Falls are the leading cause of injuryrelated death for individuals 65 and older (Centers for Disease Control and Prevention, 2001). The risk of falling increases exponentially with age (Samelson, Zhang, Kiel, Hannan, & Felson, 2002). An individual who is living independendy in the community may fall for different reasons than a hospitalized individual who is acutely ill or a resident of a long-term care facility. Health conditions affecting mobility, such as physical inactivity, frailty, or balance problems, lead to falls in the community-dwelling older population (Agostini, Baker, & Bogardus, 2001).
In contrast, falls occurring in health care settings are often attributed to a blend of the individual's health status and institutional factors. Hospital units staffed with less experienced nurses have higher rates of falls than units staffed by more experienced nurses (Biegen, Vaughn, & Goode, 2001). Many hospital falls occur during the first week following admission and during the daytime shift (Tutuarima, de Haan, & Limburg, 1993). Patient characteristics among hospital fallers include weakness, dizziness, sleeplessness, altered mobility, confusion, depression, substance abuse history, long hospital stays, lack of exercise, and incontinence (Bakarich, McMillan, & Prosser, 1997; Hendrich, Nyhuis, Kippenbrock, & Soja, 1995; Stevenson, Mills, WeKn, & Beai, 1998).
Similarly, in long-term care settings, low staffing levels contribute to falls that occur during nursing shift changes, in private locations (i.e., bedroom, bathroom), or when residents report being unable to wait for staff assistance with care activities (Hakim, 1998; Kiely, Kiel, Burrows, & Lipsitz, 1998). Recent admission, wandering, acute illnesses, medications, dementia, hip weakness, immobility, slippery floors, and unsafe furniture may also lead to falls in long-term care residents (Hakim, 1998; Kiely et al., 1998).
The purpose of this Fall Prevention Protocol is to describe strategies for identifying individuals at risk for falling and for preventing falls in older adults while maintaining autonomy and independence. The goals of this protocol are to:
* Detect individuals who have experienced a fall.
* Identify fall risk factors.
* Prevent the occurrence of falls and fall-related injuries.
DEFINITION OF FALLS
A fall is defined as unintentionally coming to rest on the ground, floor, or other lower level from a standing, sitting, or horizontal position (Agostini et al., 2001). Evidence of a fall is based on the recollection of the individual who fell and descriptions of the fall from witnesses.
INDIVIDUALS AT RISK FOR FALLS
The strongest predictor of future falling is a previous fall. Other risk factors include gait or balance deficit, muscle weakness, assist device use, visual deficit, arthritis, activities of daily living impairment, depression, cognitive decline, and age older than 80 years. The greater the number of risk factors, the greater the risk of falling (Agostini et al., 2001; American Geriatrics Society [AGS], 2001).
MULTIDIMENSIONAL FALLS ASSESSMENT
Prevention programs that decrease falls in older adults have included a Multidimensional Falls Assessment as the foundation for subsequent intervention (Close et al, 1999; Ray et aL, 1997; Tinetti, Baker, et aL, 1994; Tinetti, McAvay, & Claus, 1996). The goal of this assessment is to pair individual fall risk factors with targeted interventions to reduce the effects of chronic health conditions common to many older adults. A threestep Multidimensional Falls Assessment that includes a Fall History Review, a Fall Potential Assessment with gait and balance screening, and a Comprehensive Fall Evaluation for high-risk individuals is recommended (AGS, 2001).
GAIT & BALANCE SCREENING: TIMED "UP & GO" TEST (PODSIADLO & RICHARDSON, 1991)
Step 1: Fall History Review
Ask all older adults or their caregivers about the occurrence of a fall during the past year (AGS, 2001). If the older adult and the caregivers report no fall or a single fall in the past year, complete a Fall Potential Assessment (Step 2) with a simple gait and balance screening exercise. If the older adult and the caregivers report recurrent falls in the past year, or if the older adult presents to the health provider or facility following a fall, omit the Fall Potential Assessment and conduct a Comprehensive Fall Evaluation (Step 3).
Step 2: Fall Potential Assessment
The Fall Potential Assessment includes a review of the circumstances surrounding the fall that occurred during the past year, followed by a brief screening for gait and balance problems. The Fall Circumstances Review outlines the location of the fall, activity prior to the fall, loss of consciousness, use of walking aids (e.g., cane, walker) and protective devices (e.g., hip protectors, helmet, gait belt), environmental conditions (e.g., snow, ice, dim lighting, glare, wet floors), and injuries resulting from the fall. If another individual witnessed the fall, this account of the fall is also documented (AGS, 2001).
Use the Timed "Up & Go" Test to screen for gait and balance (Podsiadlo & Richardson, 1991). If no gait or balance problem is identified (score =S 19 or less), no further falls assessment is required. A review of fall riskfactors and information about fall prevention strategies may be offered to all older adults. Reassess Fall History and Fall Potential in 1 year, or if a fall occurs. If a gait or balance problem is identified (score 5= 20), complete the Comprehensive Fall Evaluation (Step 3). Instructions for completing and interpreting the Timed Up & Go Test are included in Table 1.
Step 3: Comprehensive Fall Evaluation
For older adults who report recurrent falls in the past year, who present to the health care provider or facility following a fall, or who are identified as having gait or balance problems on the Timed Up & Go Test (Score 5* 20), conduct a Comprehensive Fall Evaluation (Sidebar on page 11). The purposes of the comprehensive fall evaluation are to describe any fall-related circumstances; delineate modifiable and non-modifiable fall risk factors; assess functional status; and target fall prevention strategies (AGS, 2001). A registered nurse completes this evaluation. However, components of the assessment may require advanced diagnostic training. Referral to an appropriate specialist (e.g., nurse practitioner, geriatrician, physical therapist, cardiologist) for further evaluation may be required (AGS, 2001).
Fall History, Fall Circumstances, and Fall Risk Factors Assessment. Information about fall history, fall-related circumstances, fear of falling, and fall risk factors can help determine an individual's potential for additional falls. Identify which risk factors can be changed (e.g., medications, uncorrected sensory impairments, poorly fitted shoes) from those that cannot be modified (e.g., history of falls, age, gender) (AGS, 2001; Tinetti, Mendes de Leon, Doucette, & Baker, 1994).
Health History and Functional Assessment. Information about health history, sensory deficits, and chronic health conditions, as well as a standardized assessment of cognitive and functional status can help determine the appropriateness of fall prevention interventions (AGS, 2001).
Medication and Alcohol Consumption Review. Assessment and modification of prescription and overthe-counter medications and alcohol consumption is an important feature of any fall prevention program (AGS, 2001). Monitor for recent changes in medication regimen, drug side effects, and polypharmacy. The use of more than three or four medications a day is associated with an increased risk for falls (Leipzig, Cumming, & Tinetti, 1999a, 1999b; Tinetti, Baker et al., 1994)
Vital Signs and Pain Assessment. Alterations in an individual's vital signs (i.e., temperature, respiratory rate and rhythm, heart rate and rhythm, orthostatic blood pressure), including the presence of pan, may indicate an acute illness, injury, or inflammatory process, any of which may make an older adult more vulnerable to falling (Agostini et al., 2001).
Vision Screening. Visual problems contribute to an individual's fall risk (AGS, 2001). Note any eye problems, including cataracts, glaucoma, diabetic neuropathy, or macular degeneration Determine whether vision correction devices are clean, well-fitted, and regularly and appropriately worn.
Musculoskeletal and Foot Assessment. Individuals with musculoskeletal changes, osteoarthritis, lower extremity amputation, or foot problems (e.g., corns, calluses, bunions) may have difficulty walking, which can lead to problems with falling (AGS, 2001). Assess disability of lower extremities including reduced strength, sensation, balance, and range of motion.
Cardiovascular Assessment. Cardiovascular conditions are often present in older adults who have experienced a fall (Agostini et al., 2001; AGS; 2001; Oliver, Hopper, & Seed, 2000). Review cardiac history and assess symptoms of cardiovascular disease (e.g., arrhythmias, valve disease, myocardial infarction, heart blocks, drop attacks, syncope, faintness, bruits, murmurs). Note current use of diuretics, antiarrhythmic agents, and cardiac glycosides/digoxin (Leipzig et aL, 1999b).
Neurological Assessment. Neurological conditions, especially those causing alterations in gait, balance, level of consciousness, or cognition are associated with falls (Agostini et al., 2001; AGS, 2001; Oliver et al., 2000). Note history of stroke, transient ischemic attacks, seizure disorder, dementia, vestibular dysfunction (i.e., vertigo or dizziness), or neurological diseases associated with gait disorders (e.g., Parkinson's disease, muscular dystrophy, multiple sclerosis). Assess neuromuscular symptoms (e.g., muscle rigidity, spasticity, tremors, involuntary movements) and peripheral innervation (e.g., sensitivity to light touch, pain, temperature, vibration).
Depression Screening. Screen for presence of depression using a standardized assessment tool. Antidepressant medications may increase the risk of falling in older adults (Leipzig et al., 1999b).
Continence Assessment. Individuals with urinary incontinence, fecal incontinence, nocturia, diuretic use, or other kinds of urinary tract symptoms may be at increased risk of falling (Bakarich et al., 1997; Leipzig et al., 1999b; Stevenson et al., 1998).
Walking Aids, Assistive Technologies, and Protective Devices Assessment. Appropriate and correct use of walking aids and other assistive technologies is a component of any fall intervention program (Agostini et al., 2001; AGS, 2001; Oliver et al., 2000; Tideiksaar, 2002). Note use of footwear with respect to slippery soles and fit Assess correct use of walking aids (e.g., canes, walkers, crutches), assistive technologies (e.g., wheelchairs, motorized scooters, transfer boards, gait belts), and protective devices (e.g., hip protectors, helmets).
Environmental Assessment. Physical hazards may cause an individual to slip or trip and can lead to a fall (Agostini et al., 2001; AGS, 2001; Oliver et al., 2000; Tideiksaar, 2002). An environmental assessment often can identify modifiable risk factors, such as loose rugs, trip hazards, inadequate lighting, slippery or uneven floors or outside surfaces, a lack of handrails in strategic locations, improper height of furniture or bathroom fixtures, personal items or "clutter" stored on floors or stairways, and temporary environmental hazards, such as medical equipment, in hallways.
DESCRIPTION OF FALL PREVENTION INTERVENTIONS
Following the Multidimensional Falls Assessment, the health professional, older adult, and caregivers have a rich source of information with which to plan a targeted fall prevention program. Strategies must be individualized, reduce fall risk factors, and use resources available to the older adults in the setting where they reside. Fall prevention programs based upon an interdisciplinary comprehensive falls evaluation combined with exercise and risk factor modification appear to be the most effective for reducing falls in older adults (Agostini et al., 2001; AGS, 2001; Hill- Westmoreland, Soeken, & Spellbring, 2002; Oliver et al., 2000). An overview of specific fall prevention interventions is available in the Sidebar. Staff educational programs are a necessary feature of any fall prevention intervention, but are not sufficient on their own to reduce falls (Ray et al., 1997).
Interventions for Fall Prevention
Comprehensive Fall Evaluation and Treatment of Health Problems. The most important steps in any fall prevention program are to identify individuals who have experienced a fall, determine fall potential, and modify individual fall risk factors through the ongoing treatment of health problems (AGS, 2001; Close et al., 1999; HillWestmoreland et al., 2002; Ray et al., 1997; Tinetti et al., 1996).
Medication Modification. Review of medications without modification is of little benefit for fall prevention (AGS, 2001). Whenever possible, reduce medications or dosage for older adults who take four or more medications and for those who take psychotropic medications (Agostini et aL, 2001; AGS, 2001; Campbell, Robertson, Gardner, Norton, & Buchner, 1999; Close et al., 1999; Tinetti, Baker et al., 1994; Ray et al., 1997).
Exercise, Gait and Balance Training, and Appropriate Use of Walking Aids. Exercise programs, gait and balance training, and appropriate use of assistive devices and walking aids are important fall prevention strategies for older adults (AGS, 2001; Campbell et al., 1997; Gillespie et al., 2002; HillWestmoreland et al., 2002). Exercise programs that have been offered as fall prevention strategies in older adults include walking, balance and strength training, aerobics, stationary cycling, and Tai Chi. However, research has not supported the benefits of improving physical mobility and endurance through these interventions without concurrent reduction of other fall risk factors (Agostini et al., 2001; AGS, 2001). Exercise programs that are sustained for a minimum duration of 10 weeks are more successful than shorter programs (AGS, 2001).
Environmental Modification. Research fails to support environmental modification alone as a fall prevention strategy (Peel, Steinberg, & Williams, 2000; Sattin, Rodriguez, DeVito, & Wingo, 1998). However, as a component of a multifactorial falls intervention, environmental modification may help decrease fall risk in some older adults (Cumming et al., 1999; Gillespie et al., 2002; Ray et al., 1997).
Continence Promotion. Toileting programs are useful components of a fall prevention program in acute care settings (Bakarich et al., 1997; Hendrich et al., 1995; Stevenson et al., 1998).
Use of Protective Devices. Hip protector use does not reduce the risk of falling but seems to prevent hip fractures in older adults who fall in non-hospital settings (AGS, 2001). There is insufficient evidence to recommend use of hip pads in hospitals (Agostini et al., 2001). Similarly, evidence to support bed or wheelchair alarms as fall prevention strategies in hospitals is lacking (Agostini et al., 2001; AGS, 2001; Oliver et al., 2000; Parker, Gillespie, & Gillespie, 2002).
Special Identification of High Risk Fallers. Identification of high-risk patients through colored bracelets, bedside signs, or health record tags and stickers is often incorporated in multifactorial interventions to prevent falls. However, there is little evidence to demonstrate that the exclusive use of such identification systems significantly reduces falls (Agostini et al., 2001; Oliver et al., 2000). These interventions might adversely affect rehabilitation and promotion of functional independence by causing stigma and anxiety among patients and their family members (Oliver et al., 2000).
Physical Restraints Do Not Prevent Falls. There is no scientific evidence supporting the use of physical restraints for fall prevention (Agostini et al., 2001; AGS, 2001; Capezuti, Evans, Strumpf, & Maislin, 1996). Restraint reduction programs do not cause a significant increase in the total number of falls and may reduce the seriousness of injuries sustained during a fall (Agostini et al., 2001; Neufeld et al., 1999).
EVALUATION: OUTCOME AND PROCESS INDICATORS
Fall-related outcomes are selected based on the goals of the individual, providers, and organization. Outcome indicators are factors expected to improve with consistent and appropriate use of the Fall Prevention Protocol and include, among others, a decreased number of falls and decreased number and severity of fall-related injuries. Determine baseline fall rates (Sidebar on page 12) prior to implementing fall prevention programs to allow comparisons over time, between units, and across institutions (Tideiksaar, 2002). Process indicators are interpersonal and environmental factors that can facilitate the use of an evidence-based practice guideline. The Fall Prevention Protocol Quality Improvement Monitor aids in tracking process outcomes (Table 2).
FALL PREVENTION PROTOCOL QUALITY IMPROVEMENT MONITOR
- Key: (R) Research, (L) Literature, (N) National Guidelines
- Agostini, J.V., Baker, DJ, & Bogardus, S.T, Jr. (2001). Prevention of falls in hospitalized and institutionalized older people. In A.J. Markowitz, K.G. Shojania, B/W Duncan, K.M. McDonald, & RM. Wachter (Eds.), Making health care safer: A critical analysis of patient safety practices (No. 43, pp. 281-299). Rockville, MD: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. (N)
- American Geriatrics Society. (2001). Guideline for the prevention of falls in older persons. Journal of the American Geriatrics Society, 49(5), 664-672. (N)
- Bakarich, A, McMillan, V, & Prosser, R (1997). The effect of a nursing intervention on the incidence of older patient falls. Australian Journal of Advanced Nursing, 15(V), 26-31. (R)
- Biegen, MA, Vaughn, TE, & Goode, C.J. (2001). Nurse experience and education: Effect on quality of care. Journal of Nursing Administration, 31(1), 33-39. (R)
- Campbell, AJ, Robertson, M.C, Gardner, M.M, Norton, R.N, & Buchner, D.M (1999). Psychotropic medication withdrawal and a home-based exercise program to prevent falls: A randomized, controlled trial. Journal of the American Geriatrics Society, 47(7), 850853. (R)
- Campbell, A.J, Robertson, M.C, Gardner, M.M, Norton, RN, Tilyard, M. W, & Buchner, DM. (1997). Randomised controlled trial of a general practice programme of home based exercise to prevent falls in elderly women. BMJ, 37X7115), 1065-1069. (R)
- Capezuti, E, Evans, L, Strumpf, N, & Maislin, G. (1996). Physical restraint use and falls in nursing home residents. Journal of the American Geriatrics Society, 44(6), 627-633. (R)
- Centers for Disease Control and Prevention. (2001). Web-hased injury statistics query and reporting system (WISQARS) [Database online]. Retrieved September 14, 2005, from www.cdc.gov/ncipc/wisqars (R)
- Close, J, Ellis, M, Hooper, R, Gkicksman, E, Jackson, S, & Swift, C. (1999). Prevention of falls in the elderly trial (PROFET): A randomised controlled trial. Lancet, 3?3(9147), 93-97. (R)
- Cumming, RG, Thomas, M, Szonyi, G, Salkeld, G, O'Neill, E, Westbury, C, & Frampton, G. (1999). Home visits by an occupational therapist for assessment and modification of environmental hazards: A randomized trial of falls prevention. Journal of the American Geriatrics Society, 47(U), 1397-1402. (R)
- Gillespie, LJ), Gillespie, W.J, Robertson, AtC, Lamb, S.E, Cumming, RG, & Rowe, B.H. (2002). Interventions for preventing falls in the elderly. The Cochrane Database of Systematic Reviews, Issue 2. (Art. No.: CD000340. DOI: 10.1002/14651858. CD000340) (R)
- Hakim, RM. (1998). Factors associated with falls of geriatric residents during a restraint reduction program in a skilled nursing facility. Issues on Aging, 21(3), 23-25. (R)
- Hendrich, A, Nyhuis, A, Kippenbrock, T, & Soja, M. (1995). Hospital falls: Development of a predictive model for clinical practice. Applied Nursing Research, 8(3), 129-139. (R)
- Hill-Westmoreland, E, Soeken, K, & Spellbring, A (2002). A meta-analysis of fall prevention programs for the elderly: How effective are they? Nursing Research, 51(1), 1-8. (R)
- Kiely, D, Kiel, D, Burrows, A, & Lipsitz, L. (1998). Identifying nursing home residents at risk for falling. Journal of the American Geriatrics Society, 46(5), 551-555. (R)
- Leipzig, RM, Cumming, RG, & Tinetti, M.E. (1999a). Drugs and falls in older people: A systematic review and meta-analysis: I. Psychotropic drugs. Journal of the American Geriatrics Society, 47(1), 30-39. (R)
- Leipzig, RM, Cumming, RG, & Tinetti, M.E. (1999b). Drugs and falls in older people: A systematic review and meta-analysis: II. Cardiac and analgesic drugp.Joumalofthe American Geriatrics Society, 47(1), 40-50. (R)
- Neufeld, RR, Libow, L.S, Foley, WJ, Dunbar, J.M., Cohen, C, & Breuer, B. (1999). Restraint reduction reduces serious injuries among nursing home residents. Journal of the American Geriatrics Society, 47(10), 1202-1207. (R)
- Oliver, D, Hopper, A, & Seed, R (2000). Do hospital fall prevention programs work? A systematic review. Journal of the American Geriatrics Society, 48(12), 1679-1689. (R)
- Parker, MJ, Gillespie, LD., & Gillespie, WJ. (2002). Hip protectors for preventing hip fractures in the elderly. The Cochrane Database of Systematic Reviews, Issue 3. (Art. No.: CD001255. DOI: 10.1002/14651858. CD001255.pub2) (R)
- Peel, N, Steinberg, M, & Williams, G. (2000). Home safety assessment in the prevention of falls among older people. Australian & New Zeaknd Journal of Public Health, 24(5), 536539. (R)
- Podsiadlo, D, & Richardson, S. (1991). The Timed 1Up & Go": A test of basic functional mobility for frail elderly persons. Journal of the American Geriatrics Society, 39, 142-148. (R)
- Ray, WA, Taylor, JA, Meador, K.G, Thapa, RB, Brown, AJK.., Kajihara, H.K., Davis, C, Gideon, R, & Griffin, M.R (1997). A randomized trial of a consultation service to reduce falls in nursing homes. Journal of the American Medical Association, 278(7), 557-562. (R)
- Samelson, EJ, Zhang, Y, Kiel, D.P, Hannan, MT, & Felson, DT. (2002). Effect of birth cohort on risk of hip fracture: Age-specific incidence rates in the Framingham Study. American Journal of Public Health, 92(5), 858-862. (R)
- Sattin, RW, Rodriguez, J.G, DeVito, CA., & Wingo, RA. (1998). Home environmental hazards and the risk of fall injury events among community-dwelling older persons. Journal of the American Geriatrics Society, 46(6), 669-676. (R)
- Stevenson, B, Mills, E, Welin, L, & Beai, K. (1998). Falls risk factors in an acute-care setting: A retrospective study. Canadian Journal of Nursing Research, 30(1), 97-111. (R)
- Tideiksaar, R (2002). FaUs in older people: Prevention & management (3rd ed.). Baltimore: Health Professions Press. (L)
- Tinetti, M.E, Baker, D, McAvay, G, Claus, E, Garrett, P, Gottschalk, M, Koch, M, Trainor, K, & Horwitz, R (1994). A multifactorial intervention to reduce risk of falling among elderly people living in the community. New Enghnd Journal of Medicine, 331(13), 821827. (R)
- Tinetti, M.E, McAvay, G, & Claus, E. (1996). Does multiple risk factor reduction explain the reduction in fall rate in the Yale FICSTT Trial? Frailty and injuries cooperative studies of intervention techniques. American Journal of Epidemiology, 144(4), 389-399. (R)
- Tinetti, M.E, Mendes de Leon, CF, Doucette, JT, & Baker, D.I. (1994). Fear of falling and fall-related efficacy in relationship to functioning among community-hving elders. Journal of Gerontology, 49(3), M140-M147. (R)
- Tutuarima, JA, de Haan, RJ, & Limburg, M. (1993). Number of nursing staff and falls: A case-control study on falls by stroke patients in acute-care settings. Journal of Advanced Nursing, 18(7), 1 101-1 105. (R)
GAIT & BALANCE SCREENING: TIMED "UP & GO" TEST (PODSIADLO & RICHARDSON, 1991)
FALL PREVENTION PROTOCOL QUALITY IMPROVEMENT MONITOR