Falls in Older People: Prevention & Management

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• Marianne Matzo, PhD, APRN, BC, GNP, FAAN Book Review Editor

Approximately one-third of people over age 65 fall each year, with rates even higher among hospitalized elders and those living in nursing facilities. Accidents and injuries are the fifth leading cause of death in the population over age 65, and falls make up a large portion of this category. The greatest concern with falls is the risk of hip fracture, which occurs in about 1% of all falls. The morbidity and mortality associated with hip fracture in older adults is significant, although many elders dismiss falls as a minor incident and fail to report the occurrence to health care professionals. Some fear that admitting a tendency to fall may result in a recommendation for nursing home placement. Family members may seek institutionalization in an attempt to prevent or limit injuries in people who continue to experience recurrent falls at home. However, many of those patients continue to fall even after being transferred to a long-term care facility.

The topic of falls breaks down into epidemiology, intrinsic and extrinsic risk factors, fall risk assessment, diagnostic workup, treatment plan for prevention and management, and ongoing evaluation of interventions individualized for each patient. Another way to think of fall management is to identify environmental and medical risk factors, as well as target interventions for both.

Falls in Older People: Prevention and Management (3rd ed.) by Rein Tideiksaar has several key features. The basic writing and illustrations make it particularly useful for patient and family education and for use on nursing facility teams. Similar texts may state that environmental modifications are necessary (e.g., a lower bed, different seating system, increased lighting). This book spells out clearly and specifically the number of inches the chair seat should be from the floor, the angle of the chair back, the length of the chair cushion, and so on. Illustrations are clear and helpful, making this text useful in educating patients and families about environmental modifications in the home as well as educating nursing staff in long-term care facilities.

The book is divided into sections on causes of falls, clinical evaluation, and preventative strategies, including information from professionals from several disciplines. There is less focus on medical issues and more on environmental ones. However, another advantage is the content related to long-term care facility teams and how to approach the problem of fall prevention from an interdisciplinary perspective. The text includes references to the minimum data set tool, forms for incident reports, environmental falls assessment tools, and side rail and restraint use forms. Having these easily reproducible forms increases the chance that these tools will actually be implemented, rather than simply sit unused at the nurse’s station.

Often in long-term care, there is a feeling that because the patients are so frail, they are inevitably going to fall. This book provides concrete, user-friendly ideas that can be shared in quality assurance meetings or fall committee meetings, which are likely to encourage increased accountability on the part of certified nursing assistants, rehabilitation staff, and nurses. Again, specific advice is given for restraint reduction, side rail reduction, and other issues specific to long-term care. The author briefly reviews the role of external hip protection and the importance of patient and staff compliance.

Perhaps one conclusion that can be questioned is the author’s contention that bed alarm systems work to prevent or reduce falls. He cites 2 references, 1 from 1992 and 1 from 1985, which were multifaceted fall prevention programs including bed alarms as part of a comprehensive plan of care. No subsequent studies have proven that bed alarms alone reduce or prevent falls; in fact, some experts believe they may even contribute to falls by startling the patient with a loud noise. In facilities that use these devices frequently or with a large number of patients, the overall quality of life in the facility can be questioned, because loud, buzzing alarms can be heard almost all the time. In addition, as the author points out, if the system is not user-friendly and the staff’s response is not rapid, the fall cannot be prevented in many cases. Although newer alarm systems are being developed that get around some of these issues, this area needs further study.

The final sections on case studies, forms, and guidelines are particularly useful and could be used to teach physicians, advanced practice nurses (APNs), medical or APN students, or nursing home staff. Home-care nurses could carry this small paperback reference with them and use it to explain to patients or families why certain environmental modifications in the home might be necessary for improved safety. In conclusion, for APNs or RNs working in long-term care, I would recommend this book. For physicians and APNs, I would suggest this text in combination with the American Medical Directors Association Clinical Practice Guideline on Falls Prevention, available at www.amda.com.

Stephen R. Lord is a well-known falls researcher who has authored or coauthored many articles, as well as served on expert panels for guideline development over the years. His new text, Falls in Older People: Risk Factors and Strategies for Prevention, is coauthored by Catherine Sherrington and Hylton B. Menz. This heavily referenced text goes into detail on fall risk factors, specifically addressing postural stability and sensory, neuromuscular, medical, medication, and environmental factors. These sections include references to current literature and comparisons of previous studies, with a final evaluation on how the relative importance of various risk factors should be viewed.

Lord and colleagues’ text gives considerable background on the evaluation of gait and balance, vestibular sense, reaction time, and other measures that can be helpful in evaluating falls. Again, the focus is on reviewing the literature and original research in this field, so that the practitioner has an idea of where to focus efforts with a particular patient, based on the evidence.

In strategies for prevention, attention is given to footwear, assistive devices, and environmental modifications. A nice overview of which risk factors are likely to be modifiable and which are not is helpful. The section on exercise is somewhat longer than in Tideiksaar’s book, but neither is sufficiently detailed to help the clinician caring for younger seniors to design an individualized program for each patient. Because this intervention usually involves a physical therapist, however, the information provided in Lord’s text is generally adequate.

Overall, this text is an excellent review of evidence-based literature on the topic of fall risk factors and strategies for prevention. The focus is on outpatient management of community dwelling fallers, although hospital and long-term care facility falls are briefly discussed.