It was with great interest that I read Diane Goodman's Viewpoint, "An Insider's View on Fall Prevention" (April). While I agree with the author that the use of rehabilitative services is critical in improving functional independence, balance, and strength, and in reducing fall risk, one factor she didn't mention is a person's cognitive level.

One study shows that the fall rate for cognitively impaired patients is 12.9%-versus 4.2% for older adults without cognitive impairment.1 In another, 29.7% of falls in an in-patient facility were "impulsivity related falls," and cognitive impairment and inattention were the strongest predictors of these.2 Ms. Goodman mentions that hospitals typically focus on extrinsic factors but that to examine these alone "means overlooking the link between disease and disease management." However, a patient who has decreased awareness and perceptual deficits requires greater management of extrinsic measures.

Nurses have reported that confusion, gait problems, and the inability to follow safety instructions are among the most frequent reasons for falls.3 They found the most effective interventions to be extrinsic measures, such as reducing tripping hazards and keeping floors clean and dry.

David Reznik, RN

Staten Island, NY

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