According to the Centers for Disease Control and Prevention (CDC), one out of three older adults have fallen each year and twenty five percent of these incidents result in severe injuries such as head traumas, hip fractures or lacerations. The quality of life of older adults who fall decreases due to the injuries or fear of future falls which might limit their activities, reduce mobility and body fitness and in turn increase the risk of falling. The direct medical cost of falls was estimated to be around $30 billion. Indirect cost of falls is long-term effects: such as disability, lost of independency, lost time from house duties, and reduced quality of life. (CDC, 2012).
Clinical practice guideline, prevention of falls in older persons is published on the American Geriatrics Society’s Web site
. The guideline was developed by American Geriatric Society (AGS) together with British Geriatric Society (BGS). Panel members came from different professional organizations. Most of them were medical doctors who work or teach in very prestigious hospitals and universities. Some other members included: the public health worker, the pharmacist, the physical and occupational therapist and Registered Nurse with PHD who works at New York University. There was no psychotherapist, psychologist, social worker or recreation worker on the panel. Old 2001 guideline was intended to support health professionals in assessment of fall risk and also help management of older adults who had a history of fall or were at risk of falling. (Journal of American Geriatric Society, 2001) This was update to the previous version of 2001 guideline which was developed by American Geriatrics Society, Geriatrics Society, American Academy Of and Orthopedic Surgeons.
2010 guideline was endorsed by The American College of Emergency Physicians, the American Medical Association, the American Occupational Therapy Association, and the American Physical Therapy Association. Most panel members had no financial interest or commercial interest for the work they provided. Only one doctor received grants from the American College of Emergency Physicians and one member National Association for Home Care and Hospice held shares in various pharmaceutical companies. A preliminary draft of 2010 guideline was peer reviewed by many professional organizations.
The Rating System
To analyze all studies and grade the evidence, the U.S. Preventive Services Task Force (USPSTF) rating system with 40 years of experience was used. This organization has volunteer members of national experts in prevention and evidence-based medicine. Quality of evidence rating system used a grade of A, B, C or D for each recommendation and I for insufficient evidence. A grade meant strong recommendation that physicians provide intervention to eligible patients, B grade meant a recommendation that clinicians provide this intervention to these patients, C grade meant no recommendation for this intervention and D grade meant when recommendation is made against the routinely providing the intervention to asymptomatic patients.
Different clinical algorithm annotations were used. The guidelines made for different settings or situations: community residing elderly, screening for falls or risk of falling, screening positive for falls or risk for falling, screening falls last 12 months, evaluating gait and balance and determining multi factorial risks for falling. This new guideline doesn’t consider fall risk assessment to be done for elderly who reported just one fall without reported or demonstrated unsteadiness.
The Quality of Evidence
Selection of evidence was well organized three step process. In the first step, researchers collected studies from high level: meta-analyses, systematic reviews, randomized controlled trials (RCTs) and cohort studies between May 2001 and April 2008. The databases were Medline/PubMed, Cochrane Central Register of controlled Trials, Database of Abstracts of Reviews of Effectiveness and Centre for Reviews and Dissemination/Health Technology Assessment. They also added some studies conducted before 2001 since, in some areas, there were no recent studies available. In a second step, members performed review of abstract of these studies and also the exclusion and inclusion process. Ninet-one studies met inclusion criteria. Only high level of studies published in English and population in those studies age 65 and older were included. In a final step they obtained full texts of these ninety-one studies and made an evidence tables. Since some interventions were different in those studies, researchers mostly focused on the individual studies, however, they still submitted five most recent meta-analysis and evidence based guidelines.
Since guideline was intended for fall preventions in community, some topics such as hospital based fall preventions, bone health and protection, syncope and restraints were excluded. Those included specific recommendations for elderly residing in long term care settings such as nursing homes and elderly with cognitive impairment. These extra recommendations make this guideline used on broader settings.
To address identified risks and to prevent falls “Multifactorial” and “Multicomponent” interventions were used. Multifactorial is most used in long term settings where set of interventions are offered to all participants when Multicomponent is used in community settings where customized set of interventions that target risk factors are offered.
Most components of both kind of intervention are: different kind of exercises and physical activity, medication adjustment, especially psychoactive medications, medical assessment and management, environment adjustment and education. Considerable evidence, two meta-analyses proved that this kind of approach prevents falls in elderly. Multiple studies with high number of participants groups found Gait/Balance, Strength and Flexibility type of exercises very effective. And multiple studies in high risk of fall 140 participants showed that functional type of exercises are even harmful. The management of visual and medical problems and postural hypotension remained particularly effective.
A Systematic review found no compelling evidence that verified effectiveness of vision correction in falls reduction in community or long-term setting residents except for first eye cataract surgery. This conclusion is made primarily with the lack of well-designed randomized studies.
The strongest risk-relations arise with psychotropic medications and polypharmacy. Even dose reductions of these medications when discontinuation is not possible due to medical conditions found to reduce falls, while multifactiorial interventions: assessment, adjustment and discontinuation found to be very affective. Medication review provided inconclusive evidence whether it is effective in reducing falls in Long Term Care (LTC) setting
Three RCTs showed benefits with treating of postural hypotension in addition to medication reduction, optimization of fluids and behavioral interventions in community and LTC settings and tree RCTs were ineffective in LTC settings. About 30 percent of patients 65 and older do experience syncope and they will not be aware of fainting. Instead they will report the falling. (Kenny, Bhangu & King-Kallimanis, 2013). Two RCTs showed significant reductions when this intervention was incorporated with environment assessment and modification in LTC setting.
Several meta-analysis and RCTs showed benefit of vitamin D supplementation in fall prevention. AGS recommends to the healthcare providers to use Vitamin D 4000 IU per day for their patients.. Even in old people with normal serum vitamin D levels, vitamin D supplementation showed benefits. Vitamin D is safe and inexpensive, improves uptake of calcium to reduce osteoporosis and loss of muscle mass which both can contribute to falls. (Tangalos, 2013)
Although AGS/BGS guideline discusses overall importance of managing foot and footwear problems it does not significantly make any recommendations for LTC residents. However best practices should be a foot screening to be completed on an admission day to an LTC facility and quarterly evaluation at least to make sure that any skin integrity issues are identified and addressed in a timely manner. To review resident’s footwear for any poor fitting, unsafe shoes should be accompanied to these screenings (Willi & Osterberg, 2014).
Guideline discussed modifications of environment home and LTC settings. While two studies found a use of home environment modification intervention alone in community elderly effective, one study didn’t support it. Fifteen studies found that this type of intervention as a part of multifactorial fall prevention programs will make a big difference by reducing risk of falls.
Patients and caregiver education was discussed as primary and secondary prevention measures. Examples of educating patients were: how to use assistive devices correctly, how to participate in local exercise program, or how improving health and building fall preventions skills was found effective in community settings. Education in long term care staff in some large number of studies got mixed results while some studies showed effectiveness of healthcare staff training about fall prevention strategies, some found insignificant reduction in falls.
While cognitive impairment can be independent risk factor for falls, guideline did not find sufficient evidence to recommend, for or against, single or multifactorial interventions in home setting elderly with cognitive impairment. One systematic review found physical activities effectiveness in reducing falls in cognitively impaired patients. A study of patient education in addition of staff education, environmental modification, drug review, exercise and other multicomponent intervention programs was associated significant effect on falls in groups with higher Mini-Mental State Examination scores, not with lower scores.
Although considerable guidelines exist on fall prevention, there is no solid evidence that demonstrates the cost benefit on investment of all prevention and injury protection programs in LTC settings. While there are a lot of recommendations and interventions outlined in the guideline, there is still no clear guidance for specifying the right combinations of interventions to protect specific risk-population, residents with dementia or osteoporosis. (Quigley, Bulat, . Kurtzman, Olney, Powell-Cope & Rubenstein, 2010).
Historically, calcium and vitamin D administration improved bone health but in 2013 some controversy regarding these supplements arose when the USPSTF issued statement that evidence was insufficient whether more than 400 International Units of vitamin D3 and more than 1000 mg of calcium can be primary preventions of fractures. Although USPSTF guideline was for younger men and women and nonistitutionalized postmenopausal women and not for institutionalized elderly questions were still raised about use of this vitamin. Vitamin D supplement not routinely prescribed in LTC settings.
While it is a routine in LTC facilities to include orthostatic hypotension assessments to evaluate residents risks and reevaluate after each fall, usually they are often administered by licensed practical nurses or certified nursing assistants who maybe unaware or resident’s recent medication change or history of heart arrhythmias. If the measurements are not taken accurately at correct time intervals, the errors will arise. (Parry % Tan, 2010). Modification of medications should be communicated among nursing staff to enable them to take appropriate interventions. This recommendation can make big difference for my patients.
Environment assessment and interventions should be a part of fall risk management protocol but it should be incorporated with multifactorial interventions since no date supports that environment change alone will decrease risk of falls.
Addressing staffing issues also can be very important. The consistent assignment of staff to same resident s can be very effective to reducing falls. It allows staff to anticipate the residents’ unsafe and high-risk behaviors and have a better ability to intervene before a fall occurs. *(Quigley, Neily, Watson, Wright & Strobel, 2012). Caregivers would be more effective if they are not moved to different units. Finally, all staff making frequent rounds and checking on patients regardless of call light use can further support an environment of heightened safety awareness.
In the LTC facility where I work we do in-service not only nursing but every disciplinary staff members about awareness of fall strategies. We came with 4P strategies which stand for: Pain, Positioning, Personal items, and Potty/toileting. Every disciplinary member is assigned scheduled hourly rounds check if all four problems are addressed.
While guideline never discussed using personal alarms on residents as an intervention to reduce falls it is still used as first intervention after fall happens. Meanwhile staff response to an alarm sound hardly ever results in prevention of falls. (Rader, Frank & Brady, 2013). While we still continue to use “personal alarms” in LTCs these alarms in dementia residents can result more agitated behaviors, physical aggression, and attempt to escape the stimulation. To replace these auditory clutter with silent alarms, visual monitoring system, motion detectors and staff presence will make difference. (Guildermann, 2013). Our facility also use overhead paging system 24 hours of day which can cause overstimulation of residents. LTC facilities should be more home-like unlike the hospitals and healthcare staff should change our culture how we communicate. We started giving personal phones to the staff while in the facility to cut use of overhead paging.
Summary and Final Recommendation
AGS/BGS guidelines do not make recommendations for hip protectors, however, the Veterans Administration Safety Center adopted their use as best practice. Hip protectors use will benefit residents with a history of unresolved fall risk, diagnosis of osteoporosis and level of compliance with regard to these devices. Recent literature found that compliance as a challenge, and “compliance issues must be tackled if hip protectors are to be part of a resident-centered approach. (Combes & Price, 2014). Most people discontinue its use due to discomfort and dislike of how these devices made them look but new designs to high impact pads may resolve this issue. Newly designed hip protectors are made from polyurethane foam, which absorb about 90 percent of the impact of a fall. They are thinner and new clothing is designed to place these pads in such a way that would make it more practical and attractive, making daily tasks easier.Two meta-analyses showed that hip protectors’ effectiveness in community or institutional settings. (Quigley et al., 2010).
While guideline didn’t discuss pain assessment, one study (Eggermont, Penninx, Jones & Leveille, 2012) published in the Journal of American Geriatrics Society found that depressive symptoms are associated with fall risk and are mediated in part by chronic pain. When Interdisciplinary team (IDT) meets to discuss risk management of actual fall residents who tried to attempt to transfer unattended or fell after sliding from well-chair, first thing team looks at is a urinary tract infection, thinking that resident may want to use toilet or blame resident behavioral problems most of the times they miss recognizing pain, discomfort and desire to move. Residents should be regularly evaluated for pain and non-pharmacologic interventions should be used first. If that does not alleviate the pain, mild analgesics should be administered.
In my opinion exact combinations of interventions for specific population should be built on the assumption that all residents are risk for falls in order to provide a better protection. And prevention will be most effective when based on understanding of fall risk factors at individual, staff and organization levels.