Preventing Falls in Nursing Homes: Are They Preventable?

Introduction: The Scope of Falls in Nursing Homes

Falls are unintentional events in which a person comes to rest at a lower level under the effect of gravity. They commonly affect the elderly population. Research shows that approximately one-third of the community-dwelling population older than 65 years fall each year, and worryingly, half of these individuals experience multiple falls. These figures do not account for unreported falls. Moreover, nursing home residents older than 65 years are more likely to fall than their community-dwelling counterparts. Fifteen to twenty percent of nursing home falls result in fractures or hospital admissions, compared to approximately 5% of community falls. Additional consequences include lacerations, internal organ damage, intracranial hemorrhage, increased fear of falling, and exposure of nursing homes to potential litigation. Health care providers must therefore aim to reduce both the rate of falls and the rate of fall-associated morbidity within long-term care settings (Vu, Weintraub & Rubenstein, 2006).

Research shows that approximately 10% to 20% of falls within nursing homes lead to serious injuries, and 2% to 6% result in fractures. Falls can cause debility and functional degeneration along with decreased quality of life. Fear of falling can lead to further functional loss, psychological stress, feelings of helplessness, and social isolation (Centers for Disease Control and Prevention, 2015).

Risk Factors for Falls in the Elderly

It remains unclear whether interventions will reliably reduce fall rates in elderly patients, particularly those residing in long-term care facilities. Falls result from several risk factors acting simultaneously on an individual, making it difficult to construct effective fall prevention programs. Potential fall-risk factors include both intrinsic risk factors — such as cognitive impairment, visual impairment, muscle weakness, neurologic impairment, gait and balance impairment, and cardiovascular dysfunction — and extrinsic risk factors, which are environmental and iatrogenic in nature. Because falls are often the result of the interplay of two or more risk factors, interventions targeting only some of the existing risk factors may not be effective in preventing falls (Vu, Weintraub & Rubenstein, 2006).

Evidence-Based Intervention Programs

Research has identified preventive interventions that effectively reduce the incidence of falls in community-dwelling patients. These include detection and abatement of risk factors, exercise interventions, environmental modification, and multifactorial intervention programs that incorporate fall risk assessments, medication adjustments, exercise, environmental hazard reduction, and fall-risk education (Vu, Weintraub & Rubenstein, 2006; Quigley et al., 2010). High-quality evidence suggests that durable exercise programs for active older adults, along with environmental modifications within the homes of frail elderly individuals, can reduce falls and possibly fall-associated injuries (Weatherall, 2008).

The American Geriatric Society, the British Geriatric Society, and the American Academy of Orthopaedic Surgeons Panel on Falls Prevention have published guidelines for health care providers on managing fall risk factors in elderly patients in both community and long-term care settings. A review of the literature indicates that several fall prevention programs were effective in reducing falls within nursing homes. Although these programs do not consistently prove effective in long-term care facilities across all assessments, the practice continues within nursing homes.

The current literature permits assessment of the following as individual interventions: environmental assessment and modification, exercise intervention programs, hip protector use, and medication assessment and modification. Group and home-based exercise programs, along with home safety interventions, have been shown to reduce fall rates and fall-related risk. Multifactorial evaluation and intervention programs can reduce the number of falls; however, they cannot eliminate the risk of falling entirely (Gillespie et al., 2012).

Conclusion: Toward Effective Fall Prevention

Sadly, there are no trials examining the effect of all remaining interventions individually on nursing home fall rates. These components could nevertheless have significant roles in reducing fall rates within multifactorial fall prevention trials that included them in their respective intervention arms. Clinical trials involving fall prevention measures directed at nursing home residents have been fewer and less conclusive than those conducted in community settings. Fall prevention strategies applied successfully in community-dwelling geriatric patients have often failed to yield similar results in nursing home patients (Vu, Weintraub & Rubenstein, 2006).

In conclusion, while the evidence base for fall prevention in nursing homes remains incomplete, environmental modification and staff education show the strongest support. Hip protector use appears to reduce fall-associated morbidity even when it does not reduce fall rates. Future research should examine the individual and combined effects of medication modification, gait training, and assistive device correction on fall rates in long-term care settings to better inform evidence-based guidelines.

References

Berry, S. D., Lee, Y., Cai, S., & Dore, D. D. (2013). Nonbenzodiazepine sleep medication use and hip fractures in nursing home residents. JAMA Internal Medicine, 173(9), 754–761.

Centers for Disease Control and Prevention. (2015). Falls in nursing homes. Retrieved from

Gillespie, L. D., Robertson, M. C., Gillespie, W. J., Sherrington, C., Gates, S., Clemson, L. M., & Lamb, S. E. (2012). Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews, 9(11).

Quigley, P., Bulat, T., Kurtzman, E., Olney, R., Powell-Cope, G., & Rubenstein, L. (2010). Fall prevention and injury protection for nursing home residents. Journal of the American Medical Directors Association, 11(4), 284–293.

Sorock, G. S., Quigley, P. A., Rutledge, M. K., Taylor, J., Luo, X., Foulis, P., ... & Baker, S. P. (2009). Central nervous system medication changes and falls in nursing home residents. Geriatric Nursing, 30(5), 334–340.

Vu, M. Q., Weintraub, N., & Rubenstein, L. Z. (2006). Falls in the nursing home: Are they preventable? Journal of the American Medical Directors Association, 7(3), S53–S58.

Weatherall, M. (2008). Prevention of falls and fall-related fractures in community-dwelling older adults: A meta-analysis of estimates of effectiveness based on recent guidelines. Internal Medicine Journal, 34(3), 102–108.