1. When People Fall: Prevention for Those at Risk by Marie Boltz, MSN, CRNP, NHA Gerontological Nursing Consultant Reviewed and updated in summer 2012 by: Ingrid Sidorov, MSN, RN Brian H. Kim, MD and Carol A. Maritz, PT, EdD, GCS
This program is designed to assist you and your agency to reduce the number of falls and also injuries due to falls.
Why is this topic important?
That may seem obvious, but here is some specific information to think about:
What is a fall?
Falls and related injuries have had varying definitions. Falls may be precipitated by intrinsic or extrinsic factors. Intrinsic factors are those that have a physiologic origin, and extrinsic factors are those precipitating from environmental or other hazards. Distinguishing between intrinsic or extrinsic risk factors can facilitate identification of preventive strategies.
According to Tinetti, Speechley, and Ginter, a fall in the non-hospitalized geriatric population is defined as “an event which results in a person coming to rest unintentionally on the ground or lower level, not as a result of a major intrinsic event (such as a stroke) or overwhelming hazard.” Agostini, Baker, and Bogardus adapted this definition for the inpatient, acute, and long-term care areas to define a fall as “unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of syncope or overwhelming external force.”
Other definitions are broader and include falls related to intrinsic events such as syncope or stroke. For example, Nevitt’s46 definition of a fall is “falling all the way down to the floor or ground, or falling and hitting an object like a chair or stair.” The ANA–NDNQI provides an all-inclusive definition: “An unplanned descent to the floor (or extension of the floor, e.g., trash can or other equipment) with or without injury. All types of falls are included, whether they result from physiological reasons or environmental reasons.

2. Why Talk About Falls? Falls happen often
1 in 3 older adults fall each year; 1 in 2 in long term care fall each year
Falls are dangerous
25% of falls cause minor injury
11% of falls cause major injury
such as hip fracture
88% of falls are related to medical and or physical conditions
Many (about 2/3) fall associated injuries and deaths can be prevented
How often do falls happen?
According to the Center for Disease Control and Prevention, one in every three adults age 65 and older in the United States falls each year. Two-thirds of those will fall a second time during that year.
Falls happen often and are dangerous.
Falls are the leading cause of injury-related deaths among people 65 years and older. Most falls result in no injury. Somewhere between 10 and 25% result in minor injury. About 11% result in serious injury, such as hip fractures, and the mortality of hip fractures is significant- approximately 20%.
Almost 90% of falls are associated with medical and/or physical conditions such as arthritis, pain or incontinence.
Many falls can be prevented.
The U .S. Public Health Services estimates that two thirds of the deaths associated with a fall are preventable.

3. Seriousness of Falls
After older adults fall
40% become less active
40- 70% report fear of falling
Almost 10% go to the ER for treatment after falling
Falls may be a warning sign of new or worsening illness.
Consequences of falls:
Approximately 40% of fallers reduce activity after falls, and % of fallers report fear of falling after falls.
This results in decreased activity and less independence.
10% of the older adults go to the ER for treatment after falling.
Falls may be a warning sign (symptom) of new or worsening illness.
Falling in older adults is often a symptom of acute medical problems, such as urinary tract infection, respiratory infection, or insufficient blood flow to the head or heart. In the person with chronic illness, diligent monitoring to detect acute illness and prompt intervention will minimize the risk of injurious falls. Pain management and sleep hygiene also lessen the risk of falls and injuries related to them.

4. Objectives At the end of this program you will be able to:
1. Identify risk factors and common
causes for falls.
Describe proper assessment after a fall.
Discuss intervention and prevention strategies.
Objectives. These are the things you will be able to do after this module:
1. Identify risks factors with the use of a fall risk assessment.
2. Identify common causes for falls.
3. Describe proper resident assessment after a fall.

5. Who Falls? Older adults who are acutely ill.
Older adults admitted to a new setting.
Those with functional loss.
Elders with problems walking, hearing, vision and memory.
Who Falls?
Those who are acutely ill. In addition, falls are often a warning sign that the resident is acutely ill. Those with repeated falls tend to fall more when they are experiencing an acute illness, very commonly a urinary tract infection or pneumonia.
Elders newly admitted: unfamiliar surroundings, stress, and anxiety can cause unsteadiness.
Elders with functional loss, including problems with walking, hearing, visionand memory problems fall more than those with less impairment. Problems with walking, hearing, vision and memory are much more common in those who fall.

6. Where do Falls Happen? 10% in long term care 30% in public places
60% at home
As mentioned, many falls do happen in long term care, others while out and about in a grocery store or on the sidewalk, but MOST falls happen in the elder’s home.

7. Age-Related Risk Factors
Consider age-related changes:
Gait
Posture
Muscle Strength
Balance issues
Response to medication
Response to stress
Reduced vision or hearing
Urinary frequency/incontinence
How do you assess a person’s risk of falling?
Physical Changes with gait and posture (a list of these changes is in Tab 3, Participants’ Materials)
A decrease in muscle strength is quite common and may affect ability to stand/sit or grasp objects.
Many older adults also suffer from issues with balance – so something as simple as turning around or standing on one foot may cause a fall.
Increased sensitivity to medications, especially those causing confusion, sedation, changes in blood pressure.
Decreased ability to deal with stress. Mental status may change when older adults are stressed by physical illness, change in routine/environment, or emotional discomfort. These changes make the older adult prone to falling; they do not make falling a part of normal aging. Underlying pathology also contributes to a risk for falls/injuries.
Incontinence is commonly asssciated with falls. Remember – incontinence is NOT a normal part of aging. Examples:
A person with diminished strength and/or balance attempts to hurry to the bathroom, loses balance and falls.
An older adult with cognitive loss may have difficulty finding the bathroom, become incontinent, then slip on a wet floor and fall.
The use of diuretics, stool softeners, and laxatives also create urgency that can result in falls.
Muscle strength – As people become less active their hip and shoulder muscles weaken. Hip weakness predisposes people to falls as they will have increased difficulty getting up from a chair, toilet and bed. Also, the ability to grasp onto an object may be affected.
Balance – Balance is affected in the elderly, so that something as simple as turning around or standing on one foot may cause a fall.
Eyesight and Hearing diminish – changes in eyesight (cataracts, drying of the eyes, etc.) and or diminished hearing affect the elderly’s ability to adjust to their environment – especially in the dark.

8. Fear of Falling About 30% of older adults have a fear of falling.
This includes people who have NOT fallen.
Fear of falling affects how people react to their environment and actually increases the risk of falling.

9. Should a Single Fall be of Concern?
ABSOLUTELY!
Every fall has the potential for being serious.
Consider changes in health, risk factors.
Has anything changed? Medications, infection, new diagnosis, change in mood, change in mental status, change in environment and d/w older adult and/or family.

10. Health Problems As Risk Factors
1. Heart disease and stroke
2. Diabetes
3. Osteoporosis
4. Gait disorders
5. Depression
6. Polypharmacy
7. Dementia
Circulation that is poor to the brain and heart lead to dizziness/ confusion/ imbalance.
Circulation refers to blood pressure and blood volume. Blood pressure and volume changes, either higher or lower can cause falls. (examples: Congestive Heart Failure, venous insufficiency, dehydration, blood pressure changes, transient ischemic attacks and stroke, some medications)
Diabetes – affects blood sugar level - Hypoglycemics are medications to lower blood sugar in diabetics. These medications can cause acutely low or high sugar levels which can lead to confusion and coma. Blood sugar levels may also change with infection and stress or with people that don’t control their diabetes well. Diabetes may also cause “neuropathies” that affect sensation.
Osteoporosis – weak bones can break due to very little stress on them and if someone is unaware of a fracture this increases the chance for falling.
Gait Disorders - people who have had a stroke may have weakness, contractures, balance issues or problems with vision that may affect their stability. Problems with muscle strength, trembling or lack of control also increase the risk for falls – i.e.Parkinson’s Disease, or ALS. Arthritis causes pain and affects movement, as do fractures, deconditioning and foot problems like bunions, etc.
Polypharmacy- too many drugs or side effects can lead to confusion and low blood pressure (orthostatic hypotension). Antidepressants can cause postural hypotension, urinary retention and incontinenceHypnotics and antianxiety agents can cause sedation and cognitive impairment. Antipsychotics can cause sedation, muscle rigidity, and postural hypotension.
Depression – can affect “get up and go” which causes deconditioning, appetite, mood, etc.
Dementia – causes changes in memory, judgement, communication.

11. Cognitive Loss As a Risk Factor
Anxiety from not recognizing environment
Lack of insight and judgment about safety
Sundowning
Behavior issues
Persons who are confused or emotionally upset tend to fall more than those who are not. The older person who is losing thinking (cognitive) skills may show anxiety leading to:
exit-seeking behavior
exhaustion
lack of safety awareness
All of these place him/her at risk for falls and injuries.
Think of older adults that are admitted to the hospital or long term care facility =
Sundowning – late afternoon or evening change in cognition with confusion, etc.
Behaviors that may lead to falls, like becoming agitated and acting out by hitting, etc.

12. Environmental Risk Factors
Lighting
Flooring/Pavement
Stairs
Furniture
Equipment/Physical Obstruction
Improperly fitted clothing
Threats to safety include:
Lighting -Dim lights or glare on shiny floors
Flooring- Uneven, patterned, or slippery and rugs. Outdoor issues with pavement, etc. SLIPPERY?
Furniture/Chairs - too low, too soft, poor back support, or tipped easily
Stairs
Equipment-
Assistive devices that are broken or incorrectly sized
or not used properly, example, ‘flying’ cane
No grab bars in bathrooms
Physical Obstructions-
Secure areas that contain hazards e.g. stairwells
Clutter – It is not uncommon for people to have piles of stuff laying around that they have to walk around which could cause a fall
Improperly fitted shoes or clothing - Too high, too tight, too long, or too loose
Long term care facilities can adjust the environment to help prevent falls.
Many residents of nursing homes fall at night – this may be related to physical issues such as, insomnia, pain and/or incontinence as well as environmental issues, such as poor lighting, use of side rails or unfamiliar surroundings.

13. Assessment After a Fall: What Should Staff Do?
Assess all skin and joints for injuries
Check vital signs
Move to a safe location off floor
Notify nurse supervisor
Notify family member
Response differs by location or type of services.
Immediately after the fall, staff should:
Personal Care Agency
Assess for injuries - Follow your agency policy/procedure.
In the event the older adult requires emergency assistance, see below.
If you are alone, call “911” first, then start emergency first aid.
If someone is with you, tell him/her to call “911” while you start first aid procedure.
*Do not move older adult unless you are able to do so independently or with minimal assistance.
Once all is safe and secure, notify your agency.
Continue to monitor the individual according to policy.
Complete the incident report. Describe incident factually.
Conduct a post-fall assessment, assessing extrinsic (environmental, lack of assistive devices, etc.) vs. intrinsic factors (orthostasis, sedation, signs of illness etc.) Note any relationship of the fall to activity (e.g., eating, getting out of bed, defecating)
Notify all team members (including nursing administration) of the fall. Orthostatic BP checks may be indicated.
Notify family
Adult Day Service
Follow center policy as established.
Center Director or nurse will report the incident as required, call family, physician, etc.

14. Strategies to Compensate for Physical Impairment:
Sensory loss
Muscle weakness
Approach
Eyeglasses and hearing aids
Exercise – Physical therapy consult
Restorative mobility program
Assistive devices
Sensory loss (particularly of hearing and vision). Glasses and hearing aides are essential tools, not only for communication, but also for safety. Care plans need to provide a plan, not only for use, but also for storage, accessibility and maintenance.
Muscle weakness, research shows, is the most significant risk factor for falls. The following approaches will also assist with balance problems and gait deficits which are additional threats to mobility.
Exercise, adapted to the resident's functional level, improves function and quality of life, as well as reducing risk factors, especially weakness and impaired balance.
Recommended exercises include strengthening, endurance, stretching, and balance. Regular walking is a standard component of an exercise program. Range of motion should be provided to residents at risk for contracture.
A restorative mobility program designed by a PT that promotes self-care during dressing, grooming, meals and recreational activities is encouraged. Persons who are able should be assisted to ambulate to meals and activities, stopping to sit and rest as needed when walking long distances. Tai Chi and yoga promote strength, flexibility , and balance.

15. Strategies for Cognitive Loss
Biographical profiles
Communication/re-direction
Structured daily routine
A security system
Exercise
The following interventions may prevent falls/injuries:
 Behaviors – recognize that ALL behavior means SOMETHING – hungry, tired, anxious, bored, have to go to the bathroom?
Pay attention to cues and react calmly and reassuringly.
A communication approach that is adapted to memory loss by utilizing simple one-step requests and providing visual cues, re-direction, and validation as indicated.
Primary life stories that help staff to understand residents’ communication and behavioral patterns. The result will be increased security and less anxiety .
Provide a structured daily routine of personal care, activities, continence care, and walking programs that promote function and emotional well-being.
A resident with nearby access to assistance such as a walker, to cue the person to use them.
A security system that promotes identification and surveillance of those at risk for falls/injuries.
Exercise - to help delay the progression of cognitive changes as well as improve muscle strength and balance.

16. Strategies for Incontinence
Medical evaluation
A consistent toileting program
Proper bathroom equipment
Constipation may be the cause
Reduce the risk of incontinence related to falls with the following approaches:
A medical evaluation to determine and treat any reversible cause of incontinence (e.g., a urinary tract infection or a fecal impaction
A consistent toileting program, e.g., morning, after meals, and bedtime.
The use of absorbent properly fitted incontinence garments.
Hydration to prevent urinary infection, impaction, and hypovolemia--all of which contribute to falls.
Constipation actually may be the cause of the incontinence and needs to be evaluated and treatment in a timely manner.
The use of safe bathroom equipment, especially at night: treaded socks, grab bars beside toilet, night light, call bell or other communication device nearby.
Provide a drawing of toilet on the bathroom door as a visual cue for residents with memory loss.

17. Prevention and Management Program
Assess each person in your care
Provide a safe and enabling environment
Implement balance and fitness programs designed by PT
Educate families and staff about falls and a restraint-free environment
Elements of a Prevention and Management program:
Assess each older person.
Provide a safe and enabling environment
Plan and implement balance and fitness programs
Educate families and staff about falls and a restraint-free environment that promotes safe freedom of movement– the use of a low bed with mats on the floor; a bed or chair alarm; HIPSAVERS, etc.
Institute quality improvement (period reassessment and improvement of plan)
Later we will see a video of what a program with all of these components might look like.

18. SAFE ENVIRONMENT Lighting Handrails Chair height
Equipment and items in reach
Shoes that fit
Carpeting
Lighting – especially at night (night light) and over stairs
Handrails – on both sides of stairs; in bathroom
Chairs should be high enough and with arms to enable sitting and standing
Shoes and slippers that FIT with non skid soles
Keep frequently uses items in cabinets that don’t requiring reaching and adaptive equipment within reach.
NO THROW RUGS and secure carpet edges.
Watch for obstruction, electrical cords, clutter, etc.

19. THE BATHROOM Grab bars by shower and toilet
Rubber mats in bathtub/shower
Raised toilet seat
Drawers kept closed
Since the bathroom is often the place that falls happen, consider simple, yet effective, methods of increasing safety.

20. Prevention and Management: Fitness & Activity Programs
Individual programs: Exercise, self-care, walking
Group programs: Exercise, yoga, walkercise, games/sports, dance/movement, tai chi
Other activity: Art, cooking, gardening, “mental gymnastics”
Managing risk factors, as discussed earlier, is clearly an integral component of a fall prevention and management program. Equally important are those proactive steps taken to restore and maintain mobility and function.
Physical and Occupational therapy and activities staff take a lead role in developing a daily routine for older persons that promotes consistent, maximum range of motion, gross motor movement, fine motor movement, and balance.
The approaches to promote mobility are incorporated into individual routines, which the resident performs alone, and group activities.

21. Prevention and Management: Fitness & Activity Programs
Exercise programs
Incorporate both balance and strength training
Balance training should include both static and dynamic activities performed at moderate to high challenge
Ideal program duration – 3-12 months
Static balance exercises include standing with eyes open and then closed while changing base of support
Dynamic balance exercise include walking in circles, both clockwise and counter clockwise

22. Education Program Staff education for each caregiver role
Safety education and fall/injury prevention for all: Staff, older adults, and family
Relaxation techniques
All staff should be educated on:
Age-related changes in older persons.
Factors that predispose people to falls and interventions.
The clinical presentation and course of dementia and the meanings behind behavior. Also communication techniques for working with residents with cognitive loss to maintain/restore function.
How to promote a sense of well being and prevent the anxiety and loss of function that can lead to falls.
Restorative care and the value of meaningful activity.
Safety education should involve the person at risk, the family, and all members of the interprofessional team. General safety precautions include the following:
Keep environment free of clutter, with clear pathways, adequate lighting, free of glare.
Report symptoms that suggest a predisposition to falls: mental status changes, dizziness, gait and balance problems, etc.
Implement approaches to prevent falls- exercise, nutrition/hydration, medication review, as well as "safe ways to fall."
The facility procedure for reporting safety hazards.
Relaxation techniques – can be used by caregivers to help person at risk who is afraid of falling to work through the fear – deep breathing, imagery (imagining themselves walking), etc.

23. Education Program Education of the person at risk for falls
Nurses are responsible for education programs of older adults. CNAs should remind older adults of safe techniques as they complete assigned tasks.
  Individual persons at risk should be educated as to their:
Restorative plans
Medication use and side-effects symptoms to report that suggest fall risk
Use of equipment
Hydration and nutrition
Safe method to fall if risks cannot be adequately controlled

24. Objectives Review Can you now
Identify risks factors and common causes for falls?
Describe proper assessment after a fall?
Discuss intervention and prevention strategies?
Objectives. These are the things you will be able to do after this module:
 1. Identify risks factors and common causes for falls.
2. Describe proper assessment after a fall.
3. Discuss intervention and prevention strategies.

25. Thank you for your attention!
The End