Tumbles cause more than just a few bruises: Spot patients at risk for falls

Reduce falls with thorough assessment for risk

The statistics are alarming:

  • One out of every three people over the age of 65 falls each year.1
  • Among people age 65 and older, falls are the leading cause of death due to injury and serious injury.2
  • Of people older than 65 who fall, 10% to 25% suffer a serious injury such as hip fractures.3
  • Between 15% and 25% of hip fracture patients will die within a year of their injury.4
  • Half of older adults hospitalized for hip fractures do not return to their prior level of function.5

These statistics and a desire to reduce the number of falls experienced by her agency’s patients were the impetus for Linda J. Coccia, BS, OT, occupational therapist at Adventist Home Health Care and Hospice in Hanford, CA, to develop a falls risk assessment program. "We are dealing with patients who are at risk for falls because of their age, the medications they take, and their physical illnesses," Coccia says. "We can minimize the risk with early identification of patients who are more likely to fall," she adds.

After researching the factors that contribute to falls, Coccia worked with other home health staff to develop an assessment tool for the nurse to use on the admission visit. "You have to look at several factors when assessing risk," she says. "We look for history of neurological problems, diabetes, or stroke, as well as medication use, emotional status, and the environment," she adds.

Some of the factors that increase the risk of falls include:

Use of multiple medications, or medications such as psychotropics, sedatives, hypnotics, diuretics, or anti-hypertensives. Combinations of medications or the use of some medications can cause dizziness, Coccia explains. When that is a problem, the nurse usually works with the physician to review the patient’s prescriptions and make changes, she adds. (Hospital Home Health, August 2002, p. 85.)

• Incontinence. "Patients who are incontinent may rush to the bathroom or may slip on urine on the floor if they had an accident before reaching the bathroom," points out Coccia. In this case, nurses and occupational therapists can work together to address the patient’s needs, even adding a bedside toilet if necessary, she says. (See HHH, July 2002, p. 77.)

• Sensory deficit such as vision or hearing problems. If patients can’t see where they are going, they might trip on the edge of rug, or something lying on the floor, Coccia points out.

Previous falls. According to the National Center for Injury Prevention and Control in Atlanta, an older person who falls once is two- to three-times more likely to fall again within a year, she says.

• Fear of falling. One factor that affects a person’s overall quality of life in addition to increasing the risk of falling is fear of falling, says Pamela Toto, MS, OTR/L, BCG, an independent occupational therapist who works with Family Home Health Services in Pittsburgh. One-third to one-half of older people have a significant fear of falls even if they’ve never fallen, she says.

Because these people then limit their activities to avoid any risk of falling, they actually increase their risk because their limited activity increases the likelihood that they will lose balance, she adds.

Her agency’s form clearly identifies factors that contribute to the risk of falls and assigns point values to each factor, Coccia says. (See Falls Risk Assessment Tool, below.) "If a patient scores three or higher, physical therapy and occupational therapy are brought in to assess the patient," she says. There are some factors, such as unsteady gait, sensory deficit, history of falls, and diagnoses that contribute to unsteady gait, that warrant immediate referral to physical and occupational therapy, she adds.

Falls Risk Assessment Tool

The following risk assessment tool for determining the risk level for falls in home health patients was developed by Linda Coccia, OTR, and Karen Little, RN, of the Adventist Home Health Care & Hospice in Hanford, CA.

Risk Factors: Circle factors that apply

Postural Hypotension (> 20 mm Hg drop or < 90 mm Hg on standing) 1 pt.

Use of sedatives/hypnotics/diuretics/anti-hypertensives or psychotropics 1 pt.

Use of more than four prescriptive medications 1 pt.

Environmental hazards (stairs, floor surfaces, clutter, bathroom, lighting, pets, furnishings blocking walkways, rugs). Two or more hazards to score ** 1 pt.

Patient with unsteady gait, weakened lower extremity strength, foot problems ** 3 pts.

History of falls/fear of falling 3 pts.

Sensory deficit — hearing, low vision, peripheral neuropathy ** 1 pt.

Diagnoses — diabetes, neurological, orthopedic, arthritis ** 1 pt.

Incontinence of bowel/bladder 1 pt.

Noncompliance with safety instructions 1 pt.

Total: _________________

Comments: _______________________________________________________________________________

**Refer to physical therapy/occupational therapy

Score: 0-2: Low risk for falls. Action: Reinforce safety instructions in Safety Teaching Guide.

Score greater than 3: High risk for falls. Action: Inform patient/caregiver; reinforce safety and refer to physical therapy/occupational therapy.

Patient Name __________________________________________ Patient # ______________________

Signature _____________________________________________ Date _________________________

Source: Adventist Home Health Care & Hospice, Hanford, CA. Reprinted with permission.

The assessment form developed by Toto, measures the same factors but does not assign a point value. "The nurse uses the responses to the 13 questions and clinical judgment to rate the patient’s risk of falling as low, medium, or high," she explains.

Environmental safety in the patient’s home is an important aspect to evaluate, but it is not the predominant cause of falls, points out Toto. "We spend a lot of time and energy with home safety checklists," she says. "They should not be eliminated, but we need to be sure to point out to nurses and family caregivers that addressing items on the checklist is just part of what we have to do to protect the patient," she says.

Toto also points out that there are several mobility tools for assessment that are not designed just for occupational and physical therapists to use, although therapists are the ones to administer the tests in most cases. "Both the timed Up and Go’ test6 and the Tinnetti Balance and Mobility Assessment7 are fairly straightforward and easy to use," she says. Her agency allows therapists to choose whichever test they prefer when asked to assess a patient’s mobility and risk of falling, she adds.

The key to success in developing a falls risk assessment program that works is to be realistic, Toto says. "Staff members had mixed feelings about the program when we introduced it because nurses believed that they already knew how to identify patients at risk for falls and they did not want to spend time doing more forms," she says. Because the form takes very little time to complete and does identify more factors that increase risk of falls than most clinicians typically think about, nurses were more receptive after inservice education.

Once patients are identified as at risk for falls, the entire team of nurses, aides, and therapists meets once a month to review and plan care, says Coccia. "There is no cure for falls, but we can make sure we’ve covered as many bases as possible," she says. As goals for each discipline are met, visits are decreased and discharge plans are developed, she adds.

Fall prevention does require change, Coccia points out . "The patient may need environmental assistance such as handrails in the shower, the physician may have to review medications, extra light sources may be needed in some rooms, and the patient and family members need to be educated," she says. If funding is a problem for families who need to purchase equipment, the agency social workers try to find resources, she says. "We also adapt items such as an inexpensive lawn chairs that can serve as a shower chairs."

Once a falls risk assessment program is developed, you must conduct inservice education for all staff members, says Toto. If your agency uses contract therapists, you need to add your expectations for the identification and addressing problems of patients who are at risk for falls to the therapists’ evaluation forms, she suggests. If you want the timed "Up and Go" or the Tinnetti test performed on every patient, build that into your agreement, she adds.

"Fall prevention and identification of risk is one competency for which all of our nurses and aides are evaluated each year," Coccia says. "We’ve made the assessment easy for nurses because it comes up as a screen in OASIS [Outcomes and Assessment Information Set], so it is just one more part of the admission visit."

A home health agency also needs to make it easy for staff members to report falls, suggests Coccia. Home health staff always document unattended falls, but if the fall occurs while they are present, the documentation may not be completed because they fear punitive actions, she says. "You have to allow for falls and make sure employees report all falls so the patient’s care can be evaluated," she adds.

The most important reason to look at a falls risk assessment program is that it is a way to improve patients’ quality of life and make sure they stay at home, Coccia says.

No program, however, can prevent falls completely because there is one factor that no one can change, she adds. "We can’t change gravity, and gravity will get all of us one day."

[For more information about development of falls risk assessment programs, contact:

  • Linda J. Coccia, BS, OT, Occupational Therapist, Adventist Home Health Care & Hospice, 823 W. Lacy Blvd., Hanford, CA 93230. Telephone: (559) 585-3425, ext. 1134. Fax: (559) 585-3420. E-mail: linda-synchronics@prodigy.net.
  • Pamela Toto, MS, OTR/L, BCG, Occupational Therapist, Family Home Health Services, 2510 Mosside Blvd., Monroeville, PA 15146. E-mail: PEToto25@aol.com.

For falls assessment program resources, contact:

  • National Center for Injury Prevention and Control, Mailstop K65, 4770 Buford Highway N.E., Atlanta, GA 30341-3724. Telephone: (770) 488-1506. Fax: (770) 488-1667. Web site: www.cdc.gov/ncipc. The National Center for Injury Prevention and Control, a division of the Centers for Disease Control and Prevention in Atlanta offers several publications related to falls among the elderly. All publications are free and can be ordered in printed form or found on-line at the web site under "publications." Documents related to falls include: U.S. Fall Prevention Programs for Seniors, a description of selected programs using home assessment and modification; A Tool Kit to Prevent Senior Falls, which includes fact sheets, graphs, and brochures; Check for Safety: A Home Fall Prevention Checklist, a patient brochure that is also available in Spanish; and What You Can Do to Prevent Falls, a patient brochure that also is available in Spanish.]

References

1. Sattin RW. Falls among older persons: A public health perspective. Annu Rev Public Health 1992; 13:489-508.

2. Murphy SL. Deaths: Final data for 1998. National Vital Statistics Reports; Vol. 48, No. 11. Hyattsville, MD: National Center for Health Statistics; 2000.

3. Rubinstein LZ, Josephson KR. "The epidemiology of falls and syncope." In: Kenny RA, O’Shea D, eds. Falls and Syncope in Elderly Patients: Clinics in Geriatric Medicine, Philadelphia: W.B. Saunders Co.; 2002.

4. Sattin RW, et al. The incidence of fall injury events among the elderly in a defined population. Am J Epidemiol 1990; 131:1,028-1,037.

5. Scott JC. Osteoporosis and hip fractures. Rheum Dis Clin North Am 1990; 16(3): 717-740.

6. Podsiadlo D, Richardson S. The timed Up & Go’: A test of basic functional mobility for frail elderly person. J Am Geriatr Soc 1991; 39:142-148.

7. Tinnetti ME. Performance-oriented assessment of mobility problems in elderly patient. J Am Geriatr Soc 1986; 24:119-126.