How to Decrease Fall Risk in Nursing Home Residents

According to the National Council on Aging, falls are the “leading cause of fatal and nonfatal injuries” in older Americans. Not only do falls pose a threat to older adults’ safety but they threaten seniors’ independence and contribute to patient and facility costs.¹

Concerning for health care professionals in long-term care settings is that falls occur more frequently among nursing home (NH) patients than among older adults within the community.² Indeed, the Centers for Disease Control and Prevention estimate that between 50% and 75% of NH residents suffer from falls each year, which is twice the rate of falls for community-dwelling elders.²

However, research suggests that some NH falls are preventable when facilities and staff take the proper precautions and/or have fall prevention programs in place. Part of these precautions involve keeping staff educated on the most up-to-date fall prevention strategies and guidelines, assessing new patients for their potential risk for falling, and staying aware of residents with high fall risks.³

To gain more clinical insight into preventing falls in NH residents, including residents with comorbidities and dementia, Annals of Long-Term Care: Clinical Care and Aging spoke with Elizabeth Landsverk, MD, adjunct professor of Medicine at Stanford University (San Francisco, CA), and medical director at Silverado Senior Living (Belmont, CA) and Kensington Place (Redwood City, CA). Dr Landsverk provides her professional recommendations on what risk factors to look for and how to decrease fall risks. 

In long-term care settings, what do you think are the biggest contributing factors to the high rate of falls in older adults? Are there specific health conditions or environmental factors that are more influential than others? 

There are many reasons for the high rate of falls in elders. Some of the more common reasons include decreased vision acuity, weakness of legs, decline of balance, poor safety awareness, and vanity.

Cataracts are common and can decrease visual acuity. Also, macular degeneration will decrease acuity and can often impair peripheral vision, so there is less warning of trip hazards. If a resident’s vision is worse in one eye, there can be loss of stereo vision and loss of depth perception. If an elder has not gotten an eye exam (advised to check yearly), the prescription lenses may no longer be appropriate and can impair clear vision. Diabetes will also lead to visual decline.

Weakness is also a huge contributing problem. As elders age from their 60s to their 80s, there is an acceleration of sarcopenia. Inflammatory conditions and diabetes mellitus also hasten muscle wasting. This is all exacerbated by a sedentary lifestyle—more time watching TV or sitting in day programs or at home doing less activity. As elders’ cognition declines, their incentive to be active (in most cases) declines as well. The good news is that this is the area where the best results of intervention can be achieved. Try to keep them moving! The other side effect of sitting most of the day is the contractions of the hamstring tendons. Over time, the resident will no longer be able to extend the leg to 180 degrees, and contractures sometimes to ~100 degrees will result from constant sitting; standing with bent legs takes much more energy, is painful, and is less stable—all of which lead to increased falls risk.

Another contributing factor to fall rates is a decline in residents’ balance. This could be from peripheral neuropathy (the loss of sensation from peripheral nerves), most common in alcoholism, low B₁₂, and diabetes mellitus. Diagnosis and treatment for any treatable conditions is crucial. Rare inflammatory conditions can also lead to neuropathy. Studies have shown that tai chi is one of the most powerful interventions to improve strength and balance.

Poor safety awareness is another factor. As we age, our memory slowly declines. In the case of dementia, the decline is more significant and affects our ability to care for our daily needs. The frontal lobes are the source of executive function, abstract reasoning, and risk assessment, so one of the first changes is decline in judgement. Decline in brain function from inflammation—due to multiple sclerosis, rheumatoid arthritis, Alzheimers protein deposition, small strokes (small vessel ischemia) more often associated with cardiac risk factors, diabetes mellitus, or estrogen use—can lead to early decline in safety awareness and falls/injury in elders who otherwise seem OK. For example, choosing to bend over without support to pick up a thread on the carpet or walking over uneven surfaces without caution or assistance may lead to falls.

The final factor I would like to touch on is residents’ vanity. For instance, the elder woman insisting on the high heel pumps she has always worn or insisting on not using a cane or a walker, which would stabilize and likely prevent falls. Also, when I was working in New York City, it seemed that falls from exiting the taxi were common. These types of falls would be multifactorial: balance, safety awareness, strength of lifting and putting out the leg, and stepping out. 

What other preventative measures could be implemented alongside current interventions/screenings? What measures can be taken in the NH setting specifically? In those who are more cognitively impaired? In those who are almost completely bedridden?

First, I would defer to the assessment of my physical therapists. They guide my care plan in this area, but they need the support of the nursing and nursing assistant staff to implement a program of movement. While it is often easier for staff to leave elders sitting in their chairs, this leads to the weakness that increases the risk of falls. I would advise that the facility costs of having nursing assistants to bathe, transfer, and lift residents that can no longer walk could be reduced through a concerted walking program with a restorative aide to walk residents daily. There is no replacement for exercise.

In addition, I strongly believe that exercise is a much better way to ensure good sleep at night than using sedatives and hypnotics. Antipsychotics have been identified as increasing the risk of stroke, sudden death, decline, and falls; thus, there has been a move to use benzodiazepines and hypnotics to address agitation and insomnia. In our practice, we use no benzodiazepines or hypnotics. Instead, we work to restrict daytime sleep to 1 hour in the afternoon and advise to avoid all caffeine, also known to aggravate insomnia. 

Adjuncts to exercise would be to monitor protein intake. For instance, the a resident who only likes cookies at mealtimes needs to have fortified milk or protein powder in her oatmeal or mashed potatoes. Checking the albumin and addressing inflammatory conditions as often as  possible is also useful. Staff can request the physician also restrict the use of prednisone and other steroids as much as possible as these medications have been linked with osteoporosis. More recent guidelines advise that, if used for chronic obstructive pulmonary disease, they be tapered after 2 weeks, not left on indefinitely. If steroids cannot be avoided, then it is even more important to treat any osteoporosis with bisphosphates, calcium, and vitamin D. Making sure that vitamin D₃ is in a therapeutic range is important. 

For cognitively impaired residents, again, the most helpful thing staff can do is to keep them walking! Exercise has been found to decrease the rate of progression of dementia in some cases. For these patients, the front-wheeled walker is much safer than the cane. The “footed” cane is not a good choice, since it often is used by putting the two front prongs down then the back two prongs and is not a secure source of stability. The walker gives two points more stability and is preferable to a cane or no balance aides. In small spaces, the hemi walker is useful, since it gives stability but does not need the 3-foot clearing radius that a standard walker would need. 

If a person with dementia has lost safety awareness, then supervised walking is required, even though it is more difficult to provide in a skilled nursing facility. The Merry Walker is one option (a contraption that looks like a toddler walker made out of PVC) that assures safety (if correctly sized and the elder does not try to climb out of it). A standard wheelchair may be useful, without the foot rests, to allow the resident to move about the community on their own.

More concerning is the person with dementia who constantly tries to stand. But guidelines advise against restraints, since if they lose balance and are tied in the chair, the chair may fall on them and worsen injury. There is debate about using a releasable Velcro strap as a reminder; I have also seen the use of cushions that insert into the sides of the wheelchair and can release but do not give way without some conscious pressure (a gel cushion should be used with any wheelchair to decrease the risk of pressure ulcers).

For residents who are nearly bedbound, I would advise to have them in a reclining wheelchair with extending foot rests. This will allow the caregiver to reposition the elder every 2 hours to decrease the risk of pressure ulcers. The chair should be evaluated by the physical therapist to ensure that the weight dynamics will not likely lead to the chair tipping back; transport chairs should never be used for daily wheelchairs. Getting a debilitated resident up improves quality of life and engagement and decreases the risk of aspiration from lying flat. The extended foot rests are important to keep the legs from contracting.

Based on their specific care role, how can nurses, primary care physicians, physician assistants, pharmacists, nursing assistants, caregivers, and family members help reduce the number of falls in older adults? 

As far as nurses and physicians go, two of the main things to be aware of—and that often get overlooked—are the prevalence of sedating medications and the overtreatment of blood pressure (BP). Residents’ BP should be monitored closely to ensure that they are not being overtreated for high BP. For the “old old” those in their later 80s and 90s, it is best not to treat high BP unless the systolic BP is greater than 150 standing. Physical therapists and nurses can consult with a physician to decide if the resident is on too much BP medication.

Health care professionals should also make sure that residents are not on any (or on as little as possible) sedating drugs that can cause them to feel drowsy, which may make them more prone to tripping and falling. 

In terms of what family members can do to help, they can do their best to make sure their loved ones are eating and drinking properly, so that they have sufficient energy and do not become weak. Protein in their diet is essential. Family members should also try to encourage physical activity when possible and limit daytime sleeping. 

1. National Council on Aging. Falls prevention facts. NCOA website. https://www.ncoa.org/news/resources-for-reporters/get-the-facts/falls-prevention-facts/. Accessed May 8, 2017.

2. Centers for Disease Control and Prevention. Falls in nursing homes. CDC website. https://www.in.gov/isdh/files/CDC_Falls_in_Nursing_Homes.pdf. Accessed May 8, 2017.

3. Vu MQ, Weintraub N, Rubenstein LZ. Falls in the nursing home: are they preventable? J Am Med Dir Assoc. 2004;5(6):401-406.