The psychology of falls in long-term care
Eleanor Feldman Barbera, Ph.D.
According to the American Geriatrics Society, one in three adults over the age of 65 falls each year. Falls represent the leading cause of fatal and nonfatal injuries among older adults. You might be surprised to hear some of the contributing factors of falls and the psychology behind them. I also have advice on ways residents and staff can reduce the likelihood of falls./p>
Factors associated with falling
Falls are caused by many different influences, often in combination. Some common elements1 include:
- Medication — the major contributors are psychotropics (especially benzodiazepines, antidepressants, and antipsychotics), medications that reduce blood pressure and anticonvulsants
- Polypharmacy — one study found a 14% increase in fall risk with the addition of each medication beyond a four-medication regime, regardless of the group of drugs studied
- Orthostatic hypotension — researchers noted a 69% increased risk of having an injurious fall during the first 45 days following antihypertensive treatment
- Alcohol abuse
- Diabetes mellitus
- Confusion and cognitive impairment
- Gait and balance disorders
- Muscle weakness
- Poor vision
- Urinary incontinence
- Inappropriate footwear
- Environmental factors including home hazards
Impact of falls for residents
Falls can have a huge effect on the quality of life of our elders, who may have diminished mobility following an injurious fall. One-third of those who have fallen develop a fear of falling again and often reduce their activities in order to decrease the likelihood of similar mishaps. For those who have fallen in a facility, staff may limit the resident's activities. Restricted activities, whether self-imposed or enforced by others, can contribute to depression. As noted above however, prescribing anti-depressants can increase the risk of future falls.
Due to fear that their independence will be limited, some elders may hide the fact they've fallen. Residents have confessed past falls to me in their psychotherapy sessions, saying they were afraid they'd be forced into a wheelchair if anyone knew, or that they wouldn't be allowed to go home after rehab. Psychotherapy might focus on the toll of untreated injuries due to silence following a harmful fall, whether or not returning home is realistic, or on ways to safely manage the activity that led to the fall.
We can address residents' concern about maintaining their independence by giving them the tools they need to reduce the likelihood of falls.
Residents who are educated about the causes of falls can become their own best fall-prevention advocates. A recent study empowered elders by including with each filled prescription a pamphlet on how to safely reduce medication usage. This resulted in a medication reduction of 27% as compared to 5% of the control group.2 We can apply this idea to fall prevention by providing fact sheets or holding information sessions, keeping in mind that interventions that are framed as “maintaining independence” tend to be more successful than those that center on “reducing falls.”
Information pamphlets on preserving autonomy might emphasize things residents can do or initiate on their own, such as getting their vision checked, wearing clean eyeglasses, and avoiding bifocals, progressive or color-changing lenses, as well as abstaining from excessive alcohol. Residents can ask for their medications to be reviewed and perhaps reduced, wear proper footwear, and identify possible hazards in their rooms or homes.
They also can participate in exercises that improve balance (such as Tai Chi), which have been shown to reduce the likelihood of falling. When offering classes for residents, note that it's more effective to refer to ways to “get moving” or “stay active” than to call it “exercise.”
Empowering care teams
In addition to offering fact sheets and Tai Chi for residents, there are a number of ways staff can reduce the likelihood of falls.
Perhaps the most important is providing regular medication reviews to reduce number of medications, especially those associated with an increased risk of falling. Prescribing vitamin D has been shown to be helpful in reducing falls for those with a deficiency.
Staff members are generally diligent about cleaning up spills to prevent falls, but they might not be as aware of the hazards of moving furniture such as tray tables and chairs in a resident's room.
Staff might also need additional training regarding the need to provide residents with their eyeglasses on a daily basis — and to clean them. More often than not, my weekly psychotherapy sessions began with washing off eyeglasses smeared with grime (generating an instant mood lift, regardless of what we discussed).
Facilities can hold an annual “Falls Awareness Day,” offering information and activities such as a “Sloppy Slipper Swap,” where residents trade old unsafe slippers for new ones, or “Fall Prevention Trivia,” with nightlights distributed to participants. Such events raise awareness for staff, residents and families alike.
A last thought on empowerment
Most residents want to remain as active as they can, despite the possibility of a fall, but sometimes they misjudge their capabilities. All facilities want to avoid falls, which can reflect badly upon them and their quality of care, and frequently adopt an overly cautious stance such as routinely assigning wheelchairs to prevent falls.
I've often wished capable residents could sign a document stating they understand the risk of falling but nevertheless want to ambulate on their own, allowing them the freedom to walk independently as long as possible and releasing the facility from liability. Perhaps any falls that occur under these circumstances could be documented differently. If you're aware of any programs offering this opportunity, please share your experience in the Comments section or write to me directly via MyBetterNursingHome.com.
Eleanor Feldman Barbera, PhD, is a 2014 Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program and also is the Gold Medalist in the Blog-How To/Tips/Service category of the 2014 American Society of Business Publication Editors Midwest Regional competition. A consultant with nearly 20 years of experience as a psychologist in long-term care, she maintains her own award-winning website at MyBetterNursingHome.com.