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More than one in four American adults 65 years of age and older have reported falling and one in 10 reported a severe fall related injury, including fractures and traumatic brain injuries. Falls account for over 50% of injury-related deaths in older adults annually (Haddad et al., 2018). Nurses play an integral role in reducing patients’ fall risk by implementing a risk assessment scale, early intervention strategies and education.

Risk Factors for Fall (Lee, Lee & Khang, 2013; Kiel, 2018a; Centers for Disease Control & Prevention, 2017)

Intrinsic Factors

  • Fear of falling: a geriatric syndrome that may contribute to further functional decline and may limit ambition to participate in physical activities; can lead to weakness, muscle atrophy, decreased agility, and predisposition to falls
  • Advanced age
  • Female sex
  • Previous falls
  • Muscle weakness
  • Gait and balance impairments
  • Visual impairment
  • Postural hypotension (orthostasis)
  • Chronic conditions: arthritis, stroke, incontinence, Parkinson’s disease, dementia/cognitive impairment, diabetes

Extrinsic Factors

  • Polypharmacy and psychoactive medications
  • Lack of stair handrails and bathroom grab bars; poor stair design
  • Dim lighting, obstacles and tripping hazards
  • Slippery or uneven surfaces
  • Improper use of assistive devices (canes or walkers)

The Community Setting Screening for Falls Risk (Lee et al., 2013; Kiel, 2018b)

  • At each visit, ask patient about history of falls, frequency of falls, and gait or balance disturbances.
  • For patients who report a fall or gait/balance impairment, follow up with further risk assessment.
  • Review medical history and medications
  • Physical examination
  • Cognitive evaluation, visual acuity, and functional assessment
  • Cardiovascular system, include heart rate and rhythm, postural hypotension
  • Neurological impairment
  • Muscular strength
  • History of falls
  • Feet and footwear
  • Environmental hazards/Home safety evaluation
  • Get Up and Go test
  • Ask patient to rise from chair, walk 9 feet, turn around, walk back to chair and sit back down
  • Normal time is 14 seconds or less
  • Observe postural stability, gait, stride length, sway, and leg strength


 Falls Prevention (Lee et al., 2013; Kiel, 2018b)

  • Exercise/physical therapy targeting balance, gait and strength (ideally three hours per week)
  • Medication modification, as appropriate (for example, decreasing or stopping psychoactive medications)
  • Vitamin D supplementation for patients deficient or a high fall risk (800-1000 international units cholecalciferol daily)
  • Evaluation and modification of the home environment (most effective when directed by occupation therapist)
  • Patient education

For patients with comorbidities, consider the following recommendations (Kiel, 2018b):

  • Postural hypotension
  • Fluid optimization
  • Compression stockings
  • Medications (fludrocortisone or midodrine)
COMORBIDITY POSSIBLE INTERVENTIONS
Carotid sinus hypersensitivity Insertion of cardiac pacemaker insertion in appropriate patients
Cataracts Surgical correction
Malnutrition
  • Refer for nutrition counseling
  • Nutritional supplementation
Postural hypotension
  • Fluid optimization
  • Compression stockings
  • Medications (fludrocortisone or midodrine)
Foot pain/neuropathy Refer to podiatry

 

The Nursing Care Facility or Hospital Setting
Screening for Falls Risk (Kiel, 2018a)

  • Utilize standardized screening tools
  • Morse Fall Scale
  • Hendrich II Fall Risk Model
  • Schmid Fall Risk Assessment Tool
  • Johns Hopkins Hospital Fall Risk Assessment Tool
  • St. Thomas’ Risk Assessment Tool (STRATIFY)
  • Falls Prevention (Lee et al., 2013; Berry & Kiel, 2018)
  • Exercise/physical therapy
  • Medication modification (i.e. decreasing or stopping psychoactive medications, if appropriate)
  • Call bell in reach
  • Patient’s hearing aids or glasses in reach
  • Hourly rounding to assess pain, positioning, toileting, and personal needs
  • Early and frequent mobilization
  • Nonslip footwear
  • Elimination of barriers to transfer and ambulation
  • Avoidance of restraints
  • Use of bed alarm, when appropriate
  • Bed in lowest position to the floor
  • Vitamin D supplementation for patients deficient or a high fall risk (800-1000 international units cholecalciferol daily)
  • Patient and family education