Lessons learned from analyzing fall prevention programs
Falls in the elderly can be a devastating event. They are the leading cause of hospital admissions for trauma and the leading cause of injury deaths for this age group, and amount to a direct medical cost of nearly $20 billion per year in the United States alone.
Even without a serious injury, the act of having fallen is in itself disabling, causing limitation of activities simply out of fear of falling again. Not all falls can be prevented, but it is our responsibility to do everything in our power to prevent elderly and vulnerable patients from injury.
Data and research studies in long-term care facilities began proliferating since the 1990s, evaluating attempts by whatever means possible to help identify patients at risk and to prevent their falls and injuries. The issue of preventing falls is complex because in so many basic ways it involves simple common sense actions (repeated constantly): once appropriate footwear, removal of obstacles and clutter, adequate lighting, optimal vision and hearing, and education regarding call systems, telephones and keeping personal items within easy reach has happened, then assessments can begin.
Rapidly developing technology needs evaluation
It is fascinating to study the literature on fall prevention. It largely deals with trying to determine long lasting, affordable, and effective methods of preventing falls using multidisciplinary personnel and evaluating individual patients and their weaknesses, assessing medications and treating concurrent illnesses, monitoring of fluid status, and educating all staff involved. Contrast this with the developing technology for fall prevention (in parallel, and almost independent of these efforts), which is often as yet not assessed.
The proliferation of technology happens so quickly, the literature cannot keep up: we have shock absorbent pads (designed to protect from falls) in undergarments and for the floor. We have low beds, pressure alarms, personal motion detectors, personal alarms, positioning strategies, pommel seats and traction surfaces for wheelchairs, and self-releasing restraints.
These simple items all strongly imply the ingenuity of common sense at work, yet none are effective if they are not used properly or are ignored.
The literature has by now advanced along two lines: Once a patient is identified by past history or current disabilities or summation of problems as being at risk for falls, does a single intervention make a difference, or is a multidisciplinary team effort required for a more holistic approach to the problem?
The essential elements of most approaches have seemed to focus on two features to reduce risk from falling: improving balance and increasing stamina. There is data to suggest that exercises directed at these issues for community dwellers or more capable long-term care residents might focus on any of several different group programs (think tai chi as one example), while other studies lead to the conclusion that in frail, subacute skilled nursing home patients a multidisciplinary team may be required.
Effective interventions require conscientious follow-up
There are recent exciting studies that imply that a deficiency of vitamin D so often found in nursing home populations contributes to lower extremity weakness and falls, a relatively easy thing to fix. The understanding that sometimes bones break and then people fall has also helped explain previously inexplicable events and injuries, and reinforces the necessity to help make bones stronger through appropriate medical and therapy interventions.
Finally, with the majority of nursing home patients in the United States having some element of dementia, this constantly changing overlay of incapacity cannot be ignored. This simply reinforces what the literature suggests: those interventions that are made and subsequently followed up on seem to show the most lasting results.
Our most recent review of the last 10 years of reports of fall intervention programs indicate that 9% to 12% of falls can be prevented, even taking into account all of the simultaneous and parallel initiatives in strategies and technology that are brought to bear on this serious and important problem. Clearly, the geriatric syndrome of falls and their sequelae has gotten the attention of patients and their families, providers and litigators.
Gravity never takes a day off and our population of frail elderly continues to increase and represent bodies at risk for injuries. For anyone who has ever seen the simple tragic and seemingly instantaneous act of an older person falling with injuries, doing our best to lessen their risk is worthy of all the effort that it most certainly requires.
Melvin Hector, MD, is a geriatrician and professor at the College of Medicine, University of Arizona at Tucson. Myunghan Choi, PhD, MPH, APR-BC, is an adult nurse practitioner and professor at College of Nursing & Health Innovation, Arizona State University in Phoenix.
Drs. Hector and Choi are post-acute providers with IPC The Hospitalist Company in Tucson, Arizona. Their study, “Effectiveness of Intervention Programs in Preventing Falls: A Systematic Review of Recent 10 Years and Meta-Analysis,” was published in the Journal of the American Medical Directors Association (doi:10.1016/j.jamda.2011.04.022).