Inpatient falls and fall-related injuries continue to be the largest category of reported incidents in the acute care setting. Falls occur in many settings: In one week, my colleague received four calls about falls: a young brain injured woman who fell off a treadmill at home while under the care of an aide, an elderly woman who fell getting off an examining table in a doctor’s office, a woman who fell in the hospital just before the nurse reached her side, and a man who fell walking out an adult day care setting. The first three cases resulted in lawsuits. The last one has not been filed yet.

About 1,800 fatal falls occur among residents of US nursing homes each year.   About 10-20 percent of nursing home falls cause serious injuries. Two to six  percent cause fractures.  Many patients need to spend at least a year recovering in a long term care facility. Some never return to their homes.  In addition to fractures, elderly people suffer soft issue injuries, head trauma, and lacerations.

The 1% of elderly people who fall and sustain a hip fracture have a 20-30% mortality rate within a year of the fracture. One quarter to three quarters of people who lived in the community do not recover their prefracture level of function in ambulation or activities of living. A fall can be life-altering for this group. Fear of falling can lead to reduced mobility, deconditioning, dependency, social isolation, and diminished quality of life. A fall can result in a major disruption to an older person’s life- injury, hospitalization, and rehabilitation.

Falls have many liability issues. Some center around what should have been done to prevent the fall. Hot issues include use of side rails, frequency of monitoring to prevent a fall, responsiveness to the patient’s requests for help, and unsafe equipment such as wheelchairs. A delay in treatment can close a window of  opportunity to change the outcome- such as in head injury or spinal cord injury that results from a fall. Healthcare providers are expected to act as patient advocates to secure help for their patients.

A delay in treatment may occur because:

• The healthcare providers did not collect the appropriate data needed to assess the patient’s condition. The person who fell was not thoroughly assessed and an injury was missed.
• The appropriate data was collected but the healthcare provider did not have the knowledge to critically analyze the data to find its meaning. The signs of a fracture were overlooked.
• The data was collected and analyzed, but the appropriate healthcare provider failed to respond to another person’s concerns. The nurse could not get the attention of the physician or the nurse’s concerns were dismissed.
• The concerns of the bedside clinician were heard, but the provider did not or could not make timely decisions about what to do about the changes in the patient’s condition.

Some facilities have implemented a system of hourly rounds to reduce the factors that result in falls. Think of the four “Ps”:

• Potty
• Positioning
• Pain
• Possessions- phones, water, glasses, call lights and bedpans within reach.

Interested in learning more?

There is an upcoming teleseminar about this very subject.  MedLeague will host this seminar on February 23, 2010 at 12 EST with Dr. Deanna Gray-Miceli.  You can register for the program here.  The seminar is targeted to attorneys and legal nurse consultants and will cover how to identify the meritorious claims involving falls, look at damages as they are related for injuries from falls and the core elements that should be in place to prevent falls.

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As fall prevention programming becomes embedded in more community sites, as well as health care settings, it is useful to find a statistical analysis of the evidence regarding the most effective types of exercise programming.  A meta-analysis was conducted to establish the effect of exercise on falls rates and to determine the particular features of effective fall prevention exercise programs.  After identifying 1,107 relevant studies, the authors applied strict inclusion standards resulting in a final sample of 44 randomized clinical trials where it was possible to discern the specific exercise intervention and falls were measured as the outcome.  Combined, these trials involved a total of 9,603 older adults, the majority of which were community dwelling.  However, 6 studies involved older adult nursing home patients.  Estimates of the effects of exercise were statistically extracted from each study.  

Results:  This review suggests that among older adults, exercise programs can reduce fall rates by as much as 17%.  Sub-analysis excluding nursing home residents did not change the results.  The greatest effects of exercise on falls were obtained from programs that:                          

• Challenge balance to a high extent—starting at an appropriate level and individualizing the program to gradually increase the challenge to standing balance.  The authors suggest that Tai Chi is effective for fall prevention because it meets these criteria.
•  Include a higher total dose of exercise—the minimum effective dose equates to a twice-weekly program lasting 25 weeks.  It is suggested that supervised sessions that gradually increase intensity, should be interspersed with instructions to practice between classes at home.  The typical 10 week courses are too short.

(Having both of the above was particularly effective.)

• Did not include a walking program—The authors speculate that this unexpected finding may be due to:    

a) time spent walking may reduce the amount of time spent practicing balance, for example in a timed center-based class, or

b) an increase in activity, such as walking, could precipitate more falls among frail people. 

They observed that walking programs were often offered to more high risk populations.  *The authors note that walking offers many health benefits and that it is to be encouraged.  But if the goal is fall prevention, time is better spent practicing balance. 

Strength training was not shown to be effective in reducing falls.  The authors speculate that increasing strength in the absence of improving balance may account for this finding.  Strength training increases strength, whereas standing balance exercises improve balance and because they include maneuvers that involve maintaining control of body weight-against-gravity, to some extent they simultaneously improve strength.

Sherrington C, Whitney JC, Lord SR, Herbert RD, Cumming RG, Close CT.  (2008). Effective exercise for the prevention of falls: A systematic review and meta-analysis.  JAGS 56: 2234.   

Source: CT Collaboration for Fall Prevention

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Traditionally vitamin D has been recommended with respect to preventing osteoporosis, reasoning that improving the absorption of calcium improves bone strength making them less likely to fracture, should there be a fall.  Thereafter it was discovered that vitamin D has direct effects on muscle strength.  Severe vitamin D deficiency (as one might see in those nursing home residents who do not eat well and are virtually never in the sun) can present as muscle weakness and pain which resolves with vitamin D supplementation.  

Several early trials examining the extent to which vitamin D could prevent falls were unsuccessful.  These studies may have failed to produce the hypothesized result due to methodological issues:  low doses of vitamin D were used; vitamin D is available over-the-counter and may have been in use by those in the control group creating bias toward the null; and finally an issue we can all identify with — the difficulties associated with ascertaining the prevalence of falls due to using an unstandardized definition or incomplete ascertainment.  

A meta-analysis (“study of studies”) conducted by an international team of researchers, was recently published in the British Medical Journal1 to further address this issue.  The meta-analysis included 8 double blind randomized controlled trials of individuals 65 years or older receiving a defined oral dose of supplemental vitamin D3,  vitamin D2  or an active form of vitamin D and with sufficiently robust fall ascertainment.  The aim was to assess the efficacy of vitamin D supplementation for the prevention of falls among older persons by dose and serum concentration of vitamin D [25(OH)D].  The primary outcome measure was the relative risk of having at least one fall among persons receiving vitamin D (with or without calcium) compared to those receiving placebo or calcium supplementation alone.  Note that the current recommended adult daily dose of vitamin D is 400 international units. 

Results:

No fall reduction was observed for a daily dose of less than 700 IU vitamin D or achieved serum 25(OH)D concentrations below 60 nmol/l. 

Daily vitamin D doses in the range of 700 IU to 1000 IU or achieved serum concentrations between 60 nmol/l and 95 nmol/l reduced the risk of falling by 19%.   It is possible that higher doses of vitamin D or higher 25(OH)D concentrations would further reduce falls.  Results were attained with treatment for less than a year (2-5 months) and the benefit was sustained for 12-36 months.

 Preventing falls using this higher dose of vitamin D may not depend on taking additional calcium.

The authors note: “Binding of vitamin D to its nuclear receptor in muscle tissue may lead to de novo protein synthesis, a benefit that appears to precede the effect of vitamin D on bone.”  

*Since vitamin D is fat soluble and stored in the body it can accumulate to toxic levels over time and therefore periodic blood levels should be assessed.

1.  Bischoff-Ferrari HA, Dawson-Hughes B, Staehelin HB, Orav JE, Stuck AE, Theiler R, Wong JB, Egli A, Kiel DP and Henschkowski J.  Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomized controlled trials.  BMJ 2009; 339:b3692.

Source: CT Collaboration for Fall Prevention

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I had a workers compensation case not long ago in which an older lady (Ms. “S”) fell at her job as a waitress and suffered a tibial plateau fracture.  The fracture healed, but she required a very lengthy healing period primarily because she was fearful of falling again.  Ms. “S” continued to use a walker long after she was told to discontinue this.  She even took it upon herself to move to a cane before discontinuing the walker as directed.  Returning her to the work environment was nearly impossible due to self restrictions due to this fear of falling.  Case management, the physician, and the therapist all worked diligently to improve her functioning while eliminating her fear.  This proved difficult at best.

Falling and fear of falling have been identified as common problems among older adults.  This fear of falling may reduce physical activity and decrease ability to perform activities of daily living thereby increasing the likelihood of future falls.  It is a vicious cycle.

A recent study estimated the frequency of falls and the prevalence of the fear of falling among a sample of community-living older adults aged 65 and older.  The CDC conducted a telephone survey and asked respondents if they had fallen recently (within three months).  If so they were then asked to rate their fear of falling.  Several questions were posed about beliefs and behaviors for preventing calls such as, “In the past twelve months, has your doctor or pharmacist reviewed with you each bottle of medication you are taking?” and “How important do you believe it is to be physically active in order to keep from falling?”.

The study found that 10% of the US adults questioned had fallen in the past three months.  About 1.7 million of those were injury and 875,000 sought medical treatment.  More than one-third of US older adults were moderately or very afraid of falling.  Those who were moderately or very afraid of falling were more likely to be women, single, have lower incomes and aged 75 or older.  My patient mentioned above met all of these criteria with the exception of age.  Ms. “S” was in her late 60′s.

The study also revealed that while many older adults believed that physical activity and medication review could prevent falls, the majority of the people who had falling did not change their behavior in order to prevent future falls.  65% reported no change in the physical activity and almost 22% had actually decreased their physical activity.
Healthcare providers should ask senior adults about falls, address risk factors for falling and implement interventions to reduce those risks.  Home exercise plans, multi-factorial fall-related programming and community-based Tai Chi provided in a group format have been proven to be effective in reducing fear of falling and therefore should be encouraged.  What do you do to encourage your patients after a fall?  Do you find fear of falling a significant problem in your practice?

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Good posture means keeping the three natural curves of the spine in balanced alignment. When viewed from the side, a normal spine curves slightly forward in the neck or cervical area, slightly backwards in the upper back or thoracic segment of the spine, and slightly forward in the lower back or lumbar region. The back’s natural curves depend on strong and flexible muscles along with healthy hip, knee and ankle joints to make it possible to maintain good posture in any position and during movement.  Kyphosis in the thoracic spine means an exaggerated deviation from the thoracic spine’s normal backward curve. In addition, the normal curvature in the cervical and lumbar regions may be reduced contributing to an over-all “pitched forward posture”. Hyperkyphosis, or forward leaning posture, is commonly observed among older adults. Initially thought to be primarily a consequence of osteoporotic fractures, recent studies have demonstrated that many older adults who are most affected by hyperkyphosis do not have vertebral fractures. Other conditions associated with excessive curvature include degenerative joint disease, decreased physical functioning, sedentary lifestyle, and impaired pulmonary function.

While prior research has demonstrated that abnormal postural changes alter the fundamental characteristics of balance and gait, the association between hyperkyphosis and increased risk of falling had not been studied.

A study of 1,900 older adults revealed that 31.6% exhibited hyperkyphosis and twice as many men were hyperkyphotic.  Their hyperkyphosis was also was more severe than that of the women.  The participants reported falls in which 33% reported a serious injury such as fracture.  Women were more likely to fall, but when adjusting for hyperkyphotic posture the men with moderate hyperkyphosis were at greatest risk for injury in a fall.

The study did not address how hyperkyphotic posture might influence the biomechanics of falling.  The study does provide support for including postural exercises in balance training programs to prevent or delay the progression of hyperkyphosis.

*Taken from CT Collaboration for Fall Prevention; by Mary E. Tinetti, MD

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In my work as a fall assessment specialist, we have to take in all sorts of environmental factors when determining a client’s risk for falls.  Age, medications, floor coverings, steps, proximity of furniture, it all plays a part in our risk for falls.  A recent article by Bill Hendrick of WebMD Health News reminds us of another such environmental risk.  He notes that tens of thousands of people trip over their pets each year causing fractures or other nonfatal fall related injures.  Falls resulting in emergency treatment averaged nearly 87,000 per year with 88% related to dogs.

Some interesting findings:

• Women were more likely to be injured.
• Dogs were responsible 7.5 times over that of cats.
• Injuries from animals is most common in persons aged 35-54 or 14 and under
• Highest fracture rate though was in persons over 75
• Most falls occurred at home

By percentages:

Dog related

• 31.3%-fell or tripped over dog
• 21.2%-pushed or pulled by the dog

Cat related

• 66.4% fell or tripped over cat

When considering a pet, especially for those at risk of falling, keep in mind these statistics.  Consider obedience training for your pets so they will be less likely to push or pull you down or get under feet.  As the owner of a 4 pound Yorkshire Terrier and a 17 pound Poodle Yorkie mix, I don’t think that size has much bearing.  Both of my dogs tend to get under my feet at times.  They especially love hanging out under feet when we are cooking.  My Poodle mix crawls under the vanity each morning while I get ready for work and I never know when he is going to have his leg sticking out just as I take a step.  As a precaution, consider these safety tips…

• Discourage pets from lying beside the bed at night or at the foot of chairs or stairs.  Always check to see where your pet is before jumping up.
• Don’t leave pet toys out in the middle of the floor.
• Be aware of spills around pet bowls and clean up quickly to prevent slips and falls.
• Keep areas where a pet is likely to sleep, play or eat well lighted.
• Curb unwanted pet behaviors such as jumping.
• Ask for help handling the leash when walking your dog if necessary.

As much as I love my pets, they do put us at risk at times.  Before considering bringing a pet into a home, please consider these risks first.

Do you have a pet that is constantly underfoot?  Have you been injured in a fall or other injury that involved a pet?  I would love to hear about the cause and how you think this incident might have been prevented.

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As  a nurse caring for the geriatric communication, fall prevention can mean the difference in a long life or a complicated hospital stay.  Whether you, yourself are a senior, or if you have senior loved ones, take a look at this post from the Mayo Clinic staff which addresses six ways in which to reduce your risk of falling.

photo credit: fish2000

You may feel you already know how to prevent falls, but take a look and you may be surprised at just how many things you have never considered before.  Isn’t it better to be safe than sorry?

A recent study of the epidemiology of hospital in paitent falls, their characteristics and circumstances was conducted in a 1300 bed facility over a thirteen week period.  A multifaceted intervention program was used which included daily assessment of fall risk, review of the prevention measures with the patient or family, signage, and other strategies resulted in a reduction of falls by 23%.