Falls continue to be a leading cause of injury and death in individuals 65 and older. According to the Centers for Disease Control and Prevention (CDC; 2017), millions of individuals fall each year, with one in five falls resulting in serious injury, including death. The chances of an older adult falling again doubles with the first fall. The cost of falls continues to rise with expenditures currently exceeding $31 billion in 2015 for non-fatal falls (Burns, Stevens, & Lee, 2016). The Centers for Medicare & Medicaid Services (2008) has identified fall prevention as a key element in the survey process for long-term care facilities, and now designates falls in the acute care setting as “never events” with restricted payment for treatment of injuries or other adverse effects of falls.
Older adults are at risk for falls due to a variety of risk factors: age; gender; health conditions, including comorbidities; medication use, including side effects; poor mobility; and environmental factors (World Health Organization [WHO], 2016). There are a variety of setting-specific risk factors that need to be considered as well. Individuals living in the home setting may fall for different reasons than individuals living in the nursing home setting (Panel on Prevention of Falls in Older Persons, American Geriatrics Society [AGS], & British Geriatrics Society, 2011). Individuals living in the community have multifactorial reasons for falls, including immobility, balance issues, frailty, and physical inactivity. Environmental hazards can also play a role in the aging individual's risk for falls, including stairways, the absence of hand-rails, and uneven floors, such as hard wood floors next to carpeted floors. In addition, individuals living in the community are at risk for falls due to their ability to access the outdoors. This access brings with it a higher risk for falls based on current health conditions and a greater potential for accidental falls (Hellstrom et al., 2013). In comparison, falls in health care settings carry risks that tend to focus on the health of the individual and the environment. When admitted to the hospital, older adults are already at higher risk of falls due to the health issue or accident that brought them to the hospital. In addition, their unfamiliarity with their surroundings leads to an increase in their risk for falls. If the length of stay is prolonged, the risk for falls increases due to further physical debilitation and comorbidities. Polypharmacy can also play a role due to medications associated with comorbidities (Lyons, 2014). In the long-term care setting, factors associated with falls are similar to those of community-dwelling and hospitalized older adults. These factors include frailty, comorbidities, and polypharmacy. Additional issues related to the environment can have an impact on falls, including wet floors, poor lighting, and assistive devices that are not maintained or are ill-fitting. Special consideration needs to be given to those older adults who are at risk for falls and attempt to complete activities of daily living without the necessary support, such as bathing, using the bathroom, or transferring from one surface to another (CDC, 2017).
Multidimensional Falls Assessment
A multidimensional falls assessment program is essential in reduction of falls in older adults. The goal is to target fall risk for individuals. If a risk for falls exists, developing a fall prevention plan that incorporates interventions specific to each individual is essential. The Panel on Prevention of Falls in Older Persons et al. (2011) developed a 10-step assessment protocol incorporating a fall history, potential for falling, and a comprehensive evaluation (Figure). Completing a gait and balance screening for any individual who has fallen at least once in the past year is important to this evidence-based practice guideline. Based on the assessment, if an individual is at risk for falls, has fallen in the past year, or has gait or balance impairments, a comprehensive fall evaluation needs to be completed that incorporates appropriate fall prevention strategies to meet the specific needs of the individual.
Step 1: Older Adult Meets with Health Care Provider
The first step of the protocol involves the moment an older adult meets with a health care provider. This is the point that the older adult has the opportunity to have his or her fall history reviewed as well as any other risk factors that may be present (Panel on Prevention of Falls in Older Persons et al., 2011).
Step 2: Fall Screening
Step 2 requires the health care provider to screen the older adult for falls or risk of falling. This determination should be made regardless of the environment where the older adult is currently residing, either temporarily or permanently, by a primary care provider, the health care team in the emergency department (ED), during admission to a nursing home or assisted living facility, or during the assessment process for home health services (Panel on Prevention of Falls in Older Persons et al., 2011).
Step 3: Analysis of Fall Risk
Step 3 requires the care provider to analyze the information obtained to determine if the individual is at risk for falls. Questions related to fall risk have been asked and if the older adult answered yes to any of those questions, the recommendation is to go to Step 7, which is when a comprehensive fall assessment is completed. If the older adult answered no to the fall questions, the recommendation is to move to Step 4, which is the determination of a fall in the past year (Panel on Prevention of Falls in Older Persons et al., 2011).
Step 4: Determination of a Fall in the Past Year
The health care provider continues the screening and asks the older adult and/or caregiver if the older adult has had one fall in the past year. If the answer is affirmative, the recommendation is to move to Step 5, which is the evaluation of gait and balance. If the answer is negative, the recommendation is to move to Step 10, which requires no further immediate action but reassessments should be completed periodically (Panel on Prevention of Falls in Older Persons et al., 2011). If there has been a fall in the past year, documenting the events surrounding the fall are important, especially if further action is required, such as the evaluation of gait and balance. Documentation should include the following:
- date of the fall;
- day of the week the fall occurred;
- time of the fall;
- what the individual was doing immediately prior to the fall and at the time of the fall;
- indoor environmental factors (e.g., poor lighting, clutter on the floor, wet floors);
- if the fall occurred outside, environmental factors including uneven pavement, concealed holes in the lawn, snow or ice, or other obstacles; and
- health factors including comorbidities, polypharmacy, and emergent medical issues.
This information is added to the individual's health record and used in the completion of the evaluation of gait and balance as part of the completed comprehensive fall assessment and in the development of the individualized multifactorial intervention program.
Step 5: Evaluation of Gait and Balance
Based on the results of the fall determination, any older adult who has fallen within the past year will have an evaluation of his/her gait and balance. This evaluation will determine if the older adult has any outward issues with gait or balance, including unsteadiness and difficulty rising from and returning to a sitting position in a chair. There are a variety of tools that can be used to evaluate gait and balance including the following:
- Get-Up and Go Test (Mathias, Nayak, & Isaacs, 1986).
- Timed Up and Go Test (Podsiadlo & Richardson, 1991).
- Berg Balance Scale (Berg, Wood-Dauphinee, Williams, & Maki, 1992).
- Performance-Oriented Mobility Assessment (Tinetti, 1986; Tinetti, Speechley, & Ginter, 1988).
Following completion of the evaluation for gait and balance, the recommendation is for the provider to move to Step 6, which is the determination of abnormal gait and/or balance (Panel on Prevention of Falls in Older Persons et al., 2011).
Step 6: Determination of Abnormal Gait and/or Balance
In this step, the health care provider analyzes the results of the gait and balance assessment using a tool specifically identified for this purpose. If no gait or balance problems are identified by the results, the recommendation is to move to Step 10. If the results identify gait or balance problems, the recommendation is to move to Step 7, which is when a comprehensive fall assessment is completed (Panel on Prevention of Falls in Older Persons et al., 2011). The Get-Up and Go Test can be used to assess gait and balance (Mathias et al., 1986). For this test, the older adult is asked to complete specific maneuvers. The individual conducting the test scores each maneuver based on the older adult's ability to complete the maneuver. If the individual scores normal, the older adult is not at risk for falls. If this is the case, the provider can move to Step 10. If the older adult's score is not normal, the provider proceeds to Step 7 and completes a comprehensive fall assessment.
Step 7: Comprehensive Fall Assessment
This step is intended for older adults who reported yes to any of the screening questions or experienced issues with gait or balance. For this step, the provider completes a comprehensive fall assessment that includes medical history, history of falls, previous physical examinations regardless of provider, previous cognitive evaluations, and previous functional assessments. Multifactorial risk for falls for each individual is determined based on a variety of factors (Table 1).
Comprehensive Fall Assessment
History of Falls. Fall history is important for the comprehensive assessment. Previous falls are an indicator of future risk for falls. Fall history information should include circumstances surrounding any fall, any physical impairments, sensory impairments, medication use, and any support devices required for ambulation but not used or used improperly. Whether the individual has a fear of falling should also be considered, as this can be a fall risk if the individual is either over-cautious or not cautious enough.
Medical History, Previous Physical Examinations, and Previous Cognitive Assessments. Information related to past and current medical history, previous physical examinations, and previous cognitive assessments should be considered to determine any medical issues that place the older adult at risk for falls. The medical history should include the following information:
- emergent health issues that are currently acute;
- primary health issues the older adult is or is not being treated for above and beyond the emergent health issues;
- previous health issues that have resolved;
- chronic health care issues in addition to primary health issues (Fairhall et al., 2014), as well as comorbidities;
- presence of sleep deficits (Fairhall et al., 2014), such as sleep apnea or chronic insomnia;
- age and gender;
- nutritional consideration, especially if there are nutritional deficits; and
- skin assessment.
Medications. The medication review is an important part of the complete fall assessment due to certain medications having properties that increase the risk for falls. The Beers listing provides information regarding medications that should be avoided in the care of older adults (Onder et al., 2014). Additional information regarding the Beers Criteria can be found at the Agency for Healthcare Research and Quality (access http://www.guideline.gov/content.aspx?id=37706) or the Hartford Institute for Geriatric Nursing (access http://www.gericonsult.org) websites. All medication taken or recently discontinued or medications being taken for resolved health issues should be considered. It is also important to assess for polypharmacy (Elsawy & Higgins, 2011).
In addition to a comprehensive medication review, the use of alcohol and/or drugs other than those prescribed needs to be completed. The amount and how often alcohol and/or drugs are being taken should be considered as well as the proximity to any fall that has occurred (Brito, Coqueiro, Fernandes, & de Jesus, 2014). Alcohol and/or drug misuse is on the rise among older adults and needs to be considered as part of the comprehensive fall assessment.
Gait, Balance, and Mobility. Gait, balance, and mobility need to be assessed as part of the comprehensive fall assessment. If the older adult met the criteria for the gait and balance test (Step 4), this test was completed in Step 5. However, if the older adult did not meet the criteria in Step 4, but additional data are collected during the assessment that cause concerns regarding gait, balance, and mobility, the provider should perform an evaluation of gait and balance. This evaluation is also an opportunity to assess the individual for proper use of assistive devices and appropriate footwear.
Visual Acuity and Other Neurological Impairments. Older adults with vision problems are at higher risk for falls (National Institute on Aging, n.d.). Issues such as cataracts and other degenerative eye disorders, night blindness, and other vision problems should be examined. Use of glasses for reading and general use should be reviewed. It should also be determined if glasses are being worn appropriately and whether the prescription is current.
Hearing problems and whether the individual is wearing any type of hearing aid should be assessed. This assessment should include a check for potential cerumen build up in the ears, which can impact balance and risk for falls.
Additional neurological conditions that can impact gait, balance, and mobility include history of stroke, seizure disorder, and brain injury; Parkinson's disease; peripheral neuropathy; and cognitive issues.
Muscle Strength. Muscle strength is an important consideration when completing a comprehensive fall assessment. Older adults who are experiencing limitations related to declining muscle strength are at greater risk for falls. A history of osteoarthritis and osteoporosis should be considered (Elsawy & Higgins, 2011). Any abnormalities of the extremities, including amputations, should also be assessed.
Completion of the comprehensive fall assessment should also include the following information: heart rate and rhythm/vital signs; postural and orthostatic hypotension; feet and footwear; environmental hazards (Garcia et al., 2012; Panel on Prevention of Falls in Older Persons et al., 2011; Waldron, Hill, & Barker, 2012); depression screening; and pain, continence, cardiovascular, skin, sleep, and nutrition assessments.
Following completion of the comprehensive fall assessment, the next step is to analyze the information and determine if there is an indication for additional interventions, which is Step 8 (Panel on Prevention of Falls in Older Persons et al., 2011).
Step 8: Indication for Additional Interventions
In this step, the provider determines whether additional interventions are indicated. If indicated, the provider moves to Step 9, which requires the initiation of an individualized multifactorial intervention program based on identified risks for falls with the goal of fall prevention. If no additional interventions are required, the next step is Step 10, which requires no further immediate action but reassessments are completed periodically (Panel on Prevention of Falls in Older Persons et al., 2011).
Step 9: Development of an Individualized Multifactorial Intervention Program
This step requires the provider to develop an individualized multifactorial/multicomponent intervention program based on the identified risks of the older adult with the goal to prevent future falls (Table 2). Review of the assessment completed in Step 7 is necessary to determine those areas that have been identified as risk factors and develop the steps necessary to reduce the risk. For example, if the individual is using a variety of medications which place him/her at risk for falls, the goal would be to reduce the medications either through dosage reduction or eliminating the medication if possible.
Individualized Multifactorial Intervention Program
Exercise should also be incorporated, as it provides its own benefits, including building stamina, improving muscle strength, and improving functionality (Al-Aama, 2011).
The individualized multifactorial intervention program also needs to consider the setting the older adult lives in to ensure all components have been reviewed and considered.
Interventions for Older Adults Living in the Community. The focus for older adults living in the community shifts slightly to include the goals of reducing polypharmacy, improving physical mobility, ensuring appropriate care for health issues, and modifying environmental factors to increase safety. Reducing polypharmacy requires a comprehensive medication review to ensure the older adult is only taking required medications. This review should also assess whether the older adult is taking any over-the-counter medication(s).
Interventions for Older Adults Living in Long-Term Care or Assisted Living Facilities. Interventions for older adults living in long-term care (i.e., nursing homes) or assisted living facilities should focus on completing a comprehensive fall assessment, determining the risk factors associated with individual falls, developing a multifactorial fall intervention program that is individualized to the older adult, improving physical mobility, and modifying the environment as possible to reduce environmental risk factors. Included in the development of intervention programs is the importance of educating staff regarding the interventions used and why they are used. Polypharmacy, pain, and reduced physical mobility also need to be assessed.
Interventions for Older Adult Patients in Acute Hospital Settings. A primary concern for older adults who are admitted to an acute care hospital is the risk for falls related to functional decline. The longer the older adult is confined to bed or is only getting out of bed periodically throughout the day, the greater the risk for functional decline. Interventions need to focus on these issues and should include environmental factors, use of assistive devices, appropriate footwear, physical therapy as needed, occupational therapy as needed, pain management, and assessment for polypharmacy and use of psychotropic medications.
Regardless of where the older adult lives, there needs to be an understanding of what does and does not work in the development of a comprehensive fall program. The use of psychotropic medications, restraints, and alarms does not reduce the risk for falls. Hourly rounding is proving to be an appropriate and effective strategy as part of a comprehensive fall program (Dyck, Thiele, Klassen, & Erenberg, 2013). With this step, the expectation is that the intervention program will be reviewed as frequently as necessary to ensure the program is working for each intervention included.
Step 10: Reassess for Fall
Step 10 is the final step in the assessment protocol, and recommends providers reassess periodically for fall risk.
Evaluation: Outcome and Process Indicators. A comprehensive fall assessment should be completed to obtain information in the development of a multifactorial fall intervention program that is individualized to each older adult. Providers need to be aware of the underlying causes for falls and the interventions that will reduce or eliminate risk for falls. Regardless of where the older adult lives, interventions to reduce risk for falls can be developed based on the older adult's history.
Special consideration needs to be given to those interventions that have proven to be ineffective, with a move toward successful interventions. Ineffective interventions not only include those interventions that do not reduce the risk for falls but also those interventions that have an added risk for harm to the older adult by limiting mobility. According to Growdon et al. (2017), mobility programs developed for the aging population need to reduce risk for falls while maintaining mobility. The Hospital Elder Life Program (HELP) was developed by Sharon K. Inouye and colleagues at Yale University School of Medicine to reduce risk for falls while maintaining mobility of the aging population in the hospital setting. Additional information can be found at http://www.hospitalelderlifeprogram.org/about.