_____________________________________________________________________ Falls and Fall Prevention
FALL RISKS Personal fall risks can be organized into two categories: those associated with environmental (extrinsic) hazards and those related to age, general health, and mobility (intrinsic factors). Extrinsic factors include poor lighting, lack of personal ambula- tion aids (if needed), loose carpets, slippery floors, low objects (e.g., low toilets), steps, cords, or improper footwear. Intrinsic factors are those associated with aging, intoxication, and/or chronic disease, such as weakness, disturbances of gait and bal- ance, declining vision, and medication side effects. Examples of intrinsic factors that lead to an increased risk of falling are gait abnormalities associated with Parkinson or vestibular diseases; bradycardia from beta blockers; drowsiness associated with sedative medication; reduced visual acuity from retinopathy or cataracts; hypotension (postural, medication induced, or hypovolemic); delirium and orthostatic instability related to acute infection and febrile states; and general loss of functional capacity associated with aging [2; 12]. Fall risk assessment and prevention is a matter of increasing concern for hospitals, given that falls among inpatients occur often, particularly in acute care settings [24]. One study demon- strated that the highest incidence of falling was among patients admitted with neurologic diagnoses; the lowest incidence of falls was among those on the surgical service. Important risk factors identified by the study were advanced age, emergency arrival, hospital-to-hospital transfers, and prolonged hospital stay [24]. Fall prevention in hospitals and long-term care facili- ties has been more difficult following the onset of the COVID- 19 pandemic. Since 2020, patient-nurse ratios have increased, along with high turnover rates in organizations. High turnover rates and frequent change of staff have been associated with an increased incidence of adverse events, including increased fall rates, especially in nursing home settings [2]. This scenario is concerning, because staff who are not able to be fully aware of a resident’s functional abilities are less apt to intervene with preventive measures or timely assistance [2]. Situational factors (e.g., activities, habits) can also impact fall risk associated with any setting and type of fall [12]. The likelihood of falling is dependent on a person’s strength, agil- ity, and capacity to maintain mobility and an upright posture in response to sudden situational challenges. Unfamiliarity when traversing new terrain or visiting new locations may also increase the risk of falling. Distractions (e.g., walking and talking at the same time), missing a step or curb, or rushing to get from place to place (e.g., the telephone or restroom) increase risk [12]. Fear of repeated falls can cause situational anxiety that also increases risk of another fall. While falls are multifactorial, history of previous falls is the best predictor of the likelihood of future fall events.
FALL RISK SCREENING, ASSESSMENT, AND INTERVENTION Several approaches to fall prevention have been developed by specialty societies and public health agencies to assist care providers and healthcare systems reduce the likelihood of falls and fall-related injuries. Strategies differ somewhat in reference to the clinical context: those applicable to persons residing in the community and those applicable to patients residing in hospitals and long-term care facilities. However, certain interventions have been identified as useful in all residential settings, whether community or inpatient care facility [12]: • Safety devices (e.g., grab handles, high friction floors, appropriate footwear) • Regular exercise, leg muscle strengthening, gait training, and balance exercises • Medication review and management • Vitamin D supplementation to improve bone health and muscle strength • Review of environmental issues, including evaluation of the current living conditions COMMUNITY FALL PREVENTION PRACTICES The development of best practices for fall prevention in community-dwelling adults is the purview of primary care providers and centers on preventive care of the older adult patient. Reducing the risk of falls and fall injury in older adults is part of the CDC’s Stopping Elderly Accidents, Deaths, & Injuries (SEADI) program [29]. The CDC SEADI program has developed clinical materials and a toolkit (assessment techniques) designed help care providers assess and manage risk in their older patients. Included is a streamlined algorithm for fall risk screening, assessment, and intervention ( Figure 1 ). Office-based screening of older patients is recommended yearly, and a brief questionnaire is provided for this purpose. Patients identified as being at increased risk should receive an assessment for prior fall events and modifiable risk factors. SEADI has also developed an assessment protocol designed for evaluating functional strength and balance (e.g., Timed Up and Go Test; 4-Stage Balance Test), reviewing medication side effects, asking about home hazards (e.g., throw rugs, slippery tub floor), measuring orthostatic blood pressure (lying and standing positions), and checking for visual acuity. Specific interventions to reduce fall risk are guided by the results of risk assessment, paying attention to other factors such as footwear (e.g., shoe fit, traction, heel height), likelihood of vitamin D deficiency, and potential impact of comorbidities.
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