Falls in Older People Prevention & Management, Third Edition By Rein Tideiksaar, Ph.D.

Excerpted from the Introduction of Falls in Older People: Prevention & Management, Third Edition, by Rein Tideiksaar, Ph.D.

Copyright © 2002 by Health Professions Press. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.

Introduction

One of the most common and often critical problems faced by institutionally based health care providers is that of falls among older adults. Hospital falls represent a leading cause of adverse events, accounting for 25%-89% of all reported inpatient incidents.(1) To a large extent, this wide range is attributable to differences in various institutional policies (i.e., how falls are defined and reported) and the specific site or location of fall occurrence (e.g., rehabilitation, psychiatric, critical care, orthopedics, medical, surgical). For instance, in subacute or rehabilitation settings up to 46% of patients fall,(2) and in psychiatric hospitals, up to 36% of patients experience one or more falls.(3) In addition, more than 50% of falls in hospitals are not witnessed,(4) which is another factor responsible for inexact knowledge of fall frequencies.

Regardless of exactly how many people fall, people age 65 and older experience the majority of these falls. Studies that compare the age distribution of people with falls show that older people are overrepresented,(5,6) averaging about 1.5 falls per bed annually.(7) As many as 50% of these older inpatients fall repeatedly.(8) In the nursing facility, a setting to which older people are often admitted for safety reasons, falling is equally problematic. More than 50% of all nursing facility residents fall each year, and greater than 40% experience recurrent episodes.(9,10) The probability of falling, in both hospitals and nursing facilities, increases with advancing age; the highest incidence of falling occurs in the 80- to 89-year-old age group.(11, 12) This high incidence is more a reflection of the increasing illness and frailty that accompanies aging than it is old age itself. Falls, particularly repeated falls, are a major cause of physical and psychological trauma. Falls that occur repeatedly are likely to produce a cumulative adverse effect on the individual's capacity for mobility, causing periods of immobility and, as an outcome of complications, premature death.

In an effort to prevent falls, health care professionals have tried to protect patients and residents by limiting their mobility, often resorting to the use of physical or chemical restraints. However, mobility restrictions and restraint use have proven to be ineffective in reducing falls and are associated with a host of negative outcomes for older people. Moreover, federal and state governing bodies responsible for regulating hospitals and nursing facilities are focusing their attention on the problem of mechanical and chemical restraints and the methods employed to reduce them. In particular, they have stated strongly that mechanical restraints have a very limited role in the prevention of falls and are asking institutions to implement restraint-reduction programs. A better understanding of the phenomenon of falls will help health care professionals to prevent falls without resorting to traditional methods of restraint use.

Historically, the blame for falling has, for the most part, been borne by the host, the person who falls. Popular mythology holds that falls are attributable to either individual carelessness or the process of aging. Falls are considered to be either a "normal" phenomenon of aging — a manifestation of a general decline that is bound to occur — or, in people with multiple disorders, one aspect of a "hopeless" state in which one disorder after another leads inevitably to a negative conclusion. Many health care providers have dealt with falls and their adverse consequences for so long that they have become hardened; they no longer identify them as problems with solutions, other than to restrict the individuals' mobility. Moreover, providers may be reluctant to expect the possibility of better solutions.

Contrary to popular myth, falls, to a large degree, rarely "just happen" — they are neither accidental nor random events — but are predictable occurrences, the outcome of a multitude of host-related and environmental factors that occur either alone or in conjunction with one another. Many of the factors that contribute to falls are potentially amenable to interventions. By minimizing or eliminating these risk factors, falls can be reduced or prevented altogether.

In order to implement preventive measures, health care providers must take the following steps. First, they must understand the conditions under which falls occur and the factors that are associated with fall risk. With an increased knowledge of why older people fall and what factors are associated with fall risk, providers will be able to more easily identify patients and residents at risk and explore appropriate solutions aimed at reducing fall risk. Many of the factors responsible for falls are quite easy to fix, particularly for someone with a practiced eye, a different perspective, and different expertise. The second step health care providers must take is to mount an organized approach to the clinical assessment of fall risk and falls and put in place intervention strategies for both.

Although hospitals and nursing facilities more or less differ in their goals, distribution and orientation of staff, population of individuals cared for, and environmental design principles, the factors associated with falls as well as intervention strategies within each institution are similar in many respects. An apple-to-apple comparison between the two institutional settings may not always be possible — for instance, what works for hospitals with respect to preventing falls may not work for nursing facilities and vice versa — so when it becomes necessary to consider the specificity of each institution, it is noted and differences appropriate to each are set forth.

Falls are complex problems, often associated with a variety of causes. A great deal is known about older adults and falls; a wealth of information is available on their causes, and more important, on how to prevent falls. The challenge is how to take what is known and apply it. Although there is no "quick fix" for preventing falls, evidence suggests that an organized approach toward identifying patients and residents at risk for falling and targeting interventions aimed at reducing risk is beneficial. To achieve this goal, health care professionals in hospitals and nursing facilities need to make a serious, long-term commitment to addressing the problem of falls as they apply to their individualized setting by developing clinical programs focused on preventing falls.

Content of the Book: The book is divided into two sections. Section One gives an overview and specific suggestions for helping the reader understand the underlying causes of falls and how to develop and maintain an effective falls management program. Chapter 1 examines the outcome of falls with respect to their consequences in patients and residents, their families, and the institution. Chapter 2 reviews the multiple age-related physiological changes, pathological conditions, medications, and environmental and institutional factors associated with falls and fall risk. The clinical approach to the assessment of both falls and fall risk is examined in Chapter 3. Chapter 4 explores a number of medical, rehabilitative, and environmental strategies that reduce fall risk. Common environmental causes of falling (e.g., lighting conditions, ground surfaces, furnishings) and their modifications are covered in Chapter 5. Chapter 6 is devoted to a discussion of the issues surrounding physical and chemical restraints in the management of falls.

Section Two is divided into two parts. Part A provides guidelines, while Part B provides helpful photocopiable forms referenced throughout the book. Guidelines include a "best clinical practice" approach to the management of falls and fall risk in acute care hospitals and nursing facilities. Guidelines are also provided to help readers understand the structure and process of fall prevention and restraint-avoidance programs (i.e., what is needed and what has to happen in order to achieve success).

Forms include the comprehensive Performance-Oriented Environmental Mobility Screen (POEMS), as well as a restraint and nonrestraint assessment and care planning tool, a wheelchair problems and modifications checklist, and discharge teaching sheets that can be given to families when a patient or resident leaves a facility to ensure the optimum safety of the individual at risk of falling at home.

Notes

(1) Maciorowiski, L.F., Bruno, B., Dietrick-Gallagher, M., McNew, C., Sheppard-Hinkel, E., Wanich, C., & Regan, P. (1988). A review of the patient fall literature. Journal of Nursing Quality Assurance, 3, 18-27.

(2) Tutuarima, J., van der Meulen, J., de Haan, R., van Straten, A., & Limberg, M. (1997). Risk factors for falls of hospitalized stroke patients. Stroke, 28, 297-301.

(3) Tay , S.C. , Quek, C., Pariyasami, S., Ong, B.S., Wee, B.M., Yeo, J., and Yeo, S. (2000). Fall incidence in a state psychiatric hospital in Singapore . Journal of Psychosocial Nursing, 38, 11-16.

(4) Nyberg, L., & Gustafson, Y. (1995). Patient falls in stroke rehabilitation: A challenge in rehabilitation strategies. Stroke, 26, 838-842.

(5) Goodwin, M.B., & Westbrook, J.I. (1993). An analysis of patient accidents in hospital. Australian Clinical Review, 13(3),141-149.

(6) Rigby, K., Clark, R., & Runciman, W. (1999). Adverse events in health care: Setting priorities based on economic evaluation. Journal of Quality Clinical Practice, 19, 7-12.

(7) Rubenstein, L.Z., Robbins, A.S., Schulman, B.L., Rosado, J., Osterweil, D., & Josephson, K.R. (1988). Falls and instability in the elderly. Journal of the American Geriatrics Society, 36, 278-288.

(8) Gaebler, S. (1993). Predicting which patient will fall...and again. Journal of Advanced Nursing, 18, 1895-1902.

(9) Nygaard, H. (1998). Falls and psychotropic drug consumption in long-term care residents: Is there an obvious association. Gerontology, 44, 46-50.

(10) Kiely, D., Kiel , D., Burrows, A., & Lipsitz, L. (1998). Identifying nursing home residents at risk for falling. JAGS, 46, 551-555.

(11) Luukinen, H., Koski, L., Hiltunen, L., & Kivela, S.L. (1994). Incidence rate of falls in an aged population in northern Finland . Journal of Clinical Epidemiology, 47, 843-850.

(12) Rubenstein, L.Z., Robbins, A.S., Josephson, K.R., Schulman, B.L., & Osterweil, D. (1990). The value of assessing falls in an elderly population: A randomized clinical trial. Annals of Internal Medicine, 113, 308-316.