Lippincott Nursing Pocket Card

Assessing Fall Risk and Reducing Falls

icon-howtouse.jpg

Assessing Fall Risk and Reducing Falls

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 an integral 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 Falls Risk (Lee et al., 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

Falls Prevention (Lee et al., 2013; Kiel, 2018b)

  • Exercise/physical therapy targeting balance, gait and strength (ideally three hours per week)
  • Medication modification, as appropriate (for example, 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):

Comorbidity Possible Interventions
Carotid sinus hypersensitivity
  • Insertion of cardiac pacemaker insertion in appropriate patients
Cataracts
  • Surgical correction
Malnutrition
  • Refer for nutrition counseling
  • Nutritional supplementation
Postural hypotension
  • Fluid optimization
  • Compression stockings
  • Medications (fludrocortisone or midodrine)
Foot pain/neuropathy
  • Refer to podiatry

icon-info.jpg

The Nursing Care Facility or Hospital Setting

Screening for Falls Risk (Kiel, 2018a)

  • Utilize standardized screening tools
    • Morse Fall Scale
    • Hendrich II Fall Risk Model
    • Schmid Fall Risk Assessment Tool
    • Johns Hopkins Hospital Fall Risk Assessment Tool
    • St. Thomas’ Risk Assessment Tool (STRATIFY)

Falls Prevention (Lee et al., 2013; Berry & Kiel, 2018) 

  • Exercise/physical therapy
  • Medication modification (i.e. decreasing or stopping psychoactive medications, if appropriate)
  • Call bell in reach
  • Patient’s hearing aids or glasses in reach
  • Hourly rounding to assess pain, positioning, toileting, and personal needs
  • Early and frequent mobilization
  • Nonslip footwear
  • Elimination of barriers to transfer and ambulation
  • Avoidance of restraints
  • Use of bed alarm, when appropriate
  • Bed in lowest position to the floor
  • Vitamin D supplementation for patients deficient or a high fall risk (800-1000 international units cholecalciferol daily)
  • Patient and family education

References:

Berry, S., & Kiel, D. (2018). Falls: prevention in nursing care facilities and hospital setting. UpToDate. Retrieved from https://www.uptodate.com/contents/falls-prevention-in-nursing-care-facilities-and-the-hospital-setting

Centers for Disease Control and Prevention. (2017) Risk Factors for Falls. Retrieved from https://www.cdc.gov/steadi/pdf/Risk_Factors_for_Falls-print.pdf

Haddad, Y., Bergen, G., & Luo, F. (2018). Reducing fall risk in older adult. American Journal of Nursing (AJN), 118(7), 21-22. doi: 10.1097/01.NAJ.0000541429.36218.2d Lee, A.,

Kiel, D. (2018a). Falls in older persons: risk factors and patient evaluation. UpToDate. Retrieved from https://www.uptodate.com/contents/falls-in-older-persons-risk-factors-and-patient-evaluation

Kiel, D. (2018b). Falls: prevention in community-dwelling older patients. UpToDate. Retrieved from https://www.uptodate.com/contents/falls-prevention-in-community-dwelling-older-persons

Lee, K-W., & Khang, P. (2013). Preventing falls in the geriatric population. The Permanente Journal, 17(4), 37-39. doi: 10.7812/TPP/12-119

Moncada, L, & Mire, L. (2017). Preventing falls in older persons. American Family Physician, 96(4), 240-247. Retrieved from https://www.aafp.org/afp/2017/0815/p240.html