FALL PREVENTION FOR OLDER ADULTS

Transcription

1 The University of Iowa College of Nursing GNIRC Research Translation and Dissemination Core (RTDC) EVIDENCE BASED PRACTICE GUIDELINE FALL PREVENTION FOR OLDER ADULTS AUTHOR: Stacie Salsbury Lyons, MSN, RN Series Editor: Marita G. Titler, PhD, RN, FAAN This is a general evidence-based practice guideline. Patient care continues to require individualization based on patient needs and requests. The guidelines in this series were produced with support provided by Grant #P30 NR03979, [PI: Toni Tripp-Reimer, The University of Iowa College of Nursing], National Institute of Nursing Research, NIH. Fall Prevention for Older Adults The University of Iowa Gerontological Nursing Interventions Research Center Research Translation and Dissemination Core Written 02/04

2 Fall Prevention For Older Adults 1 Fall Prevention For Older Adults Gerontological Nursing Interventions Research Center Research Translation and Dissemination Core (RTDC) The University of Iowa Iowa City, Iowa Table of Contents Page Scheme for Grading the Strength and Consistency of Evidence in the Guideline 3 I. Evidence-Based Guideline 4 A. Purpose 4 B. Definition of Falls 4 C. Individuals at Risk for Falls 4 D. Setting-Specific Fall Risk Factors 5 E. Fall Prevention for Older Adults Algorithm 6 F. Multidimensional Fall Assessment 9 1. Fall History 9 2. Fall Potential Comprehensive Fall Evaluation 11 G. Description of Interventions--Implementing Fall Prevention Interventions Community Long-Term Care and Assisted Living Acute Hospital Settings Specific Fall Prevention Interventions Preventing Fall-Related Injuries with Protective Devices Physical Restraints and Falls in Older Adults 24 II. Evaluation: Process and Outcome Indicators 24

3 2 Fall Prevention for Older Adults A. Process Indicators Fall Prevention for Older Adults Knowledge Assessment Test Process Evaluation Monitor Fall Prevention for Older Adults Quality Improvement Monitor Other Process Indicators 25 B. Outcome Indicators Patient/Resident Fall/Fall Injury Rates Fall Prevention for Older Adults Quality of Care Monitor Nursing Outcomes Classification (NOC) 26 III. Appendices A. Appendix A: Fall Risk Factors Checklist 27 B. Appendix B: Falls Screening Tool 29 C. Appendix C: Gait & Balance Screening: Timed Up & Go Test 30 D. Appendix D: Fall Circumstances on Long-Term Care Residents 32 E. Appendix E: Falls Diary 33 F. Appendix F: Performance-Oriented Assessment of Balance and Gait 35 F.1 Performance-Oriented Assessment of Balance 36 F.2 Performance-Oriented Assessment of Gait 37 G. Appendix G: Formulas for Calculating Fall Rates and Fall Injury Rates 38 H. Appendix H: Fall Prevention for Older Adults Knowledge Assessment Test 39 I. Appendix I: Process Evaluation Monitor 42 J. Appendix J: Fall Prevention for Older Adults Quality Improvement Monitor 44 K. Appendix K: Fall Prevention for Older Adults Quality of Care Monitor 47 L. Appendix L: Nursing Outcomes Classification (NOC) 50 IV. References 53 V. Contact Resources 60

4 Fall Prevention For Older Adults 3 The University of Iowa Gerontological Nursing Interventions Research Center Research Translation and Dissemination Core Scheme for Grading the Strength and Consistency of Evidence in the Guideline Evidence-based practice guidelines are developed from several sources of evidence, such as research findings, case reports and expert opinion. The practice recommendations are assigned an evidence grade based upon the type and strength of evidence from research and other literature. The grading schema used to make recommendations in this evidence-based practice guideline is: A = Evidence from well-designed meta-analysis, or well-done synthesis reports such as those from the Agency for Healthcare Policy and Research (AHRQ), or the American Geriatric Society (AGS). B = Evidence from well-designed controlled trials, both randomized and nonrandomized, with results that consistently support a specific action (e.g. assessment, intervention or treatment). C = Evidence from observational studies (e.g. correlational descriptive studies) or controlled trials with inconsistent results. D = Evidence from expert opinion or multiple case reports. For example, in this guideline on page 24 under the Physical Restraints and Falls in Older Adults, a sentence is written as Restraint reduction programs do not seem to cause a significant increase in the total number of falls and may reduce the number and/or seriousness of injuries sustained during a fall (Agostini et al., 2001; Hanger et al., 1999; Neufeld et al., 1999; Tinetti et al., Evidence Grade = C). This means that the practice recommendation is based upon the evidence from observational studies (e.g. correlational descriptive studies) or controlled trials with inconsistent results.

5 4 Fall Prevention for Older Adults PURPOSE The purpose of this evidence-based guideline is to describe strategies for identifying persons at risk for falling and for preventing falls in older adults while maintaining autonomy and independence. The goals of this guideline are to: 1) identify factors that place an individual at risk for falling, 2) detect persons who have experienced a fall, 3) prevent the occurrence of falls, and 4) prevent injury from falls among older adults. This guideline includes information regarding risk factors for falling, fall evaluation tools, fall prevention interventions, and outcome evaluations that pertain to the care of older adults in primary care, acute care, long-term care, and community settings. DEFINITION OF FALLS A fall is defined as unintentionally coming to rest on the ground, floor, or other lower level from a standing, sitting or horizontal position (Agostini, Baker, & Bogardus, 2001). In many instances, a person who has seemingly fallen may not remember the circumstances surrounding a fall, or alternatively, the fall may not have been witnessed. Evidence of a fall is based on the recollection of the person who fell and/or a description of the fall from a witness (Ledford, 1996; Morse, Tylko, & Dixon, 1987). Falls can be classified as one of three types: 1) anticipated physiological, 2) unanticipated physiological, and 3) accidental falls (Ledford, 1996; Morse, Tylko, & Dixon, 1987; Rubenstein, Robbins, & Josephson, 1991). 1) Anticipated physiological falls are falls that occur among people who are at high risk for falling. Characteristics of persons who experience anticipated physiological falls include disorientation, difficulty walking, and gait changes associated with neurological diseases (e.g. Parkinsonian shuffle, scissors gait, and a shift in the center of gravity associated with some dementias). 2) Unanticipated physiological falls are falls that cannot be predicted prior to the first occurrence. Persons who experience unanticipated physiological falls are typically cognitively oriented, but may report drop attacks (sudden loss of muscular tone without the loss of consciousness), dizziness (vertigo), drug reactions, or faintness (syncope). 3) Accidental falls are falls that can be attributed to an environmental factor or mishap. INDIVIDUALS AT RISK FOR FALLS Several factors place older adults at an increased risk for falling. Fall risk factors include setting specific features, health conditions, as well as epidemiological, pharmacological, ergonomic, and environmental factors (Fall Risk Factors Checklist in Appendix A). One of the strongest predictors of future falling is having previously fallen (Agostini et al., 2001; American Geriatric Society (AGS), 2001; Covinsky et al., 2001; Hendrich et al., 1995; Kiely et al., 1998; Tromp et al., Evidence Grade = A). Asking older adults about their fall history is an essential component of this guideline.

6 Fall Prevention For Older Adults 5 Additional risk factors that are repeatedly identified in studies of falls and falling include muscle weakness, gait deficit, balance deficit, use of assist devices, visual deficit, arthritis, impaired activities of daily living (ADL), depression, cognitive impairment, and age >80 years (Agostini et al., 2001; AGS, Evidence Grade = A). The greater the number of risk factors an individual reports, the higher the risk of falling (Agostini et al., 2001; AGS, 2001; Robbins et al., 1989; Tinetti et al., Evidence Grade = A). For example, Tinetti et al., (1988) found that the risk of falling increased from 19% when one risk factor was present to 78% in the presence of four or more risk factors. Some factors associated with fall risk in the hospital setting may differ from those in community-dwelling or institutional settings. For example, the onset of acute illness leading to hospitalization may increase fall risk due to immobility, deconditioning, and/or medical treatments that require the alteration or addition of new medications (Agostini et al., 2001). Older adults who report recurrent falls in the past year, present to a health care provider/facility following a fall, or who are identified as having gait or balance problems are at higher risk for falling than persons who report no falls or a single fall. Older adults at high risk for falls should have a comprehensive fall evaluation conducted on an annual basis and following any reported fall. Assessment of personal risk factors and implementation of the targeted fall prevention strategies are strongly recommended (AGS, Evidence Grade = A). SETTING-SPECIFIC FALL RISK FACTORS Many setting specific risk factors are associated with falls in older adults (outlined below). An individual who is living independently in the community may fall for different reasons than an acutely ill person in the hospital or a frail resident of a long-term care facility (Agostini et al., 2001). However, many of the setting-specific risk factors for falls are related to health conditions, impaired mobility, and functional and cognitive status limitations that are common to older adult populations residing in any setting (Agostini et al., Evidence Grade = A). Community Settings Older adults living in the community are at risk for falling because of their mobility status. Conditions that affect mobility, including immobility, physical inactivity, physical frailty, or balance problems, lead to higher fall rates (Isberner et al., 1998; King & Tinetti, Evidence Grade = C). Environmental hazards, stairways, an absence of handrails, or the presence of uneven floors contribute to falls in this group (Allander et al., 1998; King & Tinetti, Evidence Grade = C). In addition, persons with acute illnesses, who use certain medications (e.g., psychotropics), have homebound status or dementia fall more often than older adults with better functional or cognitive statuses (Isberner et al., 1998; King & Tinetti, Evidence Grade = C). Acute Care Settings Older adults admitted to a hospital setting are at risk for falling as a result of their debilitated health status, medical treatments, or unfamiliarity with the environment. Many hospital falls occur during the first week after admission (Tutuarima et al., Evidence Grade = C) and during the daytime shift (Tutuarima et al., 1993; Tutuarima et al., Evidence Grade = C). Neuroscience,

7 6 Fall Prevention for Older Adults psychiatric, and oncology departments have been associated with higher fall rates than other hospital departments (Rohde et al., Evidence Grade = C). Some nursing-related practices are related to hospital falls. Units staffed with less experienced nurses report higher rates of falls than units staffed by more experienced nurses (Blegen, Vaughn, & Goode, Evidence Grade = C). The use of physical restraints, including bedrails and siderails, as a fall prevention strategy has been shown to contribute to falls and is discouraged in most cases (Hanger et al., 1999; Mosley et al., Evidence Grade = B). Patient characteristics associated with falls in hospitals include weakness, decreased lower limb mobility, sleeplessness, confusion, depression, substance abuse history (Janken et al., Evidence Grade = C), long hospital stays, assistance needed during walking, hygiene independence, lack of exercise (Stevenson et al., Evidence Grade = C), and incontinence or toileting activities (Bakarich et al., 1997; Janken et al., 1986; Stevenson et al., Evidence Grade = B). A predictive model of hospital falls found significant fall risk factors to include a recent history of falls, depression, altered elimination patterns, dizziness or vertigo, primary cancer diagnosis, confusion, and altered mobility (Hendrich et al., Evidence Grade = C). Long Term Care Settings Many of the factors related to falls in long-term care settings are similar to those experienced by older adults in community and acute care settings. Recent admission to the facility, wandering behavior, acute illnesses, medications, impaired cognition or dementia, hip weakness or immobility, slippery floors, and unsafe furniture may lead to falls in this setting (Hakim, 1998; Kiely et al., Evidence Grade = C). Low staffing levels contribute to falls that occur during nursing shift changes, in private locations such as the bedroom or bathroom, during activities of daily living (i.e., toileting, getting out of bed), or when residents report being unable to wait for staff assistance with activities or forgetting to lock their wheelchair brakes (Fleming & Pendergast, 1993; Hakim, Evidence Grade = C). Excessive middle ear cerumen and resident overestimation of their own abilities have also been implicated in long-term care falls (Hakim, 1998; Robbins et al., Evidence Grade = C). Like in acute care settings, the use of physical restraints in long-term care settings has been shown to increase falls and injuries related to falls in older adults and is discouraged in most instances (Capezuti, Evans, Strumpf, & Maislin, Evidence Grade = C). FALL PREVENTION FOR OLDER ADULTS ALGORITHM A five-step algorithm for fall prevention for older adults is presented on page 8. Steps 1, 2, & 3 review the multidimensional falls assessment, Step 4 summarizes falls interventions, and Step 5 outlines falls evaluation. A brief overview of the steps included in the algorithm is presented below. Steps 1, 2, & 3: Multidimensional Falls Assessment The AGS Panel on Falls in Older Adults (2001) recommends a three step falls assessment plan that is based upon an individual s fall history and current falling potential. The three-step multidimensional falls assessment includes a review of the individual s fall history, determination

8 Fall Prevention For Older Adults 7 of his or her fall potential, and a comprehensive falls evaluation. In this Fall Prevention for Older Adults evidence-based practice guideline, the AGS (2001) falls assessment plan has been modified to screen all older adults for gait and balance problems. All older adults are asked about their recent fall history (Step 1). Persons reporting no recent fall or a single fall in the past year are asked questions about the fall situation and complete a brief gait and balance screening test (Step 2). If the individual has not experienced a fall or has had only one fall in the past year (Step 1) AND does not have a gait or balance problem (Step 2), no fall prevention intervention is required. Fall prevention strategies should be reviewed as detailed in the algorithm. If the individual presents to the health care facility with a fall or reports recurrent falls (Step 1) or is identified as having a gait or balance problem (Step 2), he or she is asked to participate in a comprehensive fall evaluation (Step 3). Step 4: Falls Intervention Health care professionals should assist all older adults who have completed the comprehensive falls evaluation to select appropriate fall prevention strategies (Step 4). Interventions should be selected based upon individual fall risk factors and fall prevention goals. Step 5: Evaluation Outcome and process evaluations are an important part of any fall prevention program (Step 5). Fall-related outcomes and process indicators should be selected based upon individual, provider, and organizational goals.

9 8 Fall Prevention for Older Adults Fall Prevention in Older Adults Algorithm American Geriatrics Society (AGS) CONSIDER REVIEW OF FALLS RISK FACTORS CHECKLIST. START HERE STEP 1: FALL HISTORY Ask all older adults and/or their caregiver about falls in past year Reports No Fall Or Single Fall OFFER FALL PREVENTION STRATEGIES: Review use of walking aids Review/modify medications Encourage exercise & balance training programs Modify environment Treat postural hypotension Treat cardiovascular disorders REASSESS IN ONE YEAR OR IF A FALL OCCURS Presents With A Fall Reports Recurrent Falls STEP 3: COMPREHENSIVE FALL EVALUATION Fall History, Circumstance & Risk Health History & Function Status Medications & Alcohol Review Vital Signs & Pain Assessment Vision Screening Gait & Balance Screening Musculoskeletal/Foot Assessment Continence Assessment Cardiovascular Assessment Neurological Assessment Depression Screening Assistive & Protective Devices Environmental Assessment Gait or Balance Problem STEP 2: FALL POTENTIAL FALL SITUATION: Describe circumstances of any fall in past year. GAIT & BALANCE: What were results of Timed Up & Go Test? Score 19 seconds or less No Gait or Balance Problem Score 20 seconds or greater Gait or Balance Problem STEP 4: FALLS INTERVENTIONS (Select as appropriate) Gait, Balance & Exercise Program Medication Modification Impaired Vision Treatment Neurological Disorder Treatment Postural Hypotension Treatment Cardiovascular Disorder Treatment Incontinence Treatment Depression Treatment Assistive & Protective Devices Environmental Modifications No Gait or Balance Problem STEP 5: EVALUATION (Select as appropriate) Outcomes Decreased number of falls Decreased number and severity of fallrelated injuries Process Correct use of walking aids Safety precautions when taking medicines that increase fall risk Decreased use of psychotropic medicine Use safe transfer procedures American Geriatrics Society Panel on Falls in Older Persons. (2001). Guideline for the prevention of falls in older persons. Journal of the American Geriatrics Society, 49(5), 666. Blackwell Publishing. Adapted and reprinted with permission.

10 Fall Prevention For Older Adults 9 MULTIDIMENSIONAL FALLS ASSESSMENT Many fall prevention studies that have shown a significant reduction in falls in older adults have included a multidimensional falls assessment as the foundation for subsequent intervention (Close et al., 1999; Ray et al., 1997; Rubenstein et al., 1990; Steinberg et al., 2000; Tinetti, Baker, McAvay et al., 1994; Tinetti, McAvay, & Claus, Evidence Grade = B). The goal of the multidimensional falls assessment is to target individual fall risk factors with interventions that will reduce the effects of multiple, chronic impairments that are common problems for many older adults (Tinetti, McAvay, & Claus, Evidence Grade = B). The purposes of the multidimensional falls assessment are to: 1) determine whether or not an individual is likely to experience a fall in the future based upon his or her fall history and current risk factors, and 2) assist clinicians to select fall prevention interventions that target an individual s personal fall risk factors. Although the American Geriatrics Society (2001) recommends a three-level fall assessment plan: fall history, fall potential, and comprehensive fall evaluation with gait and balance screening for persons who have experienced at least one fall in the past year, this guideline recommends a brief gait and balance screening for all older adults as a way to identify people who have had recent or previously unrecognized gait and balance changes and who may be at risk for their first fall. Older adults who have not fallen or who have experienced only one fall in the previous year and who have no gait or balance impairments have a low risk of falling in the future and are not likely to benefit from a comprehensive fall evaluation. Individuals who present to a health care provider with a fall, report recurrent falls, or demonstrate gait or balance impairments may benefit from a comprehensive fall evaluation (AGS, Evidence Grade = A). Brief assessment forms for Step 1: Fall History and Step 2: Fall Potential are included in the Falls Screening Tool (See Appendix B), and was adapted from the American Geriatrics Society Panel on Falls in Older Persons (2001) and is suitable for older adults treated in primary care and acute care settings. Fall History (Step 1) Detecting a history of falls is a crucial component of this guideline. ALL older adults presenting to ANY health care facility or provider are asked about their recent fall history (AGS, Evidence Grade = A). This recommendation includes older adults who are patients in primary care, acute care, and home health care settings as well as residents of long-term care and assisted living facilities. 1) Ask all older adults and/or their caregiver about the occurrence of falls during the past year. 2) If the older adult and/or their caregiver REPORTS NO FALL OR A SINGLE FALL in the past year, assess their fall potential (Step 2)

11 10 Fall Prevention for Older Adults 3) If the older adult and/or their caregiver REPORTS RECURRENT FALLS in the past year, or if the older adult PRESENTS FOLLOWING A FALL, Complete a COMPREHENSIVE FALL EVALUATION (Step 3). For residents of long-term care facilities, the Minimum Data Set (MDS) can be used to determine an individual s fall history if the resident has had no fall in the past 180 days or only a single fall in the past 30 days (MDS Item J4a) or past days (MDS item J4b), GO TO STEP 2: FALL POTENTIAL. If the resident has had more than one fall, GO TO STEP 3: COMPREHENSIVE FALL EVALUATION. Fall Potential (Step 2) For persons who are at relatively low risk for falling (reports no fall or single fall in the past year in Step 1), determination of the person s fall potential is recommended (AGS, Evidence Grade = A). A fall potential assessment includes a review of the circumstances surrounding the previous fall (if they have fallen) and a brief assessment of gait and balance using a tool such as the Timed Up & Go Test (Podsiadlo & Richardson, 1991) found in Appendix C. For older adults and/or their caregivers who report no fall or a single fall in the past year, determine the older adult s fall potential using the Falls Screening Tool in Appendix B. Identify the circumstances surrounding any fall that occurred during the past year. This assessment includes the location of fall, activity prior to fall, loss of consciousness, use of walking aids (e.g., cane, walker) and/or protective devices (e.g., hip protectors, helmet), environmental conditions (e.g., snow, ice), and injuries that resulted from the fall. If another person witnessed the fall, his or her account of the fall is included. Information for assessing fall circumstances in long-term care residents using the MDS is included in the Fall Circumstances in Long-term Care Residents (See Appendix D). Screen for gait and balance problems using the Timed UP & GO Test (Podsiadlo & Richardson, 1991) or similar gait and balance assessment tool (Mathias, Nayak, & Isaacs, 1986). Instructions for the Timed UP & GO Test are included in Appendix C. Individuals with an average score of 10 seconds or less on the Timed Up & Go Test are freely mobile and are considered to have a low risk of future falls. No further fall assessment is needed. Persons with an average score of 11 to 19 seconds on the Timed Up & Go Test are independently mobile and considered to have a low to moderate risk of future falls. For this group of individuals, further brief risk factor screening may include identifying other risk factors using the Fall Risk Factors Checklist (Appendix A) or conducting a targeted fall evaluation of modifiable risk factors (for example, medication review or vision assessment). Information about fall prevention strategies should be presented and modifiable risk factors addressed. The risk assessment should be done to target fall prevention strategies for that individual (Oliver, Hopper, & Seed, Evidence Grade = A).

12 Fall Prevention For Older Adults 11 Individuals with an average score of 20 to 29 seconds on the Timed Up & Go Test have variable mobility and are considered to have a moderate to high risk of future falls. A comprehensive fall evaluation (See Step 3 below) to identify individual fall risk factors is strongly recommended. Fall prevention information, referral to appropriate specialists for further assessment and treatment (for example, gerontological nurse practitioner, clinical nurse specialist, geriatrician, cardiologist, physical therapist, occupational therapist, and eye doctor), and implementation of targeted and individualized fall prevention strategies are encouraged. Individuals with an average score of 30 seconds or greater on the Timed Up & Go Test have variable mobility and are considered to have a high risk of future falls. A comprehensive fall evaluation (See Step 3 below) to identify individual fall risk factors is strongly recommended. Fall prevention strategies, referral to appropriate specialists for further assessment and treatment (for example, gerontological nurse practitioner, clinical nurse specialist, geriatrician, cardiologist, physical therapist, occupational therapist, and eye doctor), and implementation of targeted and individualized fall prevention strategies are strongly encouraged. Use of protective devices, such as hip protectors, should be considered. If no gait or balance problem is identified on the Timed Up & Go Test or other brief screening tool, NO FURTHER ASSESSMENT OR INTERVENTION IS REQUIRED. A review of individual fall risk factors (See Appendix A: Fall Risk Factors Checklist) may be considered for older adults with a low to moderate risk (Score 19 or less). Offer information about fall prevention strategies. Reassess fall history and fall potential in one year or if a fall occurs. If a gait or balance problem is identified (Score > 20), complete the Comprehensive Fall Evaluation (Step 3). For residents of long-term care facilities, the gait and balance testing procedures are slightly different. The MDS 2.0 User s Manual (Morris, Murphy & Nonemaker, 1995; Brown et al., 2000) offers detailed testing alternatives. See the MDS 2.0 User s Manual pages 3-91 to 3-95 for more information on balance testing and RAP 11 Falls, page 3 for gait testing. Comprehensive Fall Evaluation (Step 3) For older adults who report recurrent falls in the past year, who present to the health care provider/facility following a fall, or who are identified as having gait or balance problems on the Timed Up & Go Test (Score > 20), (Podsiadlo & Richardson, 1991), conduct a comprehensive fall evaluation. The purpose of the comprehensive fall evaluation is to describe the circumstances surrounding recent falls, identify fall risk factors, delineate modifiable and non-modifiable risk factors, assess functional status, and target fall prevention strategies (AGS, Evidence Grade = A). Referral to a specialist (e.g., gerontological nurse practitioner, clinical nurse specialist, geriatrician, physical therapist, occupational therapist, cardiologist, eye doctor) for a comprehensive fall evaluation or for particular components of the evaluation may be required (AGS, Evidence Grade = A).

13 12 Fall Prevention for Older Adults The comprehensive falls evaluation is discussed in detail below. A registered nurse or advanced practice nurse may complete the comprehensive falls evaluation. Components of this assessment that may require advanced diagnostic training are noted. Briefly, the comprehensive falls evaluation includes the following components: Fall History, Fall Circumstances, and Fall Risk Factors Assessment Health History and Functional Assessment Medications and Alcohol Consumption Review Vital Signs and Pain Assessment Vision Screening Gait and Balance Screening and Assessment Musculoskeletal and Foot Assessment Continence Assessment Cardiovascular Assessment Neurological Assessment Depression Screening Walking Aids, Assistive Technologies, & Protective Devices Assessment Environmental Assessment Falls Assessment in Long-Term Care: RAP Triggers 1) Fall History, Fall Circumstances, and Fall Risk Factors Assessment Information about fall history, fall circumstances, and fall risk factors can help determine a person s potential for falling and identify which risk factors can be changed (modifiable risk factors such as medications, uncorrected sensory impairments, or poorly fitted shoes) from those which cannot be altered (non-modifiable risk factors such as a history of falls, age, or gender). The Fall Risk Factor Checklist (Appendix A) may be useful for documenting the presence of common fall risk factors. Ask about the occurrence of falls during the past year (see Step 1: Fall History). Identify the circumstances surrounding any fall(s) that occurred during the past year (see Step 2: Fall Potential.) For individual s who are experiencing recurrent falls, the Falls Diary (Appendix E) may be useful for identifying fall patterns. Note history of falls or tripping (Blake et al., 1988; Covinsky et al., 2001; Kiely et al., 1998; Tromp et al., Evidence Grade = C). Note anxiety or fear of falling (Tinetti, Mendes de Leon et al., Evidence Grade = C). The Falls Self-Efficacy Scale may help determine the types of activities an older adult avoids related to a fear of falling (Tinetti, Richman, & Powell, Evidence Grade = C). Note number of fall risk factors: a greater number of risk factors predict higher risk (Robbins et al., 1989; Tinetti et al., Evidence Grade = C). Determine whether a fall risk factor is modifiable or non-modifiable in order to target fall and individualize prevention strategies (Robbins et al., 1989; Tinetti et al., Evidence Grade = C).

14 Fall Prevention For Older Adults 13 2) Health History and Functional Assessment Information about past health history and functional status can help health professionals determine the appropriateness of fall prevention interventions. Acute illness (Kuehn & Sendelweck, Evidence Grade = C) Chronic health problems (see assessments below for conditions associated with falls) including: a. Sleep problems (Brassington et al., Evidence Grade = C) b. Sensory deficits (i.e., visual, auditory, vestibular) (Tinetti et al., Evidence Grade = C) Advanced age (Vlahov et al., Evidence Grade = C) Gender: higher prevalence in females (Blake et al., Evidence Grade = C) a. Female gender: Medication use (total number of drugs, psychotropic drugs, and drugs liable to cause postural hypotension), standing systolic blood pressure of less than 110 mmhg, and evidence of muscle weakness (Campbell et al., Evidence Grade = C) b. Male gender: Decreased levels of physical activity, stroke, arthritis of the knees, gait impairment, and increased body sway (Campbell et al., Evidence Grade = C) Functional dependence a. Functional status using the Katz Index of Independence in Activities of Living Scale (Katz et al., 1970) or other functional assessment tool b. Assess ability to transfer safely (McLean & Lord, Nyberg & Gustafson, Evidence Grade = C) 3) Medications and Alcohol Consumption Review Some medications are thought to increase the chance of a fall. Assessment and modification of medications and alcohol consumption is an important feature of any fall prevention program. Review current prescription medications Review over-the-counter medications, dietary supplements, and recreational drug use Review alcohol consumption, including amount, frequency, and any relationship between alcohol consumption and falls (Malmivaara et al., Evidence Grade = C) Monitor for recent changes in medication regimen Monitor for drug side effects such as, drowsiness, dizziness, daytime sedation, changes in bladder or bowel function, impaired balance and reaction time, or hypotension (Campbell, Evidence Grade = D) Monitor for polypharmacy: Taking more than 3 or 4 medications a day is an increased risk for falls (Leipzig et al., 1999a, b; Tinetti et al., Evidence Grade = A) If the individual is taking medications from any of the following drug classifications, he or she is at an increased risk for falls: a. Any central nervous system/psychotropic drug (Agostini et al., 2001; Campbell et al., 1999; Leipzig et al., 1999b. Evidence Grade = A) Sedatives/hypnotics (Agostini et al., 2001; Leipzig et al., 1999b. Evidence Grade = A) Antidepressants 1. Tricyclic antidepressants (Leipzig et al., 1999b. Evidence Grade = A)

15 14 Fall Prevention for Older Adults 2. Selective serotonin-reuptake inhibitors (Thapa et al., Evidence Grade = C) Antipsychotics/neuroleptic agents 1. Increased risk in non-psychiatric inpatient (Leipzig et al., 1999b. Evidence Grade = A) Benzodiazapines (Agostini et al., 2001) 1. No difference in short/long acting drugs (Leipzig et al., 1999b. Evidence Grade = A) 2. Higher risk in very short/short acting drugs (Passaro et al., Evidence Grade = C) b. Cardiovascular drugs (Leipzig et al., 1999a. Evidence Grade = A) Diuretics Antiarrhythmics Cardiac glycosides c. Antidiabetic agents (Passaro et al., Evidence Grade = C) 4) Vital Signs & Pain Assessment Alterations in a person s vital signs, including the presence of pain, may indicate an acute illness, injury, or inflammatory process, any of which may make an older adult more vulnerable to falling. Presence of pain, assessed with a standardized pain assessment tool tested for use with older adults, such as a verbal descriptor scale, numeric rating scale, or faces pain scale (Herr & Mobily, 1993; Herr, Mobily, Kohout, & Wagenaar, 1998). Change in temperature indicative of signs of infection or inflammation Change in respiratory rate and rhythm suggestive of infection or inflammation Abnormal heart rate and rhythm that may suggest cardiac dysfunction Orthostatic hypotension (Agostini et al., 2001). Assess pulse and blood pressure in the lying, sitting, & standing positions a. Note presence of orthostatic hypotension (an immediate drop of > 20mm of systolic blood pressure after moving from a supine to a sitting position or standing position) b. While research has suggested that orthostatic hypotension may not be a good predictor of falling for healthy, community-dwelling older adults (Liu et al., Evidence Grade = C), current fall prevention guidelines recommend the measurement of postural pulse and blood pressure in older adults at risk for falling (Agostini et al., 2001; AGS, Evidence Grade = A). 5) Vision Screening Visual problems contribute to an individual s fall risk (Ivers et al., 1998; Kamel et al., 2000; Lord & Dayhew, Evidence Grade = C). Note eye problems including cataracts, glaucoma, diabetic neuropathy, or macular degeneration

16 Fall Prevention For Older Adults 15 Note history of and/or current problems with poor visual acuity, reduced visual field, impaired contrast sensitivity, depth perception, or distant-edge-contrast sensitivity Note date and results of most recent eye examination Note whether vision correction devices are clean, well-fitted, regularly and appropriately worn Assess visual acuity, particularly near vision acuity, with the Rosenbaum pocket vision screener 6) Gait & Balance Screening & Assessment A simple gait and balance screening can identify individuals who would benefit from the comprehensive fall evaluation. Results from the Timed Up & Go Test (Appendix C) (Podsiadlo & Richardson, 1991) or the MDS gait and balance assessments (Morris, Murphy, Nonemaker, 1995; Brown et al., 2000). For individuals who show gait or balance problems on the gait and balance screening tests (Timed Up & Go Test), conduct an in-depth gait and balance assessment (See Appendix F) (Tinetti, 1986) 7) Musculoskeletal and Foot Assessment Individuals with musculoskeletal changes or foot problems may have difficulty walking which in turn can lead to problems with falling. Note presence of osteoarthritis, especially of the knees (Blake et al., Evidence Grade = C) Note presence of lower extremity amputation (Vlahov et al., Evidence Grade = C) Note presence of foot problems (corn, calluses, bunion) (Blake et al., Evidence Grade = C) Note presence of skeletal/joint deformities or fractures Assess disability of lower extremities, including reduced strength, sensation, or balance Assess lower limb joints, including range of motion 8) Continence Assessment Persons with urinary or fecal incontinence and other kinds of urinary tract symptoms may be at increased risk of falling (Bakarich et al., 1997; Brown et al., 2000; Stevenson et al., Evidence Grade = C). Note presence or history of any type of urinary incontinence and/or fecal incontinence Note diagnosis of urge incontinence or overactive bladder Note presence of symptoms such as urinary frequency, urgency, or rushing to the toilet Note presence of nocturia Note current use of medication for the treatment of incontinence or overactive bladder Note current use of diuretics (Leipzig et al., 1999a. Evidence Grade = A) 9) Cardiovascular Assessment Several cardiovascular conditions, referenced below, are found more often in older adults who have experienced a fall (Agostini et al., 2001; AGS; 2001; Oliver et al., 2000). Note history of cardiovascular disease and/or cardiac dysfunction (e.g., arrhythmias, valve disease, myocardial infarction, heart blocks, etc.)

17 16 Fall Prevention for Older Adults Note current use of cardiovascular drugs including diuretics, antiarrhythmic agents, and/or cardiac glycosides/digoxin (Leipzig et al., 1999a. Evidence Grade = A) Note reports of syncope, faintness, dizziness, or blackouts (Blake et al., 1988; O'Mahony, & Foote, Evidence Grade = C) Note reports of drop attacks and/or diagnoses associated with drop attacks (Dey et al., 1997; O'Mahony & Foote, Evidence Grade = B) a. Cardioinhibitory cartoid sinus syndrome (CSS), mixed CSS, vasodepressor CSS, orthostatic hypotension, or vasovagal syncope Note reports of postprandial (after a meal) hypotension (Aronow & Ahn, 1994; Aronow & Ahn, Evidence Grade = B) Assess for cardiac arrhythmias, carotid bruits, or heart murmurs Assess heart rate and blood pressure responses to carotid sinus stimulation, as appropriate (Note: Requires advanced diagnostic training) 10) Neurological Assessment Neurological conditions, especially those that cause alterations in an individual s gait, balance, level of consciousness, or cognitive status are commonly associated with falls (Agostini et al., 2001; AGS, 2001; Oliver et al., Evidence Grade = A). Note history of cerebrovascular accident/stroke (Vlahov et al., Evidence Grade = C) Note history of transient ischemic attacks/tia Note history of epilepsy/seizure disorder Note history of neurological diseases associated with gait disorders (Parkinson s disease, muscular dystrophy, multiple sclerosis, normal pressure hydrocephalus) Note history of other neurologic disorders (cervical or lumbar spondylosis, cerebellar disease, brain lesions, peripheral neuropathy) Note history of dementia, impaired cognition, or impaired mental status a. Dementia with Lewy bodies (Ballard et al., Evidence Grade = C) Note history or presence of vestibular dysfunction (vertigo, dizziness) Note presence of muscle rigidity, spasticity, tremors, or involuntary movements Assess peripheral innervation (sensitivity to light touch, pain, temperature, vibration) Assess proprioception/cerebellar function a. Romberg test: able to stand with eyes closed and feet together without swaying for 5 seconds b. Heel-to-shin: able to run heel of each foot down the opposite shin Assess grip strength of dominant and non-dominant hand a. Reduced grip strength in dominant hand (Blake et al., Evidence Grade = C) Conduct a cognitive status screening using the Mini-Mental State Exam (Folstein, Folstein & McHugh, 1975) or other assessment instrument 11) Depression Screening Antidepressant medications have been noted to increase the risk of falling in older adults (see below). Therefore, a depression screening (For further information, see the Evidence-Based Guideline: Detection of Depression in the Cognitively Intact Older Adult by Piven, 1998) can be useful for determining fall risk. Note history or current diagnoses of depression Note current use of antidepressant medications

18 Fall Prevention For Older Adults 17 a. Tricyclic antidepressants (Leipzig et al., 1999b. Evidence Grade = A) b. Selective serotonin-reuptake inhibitors (Thapa et al., Evidence Grade = C) Conduct depression screening a. For cognitively intact older adults (MMSE score of 23 or greater), use a depression assessment tool such as the Geriatric Depression Scale (Yesavage et al., 1983) b. For cognitively impaired older adults (MMSE score of 22 or less), use a depression assessment tool such as Cornell Scale for Depression in Dementia (Alexopoulos et al., 1988) 12) Walking Aids, Assistive Technologies, & Protective Devices Assessment Appropriate and correct use of walking aids and other devices is a component of any fall intervention program for older adults (Agostini et al., 2001; AGS, 2001; Oliver et al., Evidence Grade = A). Note use of walking aids (e.g., canes, walkers, crutches, merrywalkers, etc.) Note use of other assistive technologies (e.g., wheelchairs, motorized scooters, etc.) (Nyberg & Gustafson, Vlahov et al., Evidence Grade = C) Note use of protective devices (e.g., hip protectors, helmets, etc.) Note use of footwear with respect to slippery soles and how well they fit (Connell & Wolf, Evidence Grade = C) Assess assistive and protective devices for proper fitting and signs of wear or damage Assess correct use of walking aids, assistive technologies, and protective devices 13) Environmental Assessment Older adults cite tripping and slipping as two of the most common reasons for a fall (Blake et al., Evidence Grade = C). Physical hazards are often involved. An environmental assessment can often identify modifiable risk factors, such rugs, floor matts, a lack of handrails in toilets, or clutter, that contribute to falls in older adults. The following are environmental factors that increase risk of falling or are interventions in which the potential harm outweighs the benefits, such as use of physical restraints and side-rails (Agostini et al., 2001; AGS, 2001; Oliver et al., 2000) Use of physical restraints (Agostini et al., 2001; AGS, 2001; Arbesman, & Wright, Evidence Grade = A) Use of bedrails/siderails (Hanger et al., 1999; Mosley et al., Evidence Grade = B) Lack of handrails in strategic locations. Consider: height, location, availability, use (Isberner et al., Evidence Grade = C) Slippery and glaring floor surfaces (Isberner et al., Evidence Grade = C) Snow, ice, cold weather, or slippery outdoor surfaces (Bulajic-Kopjar, 2000; Campbell, Spears et al., Evidence Grade = C) Temporary environmental hazards such as equipment in hallways (Connell & Wolf, Evidence Grade = C) Inadequate lighting (Connell & Wolf, 1997; McLean, & Lord, Evidence Grade = C) Uneven flooring (Isberner et al., Evidence Grade = C) Loose throw rugs, frayed carpets, cords and wires (Tideiksaar, Evidence Grade = D) Cracked and uneven sidewalks (Tideiksaar, Evidence Grade = D) Facilities (toilets, tubs) and furniture with inappropriate height for transfers (Fleming & Pendergast, Evidence Grade = C)

19 18 Fall Prevention for Older Adults Item Bed Chairs Toilets Equipment and Furniture Guidelines for Older Adults (Tideiksaar, Evidence Grade = D) Recommendation Adjustable height Height appropriate when person can sit on edge of mattress with knees flexed at 90 degree angle and plant both feet on the floor Bed wheels in locked position during transfers Height inches Width at least 18 inches Depth inches Measure chair height using distance from the feet flat on the floor to the knee / popliteal space behind the knee Arms come fully forward Offer a variety of models A minimum of one easy chair per bed plus a dining or work area chair Toilet seats raised to ease transferring Wall-mounted grab bars or toilet safety frame One commode for every two beds beyond 40 feet from toilet Overbed tables One per bed Height 4-6 inches above top of mattress Avoid pedestal tables and wheeled tables Tideiksaar, R. (2002). Falls in Older People: Prevention & Management, 3 rd Edition. Baltimore, MD: Health Professions Press. 14) Falls Assessment in Long-Term Care: Resident Assessment Protocol (RAP) Triggers For residents of long-term care facilities, the Long-Term Care MDS and Resident Assessment Protocol (RAP) can be used to guide a comprehensive fall evaluation. Specific assessment criteria from the FALLS RAP TRIGGERS section of the MDS are provided below: What FALLS RAP Triggers were identified on most recent MDS? Wandering (E4aA) Parkinson s Disease (I1y) Incontinence (H1) CVA (I1t) Unstable chronic / acute condition (J5a, J5b) Alzheimer s Disease (I1q) Other Dementia (I1u) Cardiac Dysrhythmia (I1e) Hemiplegia / hemiparesis (I1v) Hypotension (I1i) Syncope (J1m) Seizures (I1aa) Delirium (B5) Loss arm/ leg movement (G4b, G4d) Device/restraint (P4a, P4b, P4c, P4d, P4e) Impaired vision (D1, D2) Impaired hearing (C1) Decline functional status (G9) Decline cognition (B6) Dizziness/ Vertigo (J1f) Joint pain (J3g) Unsteady gait (J1n) Osteoporosis (I1o) Missing limb (I1n) Arthritis (I1l) Fracture of hip (I1m, J4c) Manic depression (I1ff) Psychotropic medicine (O4a, O4b, O4c, O4d) Pacemaker (health record) Cardiovascular medications (health record) Diuretic medications (O4e) Cane / walker / crutch (G5a)

20 Fall Prevention For Older Adults 19 DESCRIPTION OF INTERVENTIONS Fall prevention strategies that are implemented will depend upon the findings of the multidimensional falls assessment, individual fall risk factors, and the resources available to the older adult and/or his or her caregivers. Following the COMPREHENSIVE FALL EVALUATION, the health professional has a rich source of information with which to plan targeted fall prevention strategies that are individualized for each person and based on the presence of fall risk factors. While referring to the completed Falls Risk Factors Checklist (Appendix A), the health professional can discuss with the older adult and/or caregiver the most likely risk factors contributing to his or her risk of falling, and begin planning nursing interventions to prevent falls. Fall prevention programs that combine exercise with risk factor modification and those based upon an interdisciplinary comprehensive falls evaluation appear to be the most effective for reducing falls in older adults (Agostini et al., 2001; Hill-Westmoreland et al., Evidence Grade = A). Implement Fall Prevention Interventions (Step 4) Fall prevention interventions that address modifiable fall risk factors are suggested by specific settings below (Agostini et al., 2001; AGS, 2001; Oliver et al., Evidence Grade = A). Information is included for older adults living in community settings, residents of long-term care or assisted living facilities, and elders in acute care settings. Following the specific settings information is an overview of specific fall prevention interventions which includes information on 1) comprehensive fall evaluation and treatment of health problems, 2) medication review and modification, 3) improving physical mobility: exercise programs, balance and gait training, and appropriate use of walking aids, 4) environmental management, 5) staff education programs, 6) continence promotion and toileting programs, 7) physical restraint reduction, and 8) preventing fall-related injuries with protective devices. Interventions For Older Adults Living In The Community Fall prevention interventions for persons living in the community focus on three areas: 1) improving physical mobility, 2) decreasing medication side effects, and 3) treating underlying health conditions. Studies conducted with community-dwelling older persons support the following interventions (Agostini et al., 2001; AGS, Evidence Grade = A): Gait training and advice on the appropriate use of assistive devices (Close et al., 1999; Tinetti et al., Evidence Grade = B) Review and modification of medications, including psychotropic medications a. Reduction in the number and dosages of prescribed medications (Campbell et al., 1999; Close et al., 1999; Tinetti et al., Evidence Grade = B) Exercise and balance training programs (Campbell et al., 1999; Steinberg et al., 2000; Tinetti et al., Evidence Grade = B)

21 20 Fall Prevention for Older Adults Assessment and treatment for any identified health problems (Close et al., Evidence Grade = B) a. Treatment of postural hypotension (Close et al., 1999; Tinetti et al., Evidence Grade = B) b. Treatment of cardiovascular disorders (Close et al., Evidence Grade = B) c. Treatment of visual problems (Close et al., Evidence Grade = B) Modification of environmental hazards (Cumming et al., 1999; Tinetti et al., Evidence Grade = B). Interventions For Older Adults Living In Long-Term Care Or Assisted Living Facilities Fall prevention interventions for persons living in long-term care or assisted living facilities focus on five areas: 1) identifying fall risk factors through a comprehensive fall evaluation, 2) improving management of falls through staff education programs, 3) improving physical mobility, 4) decreasing medication side effects, and 5) modifying the physical environment. Studies of interventions to prevent falls among older persons living in long-term care facilities support the use of the following interventions (AGS, 2001; Ray et al., 1997; Rubenstein et al., Evidence Grade = B): Comprehensive fall evaluation (Ray et al., 1997; Rubenstein et al., Evidence Grade = B) Improvement in room lighting, flooring, and footwear (Agostini et al., 2001; Ray et al., Evidence Grade = B) Staff education programs (Ray et al., Evidence Grade = B) Wheelchair use and maintenance by an occupational therapist (Ray et al., Evidence Grade = B) Gait training and advice on appropriate use of assistive devices (Ray et al., Evidence Grade = B) Review and modification of medications, including psychotropic medications (Ray et al., Evidence Grade = B) Interventions For Older Adult Patients In Acute Hospital Settings Research on multi-component fall prevention programs in the hospitalized setting suffer from small sample sizes and methodological issues (Agostini et al., Evidence Grade = A). A meta-analysis of hospital-based fall prevention programs revealed that pooling the effects from three controlled trials resulted in no effect that is no benefit in reducing falls (Oliver et al., Evidence Grade = A). This same meta-analysis demonstrated that pooling the effects from seven prospective studies with historical controls, fall rates declined by about 25% (Oliver et al., Evidence Grade = A). The interventions employed in these studies were heterogeneous and often several interventions were employed simultaneously (Oliver et al., 2000). In studies in hospitalized settings, practices included educational activities for nurse and support staff, patient orientation activities, review of prior falls, and improvement of surrounding environment. Specific environmental components included reducing physical obstacles in rooms, adding supplemental lighting and grab bars in bathrooms, and lowering

22 Fall Prevention For Older Adults 21 bedrails and bed height. Other studies have attempted to improve transfer and mobility by scheduled ambulatory and physical therapy activities and provision of better footwear. Studies also incorporated interventions for cognitively impaired patients through education of families, minimizing sedating medications, and locating confused patients close to nursing staff. Because many of these studies used small sample sizes, and lacked precise standardization and description of the interventions, the generalizability and reproducibility of findings are limited (Agostini et al., Evidence Grade = A). Fall prevention strategies that are commonly used in acute care settings, including wristbands or overbed stickers to identify persons at high risk for falls, bed alarms, or physical restraints, show little benefit for reducing falls in hospitalized older adults (Oliver et al., Evidence Grade = A). Fall prevention programs that identify an individual s fall history and fall risk with subsequent implementation of targeted modifiable risk factors may help prevent falls in hospitalized older adults (AGS, 2001; Oliver et al., 2000). In addition, ensuring that hospital units are staffed adequately so that nurses and assistive personnel are available to assist older adults with transfers, toileting, and other basic physical needs should be a priority (Blegen, Vaughn, & Goode, Evidence Grade = C). Agostini et al., notes that in the hospital, several interventions have been employed as part of multiple risk factor intervention studies, but many have been poorly described and standardized. Practices include educational activities for nurse and support staff, patient orientation activities, review of prior falls, and improvement of the surrounding environment. Specific Fall Prevention Interventions Major interventions that have been recommended as fall prevention strategies for older adults include: 1) comprehensive fall evaluation and treatment of health problems, 2) medication review and modification, 3) improving physical mobility: exercise programs, balance and gait training, and appropriate use of walking aids, 4) environmental modification, and 5) continence promotion and toileting programs. A brief overview of each intervention, as well as information on physical restraint reduction and preventing fall-related injuries with protective devices, is provided. Educating direct care givers who assess fall risk and initiate individualized interventions is an important component of fall reduction. Educational programs for the staff involved in fall prevention are necessary but not sufficient to reduce falls (Ray et al., 1997). Comprehensive Fall Evaluation and Treatment of Health Problems The most important steps in any fall prevention program are to identify persons who have previously experienced a fall, determine the potential for future falls, and outline and reduce individual fall risk factors (AGS, 2001; Westmoreland-Hill et al., Evidence Grade = A). This is accomplished through the baseline fall screening, comprehensive fall evaluation, and ongoing treatment of health problems (Close et al., 1999; Ray et al., 1997; Rubenstein et al., 1990; Tinetti et al., 1996; Westmoreland-Hill et al., Evidence Grade = B). Older adults at risk for falls cannot benefit from targeted fall prevention interventions unless underlying health conditions are identified and will not benefit unless these conditions are treated. Common health conditions if left untreated in older adults that contribute to fall risk include postural hypotension (Close et al., 1999; Tinetti et al., 1996.

23 22 Fall Prevention for Older Adults Evidence Grade = B), cardiovascular disorders (Close et al., Evidence Grade = B), visual problems (Close et al., Evidence Grade = B), and urinary incontinence (Bakarich et al., Evidence Grade = C). Identification of high risk patients through bracelets, signs or tags have been incorporated in multifactorial interventions to prevent falls (Agostini et al., 2001; Oliver et al., 2000). A randomized controlled study on use of colored bracelets to identify high risk inpatients did not demonstrate a statistically significant treatment effect; thus there is no evidence that use of such an identification system reduces falls (Agostini et al., 2001; Oliver et al., 2000). Use of such identification systems might, in fact, adversely affect rehabilitation and promotion of functional independence by causing stigma and anxiety among patients and their family members (Oliver et al., 2000). Although this strategy is used in fall prevention programs, there is little evidence to demonstrate the effect on reduction of falls (Agostini et al., 2001; Oliver et al., Evidence Grade = A). Medication Review and Modification Reduction of the number of medications has been a component of many multifactorial fall prevention programs conducted in a variety of settings (Campbell et al., 1999; Close et al., 1999; Tinetti et al., 1994; Ray et al., Evidence Grade = B). Review of medications without modification appears to be of little benefit (AGS, Evidence Grade = A). Older adults who have fallen should have their medications reviewed and altered or stopped as appropriate. Whenever possible, health care providers should consider reducing medications for older adults who take four or more medications and for those who take psychotropic medications (Agostini et al., 2001; AGS, Evidence Grade = A). Although several studies have included medication review and adjustment as part of multifaceted interventions, the independent effect of this intervention on fall outcomes has not been reported (Agostini et al., 2001). Improving Physical Mobility: Exercise Programs, Balance Training, Gait Training, and Appropriate Use of Walking Aids Exercise programs, gait and balance training and appropriate use of assistive devices and walking aids have been shown to be important strategies to prevent falls for older adults (AGS, 2001; Campbell et al., 1997; Gardner et al., 2000; Gillespie et al., 2002; Province et al., 1995; Westmoreland-Hill et al., Evidence Grade = A). The benefits of improving physical mobility and endurance through any of these interventions alone as a fall prevention intervention, without concurrent reduction of other fall risk factors has not been supported (Agostini et al., 2001; AGS, Evidence Grade = A). Exercise programs that have been offered as fall prevention strategies in older adults include walking, balance training, resistance/strength training, aerobics, stationary cycling, and Tai Chi C uan. Exercise programs that have a minimum duration of at least 10 weeks are more successful than shorter programs (AGS, Evidence Grade = A). Exercise programs must be sustained for sustained benefits (AGS, Evidence Grade = A). Minimization of bedrest in hospitalized elders is a practical, real-world intervention that has implications for prevention of falls as well as other hospitalacquired complications (Agostini et al., 2001). To learn more about exercise programs for older adults, please see the Gerontological Nursing Interventions Research Centers Research Translation and Dissemination Core Evidence-Based

24 Fall Prevention For Older Adults 23 Guidelines: Exercise Promotion: Walking in Elders by Jitramontree, 2001; and Progressive Resistance Training by Mobily and Mobily, 2002; or the National Institute on Aging (1998) for an educational program entitled Exercise: A Guide From the National Institute on Aging. Environmental Modification Assessment and modification of environmental hazards is often suggested as a fall prevention strategy. Unfortunately, research studies of environmental hazard modification have had small samples and insignificant statistical results (Abreu et al., 1998; El-Faizy & Reinsch, Evidence Grade = C). Larger studies have failed to support environmental modification alone as a fall prevention strategy (Peel et al., 2000; Sattin et al., 1998; van Haastregt et al., Evidence Grade = B) although as a component of multifactorial fall prevention interevention, environmental modification may help decrease fall risk in some older adults (Cumming et al., 1999; Gillespie et al., 2002; Ray et al., 1997; Steinberg et al., Evidence Grade = B). To learn more about environmental modifications strategies for fall prevention, contact the National Center for Injury Prevention and Control on the Internet at or by phone at The following brochures are available free of charge and provide an overview of home safety measures to prevent falls in older adults: Check for Safety: A Home Fall Prevention Checklist for Older Adults ( ) Check for Safety (Spanish) ( ) What YOU Can Do to Prevent Falls (Spanish) ( ) What YOU Can Do to Prevent Falls, 1999 ( ) Continence Promotion and Toileting Programs Older adults with urinary incontinence are at risk of falling (Bakarich et al., 1997; Brown et al., 2000; Hendrich et al., 1995; Janken et al., 1986; Stevenson et al., Evidence Grade = C). In acute care settings, falls occur during toileting activities (Bakarich et al., 1997; Janken et al., 1986; Stevenson et al., Evidence Grade = C) while in long-term care, falls occur in private locations such as bathrooms, during activities of daily living (e.g., toileting), and when residents report being unable to wait for staff assistance (Fleming & Pendergast, 1993; Hakim, Evidence Grade = C). A continence assessment to determine type and severity of urinary incontinence and/or fecal incontinence and type-specific treatment of any incontinence is a suggested component of a fall prevention program for older adults. Older adults in acute care settings may benefit from a toileting program (Bakarich et al., Evidence Grade = B) as may older adults with functional and/or cognitive challenges. For further information about prompted voiding programs for older adults, please see the Evidence-Based Guideline: Prompted Voiding for Persons with Urinary Incontinence (Lyons & Specht, 1999). Preventing Fall-Related Injuries with Protective Devices (Hip Protectors, Alarms) Use of hip protectors does not seem to reduce the risk of falling, but there is strong evidence to support the ability of hip protectors to prevent hip fractures in persons 65 years of age and older, in nonhospitalized settings, who fall (Agostini et al., 2001; AGS, 2001; Parker et al., Evidence

25 24 Fall Prevention for Older Adults Grade = A). Most studies have been done in community dwelling settings or nursing homes; the efficacy in hospitalized settings has not been reported (Agostini et al., 2001). The principle of wearing hip protectors is to absorb the impact of a fall and reduce the risk of fracture by shunting the energy away from the hip region (Agostini et al., 2001). Hip protectors are usually made of hard plastic pads or shields that are padded or constructed with foam-type materials. They fit into specially designed pockets in undergarments or pants. Long-term compliance of wearing hip-protectors is low, and the potential harm of skin irritation and skin breakdown are unknown (Agostini et al., 2001). While the use of hip protectors has been shown to improve fall self-efficacy scores in older adults (Cameron et al., Evidence Grade = B), widespread acceptance of hip protectors by nursing home residents has been low (Hubacher & Wettstein, Evidence Grade = B). A commonly used protective device is the bed or wheelchair alarm. The purpose of these devices is to alert staff when an individual who is at risk for falls is rising from a bed or chair. There is no evidence that use of bed alarms reduces falls, and may, in fact, provide a false sense of security for staff regarding fall prevention (Agostini et al., 2001; AGS, 2001; Oliver et al., 2000). Implementation requires adequate staffing to respond in a timely manner to the alarms (Agostini et al., 2001). Considering the cost associated with purchase of bed alarms, with no evidence of their benefit (Agostini et al., 2001; AGS, Evidence Grade = A), it is unclear why these devices continue to be used as a fall prevention intervention. There is insufficient evidence to recommend use of bed alarms as a fall prevention strategy for hospitalized older adults (Agostini et al., 2001; AGS, 2001; Oliver et al., Evidence Grade = A). Physical Restraints and Falls in Older Adults The Health Care Financing Administration defines physical restraints as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the patient that the individual cannot remove easily which restricts freedom of movement or normal access to one s body (Agostini et al., 2001, p. 287). There is no scientific evidence that supports the use of physical restraints as a fall prevention strategy for older adults (Agostini et al., 2001; AGS, Evidence Grade = A). While some care providers may believe that an older adult is at less risk of falling and hurting him- or herself when wearing a restraint, the opposite is actually true. Older adults who are restrained are more likely to experience a fall than those who are not restrained (Capezuti et al., Evidence Grade = C). Restraint reduction programs do not seem to cause a significant increase in the total number of falls and may reduce the number and/or seriousness of injuries sustained during a fall (Agostini et al., 2001; Hanger et al., 1999; Neufeld et al., 1999; Tinetti et al., Evidence Grade = C). In addition, some restraints, such as bedrails have been implicated in serious entrapment injuries or deaths (Parker & Miles, Evidence Grade = C). There is growing evidence that physical restraints (bedrails and mechanical restraints) have a limited role in healthcare (Agostini et al., 2001). Restraints limit physical mobility, and increase risk of iatrogenic events (Agostini et al., 2001). For further information on developing restraint reduction programs, please see the evidence-based practice guideline entitled Restraints, by Ledford and Mentes, 1997.

26 Fall Prevention For Older Adults 25 EVALUATION (Step 5): PROCESS AND OUTCOME INDICATORS Evaluation is an important part of any intervention program. In order to determine the effectiveness of this guideline for identifying persons at risk for falls and for preventing falls and/or fall-related injuries in older adults, process and outcome factors must be evaluated. Fall-related outcomes should be selected based upon the individual s, providers, and the organization s goals. Process Indicators Process indicators are interpersonal and environmental factors that can facilitate the use of an evidence-based practice guideline. Three tools for assessing process indicators are included in this guideline: The Fall Prevention For Older Adults Knowledge Assessment Test (Appendix H) measures staff knowledge about falls and should be assessed before and after staff education on the use of this guideline. The Process Evaluation Monitor (Appendix I) determines the provider s perception of his/her own knowledge and use of fall reduction strategies as well as the administrative support he/she receives for carrying out the guideline. It is recommended that health care providers using the guideline fill out the monitor approximately one month after initiation of the guideline and then on an at least yearly basis. The Fall Prevention For Older Adults Quality Improvement Monitor (Appendix J) aids in tracking the falls outcomes per patient / resident. Use this monitor on a weekly basis during the first month of the intervention, and then at least once a month following this initial month to determine whether falls and fall assessments are being documented in the health record. Other process indicators that may influence the use the Fall Prevention for Older Adults guideline include: Outcome Indicators Correct use of assistive devices Use of precautions when taking medications that increase risk of falls Decreased use of psychotropic medications Use of safe transfer procedures Outcome indicators are factors expected to change or improve with consistent and appropriate use of the Fall Prevention in Older Adults evidence-based practice guideline and include: Decreased number of falls Decreased number and severity of fall-related injuries Several tools for assessing outcome indicators are included in this guideline:

27 26 Fall Prevention for Older Adults The Patient/Resident Fall Rate and Injury Rate (Appendix G) must be calculated prior to guideline implementation to provide a baseline comparison rate and at specified time periods following implementation of the guideline. The Fall Prevention For Older Adults Quality Of Care Monitor (Appendix K) aids in tracking fallrelated clinical outcomes at the organizational level. Completion of this monitor is recommended on a quarterly basis to calculate facility-wide fall rates and to determine whether fall screening and assessments are being completed on all patients/residents. For information about specific patient/resident outcomes, refer to the Nursing Outcomes Classification (Iowa Outcomes Project, 2000) (Appendix L): Safety Status: Falls Occurrence Safety Behavior: Fall Prevention Safety Behavior: Home Physical Environment

28 Fall Prevention For Older Adults 27 APPENDIX A FALL RISK FACTORS CHECKLIST PURPOSE: The Fall Risk Factors Checklist can be used to record individual fall risk factors that are noted during a comprehensive fall evaluation. The Fall Risk Factors Checklist could be used as a brief screening tool for older adults who desire more information about their own fall potential or as a guide for assisting health professionals in care planning activities. SUBJECTS & SETTING: Primarily older adults in the community, acute care, long-term care, home health care, or clinic settings who are at moderate to high risk of falling and who would benefit from a comprehensive fall evaluation. Most subjects will have: 1) presented to a health facility/provider following a fall, 2) reported recurrent falls, or 3) been identified as having a gait or balance impairment on the Timed Up & Go Test (Podsiadlo & Richardson, 1991). CHECKLIST DETAILS: 1) Risk factors are divided into five factor domains: a) epidemiological, b) pharmacological, c) health conditions, d) environmental, and e) ergonomic factors; 2) Items in BOLD are those most commonly associated with falls in older adults. INSTRUCTIONS: The health care professional conducts a comprehensive fall evaluation on an older adult. Fall risk factors identified during the comprehensive fall evaluation are checked. INTERPRETATION: Older adults with more fall risk factors checked are more likely to experience a fall than older adults with fewer fall risk factors checked. Health care professionals, older adult, and his or her caregiver discuss potential risk factors, make fall prevention goals, and select interventions that address each of the fall risk factors identified on the checklist. MAKE A COPY OF THE FALL RISK FACTORS CHECKLIST FOUND ON THE NEXT PAGE. For each person receiving the Fall Prevention For Older Adults Guideline, place a completed copy of the Fall Risk Factors Checklist in his or her health record. Provide a copy of the completed form to the individual and/or his/her caregiver. Refer to this checklist when identifying fall prevention interventions.

29 28 Fall Prevention for Older Adults FALL RISK FACTORS CHECKLIST Date Patient/Client: Epidemiological Factors History of falls Advanced age (>80 years) Female gender Recent admission to heath care facility Any acute illness Sensory impairment (vision, hearing, vestibular, proprioceptive) Impaired cognition Functional dependence Impaired activities of daily living Physical immobility Housebound Fear of falling Low staff-patient ratios in health care facilities Unsupervised activities in health care settings Pharmacological Factors Use of more than 3 or 4 medications Recent increased use of medications Drugs causing daytime sedation Use of any laxative Any Central Nervous System/ Psychotropic Drugs Barbiturates Hypnotics / sedatives Alcohol Tricyclic antidepressants Antipsychotics Antiparkinsonians Analgesics Tranquilizers Anticonvulsants Cardiovascular Drugs Diuretics Hypotensive agents Antiarrhythmics Vasodilators Cardiac glycosides Health Condition Factors Musculoskeletal disorders Arthritis Foot problems (corns, calluses, bunions) Musculoskeletal deficit Muscle weakness Hip weakness Cardiovascular disease Myocardial infarction Cardiac arrhythmias Heart valve disease Heart block Orthostatic hypotension Neurological disease Cerebrovascular accident/ stroke Transient ischemic attack Epilepsy Cervical spondylosis Lumbar spondylosis Cerebellar disease Peripheral neuropathy Parkinson s disease Normal pressure hydrocephalus Syncope Feelings of faintness Dementia Acute confusion Respiratory disease Pulmonary embolus Pneumonia / infection Pneumothorax Other health conditions Diabetes mellitus Hyperglycemia Hypoglycemia Depression Incontinence Substance abuse Sleeplessness General weakness Pain Environmental Factors Physical restraints Use of bedrails Slippery floors Glare on floors Lack of handrails Inappropriate height of handrails Inappropriate location of handrails Inappropriate height of bathroom facilities (e.g., toilet, tub) Inappropriate height of furniture (e.g., bed, chair) Loose rugs / carpets Frayed carpets Presence of electrical cords Uneven sidewalks Snow/ice on sidewalks Inadequate lighting Environmental hazards Ergonomic Factors Distance between chair/bed and bathroom Toileting Wheelchair transfers Use of assistive devices for ambulation Ill-fitting shoes Shoes with slippery soles Reduced grip strength in dominant hand Gait impairment Balance impairment Increased postural sway Disability of lower extremities Reduced strength in lower extremities Reduced sensation in lower extremities BOLD = Most common fall risk factors in older adults

30 Fall Prevention For Older Adults 29 APPENDIX B FALLS SCREENING TOOL NAME: ID: DATE: PROVIDER: STEP 1: FALL HISTORY Ask patient/resident or caregiver: During the past year, have you had a fall? Check appropriate box. NO FALL Go To Step 2: Fall Potential Conduct Timed Up & Go Test SINGLE FALL Go To Step 2: Fall Potential Assess Fall Situation Conduct Timed Up & Go Test MORE THAN ONE FALL Go To Step 3: Fall Evaluation PRESENTS WITH A FALL Go To Step 3: Fall Evaluation STEP 2: FALL POTENTIAL FALL SITUATION What were the circumstances surrounding any fall that occurred in the past year? Location Of Fall: Activity At Time Of Fall: Witnessed: YES NO Loss Of Consciousness: YES NO Assistive Device Used: Protective Device Used: Injury: Environmental Conditions: Comments: GAIT & BALANCE What were the results of the Trial 1 Seconds Trial 2 Seconds Trial 3 Seconds Average of 3 Trials Seconds Timed Up & Assistive Device None Cane Walker Other Go Test? Footwear Worn Dress Walking Barefoot Other Gait & Balance Problem Identified Timed Up & Go Test average time 20 seconds or greater Was a gait and o GO TO STEP 3: Conduct Comprehensive Fall Evaluation / or balance o OR Refer To Specialist For Fall Evaluation problem o AND Offer Fall Prevention Information identified on the Comments: Timed Up & Go Test? No Gait & Balance Problem Identified Timed Up & Go Test Average time 10 seconds or less or Timed Up & Go Test average time 11 to 19 seconds o Assess individual risk factors using Fall Risk Factor Checklist o Address modifiable risk factors and offer fall prevention information Offer Fall Prevention Information Reassess in one year or if a fall occurs Comments: STEP 3: FALL EVALUATION Older adults who report recurrent falls in the past year, present to the health care provider/facility following a fall, or who are identified as having gait or balance problems are at higher risk for falling. A comprehensive fall evaluation (See pages 11-18), is recommended to assess fall risk, identify modifiable risk factors, and to provide information for fall prevention interventions. A referral to a specialist may be required for a comprehensive fall assessment.

31 30 Fall Prevention for Older Adults APPENDIX C GAIT & BALANCE SCREENING: TIMED UP & GO TEST (Podsiadlo & Richardson, 1991) PURPOSE: The Timed Up & Go Test (Podsiadlo & Richardson, 1991) is an easy to conduct initial screening test designed to identify gait and balance problems in community-dwelling older adults as well as frail older adults in other settings. The Timed Up & Go Test takes only 1-2 minutes to complete. SUBJECT & SETTING: Older adults in the community, acute, long-term, or home care, or clinics. TASKS: The Timed Up & Go Test asks the older adult to get out of an armchair, walk 10 feet (3 meters), turn around, walk 10 feet, and sit back down in the chair. EQUIPMENT: 1) a standard armchair (seat height = 18.4 inches/46 cm), 2) a clock with second hand or stopwatch, and 3) a clearly marked, unobstructed, measured path that is 10 feet (3 meters) in length and allows room for walking and turning with usual walking aid (e.g. cane, walker, crutches, etc). TESTING DETAILS: 1) use of usual walking aid during testing, 2) wearing of regular footwear, 3) no physical assistance is given during test, and 4) following one successful practice trial, three actual timed trials are completed and scored. INSTRUCTIONS: The health care professional gives the following instructions and provides a demonstration of the Timed Up & Go Test prior to testing. Start with back against chair, arms resting on chair s arms, and walking aid at hand. At the word go, rise from the chair. Walk at a comfortable and safe pace to the line on floor 10 feet away. Turn around. Walk back to the chair and sit down. SCORING: Three timed trials of the Timed Up & Go Test are completed. The times are averaged prior to interpretation of test results. INTERPRETATION: The table on the following page can be used to interpret an individual s fall risk based upon their performance of the Timed Up & Go Test.

32 Fall Prevention For Older Adults 31 TIMED UP & GO TEST INTERPRETATION OF RESULTS (Podsiadlo & Richardson, 1991; Mathias, Nayak, & Isaacs, 1986) Time to 10 seconds or seconds seconds 30 seconds or more completion less Mobility Freely mobile Independent mobility Variable mobility Impaired mobility status Risk for fall LOW RISK LOW TO MODERATE TO HIGH RISK HIGH RISK MODERATE RISK Further assessment None Fall risk factors Targeted fall evaluation Comprehensive Fall evaluation Comprehensive fall evaluation Intervention Fall prevention information Give fall prevention information Address modifiable risk factors Give fall prevention information Initiate individualized fall prevention interventions based on results of comprehensive fall evaluation Give fall prevention information Initiate individualized fall prevention interventions based upon results of the comprehensive fall evaluation Consider use of protective devices (e.g. hip protectors) to reduce injury from falls.

33 32 Fall Prevention for Older Adults APPENDIX D FALL CIRCUMSTANCES IN LONG-TERM CARE RESIDENTS For residents of long-term care facilities, the investigating factors contributing to a fall are guided by the Resident Assessment Instrument. The Minimum Data Set (MDS 2.0) Long Term Care Facility Resident Assessment Instrument (RAI) User s Manual (Morris, Murphy & Nonemaker, 1995; Brown et al., 2000) suggests specific information to collect following a fall. See RAI User s Manual RAP 11 Falls, page 3 for more detailed information. An overview of this assessment is presented below: What were the circumstances surrounding a fall that occurred during the past 180 days? Resident Name: Date of fall: Time of fall: Time since last meal: Walking aid or assistive device used: Protective device used: Vital Signs & Injury Supine blood pressure: Upright blood pressure: Loss of Consciousness? YES / NO Any injury? YES / NO Supine heart rate: Upright heart rate: Explain: Explain: Fall Situation Activity at time of fall: Was this activity unusual for this resident? YES / NO Was resident responding to a bladder/bowel urge? YES / NO Was resident in a crowd? YES / NO Was resident standing still? YES / NO Was resident walking? YES / NO Was resident reaching? YES / NO Was the fall witnessed? YES / NO Witness report: Fall Environment Was there glare or liquid on floor? YES / NO Were foreign objects present? YES / NO Was new furniture present? YES / NO Other environmental conditions:

34 Fall Prevention For Older Adults 33 APPENDIX E FALLS DIARY (Tideiksaar, 2002) The Falls Screening Tool in Appendix B is a useful form for the documentation of a single fall. Additional copies of the Falls Screening Tool can be used over time to record multiple falls. The Falls Diary on the following page may be copied as an alternative to Appendix B, and placed in the health record of an individual who experiences recurrent falls. Using this diary may help the staff identify patterns in the factors that precipitate falls in a person who experiences multiple falls. Please note that the Falls Diary does not include the Timed Up & Go Test. MAKE A COPY OF THE FALLS DIARY FOUND ON THE NEXT PAGE. For each person receiving the Fall Prevention For Older Adults Guideline, place a copy of the Falls Diary in his or her health record. Complete the Falls Diary following each fall. Consistent use of the Falls Diary may help to identify patterns of falls and to assist the care provider in targeting fall prevention interventions for the individual. TO USE THE FALLS DIARY: Record the specifics of each fall episode in the designated columns of the Falls Diary. Completion of the Falls Diary for at least five falls may be necessary in order to detect patterns in frequent fallers. Continue to document each fall until a pattern is detected. For example: Does a fall seem to occur at certain times of the day? Is someone or something always present in the environment when the fall occurs?

35 34 Fall Prevention for Older Adults FALLS DIARY NAME ID NUMBER: DATE & TIME LOCATION OF FALL ACTIVITY AT TIME OF FALL FALL TRIGGERS RESPONSE TO FALL WITNESS REPORTS

36 Fall Prevention For Older Adults 35 APPENDIX F PERFORMANCE-ORIENTED ASSESSMENT OF BALANCE AND GAIT (Tinetti, 1986) PURPOSE: The Performance-Oriented Assessment of Balance (Appendix F.1) and Gait (Appendix F.2) (Tinetti, Evidence Grade = D) is designed to assess balance and walking ability in older adults. SUBJECTS & SETTING: The Performance-Oriented Assessment of Balance and Gait is recommended for further evaluation of persons whose score and performance on the Timed Up & Go Test (Podsiadlo & Richardson, Evidence Grade = C) indicates a balance or gait problem and suggests a moderate to high risk for falling (for example, an individual whose average score was 21 seconds on the Timed Up & Go Test). TASKS: In order to determine an individual s risk for falls, the person is asked to perform each of the balance and walking MANEUVERS described in the charts on the following pages, under the supervision of the health care provider. Observations are made for each Maneuver. The health care provider records his or her observations according to the established criteria for each maneuver. Accurate assessment is dependent upon close observation during each maneuver. EQUIPMENT: Obstacle-free hallway and usual walking aid. SCORING: The health care provider s observations are recorded in the SCORE column of the Tables found on the following pages. Performance-Oriented Assessment of Balance There are three possible responses for each balance maneuver. The individual s performance of the BALANCE MANEUVERS is categorized as a NORMAL (coded as 0 ), ADAPTIVE (coded as 1 ), OR ABNORMAL (coded as 2 ) response. Performance-Oriented Assessment of Gait There are two possible responses for each gait maneuver. The individual s performance of the GAIT/WALKING MANEUVERS is categorized as a NORMAL (coded as 0 ) OR ABNORMAL (coded as 1 ) response. INTERPRETATION: A higher score on the Performance-Oriented Assessment of Balance and Gait indicates that the individual is at a high risk for falls and may benefit from individualized interventions for fall prevention. Tinetti, M. E. (1986). Performance-oriented assessment of mobility problems in elderly patients. Journal of the American Geriatrics Society, 34(2), Blackwell Publishing. Adapted and reprinted with permission. PLEASE MAKE A COPY OF THE CHARTS LOCATED ON THE NEXT TWO PAGES. For individuals receiving the Fall Prevention For Older Adults Guideline, place the completed form in the health record.

37 36 Fall Prevention for Older Adults APPENDIX F.1: PERFORMANCE-ORIENTED ASSESSMENT OF BALANCE (Tinetti, 1986; adapted by Ledford, 1996) PATIENT RESPONSE TO MANEUVER ASKED TO PERFORM Maneuver Normal = 0 Adaptive = 1 Abnormal = 2 Score Balance while sitting in chair. Steady, stable. Holds onto chair to keep Leans, slides down in chair. upright. Rising from chair. Able to arise in a single movement without using arms. Uses chair arms or walking aid to pull or push up and/or moves forward in chair before attempting to rise. Multiple attempts required or unable without personal assistance. Immediate standing balance; first 3 to 5 seconds after standing. Standing balance. Balance with eyes closed. Feet as close together as possible. Turning balance (360 ). Nudge with light, even pressure over sternum to determine ability to withstand displacement. Stands with feet as close together as possible. Neck turning. Turns head side-to-side and then to look up while standing with feet as close together as possible. One leg standing balance. Back extension. Leans back as far as possible, without holding onto object. Reaching up. Attempts to remove an object from a shelf high enough to necessitate stretching or standing on toes. Bending down. Asked to pick up small objects, such as a pen, from the floor. Sitting down. Steady without holding onto walking aid or other object for support. Steady, able to stand with feet together without holding for support. Steady without holding onto any object, feet together. No grabbing or staggering. No need to hold onto any objects. Steps continuous. Turns in flowing movement. Steady, able to withstand pressure. Able to turn head at least halfway side-to-side / bend head back to look at ceiling. No staggering or grabbing. No lightheadedness, pain, or unsteadiness. Able to stand on one leg for 5 seconds without holding object for support. Good extension without holding object or staggering. Able to take down object without holding onto other object for support and without becoming unsteady. Able to bend down and pick up the object and able to get up easily in single attempt without needing to pull self up with arms. Able to sit down in one smooth movement. Steady, but uses walking aid or other object for support. Steady, but cannot put feet together. Steady with feet apart. Steps are discontinuous. Needs to move feet, but able to maintain balance. Decreased ability to turn side-to-side and to extend neck backward. No staggering or grabbing. No lightheadedness, pain, or unsteadiness. Able to stand on one leg for 5 seconds but needs an object for support. Attempts. Range of motion decreased or needs to hold object to attempt extension. Able to get object but needs to steady self by holding onto something for support. Able to get object and get upright in single attempt but needs to pull self up with arms or hold onto something for support. Needs to use arms to guide self into chair or not a smooth movement. Any sign of unsteadiness (e.g., grabbing objects for support, staggering, more than minimal trunk sway). Any sign of unsteadiness or holds onto an object. Any sign of unsteadiness or holds onto an object Any sign of unsteadiness or holds onto an object. Begins to fall, or examiner has to help maintain balance. Any sign of unsteadiness or symptoms when turning head or extending neck backward or inability to do either. Unable to balance on one leg without falling. Will not attempt or no extension ability or staggers heavily. Unable or unsteady. Unable to bend down or unable to get upright after bending down or takes multiple attempts to upright self. Falls into chair or misjudges distances and lands off center. Add up numbers in SCORE Column to get TOTAL SCORE: A higher score reflects a greater risk for falls. Select and initiate individualized fall prevention interventions. TOTAL SCORE

38 Fall Prevention For Older Adults 37 APPENDIX F.2: PERFORMANCE-ORIENTED ASSESSMENT OF GAIT (Tinetti, 1986; adapted by Ledford, 1996) OBSERVATION COMPONENTS NORMAL = 0 ABNORMAL = 1 SCORE Begins walking immediately without Hesitates; multiple attempts; observable hesitation; initiation of initiation of gait not a smooth gait is single, smooth motion motion INITIATION OF GAIT Ask to begin walking down hallway. STEP HEIGHT--observe from side Begin observing after first few steps Observe one foot, then the other STEP LENGTH--observe from side, one side at a time Observe distance between toe of stance foot and heel of swing foot Do not judge first few or last few steps STEP SYMMETRY-- observe from side Observe the middle part of the walk not the first or last steps Observe distance between heel of each swing foot and toe of each stance foot STEP CONTINUITY PATH DEVIATION--observe from behind Observe one foot over several strides Observe in relation to line on floor (e.g., tiles) if possible May be difficult to assess if walker used TRUNK STABILITY--observe from behind Side to side motion of trunk may be a normal gait pattern--need to differentiate this from instability WALK STANCE--observe from behind TURNING WHILE WALKING Swings foot completely clears floor but by no more than 1-2 inches At least a foot between the stance toe and swing heel Step length is usually longer but foot length provides basis for observation Step length same or nearly same on both sides for most step cycles Begins raising heel of one foot (toes off) as heel of other foot touches the floor (heel strike) No breaks or stops in stride Step lengths equal over most cycles Foot follows close to straight lines as patient advances Trunk does not sway Knees or back are not flexed Arms are not abducted in effort to maintain stability Feet should almost touch as one passes other No staggering Turning continuous with walking Steps are continuous while turning Swings foot, not completely raised off floor (may hear scraping) or is raised too high (> 1-2 inches) Step length less than described under normal conditions Step length varies between sides or patient advances with same foot with every step Places entire foot (heel and toe) on floor before beginning to raise other foot Stops completely between steps Step length varies over cycles Foot deviates from side to side or toward one direction Any of preceding features present Feet apart with stepping Staggers Stops before initiating turn Steps are discontinuous Add up numbers in SCORE Column to get TOTAL SCORE: A higher score reflects a greater risk for falls. Select and initiate individualized fall prevention interventions. TOTAL SCORE NOTES: The following notes are keyed within the above table. Also ask patient to walk at a more rapid than usual pace and observe whether any walking aid is used correctly. Abnormal gait finding may reflect a primary neurologic or musculoskeletal problem directly related to the findings or reflect a compensatory maneuver for other, more remote problem. Abnormality may be corrected by walking aid such as cane, observe with and without walking aid if possible.

39 38 Fall Prevention for Older Adults APPENDIX G FORMULAS FOR CALCULATING FALL RATES AND FALL INJURY RATES FALL RATES AND FALL INJURY RATES SHOULD BE ASSESSED AT LEAST ONCE PRIOR TO IMPLEMENTATION OF THE FALL PREVENTION GUIDELINE (Tideiksaar, 2002, p. 150, Evidence Grade = D). The purposes of fall rate calculations are to establish an organization s baseline fall rate, to determine the ratio of patients/residents who are falling, and to allow comparisons of fall rates over time and across institutions. Several methods can be used to calculate fall rates and fall injury rates within an institution (Tideiksaar, 2002, p Evidence Grade = D). Fall rate statistics will allow guideline implementers to monitor the effectiveness of fall prevention interventions. Successful implementation of a fall prevention intervention should contribute to a decrease in fall rates and fall injury rates over time. These rates should be recalculated at specified periods (e.g., every 3 months), as the patient/resident population within an institution is continually changing (i.e., admissions, discharges, transfers, deaths) (Tideiksaar, 2002, p Evidence Grade = D). Fall rates and fall injury rates can be standardized to allow comparison to similar patient / resident populations (Tideiksaar, 2002, p Evidence Grade = D). The formulas offered below are standardized to 100. These statistics are suitable for smaller institutions. Larger institutions that serve large numbers of patients / residents annually may prefer to standardize their fall rates to Fall Rates The formula to calculate the fall rate is (Tideiksaar, 2002, p Evidence Grade = D): Number of patient/resident falls X 100 = Fall Rate Number of patient/resident bed days Fall rate is the most important statistic for a facility to calculate. However, this formula does not take into account that generally it is a few patients/residents who produce most of the falls within a geographical area (health facility, department, unit). A more specific formula takes into account the number of patients/residents who have fallen within a particular time period (for example, the number of hospital discharges for a specified period) without counting the patient/resident more than once. Number of patients/residents who fell X 100 = Patients/Residents Who Fell Rate Number of patients/residents (census) Fall Injury Rates A similar formula may be used to calculate fall injury rates (Tideiksaar, 2002, p Evidence Grade = D). A fall injury is defined as any physical injury that results from a fall and may include skin abrasions, bruises, lacerations, sprains, fractures, dental injuries, or head injuries. Number of patients/residents injured during a fall Number of patient/resident falls X 100 = Fall Injury Rate

40 Fall Prevention For Older Adults 39 APPENDIX H FALL PREVENTION FOR OLDER ADULTS KNOWLEDGE ASSESSMENT TEST The individual who will be managing the use of the Fall Prevention For Older Adults EBP Guideline and coordinating education of staff should be the only person who has access to this test key. Following staff education with regard to falls in older adults, each health care provider who will be using the Fall Prevention EBP Guideline should be given an opportunity to take the knowledge assessment test. Use this test as a learning tool only. Have each health care provider take this test without the key present, and once he/she is completed the test, let him/her score how many questions he/she answered correctly and incorrectly. Guidance in determining why he/she answered as he/she did can also be part of the learning process. 1) A 2) D 3) A 4) C 5) B 6) B 7) A 8) A 9) D 10) B 11) A 12) A 13) A 14) A FALL PREVENTION FOR OLDER ADULTS KNOWLEDGE ASSESSMENT TEST KEY

41 40 Fall Prevention for Older Adults FALL PREVENTION FOR OLDER ADULTS KNOWLEDGE ASSESSMENT TEST Directions: Please circle the correct answer. 1. A recent history of falls is an important risk factor for a subsequent fall. A. True B. False 2. A comprehensive fall evaluation should be conducted for older adults with which of the following characteristics: A. Experienced a fall in the past year B. Identified with a gait or balance problem C. Presented to a health care facility following a fall D. All of the above 3. Falls in acute care hospital settings most often occur during which nursing shift: A. Daytime shift B. Evening shift C. Night shift 4. Which of the following clinical assessment tests is recommended as a general screening tool to determine an older adult s potential for falling: A. Falls Self-Efficacy Scale B. Katz Index of Independence in Activities of Daily Living Scale C. Timed Up & Go Test D. Performance-Oriented Assessment of Gait & Balance 5. Review of medications alone is an effective intervention for reducing falls in older adults. A. True B. False 6. The use of physical restraints is effective for reducing fall-related injuries in older adults. A. True B. False 7. A baseline Patient/Resident Fall Rate for the health care facility should be calculated prior to implementation of the Fall Prevention for Older Adults EBP Guideline. A. True B. False

42 Fall Prevention For Older Adults In the Timed Up & Go Test, the older adult is allowed to use his or her customary walking aid / assistive device (e.g., cane, walker) during testing. A. True B. False 9. Persons who take 30 seconds or greater to complete the Timed Up & Go Test are at what level of risk for falls: A. Low risk B. Low to moderate risk C. Moderate to high risk D. High risk 10. A higher score on the Performance-Oriented Assessment of Balance and Gait indicates that an individual is a lower risk for falls. A. True B. False 11. When completing the Fall Monitor Log, Fall Situation form, or other post-fall assessment, a witness account of the fall should be collected. A. True B. False 12. The presence of orthostatic hypotension is a risk factor for falls. A. True B. False 13. The use of psychotropic drugs is associated with a higher risk of falls in older adults. A. True B. False 14. Gait training and advice on the appropriate use of assistive devices are interventions to prevent falls. A. True B. False

43 42 Fall Prevention for Older Adults APPENDIX I PROCESS EVALUATION MONITOR The purpose of the Process Evaluation Monitor is to determine health care providers perceptions of her or his own knowledge and use of the Fall Prevention For Older Adults EBP Guideline and the administrative support they receive for carrying out the guideline. PLEASE COPY THE FORM ON THE NEXT PAGE. STEP 1: Ask each health care provider who uses the Fall Prevention For Older Adults EBP Guideline to fill it out approximately one month following her/his initial use of the guideline. STEP 2: The individual in charge of implementing the Fall Prevention For Older Adults EBP Guideline scores the Process Evaluation Monitor. For the fifteen questions, tally up the responses provided by adding up the numbers circled. For example, if Question 1 is answered 2 and Question 2 is answered 3 and Question 3 is answered 4 the score for those three questions (2+3+4) equals 9. The lowest total score possible on this monitor is 15, while the highest total score possible is 60. STEP 3: The individual in charge of implementing the Fall Prevention For Older Adults EBP Guideline evaluates the health care provider s score on the Process Evaluation Monitor. Health care providers who have higher scores on this monitor are indicating that they perceived that they understand the purposes and appropriate use of the EBP Guideline of Fall Prevention For Older Adults and are well equipped to implement the assessment and interventions in the guideline. Health care providers who have relatively low scores on this monitor are in need of more training and/or support in the use of the EBP Guideline. STEP 4: The individual in charge of implementing the Fall Prevention For Older Adults EBP Guideline reviews each form with the health care provider who completed it to determine her or his specific needs for further training, resources, support, or areas for improvement.

44 Fall Prevention For Older Adults 43 PROCESS EVALUATION MONITOR Directions: Please circle the number that best describes your perception about your own use of the Fall Prevention For Older Adults guideline. 1. I feel knowledgeable in carrying out the assessment components of the Fall Prevention For Older Adults EBP guideline. 2. I feel supported in my efforts to select and initiate interventions to reduce falls. 3. I am able to identify fall risk factors in older adults. 4. I am able to determine an older adult s fall history. 5. I am able to determine an older adult s fall potential. 6. I feel able to conduct a gait and balance evaluation with older adults. 7. I feel able to conduct a comprehensive fall evaluation with older adults. 8. I feel able to identify fall prevention interventions for older adults. 9. I feel able to carry out fall prevention interventions with older adults. 10. I feel able to evaluate fall outcomes of older adults. 11. I feel that I had enough time to learn how to do a fall risk assessment and implement individualized fall prevention interventions. 12. I feel there are enough resources available to effectively do fall risk assessment and initiate fall prevention interventions. 13. I feel that I am managing falls better with the use of fall risk assessment and fall prevention interventions from the Fall Prevention for Older Adults EBP Guideline. 14. I feel this organization is managing falls better with the use of the Fall Prevention For Older Adults EBP Guideline. 15. I feel implementing the Fall Prevention For Older Adults EBP Guideline enhances health care quality. Strongly Disagree Disagree Agree Strongly Agree

45 44 Fall Prevention for Older Adults APPENDIX J FALL PREVENTION FOR OLDER ADULTS QUALITY IMPROVEMENT MONITOR PLEASE MAKE A COPY OF THE QUALITY IMPROVEMENT MONITOR ON THE NEXT PAGE. Place a copy of the Quality Improvement Monitor in the health record of each person who is receiving the Fall Prevention Guideline. Conduct patient/resident and/or caregiver interview(s) and a health record review to determine whether key components of the guideline were completed during the monitor period. Mark the appropriate criteria key next to the outcome for each assessment. Use the Comments area to document why criteria were not met. In long-term care or home care settings: It is recommended that the outcomes on the Quality Improvement Monitor be assessed and recorded for each individual on a weekly basis during the first month of falls management and then on a monthly basis as long as the Fall Prevention For Older Adults EBP Guideline is in use. In acute care settings: It is recommended that the outcomes on the Quality Improvement Monitor be assessed and recorded for each individual as long as the Fall Prevention For Older Adults guideline is in use. Based upon a care unit s typical length of stay and other patient-related statistics, quality improvement personnel and/or administrators should determine the frequency with which the monitor is to be completed. In primary care settings: It is recommended that the outcomes on the Quality Improvement Monitor be assessed and recorded for each individual at each primary care provider appointment as long as the Fall Prevention For Older Adults EBP Guideline is in use. TO USE THE MONITOR: Place the appropriate criteria key next to the outcome for each assessment. Circle/highlight the week or month and enter the number of the assessment week/month. Example The example below is for the first outcome (Interview) and displays the various criteria keys. Criteria Key Y=Yes/Criteria met N=No/Criteria not met N/A=Criteria not applicable Fall Prevention for Older Adults Quality Improvement Monitor Date: Date: Date: Date: Outcome 1: Detect a recent fall. Reports fall in this monitor period Comments: Week 4: Patient experienced a fall and fractured left hip. Month 2: Patient not included in monitor as she has been hospitalized for treatment and rehabilitation of left hip fracture.

46 Fall Prevention For Older Adults 45 FALL PREVENTION FOR OLDER ADULTS QUALITY IMPROVEMENT MONITOR Criteria Key Y=Yes/Criteria met N=No/Criteria not met N/A=Criteria not applicable Fall Prevention for Older Adults Quality Improvement Monitor Date: Date: Date: Date: Outcome 1: Detect a recent fall. Reports fall in this monitor period Fall documented in this monitor period Physical evidence of falls (i.e., bruising, fracture) documented Treatment of fall-related injury documented Outcome 2: Identify fall risk factors. Fall circumstances documented Fall witness report documented Gait and balance screening completed Comprehensive fall evaluation completed Outcome 3: Prevent the occurrence of falls and fall-related injuries. Treatment of underlying health condition(s) Review & modification of medications Specialist referral Exercise program Gait and balance training Vision aids available and used Use of well fitting, slip resistant footwear Environmental modifications made Ambulation assistive devices used Protective devices used Toileting program Other: Comments:

47 46 Fall Prevention for Older Adults Comments: Week/Month # : Week/Month # : Week/Month # : Week/Month # : Week/Month # : Week/Month # : Week/Month # : Week/Month # :

48 Fall Prevention For Older Adults 47 APPENDIX K FALL PREVENTION FOR OLDER ADULTS QUALITY OF CARE MONITOR The staff member who is managing the facility-wide implementation of the Fall Prevention For Older Adults EBP Guideline should complete the Quality of Care Monitor on a quarterly basis. Review the health record of each person age 65 years or older seen in the health care facility (HCF) during the previous 3 months. Or, alternatively, review a random sample of health records for all persons age 65 years or older seen in the HCF during the previous 3 months. Record the number of health records in which the 1) Fall History Screening, 2) Fall Situation Assessment, 3) Gait & Balance Screening, and 4) Comprehensive Falls Evaluation were documented. In the Comments section, discuss discrepancies between the actual number of health records found with the required documentation and the total number of health records examined. PLEASE MAKE A COPY OF THE CHART ON THE FOLLOWING PAGE.

49 48 Fall Prevention for Older Adults FALL PREVENTION FOR OLDER ADULTS QUALITY OF CARE MONITOR Please place the appropriate number or letter next to the outcomes for each assessment period. Health record review Quarter 1 Quarter 2 Quarter 3 Quarter 4 Date: Total number of patients/residents age 65 years or older seen in HCF in past 3 months (TOTAL CENSUS) Total number of health records reviewed Is this quality of care monitor conducted for the a) TOTAL CENSUS or b) RANDOM SAMPLE? STEP 1: FALL HISTORY MONITOR Outcome 1a: Number of health records that indicate a Fall History Screening was completed upon admission and/or during the previous year. Outcome 1b: Number of health records that indicate that the individual experienced a fall in the past 3 months. Outcome 1c: Calculate Patients/Residents Who Fell Rate STEP 2: FALL POTENTIAL MONITOR Outcome 2a: Number of health records that indicate the Fall Situation Assessment was completed. Outcome 2b: Number of health records that indicate the Gait & Balance Screening was completed. Outcome 2C: Number of health records that indicate a gait or balance problem was identified during screening. STEP 3: FALL EVALUATION MONITOR Outcome 3a: Number of health records that indicate a comprehensive falls evaluation was completed. Outcome 3b. Individualized fall prevention interventions initiated. Gait, strength, endurance training. Regulation ambulation Review & modification of medications Toiliting rounds Provision and use of well fitting, slip resistant footwear. Visual aids available and used Ambulation assistive devices available and used Environmental modifications made: Lighting No rugs Other: Referral to physical therapy Treatment of underlying health problem Other:

50 Fall Prevention For Older Adults 49 Comments on discrepancies: Quarter 1: Quarter 2: Quarter 3: Quarter 4:

51 50 Fall Prevention for Older Adults APPENDIX L NURSING OUTCOMES CLASSIFICATION (NOC) (Iowa Outcomes Project, 2000) The Nursing Outcomes Classification (NOC) (Iowa Outcomes Project, 2000) includes several labels that are useful for the measurement of fall-related outcomes. Three NOC outcomes are included in this guideline: 1) Safety Behavior: Fall Prevention, 2) Safety Status: Falls Occurrence, and 3) Safety Behavior: Home Physical Environment. A brief description of each label follows. For more information about using the Nursing Outcomes Classification in a fall prevention program see the references below. Safety Behavior: Fall Prevention is defined as individual or caregiver actions to minimize risk factors that might precipitate falls. Safety Behavior: Home Physical Environment is defined as individual or caregiver actions to minimize environmental factors that might cause physical harm or injury in the home. Safety Status: Falls Occurrence is defined as the number of falls in the past week. This outcome is especially useful in determining the effectiveness of a fall prevention program. Nursing Outcomes Classification References: Iowa Outcomes Project. (2000). Johnson, M., Maas, M., & Moorhead, S. (Eds.). Nursing Outcomes Classification (NOC) (2 nd Ed.). St. Louis, MO: Mosby, Inc. Stolley, J. M., Lewis, A., Moore, L., & Harvey, P. (2001). Risk for injury: Falls. In M. L. Maas, K. C. Buckwalter, M. D. Hardy, T. Tripp-Reimer, M. G. Titler, & J. P. Specht (Eds.), Nursing care of older adults: Diagnoses, outcomes, & interventions. St. Louis, MO: Mosby, Inc.

52 Fall Prevention For Older Adults 51 Nursing Outcomes Classification (Iowa Outcomes Project, 2000) Safety Behavior: Fall Prevention Definition: Individual or caregiver actions to minimize risk factors that might precipitate falls Safety Behavior: Fall Prevention Slightly Moderately Substantially Totally Not adequate 1 adequate 2 adequate 3 adequate 4 adequate 5 Correct use of assistive devices Provision of personal assistance Placement of barriers to prevent falls Use of restraints as needed Placement of handrailings as needed Elimination of clutter, spills, glare from floors Tacking down rugs Arrangement for removal of snow and ice from walking surfaces Appropriate use of stools / ladders Use of well-fitting tied shoes Adjustment of toilet height as needed Adjustment of chair height as needed Adjustment of bed height as needed Use of rubber mats in tub / shower Use of grab bars Agitation and restlessness controlled Use of precautions when taking medications that increase risk for falls Use of vision-correcting Devices Use of safe transfer procedure Compensation for physical limitations Other (specify) Reference: Iowa Outcomes Project. (2000). Johnson, M., Maas, M., & Moorhead, S. (Eds.). Nursing Outcomes Classification (NOC) (2 nd Ed.). St. Louis, MO: Mosby, Inc., page 371, reprinted with permission.

53 52 Fall Prevention for Older Adults Nursing Outcomes Classification (NOC) (Iowa Outcomes Project, 2000) Safety Status: Falls Occurrence Definition: Number of falls in the past week Safety Status: Falls Occurrence Over 9 1 TOTAL NUMBER OF FALLS PER WEEK Number of falls while standing Number of falls while walking Number of falls while sitting Number of falls from bed Number of falls while transferring Number of falls climbing steps Number of falls descending steps Other (Specify) Reference: Iowa Outcomes Project. (2000). Johnson, M., Maas, M., & Moorhead, S. (Eds.). Nursing Outcomes Classification (NOC) (2 nd Ed.). St. Louis, MO: Mosby, Inc., page 377, reprinted with permission None 5 Nursing Outcomes Classification (NOC) (Iowa Outcomes Project, 2000) Safety Behavior: Home Physical Environment Definition: Individual or caregiver actions to minimize environmental factors that might cause physical harm or injury in the home Safety Behavior: Home Physical Environment Not adequate 1 Slightly adequate 2 Moderately adequate 3 Substantially adequate 4 Totally adequate 5 Provision of lighting Placement of handrailings Use of personal alarm system Provision of accessible telephone Placement of appropriate hazard warning labels Provision of assistive devices in accessible location Provision of equipment that meets safety standards Arrangement of furniture to reduce risks Placement of window guards as needed Other (Specify) Reference: Iowa Outcomes Project. (2000). Johnson, M., Maas, M., & Moorhead, S. (Eds.). Nursing Outcomes Classification (NOC) (2 nd Ed.). St. Louis, MO: Mosby, Inc., page , reprinted with permission.

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61 60 Fall Prevention for Older Adults CONTACT RESOURCES If you have any questions regarding this guideline, please contact the author: Stacie Salsbury Lyons, MSN, RN Doctoral Candidate The University of Iowa College of Nursing 30A Nursing Building Iowa City, IA Or you may contact the series editor, Marita G. Titler, PhD, RN, FAAN, using the information below. Acknowledgments The University of Iowa Gerontological Nursing Interventions Research Center Research Translation and Dissemination Core wishes to acknowledge Lajana Ledford, BSN, MA, GNP, CNS, of Veterans Administration Medical Center, Fresno, California, for her contributions as author of the Prevention of Falls Research-Based Guideline (1996) which the Fall Prevention for Older Adults Evidence-Based Guideline (2002) updates and extends. In addition, the GNIRC-RDC wishes to acknowledge Deborah Perry Schoenfelder, PhD, RN, Associate Clinical Professor, College of Nursing, The University of Iowa, Iowa City, Iowa; and Jacqueline M. Stolley, PhD, RN, CS, Associate Professor, Trinity College of Nursing, Moline, Illinois, for their contributions as content expert reviewers. Finally, the author and the GNIRC-RDC wishes to thank Mary J. Dyck, PhD(c), RN,C, LNHA, for sharing her expertise on the Long-Term Care Minimum Data Set and Kennith Culp, PhD, RN, for his feedback on calculating fall rates. This guideline is one of a number of evidence-based guidelines made available by The University of Iowa College of Nursing Gerontological Nursing Interventions Research Center Research Translation and Dissemination Core. For information on how to obtain additional evidence-based guidelines, please contact The Research Translation and Dissemination Core. In Writing: By Phone: Marita G. Titler, PhD, RN, FAAN (319) Westlawn By FAX: Iowa City, Iowa (319) By [email protected] By Internet Access: