Falls are problematic for older adults and are particularly prevalent in the nursing home environment, with between half and three quarters of nursing home residents falling every year, and an average of 2.6 falls per resident per year (Centers for Disease Control and Prevention [CDC], n.d.). Morbidity and mortality resulting from falls in this population is high, with up to 6% of falls resulting in fractures and up to 20% leading to serious injury (CDC, n.d.). Quality of life can also be adversely affected by falls, with an association between falls and functional decline, isolation, and depression (CDC, n.d.). Residents at risk for falls can be identified through both fall risk assessments and analysis of known risk factors, including previous falls, disability, use of walking aids, cluttered living spaces, and potentially inappropriate medication (PIM) use (American Geriatrics Society 2012 Beers Criteria Update Expert Panel [AGS], 2012; CDC, n.d.; Deandrea et al., 2013). In the nursing home population, additional risk factors include issues with muscle weakness and gait, which are responsible for 24% of falls (CDC, n.d.).
The Centers for Medicare and Medicaid Services (CMS) has recently renewed efforts to influence nursing homes to improve clinical outcomes such as falls in older adults. Nursing homes must develop Quality Assurance (QA) and Performance Improvement Plans per CMS regulations under Section 6102(c) of the Affordable Care Act. The rule is currently in the Proposed Rule Stage in the Unified Agenda as of fall 2013 (CMS, n.d.). When a final rule is passed, nursing homes will have 1 year to implement strategies for continuous identification and resolution of quality deficiencies while sustaining performance. Examination of quality improvement processes in fall risk prevention is already occurring in nursing homes, with employee flexibility, adaptability, and communication considered to be key traits for successful programs (Abrahamson, Davila, Mueller, Inui, & Arling, 2013). Official fall prevention guidelines can provide further assistance to nursing homes regarding strategies for fall risk reduction in older adults (Moyer, 2012; Panel on Prevention of Falls in Older Persons, AGS, & British Geriatrics Society [BGS], 2011).
As previously stated, PIM use is associated with falls (Deandrea et al., 2013). Some medication classes (e.g., psychotropic agents) have been implicated in increasing fall risk in older adults, particularly upon initiation or dose change (Echt, Samelson, Hannan, Dufour, & Berry, 2013). Because of the importance of identifying medications that increase fall risk, many of these medications are included on the AGS Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (AGS, 2012). This list (which can be accessed at http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf) will soon have a direct effect on the nursing home Five-Star Quality Rating System, which will reflect practitioner involvement in assessing appropriate use of medications that can lead to an increased fall risk. Specifically, the National Committee for Quality Assurance (NCQA), which produces the Healthcare Effectiveness Data and Information Set (HEDIS), will use the Beers Criteria in HEDIS 2014 (NCQA, n.d.).
Medication-related initiatives can have an effect on preventing both falls as well as fall-related morbidity and mortality. For example, supplementation with vitamin D has been shown to decrease both falls and injuries resulting from falls (Annweiler et al., 2010). In addition, tapering and discontinuing medications such as psychotropic agents that affect sleep, depression, and/or anxiety can reduce falls (van der Velde, Stricker, Pols, & van der Cammen, 2007). In a recent randomized controlled trial, 1,314 home-dwelling Finlanders ages 70 or older were randomized into either a 12-month fall prevention program intervention group or a control group. Interventions focused on strength and balance training, medication reviews, adequate intake of calcium and vitamin D, and home hazard assessment and modification. At 12 months, the rate of falls was approximately 30% lower in the intervention group (Palvanen et al., 2013). These national initiatives coupled with concern for resident safety led to a multi-faceted pharmacist-led approach to reduce risk factors, namely medication related, that can lead to falls and fractures. This article will highlight these interventions as well as some preliminary findings.
Quality Assurance Interventions
Vitamin D Quality Assurance Initiative
The National Center for Health Statistics reported that up to 7% of men and 11% of women older than 70 are at risk of vitamin D deficiency (Looker et al., 2011). In the nursing home population, more than 40% of residents have a vitamin D deficiency, defined as a vitamin D level < 20 ng/mL (Kojima et al., 2013). A recent study showed that men and women older than 65 with low levels of vitamin D had up to a 40% increased risk for hip fracture compared to those with high vitamin D levels (Holvik et al., 2013). The AGS and BGS guidelines on the prevention of falls recommend adequate calcium and vitamin D supplementation for all older adults, as it is a safe and inexpensive intervention to improve bone health and reduce fracture rates (Panel on Prevention of Falls in Older Persons et al., 2011). This standard of care is assessed on at least a monthly basis as part of the vitamin D QA program conducted by the pharmacist during the federally mandated medication review at the long-term care site. This audit ensures that vitamin D levels are obtained on all new admissions as well as tracked at least annually for all chronic care residents. Furthermore, the monthly reports given during QA meetings provide the medical team with the vitamin D blood levels (baseline and follow-up, if applicable) as well as vitamin D supplementation regimen (if applicable).
The audit has helped optimize both the monitoring as well as utilization of vitamin D supplementation among nursing home residents. Since the implementation of this program in June 2013, there has been an improvement of only 14% of the residents not having any vitamin D monitored compared to 31% at baseline. Furthermore, not only has the use of vitamin D supplementation increased but the attention given to the changes in formulations and dosage during transitions in care has improved. This process has not only improved vitamin D monitoring but identified communication gaps among the various health care systems and providers as well as between the facility and the laboratory services.
Fall Risk Quality Assurance Evaluation Form
A fall risk QA evaluation form was designed to assist the care team with identifying modifiable risk factors for assisted living residents who fall frequently (Appendix A, available in the online version of this article). This evaluation is performed in addition to other ongoing pharmacy evaluations, which are conducted every 3 to 6 months. The form consists of listing a resident’s medical history, recent vital signs, any elimination issues, use of any assistive device for ambulation, prior care of physical or occupational therapy, current calcium and vitamin D supplements, and any over-the-counter and prescription medications.
The final portion of the form includes medication-related recommendations for the care team, with sections on optimizing bone health, reducing medications that can contribute to falls, and other miscellaneous issues related to increasing fall risk. Upon completion of the form, a consultant pharmacist and student pharmacists will notify the care team to assess patient-specific recommendations. This form provides the care team a snapshot of the multiple factors that can contribute to the fall risk and recommendations to reduce the risk. Overall, there has been a heightened awareness to fall risk factors and person-centered care interventions.
Education In-Service and Training
Ongoing education and training is an essential component to improve care and was another facet to the fall risk reduction program. Nursing staff are at the forefront of direct patient care and often the first to identify medication-related concerns. The interactive aspect of the in-service focused on how direct care staff can recognize any side effects of medications and how they could contribute to falls. For example, antipsychotic medications are known to cause tremors or shuffling, which may increase the risk of falls in residents. A handout was given, in addition to the presentation, that lists specific medications and adverse side effects that could lead to falls (Table). Instructions were provided to nursing staff that instead of viewing new tremors or other conditions as requiring additional medication, they should first look to the existing medication regimen as a potential cause for the falls.
Medication Examples That May Increase Fall Risk
The in-service also focused on warning about medications that could worsen a patient’s condition after a fall, such as using anticoagulant agents that may lead to higher bleed risk. Additionally, this educational program not only addressed potential adverse consequences but also how to optimize bone health. A short discussion centered on pharmacological approaches (e.g., bisphosphonate agents) as well as diet and exercise.
Implications for Gerontological Nurses
An interdisciplinary approach involving close cooperation between nurses, physical therapists, and pharmacists will help reduce the many causes of falls in older adults, among other conditions. These interventions help show the role pharmacists can play in complementing nurses’ and physical therapists’ unique knowledge and skill set derived from daily bedside interaction with patients.
It is common for nursing home residents to be taking multiple medications and go through transitions of care, which may make it difficult for nurses who directly interact with patients to discern whether a new issue is in fact medication related. With the help of a pharmacist, nurses can stay up-to-date on drug side effects, interactions, and monitoring parameters. In addition to the responsibilities of monthly medication reviews in the nursing home, the pharmacist can be a valuable resource for drug knowledge and program development. Each member of the care team has specialized knowledge and skills, which together can provide consistent and safe patient care.
QA and educational programming on the subject of fall prevention is important across all settings of care. Although the number of fall incidents in a facility may be unknown, beginning education on QA and educational programming for both the residents and staff is a critical first step. This not only will help the facility meet future CMS requirements, but also more importantly, improve the quality of care and life for older adults in protecting them from falls and fractures.
Appendix A: Falls Risk Evaluation Form
- Abrahamson, K., Davila, H., Mueller, C., Inui, T. & Arling, G. (2013). Examining the lived experience of nursing home quality improvement: The case of a multifacility falls reduction project. Journal of Gerontological Nursing, 39(9), 24–30. doi:10.3928/00989134-20130627-02 [CrossRef]
- American Geriatrics Society 2012 Beers Criteria Update Expert Panel. (2012). American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 60, 616–631. doi:10.1111/j.1532-5415.2012.03923.x [CrossRef]
- Annweiler, C., Montero-Odasso, M., Schott, A.M., Berrut, G., Fantino, B. & Beauchet, O. (2010). Fall prevention and vitamin D in the elderly: An overview of the key role of the non-bone effects. Journal of NeuroEngineering and Rehabilitation, 7, 50. doi:10.1186/1743-0003-7-50 [CrossRef]
- Centers for Disease Control and Prevention. (n.d.). Falls in nursing homes. Retrieved from http://www.cdc.gov/HomeandRecreationalSafety/Falls/nursing.html
- Centers for Medicare and Medicaid Services. (n.d.). Reform of requirements for long-term care facilities and quality assurance and performance improvement (QAPI) program (CMS-3260-P). Retrieved from http://www.reginfo.gov/public/do/eAgendaViewRule?pubId=201310&RIN=0938-AR61
- Deandrea, S., Bravi, F., Turati, F., Lucenteforte, E., La Vecchia, C. & Negri, E. (2013). Risk factors for falls in older people in nursing homes and hospitals: A systematic review and meta-analysis. Archives of Gerontology and Geriatrics, 56, 407–415. doi:10.1016/j.archger.2012.12.006 [CrossRef]
- Echt, M.A., Samelson, E.J., Hannan, M.T., Dufour, A.B. & Berry, S.D. (2013). Psychotropic drug initiation or increased dosage and the acute risk of falls: A prospective cohort study of nursing home residents. BMC Geriatrics, 13, 19. doi:10.1186/1471-2318-13-19 [CrossRef]
- Holvik, K., Ahmed, L.A., Forsmo, S., Gjesdal, C.G., Grimnes, G., Samuelsen, S.O. & Meyer, H.E. (2013). Low serum levels of 25-hydroxyvitamin D predict hip fracture in the elderly: A NOREPOS study. Journal of Clinical Endocrinology and Metabolism, 98, 3341–3350. doi:10.1210/jc.2013-1468 [CrossRef]
- Kojima, G., Tamai, A., Masaki, K., Gatchell, G., Epure, J., China, C. & Tanabe, M. (2013). Prevalence of vitamin D deficiency and association with functional status in newly admitted male veteran nursing home residents. Journal of the American Geriatrics Society, 11, 1953–1957. doi:10.1111/jgs.12495 [CrossRef]
- Looker, A.C., Johnson, C.L., Lacher, D.A., Pfeiffer, C.M., Schleicher, R.L. & Sempos, C.T. (2011). Vitamin D status: United States, 2001–2006. National Center for Health Statistics Data Brief, 59, 1–8.
- Moyer, V.A. (2012). Prevention of falls in community-dwelling older adults: U.S. Preventive Services Task Force recommendation statement. Annals of Internal Medicine, 157, 197–204. doi:10.7326/0003-4819-157-3-201208070-00462 [CrossRef]
- National Committee for Quality Assurance. (n.d.). List of HEDIS 2014 measures. Retrieved from http://www.ncqa.org/Portals/0/HEDISQM/HEDIS2014/List%20of%20HEDIS%202014%20Measures.pdf
- Palvanen, M., Kannus, P., Piirtola, M., Niemi, S., Parkkari, J. & Järvinen, M. (2013). Effectiveness of the Chaos Falls Clinic in preventing falls and injuries of home-dwelling older adults: A randomised controlled trial. Injury, 45, 265–271. doi:10.1016/j.injury.2013.03.010 [CrossRef]
- Panel on Prevention of Falls in Older Persons, American Geriatrics Society, & British Geriatrics Society. (2011). Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. Journal of the American Geriatrics Society, 59, 148–157. doi:10.1111/j.1532-5415.2010.03234.x [CrossRef]
- van der Velde, N., Stricker, B.H.C., Pols, H.A.P. & van der Cammen, T.J.M. (2007). Risk of falls after withdrawal of fall-risk-increasing drugs: A prospective cohort study. British Journal of Clinical Pharmacology, 63, 232–237. doi:10.1111/j.1365-2125.2006.02736.x [CrossRef]
QA Falls Risk Reduction Pharmacy Evaluation
The intent of this evaluation is to assist the care team with identifying possibly modifiable risk factors to assist with falls reduction in residents who are frequently falling. This is in addition to the current ongoing pharmacy evaluations, which are conducted every 3–6 months in the assisted living facility.
Medication Related Recommendations:
After reviewing the resident’s medications the following medication related recommendations were identified:
Evaluation Conducted by: _____________________________ Date: _________________
Reviewed by AL Nurse Manager and Care Team: ______________________ Date: _______
Medication Examples That May Increase Fall Risk
||Mechanism for Falls
|ACE inhibitor agents
||Benazepril, captopril, enalapril, fosinopril, lisinopril, quinapril, ramipril
|Alpha receptor blockers
||Doxazosin, prazosin, terazosin
||Isosorbide dinitrate, isosorbide mononitrate, nitroglycerin, digoxin, atenolol, metoprolol, carvedilol
||Carbamazepine, gabapentin, lamotrigine, levetiracetam, phenobarbital, phenytoin, topiramate, valproic acid
||Confusion, blurry vision
||Amitriptyine, bupropion, citalopram, desipramine, doxepin, escitalopram, fluoxetine, mirtazapine, nortriptyline, paroxetine, sertraline, trazodone, venlafaxine
||Confusion, blurry vision
||Cetirizine, chlorpheniramine, doxylamine, diphenhydramine, hydroxyzine, meclizine, promethazine
||Rigidity, shuffling gait, slowed movement
||Chlorpromazine, clozapine, haloperidol, olanzapine, quetiapine, risperidone
|Muscle relaxant agents
||Sleepiness, weakness, confusion
||Baclofen, carisoprodol, cyclobenzaprine, methocarbamol, tizanidine
||Sleepiness, dizziness, confusion
||Butorphanol, codeine, fentanyl, hydrocodone, hydromorphone, meperidine, methadone, morphine, oxycodone, oxymorphone
|Benzodiazepine (BZD) and non-BZD sedative hypnotics
||Confusion, slowed psychomotor reflexes
||Alprazolam, diazepam, lorazepam, midazolam, oxazepam, phenobarbital, temazepam, triazolam, zopiclone, zolpidem
|Oral antidiabetic agents
||Chlorpropramide, glyburide, glimepiride, glipizide
||Weakened bone density
||Budesonide, cortisone, dexamethasone, fludrocortisone, fluticasone, prednisolone, prednisone