Reducing Fall Risk in Long-Term Care Residents Through the Interdisciplinary Approach

Falls among long-term care (LTC) residents are associated with increased morbidity and mortality due to a high prevalence of co-morbidities such as osteoporosis and neurological disorders. Although we cannot eliminate all falls among frail LTC residents, we can reduce their risk for falls by conducting a thorough interdisciplinary falls evaluation and by minimizing amendable risk factors.^1,2 This article will provide insight into fall etiology and a format for coordination between members of the interdisciplinary team (IDT) to reduce fall risk. Whenever possible, the strength of scientific support for our recommendations will be described (Table I).²

It is not the intent of this article to create a standard of care, but rather to provide an approach to reduce fall risk. Although the definition of recurrent fallers may vary, a systemic approach and work-up for fall prevention should be considered with all individuals who fall or who are at risk for falling in LTC facilities (Table II). The first section of this article discusses multiple comorbid conditions that impact upon fall risk, and the various interventions that, when coordinated through the IDT and appropriately implemented, can reduce such risk. The subsequent section describes institution-wide approaches to reducing fall risk, and presents roles to be considered for the different members of the administrative team in reviewing fall risk. Quality assurance (QA) meetings, as well as care planning, restraint reduction committees, and assessments of high-risk residents, are appropriate venues in which to review recurrent fallers.

LTC RESIDENTS AT RISK FOR FALLS

Medical Conditions
Medical conditions may impact upon fall risk and include both chronic and acute clinical issues. Endocrinopathies, such as hypothyroid states and adrenal insufficiency, may increase the propensity for falls. Type II diabetes mellitus increases fracture-risk.³ Inadequately treated seizures have a direct and obvious effect on falls, as do gait disorders and other neurological conditions. Parkinson’s disease increases fracture risk.³ Cognitive impairment increases the risk for falls,⁴ as does delirium. Protein-calorie malnutrition reduces sustainable strength, reserve strength, and balance. In contrast, postprandial hypotension may contribute to fall risk in some cases.⁵

Acute (or subacute) clinical problems that may increase the risk for weakness and falls include infections (eg, urinary tract infections, pneumonia), anemia, hypoxia, dehydration (and/or volume depletion), pulmonary emboli, exacerbation of chronic obstructive pulmonary disease, impaction, and urinary retention. These risk factors should be worked up according to the patient’s clinical presentation. Recent occult fractures should always be suspected for sudden changes in gait associated with falls, as should subdural hematoma with recent history of head trauma accompanied by changes in gait, mentation, and/or function. This is particularly crucial in residents who are anticoagulated.

If appropriate, chronic subdural hematomas and normal pressure hydrocephalus should be considered in residents with more protracted clinical courses. It is helpful to review falls and fall etiology with the facility medical director, whose focus is clinical quality issues, systems integrity as related to clinical outcomes, process review, policy participation, and education.⁶ The medical director provides a resource for review and education for falls assessment and strategies to reduce risk. Residents who fall are considered “high-risk” and should be reviewed on a regular basis during IDT care planning and continuing quality improvement (CQI) meetings.⁷ In addition, the medical director should encourage identification and treatment of comorbidities associated with falls morbidity, such as osteoporosis.

Orthostasis and Hypotension
The contribution of orthostatic hypotension as a risk factor for falls in residents of LTC facilities is controversial. Maurer et al⁸ found that orthostatic hypotension, when measured in LTC residents using beat-to-beat tonometry, was not predictive of falls. In community populations, orthostasis is not infrequent among community-dwelling elderly, and as a consequence, is difficult to demonstrate as causative in population-based studies.⁹ Although elderly individuals may experience orthostasis apart from falls, it is the combination of orthostasis (and/or hypotension) and falls (or unstable gait) that should raise the suspicion that a clinical association may exist. Potential causes of such an association may be drug-induced effects and volume depletion, as well as autonomic dysfunction.¹⁰ Even though subjective postural dizziness is a higher risk factor for falls than objective orthostasis,¹¹ it is prudent to screen recurrent fallers for episodes of hypotension at different times of the day as well as after blood pressure–reducing medications, activities, and meals.

Medications
Medications (Table III) can be critical in increasing the risk for falls (Class I; see Table I).^2,12,13 Mechanisms can vary. Diuretics, short-acting antihypertensives, and antipsychotics may cause orthostasis and/or hypotension, while antipsychotics, hypnotics, and anticholinergics may alter balance, gait stability, and cognitive sequencing. Antidepressants in general may increase fall risk and include both tricyclic (and related antidepressants) as well as selective serotonin reuptake inhibitors. Carbidopa/levodopa may increase fall risk by lowering blood pressure in frail elderly patients with Parkinson’s disease.¹⁴ In such situations, a titration of medication balancing orthostasis with Parkinson’s disease–induced gait abnormality may be helpful to maximize medication efficacy and reduce fall risk.

Delirium and drug toxicity should always be considered as potential causes for falls. Recurrent falls are an important indication to reconsider the benefit–risk relationship for continuing an anticoagulation regimen. Thus, medication review is an essential part of the falls risk work-up. Consultant pharmacists should figure prominently into this evaluation, as should the medical director and the CQI team. Medications predisposing the residents to falls should be identified and called to the attention of the physician or primary care provider (Level B; see Table I).

Visual Assessment
Visual assessment is another integral component of a falls risk work-up.² The high prevalence of conditions reducing visual acuity can predispose elderly residents to falls. Reduced visual acuity may cause tripping, mis-stepping, mis-sitting, and walking into objects,¹⁵ as the aging process reduces depth perception and distant-edge contrast sensitivity.¹⁶ Visual impairment may also contribute to cognitive and functional decline in older women,¹⁷ and as such, can be part of a clinical continuum that increases the risk for falling. Poor depth perception may increase the risk for hip fracture.³

Such functional visual assessment involves practical and applicable measures of visual acuity that can be screened by nursing staff, as elderly residents do not usually perform well on traditional eye exams. For example, a certified nurse assistant (CNA) reports to the staff nurse that a resident, who was previously independent in brushing her teeth, now requires assistance to locate the toothbrush and apply the toothpaste. The resident’s ability or inability to perform “automatic,” functionally related tasks helps to identify potential visual problems. In utilizing visual assessment tools, the resident’s cognition, judgment, orientation, memory, and attention should be considered.

Although minimal usable vision may be preserved, low vision can interfere with successful performance of activities of daily living.¹⁸ Functional visual screening can be performed by an occupational therapist¹⁹ as it can by an ophthalmologist or optometrist. Nursing can also screen with an appropriately designed functional visual assessment test. The Activities of Daily Living Vision Scale²⁰ and the Visual Function-14 Index (VF-14)²¹ are tools (questionnaires) that assess community dwellers’ perceptions of their functional visual impairment. These tests are either self-administered or can be completed by telephone or personal interview. They assist in identifying functional deficits in individuals with identified visual deficits, such as cataract, macular degeneration, and retinopathies. However, their efficacy in reducing falls remains to be evaluated in the LTC setting.

Physical conditioning (Table III) remains an important issue in preventing falls (Level B; see Table I). Lower-extremity weakness is a risk factor for falls in the elderly,²² as is sensorimotor function in the maintenance of lateral stability.²³ Exercise helps to preserve such function and should be incorporated into active “activities” programs offered throughout the day, evenings, and weekends. Ambulation during the day, such as “walk and dine” programs, increases and maintains muscle tone, flexibility, and balance.

Extended periods of bed rest should be avoided, as this increases the risk for falls by producing a deconditioned state, balance impairment, and gait instability. Range of motion should be continued throughout a resident’s stay in a LTC facility. Rehabilitation therapies (physical and occupational), as part of the IDT, should review residents at risk for falls (Table II). Physical therapists evaluate balance, gait, strength, and transfers, while occupational therapists evaluate wheelchair positioning and propulsion, cognition, vision, and safety during activities of daily living. Both therapies address education and training of residents, staff, and families.

Restorative nursing as well as activities therapists are essential in the follow-through of functional maintenance programs established by therapies and nursing. Rehabilitative or restorative nursing care includes walking programs, range of motion (exercise of joints), and other activities that aim to improve/maintain function and prevent the negative effect of immobility such as contractures.²⁴ In addition, therapies evaluate sequencing and therapeutic positioning, which are critical components to wheelchair and transfer safety. Transfer safety requires a number of interacting systems, including vision, range of motion, cognitive sequencing, balance, and strength.

Timely and appropriate assistance, as well as mechanical aids and design of equipment, should be integrated into the overall strategy for safe transfer and ambulation when physical and cognitive deficits are present in the resident. Nursing Intervention In addition to active participation in the resident’s conditioning, nursing uniquely addresses resident comfort and environmental issues (Table III). Comfort is a major factor in preventing falls. Toileting schedules are essential in the care of frail, elderly residents and should be carried out throughout the day and night.²⁵ Bowel regularity and functional continence are goals to achieve and maintain.

Nutrition requires appropriate adjustments in terms of calories, protein calories, temperature, taste, and presentation. Hydration should be provided throughout the day and evening with additional fluids during warm and dry weather. Pain must be treated appropriately and monitored for treatment efficacy.²⁶

Temperature regulation is especially crucial during the extremes of seasons as well as during outings. Falls may occur when residents slide out of chairs (or wheelchairs), flip out of chairs, or attempt to rise unsafely from uncomfortable chairs. For example, many residents spend considerable time in wheelchairs; however, these were designed for transport, and their sling seats do not provide adequate support for long periods of sitting. Many products are available to adapt chairs to individual residents’ seating needs.²⁷ Similarly, comfort when walking, facilitated by properly fitting and appropriate footwear, reduces the risk for tripping. For example, athletic shoes have been associated with lower fall risk, while fall risk increases when shoes are not worn.²⁸

Cognitive function of the resident is an important determinant of their ability to transfer or ambulate safely. The resident’s safety awareness, physical and mental limitations, and ability to consistently request assistance will help direct the “team” to the most appropriate interventions. For example, it is futile to repeatedly instruct a resident to “push the call button” if the resident has significant short- and/or long-term memory deficits. The resident may perform better with visual cues and reminders or frequent room checks.

For enhanced safety, it is recommended to minimize the amount of time a confused resident is left unsupervised in a secluded area or in his or her room. The resident’s care plan should reflect a series of trials, and perhaps errors, that show attempts by the IDT to establish a successful intervention.

Environmental issues may increase the chances for falling (Table III). Toilet seat height (and color), grab bars, and access to toilet from a wheelchair are all important considerations, as is careful supervision, strategically balancing privacy with need for assistance. The condition of the path from the bed to the toilet is crucial, since this is usually negotiated at night as well as during the day. Lighting should be adequate and appropriately placed. At night, low-voltage lights and lights that are easy to turn on or automatically illuminate with motion can help prevent nighttime falls.

Bed Falls
In contrast to falls during ambulation or from wheelchairs, bed falls are a source of morbidity and mortality in LTC facilities and should also be addressed by the IDT.^29-31 This focus includes designing a safe sleeping environment and identifying high-risk residents. Those at highest risk for bed falls are generally cognitively impaired, incapable of requesting help, and unable to walk without assistance.³² Such residents should not be tied in bed,³³ nor restrained by bedrails,^29,30,32,34 but rather, alternative strategies should be developed to reduce the risk of fall-induced morbidity.

Alternatives to restraints exist as modifications of the bed environment. Beds adjusted to the resident’s lower-leg length, transfer “enablers” (handgrip or transfer pole), and non-skid mats can reduce falls while transferring from bed. Entrapment can occur with half-length bedrails³⁵ as well as full-length bedrails,³⁰ and therefore these should be avoided.³²

Mattresses with raised edges or pillows can warn residents of the bed edges. Falling onto hard surfaces increases the likelihood of serious injury; thus, a bedside cushion such as a slip-resistant, high-impact mat placed on the floor next to the bed can reduce the risk of bed fall injury. Bedside mats can destabilize a resident’s gait, and therefore should be used when the resident is in the bed and removed during egress. Alarms are another element in bed safety strategies.

Alarms can be pressure-sensitive (sounding when a resident lifts his/her buttocks off a sensor pad, or when a resident is standing with a sensor attached to the thigh). Other types of alarms activate when a magnetized or metal clip is pulled from the alarm unit when residents attempt to egress, pulling the clip via a string that is attached to their clothes. In order for any alarm system to facilitate fall prevention it must be in good working order; these devices are known to break down frequently. New alarm concepts include a voice “alarm,” a tape recorder that plays an individualized message addressing the resident by name with calm instructions.

Bed alarms may be attached to the call bell system to avoid loud and blaring noise that may disrupt the resident and/or the resident’s roommate. Some alarms require adjustment for time delay, which is the amount of time between the resident’s change in position and alarm activation. If the delay is too short, there will be frequent “false” alarms that may annoy both the resident and staff. If the delay is too long, there may be inadequate time for the staff to reach the resident. An open intercom between the resident’s room and the nursing station, or use of nursery monitors can facilitate staff-resident communication but may impact upon privacy.

Wall-mounted motion monitors are another alternative. Alarms and communication systems depend on the ability of staff to reach residents in a timely manner. When residents who are at risk for falls are located far from staff, alarms may be inadequate. When activated, staff should determine why the alarm-fastened resident attempted to exit the bed. For example, toileting, thirst, hunger, pain, discomfort, and boredom may be issues that the staff should address before returning residents to their beds.

INSTITUTIONAL APPROACH TO FALL RISK REDUCTION

Facility Medical Directors
Facility medical directors carry out several important functions in reducing fall risk in LTC residents. Firstly, medical directors coordinate medical care and provide a supportive role for the primary care physicians (and/or their clinical extenders) by reviewing clinical issues that may impact fall risk among recurrent fallers. Working together through CQI, medical directors support primary care providers in assessing clinical associations, such as hypotension and fall risk, evaluating acute (and subacute) medical conditions, developing strategies for delirium recognition and management, reviewing medication regimens, and suggesting ways to reduce the contribution of comorbid conditions to fall risk.

Medical directors may provide overall guidance in suggesting treatment of osteoporosis, discussing the use of hipsters, and cautioning about the use of anticoagulant medications in residents who are recurrent fallers. Secondly, medical directors work with the IDT in CQI efforts to help develop and monitor risk-reduction strategies. Medical directors and their directors of nursing (DONs) collaborate in assessing quality initiatives on a facility-wide basis to reduce fall risk.

Policy generation is an essential component of this effort. Additionally, the educational component to the medical director’s function is critical in creating a knowledge base from which the IDT can work together in identifying and reducing fall risk factors. By expanding this educational role to involve physicians and their clinical extenders, medical directors create a working environment whereby all involved focus their common efforts in reducing fall risk. Furthermore, by discussing fall risk issues with residents and families, medical directors recruit them into the collective effort of reducing fall risk. This also creates an understanding among residents and families that falls are inevitable in LTC populations, and that the effort will be focused on reducing risk rather than eliminating falls completely, which is not practical.

Nursing Administration, Rehabilitation, and Pharmacy Consultant
The role of nursing administration is central in reducing fall risk among LTC residents. As the major contributor to policy, staffing, and day-to-day management, nursing implements as well as designs fall-risk strategy. Nursing is the driving force in utilizing restraint alternatives, withholding medication that they deem injurious to the resident, and creating an environment that is supportive and comfortable for residents. Indeed, changes in room furniture, reallocating staff to periods of high fall occurrence, and rescheduling restorative activity to high fall times has reduced the incidence of falls in some nursing homes.³⁶

Nursing education through in-services is fundamental to a knowledgeable and coordinated nursing staff in reducing fall risk. By working together, nursing and dietary managers can review weight loss lists in order to identify and bolster diets of residents with persistently low body mass indexes and depleted muscle mass. The role of rehabilitation therapy is critical in setting up standards for transferring residents, teaching body mechanics, and insuring that residents are evaluated appropriately for functional capacity.

Rehabilitation and nursing cooperate in formulating restorative programs to reduce fall risk. Although consultant pharmacists review the medications of all residents, a focus on recurrent fallers can be helpful in identifying contributing medications. Although medications may impact fall risk directly, medications may also act indirectly (or more subtly), such as by reducing appetite and affecting muscle mass and strength, altering cognition, or affecting the metabolism or excretion of other medications.

Restraint Reduction
Physical restraints do not prevent falls,² and may actually increase fall-related morbidity^37,38 and mortality.³³ Alternatives to physical restraints reduce the risk for serious injuries when a comprehensive assessment is done.³⁹ Long-term care facilities can reduce falls without restraint use.^40,41 For example, timely toileting and appropriate transfers can reduce fall-related morbidity in LTC facilities. Although restraints should be strongly discouraged, education of staff, families, and physicians may be requisite for successful restraint-reduction programs.

Restraint alternatives are useful in the continuum of restraint reduction. Identification of restraint alternatives is an ongoing process and may take several re-evaluations to match the correct alternative strategy with each individual resident. Individualized assessment by the IDT is essential in reducing risk, eliminating restraints, and employing alternatives.⁴²

Restraint alternatives include anti-thrust cushions (step-down cushions that are higher in the front of the wheelchair seat and lower in the back) in lieu of waist restraint straps in wheelchairs. Cushions that tilt the pelvis make it more difficult for the resident to exit the wheelchair. Such obstacles to standing would be considered restraining by “gravity.” When using such alternative wheelchair strategies, it is important not to deprive residents from using their feet for moving the wheelchair. In such scenarios, wheelchairs are generally lowered so that the feet reach the floor.

More modern designs incorporate this approach into a gel seating environment. Wheelchair alarms (pin alarms, magnetic alarms, pressure alarms) alert staff to residents attempting to exit the wheelchair. Loud alarm noises can be disruptive and agitating. Such alarms are considered restraints when nursing simply places the resident back in the wheelchair. However, if the resident is assessed for reasons causing their egress (eg, pain, hunger, thirst, need to be toileted, or boredom), the alarm should not be considered a restraining device.

Communicating Fall Risk Through Flow of Information
Communicating fall prevention strategies and identifying residents at risk for falls are essential components to an overall program in fall prevention. The flow of information from the Minimum Data Set through the Resident Assessment Protocols and into the care plan is done at a nursing administrative level. However, getting the information from the care plan to the floor nurses and CNAs is a critical step in ensuring the safety of a facility’s residents. Information for line staff nursing (including CNAs) is very important in the hour-to-hour care of residents. For example, knowing which residents require a gait belt, one/two-person assist, or stand-by assist, is essential for the safety of residents during transfer.

Staff must know these procedures for each resident every time that resident is transferred 24 hours per day, 7 days per week. Violations in transfer processes can result in injurious falls. There are a number of strategies that can be employed to expedite efficient and accurate information flow from the care plan to the line staff. Some facilities have used closet cards describing resident-specific transfer and ambulation techniques. Other facilities use a CNA care plan or notes that CNAs carry with them on their rounds.

Committing resident-specific protocols to memory may be problematic and may increase the chance of error and inconsistency. Facilities may use a “falling star” program, where a star is placed at the entrance of the door and/or over the resident’s bed indicating that the resident is at risk for falls. There are additional strategies that have expedited care and reduced fall risk. Staff education is key to carrying out all strategies in a timely and accurate process. In-services as well as shift-to-shift communication are important components to line staff education.

Reducing Fall Risk in Dementia Units
Wandering can be commonly observed in dementia units where residents ambulate without specific destinations or goals. Wandering, in combination with instability of gait and flawed ability to sequence, increases the risk for falling. In such situations, it is not practical or logical for CNAs to follow residents around in dementia units to “catch” them as they fall. Such close attention by staff only agitates residents with dementia, thereby increasing their fall risk.

Restraining such residents is equally problematic, as this increases agitation, increases the possibility of entrapment, and denies residents their freedom of movement and interaction. The use of bedrails is discouraged in dementia units since bed swapping and unsupervised egress are common. Both situations create greater risk for entrapment. Therefore, other strategies should be considered to reduce the risk of falling. Staff can intervene effectively through repeated resident orientation, exercise, group activities, and distraction techniques.⁴³

Staff can also be effective by eliminating stressors that trigger wandering, employing aroma and color therapy, and utilizing familiar pictures and other items to help identify resident rooms and bathrooms. Environmental modifications, such as clear sign posting, door-locking devices, good lighting, and avoidance of loud sounds such as overhead PA systems, can reduce fall risk. Constant ambulation (especially new-onset) should be investigated for pain, need to toilet, hunger, thirst, infection, and boredom, as well as the contribution of comorbid medical conditions.

Realistic Care Planning to Reduce—Not Eliminate—Risk for Falls
Since it is not possible to prevent 100% of falls in all LTC residents, the IDT should consider appropriate care planning that recognizes the inevitability of falls. As care planning is central to team coordination and logical thinking, the approach and concept of falls inevitability should be inculcated into the care plan. Accordingly, the care planning process should focus on reducing risk for falls, not on eliminating falls. Such realistic goals are attainable and help staff avoid a sense of failure if an absolute fall reduction (no falls) is not achieved.

In reducing risk for falls, care planning should focus on assessing fall risk and coordinating IDT efforts to reduce that risk. Such care planning should take a multifaceted approach that would examine and coordinate team efforts on intrinsic as well as extrinsic factors.⁴⁴ Intrinsic factors include cognitive impairment, visual impairment, muscle weakness, neurological impairment, gait/balance impairment, and cardiovascular issues.

Extrinsic risk factors include environmental issues and medications. In addition, a multifaceted approach includes toileting (safe path to the bathroom and/or frequent staff toileting support), appropriate transfer techniques, proper foot apparel, wheelchair positioning and comfort, and ensuring comfort in general (pain control, bowel regularity, fluids, and food).

Therapies play a major role in falls prevention and should occupy a prominent part of the care planning process in assessing fall risk and fall-risk reduction. Therapies should be utilized to assess and improve balance, teach sequencing of movements, and build up lower-extremity strength. Therapies can also teach center-of-gravity appreciation to cognitive-capable residents.

Exercise and restorative programs help maximize and carry out this approach and should be included in the care plan. Communicating strategies and coordinating efforts to line nursing staff should be part of the care plan (or facility system) in reducing the risk for falls. This includes the transfer of information so that staff is informed and knows how to approach falls prevention in general, ambulation safety and observation, transfer technique, proper wheelchair positioning, and sleeping environment design.

It is helpful for the care plan (or facility system) to state how the dissemination of such information takes place, such as pre-shift sign-off, CNA care plan, and/or closet care plan. Resident/staff communication is also a part of this communication conduit. For example, specifics about call-light placement should be in the care plan. A sequel to the assessment and prevention care plan section is a strategy to reduce injury that may result from a resident’s potential falls.

Several studies have documented the efficacy of external hip protectors (eg, padded hip briefs) in preventing or reducing the severity of hip fractures in the elderly (Class I; see Table I).^45,46 Other interventions include use of a helmet (when appropriate), minimizing restraints, treating conditions such as osteoporosis⁴⁷ (increasing bone mineral density) and anemia⁴⁸ (when appropriate), and evaluating the risk–benefit of anticoagulation therapy in residents who are at high risk for falling. When residents refuse intervention, it is helpful to include resident refusal as well as resident (and/or proxy) education by the staff in a care plan strategy. On admission, residents and their families should be introduced to the inevitability of falls in the LTC setting.

Expectations on admissions should match the care plan approach of reducing (but not eliminating) falls and reducing injury from inevitable falls. The education process in terms of falls reality should start at this time so that residents (and their families) do not enter the LTC facility under the false impression that they will be kept fall-free throughout their stay.

Continuing Quality Improvement Review
Identifying consistent patterns of fall events (eg, time and place of falls) for CQI analysis may provide important clues to their etiology.⁴⁹ For example, the risk for falls after dinner when residents attempt to self-transfer into bed or onto the toilet can be reduced with strategically placed staff. Nurses should coordinate internal facility systems to reduce fall risk, as well as integrate other departments such as Activities (group exercise programs) into the effort to reduce fall risk (Table III).⁵⁰

A useful CQI tool (Table IV) compares the number of falls by location and time of day. This focuses nursing attention on problematic locations in the facility during high-risk periods of the day, and may identify staffing patterns as well as other issues such as medications and activities as contributing factors. Communication and documentation of facility efforts to prevent or reduce falls are critical to the success of all programs. Timely and accurate recording of fall-risk assessments and fall-prevention strategies in a resident’s medical record and interdepartmental care plan will assist team members in completing their respective responsibilities. The care plan should identify a resident-centered goal and strategies or approaches to implement in order to accomplish the stated goal.

CONCLUSION
Although falls among the frail elderly in LTC facilities cannot be eliminated, there are a number of co