Half of the participants were illiterate and the majority of respondents were female. The main reasons for hospitalization of these older adults were surgical treatment and lung disease. Additional information on the characterization of the participants can be found in Table 1.

The participants had an average of 1.93 days of hospitalization and had up to three comorbidities per person (Table 2). Regarding comorbidities, 29 participants reported having systemic arterial hypertension (SAH), 13 had diabetes (DM), three cases of stroke, one with chronic obstructive pulmonary disease and six mentioned other diseases; nine participants did not present any comorbidity.

Table 3 shows the frequencies of the items on the Morse Scale which compose the risk assessment for falls.

There was a predominance of high risk in evaluating the general classification of the risk scale for falls, as shown in Table 4.

Regarding the associations between variables, it was identified that patients who had lung disease as a reason for hospitalization and those who had the comorbidity of Diabetes Mellitus had a higher percentage of high risk of falls. This reinforces the importance of continuous monitoring and care for older adults, since such diseases and their complications are considered sensitive conditions to Primary Healthcare, meaning that if they are treated at this care level they could avoid hospital admissions, and in turn the risk of falls experienced in this healthcare scenario. Although there is no statistical association, it is highlighted that more than 60% of the older adults were hypertensive, and almost 70% of these were at moderate or high risk for falling. In addition, patients whose reason for hospitalization was surgical treatment had a lower percentage of high risk of falls (Table 5).

Even without statistical association, the main characteristics of the participants who presented moderate and high risk for falls are highlighted: female gender, age up to 75 years, hospital stay of up to two days and having a diagnosis of SAH.

DISCUSSION

The average age found in this study was consistent with life expectancy at birth for Brazilians, which is currently 76 years(¹³13. Instituto Brasileiro de Geografia e Estatística. Tábua completa de mortalidade para o Brasil - 2017: breve análise da evolução da mortalidade no Brasil [Internet]. Rio de Janeiro: IBGE; 2018 [citado 2019 abr. 20]. Disponível em: https://biblioteca.ibge.gov.br/index.php/biblioteca-catalogo?view=detalhes&id=2101628
https://biblioteca.ibge.gov.br/index.php... ). The risk of falling was greater at older ages, which corroborates recent literature(⁷7. Cuevas-Trisan R. Balance problems and fall risks in the elderly. Phys Med Rehabil Clin N Am. 2017;28(4):727-37. DOI: 10.1016/j.pmr.2017.06.006
https://doi.org/10.1016/j.pmr.2017.06.00... ).

Most participants were female, and having a profile similar to that found in other studies with hospitalized older adults(⁹9. Oliveira DU, Ercole FF, Melo LS, Matos SS, Campos CC, Fonseca EAM. Evaluation of falls in hospitalized elderly. Rev Enferm UFPE on line. 2017;11(11):4589-97. DOI: 10.5205/reuol.11138-99362-1-SM.1111sup201707
https://doi.org/10.5205/reuol.11138-9936... ,¹¹11. Sarges NA, Santos MIPO, Chaves EC. Evaluation of the safety of hospitalized older adults as for the risk of falls. Rev Bras Enferm [Internet]. 2017;70(4):860-7. DOI: http://dx.doi.org/10.1590/0034-7167-2017-0098
http://dx.doi.org/10.1590/0034-7167-2017... ,¹⁴14. Öztürk ZA, Özdemir S, Türkbeyler IH, Demir Z. Quality of Life and all risk in frail hospitalized elderly patients. Turk J Med Sc. 2017;47(5):1377-83. DOI: 10.3906/sag-1610-107
https://doi.org/10.3906/sag-1610-107... ). This characteristic can be explained by the fact that older adult women are more susceptible to the development of the fragility syndrome in the post-menopausal phase for example, making them more vulnerable to adverse outcomes(¹⁵15. Fhon JRS, Rodrigues RAP, Neira WF, Huayta VMR, Robazzi MLCC. Fall and its association with the frailty syndrome in the elderly: systematic review with meta-analysis. Rev Esc Enferm USP. 2016;50(6):1005-13. DOI: http://dx.doi.org/10.1590/S0080-623420160000700018
http://dx.doi.org/10.1590/S0080-62342016... ). Other studies have identified that falls are more frequent in females and are associated with worse physical performance and history of cardiovascular diseases(¹⁶16. Sharma PK, Bunker CH, Singh T, Ganguly E, Reddy PS, Newman AB, et al. Burden and correlates of falls among rural elders of South India: mobility and independent living in elders study. Current Gerontol Geriatr Res. 2017;2017:1290936. DOI: https://doi.org/10.1155/2017/1290936
https://doi.org/10.1155/2017/1290936... -¹⁷17. Sardo PM, Simões CS, Alvarelhão JJ, Simões JF, Melo EM. Fall risk assessment: retrospective analysis of Morse Fall Scale scores in Portuguese hospitalized adult patients. Appl Nurs Res. 2016;31:34-40. DOI: https://doi.org/10.1016/j.apnr.2015.11.013
https://doi.org/10.1016/j.apnr.2015.11.0... ).

Low educational level prevailed in this sample, constituting a factor which can negatively influence quality of life, and more specifically the ability to understand and acquire information related to healthcare, since other authors have identified that older adults with less education had more reports of the occurrence of falls(¹⁸18. Cruz DT, Leite ICG. Falls and associated factors among elderly persons residing in the community. Rev Bras Geriatr Gerontol. 2018;21(5):551-61. DOI: http://dx.doi.org/10.1590/1981-22562018021.180034.
http://dx.doi.org/10.1590/1981-225620180... ).

Hospitalization for lung disease had a significant association with the high risk of falling for patients in this sample, corroborating data which has already been found in research by other authors(¹⁹19. Oliveira CC, Lee AL, McGinley J, Thompson M, Louis BI, Anderson GP, et al. Falls by individual swith chronic obstructive pulmonary disease: a preliminary 12-month prospective cohort study. Respirology. 2015;20(7):1096-101. DOI: 10.1111/resp.12600
https://doi.org/10.1111/resp.12600... ). Considering that Chronic Obstructive Pulmonary Disease (COPD) presents dyspnea and fatigue upon exertion as symptoms(²⁰20. Lee J, Nguyen HQ, Jarrett ME, Mitchell PH, Pike KC, Fan VS. Effect of symptoms on physical performance in COPD. Heart Lung. 2018;47(2):149-56. DOI: 10.1016/j.hrtlng.2017.12.007
https://doi.org/10.1016/j.hrtlng.2017.12... ), it is understood that these changes are factors which can contribute to less mobility, causing risks of accidents due to falls. On the other hand, a study which investigated the risk of falls in older adult patients with COPD found only 4.2% of the population at high risk of falls(²¹21. Fiel JNA, Lima JS, Dias JM, Neves LMT. Avaliação do risco de quedas e sarcopenia em idosos com doença pulmonar obstrutiva crônica atendidos em um hospital universitário de Belém, Estado do Pará, Brasil. Rev Pan Amaz Saúde. 2016;7(4):41-5. DOI: http://dx.doi.org/10.5123/s2176-62232016000400005
http://dx.doi.org/10.5123/s2176-62232016... ).

On the other hand, a low risk of falls was significantly associated with cases in which the reason for hospitalization was the performance of a surgical procedure. The surgeries performed in the studied hospital are small and medium sized, of an elective nature, such as cholecystectomy, herniorrhaphy and hysterectomy, and therefore the routine is that hospital discharge occurs between 24 and 48 hours so that patients usually stay for a short time in the institution.

A retrospective cohort analysis of the Morse Scale scores with more than 8,000 hospitalized patients found an association between longer length of stay and higher frequency in the risk group for falls(¹⁷17. Sardo PM, Simões CS, Alvarelhão JJ, Simões JF, Melo EM. Fall risk assessment: retrospective analysis of Morse Fall Scale scores in Portuguese hospitalized adult patients. Appl Nurs Res. 2016;31:34-40. DOI: https://doi.org/10.1016/j.apnr.2015.11.013
https://doi.org/10.1016/j.apnr.2015.11.0... ). In addition, hospitalization has consequences on the physical and mental state of older adults. As an example, delirium stands out as the most frequent neurobehavioral disorder in hospitalized older adults in the association with high fall rates(²²22. Faustino TN, Pedreira LC, Freitas YS, Silva RMO, Amaral JB. Prevention and monitoring of delirium in older adults: an educational intervention. Rev Bras Enferm [Internet]. 2016;69(4):725-32. DOI: http://dx.doi.org/10.1590/0034-7167.2016690416i
http://dx.doi.org/10.1590/0034-7167.2016... ).

A study which evaluated the risk of falls among adult patients hospitalized for surgical procedures did not find an association between the size of the surgery and the risk of falls, at the same time in which it identified that the more advanced the age, the greater the high risk of falls. Moreover, the presence of comorbidities such as hypertension, diabetes and cancer were also associated(²³23. Mata LRF, Azevedo C, Policarpo AG, Moraes JT. Factors associated with the risk of fall in adults in the postoperative period: a cross-sectional study. Rev Latino Am Enfermagem. 2017;25:e2904. DOI: 10.1590/1518-8345.1775.2904
https://doi.org/10.1590/1518-8345.1775.2... ). The fact of having diabetes as a comorbidity was associated with the risk of falls in two other studies(²³23. Mata LRF, Azevedo C, Policarpo AG, Moraes JT. Factors associated with the risk of fall in adults in the postoperative period: a cross-sectional study. Rev Latino Am Enfermagem. 2017;25:e2904. DOI: 10.1590/1518-8345.1775.2904
https://doi.org/10.1590/1518-8345.1775.2... -²⁴24. Bittencourt VLL, Graube SL, Stumm EMF, Battisti IDE, Loro MM, Winkelmann ER. Factors associated with the risk of falls in hospitalized adult patients. Rev Esc Enferm USP. 2017;51:e03237. DOI: 10.1590/S1980-220X2016037403237
https://doi.org/10.1590/S1980-220X201603... ).

In this regard, the older adults in this research who had a medical diagnosis of Diabetes Mellitus (DM) had a significant association with the high risk of falls. Research conducted with older adult patients hospitalized for hip fractures due to falls found diabetes mellitus in 23.1% of respondents, second only to hypertension(²⁵25. Farias FID, Terra NL, Guerra MTE. Evaluation of the effectiveness of a care program for elderly patients with hip fractures: a network strategy. Rev Bras Geriatr Gerontol. 2017;20(5): 705-16. DOI: http://dx.doi.org/10.1590/1981-22562017020.170008
http://dx.doi.org/10.1590/1981-225620170... ). In this perspective, it is necessary to maintain greater attention to these patients in view of the potential complications arising from the pathophysiology of this disease, such as nephropathy, retinopathy and injuries due to peripheral neuropathy.

Peripheral neuropathy is associated with poor gait performance and balance deficits, sensory limitations and loss of muscle strength, which can interfere with daily tasks and consequently quality of life(²⁴24. Bittencourt VLL, Graube SL, Stumm EMF, Battisti IDE, Loro MM, Winkelmann ER. Factors associated with the risk of falls in hospitalized adult patients. Rev Esc Enferm USP. 2017;51:e03237. DOI: 10.1590/S1980-220X2016037403237
https://doi.org/10.1590/S1980-220X201603... ). The occurrence of falls is also associated with the presence of slippery floors in houses, hearing loss, vertigo, hypertension, use of multiple medications, depression and functional disability(²⁶26. Jindal HA, Duggal M, Jamir L, Sharma D, Kankaria A, Rohilla L, et al. Mental health and environmental factors associated with falls in the elderly in North India: a naturalistic community study. Asian J Psychiatr. 2019;39:17-21. DOI: 10.1016/j.ajp.2018.11.013
https://doi.org/10.1016/j.ajp.2018.11.01... ).

Arterial hypertension presented itself as another important comorbidity linked to moderate and high risk of falling. Hypertensive patients are eight times more likely to fall than non-hypertensive patients. In addition, both hypertension and the use of antihypertensive drugs are risk factors for falls(²³23. Mata LRF, Azevedo C, Policarpo AG, Moraes JT. Factors associated with the risk of fall in adults in the postoperative period: a cross-sectional study. Rev Latino Am Enfermagem. 2017;25:e2904. DOI: 10.1590/1518-8345.1775.2904
https://doi.org/10.1590/1518-8345.1775.2... ).

Monitoring episodes of falls is of paramount importance as a method to support formulating preventive measures, leading to guide management and care actions focusing on reducing the occurrence of this event. Hospital establishments should encourage the development of work resources which enable and encourage the identification, notification and analysis of this adverse event(³3. Brasil. Ministério da Saúde; Agência Nacional de Vigilância Sanitária. Programa Nacional de Segurança do Paciente. Protocolo Prevenção de Quedas [Internet]. Brasília; 2013 [citado 2018 mar. 10]. Disponível em: https://www20.anvisa.gov.br/segurancadopaciente/index.php/publicacoes/category/diversos
https://www20.anvisa.gov.br/segurancadop... ).

Given the characteristics of the studied population and the expressive number of people at high risk of falls, it is understood that the nursing team must adopt practices which are capable of preventing the occurrence of this event, such as: effective communication between health professionals and professional/patient; identification of the high-risk patient by means of a notice at the bedside or a bracelet with a different color; greater attention when moving patients; allocating patients at high risk for falls in beds closer to the nursing station; and support for personal hygiene care(²⁷27. Alves VC, Freitas Junior WC, Ramos JS, Chagas SRG, Azevedo C, Mata LRF. Actions of the fall prevention protocol: mapping with the classification of nursing interventions. Rev Latino Am Enfermagem. 2017;25:e2986. DOI: http://dx.doi.org/10.1590/1518-8345.2394.2986
http://dx.doi.org/10.1590/1518-8345.2394... ).

Besides direct care, health education actions carried out by nurses and other health professionals for patients and companions are also important, which should include guidance on bed movement and care when an older adult is using drugs with sedative effects, as these are situations which favor the occurrence of accidents(⁵5. Vaccari E, Lenardt MH, Willig MH, Betiolli SE, Andrade LAS. Patient safety and falls in the hospital environment. Cogitare Enferm. 2016;21(n.spe):1-9. DOI: http://dx.doi.org/10.5380/ce.v21i5.45562
http://dx.doi.org/10.5380/ce.v21i5.45562... ,²⁶26. Jindal HA, Duggal M, Jamir L, Sharma D, Kankaria A, Rohilla L, et al. Mental health and environmental factors associated with falls in the elderly in North India: a naturalistic community study. Asian J Psychiatr. 2019;39:17-21. DOI: 10.1016/j.ajp.2018.11.013
https://doi.org/10.1016/j.ajp.2018.11.01... ).

An investment in equipment and utensils such as electric beds, safety bars in the bathrooms and bells in the bedrooms, in addition to adopting awareness and orientation strategies for patients, family members and nursing staff, is able to reduce the occurrence of the fall event in institutions. It is also important to highlight the role of nurses in fall prevention programs, as this professional can assess the risk of patients, plan and implement preventive interventions, and finally evaluate their results(²⁸28. Luzia MF, Cassola TP, Suzuki LM, Dias VLM, Pinho LB, Lucena AF. Incidence of falls and preventive actions in a University Hospital. Rev Esc Enferm USP. 2018;52:e03308. DOI: http://dx.doi.org/10.1590/S1980-220X2017024203308
http://dx.doi.org/10.1590/S1980-220X2017... ), being supported by the use of instruments such as the Morse Scale used in the present study.

The nurse must encourage the autonomy, independence and functional capacity of older adults, recognizing their role in health advocacy and aiming to guarantee the quality of care, as the professional is continuously present in the care of hospitalized, institutionalized or domiciled older adults. When developing fall prevention activities, the nurse must also consider an assessment of the patient’s knowledge and educational interventions implemented in the hospital environment(²⁹29. Figueira AB, Barlem ELD, Tomaschewski-Barlem JG, Dalmolin GL, Amarijo CL, Ferreira AG. Actions for health advocacy and user empowerment by nurses of the Family Health Strategy. Rev Esc Enferm USP. 2018;52:e03337. DOI: http://dx.doi.org/10.1590/S1980-220X2017021603337
http://dx.doi.org/10.1590/S1980-220X2017... ).

In this sense, a recent integrative review described the indicators for quality care, which include: use of appropriate footwear, correct use of assistive devices, ambient lighting, adoption of safe transfer procedures, attention to prescribed (or not) medications, chronic and acute conditions which increase the risk of falls, and changes in blood pressure, among others. Nurses can examine the effectiveness of their interventions by adopting these indicators in evaluating patients with the Nursing Diagnosis “Risk of falls” in a real clinical environment(³⁰30. Luzia MF, Argenta C, Almeida MA, Lucena AF. Conceptual definitions of indicators for the nursing outcome “knowledge: fall prevention”. Rev Bras Enferm [Internet]. 2018;71(2):431-9. DOI: http://dx.doi.org/10.1590/0034-7167-2016-0686
http://dx.doi.org/10.1590/0034-7167-2016... ).

The Nursing Diagnosis “Risk of falls” has more than 40 interventions described in the Nursing Interventions Classification (NIC), showing the existence of innumerable care actions which nurses can perform supported by a scientific basis and which already have standardized language through a comprehensive international tool(²⁷27. Alves VC, Freitas Junior WC, Ramos JS, Chagas SRG, Azevedo C, Mata LRF. Actions of the fall prevention protocol: mapping with the classification of nursing interventions. Rev Latino Am Enfermagem. 2017;25:e2986. DOI: http://dx.doi.org/10.1590/1518-8345.2394.2986
http://dx.doi.org/10.1590/1518-8345.2394... ). The adoption of this tool can then benefit communication and minimize the occurrence of adverse events, reinforcing the importance of nurses as promoters of patient safety actions.

As nurses, it is important to note that “Risk of falls” is a nursing diagnosis which was approved almost 20 years ago, having been updated in the current taxonomy of the North American Nursing Diagnosis Association (NANDA), in which the populations at risk for such event include an age greater than or equal to 65 years and a history of falls. This classification also addresses the conditions associated with such an event, which include: pharmaceutical agents, alteration in cognitive function, proprioceptive deficit, acute disease, vascular disease, impaired balance, and orthostatic hypotension, among others.

Among the limitations of this study, it is highlighted that data were collected in a single moment during the participants’ hospitalization as it is a cross-sectional study. Thus, possible changes in health status which occurred during this period were not evaluated, preventing other potential risk factors from being analyzed.

There is a need for further research to study the influence of such conditions on the falls event as a way of supporting the development of measures which prevent its occurrence among older adults.

CONCLUSION

More than half of the older adults in the present study had a high risk for falls. This situation varied according to the reason for hospitalization and referred comorbidities, being more frequent in those hospitalized for lung disease and who had Diabetes Mellitus as a comorbidity.

The high risk of falls in hospitalized older adults found in the present study using the Morse Scale reinforces the importance of applying this instrument in healthcare practice and the need to develop strategies to prevent the risks and aggravations of falls in the hospital environment. The challenge of adopting this instrument in healthcare practice is the fact that it was only recently introduced in Brazil, and many health professionals possibly do not yet know about it. Continuous education actions can be useful to spread this knowledge and encourage the adoption of the Morse Scale in the routines of health institutions as an important measure for preventing adverse events in the hospital environment, together with the implementation of other institutional safety protocols.

Such strategies should include all health professionals and managers involved in the care of hospitalized older adult patients in carrying out health education actions, as well as in making adjustments for safer beds and wards for patients and companions, preventing the occurrence of the falls event. Furthermore, avoiding all the negative repercussions that this event represents for the health of older adults and also the high costs of prolonged hospitalizations in a health service.

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