Care home residents are three times more likely to fall than their community-dwelling peers and as a result, are 10 times more likely to sustain a significant injury (Department of Health (DoH), 2009; Cooper, 2017). One in three people over the age of 65 years, and one in two over the age of 85 years fall every year (World Health Organization (WHO), 2008; Craig, Murray, Mitchell, Clark, Saunders, Burleigh; 2013; Cooper, 2017;). Some 40% of care home admissions are falls-related and unfortunately, there is a culture and belief that falls are inevitable, and maintaining safety can result in the restriction of mobility (WHO, 2008; Cooper, 2017; Almeida et al, 2019).
The care home population is rising and notwithstanding the growing impact on unscheduled care. Falls also lead to pain, fear, loss of independence, a poorer quality of life and can ultimately contribute to death (Cooper, 2017; Almeida et al, 2019). As discussed above, there are multiple consequences of a fall, but we could divide these into two main categories: physical and psychological. In the physical consequences, we can understand immobility, incontinence, cuts, bruises, soft tissue injuries, fractures, respiratory infections, head injuries, dislocations, pressure injuries, dehydration, hypothermia and death (Care Inspectorate and NHS Scotland, 2016; Cooper, 2017). In the psychological consequences, we could discuss having feelings of uselessness, increased dependency, emotional stress, loss of control, social isolation/withdrawal, fear of further falls, low self-esteem, embarrassment, anxiety/depression, loss of confidence and carer stress (Care Inspectorate and NHS Scotland, 2016; Cooper, 2017; Almeida et al, 2019). There is a vicious cycle in the phenomena of falls (Figure 1).
In 2011, the Care Inspectorate and NHS Scotland published a good practice resource titled, ‘Managing falls and fractures in care homes for older people’ (Care Inspectorate and NHS Scotland, 2016). This contained information and tools, including a multifactorial falls risk screen; however, an audit in 2013 identified that only 30% of the Care Homes who responded had completed the resource's self-assessment, which implied a low uptake of the resource (Care Inspectorate and NHS Scotland; 2016; Cooper, 2017).
Many falls are preventable
As we get older, we often accept that falls are unavoidable; however, this is not the case. Most people over 65 years do not fall each year. Falls are not an inevitable part of ageing; it is always due to the presence of one or more ‘risk factors’ (Care Inspectorate and NHS Scotland, 2016).
Falls prevention is about recognising a person's falls risk factors, then, where possible, removing or reducing them. The risk of falling can never be completely removed, but by carrying out a multifactorial falls risk screen (MFRS) with a resident, their risk factors can be identified and action can be taken to remove or reduce risk where possible. This also takes into consideration environmental risks within the care home (Rubenstein, 2006).
However, individuals can still be at a high risk of falling despite screening, assessment and management (Table 1). In these instances, you can try to reduce the risk of harm from falls by using suitable equipment and alarm systems, ensuring residents take osteoporosis medications as prescribed, and following post-fall protocols.
Table 1. Risk factors
| Personal risk factors can be present as a result of: | Personal risk factors include: | Environmental risk factors include: |
|---|---|---|
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In your care home, the emphasis should be on anticipating and preventing falls, rather than simply managing falls once they have occurred.
Accordingt to Dhargave and Sendhilkumar (2016), the main risk factors associated with falling among older people living in long-term care homes are: history of falling; poor vision; use of multiple medications; chronic diseases; use of walking aids; vertigo; and balance problems. Women had a higher risk of falling than men (Dhargave and Sendhilkumar; 2016).
Assessment
Falling is often the first indication of an underlying problem. It may be the sign of something simple; for example, a person may require vision aids, or it may be the result of something more serious, such as postural hypotension. Gerontologists carry out physical and psychological investigations to identify the cause of falling and the measures required to remedy the situation.
As part of the multidisciplinary team (MDT), gerontologists work in conjunction with nurses, occupational therapists, physiotherapists and social workers to provide the support needed to enable people to return home. By reducing polypharmacy, treating previously undiagnosed conditions and putting appropriate mobility aids into the home, many older adults can be enabled to continue to live at home. The benefits of living at home, in familiar surroundings, far outweigh those of living in supported accommodation, such as a nursing home. Moving people from their familiar environment can cause confusion and increase the risk of falls. It is also more cost-effective for health authorities to provide support in people's homes than in long-term supported care.
Tips in prevention
- Keep active
- Individualised exercise plan
- Consider referrals with physiotherapists and occupational therapists
- Make sure the mobility/walking aids are adequate.
Consider medical conditions
A multifactorial falls risk assessment tool should be completed for all residents, no matter what their diagnosis is, paying particular attention to the risk issues presented before (Table 2).
Table 2. Community multifactorial falls risk assessment tool (adapted from multiple NHS community services)
| Physical health: guided conversation | Other medical factors | ||
|---|---|---|---|
| Any signs of infection? | Y/N | Take temperature:Take blood pressure (BP) and radial pulse Lie patient flat for 15 minutes and record BP and pulseRepeat after 1 and 3 minutes standingPulse …….beats per minute regular / irregular Lying Down BP= Standing BP 1 min= 3 min=Feels light headedness on standing? Y/N Appears unsteady? Y/NPostural HypotensionDrop of 20mm Hg or more in systolic reading and/orDrop of 10mm Hg or more in diastolic reading Y/N | |
| Any black outs or loss of consciousness?Is there postural hypotension causing falls?Any dizziness? | Y/NY/NY/N | ||
| Past / current medical history (list) | Action | ||
| Any medical conditions that potentially contribute to falls risks? | Y/N |
|
|
| Medications consider non-prescribed over counter medications recreational/herbal as well as prescribed medications | |||
| Polypharmacy—more than four medicationsAny problems with taking medication? Recent change or review?Taking any hypnotics, antidepressants, sedatives, antipsychotics or hypertensives?Self-management concerns? | Y/N | If yes consider optionsFor taking medication, consider:
|
|
| Bone health / osteoporosis | Action | ||
Known diagnosis?If no known diagnosis, screen for risk factors below.Is bone protection medication being taken correctly?Are they getting exposure to sunshine or already on calcium and vitamin D supplements?Risk Factors:
|
Y/NY/NY/NY/NY/NY/NY/N | If No, refer for medical review with appropriate professionalIf Yes, offer information leaflet from National Osteoporosis Society.Yes to 2 or more risk factorsFurther assessment required
|
|
| Strategies following a fall | Action | ||
| Are they able to get up following a fall? Do they have an alarm system that they will use? Do they have other means of summoning help? Are they aware of strategies to keep warm / relieve pressure whilst on the floor? | Y/N | If no, consider options
|
|
| Fear of falling | Action | ||
| Client fearful of falling, stopped usual activities or has poor confidence with mobility. Unable to move about and get up from floor independently?Complete assessment: Falls Efficacy Scale-International shortened version (FES-I) (Higher score=greater fear) | Y/N/28 | If yes, or high FES-I score
|
|
| Cognitive impairment/mental health | Action | ||
| Is there existing cognitive impairment or confirmed dementia diagnosis? Any difficulty with orientating themselves to negotiate their home environment safely? Is the person unable to ask for help if it is needed? Any untreated anxiety or depression? Is there any acute confusional state and/or delirium? | Y/N | If yes, consider options
|
|
| Daily living and home hazards | Action | ||
| Is there any problem with personal care, toileting or getting meals and drinks? Is there any problem with cleaning, laundry, shopping? Are there concerns about home environment safety, eg. Stairs / lighting / smoke and CO2 alarms / heating / ventilation / clutter / loose mats. | Y/N | If yes, consider options
|
|
| Gait and balance | Action | ||
| Can the person get up from a chair without using arms? Can they stand and balance unsupported for 30 seconds? Do they have adequate muscle strength/joint range? Is their gait normal? Is mobility aid appropriate and used safely? Is mobility aid in good condition? Is the person motivated to exercise? | Y/N | If no, consider options
|
|
| Feet and footwear | Action | ||
| Difficulty maintaining foot care? Foot problem inhibiting gait/balance? Unstable, loose or poorly fitting shoes/slippers worn? Numbness or sensation changes? | Y/N | If yes, consider options
|
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| Continence, nutrition and hydration | Action | ||
| Has overwhelming urgency to pass urine? Gets wet before reaching the toilet? Needs to go frequently by day? Is woken up from sleep with desire to pass urine? Does this bother them? Would they like some help? Is there a history of recurrent urine infections? Constipation or other bowel problems? Any signs of dehydration or inadequate daily fluid intake? Reduced appetite/nutrition intake or difficulty eating? | Y/N | If yes, consider optionsRecommend 6-8 glasses (250mls) of fluid per day (unless contra-indicated; e.g. renal failure). Arrange for urine tests and urinalysis. Complete bladder diary and use to guide intervention or onward referral. If not passing urine refer to urgent care If infection suspected refer to appropriate clinician. | |
| Vision/hearing | Action | ||
| Registered blind/partially sighted? Wears glasses? Are they varifocals or bifocals? Any recent change in vision/hearing? Wears hearing aid/s? Last hearing review? Last eye test was more than one year ago? | Y/N | If yes, consider optionsExplain bifocal/varifocal risk of misjudging depth perception, make sure glasses are clean, and advise to book yearly eye test If untreated double or blurred vision refer to GP | |
Create a dementia-friendly environment; for example, good signage, lighting and colour contrast between furniture and flooring.
- Managing medication
- Managing continence
- Monitor feet health
- Monitor and escalate if palpitations, dizziness, blackouts or any heart condition
- Monitor sight and hearing
- Review and assess the environment is safe
- Assess the nutritional and hydration status
- Monitor, review and escalate (if needed) for bone health(Tinetti and Williams, 1998; Demura et al, 2012; Sherrington et al, 2019).
All falls in the care home and community should be recorded, reported, and analysed routinely and a timed action plan should be created and acted on to tackle the causes of the falls. Gathering and analysing falls data can help to anticipate and prevent future falls (Tinetti and Williams, 1998; Demura et al, 2012; Sherrington et al, 2019).
Care of people who have had a fall
Normally, nurses walk to the side and slightly behind patients/clients when they are escorting them. This means that if a patient/client loses their balance, the nurse can move behind them and begin to control their descent to the ground. However, this should only be undertaken if the following criteria are presented:
- There is enough space to enable the nurse and patient to move
- There is no significant height difference between the nurse and the patient
- The patient is not much heavier than the nurse
- The patient is not resisting being handled
- The patient is falling backwards towards the nurse.
Alternatively, the nurse must clear any furniture if possible and allow the patient/client to fall to the ground, particularly if the person is falling away from the nurse.
Once on the ground, the patient/client is safe and the situation must then be assessed to find the best means of assisting them to stand up again. It may be necessary to make a patient comfortable on the ground until the requisite help arrives. People should always be assessed for injuries incurred before being moved.
The patient/client may be able to stand up unaided or be able to follow instructions that will help to do this. Some people will have previously been taught how to do this by a physiotherapist or the nursing team. An incident form is completed according to local policy.
Conclusion
Due to the increasing percentage of the world's ageing population, falls, as a common problem with adverse consequences, need to be seriously considered by policymakers and healthcare providers to make appropriate plans for interventions (Salari, et al, 2022). Most instances leading to falls in the elderly are related to their living environment; but by following simple tips and providing assistive equipment, the risk of falls can be significantly reduced. Appropriate policy to create a better living environment for the elderly, such as proper lighting of the house, use of bath chairs and toilets, use of appropriate shoes, not walking after taking sleeping pills, regular eye examinations, not carrying heavy equipment, making phones available, and installing handles in different parts of the house, can help prevent falls in the elderly (Salari et al, 2022).