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It's the age-old dilemma we face in long-term care: How do we mitigate fall risk for older adults in nursing homes? Some facilities have a blanket policy of putting non-slip socks on any residents who present as being a fall risk. Not just in the hopes that these "fall prevention socks" will help to prevent accidental falls but also to visually identify the resident to any caregivers around them that they are a potential fall risk patient and therefore should be given extra supervision.
There’s a potential problem though. According to fall prevention expert Dr Patricia Quigley, "Non-skid socks should not be on everybody. Especially people who can't feel their feet, people with peripheral neuropathy, or people who have a shuffling gait, Parkinson's patients. [...] You're actually increasing their risk hazard."1
So, if this is the case, why don’t we challenge the use of fall prevention socks as a blanket risk mitigation measure and what could alternatives be for the use of non-slip socks in long-term care?
So, is there even a place for non-slip socks in hospitals and residential care settings? Potentially, yes. However, it's vital to assess each person on an individual basis for factors that could make grip socks inappropriate and also to assess whether they are the best solution for that resident.
Dr Quigley advises, "In terms of non-skid socks, safe mobility and fall prevention means that we have to individualize the use of non-skid socks just like individualized footwear. Proper footwear requires us to individualize this, the application of shoes and the application of socks. So, we want you to stop this universal application of non-skid socks. There should be criteria for the use of non-skid socks. They should not be just put on everybody."1
So, there are use cases in which fall prevention socks might be appropriate, but this must be assessed on a case-by-case basis and not used as a blanket measure because they could potentially increase the risk for residents with certain conditions and postures.
Diabetic residents - Dr Quigley explains, "If you're taking care of diabetic patients, especially people who've had diabetes for a while, you should be assessing their lower extremity for sensory neuropathy, for numbness and pain."1
Those with sensory loss - Karen Kaminski-Ciancio advises that custom fall prevention shoes may be appropriate for residents who lack sensation. "Some of the first things that we're looking at are whether they have any other pathology that causes sensory loss, for example, lumbar radiculopathy, or anything of that nature."1
Ambulatory residents with shoes - Karen Kaminski-Ciancio advises caution with pairing fall prevention socks with shoes as the socks can get bunched up inside and lead to skin damage from the pressure on the foot. "When you put the non-skid socks in on top of an orthotic and in a custom-made shoe, that non-skid sock gets very bunched up in the resident's shoe. It can cause increased pressure and breakdown.
“And so, it's very important to make sure that, residents that are wearing shoes do not wear non-skid socks inside them. It's a really important point to make that slipper socks are not okay to wear in these [custom shoes]."1
Residents with cognitive impairment - Residents with Dementia for example may feel unsettled by the sensation of wearing non-slip socks. To adults, wearing shoes when out of bed is normal so walking in socks may be confusing for the person or even aggravating.
Non-ambulatory residents - For residents who use a wheelchair, their feet may get cold in only socks whether regular socks or specialized socks. Additionally, their feet may still need protection from potential hazards even if they aren't walking.
Residents at risk of skin breakdown - If the resident were to hit their foot on something while out of bed, could this potentially cause a wound or damage the skin of the feet? If so, then shoes may offer more protection than non-slip socks could.
Given the rising acuity of the residents in SNF settings we are now seeing, it’s perhaps more likely than ever that a number of your residents are living with some of these conditions, some of which may even make them a risk of falls while simultaneously making non-slip socks inappropriate for them. So, what other factors must healthcare professionals consider regarding foot health and fall prevention?
Dr Quigley outlined a study that tested the impact of foot pain on fall prevalence in Accora’s recent webinar An Exemplar: A Unique and Innovative Interdisciplinary Footwear Program.
"In this study, they examined the association between foot pain, the association between severity of foot pain, and the measures of foot posture and dynamic foot function that were reported, with those who fell in a large, older adult study from the Framingham foot study."1
The key stats from this study:
• Of those who reported foot pain, 13% said it was severe, 47% said moderate and 40% reported mild foot pain
• 1/3rd reported having a fall in the last year
• 263 reported one fall in the last year and 152 reported more than one fall
• Foot pain is associated with a 62% increase in the odds of having recurrent falls
As such, Dr Quigley recommends adding a question about pain, aching or stiffness in the foot as part of the routine nursing assessments or when screening for falls risk.1
Does your nursing assessment pick up these risk factors for foot pain?
• Bunions (rotation of the Hallux Valgus)
• Hammer toe
• Flat feet
• High foot arches
Since all of these deformities can be a cause of severe foot pain which as we've discovered creates a risk of falls and recurrent falls, our fall risk screening and assessments should include a record of these factors. Residents with these foot deformities may also struggle with poorly fitting shoes which can further exacerbate accidental fall risk.
In a recent online learning session, Dr Quigley described a 2021 comparative, observational, single-blinded study published in Geriatric Nursing that compared two groups of adults.2 One group was wearing appropriate-fitting shoes and the other group was wearing ill-fitting shoes.
"What they found is that there is an effect of appropriate footwear on increasing balance and decreasing fear of falling and improving functional performance.1 In their study, they identified the consequences of ill-fitting footwear. Ill-fitting footwear does increase functional limitations, does increase the risk for falls, impairs walking mobility, and can cause foot pain."3
So, we see that footwear that is not well-fitting can cause falls and also increases fear of falling which can further impact mobility for residents. In contrary, footwear that fits the resident well is associated with a decreased risk of falling and fear of falling.
While we cannot advise on whether you should use footwear over non-slip socks, we can see from the evidence of two studies and the advice of two fall prevention professionals that the use of either must be individually considered. Where possible, in cases where footwear is assessed to be the best option for that individual resident, the shoes should be assessed for comfort and fit to mitigate the risks associated with foot pain and ill-fitting footwear.
PT, Karen Kaminski-Ciancio advises that the individualized footwear program she has implemented at her SNF and rehab facility in New York has demonstrated positive resident outcomes in terms of comfort, reduced foot pain and preventing falls at no cost to the facility or the residents. This could, perhaps, be considered best practice in terms of footwear that helps prevent falls in nursing homes. You can find out more about this interdisciplinary, individualized footwear program via the link.
PhD, MPH, APRN, CRRN, FAAN, FAANP, FARN
Dr Patricia Quigley is a Nurse Consultant and Nurse Scientist. She is both a Clinical Nurse Specialist and a Nurse Practitioner in Rehabilitation, and her contributions to patient safety, nursing and rehabilitation are evident at a national level – with emphasis on clinical practice innovations designed to promote elders’ independence and safety. She is nationally known for her program of research in patient safety, particularly in fall prevention. The falls program research agenda continues to drive research efforts across health services and rehabilitation researchers.
PT, Director of Rehabilitation
An expert Physical Therapist and Director of Rehabilitation Services, at Absolut Care Westfield, practicing for over 30 years. She practices in a Skilled Nursing Facility Clinic with both long-term care and subacute rehab residents.
Karen has responsibility for clinical, administrative, education and program evaluation of rehabilitation programs to ensure the highest quality of care for residents in need of interdisciplinary rehabilitation programs. Her professional focuses include maximizing residents’ safety, function, independence and autonomy with their families and caregivers.
"So, in terms of non-skid socks, safe mobility and fall prevention means that we have to individualize the use of non-skid socks just like individualized footwear.
Proper footwear requires us to individualize this: the application of shoes and the application of socks. So, we want you to stop this universal application of non-skid socks. There should be criteria for the use of non-skid socks that should not be just put on everybody and the use of shoes for walking because you don't want, older adults walking in non-skid socks. Socks do not help to prevent falls."1 - Dr Patricia Quigley
2 - Maden T, Bayramlar K, Maden C, Yakut Y. Investigating the effects of appropriate fitting footwear on functional performance level, balance, and fear of falls in older adults: A comparative-observational study. Geri Nurs 2021;42(2):331-335
3 - Awale, A., Hagedorn, T.J., Dufour, A.B., et al. (2017). Foot function, foot pain, and falls in older adults: the Framingham foot study. Gerontology, 63(4):318–24.
