Preventing falls among elderly patients means a focus on their special needs

Noise, lighting play important role for geriatric population

How often have you walked into a patient care area and been blasted by an array of television sets with the volume cranked up to 11? How about the lovely shade of beige wall paint that flows seamlessly into the lovely shade of beige floor tile?

For your elderly patients who already are dealing with a number of physical and mental challenges, these are more than just annoyances. They can be real dangers, contributing to the already high likelihood of falls among elderly patients in your facility. The experts say that when it comes to elderly patients, your usual fall prevention strategies might not be enough. There are special steps risk managers should take.

The environment in your facility is a special concern, more so than when you’re preventing falls among patients in general, says Jennifer M. Bottomley, PT, MS, PhD, a geriatric rehabilitation program consultant and president of the section on geriatrics of the American Physical Therapy Association in Alexandria, VA. Seemingly inconsequential details — like that beige paint and beige floor tile — can conspire against the elderly patient to cause a serious fall and liability when the same factors might not affect a younger patient much, if at all.

"There are so many factors that affect an elderly population differently or more than they affect your other patients, so it is very important to look at them as a group with special needs when it comes to preventing falls," Bottomley says. "It’s not a small distinction. It is absolutely a big divide when it comes to how you prevent falls in this group."

Screen patients early and often

Elderly patients face multidiagnostic, complex medical situations, often with multiple medications that may have a range of effects — dizziness, sleepiness, confusion, an urge to urinate, for instance. Blood pressure problems can cause the patient to be unsteady. Nutrition and hydration issues can contribute to falls, as can vision and hearing problems.

"The cause of falls can be much more complex," Bottomley says. "With younger patients, the cause of a fall tends to be more clear cut and more easily remedied."

All of the fall prevention strategies that you employ throughout the organization — such as minimizing clutter and monitoring medications that may lead to falls — will benefit elderly patients as well. But you can take additional steps with the elderly, probably your most at-risk patients.

Bottomley recommends that risk managers start addressing falls among the elderly with a program for interdisciplinary screens beginning with every patient at admission and then repeating the screens as necessary, depending on the patient’s particular condition. But at a minimum, she says, every elderly patient should be screened every six months.

Roberta A. Newton, PhD, professor of physical therapy at Temple University in Philadelphia, says risk managers must include all staff in the effort, and they must be empowered. Environ-mental services staff are critical, she says. They can make sure spills are cleaned quickly and clutter is cleared, especially in the path from the patient’s bed to the bathroom. Those staff are in the rooms frequently and so they can be empowered to watch for various hazards, such as the bed raised too high, and either correct them or report them to a nurse.

"A lot of times when we think of a multidisciplinary team, we only think of the clinical staff," Newton says. "But you can include nonmedical so that everyone is empowered to help reduce falls based on their own level of skills. The housekeeper may not be trained to assist patients, but that person can do certain things that contribute to the overall safety of the patient."

Newton is a firm believer that bedrails should be down whenever possible. If the rail is down and the patient falls out of the bed, the injury probably will be less severe than if the patient had to crawl over the rail and then fell, she says. The real issue in that scenario, of course, is why the patient tried to get out of bed. Going to the bathroom is the usual cause, so Newton encourages frequent monitoring of the patient so assistance can be provided when needed.

Small changes can make a difference

Managing the patient’s environment may be the strategy that is the most different for elderly patients as opposed to reducing falls in the overall patient population, Bottomley says. The elderly patient’s vision, hearing, balance, gait, attention, and cognition issues can lead to situations in which seemingly innocuous factors in the environment create fall hazards. Manage those hazards ahead by looking at the environment from the point of view of your elderly patient, Bottomley suggests.

"You can have a substantially lower rate of falls by modifying environmental concerns like this," she says. "Environment is often neglected."

Even small issues in the environment can have a big impact, Newton says. Make sure the call button and other frequently needed items are in reach so that the patient does not have to reach.

Shiny floors are a particular problem, Newton says. Even if the floor is not actually slippery, the shininess creates a glare that can cause difficulty for the patient with vision deficits. Lighting should be of good quality, producing an even light throughout the room. Don’t forget to compensate for the varying conditions caused by sunlight at different times of the day.

Staffing ratio also a key issue

Bottomley says risk managers should also focus on the staffing ratio with an elderly patient population, especially those with Alzheimer’s or other dementia. Strength conditioning and physical therapy also are key, she says. All patients who are able to participate, even minimally, should be encouraged to participate in some sort of exercise program.

Videotape-guided exercises are good, as are tai chi classes and similar low-impact classes. Walking is always a good exercise option, and Newton says one good technique is to put interesting pictures and diversions along the hallway so that patients are encouraged to take a stroll.

Newton also advises putting elderly patients in a sitting position as much as possible. The reason for that is that if a patient is lying and then sits up suddenly, dizziness and confusion may result. When possible, have the patient sit in an area with a view or where he or she can interact with others, to keep the mind active.

Remember also that the patient is at the highest risk for falls in the first six weeks of entering a new facility or a different unit. The surroundings are unfamiliar and cognitive problems may make it difficult for the patient to adjust quickly, Newton says.

"Don’t forget education also," she says. "It’s important to educate everyone about the risk of falls and how to prevent them, and that includes staff, the patients, and family members, too."