Preventing and Reducing Falls Among Elderly Patients in Long-Term Care
Introduction
Falls are a major threat to the health and well-being of elderly patients in long-term care settings. Falls can cause serious injuries, such as fractures, head trauma, and even death, and can reduce the ability to remain independent and perform daily activities. Falls can also have negative psychological consequences, such as fear of falling, loss of confidence, and depression. Therefore, preventing and reducing falls among elderly patients in long-term care is a priority for nursing practice and research.
According to the Centers for Disease Control and Prevention (CDC), falls are the leading cause of injury death for older adults aged 65 years and older, accounting for over 36,000 deaths in 2020. Moreover, emergency departments recorded 3 million visits for older adult falls in 2020, and older adult falls cost $50 billion in medical costs annually (CDC, 2023). In long-term care facilities, an average nursing home with 100 beds reports 100 to 200 falls annually, and approximately 1,800 older adults living in long-term care facilities die each year from fall-related injuries (George, 2000; AMDA, 2005).
The purpose of this paper is to review the risk factors of falls and the current clinical guidelines for fall prevention in elderly patients in long-term care settings. The paper will also discuss the strategies and barriers for implementing a fall prevention program in long-term care facilities.
Risk Factors of Falls
Falls are multifactorial events that result from the interaction of intrinsic and extrinsic factors. Intrinsic factors are related to the individual characteristics of the patient, such as age, gender, medical conditions, medications, cognitive impairment, sensory deficits, balance problems, muscle weakness, gait disturbances, and history of falls. Extrinsic factors are related to the environmental characteristics of the setting, such as lighting, flooring, furniture, equipment, clutter, noise, and staff availability and training (George, 2000; AMDA, 2005).
Some of the most common intrinsic risk factors for falls in elderly patients in long-term care settings are:
– Age: The risk of falling increases with age due to physiological changes that affect mobility, balance, vision, hearing, and reaction time.
– Gender: Women are more likely to fall than men due to lower bone density, higher prevalence of osteoporosis, and greater use of psychotropic medications.
– Medical conditions: Chronic diseases such as diabetes, arthritis, stroke, Parkinson’s disease, dementia, and cardiovascular disorders can impair physical function and increase the risk of falling.
– Medications: Polypharmacy (use of four or more medications) and use of certain classes of drugs such as sedatives, hypnotics, antidepressants, antipsychotics, opioids, antihypertensives,
and diuretics can affect cognition, alertness, blood pressure,
and postural stability.
– Cognitive impairment: Dementia and delirium can impair judgment,
orientation,
memory,
and perception,
and increase wandering,
agitation,
and confusion.
– Sensory deficits: Vision and hearing impairments can reduce the ability to perceive and avoid hazards,
and affect balance
and coordination.
– Balance problems: Postural instability,
vertigo,
orthostatic hypotension,
and vestibular disorders can cause dizziness,
lightheadedness,
and loss of equilibrium.
– Muscle weakness: Sarcopenia (age-related loss of muscle mass
and strength),
deconditioning,
and malnutrition can reduce muscle power
and endurance.
– Gait disturbances: Abnormalities in gait speed,
stride length,
cadence,
and symmetry can affect stability
and increase the risk of tripping
and stumbling.
– History of falls: Previous falls can indicate a higher risk of future falls due to underlying risk factors
or fear of falling.
Some of the most common extrinsic risk factors for falls in elderly patients in long-term care settings are:
– Lighting: Poor lighting can reduce visibility
and contrast,
and create glare
and shadows that can obscure hazards
or impair depth perception.
– Flooring: Slippery
or uneven surfaces,
rugs,
mats,
thresholds,
and cords can create obstacles
or reduce friction that can cause slips
or trips.
– Furniture: Inappropriate height
or placement of beds,
chairs,
tables,
and other furniture can affect accessibility
or stability
or create barriers that can impede mobility
or increase the risk of bumping
or falling.
– Equipment: Improper use
or maintenance of assistive devices such as walkers,
canes,
wheelchairs,
grab bars,
handrails,
and transfer aids can compromise safety
or functionality
or increase the risk of entanglement
or malfunction.
– Clutter: Excess items such as clothes,
shoes,
books,
magazines,
and personal belongings can create disorder
or distraction
or occupy space that can interfere with movement
or increase the risk of collision
or falling.
– Noise: High levels of noise from televisions,
radios,
phones,
alarms,
and other sources can create disturbance
or annoyance
or impair hearing
or communication that can affect concentration
or awareness
or increase the risk of agitation
or falling.
– Staff: Inadequate number
or training of staff can affect the quality
and timeliness of care
or supervision that can affect the safety
and satisfaction of patients
or increase the risk of neglect
or falling.
Clinical Guidelines for Fall Prevention
Several clinical practice guidelines have been developed to provide evidence-based recommendations for fall prevention in elderly patients in long-term care settings. Some of the most widely used and recognized guidelines are:
– The American Medical Directors Association (AMDA) Clinical Practice Guideline on Falls and Fall Risk (2005), which provides a comprehensive and interdisciplinary approach to fall prevention, including assessment, intervention, monitoring, and documentation.
– The Registered Nurses’ Association of Ontario (RNAO) Best Practice Guideline on Prevention of Falls and Fall Injuries in the Older Adult (2017), which provides a systematic and holistic approach to fall prevention, including risk identification, prevention strategies, evaluation, and education.
– The National Institute for Health and Care Excellence (NICE) Guideline on Falls in Older People: Assessment and Prevention (2013), which provides a pragmatic and individualized approach to fall prevention, including case finding, multifactorial assessment, multifactorial intervention, and review.
The common elements of these guidelines are:
– A systematic process for identifying patients at risk of falling using validated screening tools such as the Morse Fall Scale, the Hendrich II Fall Risk Model, or the STRATIFY Tool.
– A comprehensive and multidimensional assessment of the intrinsic and extrinsic risk factors for falls using standardized tools such as the Tinetti Balance and Gait Test, the Berg Balance Scale, the Timed Up and Go Test, or the Get Up and Go Test.
– A multifactorial and individualized intervention plan that addresses the modifiable risk factors for falls using a combination of strategies such as medication review, exercise, environmental modification, assistive devices, staff education, patient education, and fall prevention protocols.
– A regular and ongoing monitoring and evaluation of the effectiveness of the intervention plan using outcome measures such as fall rates, fall injuries, quality of life, and patient satisfaction.
– A clear and consistent documentation and communication of the fall risk status, assessment results, intervention plan, and outcome measures among the health care team, the patient, and the family or caregivers.
Strategies for Implementing a Fall Prevention Program
Implementing a fall prevention program in long-term care facilities requires a systematic and collaborative approach that involves multiple stakeholders at different levels. Some of the key strategies for implementing a fall prevention program are:
– Obtaining leadership support and commitment from the management and administration of the facility to provide adequate resources, policies, procedures, and incentives for fall prevention.
– Establishing a multidisciplinary fall prevention team that includes representatives from nursing, medicine, pharmacy, physiotherapy,
occupational therapy,
dietetics,
social work,
and other relevant disciplines to coordinate,
plan,
implement,
and evaluate the fall prevention program.
– Conducting a baseline assessment of the current fall situation in the facility using data sources such as incident reports,
quality indicators,
patient records,
and staff surveys to identify the prevalence,
incidence,
severity,
and causes of falls
and fall-related injuries.
– Developing a fall prevention protocol that is based on the best available evidence
and tailored to the specific needs
and characteristics of the facility
and its patients.
The protocol should include clear definitions,
criteria,
goals,
objectives,
activities,
roles,
responsibilities,
and timelines for fall prevention.
– Educating and training staff on the fall prevention protocol
and providing them with the necessary knowledge,
skills,
tools,
and feedback to implement it effectively
and consistently.
Staff education should include topics such as fall risk assessment,
fall prevention interventions,
fall reporting,
fall analysis,
and fall prevention policies
and procedures.
– Educating and engaging patients
and their families or caregivers on the fall prevention protocol
and involving them in the decision-making process regarding their fall risk status,
assessment results,
intervention plan,
and outcome measures.
Patient education should include topics such as fall risk factors,
fall prevention strategies,
fall reporting,
fall analysis,
and fall prevention resources
and support.
– Implementing and monitoring the fall prevention protocol according to the established plan
and using appropriate tools such as checklists,
flowcharts,
forms,
charts,
and logs to document
and track the progress
and outcomes of the program.
– Evaluating and improving the fall prevention protocol using quantitative
and qualitative methods such as audits,
surveys,
interviews,
focus groups,
and case studies to measure
and analyze the impact
and effectiveness of the program on reducing falls
and fall-related injuries
and improving.
