Fall risk factors vary with groups

Risk managers should remember that the risk factors for falls are dependent on the situation, says Alan M. Jette, PT, PhD, FAPTA, professor of health policy and management at Boston University's School of Public Health and director of the university's Health & Disability Research Institute. The risk factors for an elderly patient living at home will be quite different from the risk factors for a patient in a hospital setting, he says. Likewise, the risks may be different for a long-term care resident than for a short-term acute care patient, he notes.

"I think people sometimes look at the literature and compile risk factors without being careful to distinguish between the settings. It's tempting to generalize, and you can compromise the value of the data that way," he says. "One big difference between those living in the community and those in a long-term care setting, for instance, is the influence of the physical surroundings. The configuration of the room and other hazards in the area can be more influential in a long-term care setting, but they also can be controlled."

Jette also notes that there is no single risk factor that determines a patient's risk for falling. Even the most significant risks, such as the use of multiple psychotropic medications, may not be as important on their own as the presence of multiple risk factors, he says.

"There is no one magic bullet you can look at," Jette says. "It's really the number of them that come together. The literature shows that multiple risk factors greatly increase the possibility of falls, even if any one of those risk factors is not so big on its own."

Fear of falling also is often overlooked as a risk factor, Jette says. When people become fearful of falling, they may become overcautious and cut back on their physical activity, which actually can increase their risk of falling when they do move.

Don't forget home care

Fall management programs can extend to home care as well, says Bridget Gallagher, senior vice president of community services at Jewish Home Lifecare in New York. All patients receiving home care services undergo an assessment for fall risks, she says. The goal is to spot patients at risk and implement strategies to prevent falls, Gallagher says, so upfront assessment is crucial. The assessment also is repeated annually, regardless of previous scores.

Using an objective assessment can help identify patients who are reluctant to admit to past falls or a fear of falling, she says. Many elderly patients are hesitant to reveal such information, because they fear it will mean they can no longer live at home, Gallagher says. Patients who score high enough on the assessment are referred to the rehabilitation department, which sends someone to the home to evaluate the environmental risks.

"Those risks can include things like an upraised donut seat on the toilet, dim lighting, loose rugs," she says. "Once we identify those risks, we can offer ways to reduce that hazard."

Gallagher also points out that patients who have already fallen often become so afraid of falling again that they increase their risk through immobilization, so any patient who has fallen before is automatically referred to the fall management program when being discharged to home care.

"The clinician has to follow our protocol, so it is not up to their subjective judgment whether the patient needs fall management or not," Gallagher says. "We sometimes have clients who refuse, but in those cases we talk to them about why it is important, and in the majority of cases, we are able to have rehab go into their homes."

A social work referral often is necessary, because any necessary home modification can create tension between the client and the fall management specialist, Gallagher says. The social worker can help mollify the client and may be able to procure public funding for some of the necessary changes.

"It can be a delicate thing to go into someone's home and tell them to change it," Gallagher says. "We have to say, 'Yes, this throw rug is lovely and I'm sure you enjoy seeing it every day, but if it winds up killing you, it's not worth having on the floor.'"

Query parents about kids' risks

Pediatric patients also need attention when you are reducing falls, says Eileen Mahler, RNC, MSN, assistant director of nursing for women and children's services at South Nassau Communities Hospital in Oceanside, NY. Children's hospitals are familiar with the risk of children falling, but it can be easy for other facilities to focus so much on elderly patients that they overlook the risk with the youngest patients.

For instance, the admissions process for young children should include asking parents about the child's walking ability and what type of bed he or she sleeps in at home. Many pediatric units put young children in cribs for added safety, but a child who is mobile and not used to sleeping in a crib may attempt to crawl out, which could result in falls.

The usual environmental safeguards, such as avoiding slippery rugs, apply to children as well, but the pediatric environment must be even more secure. Medical equipment, for instance, can be tempting for children, so staff should avoid leaving items in areas that encourage the child to climb or reach for them.

"It's similar in the way you have to assess patients for their risks, but the risk factors are going to be different in some ways with children," she says. "It may be things like whether this child is a runner or a climber, or whether he's still learning to walk. These are things you have to ask the parents up front."

Sources

For more information on reducing falls, contact:

  • Bridget Gallagher, Senior Vice President of Community Services, Jewish Home Lifecare, New York City. Telephone: (212) 870-4631. E-mail: bgallagher@jhha.org.
  • Alan M. Jette, PT, PhD, FAPTA, Director, Health & Disability Research Institute, Boston University School of Public Health. Telephone: (617) 312-2155.
  • Eileen Mahler, RNC, MSN, Assistant Director, Nursing for Women and Children's Services, South Nassau Communities Hospital, Oceanside, NY. Telephone: (516) 632-4724.