EXECUTIVE SUMMARY

Fall injuries result in millions of emergency department visits and cause 27,000 deaths each year. Case managers can help prevent falls, but determining evidence-based solutions is challenging, as the results of new research suggest.

  • Falls are a leading cause of fatal injuries among older Americans.
  • One study revealed a nurse fall care manager could help lower the rate of falls without serious injuries, but made no significant difference on the rate of serious fall injury.
  • Other research revealed falls are high in the month before someone is hospitalized.

Recent studies challenge assumptions about how case managers and other healthcare professionals can reduce fall risk among older patients with comorbidities and recent hospital stays. The key is to focus on fall risk from just before a person is hospitalized to weeks after hospitalization.

“Falls are a big problem nationally for an aging population. They’re costly, debilitating, often end in institutionalization, but they are preventable,” says Geoffrey J. Hoffman, PhD, MPH, assistant professor in the department of systems, populations, and leadership at the University of Michigan School of Nursing. Hoffman also is a member of the Institute for Healthcare Policy and Innovation at the University of Michigan.

Falls are a leading cause of fatal injuries among older Americans. They cause 2.8 million injuries treated in emergency departments each year, including 27,000 deaths and more than 800,000 hospitalizations, according to the National Council on Aging. (More information is available at: https://www.ncoa.org/news/resources-for-reporters/get-the-facts/falls-prevention-facts/.)

“Falls are a huge problem with at least one in three older people falling every year,” says Nancy Latham, PhD, clinical research director in the division of men’s health, aging, and metabolism at Brigham and Women’s Hospital, and instructor at Harvard Medical School. “One-third of them will have an injury, and one-third [of those injured] will have a serious injury.”

Non-fatal falls among older adults cost about $50 billion in the United States each year, according to the Centers for Disease Control and Prevention. (More information is available at: https://www.cdc.gov/homeandrecreationalsafety/falls/data/fallcost.html#:~:text=Falls%20among%20adults%20age%2065,spent%20related%20to%20fatal%20falls.) Injuries from falls continue at a steady pace, despite falls prevention programs. The results of recent research suggest falls are major factors in poor health outcomes among older adults.1

The question is: What can case managers and other healthcare professionals do to prevent falls and improve health outcomes for at-risk adults? “We know that some things can work to prevent falls,” Latham says.

For instance, interventions that help patients take their medication, make dietary changes, address osteoporosis, and create an effective exercise program can help reduce risk. “We know if people make these changes and stick with them, they can reduce falls and injury. That comes from reviews of many studies, and is not just an opinion,” Latham explains.

The authors of a recent study assessed the effects of nurse fall care managers on an at-risk population of adults older than age 70 years. They found a multifactorial intervention did not result in a lower rate of a serious fall injury, but did lower the rate of falls without serious injury.1

The Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) study was a pragmatic, cluster randomized, controlled clinical trial that was designed to evaluate the effectiveness of evidence-based techniques to reduce fall-related injuries. (Find out more at: https://www.stride-study.org/. See story about STRIDE in this issue.)

Authors of another recent study examined more than 10,000 all-cause hospitalizations and fall injury risk before and after hospitalization. Investigators found fall risks were disproportionately high in the month just before hospitalization.2

“We saw big spikes [in fall risk] right before the hospital stay — a week or two before — and then we also saw spikes that fall risk remained high after hospital discharge,” Hoffman explains.

The takeaway is there is a lot going on with patients’ health right before the hospital stay, and some of these problems could increase fall risk. For instance, if a patient has heart problems and he or she ends up in the hospital, it is likely the fall risk also has increased due to some type of executive functioning issues, he explains. This correlation suggests case managers and hospitals can do a better job of teaching patients about fall prevention during discharge planning.

“We did qualitative work where we showed that people who had been in the hospital and were at risk for falls were not receiving a lot of discharge information about falls,” Hoffman says.

A review of literature shows these three main tactics appear to help prevent falls, Hoffman says:

• Recommend tai chi or other flexibility and balance exercises. “If you look at the Cochrane review of all literature out there on falls, things like tai chi and improving gait and balance help,” Hoffman says.

The authors of a recent study found high-quality evidence that tai chi is an effective intervention for preventing falls in community settings, although there is less clear evidence for long-term care facilities. The authors suggested tai chi may offer a superior tactic for reducing falls because of its benefits on cognitive functioning.3

Some community organizations offer tai chi for older adults, and case managers could provide patients with information about those programs.

• Suggest home safety modifications. The most recent studies on falls prevention reveal a benefit to installing grab bars in showers and making other home safety modifications, Hoffman says.

One study revealed occupational therapists are effective in reducing fall hazards in the homes of older adults. They can make a comprehensive list of specific fall hazards in and around the home.4 “The problem is connecting people to those services,” Hoffman notes. “Medicare doesn’t pay for fall prevention.”

Some value-based healthcare plans might offer built-in incentives for preventive care, including fall prevention. Generally, Medicare and commercial payers do not cover fall prevention.

“My thinking is if it’s a bundled payment plan, they could pay to put up grab bars,” Hoffman says. “If we’re serious about falls, which cost a ton of money for Medicare, then we want to think about having providers come up with creative ways to address it.” It will take harmonized incentives across care settings.

• Provide medication reconciliation. Polypharmacy and medication risks are well known. “If you take psychotropic medication and benzodiazepines, it can increase your risk of falls,” Hoffman explains.

Some medications cause drug interactions that could lead to dizziness and other conditions that create a fall risk. High-risk drugs include central nervous system-acting agents, nonsteroidal anti-inflammatory drugs, cough suppressants, antiplatelet agents, diuretics, hypoglycemic drugs, nasal preparations, anti-Alzheimer’s agents, and antiglaucoma eye preparations. (Find out more at this link: https://pubmed.ncbi.nlm.nih.gov/24966681/.)

“Patients need someone to work with them and to help them get the right drug and dosage to minimize fall risk,” Hoffman says.

A Canadian falls prevention clinic found high compliance for medication changes among community-dwelling older adults who experienced one fall requiring medical attention within the previous 12 months. The patients had a 78% compliance rate with medication changes to prevent falls, compared with a 58% compliance rate for exercise and a 35% compliance rate for lifestyle modifications.5

REFERENCES

  1. Bhasin S, Gill TM, Reuben DB, et al. A randomized trial of a multifactorial strategy to prevent serious fall injuries. N Engl J Med 2020;383:129-140.
  2. Hoffman GJ, Tinetti ME, Ha J, et al. Prehospital and posthospital fall injuries in older US adults. JAMA Netw Open 2020;3:e2013243.
  3. Nyman SR. Tai chi for the prevention of falls among older adults: A critical analysis of the evidence. J Aging Phys Act 2020;1-10. doi: 10.1123/japa.2020-0155. [Online ahead of print].
  4. Keglovits M, Clemson L, Hu Y-L, et al. A scoping review of fall hazards in the homes of older adults and development of a framework for assessment and intervention. Aust Occup Ther J 2020. doi: 10.1111/1440-1630.12682.
  5. Davis JC, Dian L, Parmar N, et al. Geriatrician-led evidence-based Falls Prevention Clinic: A prospective 12-month feasibility and acceptability cohort study among older adults. BMJ Open 2018;8:e020576.