Assessing Fall Risk and Reducing Falls

Background

More than one in four American adults 65 years of age and older have reported falling and one in 10 reported a severe fall-related injury, including fractures and traumatic brain injuries. Falls account for over 50% of injury-related deaths in older adults annually (Haddad et al., 2018). Nurses play a vital role in reducing patients’ fall risk by implementing a risk assessment scale, early intervention strategies and education.

Risk Factors for Fall (Lee, Lee & Khang, 2013; Kiel, 2018a; Centers for Disease Control & Prevention, 2017)

Intrinsic Factors  

• Fear of falling: a geriatric syndrome that may contribute to further functional decline and may limit ambition to participate in physical activities; can lead to weakness, muscle atrophy, decreased agility, and predisposition to falls
• Advanced age
• Female sex
• Previous falls
• Muscle weakness
• Gait and balance impairments
• Visual impairment
• Postural hypotension (orthostasis)
• Chronic conditions: arthritis, stroke, incontinence, Parkinson’s disease, dementia/cognitive impairment, diabetes

Extrinsic Factors

• Polypharmacy and psychoactive medications
• Lack of stair handrails and bathroom grab bars; poor stair design
• Dim lighting, obstacles and tripping hazards
• Slippery or uneven surfaces
• Improper use of assistive devices (canes or walkers)

The Community Setting

Screening for Fall Risk (Lee, Lee & Khang, 2013; Kiel, 2018b)

• At each visit, ask patient about history of falls, frequency of falls, and gait or balance disturbances.
• For patients who report a fall or gait/balance impairment, follow up with further risk assessment.
  • Review medical history and medications
  • Physical examination
    • Cognitive evaluation, visual acuity, and functional assessment
    • Cardiovascular system, include heart rate and rhythm, postural hypotension
    • Neurological impairment
    • Muscular strength
  • History of falls
  • Feet and footwear
  • Environmental hazards/Home safety evaluation
  • Get Up and Go test
    • Ask patient to rise from chair, walk 9 feet, turn around, walk back to chair and sit back down
    • Normal time is 14 seconds or less
    • Observe postural stability, gait, stride length, sway, and leg strength

Fall Prevention (Lee, Lee  & Khang, 2013; Kiel, 2018b)

• Exercise/physical therapy targeting balance, gait and strength (ideally three hours per week)
• Medication modification, as appropriate (i.e. decreasing or stopping psychoactive medications)
• Vitamin D supplementation for patients deficient or a high fall risk (800-1000 international units cholecalciferol daily)
• Evaluation and modification of the home environment (most effective when directed by occupation therapist)
• Patient education

For patients with comorbidities, consider the following recommendations (Kiel, 2018b):