Fall Prevention in Nursing Homes

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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

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    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).

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