1 - It starts with a fall risk assessment
2 - Assess medications and consider polypharmacy
5 - Engage residents with cognitive impairment
According to the Nursing Home Abuse Centre, between 50-75% of nursing home residents fall every year and older adults are at least twice as likely to fall in a residential nursing home like a long-term care or skilled nursing facility than in the community1. Therefore, it's up to health care providers to accurately assess the risk of falls and mitigate the modifiable factors as much as possible for each individual, but where to start? To give you some inspiration, we’ve got 7 actionable ways you can prevent falls in senior care settings.
The approach to falls prevention for health care providers must be, by nature, multi-faceted and agile to adequately adapt to the changing acuity and needs of an aging population. One thing that can sometimes detract from this is mistaking screening for fall risk for a fall risk assessment.
Fall prevention expert, Dr Patricia Quigley2 advises,
"When they come into our care, we screen [...] for example, fall history. But just screening through someone's fall history is not enough and that's why we have to go from asking someone if they have a history of falls to actually doing an assessment."
So, what does a thorough fall risk assessment look like? Dr Pat recommends the HD Nursing fall risk assessment tool3 which is available through their unique program, but short of that, do ensure that you're looking beyond yes/no questions to identify a risk for falls to an investigation into why that person could be at risk for falls and ensure that those individual risk factors for falls are reflected in their care plan and communicated to the wider team.
"Whatever role you have; if you're a nursing assistant, or an LPN, or nurses, or therapists, all that are taking care of residents, you should know what those individual risk factors are, not just that they're a high fall risk." - Patricia Quigley
After the clear effects of the opioid epidemic in recent times, healthcare professionals now generally understand that some classes of medications can increase fall risk, but which ones should be watched?
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Well, Dr. DeLon Canterbury advised in the webinar he presented for Accora, Identifying Deprescribing Opportunities to Reduce Falls Risk in Older Adults that the following classes of drugs increase the risk of falling for older adults4.
As a rule, any substance that causes dizziness, fatigue or changes in blood pressure is likely to exacerbate or create a fall risk, but he also advised that the drug classes alone were not the biggest risk factor regarding falls. The biggest risk of falls had to do with the number of medications, not what those medications were themselves.
Polypharmacy (4 or more medications) has been associated with an increased risk of falls of 75%. That's more than any one class of medications alone including opioids, so polypharmacy is a very notable risk factor for falls in older adults and deprescribing in favor of other holistic methods of pain and other symptom management is well worth looking into periodically.
Performing a medication review to periodically audit the prevalence of fall-risk-inducing medication reliance and polypharmacy is advisable. Consult with your pharmacist to establish a regular audit schedule where caregivers and medication experts can jointly perform a medication review.
We all know that all cells in the body need oxygen and nutrients to survive and the factors that can negatively impact those two things are many and varied. Nutrition and hydration are just two of those factors and yet modifying them can have a massive impact on fall risk.
Long-term care dietician consultant Janet McKee states, "Weight loss causes muscle mass catabolism, muscle wasting and weakness. [...] Muscles that are weak cannot sustain balance and that causes falls. So, we want to keep these muscles as strong as possible."5
Now, there are two sides to that statement: building strength and weight loss. We'll cover physical activity and strengthening programs later in this article but in terms of preventing weight loss and muscle wastage, here are the top takeaways:
• Defend against dehydration - "Fluid deficits cause dehydration and imbalance of sodium, potassium and electrolytes, which affects cognition, joint lubrication, [...] it affects balance and the ability to walk. [...] If your potassium is off, it causes confusion. Your brain waves do not coordinate with your muscles clearly and therefore you're a fall risk."
• Liberalize the diet - "If you have someone that is a fall risk because they've lost weight and they also have a poor intake, even if they have CHF if they're only eating 25% of their diet, is it really necessary to put them on a 2-gram sodium diet? I don't think so." A varied diet is a health requirement for all of us, including older adults.
• Ask the family - Check in with the resident and their loved ones about their food and drink preferences as well as any dietary allergies they might have. It could save you a whole lot of refusals during their stay.
• Fortify foods - Where appropriate, Janet urges healthcare providers to consider fortified foods and drinks to prevent the catabolism of weight loss, sarcopenia and the resulting falls. She also stresses the importance of dairy and dairy alternatives for their contents of calories and protein and in preventing vitamin D deficiency which is a well-known factor for falls risk.
We're well aware as caregivers of the cycle of falls in older adults. Whatever the factors were that contributed to the fall, once it happens that person will typically develop a fear of falling again which makes them more cautious and therefore move less. This in turn means they lose strength and mobility which increases their risk of falling creating a self-fulfilling prophecy6. Add into that cycle a serious head injury or hip fracture when they fell, and you've got a real disaster in the making.
Some falls we cannot prevent but at a foundational level, we can try to set our residents up for success before they even set foot in the building. We're talking about design elements that can help prevent slips, trips and falls. Here are some elements to consider when designing for, or modifying, senior living environments.
• Flooring - Not just in terms of non-slip, but also think about color contrasts and making mindful decisions in terms of changes of flooring. A distinct contrast in flooring texture and/or color should indicate a change of some kind, a different part of the room or a change of plane perhaps. Wherever two contrasting types of flooring meet there should be a reason for caution.
• See through their eyes - The aging eye7 translates colors and textures differently than a younger counterpart and when considering cataracts, bifocal glasses and even dirty glasses the environment becomes far from clear through their eyes. What's more, falling because of a misalignment of judgment between what the eye sees and what is there can reinforce that fear of falling. Mistrusting your own eyes creates a reluctance to move which then exacerbates the problem.
• Consult therapy - Before placing grab bars or other assistive equipment, it's a great idea to consult occupational therapists to establish optimum placement and be prepared to adjust these fixtures based on what individual residents require. People come in all different shapes, sizes and heights and we must accommodate that.
• Light the way - To aid with pathfinding and visibility of hazards, we need to ensure that lighting is ample and well-maintained. Light in the bedrooms can disrupt natural circadian rhythms but the lack of it can be dangerous if a resident tries to get up without you. Some health care providers tackle this with glow-in-the-dark footprints on the floor, downward-facing under-the-bed lighting or motion-activated lights as a fall prevention strategy.
For more information on how design elements can influence fall risk, see our free, downloadable guide, Falls Prevention by Design.
One of the most challenging considerations we deal with in long-term care is establishing how we can assist with fall prevention when residents are living with a cognitive impairment such as Alzheimer's or another dementia.
Dementia expert, Rachel Wonderlin8 suggests that during the daytime, meaningful activities with a clear and instinctive purpose behind them are the key to engaging memory care residents to delay exit-seeking and reduce anxieties, both of which can reduce the risk of falls.
"When people are feeling calm and situated, guess what they're not doing? They're not walking down the hall, stressed as anything, looking for their loved ones, looking for the exit. Getting people to sit and engage, do something with their hands is going to be so key for preventing falls in dementia care." - Rachael Wonderlin.
In the webinar she presented for Accora8 she made several suggestions for life stations and creativity boxes to engage residents with safe and meaningful activities. Some of her suggestions are below.
• Pairing toddler socks
• Folding towels/dish towels
• Sorting silverware
• Shape and pattern puzzles (just make sure they are not childish)
• Arranging plastic flowers
• Gardening station with no-soil aeroponic growers
• Baby dolls in a nursery or changing station
• Pet shop or groomers
• Travel stations like a bus stop or train carriage
Anything that is age-appropriate, driven by instinct or creativity and appears to have a purposeful output can help to engage residents in the moment.
Dr. Pat Quigley is an advocate of moving furniture around to better suit an individual's needs and specific physiology. For example, turning the bed so the resident is going to try to exit the bed towards their stronger (or if they are building up strength, towards their affected) side can be beneficial for orienting themselves in the room safely. If they are ambulatory, then consider where they will be trying to get to when they move about the room and make sure pathways between doors and the bed are clear and defined.
Dr. Pat is also a believer in implementing an individualized bed height program9. She advises that people of different heights need an individual bed height to support them in getting in and out of their bed in the safest way. Even if transfers are assisted, it's good practice to have a set height for each resident so every single caregiver knows at what level their bed should be set at for transfers.
You might also wish to consider whether the DME you have in your facility is supportive of fall prevention best practices. Many nursing homes have low beds and fall mats to reduce the impact of falls, but some beds work harder to support your resident's safety than others.
The Accora Empresa FloorBed for example, takes "ultra-low" beds to a whole other level: Floor-level, as a matter of fact. Falling from this bed in its lowest setting of 3.9 inches typically results in no injuries. One clinical trial of high-fall-risk residents in a Skilled Nursing Facility found that when the Empresa was used in conjunction with the level-plane safety mat injuries from bed falls were eliminated by 100% and the number of bed falls significantly reduced. The safety mat is not the same as a fall mat because it doesn't just cushion the impact of a fall, it prevents them.
If a resident exits the bed while it is in its lowest position and the safety mat is next to the bed, the resident will simply roll onto the mat without any change of plane. The result: no injury and no reportable fall. Plus, it does everything else you want a long-term care bed to do. It profiles, it rises to full nursing height for ease of assistance with Activities of Daily Living (ADLs) and has various width and length options to cater for almost any resident.
The role of rehab, physical and occupational therapists are instrumental in regaining, maintaining and building strength and muscle for your residents. Sarcopenia and mass wastage are recognized risk factors for falls as we mentioned earlier regarding nutrition, but they are also modifiable factors. Right from the design of a building, grab bar placement, all the way to activity and strength training programs, therapy should be involved every step of the way.
Physical Therapist Shelly Denes recommends6 encouraging healthy proprioception in long-term care residents through movement, even if it's not self-propelled. Anything that connects the brain with the outer extremities can help the body re-learn where it is in space which improves balance and confidence. Still, therapy personnel are not the only people who can participate in strengthening and mobility-centered programs for residents.
Restorative nursing programs10 are carried out by the nursing staff rather than consultant therapists and both types, technique programs and training and skill programs, can involve restoring or maintaining range of motion or mobility. Not only are restorative programs beneficial to the resident's well-being but nursing homes can also claim reimbursement from CMS for successful implementation. It could be as simple as formalizing the walk-to-dine program you already encourage but the bottom line is, that motion is lotion and physical activity is vital for fall risk reduction.
Whatever the reason for your finding yourself reading this article, we assume you are interested in improving resident outcomes by reducing the likelihood of them falling and namely injuring themselves. Hopefully, you've found some new ideas from some of the top experts in fall prevention that you can implement into your fall prevention program, but we are always investigating new concepts and methods of preventing falls for older adults.
To stay up to date with our fall prevention content and find out first about our free online training sessions, sign up for the Accora Cares newsletter. Our regular newsletter tackles challenges that senior care facilities face including fall prevention, pressure ulcer management and compliance concerns.
1 - https://www.nursinghomeabusecenter.com/nursing-home-injuries/falls-fractures/
2 - https://us.accora.care/blog/fall-prevention-for-nurses-and-caregivers-lets-get-clinical
3 - https://www.hdnursing.com/
5 - https://us.accora.care/blog/linking-nursing-nutrition-and-falls-in-long-term-care-settings
6 - https://us.accora.care/webinars/reducing-fall-risk-in-older-adults-beyond-just-gait-and-balance
7 - https://us.accora.care/blog/design-for-an-aging-population
8 - https://us.accora.care/webinars/5-tangible-ways-to-prevent-falls-in-dementia-care
9 - https://us.accora.care/blog/10-tips-for-safer-bed-exits-in-long-term-care-with-dr-pat-quigley
10 - https://us.accora.care/webinars/elements-of-a-successful-restorative-nursing-program-webinar
