Falls and Patient Safety for Older Adults
America is “graying.” Currently, the elderly (65 years of age and older) represent 12.4% of the US population, with nearly 1.8% over age 85.1 It is anticipated that by the year 2020 more than 20% of the population will be older than 65 years of age.2 States with higher than average proportions of older adults include California, New York, Pennsylvania, West Virginia, and Florida.1
Healthcare professionals faced with the challenge of providing post-fall care frequently required in this population are increasingly concerned about the conditions and events that may be antecedents to falls. For instance, the elderly have a higher incidence of chronic illness compared with acute illness, with each person having at least one chronic illness2 that potentially could precipitate a fall. The medical condition, health, and environmental factors often reported to contribute to falls are listed in Table 1.
Falls have garnered the attention of regulatory agencies. The Federal Nursing Home Reform Act (1987) created a national set of minimum standards of care and rights for people living in certified long-term care facilities. The standards emphasize quality of life and quality of care, including the right to be free of unnecessary or inappropriate physical and chemical restraints. Error reduction in safe care provision also has become a national concern. In 2001, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) began publishing standards for patient safety as a means to protect patients in all types of healthcare settings from injury; the safety standard for fall prevention was added in 2005.3
Federal regulations for long-term care facilities, known as F-tags, were established to set conditions for participation in the Medicare certification and payment system. A recent modification of F-Tag 323, which deals with patient safety in the resident’s environment (eg, throw rugs, furniture), combined preventing accidents and providing residents with supervision. The new tag states that a facility should provide 1) an environment free from hazards over which the facility has control and 2) appropriate supervision for each resident to prevent avoidable accidents. Included in the amended tag are quality improvement measures relating to the identification of hazards and risks, evaluation and analysis of hazards and risks, implementation of interventions, and continuous monitoring of the effectiveness of intervention and modification of the interventions as needed.
Falling and the Elderly
Because older adults are prone to falls, many healthcare providers assert that falling is a major geriatric syndrome.4 According to geriatric experts, older adults are not aware of their risk for falling and may not want to be considered old and dependent, so they do not report their frailty or event(s) of falling to their healthcare providers.5,6 Hence, opinion is that falls are under-reported in this age group.4,6
Secondary sources report nearly one third of adults over age 65 living at home and 50% of institutionalized elderly patients have fallen at least once during a 24-month period6-8; Lord et al9 reported in a prospective cohort study that 65% of intermediate care residents (N = 1,000) have incurred one or more falls. The average incidence rate of falls in long-term care facilities is 200 to 3,600 falls per 1,000 residents.5
A 7-year retrospective cohort study10 conducted in a psychogeriatric unit of 1,834 patients reported a 9.5% fall rate, which was higher than the general medical unit. In this institution, falls accounted for 24.8% of the explained variance of hospital length of stay for patients in the study group. Dementia also was associated with falls; for this subgroup, falls occurred on mean day 101 ± 8.3 of hospitalization. The study also reported that older adults receiving electroconvulsive therapy (ECT) were more likely to fall.10
Review of the literature denotes the importance of describing circumstances of a fall in order to make necessary changes in the older adult’s healthcare needs or environment.7 It has been reported in a convenience sample study of adults (N = 220) living in a continuing care retirement community that older adults are more likely to fall between the hours of noon and midnight, primarily due to sleep disturbance such as insomnia at night.11 Edelberg reports that 10% of older adults living independently in the community fall when using stairs.7 Falls in long-term care facilities tend to occur as a result of environmental conditions during transfer or when bed- or chairbound residents use improperly fitting equipment.7 Falls occur most often in the bathroom or bedroom as the individual is going to or coming from the bathroom.11 Environmental hazards such as throw rugs, furniture, and poor lighting account for nearly 22% of the falls in older adults.12 Falls also can occur when the older adult leans forward out of a chair. It can be inferred that the more active an older adult, the more likely a fall.
Risk Factors Associated with Falling
Intrinsic factors. Identified risk factors for falling can be divided into two categories: intrinsic and extrinsic. Intrinsic factors include age-related changes and disease, lower extremity weakness, poor grip strength, balance disorders, functional and/or cognitive impairment, and visual deficit.4-8,12-19 According to a cross-sectional retrospective study completed by Menz, Pod, and Lord20 of 135 community-dwelling men and women, a history of falls and a higher level of foot problems such as hallux valgus was a significantly higher predictor (P <0.05) of fall risk. A review of the literature6 reveals that many healthcare providers believe falls to be a symptom of a disease process or drug side effect unless these diagnoses are ruled out. Comorbid diseases, such as osteoporosis and age-related physiological decline (ie, slower reflexes, changes in vision and gait) often are associated with falls in the elderly.5
De Rekeneire et al15 performed a cross-sectional analysis of 12 months of fall reports involving 3,075 elderly individuals (70 to 79 years) living independently in the community. They found that older adults who fall are more likely to be Caucasian, female, have a chronic disease, take multiple medications, have difficulty rising from a chair, carrying a 10-lb object, and have a relatively poor functional status including a decrease in total leg muscle and strength of the lower extremities. A few studies suggest that women fall more frequently than men.15,16
Underlying diseases and conditions. Several studies and summary articles have found underlying diseases — including chronic health conditions, frailty, and neurological and gait disorders — to be interrelated with falling.7,9,13,18 Urinary incontinence also is associated with a higher risk of falling.9,15 Syncope accounts for 4% to 8% of falls, with approximately one third of older adults having recurrent events.7 A 13% to 38% prevalence rate of dizziness in older adults, linked to fall frequency, was noted in a review of the literature.18 A prospective cohort study of 199 men and women living in residential facilities found that normal changes associated with aging such as neuromuscular and cardiac hemostasis, degeneration in large joint mechanoreceptors, postural instability, increased sway from a decreased ability to control a narrow base of support, and decrease in stride length also have been identified as risk factors for falling in the elderly.14
Neurological problems related to falling include gait and balance deficits, periventricular white matter disease, cervical spondylosis, multisensory deficit, normal pressure hydrocephalus, progressive super nuclear palsy, stroke with hemiparesis, and Parkinson’s.7 Dementia was found to be an independent risk factor in a prospective cohort study of patients (N = 2,015) in 59 long-term care facilities.15 Older adults living in long-term care facilities were found to be two times more likely to fall than residents without a diagnosis of dementia.16
Gait abnormalities affect 20% to 50% of adults 65 years or older.13 Although gait and balance abnormalities have been identified as risk factors for falling in the elderly, many practitioners, particularly in physical therapy, include foot disorders such as long toe nails and bunions as risk factors.7,20
Difficulty falling asleep and staying asleep is part of the aging process. Older adults spend more time in lighter (stage 2) sleep; fewer hours of deep sleep could possibly increase fatigue.4 Difficulty sleeping is considered a contributing factor to nighttime falls.4 Healthcare practitioners should realize that older adults with sleep disturbances are at a higher risk for falling if a tendency to experience postural hypotension — defined as a 20 mm Hg drop in the systolic blood pressure when moving from a seated to standing position — also exists. This medical condition affects 20% to 30% home-dwelling older adults and has been implicated in 5% of falls.7 The same study also found a relationship between postural hypotension, medications, dehydration, and deconditioning — factors in older adults falling.7
Although not as common as chronic illness in this age group, acute illness is often the only precipitating event to falling in older adults.6,9,21 Two prospective cohort studies conducted by Kallin et al14,21 reported that 25% to 27% of falls were preceded by acute illness, 7.9% of which were urinary tract infections. One study also reported that 10% of falls were secondary to delirium associated with acute conditions.14
A prospective cohort study (N = 667) in Australia examined the relationship between serum vitamin D levels and falls.17 The researchers measured serum 25-hydroxyvitamin D (25D), a metabolite present in the blood reflecting vitamin D status. It was found that a low serum vitamin D level was an independent predictor of falls, excluding the bedbound older adult. Lower vitamin D levels also were found to be associated with poorer cognitive function, as well as wandering and falling. Nearly all of the residents of long-term care facilities were found to have a low level of 25D (25 to 168 nmol/L). Only 8% of residents in hostels and nursing homes were taking a vitamin D supplement.
Some researchers consider medication an intrinsic risk factor (see Table 1).6 One retrospective cohort study (N = 1,834) demonstrated that a patient receiving diuretic therapy would fall on day 12.5 ± 9.4 of hospitalization compared to the patient not receiving diuretic therapy (day 9.5 ± 7.9).10 These data appear to contradict clinical observations by practitioners that administering diuretics to the elderly leads to frequent urination and potential incontinence, which can potentially lead to falls.
Extrinsic factors. Extrinsic factors include polypharmacy (greater than or equal to four medications) and environmental factors.6-8,12-14,19,22
Medications. Drug side effects have been reported to be responsible for approximately 10% of falls.21 Older adults taking a psychotropic medication were 28 times more likely to fall.4 Although medication can increase the risk of falling, it is not always a predictor for falls in older adults.12 As previously mentioned, older adults may not sleep as well, so anything that interferes with what little sleep they get could compound other problems — as such, the use of medications known to be causative agents for falling in older adults compounds the effects of fewer hours of deep sleep.
Obstacles and impediments. A review of the literature leads to the assumption that most falls are due to environmental factors or situations, such as an over-crowded area in a store or shopping mall or wearing loose, long clothing in the course of normal activity.5-7,12,13 Specific external or extrinsic factors cited in the literature include obstacles or material defects (ie, hip protectors that are faulty or ill-fitting, clothing), errors of judgment (ie, not noting location of furniture, throw rugs), problems transferring from bed to chair to bed, misuse of walkers or other devices to aid ambulation, mistakes by healthcare staff (ie, leaving patient in bathroom unassisted, forgetting to put on parts of the wheelchair, turning off a night light), or mistreatment by other residents of the long-term care facility.7,9,12 Researchers have found that a history of poor visual contrast (eg, walls, furniture, and flooring a similar color) led to an increased the likelihood of older adults falling.9,12 It has been noted in summary articles that footwear influences the risk of falling — wearing a thin, hard sole is best for older adults.6,7
Physical restraints are an important environmental consideration in healthcare facilities. Studies have yielded differing conclusions — some have shown that decreasing the use of restraints (eg, bed rails or trunk restraints) can lead to an increase in falls6,7,12,16 but one matched case-control study of hospitalized patients (N = 456) found no evidence that using restraints decreased the occurrence of falls.22 The use of restraints decreases muscle mass, joint flexibility, and strength, which also can lead to falls.
The risk for falling increases as the number of risk factors increases.5 One study5 reported the risk of falling in older adults increased from 27% to 78% for patients with four or more risk factors. Among community-dwelling older adults, recurrent falls increased from 10% to 69% as the number of risk factors increased from one to greater than four. Vassallo and associates’13 prospective observational study of 1,025 patients admitted to a geriatric non-acute hospital described recurrent fallers as more likely to have pre-admission falls, unsafe gait, and taking tranquilizers and antidepressants. Confusion and unsafe gait were also common factors related to both single and recurrent fallers in the Vassallo study. Recurrent falls were generally associated with older adults taking antidepressants while single fallers more commonly had impaired hearing.13 A descriptive study conducted by Huang and associates18 of 103 residents in an elder housing apartment reported that the combined factors of physical function, environment, footwear, social support, cognitive status, and previous falls put older adults at risk for falling.
The Lord et al9 prospective cohort study of intermediate care residents (N = 1,000) found that medical conditions were more often a causative factor in the falls of older adults who stand unaided compared to those needing assistance to stand. In this study, more severe illness, impaired cognitive status, Parkinson’s disease, incontinence, and administration of sedatives and antidepressants were found to be the primary risk factors for falls,10 which supports Nevitt’s23 findings that fall risk increases when the older adult has four or more risk factors. The Lord et al study demonstrated falls were significantly (P <0.05) associated with poor visual contrast sensitivity, quadriceps strength, slower reaction time, increased postural sway, and poor static balance and sit-stand ability. Nevitt et al23 also found a strong linear relationship also existed between standing balance and falls of residents in long-term care facilities. Fall rates were highest in older adults who could rise from a chair but could not stand unaided, intermediate in those who could do both, and lowest in those who could neither rise nor stand unaided.9 Obviously, the injury when falling from a chair or low-level bed was less serious due to the lower height. The ability to rise from a chair but not stand was consistent with a higher prevalence of falls in nursing homes that occurred from a chair or bed and while transferring.9
Injury as a Result of Falling
Falls in the older adult can increase mortality and morbidity rates and reduce function; they are factors in premature admission to long-term care facilities.5,6,18 Fall-related injury is the sixth highest cause of death in older people.6 The injury rate of long-term care facility residents whose fall results in fracture, laceration, and head injury requiring hospital care ranges from 10% to 25%.5-7,21 Between 12% and 33% of older adults who fall one or more times will have at least one fracture21; 50% of older adults over 75 years old who have fractured a hip will die within 1 year of the fall and injury.6 Older adults having multiple falls have an increased mortality rate. One study6 noted that 10% of hospitalized older adults with multiple falls die before discharge from the facility.
Falls in older adults are associated with major health complications that can result in health decline, increased healthcare cost, and death. One cross-sectional, retrospective study of 135 community-dwelling adults over age 75 years found that 58% of reported falls that resulted in a fracture were due to acute illness, such as cerebral vascular accident.20 According to a panel of geriatricians who developed guidelines for the prevention of falls in older persons, at least 5% of the elderly who fall are hospitalized.4
Healthcare costs for falls in older adults in 1998 averaged $19,440 per person, accounting for 6% of the medical costs for adults 65 years and older in the US based on data compiled by the US Health Care Financing Administration and Connecticut Long Term Care Registry.24 Falls account for 20% of hospital and 40% of nursing home admissions each year2 and result in more than 75% of the deaths in older adults, of which 13% occur in the population age 65 and older.5 Based on the review of literature, recurrent falls are the most common reason for older adult readmission to long-term care facilities.
A Scandinavian retrospective study25 provides additional information regarding the types of injuries sustained by 65- to 74-year-olds as a result of falling. The sample of 332 patients admitted to the hospital showed that more than 50% of distal forearm fractures occurred secondary to a fall outdoors and approximately 66% of hip fractures occurred from falling indoors. Women were more likely to sustain a fracture (74%, P = 0.05), most commonly on the distal forearm. Hip fracture was seen more often in men (24%). Bone quality and fall impact determined the resulting fracture. Other injuries from falling that may need treatment include bruises, head injury, and lacerations.26
Psychological and Long-Term Effects of Falling
It can be inferred that for many older adults, the fear of falling becomes a focal point in their lives — a potential root cause of their social isolation and subsequent depression. Many older adults who have fallen, and particularly who sustain fall-related injury, experience post-fall syndrome, defined as the older adult experiencing hesitancy in ambulation and a loss of confidence, leading to decreased mobility and independence.6
Fear of falling affects 25% to 40% of the elderly and is an independent risk factor.4 In a prospective cohort study of community-dwelling older adults in senior living facilities in Atlanta, Kressing et al27 reported the prevalence of fear of falling is 29% to 77%. The study revealed that fear of falling is common among older adults regardless of age. Fear of falling was greater among African-Americans compared to Caucasians (odds ratio of 2.7 for Activities-Specific Balance Confidence Scale; 2.1 for Falls Efficacy Scale). Individuals who were depressed in addition to having a slow gait and using walker had a greater fear of falling.27 Another study found that antidepressant use was a more significant factor (P = 0.006) in an older adult falling than depression alone.21
A prospective study conducted by Kempen et al28 examined gender differences in fall recovery. It was discovered that women did not recover as well as men from fall-related injuries. The difference in recovery for both genders was not apparent until 5 months post-injury. Neither gender was able to achieve pre-injury functional levels. Recovery for both genders was dependent on the severity of the injury.
Determining risk. Many studies have been conducted to develop fall risk assessment tools. Meyers and Nikoletti29 recently reported that nurses had the highest accuracy in predicting a patient’s fall risk compared to two established fall risk instruments presented by MacAvoy30 et al and Schmid.31 The data also showed that nurses in general overestimated the population at risk to the same degree as the two risk assessment tools used in the study; this may have occurred because prevention factors already were in place.29 The tools selected by Meyers and Nikoletti29 had intensive validity testing and the categories listed in each tool were clear and measurable.
The STRATIFY Risk Assessment Tool identifies a resident or patient’s risk for falling based on the following indicators: previous falls, agitation, impaired vision, frequent toileting, and Barthel Score for transfer and mobility.27 The STRATIFY tool was tested in three phases in the elderly care units of two acute care hospitals. Phase 1 included 232 subjects (50% control), Phase 2 included 1,217 subjects, and 331 subjects participated in Phase 3 of the study. The clinical sensitivity of the tool ranged from 92% to 93% and the specificity was 68% to 88%. The author reports that use of the tool increases the clinical accuracy of predicting patient falls.
Another tool, RISK (an acronym for Reassessment Is Safe Kare), uses four indicators to assess for fall risk.32 The original tool consisted of 26 items and was tested over a 3-month period at a large Veterans Administration hospital consisting of medical-surgical, psychiatric, and long-term care facilities. The tool was used on 10 units in the medical-surgical and nursing home units within the facility. After completing testing, a random sample of 25% (n = 208) was selected for statistical analysis. Following Pearson’s correlation coefficient, the tool was shortened to four risk factors of dizziness/unsteady gait/balance, impaired memory or judgment, weakness, and history of falls. The sensitivity and specificity of the tool to predict falls were 43% and 70%, respectively.
Other tools have been developed to assist the healthcare provider to assess fall risk without scoring risk factors34 (see Tables 2 and 3). These tools give healthcare providers a simple way to recall identified risk factors.
Environmental modifications. The use of alarms for the older adult’s wheelchair or bed to alert the nursing staff to a potential fall is an important part of anticipatory care. Modifying the environment for community-dwelling or long-term care residents also will help alleviate or decrease the occurrence of falls. Hip protectors to decrease injury to the hip are advocated for ambulatory older adults at risk for falling.6 Given current evidence that physical restraints do not reduce falls, they rarely should be used.
Counsel. Healthcare providers should routinely counsel adults 65 years and older as a means to alleviate potential falls. Counseling should include reviewing medication associated with falls and discussing exercise.6,7 The older adult should be instructed on the importance of improving and/or maintaining good gait and balance.
Exercise. Weight-bearing exercises have been found to increase strength, endurance, and coordination.6 Despite evidence that exercise can improve one’s ability to avoid falling, it is not a stand-alone prevention. Menz, Pod, and Lord’s study20 found that treating the foot problems of an older adult to improve balance and functional ability decreases the occurrence of falls.
An experimental study34 of Sun-style Tai Chi, a version of the ancient Chinese discipline of meditative movements, was conducted to determine if this particular form of exercise could improve the strength, balance, and mobility of nursing home residents at risk for falling. Results showed it improved muscle strength of knee flexors and extensors, ankle dorsiflexion, plantar flexion, and flexibility, as well as resident confidence.34
Balance assessment. Clinical measures of balance should be obtained for all older adults as a normal part of assessment during a routine visit with the primary healthcare provider or on admission to a long-term care facility. The Functional Reach test assesses how far the individual can reach beyond arm’s length while maintaining a fixed base of support while standing. The patient should be able to move the fist a distance of 15 cm; risk for falling is evident if the individual moves the fist <15 cm.18 Another measurement of balance is the Get-up and GO test (see Table 2). An older adult who moves less than 1 meter/second is at risk of falling; the higher the score, the greater the risk of falling.18
Quality indicators. Rubenstein, Powers, and MacLean35 reported that quality indicators can be used to manage falls in the elderly. Their report listed six indicators (see Table 4) that include assessing older adults risk and prescribing solutions to correct gait and balance problems. Quality indicators supported by the American Nurses Association regarding resident falls, satisfaction with education information, overall care, and nursing care are also beneficial in monitoring falls.36
Whatever method is used to monitor falls in the older adult, it should include components for data collection, analysis, change in practice such as staff education, and continuous evaluation of changes to improve fall prevention.
Focus on falls resulting in injury of older adults will increase as the population ages, expanding from long-term care facilities to home care and acute care settings. Healthcare providers must recognize that falls do not occur simply because the person is elderly; multiple underlying causes that may not be related to aging contribute to falling. Extrinsic factors are as much a cause of falls in the elderly as the physiologic changes of aging and acute illness. Falls can be precipitated by environmental obstacles; polypharmacy also needs to be addressed, perhaps with a gatekeeper such as a pharmacist.
As healthcare facilities adopt restraint-free policies, falls may increase rather than decrease. Dealing with this double-edged sword will be a difficult issue, particularly when the current approach is to keep the resident restraint-free.
Using risk assessment tools, as in pressure ulcer care, is not necessarily a completely accurate predictor of fall risk. However, assessment tools keep the potential problem of falls in the forefront. It appears from reviewing the literature that fall risk assessment tools have helped educational efforts and increase fall risk awareness among staff, family, and patients. These are important steps in fall prevention that may offset sole reliance on risk assessment. Providing education and resources to all individuals who may be affected by falling — including information on post-fall syndrome and behaviors to prevent further falls — will facilitate a better understanding of the falling phenomenon in older adults.
Research needs to continue in developing a better understanding of common characteristics of individuals who fall and their response to falling, including the extent of injury and what products might protect the older adult in a fall. To confirm and expand upon the results of the vitamin D study conducted in Australia, research to explore the relationship between nutrition and falling should be conducted.
Literature related to how wound care specialists are caring for the injuries of older adults who fall is nonexistent. Data specific to this population should be generated in order to improve understanding of how clinicians can help prevent fall injuries and improve outcomes of care once a fall has occurred. Most importantly, healthcare must continue to advocate for patient safety in all areas of care.