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Preventing falls in hospitalized older adults

Christy, Revonda BSN, RN

doi: 10.1097/01.NURSE.0000520711.64646.28
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Revonda Christy is an RN at Iredell Memorial Hospital in Statesville, N.C.

The author has disclosed no financial relationships related to this article.

AT LEAST 30% of older adults who fall in hospitals experience injuries that decrease mobility and quality of life. Common injuries include fractured hips and femurs as well as hematomas.1 And physical injuries aren't the only concern after an older patient falls: Injuries place older adults at risk for loss of mobility, which can contribute to pressure injuries, bowel obstruction, pain medication use, and urinary tract infections.1

Healey and Darowski noted that 80% of falls in hospitals occur in patients age 65 and older, with the highest fall rates and risks for injuries in those who are over 80.1 This article examines falls in older adults and nursing interventions that can be implemented to prevent falls.

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Implications of falls

Many patients who've fallen are afraid they'll fall again. Their fear and anxiety can escalate to depression and failure to thrive due to a reduction in their quality of life, loss of mobility, and comorbidities associated with the fall.2

The Centers for Medicare and Medicaid Services (CMS) no longer pays for rehabilitation care for injuries caused by falls. CMS considers falls to be a hospital-acquired condition. Hospitals must pay out of pocket for rehabilitation services for the patient.2

Because falls continue to occur, nurses caring for older adults in hospitals have implemented fall prevention interventions; for example, use of fall risk score models to assess patients' risks for falling. Besides assessing patients' mental status and medications, nurses assess their pain intensity levels and need for elimination and hydration. Nurses place a call bell within reach of patients and use a bed alarm for high-risk patients.3

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What causes falls?

To implement appropriate fall prevention interventions, nurses must first understand the causes of falls. Most occur due to patients' lack of familiarity with the hospital environment, suboptimal quality of care provided by staff, and patient risk factors.1

Some patients can't use the call bell system due to delirium or dementia. Lighting in rooms may be inadequate for visually impaired patients. Some patient rooms are cluttered with chairs and medical equipment, with little room to navigate to the sink and toilet. Inadequate staffing can prevent one-on-one care while patients are in the bathroom or sitters for continuous monitoring.4

Patients' physical and mental health disorders and the normal aging process also pose a threat to safety. The normal aging process may impair an older adult's gait, muscle strength, balance, and equilibrium. Vision can be impaired by age-related visual changes such as macular degeneration. These changes lead to muscle atrophy, poor posture, and a change in the patient's center of balance.4

Besides the normal aging processes, older patients may be diagnosed with disorders such as Parkinson disease, arthritis, peripheral neuropathy, dementia, delirium, or orthostatic hypotension. Disease processes and acute illnesses such as urinary tract infections or pneumonia, combined with age-related frailty, tremendously increase the risk of falling.4

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Related studies

Research has been conducted to determine how nursing interventions might improve fall prevention. Tzeng and Yin looked at nursing strategies that nurses and hospital housekeeping staff can implement to prevent falls in all specialty units, including telemetry, orthopedic, and medical-surgical units.5 Nurses from each of these units who were surveyed suggested 10 highly effective nursing interventions to prevent falls.

The most common interventions were as follows:5

  • Keep hospital bed brakes locked at all times.
  • Remove clutter in the room.
  • Keep floors dry.
  • Place the bed in the lowest position.
  • Keep personal possessions at the bedside.
  • Use bedside commodes.
  • Have one-on-one support while patients are in the bathroom.
  • Use transfer devices.
  • Have a call light within easy reach at the bedside.
  • Use a sitter.5

Additional research may be needed to examine targeted interventions based on patients' risk factors. To determine whether universal interventions are appropriate for all patients to decrease falls, Ang et al. conducted an 8-month randomized controlled trial of targeted interventions for patients identified as being at high risk for falls.3 The control group received universal interventions such as keeping the bed at the lowest position, keeping the bed locked at all times, and keeping the call bell within reach. The intervention group received the interventions plus targeted interventions, which included a 30-minute educational session about each patient's risk factors to increase patient and family awareness of risks for falling and provide strategies to prevent falls. For example, a patient who experienced dizziness associated with postural hypotension would have an educational session with a nurse, and the nurse would advise the participant to stand up slowly when getting up from a sitting or lying position, and explain the rationale for taking these precautionary measures.3 The researchers concluded that targeted interventions are more effective than usual nursing interventions. Targeted interventions should be piloted in an acute care setting and the effectiveness of the interventions should be evaluated afterward.

Dean categorized fall prevention interventions in bundles and compared known fall prevention interventions such as keeping personal items and the call bell within reach and using a bed alarm (basic bundle) to using newer interventions (the second-level bundle) such as cognitive, continence, and orthostatic hypotension assessments and medication reviews.6 The new interventions were used for patients at a high risk for falling. The third bundle entailed assessing patients and reviewing the causes of falls after they occurred.

Dean found that implementing the second-level bundle led to a 25% decrease in falls.6 Furthermore, patients and families became involved with their own fall prevention interventions when asked what might cause their fear of falling, and what they thought would prevent a fall. Nurses also felt more involved in preventing falls, according to the researcher: “Staff attitudes about falls prevention had been transformed from fatalism to enthusiasm, and patients said the approach made them feel happy and safe.”6

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Nursing implications

Clearly, targeted interventions are needed to prevent falls in hospitalized older adults. Nurses should use evidence-based interventions and then evaluate the outcomes. Interventions need to focus on patients who are over age 65 and who have health problems such as delirium, dementia, muscle weakness, gait abnormalities, continence issues, or orthostatic hypotension. All patient rooms must be free from fall hazards, such as unsecured tubing, cords, and trash cans in walkways to the sink and bathroom. Hallways should be free from clutter and floors should be dry when patients ambulate. Patients should wear nonskid socks when walking.

Clinical nurses and administrators should collaborate to create policies similar to those reported by Dean.6 Nurses should use the first-level bundle for all admitted patients and use the second-level bundle for all high-risk patients. Interventions in the first-level bundle include the following:

  • assessing the patient's and family's fears of falling
  • educating patients and families on how to decrease their fears of falling
  • removing clutter in patient rooms and hallways
  • assessing to see if the bed or chair is locked before use
  • placing the call bell within reach of the patient
  • using bed alarms
  • keeping personal belongings within reach
  • using walking aids, such as walkers and canes.

Interventions in the second-level bundle include:

  • assessing for medications that can increase the risk of falls, such as benzodiazepines, antihypertensive medications, diuretics, and opioids
  • assessing the patient's recent and current adverse drug-related reactions, such as dizziness and hypotension
  • notifying the healthcare provider of the concurrent use of medications that increase fall risk
  • applying nursing judgment to the use of pain medications for patients who experience hypotension and dizziness
  • teaching sleep hygiene practices, such as avoiding caffeinated beverages after lunch
  • assessing for orthostatic hypotension in all patients who report dizziness
  • performing cognitive assessments for delirium or dementia
  • obtaining a urinalysis to rule out delirium related to a urinary tract infection
  • providing a toileting routine
  • assessing visual acuity
  • assessing the need for physical and occupational therapy.

The third-level bundle involves an evaluation of what caused a fall. This should always be conducted to prevent recurring falls.

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Improving policies

Hospital administrators and clinical nurses should also collaborate to create policies that follow the American Geriatrics Society's clinical practice guidelines for prevention of falls in older adults.7 Upon admission to the hospital, nurses should ask older adults if they've fallen in the past year, how often they've fallen, what circumstances led to the fall, and whether they have difficulties with walking or balance. These questions are important to help the nurse complete the multifactorial fall risk assessment, which should be conducted for every older adult patient upon admission. During the completion of the multifactorial fall risk assessment, assess and document patients' information such as their history of falls, current medications, and a comprehensive health history including urinary incontinence, orthostatic hypotension, dementia, or osteoarthritis.

The final portion of the multifactorial fall risk assessment includes a thorough physical and functional assessment, including the following:

  • gait, balance, and mobility
  • neurologic and cognitive functions
  • muscle strength
  • cardiovascular status
  • visual acuity
  • feet and footwear
  • activities of daily living, as well as patients' perceptions of functional abilities and falling.

To assist clinical nurses in identifying high-risk older adult patients, fall risk assessment tools are available. Some of the best standardized fall risk assessment tools are the Morse Fall Risk Scale and the Hendrich II Fall Risk Model. According to Nassar et al., the Hendrich II Fall Risk Model is recommended more often than the Morse Fall Risk.8 It should be used for all inpatients in acute care settings because of its higher sensitivity and specificity.

However, nurses shouldn't rely on these assessment tools entirely. They should also apply their clinical judgment to prevent falls in older patients.

Besides the three bundles of nursing interventions, the American Geriatrics Society's clinical guidelines, and the fall risk assessment tools, nurses should continuously attempt to provide adequate staffing on nursing units. This will give nurses sufficient time to critically think and intervene to prevent falls and provide hourly rounds to meet patient needs. If patient needs such as toileting, pain relief, and hydration are met, then patients may be less likely to get out of bed or a chair unassisted when they have difficulty ambulating.

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Putting the brakes on falls

Traditional fall prevention interventions, such as using bed alarms and nonskid socks and lowering the bed, are useful nursing interventions. However, these interventions should be used in tandem with more targeted interventions and thorough patient assessments. Nurses must also remember to include patients and families in fall prevention by educating them about risks for falling, providing strategies to prevent risks, and encouraging the family to sit with patients if possible. If these interventions are used in practice, they may improve patient safety and decrease healthcare costs.

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REFERENCES

1. Healey F, Darowski A. Older patients and falls in hospital. Clin Risk. 2012;18(5):170–176.
2. Titler MG, Shever LL, Kanak MF, Picone DM, Qin R. Factors associated with falls during hospitalization in an older adult population. Res Theory Nurs Pract. 2011;25(2):127–148.
3. Ang E, Mordiffi SZ, Wong HB. Evaluating the use of a targeted multiple intervention strategy in reducing patient falls in an acute care hospital: a randomized controlled trial. J Adv Nurs. 2011;67(9):1984–1992.
4. Nazarko L. Falls: individual risk factors. Br J Healthc Assist. 2012;6(1):8–12.
5. Tzeng HM, Yin CY. Perceived top 10 highly effective interventions to prevent adult inpatient fall injuries by specialty area: a multihospital nurse survey. Appl Nurs Res. 2015;28(1):10–17.
6. Dean E. Reducing falls among older people in hospital. Nurs Older People. 2012;24(5):16, 18-19.
7. American Geriatrics Society. AGS/BGS clinical practice guideline: prevention of falls in older persons. 2016. http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/prevention_of_falls_summary_of_recommendations.
8. Nassar N, Helou N, Madi C. Predicting falls using two instruments (the Hendrich Fall Risk Model and the Morse Fall Scale) in an acute care setting in Lebanon. J Clin Nurs. 2014;23(11-12):1620–1629.
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