Practical Approaches to Reducing Falls in NFs

by Laurie Lewis

Some falls will occur in nursing homes, no matter how excellent the care. That was the case earlier this year when former President Ronald Reagan fell in his home.

"President Reagan has the best care in the world, yet he still fell and broke his hip. This illustrates that falls will happen, no matter what," said Ted Johnson, MD, MPH, Nursing Home Care Unit Medical Director at the Atlanta VA Medical Center.

Dr. Johnson participated in a panel on falls and safety at AMDA's Annual Symposium last March. He was joined by Laurence Rubenstein, MD, MPH, Professor of Geriatric Medicine at UCLA and Director of the Geriatric Research Education and Clinical Center at the Greater Los Angeles VA Medical Center, and Elizabeth Capezuti, PhD, RN, GNP, Associate Professor, Independence Foundation--Wesley Woods Chair in Gerontologic Nursing at Emory University in Atlanta.

The experts agreed that although falls can't be eliminated altogether, steps can be taken to reduce the risk and lessen the chance that falls will result in injury (also see the Policies & Procedures column in the November 2001 issue, p. 8).

Macro & Micro Approach

The panelists noted that fall prevention must be attacked on two fronts: institutionally and individually. "Every nursing home needs a standardized fall prevention program with environmental safety adaptations as well as a systematic approach to assessing risk factors in individual residents," Dr. Rubenstein said.

Many nursing facilities already keep tight control over environmental hazards. The facilities are free of clutter; bathrooms are equipped with grab rails; and spills are mopped up immediately. But additional measures, such as using adjustable height beds and removing full-length bed rails, can increase safety and reduce the risk of falls, he noted.

"Most environmentally caused falls in nursing homes wouldn't happen in individuals with better balance or perception," Dr. Rubenstein continued. Indeed, most falls can be attributed not to extrinsic or environmental factors but to risk factors in the individual resident.

Among the greatest risk factors are cognitive impairment, gait and balance problems, and lower extremity disability. Weakness in the upper extremities also is a risk factor, because residents use their arms and hands for support when rising from a bed or chair and for balance when walking.

Visual or perceptual impairments can lead to falls when a resident encounters environmental obstacles. A person who has fallen in the past has an increased risk of falling again. Someone taking multiple medications, especially psychoactive drugs or medications that can cause orthostatic hypotension, is at especially great risk for falling. After reviewing this list, Dr. Johnson commented, "virtually the entire nursing home population is at risk for falls."

That is why a fall-prevention program starts with examination of the nursing home environment and implementation of changes that increase safety on a facility-wide basis. At the same time, a basic falls assessment is done to clarify risk factors in individual residents. Interventions are then tailored to the specific problems identified.

Resident Assessment Before & After a Fall

Dr. Rubenstein noted that a basic falls risk assessment consists of five elements:

• Falls history
• Medication review
• Focused physical examination, including postural changes in vital signs, vision and hearing screening, strength testing, and gait and balance evaluation
• Review of functional and cognitive status
• Environmental survey.

This basic assessment may identify problems amenable to correction. But, Dr. Johnson cautioned, "assessment may not translate into reduction of falls in the future." To reduce the risk, post-fall assessment is useful.

The immediate response at the time of a fall is to look for physical injury. When staff are certain that the resident is not hurt, or after the injuries have been attended to, another assessment should be performed. Questions to ask include:

• Does the resident know what caused the fall?
• Are environmental obstacles evident?
• Was the resident feeling weak or dizzy just before falling?
• Did the legs "just give out"?

"Post-fall assessment is one of the most effective tools at our disposal to increase safety," Dr. Rubenstein commented.

Dr. Johnson emphasized the importance of post-fall assessment in facilities that are limiting the use of restraints. "We merged post-fall assessment with our restraint reduction program," he said. "We see these going hand-in-hand as a way to increase patient mobility and safety."

More Solutions to Increase Safety

Based on the individual resident's risk factors for falling, as well as on any post-fall assessment, nursing home personnel can begin to institute changes. "Probably the most common interventions are changes in medication, followed by an exercise program. Environmental modification is the next most likely change," said Dr. Johnson.

When the assessment indicates gait disturbances or weakness, especially in the lower extremities, patients benefit from physical therapy and strengthening and balance exercises. "An exercise program is an effective intervention because exercise targets several risk factors," said Dr. Rubenstein.

Increased activity under supervision also safely enhances a resident's mobility. Dr. Capezuti suggested a "park and dine" program, in which residents leave their wheelchairs outside the dining room and walk with an aide to a table. "Wheelchairs are meant for transport, not sitting," she said.

The sling seat of a wheelchair does not provide support, and residents who shift around in their seats may tumble from their chairs. An occupational or physical therapist may be able to suggest appropriate cushioning to increase the comfort and safety of a resident who is going to spend most of the day in a wheelchair.

Bed safety is another important issue. A resident who cannot plant her feet firmly on the ground while sitting comfortably on the edge of the bed may fall when trying to get out of bed. A patient who has to climb over side rails to get to the bathroom may get caught in the rails and fall. A mattress that doesn't fit the bed frame appropriately also can trap the resident.

Dr. Capezuti offered solutions to these problems: "Refurnish the room with an adjustable-height bed, and leave it low to the ground. Don't use side rails. Instead, put a body-length pillow on the side of the bed to create a safe barrier. Widows have said they like the comfortable pillow, because it reminds them of being in bed with their spouse."

Electronic modifications also can increase safety in the nursing home. An alarm or bell that sounds when the occupant rises from a bed or chair warns a person with orthostatic hypotension to get up slowly and also alerts staff to assist the resident. Installing lighting under a bed or in the bathroom increases visibility and can prevent nighttime falls.

Recognizing that falls will occur despite these measures, the panelists emphasized the need to minimize the impact of falls. Dr. Rubenstein noted the value of wearing hip protectors as a way to lessen the risk of hip fracture. Dr. Capezuti suggested putting a mat next to the bed so that a falling resident makes a soft landing. "We may not be able to prevent all falls, but we can reduce the likelihood that a fall will result in serious injury," she concluded.

Medical journalist Laurie Lewis is a Contributing Writer to Caring.

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