Falls in Long-Term Care - www.fallslinltc.ca

ASSESSMENT & MANAGEMENT: Clinical Practice Guidelines

Professional organizations and governments in Canada and internationally have established fall prevention guidelines based on reviews of research evidence on best practices when working with seniors. The following are three of the main clinical practice guidelines for the prevention of falls in nursing homes. They are the CPGs by the American Geriatrics Society, the British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention (which is the most widely adopted guideline); the American Medical Directors Association; and the Registered Nurses Association of Ontario.

Guidelines for the Prevention of Falls in Older Persons

Falls and Fall Risk: Clinical Practice Guideline

Prevention of Falls & Fall Injuries in the Older Adult

Prevention of Falls in Long-term Care Facilities

Other Available Guidelines

Guidelines for the Prevention of Falls in Older Persons

American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention (2001)

The purpose of this guideline is to assist health care professionals in assessing and managing older patients who are at risk of falling or who have fallen. The recommendations laid out in this guideline are from epidemiological studies that have identified certain factors as risks and from experimental studies in which an intervention benefited. The intervention strategies that were evaluated for their effectiveness were then classified as either single or multifactor strategies.

Specific recommendations: Assessment

1. Routine Care of Older Persons (Not Presenting After a Fall)

Older persons under the care of a health professional (or their caregivers) should be asked at least once a year about falls

Those who report a single fall should undergo a balance and gait test. Observe their ability to stand up from a chair without using their arms, walk several paces, and return (i.e., the “Get Up and Go Test”)
Those who demonstrated difficulty performing this test should get further assessment

2. Evaluation of Older Persons Presenting with One or More Falls or Have Abnormalities of Gait and/or Balance or Who Report Recurrent Falls

Those who report a fall or recurrent falls, or demonstrate abnormalities of gait and/or balance should have a fall evaluation performed
The fall evaluation should assess the following:

history of fall circumstances, medications, acute or chronic medical problems, and mobility levels
an examination of vision, gait, balance, and lower extremity joint function
an examination of neurological function, including mental status, muscle strength, lower extremity peripheral nerves, proprioception, reflexes, tests of cortical and extrapyramidal and cerebellar function
assessment of basic cardiovascular status: heart rate and rhythm, postural pulse and pressure, heart rate and blood pressure

Interventions to prevent falls

3. Multifactorial interventions

Gait training and prescription and teaching the use of assistive devices
Exercise programs including balance training
Review and modification of medication especially psychotropic medications
Treatment of postural hypotension
Modification of environmental hazards
Treatment of cardiovascular disorders
staff education programs

* The report noted that there were only two randomized controlled studies on the efficacy of multi-factorial interventions in long-term care settings. Both showed an overall benefit from multi-factorial interventions, but only one study documented significant reductions in subsequent falls. The study identified comprehensive assessment, staff education, assistive devices, and reduction of medications as effective interventions.

4. Single interventions

Exercise:
- Evidence is strongest from balance training
- Preliminary evidence supports use of Tai Chi
- There’s no evidence of benefit for exercise alone

Environmental Modification:
- Older persons at increased risk of falls should have an environmental assessment of their room done

Medications:
- Patients who have fallen should have their medications reviewed, especially those taking four or more medications and those taking psychotropic medications

* There is a consistent association between psychotropic medication use (i.e., neuroleptics, benzodiazepines, and antidepressants) and falls. Reduction of medications was a prominent component of effective fall reducing interventions in community-based and long-term care multi-factorial studies.

Assistive Devices
- Assistive devices such as bed alarms, canes, walkers, and hip protectors have demonstrated benefit when used in multi-factorial interventions. They are not recommended to be used in isolation from other interventions

Behavioral and Educational Programs
- Similar to assistive devices, health or behavioral education is not recommended to be used in isolation from other interventions

5. Other potential Interventions

Visual interventions:
- Residents should be asked about their vision and if they report problems, their vision should be formally assessed, and any remediable visual abnormities should be treated

Footwear interventions:
- Balance is best achieved with low-heeled hard-soled shoes

Restraints:
- No evidence to support restraint use for falls prevention, they have major drawbacks and can contribute to serious injuries

Todd and Skelton (2004) nicely summarized the central recommendations in the above guideline:

all residents should be asked about occurrence of falls at least once a year
all residents who report a single fall should be observed performing the “get up and go” test and any unsteadiness should lead to further fall risk assessment
all residents who report recurrent falls should be referred for a fall risk assessment
a falls evaluation / assessment should include:

a history of falls circumstances
clinical assessment and review (individual risk)
identification of acute or chronic medical conditions and medication review
history of rehabilitation or exercise programmes
sensory evaluation (vision, neurological, lower limb sensation)
environmental assessment and modification
an assistive device/walking aid review
continence management

American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention (2001). Guideline for the Prevention of Falls in Older Persons. J Am Geriatr Soc, 49(5): 664-672. Available at PubMed: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=search&DB=pubmed

Falls and Fall Risk: Clinical Practice Guideline

American Medical Directors Association (2003)

his guideline was developed using evidence-based and consensus-based thinking. It recommends that each interdisciplinary care team in each facility adapt the guideline to its setting and that documentation of all decisions and actions should be carefully detailed.

Recognition

Step 1 Does patient have a recent history of falls?

If the patient has a recent history of falls, this should be listed as a problem in the patient record and the problem of "potential for injury" should be addressed in the care plan

Step 2 Is there a risk of falling?

Many risks are associated with falls including gait and balance problems, muscle weakness, visual impairment, depression, and certain diseases - document risk factors for falling in patient's record and discuss it in conferences with staff - factors to look at when assessing fall risk include falls history, underlying illnesses and problems, medications, functional status, sensory status, psychological status, environmental status Assessment

Step 3 Has the patient fallen?

when a patient has fallen, a nurse should record vitals signs and examine the patient for any injuries to the head, neck, spine, and extremities - document the circumstances regarding the fall (location of fall, time of fall, related activity, etc) and the patient's position after the fall - notify patient's physician and family in an appropriate time frame - observe the patient for 48 hours afterwards because of the known incidence of delayed complications

Step 4 Define the nature, frequency, and causes of a patient's falls

after a fall or the identification of a fall risk, a more detailed analysis of the patient's fall risk should be carried out - identify the nature and frequency of the fall - identify the causes of the fall within 24 hours by reviewing the events preceding the fall - look for patterns and trends in fall incidents among those with common characteristics - continue to collect and evaluate information until the cause of falling is identified or it is determined that the cause cannot be found, or that finding a cause would not change the outcome and record all this - after a fall, review patient's current medications and have patient undergo a balance and gait test by observing their ability to stand up from a chair without using their arms, walk several paces, and return (American Geriatrics Society et al., 2001) - before assuming that chronic conditions such as dementia or Parkinsonism are the causes of falling, first consider more immediate or temporary causes such as transient ischemic attacks or postural hypotension

Step 5 Define the patient's actual and potential complications of falls

define the complications and/or potential complications of falls - e.g., those with osteoporosis more likely to get hip, wrist, and spine fractures from falls Treatment

Step 6 Develop a plan for managing falls and fall risks

use a clear and consistent approach to select interventions - be aware that risk prediction is not precise - prioritize interventions: if a patient's assessment identified several possible interventions, choose one to try first - document all tried interventions

Step 7 Manage the causes of falling

successful fall management may require repeated reassessment and adjustment - try various interventions until falling is reduced or stops - manage falls in patients with balance and gait problems by addressing underlying causes (i.e. recent illness, neurological condition) and implement rehabilitative programs - in patients with orthostatic hypotension, advise them to first rise to sitting position after lying down and then stand slowly - evaluate the patient's drug regimen (including long-standing medications that may not have caused a problem for many years) and adjust medications that may be causing falls - a physician should be involved with others in reviewing and pinpointing specific medications - document all changes

Step 8 Implement relevant general measures to address falling and fall risks

various generic approaches can be helpful in falls prevention and management such as exercise and balance training programs, reduction of physical restraints, lowered beds, chair and bed alarms, environmental modifications, and patient and staff education programs

Step 9 Manage factors that may cause serious consequences of falling

all members of interdisciplinary care team and support services including housekeeping and maintenance staff should be involved to help address risk factors - to decrease falls and seriousness of fall-injuries, use mats, transfer bars, non-skid footwear, etc - assess patients at risk of falling for osteoporosis and manage accordingly - use hip protectors in patients at risk of sustaining hip fractures Monitoring

Step 10 Monitor falling in individuals with a fall risk of fall history

monitor and document patient's response to interventions - if patient is not falling, then continue the interventions - if patient continues to fall, re-evaluate situation and reconsider current interventions and causes - document all conclusions about causes and preventive efforts in patient's medical record - be aware of delayed consequences of falls

Step 11 Conduct quality improvement activities related to falls

include analysis of falls in facility's quality improvement studies: track falls by time, location, and causes - relate this data to care plan to ensure all appropriate preventive measures are taken and to evaluate and adjust prevention and management program - assign members of interdisciplinary team to clearly defined roles in evaluating and preventing falls - care plans should address status of conditions that predispose patient to falling, specific prevention efforts and patient's response to each Summary of the above AMDA Falls guidelines: 1. Recognition ? identify risks; if patient has a history of falls, that may indicate risk of future falls 2. Assessment ? identify the nature and causes of falls and its impact. Consider physical factors (e.g. comorbid conditions), functional factors (e.g., impaired mobility), and psychosocial factors (e.g., patient's ability and willingness to adhere to treatment program). Perform individualized fall assessments and assess fall at-risk patients for osteoporosis 3. Treatment ? select and provide appropriate interventions. Balance freedom and autonomy with risk taking 4. Monitoring ? review falls status and decided whether to continue, change, or stop interventions. This guideline can be ordered at:

It also includes some very informative tables summarizing common risk factors for falls, medications that may increase fall risk, environmental factors associated with falls, potential complications of falls, examples of facility approaches to reduce falls or consequences of falls, and a checklist for assessing fall risk or performing a post-fall evaluation. The CPG also includes a decision tree that nicely summarizes the steps in the guideline.

Prevention of Falls & Fall Injuries in the Older Adult

Toronto , Canada: Registered Nurses’ Association of Ontario (2005)

This guideline is based on scientific evidence on the prevention of falls in the elderly in health care settings. The studies examined in this guideline are categorized by the strength of the evidence (depending on the method of research) and each recommendation is then assigned a grade depending on the level of evidence supporting it. The RNAO recommends this guideline to be used as a tool to assist in decision making about individualized client care, and not follow it like a “cookbook”. This guideline is for use in health care settings and not in community settings. The goals of this CPG are to the assist nurses in identifying risk factors for falls, and to decrease the incidence and severity of falls. The guideline is divided into three categories:

1. Practice Recommendations to assist with practitioner and patient decisions;

2. Education Recommendations to teach nurses the skills required for falls prevention and management; and

3. Organization and Policy Recommendations to address the importance of a supportive environment for providing high quality nursing care.

As mentioned earlier, these recommendations are not to be followed exactly as it is, and should instead accommodate the preferences of the patients and their family.

1. Practice recommendations

Perform fall assessment on admission: RNAO recommends using either the Morse Fall Scale (Morse, Morse & Tylko, 1989), the STRATIFY risk assessment tool (Oliver et al., 1997) or the Hendrich II Fall Risk Model© (Hendrich et al., 1995)
Risk factors to assess: history of previous fall, age, gender, medical conditions, cognitive impairment, balance, gait, ambulatory aids, environmental hazards, vision, systolic hypotension, and total number of risk factors (Brown and Norris, 2004)
Assess risk after a fall
Interventions:

tai chi is recommended
exercise: use strength training as part of the multi-factorial fall interventions (will not benefit if used alone)
implement a multi-factorial fall prevention plan:

staff education
environmental modifications
mobility aids
conduct periodic medication reviews, patients taking psychotropic drugs or more than five medications should be identified as high risk
use hip protectors for residents who are at high risk for fractures
educate residents on dietary, lifestyle, and treatment options for prevention of osteoporosis
educate residents and their families on their risk of falling: reduces fear of falling and improves self-efficacy

2. Education Recommendations

Nursing curricula should include on-going education on the prevention of falls and fall injuries with specific attention to:

Promoting safe mobility
Risk assessment
Multi-disciplinary strategies
Risk management
Alternatives to restraints

3. Organization and Policy recommendations

least restraint: restraints (i.e. bed rails) are not recommended
Organizations should establish a corporate policy for least restraint
organizational support: Organizations should create a supportive environment that supports interventions for fall prevention and management
medication review: Organizations should manage polypharmacy and psychotropic medications and explore alternatives to psychotropic medications

The CPG concludes with a list of implementation strategies to assist organizations that are interested in carrying out these guidelines. Click the following link for the full CPG and for ideas on where to find more resources and relevant information:

Prevention of Falls in Long-Term Care Facilities

M.A. Norris, R.E. Walton, C.J. S. Patterson, J.W. Feightner and the Canadian Task Force on Preventive Health Care (2005)

This is a guideline in which the authors conducted a systematic review of the evidence for the effectiveness of fall prevention programs in long-term care facilities (LTC). The recommendations in this guideline are from a review of 10 randomized controlled trials of fall-prevention interventions in long-term care facilities. Each of the recommendations in this guideline is graded according to its strength of evidence. For an outline of the rating scheme, visit: http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=8011&nbr=4498#s23

Main Recommendations:

The guideline made three main recommendations:

there is fair evidence to recommend a multifactorial intervention program for long-term care residents to prevent falls and reduce the rate of injuries. Residents should be assessed on admission and re-assessed after a fall
there is insufficient evidence to recommend structured multidisciplinary programs that are targeted exclusively to high risk groups
there is insufficient evidence to recommend that exercise alone or in combination with other limited interventions is effective in preventing falls in long-term care residents

Recommended Maneuvers:

all persons admitted to LTC should undergo a comprehensive and individualized risk assessment of the broad range of intrinsic and extrinsic risk factors
a multi-factorial intervention program should be tailored for each resident to reduce extrinsic and intrinsic risk factors

Conclusion

An effective prevention program must assess the wide range of environmental and individual-specific risk factors and tailor the interventions for each resident. However, for a program to be implemented safely and effectively, there must be an adequate amount of staff and resources. More research is needed to develop fall prevention strategies for high risk elderly and those with specific conditions such as cognitive impairment. As well, issues of labeling and unnecessary restrictions must be acknowledged. The prevention program must preserve the autonomy and personal choice of the residents.

Norris, M.A., Walton, R.E., Patterson, C.J.S., Feightner, J.W. (2005). Prevention of falls in long- term care facilities. London (ON): Canadian Task Force on Preventive Health Care (CTFPHC). Available at: http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=8011&nbr=4498

For a summary of the recommendations, visit: http://www.ctfphc.org/Full_Text/CTF_FallsPrevn_RS_Aug05.pdf

Other Available Guidelines

Hong Kong :

The Geriatric Subcommittee of HAHO (2003). Guideline for Prevention and Management of Elderly Falls. Accessed February 3, 2007. Available at: http://www.hkgs.org.hk/fallsguideline.pdf

Australia :

Queensland Health (2001). Falls prevention best practice guidelines for public hospitals and State Government residential aged care facilities. Brisbane (updated in 2003 with a community supplement). Available on their website at: http://www.health.qld.gov.au/fallsprevention/best_practice/default.asp

United Kingdom :
National Institute for Clinical Excellence (2004). Clinical guideline 21: The assessment and prevention of falls in older people. Available at: www.nice.org.uk

United States :

National Resource Center for Safe Aging (May 2004). Falls Toolkit. Available at: http://www.safeaging.org/model/programs/toolfall_ncps/toolfall_detail.asp#contents

The Falls Toolkit (2004) includes that following:

who should be included in that interdisciplinary fall prevention team
responsibilities of each member of the team
what to look for in falls risk assessment
compares different fall risk assessment scales: Morse Fall Scale, Heindrich fall risk assessment
intervention strategies: environmental, structural, general, and individualized interventions
post-fall procedures/management
steps in measuring the success of your program or an intervention
resource list: includes a list of annotated references and websites for those seeking more information about fall risk assessment and prevention

References:

American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention (2001). Guideline for the Prevention of Falls in Older Persons. Journal of the American Geriatrics Society , 49(5): 664-672. Available at PubMed: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=search&DB=pubmed

American Medical Directors Association (2003). Falls and Fall Risk: Clinical Practice Guideline. Available for ordering at: http://www.amda.com/tools/cpg/falls.cfm

Brown, C.J., & Norris, M., (2004). Falls: Physicians’ Information and Education Resource (PIER.) American College of Physicians. Available at: http://pier.acponline.org/physicians/screening/s168/pdf/s168.pdf

Registered Nurses Association of Ontario (2005). Falls and Fall Injuries in the Older Adult. Accessed from website on February 3, 2007. Available at: http://www.rnao.org/Page.asp?PageID=924&ContentID=810

Assessment and Management Section Index
Other parts of this section:
Recurrent Fallers
Best Practices