Falls, a common and serious problem for the elderly, are associated with significant mortality, morbidity, decreased independent functioning, and premature admission to nursing homes.¹ The incidence and the severity of complications related to falls increase steadily after age 60.¹ In 2001, more than 1.6 million seniors were treated in EDs for fall-related injuries.² Unintentional injury is the eighth leading cause of death in the elderly, and two-thirds of these unintentional injuries result from falls.¹ It’s estimated that about one-third of those older than 65 years of age fall each year; and almost half of those older than age 72 who live in the community experience falls.³ Hospitals and nursing homes have a fall incident rate almost three times higher than those living in the community — one study reported an incidence of 1.5 falls per bed annually for persons age 65 years and older.² While 20% of falls require medical attention, less than 10% result in fractures.⁴ Of this subset, individuals who sustain hip fractures are at the greatest risk for experiencing complications of immobility, disability, and death. In older persons who sustain a serious fall-induced injury, almost 50% never fully recover, and many lose their independence for life.² The total cost of fall-related injuries for persons over 65 in 2000 was slightly more than $19 billion. By 2020 the annual cost of fall injuries is expected to reach $43.8 billion.⁵

Fall survivors suffer significant consequences, including both physical and psychological injury. Experts frequently cite fear of falling as adversely affecting social well-being. Fear of falling again can diminish a person’s self-confidence to maintain mobility, leading to a self-imposed restriction on functional activities.

Nurses encounter the elderly across all practice settings and play a significant role in fall prevention by performing a thorough assessment and targeted intervention. It’s essential that they are knowledgeable about assessing risk factors, performing a post-fall assessment, as well as identifying effective measures to prevent falls.

Where falls occur

Falls occur everywhere — one’s home, public places, and health care institutions. Analysis of typical profiles and scenarios expands cumulative knowledge about the types of falls that occur in each of these settings. One epidemiologic study of falls demonstrated that greater than 50% of falls occur during some form of locomotion.⁶

Falls in the community: For example, falls in the home usually take place in the bedroom, bathroom, living room, and on the stairs, most frequently while descending. These mishaps most commonly occur during routine activities. In a study that compared falls in the elderly at home and in the community, one group of investigators found that older persons who fell in and around their own homes were more likely to have their falls caused by internal, or intrinsic, factors, such as frailty or unsteady gait.⁷

Decreased proprioception and quadricep muscle strength diminish the lateral stability necessary for transfers and activities of daily living.⁷ They also discovered that falls that occurred away from home were primarily due to environmental causes, such as uneven ground or poor lighting. The researchers concluded that both frail and vigorous elderly persons are at risk, and that the risk increases even for the vigorous elderly when they are away from familiar surroundings.⁸

Falls in healthcare settings: Falls in the acute care hospital occur at a rate of 2.5 falls to 3.5 falls per patient for every 1,000 bed days.⁹ They are frequently linked to medications, illness severity, and the use of physical and chemical restraints.⁹ Research has shown restraints do not decrease the number of falls or protect a person from injury. In fact, the risk for serious injury may actually increase.^10,11,12 Restraints promote immobility and lead to muscle wasting, diminished bone density, and pulmonary atelectasis. They are also demoralizing and can interfere with sensory stimulation, leading to disorientation and confusion.

In institutional long-term care settings, like nursing homes, falls account for 40% of all admissions.¹³ Residents with the greatest risk of falling include those with gait or balance instability, polypharmacy, orthostatic hypotension, dementia/delirium, and other comorbidities. The rate of fall-related injury is 10% to 25% in this setting, most commonly from fractures and lacerations.¹⁴

The culprits within

Falls in the elderly are typically multifactorial, owing to a combination of intrinsic (internal) or extrinsic (environmental) causes. Intrinsic factors that predispose a person to fall counts are due to normal physical changes of aging or from illness. These normal changes can alter sensory, neurological, cognitive, and musculoskeletal functions. For example, neurological diseases, such as stroke with hemi paresis, Parkinson’s disease, dementia, seizures, peripheral neuropathies, and vestibular dysfunction can impair mobility, predisposing the elderly to falls. The effects of musculoskeletal disorders, including arthritic conditions that weaken muscles, bones, or joints, along with metabolic conditions of hypothyroidism, hypoglycemia, electrolyte imbalances, and diabetes, also increase the risk for falls. Normal age-related changes linked to falls include visual impairment, orthostasis, and reduced righting reflexes. As we age we tend to be less active. Swedish researchers linked a sedentary lifestyle in men to a 1.5 times greater risk to suffer fractures and a 2.5 times greater risk to have a hip fracture as active men.¹⁵

The most common intrinsic cardiovascular risk factor is orthostatic hypotension. Orthostasis is a transient reduction in the systolic blood pressure of at least 20 mmHg that occurs when a person assumes an upright position after sitting or lying down. Certain drugs, such as antihypertensives or diuretic medications, and disorders of vascular volume depletion (e.g., diarrhea, dehydration, and gastrointestinal bleeding) cause orthostasis. Hypotension reduces brain blood flow, predisposing an individual to dizziness or fainting. Syncopal syndromes can also trigger fall-inducing hypotensive episodes. The many syncopal etiologies include cardiac syncope associated with cardiac dysrhythmias, postmicturition syncope, cough syncope following paroxysmal coughing, and carotid syncope related to carotid sinus hypersensitivity.¹⁶

The risk for falls increases when the older person is taking more than four medications and certain types of drugs. Sedatives, antidepressants, anxiolytics, and long-acting psychotropic agents are among the most commonly prescribed drugs for older people, and their adverse effects include confusion and sedation. Diuretics and antihypertensives often produce postural hypotension and fatigue. Other agents, such as aspirin, aminoglycosides, alcohol, and tobacco can negatively affect balance and vestibular function, resulting in a fall.

Finally, the elderly’s state of mind can play an important part in falls. Any condition that impairs judgment can lead to a high-risk situation for an older adult. Fear, anxiety, depression, delirium, and dementia can interfere with the ability to accurately assess the environment for hazards. And an unwillingness to accept physical limitations and assistance with certain tasks may also lead to an accident. Risk-taking behavior can lead to fall events, as the older adult may engage in activities known to contribute to falls. Consider the elderly man on a ladder outdoors — in the snow — preparing to fix the house gutters. Normal age-related changes such as decreased vision, limited range of motion, and slowed reaction time predispose this man to a fall and subsequent injury.

The danger without

The daily living space of the elderly often presents extrinsic safety hazards. Slippery floors, loose rugs, cluttered pathways, inclement weather, and uneven walking surfaces are prescriptions for danger, especially when joined by ill-fitting shoes and improper walking aides. But the activities most commonly associated with falls seem the most innocuous — transfers on and off beds or chairs and trips to the bathroom.¹⁷ Fall prevention strategies can be determined once these high-risk conditions in the home setting have been assessed. Educating patients and families about these hazards is an important measure for primary prevention.

Fall consequences

Serious medical consequences of falling include fatality and or fractures. Fractures typically involve one or more of the following bones: the pelvis, hip, femur, vertebrae, humerus, hand, forearm, or ankle. Falls are also the second leading cause of spinal cord and traumatic brain injury among older persons. Thirty percent to 50% of individuals who fall incur soft tissue damage from hematomas, sprains, and dislocations.^18,19 Finally, the elderly whose mobility is restricted during recovery from a fall are at risk for life-threatening complications of immobility, such as pneumonia, pulmonary embolism, and sepsis.

The psychological and social consequences of falls can be equally devastating to patients and families. Falls commonly trigger fear, anxiety, and depression in the elderly. Loss of confidence experienced after a fall event can be catastrophic. Fear of repeated falls can diminish a person’s self confidence in his or her ability to maintain safe mobility, leading to self-imposed restriction on functional activities. Patients may become unwilling to perform routine activities of daily living or participate in rehabilitation. Loss of independence due to immobility can result social isolation, dependency, and even institutionalization.¹⁹

Functional losses are a significant consequence of falls. They can be due to the injury itself or have a psychological etiology. The loss of mobility is associated with weakness, incontinence, compromised skin integrity and pressure ulcers, dehydration, impaired appetite and malnutrition, and a generalized debilitated state. Frail, elderly patients have low reserves, and they are highly susceptible to infections and sepsis.²⁰

Evaluating falls

A comprehensive nursing fall evaluation includes postfall assessment of injury and investigation of the root cause. It also includes a systematic appraisal of intrinsic risk factors obtained through the medical history and patient records. A fall is often the first indication of an acute underlying condition, such as infection, transient ischemic attack, or cardiac diseases so it is vital to perform a thorough medical history, review, and assessment. An exacerbation of a chronic disease, such as congestive heart failure, can also precipitate an accident. Almost 10% of falls in the community and 25% in institutions are related to an acute illness.²¹ Fall assessments should also include evaluation of extrinsic factors, such as proper use and condition of assistive devices. Type and condition of footwear must also be considered.

Often, one fall predisposes a patient to more falls. Assessment is directed toward identifying predictors of falls, such as changes in cardiovascular, pulmonary, musculoskeletal, or mental status. These findings, combined with a review of the patient’s records for preexisting conditions, medication use, and previous falls can yield important information for fall prevention. Nurses should assess the location of the fall for environmental hazards as well as the activity in which the patient was engaged at the time of the fall, for example, hurrying to the bathroom after taking a diuretic, standing up quickly, or sitting down. Activities can provide clues for contributing factors and prevention. If the fall occurred in an institution, incident reports track an individual’s fall history and the effectiveness of past intervention measures.

The Joint Commission develops National Patient Safety Goal related to patient falls

The issue of patient falls was selected by The Joint Commission as one of its National Patient Safety Goals for 2007. While not focusing specifically on the elderly, the goal considers all patients who, for reasons discussed below, are at risk for falling. National Patient Safety Goals are developed from recommendations made in JCAHO’s patient safety newsletter, Sentinel Event Alert. Aggregated information from the sentinel event database forms the derivation of National Patient Safety Goals.²² Falls accounted for approximately 4.6% of the sentinel events reviewed by The Joint Commission through the end of 2003. The goal related to patient falls is applicable to assisted living facilities, critical access hospitals, home care organizations, hospitals, and long-term care facilities. All accredited entities are expected to be in compliance with goal requirements.

The 2007 National Patient Safety Goal relating to falls states that organizations should reduce the risk of patient harm resulting from falls. The compliance requirement mandates organizations to assess and periodically reassess each patient’s risk for falling, including the potential risk associated with the patient’s medication regimen, and take action to address any identified risks.²³ The use of a fall risk model can aid in identifying both risk factors and establishing the probability of the causes associated with falls, benefiting those with a tendency to have a fall-related injury.²⁴

A thorough assessment identifies patients at risk for falls and allows a proactive approach. An assessment tool listing fall risks, including previous history of falls, cognitive impairment, impaired balance or mobility, musculoskeletal problems, chronic diseases, nutritional problems, and use of multiple medications, allows nurses to evaluate a patient’s fall potential and take a proactive approach. The Joint Commission is especially focused on the effect the patient’s medications will have on the assessed risk for falling. Compliance measures and risk reduction strategies advocated in The Joint Commission National Patient Safety Goals include installing bed alarms; adding fall prevention to the education needs of appropriate patients/residents; using low beds for those at risk for falls; ensuring adequate staffing is in place; and educating staff relative to fall prevention and risk reduction measures. Creating a fall prevention committee to look at fall statistics, determine trends and patterns, and evaluate and modify current policy based on the analysis is also recommended.²²

Implementation of a risk-oriented fall assessment tool, following through on actions dictated by assessment results, and initiating applicable risk reduction measures will help an organization successfully comply with the goal requirements.

Prevention measures

The approach to prevention is multidisciplinary, including input from nursing, medicine, nutrition, social work, and physical therapy staff. Preventive measures seek to minimize risk of falling, while also maintaining functional independence and mobility. Long-term care institutions formally assess patients’ functional status and the related nursing care needs through the Minimum Data Set (MDS). The MDS is mandated by the Centers for Medicare and Medicaid (formerly Health Care Finance Administration [HCFA]) and enforced by state health departments. It addresses falls and triggers a plan of care that is initiated upon admission for every patient, and then routinely reviewed and revised. Fall risk and prevention are addressed through this process. Additionally, many acute-care and long-term care institutions have risk management departments that also monitor fall incidents and prevention strategies. The staff needs to be vigilant in identifying and reporting any unsafe conditions that they notice within their facilities. Patients with unsteady gaits or who experience difficulty when making transfers need to be identified and referred for evaluation to physical and occupational therapists, who can guide nurses in how to properly use assistive devices and reinforce instructions to the patient.

For the older person living at home, an assessment by nurses and geriatric teams can identify environmental risks, and it offers an opportunity to educate patients and their families about ways to improve home safety. Well-defined safety measures can promote self-confidence and reduce the fear of falls. One study found that home visits by professionals reduced falls by both modifying the environment and encouraging safer behavior in high-risk elders. Safety measures include items such as nonskid rugs, handrails on stairs, grab bars near toilets and in bathtubs /shower stalls, and proper lighting, among others.²⁵

Comprehensive prevention regimens also include the assessment and treatment of underlying chronic and acute conditions, including periodic reviews of medications, physical functioning, and mental status for changes. Caregivers need to be alert for changes in patients’ nutritional and functional status as well as medications that could prompt an increase in the risk of falls. In particular, staff must be attuned to subtle changes in patients’ vigor, social interactions, and ability to communicate, areas in which alterations could indicate functional decline. Nurses can play a vital role in developing a patient’s self-efficacy — that is, confidence in the ability to perform daily activities without fear of falling. Self-efficacy, described in the Frailty and Injuries Cooperative Study of Intervention Techniques (FICSIT) trials, is an important consideration in fall prediction and prevention.²⁶ Elders should be encouraged to discuss their concerns or fears of falling with the healthcare team. Caregivers can approach these fears through cognitive-behavioral interventions, including relaxation techniques and fall prevention strategies.²⁷ Regular exercise and improving balance and strength have also been shown to be effective fall prevention strategies. “It’s never to late to start excersing,” advises Karl Michaelsson, MD, PhD, lead author of a Swedish study that indicated that men who increased their exercise even in the seventh and eighth decades of life had a corresponding decrease in fractures.¹⁵

Safety education for those at risk of falls as well as family members is critical in preventing falls and injuries. The elderly should be instructed to change body positions gradually; for example, when getting out of bed, they should sit on the side of the bed for a couple minutes before standing. Advise elders to notify their healthcare provider if their hearing, vision, or physical abilities deteriorate in any way. Also, warn them to avoid alcohol and sedatives, and to notify their healthcare provider if their medications make them feel ill or weak. Healthcare professionals should routinely review their patients’ medications with them to ensure that drugs are being taken as prescribed, that certain medications and doses remain appropriate, and to consider the effects or interactions any over-the-counter medications may have if taken with the prescribed medication.

The history component of the fall evaluation is critical. The American Geriatric Society recommends that healthcare professionals ask all older persons if they’ve experienced a fall.¹ A single incident should trigger a “Get Up and Go Test” (see sidebar); further assessment is needed if a problem is identified during testing.¹ These scores can be used to track effectiveness of intervention strategies, revise treatment plans, and set new patient goals. A more thorough fall evaluation by a qualified clinician specializing in geriatrics should be done if a patient seeks medical attention after a fall, reports more than one fall in a year, and/or has a gait and/or balance problem. A collaborative effort by healthcare professionals, the older adult, and family members is key to identifying risk, developing and initiating an individualized fall prevention plan, evaluating the effectiveness of the plan, and revising it as needed. Preventing a fall is the best chance of avoiding what can be a life-changing event.

Falls are a serious problem that affect one-third of all persons over age 65. Most falls in the elderly are predictable, preventable, and not due solely to the aging process. In spite of this data, many elderly people attribute their falls to the inevitable process of aging, and fear of institutionalization and losing independence contribute to underreporting of falls.²⁸ The FICSIT trials concluded that interventions aimed at those with the highest risk of falls could reduce their occurrence and improve the targeted elderly person’s quality of life.²⁶ Nurses and other healthcare professionals need to be able to recognize those at risk and the many intrinsic and extrinsic factors that add to their danger.