They all fall.

Strategies for reducing falls among the elderly

There's no getting around it: with aging comes an increased risk for falls. The older we get, the more likely we are to "get up and go," only to find ourselves eye level with the floor. This is particularly true of individuals who have celebrated their 60th birthday and beyond. The experts interviewed for this article estimate that about 30 percent of home-dwelling elders fall each year. In long term care facilities, that statistic extends to as many as 50 percent, with more than 40 percent of this group experiencing recurrent falls within 6 months of an initial incident.

Accidental falls in the elderly community are associated with significant clinical, mental, and economic consequences. Fractures of the hips, spine, and forearms, for instance, are common repercussions of these casualties. Furthermore, some 30 percent of cases involving hip fractures result in fatality within five months of injury. Indeed, falling is the leading cause of injury-related death for people 85 years of age and older, according to experts in the industry.

According to Kevin M. Kavanaugh, director of public affairs for the Illinois Council on Long Term Care, the psychological obstacles resulting from these falls are as dangerous to victims as the physical problems. Once someone has fallen, he explains, a powerful post-fall anxiety syndrome often sets in, "which can have a dramatic impact on one's mobility, autonomy, and overall quality of life. The old adage 'use it or lose it' truly applies here," he emphasizes.

Besides physical and mental issues, falls consume a tremendous amount of national health care resources, namely, in terms of hospital admissions, bed utilization, and the need for other health and allied services. Out-of-pocket costs to patients can be significant as well. Current reports estimate that more than $20 billion is spent annually on falls involving people [greater than or equal to] 65 years of age, according to industry experts.

Multiple risk factors

Typically, falls among the elderly result from a combination of several risk factors. Among the leading intrinsic risk factors are physiological changes in balance and gait (see "Major risk factors for falls among the elderly," page 40), often caused by the natural aging process, if not the result of a medical condition such as Parkinson's disease. For many people of advanced age, the seemingly simple task of lifting one's feet to get from point A to point B can prove to be an exhausting proposition, notes Brenda McKenzie, director of health services for Catholic Health Services in Lauderdale Lakes, Fla.

"Medications--particularly multiple ones--are a second notable risk factor," continues McKenzie, considering many of them can cause dizziness, lightheadedness, drowsiness, poor balance, and postural hypo-tension. While psychotropic agents are believed to be the most common contributor to falls, "all medicines, including antihypertensives and diuretics, place people at increased risk for these accidents," she adds.

Interestingly, investigation reveals that up to half of all nursing home residents have difficulty navigating around their environment because of vision problems (yet another key risk factor). [1] To see clearly, the elderly require two to three times as much light and three times as much color contrast as healthy younger adults, maintains Kavanaugh. "Many seniors also have trouble adjusting their eyes from a dark to light atmosphere," which can cause temporary loss of vision. Residents with dementia and those who have suffered from stroke may have visio-spatial awareness deficits as well, he says.

"Incontinence is a serious, yet frequently overlooked, cause for falls," contends Sue Gardiner, director of clinical services, Illinois Council on Long Term Care. Often by the time a senior manages to get out of bed to go to the bathroom, "he or she has already urinated on the floor," setting the stage for a second accident.

Many authorities cite fear of falling as a leading precursor to falling. It has been found, for example, that many people who fear injury favor inactivity and, as a result, experience compromised muscle strength and knee and hip function, which only exacerbates the risk for future problems.

Barb Lupo, nurse consultant for Family Care Management, Forest Villa Nursing Center, in Niles, Ill., explains that many older adults lack the cognitive judgment necessary to move about their environment safely. For instance, "a resident who requires a cane won't think twice about walking around without this mobility aid," Lupo says. This is particularly true of those who suffer from conditions such as Alzheimer's and dementia, she points out, as these ailments cause confusion and forgetfulness and lead to wandering and pacing.

According to research, consumption of an alcoholic beverage leads to numerous falls in the geriatric population, particularly among individuals who have problems with balance and gait. Additionally, the incidence of falls has been linked to poor nutritional status. Studies reveal, for example, that inadequate vitamin D intake is associated with poor muscle tone, and decreased vitamin B-12 has been found to reduce proprioception, thought to play a part in how the brain translates spatial knowledge and assist in orientation.

Environmental hazards such as slippery and bumpy floors, cluttered pathways, and loose rugs play a leading role in as many as 44 percent of falls. Inadequately fitted, poorly maintained, or improperly used mobility aids greatly increase one's chances of falling, too, along with improper clothing and footwear.

Get with the program

In the past few years, a national movement toward physical-restraint reduction for long term care residents has brought fall-prevention issues into the limelight. While experts contend facilities have done a commendable job cutting back on the use of these restraints, a byproduct of this initiative has been an increase in the number of nonserious falls. Nevertheless, investigation reveals the high rate of falls in nursing homes and comparable establishments should not be viewed as inevitable, but rather as outcomes that can and should be improved considerably via structured safety programs. [2]

A few years ago, the Illinois Council on Long Term Care developed a standardized fall protocol outlining specific interventions for its member facilities. This policy, which goes above and beyond mandatory state and federal regulations, recommends that a facility's fall-prevention program include these chief components:

* A multidisciplinary safety committee consisting of members who are knowledgeable in the area of falls, and that includes at least one employee with administrative authority who can facilitate policy change.

* An in-service education program for all nurses and medical house staff involved in resident care.

* A mechanism that identifies for all nursing shifts those residents at risk of falling immediately upon their admission. The Council also recommends residents' risk be reassessed following changes to their medical condition, medication regimen, or mobility status.

* Prompt assessment following an accident, including an evaluation of underlying medical and environmental causes.

* Expeditious implementation of fall-prevention strategies and regular follow-up that examines whether these strategies have reduced falls effectively.

To date, an impressive number of Illinois nursing facilities have adopted the Council's fall protocol and instituted official programs. "As part of our program, all residents accepted into our facility are evaluated to determine their risk for future falls," explains Carolyn Simmons, rehabilitation director at Mayfield Care Center in Chicago. "Those deemed high risk and those with a history of falls wear orange wristbands, and orange leaf stickers are placed on their doors. In addition," Simmons continues, "we keep an orange book listing the names of all program members at each nursing station," which helps staff to remember which residents require special surveillance.

Lupo notes that during their initial assessment of residents, besides looking at factors such as medications and vision problems, "we try hard to obtain information on a resident's history of falls, as cluster falls are so predictive, even in terms of estimating mortality."

An important part of any initial assessment is the physical examination, experts point out. This checkup should appraise a person's proximal muscle strength, knee and hip function, postural stability, ability to walk and climb stairs, as well as steadiness on turning and sitting. Because body weight often is considered a vital sign for the geriatric population, some authorities also recommend residents' body mass index (BMI) be assessed, along with their nutritional status.

Authorities unanimously agree that getting residents involved in regular physical activity designed to enhance muscle strength, balance, and coordination is potent fall-prevention medicine. Studies reveal, for instance, that many falls and subsequent injuries can be avoided by encouraging elders to perform simple sitting-to-standing and stretching exercises in addition to getting residents involved in more structured activities such as daily walks, yoga, and tai chi.

Many of the residents at Mayfield Care Center participate in exercise designed to increase leg strength and maximize functional independence, notes Simmons. Individuals typically reliant on wheelchairs, for example, are encouraged to walk to the dining room and up and down hallways with the help of staff, she says.

Gardiner asserts the wave of the future for long term care facilities is ongoing maintenance and improvement of residents' physical function, which, in turn, will enable them to head off future falls. She believes this will he particularly true "as the baby boomers begin looking at nursing home placement. These folks recognize the benefits of keeping fit and thus will expect to continue the same exercise regimens they were used to throughout their healthy adult years."

In Lupo's opinion, keeping residents engaged in activity, physical or otherwise, is critical. "It's okay for low-risk people to stay in their rooms and go about their daily business, but high-risk individuals need to stay central and visible whenever possible," she notes.

"One of our member facilities recently incorporated an Adopt-a-Resident program into its fall-prevention initiative," explains McKenzie. This new enterprise requires a particular employee "to keep a more vigilant eye on his or her designated high-risk 'adoptee,' largely by paying more visits to this resident throughout the day."

Help them help themselves

Patient education is of paramount importance to any prevention program, contends Kavanaugh. For example, employees must have ongoing dialogue with residents about safe transfer techniques, the importance of moving slowly from a reclined to sitting and standing positions, wearing their eyeglasses, and using handrails. "The most effective programs will be those that encourage residents to remain part of the process," he emphasizes.

"Thanks to the success of our prevention program, monthly resident falls have been reduced by 50 percent," boasts Simmons. Furthermore, rather than relying on restraints to prevent falls (Mayfield is entirely restraint-free), Simmons and colleagues work hard to devise alternatives that ensure resident safety. "Our staff recognizes that restraints do not necessarily decrease the likelihood of falls, but in fact, can lead to serious accidents from residents attempting to break free of them." (For additional fall reduction tips, see 'Ways to reduce accidental falls,' above.)

Being proactive is smart business

Experts predict that as our population continues to gray, the problems associated with falls and related injury will escalate unless more prevention programs are set in motion and taken seriously. In today's health care environment, contend experts, it is vital that long term care facilities remain proactive. "For starters, organizations that fail to institute formalized programs are placing their residents at real risk of increased morbidity and mortality," says Kavanaugh, "not to mention seriously compromising their independence and overall quality of life."

From a business standpoint, he continues, lax facilities are at definite risk of lawsuits and very much at risk of not being able to defend themselves properly when the lawyers come to call. Litigation has proven to be a mammoth problem in this country, says McKenzie, particularly in states such as Florida, where state law grants families the legal right to sue for any falling incident, regardless of whether an injury has resulted.

A facility's profitability hinges on its reputation, Lupo stresses. "To most families, a clean, home-like environment with good, safe care is the bottom line," she says. Facilities unable to show families formalized mechanisms in place to protect the well being of their moms and dads are not thinking smart, she concludes.

Nancy E. Trotto is a freelance writer based in Totowa, N.J.

References:

(1.) Kavanaugh KM, Tate B. Recognizing and helping older persons with vision impairments. Geriatric Nursing. 1996; 17:68-71.

(2.) Ray WA, Taylor JA, Meador KG, et al. A randomized trial of a consultation service to reduce fails in nursing homes. JAMA. 1997;278:557-562.

MAJOR RISK FACTORS FOR FALLS AMONG THE ELDERLY

* Balance and gait problems

* Medications (often multiple)

* Poor vision

* Incontinence

* Fear of falling

* Cognitive impairment

* Alcohol use

* Poor nutritional status

* Environmental hazards

* Other medical conditions 

WAYS TO REDUCE ACCIDENTAL FALLS

Environmental hazards

* Keep pathways clutter-free.

* Install sturdy grab bars in tub and toilet areas.

* Avoid/firmly secure small rugs and carpets with rubber, non-skid backing.

* Keep telephone and electrical cords out of traffic lanes.

* Avoid high-gloss floor wax.

* Keep doors opened flush or closed completely, chairs pushed up tightly against tables, and dresser drawers shut.

Vision issues

* Keep rooms, hallways, and stairways adequately lit. Use nightlights in bedrooms and other dim areas.

* Conduct routine screening of residents' vision, with and without their glasses or contact lenses.

* Provide color contrast, where possible. Paint doorsills, doorknobs, floor borders, and handrails a contrasting color from walls. Select furniture distinct in color from its surroundings. Place contrasting-colored tape around the edge of toilet seats.

Clothing

* Make sure hems on pants, long skirts, and robes are not torn or too long.

* Ensure bedroom slippers are closed.

* Recommend residents wear light-weight gym shoes rather than heavy, clumsy athletic shoes. All footwear should be sturdy and well-fitted, with low heels and non-slip soles.

Miscellaneous

* Remind residents to take their time getting from place to place.

* Encourage residents who tend to wake each night at the same time with a full bladder to set their alarms for an hour earlier.

* Make sure residents who require mobility aids such as walkers and wheelchairs understand how to use them properly and that these devices are fitted to users properly.