Falls and fall prevention
ContentsPhysical and psychological effects of falls Fall risk factors and prevention Medication and falls Postural (orthostatic) hypotension Vision impairment Foot and ankle disorders Home hazards Considering long-term care Finding the right long-term care Assisted living facilities Nursing home facilities Skilled nursing facilities (SNF) Other considerations Falls and long-term care FAQs
According to the Centers for Disease Control and Prevention (CDC), a senior falls every second in the U.S. While an accidental fall in the home isn't usually a medical emergency, as the body ages bones often get more brittle and healing can take longer. Seemingly minor falls can result in serious injury in elderly people. A fall-related injury can be dangerous and debilitating for elderly individuals, so it's important to limit risk factors around the home. By the end of this guide, you'll know more about the risk of falling, common physical and physiological effects of falls, prevention strategies, and the long-term care options worth considering.
Physical and psychological effects of falls
Fractures (broken bones) are unfortunately common and hazardous when an elderly individual falls (along with bruising and joint injuries) but it's hip fractures and traumatic brain injuries that are particularly dangerous. Seniors should be evaluated by a medical professional after a fall, regardless of whether they believe they need medical intervention.
Alongside physical injuries, a fall can leave behind psychological effects. Family caregivers might notice a decreasing ability to manage activities of daily living, symptoms of depression, loss of self-confidence, and a fear of falling again.
However, falls are not an inevitable part of aging. With proper screening and effective strategies, it is possible for seniors to reduce the risk of falling.
Fall risk factors and prevention
When researching fall prevention for seniors, you will likely come across a few new terms like intrinsic/extrinsic and non-modifiable/modifiable risk factors.
Intrinsic risk factors are health-related risk factors, such as advanced age, previous falls, muscle weakness, gait and balance problems, poor vision, postural hypotension (sudden drop in blood pressure), arthritis, stroke, incontinence, diabetes, Parkinson’s, and cognitive impairment, like Alzheimer's disease and other types of dementia.
Extrinsic fall risk factors include environmental factors like steep stairs, bathrooms without grab bars, poor lighting, tripping hazards, and slippery or uneven surfaces — But psychoactive medications and incorrect use of assistive devices such as walkers or canes are also extrinsic risk factors.
Non-modifiable fall risk factors are permanent risk factors like gender (falls are more common in women) and incurable diseases such as Parkinson’s disease.
Modifiable risk factors are those risk factors that can be changed to reduce the risk of falling. The CDC points out that effective fall interventions exist clinically and in the community for the following modifiable fall risk factors:
- Vestibular (inner ear) disorders/poor balance
- Vitamin D insufficiency
- Medications linked to falls
- Postural hypotension
- Vision impairment
- Foot or ankle disorders
- Home hazards
Vestibular (inner ear) disorders and hearing loss
When the vestibular apparatus is not working properly, dizziness, nausea, and vertigo usually follow close behind increasing the risk of falls.
Hearing loss can also lead to falls due to:
- Decreased environmental awareness (i.e., awareness of people and objects around oneself)
- Decreased spatial awareness (i.e., awareness of one’s position in relation to other objects)
- Cognitive overload (i.e., the brain is spending so much energy trying to understand the sounds and words around them they miss obvious falls risks)
To prevent falls, it's critical that anyone who notices signs of a vestibular disorder or hearing impairment in an elderly family member, visit a primary health care provider and ask about getting hearing and vestibular tests. If the senior wears a hearing aid, the device should be cleaned regularly and checked to ensure it is in proper working order with fully-charged batteries.
Vitamin D insufficiency
Until most recently, research appeared to demonstrate a relationship between low Vitamin D levels and an increased risk of falls in older adults. As a result, older adults with a suspected or proven Vitamin D deficiency were prescribed Vitamin D and calcium supplementation to improve bone density and muscle strength which was believed to decrease the risk of falls.
However, recent research suggests large doses of Vitamin D can increase falls in elderly adults, rather than prevent them. That's why it's recommended that you check with a primary care physician before taking any Vitamin D supplements. There is no medical consensus on the ideal Vitamin D levels for optimal health, so to determine whether you need supplements your health care provider will consider current health conditions, prescribed medications, and lifestyle factors. They may also need to directly check Vitamin D levels with a blood test.
Medication and falls
Some medications may cause dizziness or confusion in seniors increasing the risk of falls. If you suspect an elderly individual in your family might be confused as a result of their medications, you should make an appointment with their primary care provider right away to do a medication review.
At the appointment:
- Bring a full list of prescribed and over-the-counter medications or supplements
- Make sure there is a caregiver present who knows the patient's daily life and medical history
- Be ready to take notes — Patients already experiencing confusion can be overwhelmed by technical information quickly and miss important points
- Ask about blood pressure levels
Repeat a medication review at least every six months and any time there is a significant change in health.
Postural (orthostatic) hypotension
Postural or orthostatic hypotension refers to a sudden drop in blood pressure that occurs when a person gets up quickly. Blood pressure drops too fast during these position changes causing a brief reduction in blood flow to the cardiovascular system, resulting in symptoms like mild dizziness, lightheadedness, or even fainting.
Postural hypotension can be attributed to a number of factors including but not limited to:
- High blood pressure
- Heart failure
- Atherosclerosis (hardening of the arteries)
- Diuretics, antidepressants, and blood pressure medications
- Neurological conditions, like Parkinson’s disease and certain types of dementia
- Vitamin B12 deficiency or anemia
- Prolonged bed rest
To reduce postural hypotension the CDC recommends seniors:
- Move slowly when shifting to a sitting or standing position
- Keep primary care providers informed of all medications and any blood-pressure symptoms
- Modify the home to include grab bars and other equipment for fall prevention
- Increase water intake (dehydration can exacerbate symptoms)
- Use warm (not hot) water while bathing and consider getting a shower chair
Impaired vision can also lead to falls. In a study in which older adults were asked to reflect on factors that were contributing to them falling, the following issues were identified:
- Trip hazards like area rugs and stray items left on the floor
- Stairs (especially stairwells with poor lighting)
- New or recently-rearranged furniture
- Wet, slippery floors
- Navigating outside the home
If a vision-impaired senior in your family falls, first ask them what they believe led to the fall. Next, evaluate the environment. Even well-intentioned improvements to the home in an effort to decrease falls may actually be a bigger fall risk. Most individuals who experience vision loss learn the floorplan of their living space, and any changes can increase a risk of falling until the vision-impaired individual memorizes the new arrangement. Finally, make sure any elderly adult in your care gets a yearly eye exam and gets new glasses as needed.
Foot and ankle disorders
Not surprisingly, if the older adult is having problems with their feet or ankles, this can also contribute to falls. Foot and ankle disorders include three primary factors:
- Muscle weakness
- Gait difficulties
Currently, there is no widely accepted approach to using footwear as a tool to prevent falls since each person’s body and needs are different.
Common symptoms of foot or ankle issues include pain, numbness, and extremely hot or cold feet. If your loved one experiences any of these symptoms, they could be at risk for a dangerous fall. Make an appointment with a
One of the most important aspects falls prevention is the home. Small changes to the environment can make big improvements for seniors. e CDC outlined some common fall risks found in the home that can be hazardous to elderly adults and built a massive checklist to reduce falls and improve quality of life. If you're only beginning to consider fall prevention measures around the home, start with these improvements:
- Switch to brighter light bulbs throughout the home
- Reduce daylight glare with lightweight curtains
- Walk through each room and clearly a wide path clear of any tripping hazards like shoes, low furniture, or loose area rugs
- Install grab bars in the bathroom and get a non-slip mat for the shower
- Move all kitchen items your elderly family member uses daily to cabinets or shelves that can be reached out with a stepstool
- Check all shoes and slippers to make sure they aren't contributing to the problem
Considering long-term care
Despite implementing the various fall prevention strategies noted above, some elderly adults may still experience falls and sustain injuries. After experiencing a fall, many seniors decide they no longer feel comfortable living alone. Luckily, there is a large variety of long-term care options available to seniors.
Long-term care is any service that assists someone with daily tasks or health care needs on a long-term basis. Long-term care services cover a wide range of styles and approaches, finding the right one will require assessing current care needs. Starting by making a list of the activities your elderly loved one can no longer perform independently. Once this information is collected, the next step is to begin a search for a long-term care facility with a fall prevention program that meets the older adult’s needs, preferences, and financial requirements.
Finding the right long-term care
Trying to choose a long-term care facility from the numerous options available can be confusing. There are many different approaches to long-term senior care, but most can be Before making any decisions on which long-term senior care to try, it is important to first understand the differences between the three different main categories of long-term care facilities (assisted living, nursing home care, and skilled nursing services) and what services each provides.
Assisted living facilities
One of the key things to know about assisted living facilities is that they do not personally provide health care services for residents beyond assessments. When an older adult applies to live in an assisted living facility, they will be assessed by the facility staff to determine whether the facility is capable of meeting the senior's care needs.
If the facility staff decide they will be unable to meet the applicant’s care needs, they usually recommend nursing home care instead and may recommend facilities to consider. As a result, if the older adult has a health condition or multiple health conditions that require ongoing monitoring, be prepared to look into nursing home care along with assisted living.
Assisted living facilities are well-suited and designed for people who still desire and are able to maintain a relatively high level of independence. Individuals may require some assistance with dressing, bathing, or other personal care, however, this may be an additional cost. If an individual requires personal care that is not offered in an assisted living facility, hiring an outside home care provider may be necessary to cover care gaps.
Paying for care
Assisted living is usually not covered by Medicaid. However, some states do pay for assisted living costs for individuals who are no longer able to pay via Medicaid Waivers. Funds in these programs are usually very limited and there are often long wait lists. It is more common for individuals to pay for
Nursing home facilities
Unlike assisted living care, nursing homes have medical personnel on staff to provide ongoing medical care for residents. If an elderly person has any chronic or acute health conditions that require ongoing treatment and monitoring, a nursing home is usually able to meet these needs and provide adequate care.
Paying for care
Unlike most assisted living care, Medicaid may cover nursing home care if the older adult qualifies for Medicaid. To determine if the older adult qualifies for Medicaid, a Medicaid caseworker will need to assess income and assess whether it is below what is called the “maximum allowable income." "Maximum allowable income" is a pre-determined income limit set by the state.
If the applicant qualifies for Medicaid, then an additional determination of eligibility will be done to assess whether the applicant qualifies for long-term care services. Most states conduct this second assessment to determine long-term care eligibility and require a certain number of personal care service needs (also called custodial care) in order to qualify for nursing home care.
Skilled nursing facilities (SNF)
Skilled nursing facilities (SNF) provide highly skilled nursing and medical care by nurses, physical therapists, occupational therapists, speech therapists, and other
If the older adult has been injured due to a fall or has other medical conditions that they are currently receiving treatment for, they may require more highly skilled medical care before transitioning to nursing home care. In this case, choosing a Medicaid and Medicare certified “dual” care facility that provides both skilled nursing care and nursing home care in one place may a good option for meeting these needs.
Paying for care
Choosing a facility that is Medicaid and Medicare certified as both a skilled nursing facility and a nursing home allows residents to age in place while still receiving the best care for their increasing needs. In addition, these dual care facilities also usually allow many different ways to pay including long-care term insurance and private pay.
If a current resident can no longer pay to live in the dual care facility but is eligible for Medicaid, they can usually continue living in this type of facility under the Medicaid benefit. If the facility is not Medicaid certified, they may be required to move once they no longer qualified for skilled nursing care.
Regardless of the type of long-term care selected, it is important to inquire about all costs when researching possible long-term care options. It is recommended that elderly adults and their families make a list of all possible services that may be needed, make multiple copies of this list, then take a copy of this list with them when touring different facilities.
When touring and researching different facilities, there are a few considerations to consider to get the best care possible and prevent falls in the future.
For example, it is important to ask how resident falls are handled and what fall prevention measures are in place. A falls risk prevention reassessment should be done at least once every three months for long-term care residents and more frequently if a resident who has experienced multiple falls. A post-fall assessment should also be done each time a resident falls since this often reveals new information as to what is contributing to falls and often helps identify new interventions to prevent future falls.
Some other questions to ask include:
- Is a falls risk prevention assessment completed when new residents are admitted?
- How often are falls risk prevention reassessments done?
- What kind of post-fall assessment is completed after a resident falls?
- What are staff trained to do to assist a resident after a fall?
- Are loved ones notified of falls?
- Are there any additional costs potentially associated with a fall (e.g, transfer by ambulance to a hospital)?
It is important to write down what specifically causes falls for the individual requiring long-term care and what has been effective in reducing falls. This information should then be provided to the healthcare provider who will be doing the long-term care admission assessment and they should be informed that the senior has a history of falls along with a detailed description of these falls. Providing this information to the healthcare provider during the admission process is important in order for the nursing staff to prepare a customized care plan.
Seniors and their families should discuss any concerns related fall prevention during the admitting and assessment process. Preventing falls can be difficult because of the need to balance safety goals along with the desire to keep as much independence and mobility as possible. Discussing concerns and wishes with staff will ensure important needs and preferences are incorporated into the overall plan of care, easing the transition into long-term care.
Falls and long-term care FAQs
1. Will the long-term care facility be able to prevent my family member from falling again?
Unfortunately falls sometimes still happen in long-term care despite the measures that care home staff take to prevent them. The benefit of having your family member in a long-term care facility is that many falls can be prevented and the number and severity of falls can usually be reduced. A great long-term care facility staff will be trained to prevent falls.
2. How will the staff in a long-term care facility help protect my family member from falls?
Care home facilities use a variety of measures to help prevent falls. These include things such as keeping the environment free of clutter, objects, and spills that could pose a slipping or tripping hazard, keeping beds in the lowest position, ensuring side rails are kept up or down (depending on the needs of the resident), and ensuring residents wear proper footwear.
Pharmacological interventions (also known as chemical restraint) would include administering anti-anxiety or sedative medications as ordered by the physician for residents who are confused or anxious.
Finally, various forms of physical restraint may be used to help keep a resident from falling if permitted by the facility’s policies. This may include simply raising the side rails of the bed at night or locking a table tray in place in front of the resident once they are seated in a wheelchair.
Some nursing homes and care facilities do not permit the use of physical or chemical restraints to prevent falls. For this reason, it is important to inquire how each long-term care facility you consider works to reduce falls. They should have specific policies set in place to address this issues.
Despite ensuring that the environment is free of potential hazards, other interventions may be necessary to help protect your family member from falling, such as bed and chair alarms. A bed alarm is a device that is placed under the mattress on the bed. When the resident gets off the bed, the alarm is activated and staff members are immediately notified. Bed alarms are obviously only effective in preventing falls when a resident is in bed sleeping or resting. A chair alarm works the same way except it is only effective when a person is sitting down.
Other interventions include placing a mattress on the floor beside the bed and ensuring that a call bell is placed within easy reach so that a resident can call the nursing station for help whenever they need something.
3. Will I be notified if my family member falls while living in long-term care?
The next of kin or significant other as documented on the resident’s file or chart is usually notified as soon as possible when a resident falls. When selecting a long-term care facility for your family member, it is important to ask what the facility’s policy is regarding notifications of falls and aftercare for any injuries.
4. How do I know if I should be looking for a long-term care facility for my family member because of their falls? They have fallen before and didn’t require long-term care so why might they need it now?
Most people begin to consider long-term care placement for a family member when the older adult falls at home more than once or there is an increasing severity of falls. Often seniors sustain significant injuries from falling by the time they and their family begin to consider long-term care options.
In addition, it may be obvious that your family member’s physical and or cognitive abilities are declining to the point that they are unsafe to be left alone or without immediate assistance. An assessment can help determine if long-term care options would be recommended at this time.
5. Who should assess my family member?
You should arrange to have your family member assessed by their primary care physician or current healthcare provider. It is recommended that a family member or friend be present during this assessment so they can express their concerns to the physician or healthcare provider and help the older adult articulate their concerns as well.
Proximity of care is very important when considering options
Research care options that are nearby when thinking about the next step for your loved ones.
Leona J. Werezak RN, BSN, MN is a registered nurse and adjunct nursing professor. She has 24 years experience working in a variety of healthcare settings including such remote locations as the Arctic Circle. Her research in early stage dementia was published in the Canadian Journal of Nursing Research and re-published in their 40th anniversary issue which showcased exceptional research published since the journal began. Her work in dementia care has also been published in the Journal of Gerontological Nursing. She currently teaches surgical nursing care on a thoracic/vascular unit to baccalaureate nursing students. Her clinical work with nursing students involves extensive work with older adults who have multiple chronic health conditions.