Fall Prevention in Nursing Homes
Section snippets
Objective
This article summarizes current knowledge about falls, fall-related injuries, and fall-prevention measures among residents of nursing homes (NHs). Evidence of the efficacy and effectiveness of fall-prevention measures refers mainly to the recently published Cochrane review.1 However, evidence based on high-quality studies is not available for all relevant questions. Therefore, scientific evidence is complemented by recommendations based on observational data and personal experience with
Relevance of falls
NHs and ALFs are locations with particularly high risk for falls. Repeated falls and their consequences often have led to the initial institutionalization of the residents. Falls continue to affect the residents’ remaining independence, once they are living in a facility. The ability to perform activities of daily living and to participate in social activities can be compromised considerably by an increased risk of falling. Fear of falling may also contribute to increased fall risk.
Epidemiology of falls and fall-related injuries
A summary of studies performed in LTC facilities calculated a mean fall rate of 1.7 falls per person-year (range, 0.6–3.6), which is considerably higher than the fall rate observed in older people living in the community (mean 0.65; range, 0.3–1.6).2 In an LTC facility with 100 beds, a fall can be expected about every other day. The analysis of nearly 18,000 falls recorded in more than 500 NHs from Bavaria, Germany showed that more than three-quarters of all falls occurred in the rooms or
Risk factors
The prevalence of most of the known risk factors for falls is higher in residents of NHs than in people living in a community, and most NH residents have more than one identifiable risk factor.11 Therefore, residents of NHs have to be regarded as a high-risk population for falls. Examples of well-established risk factors are muscular weakness, balance and gait deficits, poor vision, delirium, cognitive and functional impairment, orthostatic hypotension, urinary urge incontinence, and nocturia.11
Fall-risk assessment in residents of NHs
Fall-risk screening and assessment tools are based on the above-mentioned risk factors and promise a suitable method to distinguish fallers from nonfallers. The usefulness of screening and assessment tools in LTC facilities, however, has been questioned because most of the ambulatory residents score as high risk.22, 23 The comparison between different fall-risk assessment methods such as the resident’s fall history, a nurse’s global judgment, or assessment tools did not demonstrate a clear
Managing falls and fall prevention in LTC facilities
Conducting a controlled trial for research purposes can be different from the implementation of a program in routine care. The most important step is to translate the evidence into daily practice. The management of fall prevention should eventually aim to be part of the routine processes because falls are so common and harmful. Routines should regularly be reevaluated in a quality-improvement process.
Benchmarking and documentation
It is highly recommended that each facility has a system for online documentation of falls and fall-related injuries. The report of a fall should be brief and precise, including information on time, location, activities associated with, and consequences of falls. Reports should be analyzed on a quarterly basis with a timely feedback system to staff members. Each major event should be discussed separately in a fall conference. Annually, the number of falls, fallers, and fall-related injuries
Running or starting a fall prevention program
The organization should discuss and prioritize possible interventions.26 Reflecting the case mix and legally mandated tasks, it should be as clear as possible what the goals of the programs should be for the next months and years. Some changes take months, if not years, to become part of the routine. Depending on the starting situation the following remarks have to be interpreted with caution. Based on a baseline assessment of at least 3 months before introducing change, different possible
Component descriptors: nonpharmacologic interventions
The successful randomized controlled trials (RCTs) on fall prevention in LTC facilities have used complex interventions. None of the studies have used factorial designs to tease out which single component was most likely to reduce the number of falls. The shared components of most successful fall-intervention programs include knowledge improvement, attitudinal change, and staff empowerment.1 The following recommendations on the possible effects of single components have to be considered as
Restraints and falls
The use of restraints to avoid falls and fall-related injuries is still common in many countries. This is a classical treatment paradox because the protective effect has never been demonstrated in controlled trials. A short-term benefit is the justification to continue this questionable practice. Numerous studies have demonstrated that fall-related injuries and other side effects are increased if restraint effects are observed over longer periods.57
Summary and perspectives
There is convincing evidence that 20% to 30% of falls in LTC facilities are preventable.1 It seems achievable to decrease the annual rate of hip fractures to less than 3%. There are marked differences between fall prevention in the community and institutions. Whereas structured exercise is the key component in home-dwelling persons, progressive strength and balance exercise in LTC facilities is one component that has to be administered in combination with other interventions to be effective.
Limitations
Based on the Cochrane review1 the authors have tried to integrate these findings with observational data and their own experience into a clinical statement. This statement has to be interpreted with caution because it reflects the authors’ personal experience.
The role of LTC facilities, NHs, and ALFs varies across countries or even within countries. Study results not only have to be interpreted within a cultural context and a specific health care system but also need to take into account local
References (57)
- et al.
Incidence rate of falls in an aged population in northern Finland
J Clin Epidemiol
(1994) - et al.
Risk factors for recurrent falls in the elderly in long-term institutional care
Public Health
(1995) The Vanderbilt Fall Prevention Program for long-term care: eight years of field experience with nursing home staff
J Am Med Dir Assoc
(2002)- et al.
Interventions for preventing falls in older people in nursing care facilities and hospitals
Cochrane Database Syst Rev
(2010) Falls in older people: epidemiology, risk factors and strategies for prevention
Age Ageing
(2006)- et al.
The prevalence of osteoporosis in nursing home residents
Osteoporos Int
(1999) - et al.
Hip fractures in institutionalized elderly people: incidence rates and excess mortality
J Bone Miner Res
(2008) - et al.
Trend of hip fracture incidence in Germany 1995–2004: a population-based study
Osteoporos Int
(2008) - et al.
Osteoporotic pelvic fractures in elderly women
Osteoporos Int
(2005) - et al.
Excess mortality after pelvic fractures in institutionalized older people
Osteoporos Int
(2010)
Fractures after nursing home admission: incidence and potential consequences
Osteoporos Int
Cost of falls in old age: a systematic review
Osteoporos Int
Falls in the nursing home
Ann Intern Med
Risk indicators for falls in institutionalized frail elderly
Am J Epidemiol
Dementia as a risk factor for falls and fall injuries among nursing home residents
J Am Geriatr Soc
Antidepressants and the risk of falls among nursing home residents
N Engl J Med
Drugs and falls in older people: a systematic review and meta-analysis: I. Psychotropic drugs
J Am Geriatr Soc
Drugs and falls in older people: a systematic review and meta-analysis: II. Cardiac and analgesic drugs
J Am Geriatr Soc
Medication as a risk factor for falls: critical systematic review
J Gerontol A Biol Sci Med Sci
Meta-analysis of the impact of 9 medication classes on falls in elderly persons
Arch Intern Med
Differing risk factors for falls in nursing home and intermediate-care residents who can and cannot stand unaided
J Am Geriatr Soc
Low bone mineral density and risk of fracture in white female nursing home residents
JAMA
Fall risk assessment measures: an analytic review
J Gerontol A Biol Sci Med Sci
Multifactorial and functional mobility assessment tools for fall risk among older adults in community, home-support, long-term and acute care settings
Age Ageing
Predicting falls in residential care by a risk assessment tool, staff judgement, and history of falls
Aging Clin Exp Res
Impact of a falls menu-driven incident-reporting system on documentation and quality improvement in nursing homes
Gerontologist
Fall prevention in residential care: a cluster, randomized, controlled trial
J Am Geriatr Soc
Implementation and evaluation of a nursing home fall management program
J Am Geriatr Soc
Cited by (65)
Estimating the health value added by nursing homes
2022, Journal of Economic Behavior and OrganizationPredicting Falls in Nursing Homes: A Prospective Multicenter Cohort Study Comparing Fall History, Staff Clinical Judgment, the Care Home Falls Screen, and the Fall Risk Classification Algorithm
2021, Journal of the American Medical Directors AssociationAssociation between sarcopenia and fall characteristics in older adults with fragility hip fracture
2020, InjuryCitation Excerpt :It has been validated as a measure of 1-year mortality risk and burden of disease; as the CCI increases, cumulative mortality attributable to comorbid disease increases stepwise [22]. Comorbidities are also reported as a risk factor for falls [12,13,21]. In this study, stepwise increases in CCI increased the risk of HF due to fragile falls.
Implementation of fall prevention in residential care facilities: A systematic review of barriers and facilitators
2017, International Journal of Nursing StudiesCitation Excerpt :These factors are needed when implementing a complex intervention such as fall prevention, because this requires that correct information about resident health status, risk factors and behaviors be available to various team members and disciplines in order to develop and evaluate a clear care plan (Becker and Rapp, 2010; Colon-Emeric et al., 2013). Although, two previous reviews also discussed the importance of communication for successful fall prevention, research findings on fall prevention communication remain scarce (Becker and Rapp, 2010; Neyens et al., 2011). Poor falls management skills—more specifically the inability to target the most important fall risk factors—was also an important barrier mentioned in the systematic review of Neyens and colleagues (Neyens et al., 2011).
Usefulness, assessment and normative data of the Functional Reach Test in older adults: A systematic review and meta-analysis
2019, Archives of Gerontology and GeriatricsCitation Excerpt :In this meta-analysis, a difference of approximately 10 cm was observed between the normative data for community-dwelling older adults and those in other settings. This difference can be explained by the assumption that non-community-dwelling older adults are older (Ellis et al., 2017), suffer more from balance problems and are at high risk of falls than community-dwelling individuals (Becker & Rapp, 2010; Lopez-Soto et al., 2015). Therefore, such differences among samples must be considered when interpreting the studies.
Funding: The preparation of the article was supported by a grant of the Forschungskolleg Geriatrie of the Robert Bosch Foundation and by the Bundesministerium für Bildung und Forschung (Förderkennzeichen: 01EL0702, 01EL0717).