Controversy in long-term care
Falls in the Nursing Home: Are They Preventable?

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Introduction

Falls are prevalent in elderly patients residing in nursing homes, with approximately 1.5 falls occurring per nursing home bed-years. Although most are benign and injury-free, 10% to 25% result in hospital admission and/or fractures. Primary care providers for nursing home residents must therefore aim to reduce both the fall rate as well as the rate of fallrelated morbidity in the long-term care setting. Interventions have been demonstrated to be successful in reducing falls in community-dwelling elderly patients. However, less evidence supports the efficacy of fall prevention in nursing home residents.

Methods

The authors conducted a Medline search using the key words Falls and Nursing Homes.

Results

Several studies examined the efficacy of multifaceted intervention programs on reducing falls in nursing homes with varied results. Components of these intervention programs include: environmental assessment, assistive device evaluation and modification, medication changes, gait assessment and training, staff education, exercise programs, hip protector use, and blood pressure evaluation. Current literature supports the use of environmental assessment and intervention in reducing falls in nursing homes, and demonstrates an association between certain medications and falls. However, there are no studies that examine the effect of medication adjustments on fall rates. Also, the literature does not strongly suggest that exercise programs are effective in fall reduction. Although not effective in reducing fall rates, the use of hip protectors appears to result in less fall-related morbidity.

Conclusion

More studies must be done to clarify the effects of high-risk medication reduction, the optimal nature and intensity of exercise programs, and patient targeting criteria to maximize the effectiveness of nursing home fall prevention programs. Based on the current literature, an effective multifaceted fall prevention program for nursing home residents should include risk factor assessment and modification, staff education, gait assessment and intervention, assistive device assessment and optimization, as well as environmental assessment and modification. Although there is no association between the use of hip protectors and fall rates, their use should be encouraged because the ultimate goal of any fall prevention program is to prevent fall-related morbidity.

Section snippets

Community-dwelling versus nursing home residents

Several studies have identified preventive interventions that are effective in reducing the incidence of falls in community-dwelling geriatric patients. These interventions include risk factor detection and abatement programs, exercise interventions,3, 4, 5, 6 environmental modification, or multifactorial intervention programs that include fall-risk assessments, medication adjustments, exercise intervention, environmental hazard adjustments, and fall-risk education.7, 8 Unfortunately, clinical

Multifaceted interventions

Because falls are the end result of synergistic interactions between multiple intrinsic and extrinsic risk factors, it is reasonable that multifaceted intervention programs addressing multiple risk factors would be most successful in preventing falls in nursing home residents. Results from several randomized, controlled clinical trials involving multifaceted fall prevention programs have yielded encouraging, if not uniform, results. Ray et al.10 found that a falls consultation service

Environmental assessment/modification

Environmental risk factors are important contributors to falls in nursing home residents. Specific factors that have been reported to be associated with falls include area rugs, loose electrical cords, wet flooring, multiple transitions in flooring surfaces, improper furniture height, poor lighting, and patient restraints. Much emphasis has been placed on the evaluation and modification of environmental contributors to falls within nursing homes in recent years. Although attention to

Exercise intervention

There are multiple trials that assess the effect of different exercise programs on nursing home residents. A recent trial (Toulotte et al.21) found that an exercise program consisting of 1 hour of strength, balance, and flexibility training twice a week for 16 weeks in 20 demented nursing home patients with a history of falls resulted in improved balance, flexibility, and gait speed in the intervention subjects compared with the control subjects. Fiatarone et al.22 examined 100 frail nursing

Hip protectors

Although the primary focus of this article is to assess the efficacy of fall prevention interventions, the ultimate goal of any fall prevention program is to reduce fall-related morbidity. A common yet serious adverse effect of falls in the elderly patient is fracture of the proximal femur. The efficacy of hip protectors in preventing hip fractures in elderly patients has been well established.26, 27, 28, 29, 30, 31 Various different models of hip protectors are currently available, but there

Medication assessment/modification

Iatrogenic contributors to falls are often present in elderly patients, in whom comorbid conditions require treatment with multiple medications that could increase fall risks either independently or in combination. In a metaanalysis of 25 observational studies, Leipzig et al.32 found that patients taking psychotropic agents (odds ratio [OR], 1.73; 95% CI, 1.52–1.97), diuretics (OR, 1.08; 95% CI, 1.02–1.16), type Ia antiarrhythmics (OR, 1.59; 95% CI, 1.05–1.42), and digoxin (OR, 1.22; 95% CI,

Conclusion

Resident falls are rightfully a concern both for primary care providers practicing in nursing homes and for nursing home administrators. As summarized previously, falls result from the synergistic interaction of multiple fall-risk factors acting on elderly patients. A review of the literature revealed that multifaceted fall prevention programs were effective in reducing falls in nursing home residents. Although fall-risk assessment on admission to long-term care facilities and then quarterly

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