Falls in the Nursing Home

Falls are responsible for considerable morbidity, immobility, and mortality among older persons, especially those living in nursing homes. Falls have many different causes, and several risk factors that predispose patients to falls have been identified. To prevent falls, a systematic therapeutic approach to residents who have fallen is necessary, and close attention must be paid to identifying and reducing risk factors for falls among frail older persons who have not yet fallen. We review the problem of falls in the nursing home, focusing on identifiable causes, risk factors, and preventive approaches. Epidemiology Both the incidence of falls in older adults and the severity of complications increase steadily with age and increased physical disability. Accidents are the fifth leading cause of death in older adults, and falls constitute two thirds of these accidental deaths. About three fourths of deaths caused by falls in the United States occur in the 13% of the population aged 65 years and older [1, 2]. Approximately one third of older adults living at home will fall each year, and about 5% will sustain a fracture or require hospitalization. The incidence of falls and fall-related injuries among persons living in institutions has been reported in numerous epidemiologic studies [3-18]. These data are presented in Table 1. The mean fall incidence calculated from these studies is about three times the rate for community-living elderly persons (mean, 1.5 falls/bed per year), caused both by the more frail nature of persons living in institutions and by more accurate reporting of falls in institutions. Table 1. Incidence of Falls and Fall-Related Injuries in Long-Term Care Facilities* As shown in Table 1, only about 4% of falls (range, 1% to 10%) result in fractures, whereas other serious injuries such as head trauma, soft-tissue injuries, and severe lacerations occur in about 11% of falls (range, 1% to 36%). However, once injured, an elderly person who has fallen has a much higher case fatality rate than does a younger person who has fallen [1, 2]. Each year, about 1800 fatal falls occur in nursing homes. Among persons 85 years and older, 1 of 5 fatal falls occurs in a nursing home [19]. Nursing home residents also have a disproportionately high incidence of hip fracture and have been shown to have higher mortality rates after hip fracture than community-living elderly persons [20]. Furthermore, because of the high frequency of recurrent falls in nursing homes, the likelihood of sustaining an injurious fall is substantial. In addition to injuries, falls can have serious consequences for physical functioning and quality of life. Loss of function can result from both fracture-related disability and self-imposed functional limitations caused by fear of falling and the postfall anxiety syndrome. Decreased confidence in the ability to ambulate safely can lead to further functional decline, depression, feelings of helplessness, and social isolation. In addition, the use of physical or chemical restraints by institutional staff to prevent high-risk persons from falling also has negative effects on functioning. Causes of Falls The major reported immediate causes of falls and their relative frequencies as described in four detailed studies of nursing home populations [14, 15, 17, 21] are presented in Table 2. The Table also contains a comparison column of causes of falls among elderly persons not living in institutions as summarized from seven detailed studies [21-28]. The distribution of causes clearly differs among the populations studied. Frail, high-risk persons living in institutions tend to have a higher incidence of falls caused by gait disorders, weakness, dizziness, and confusion, whereas the falls of community-living persons are more related to their environment. Table 2. Comparison of Causes of Falls in Nursing Home and Community-Living Populations: Summary of Studies That Carefully Evaluated Elderly Persons after a Fall and Specified a Most Likely Cause In the nursing home, weakness and gait problems were the most common causes of falls, accounting for about a quarter of reported cases. Studies have reported that the prevalence of detectable lower-extremity weakness ranges from 48% among community-living older persons [29] to 57% among residents of an intermediate-care facility [30] to more than 80% of residents of a skilled nursing facility [27]. Gait disorders affect 20% to 50% of elderly persons [31], and nearly three quarters of nursing home residents require assistance with ambulation or cannot ambulate [32]. Investigators of casecontrol studies in nursing homes have reported that more than two thirds of persons who have fallen have substantial gait disorders, a prevalence 2.4 to 4.8 times higher than the prevalence among persons who have not fallen [27, 30]. The cause of muscle weakness and gait problems is multifactorial. Aging introduces physical changes that affect strength and gait. On average, healthy older persons score 20% to 40% lower on strength tests than young adults [33], and, among chronically ill nursing home residents, strength is considerably less than that. Much of the weakness seen in the nursing home stems from deconditioning due to prolonged bedrest or limited physical activity and chronic debilitating medical conditions such as heart failure, stroke, or pulmonary disease. Aging is also associated with other deteriorations that impair gait, including increased postural sway; decreased gait velocity, stride length, and step height; prolonged reaction time; and decreased visual acuity and depth perception. Gait problems can also stem from dysfunction of the nervous, musculoskeletal, circulatory, or respiratory systems, as well as from simple deconditioning after a period of inactivity. Dizziness is commonly reported by elderly persons who have fallen and was the attributed cause in 25% of reported nursing home falls. This symptom is often difficult to evaluate because dizziness means different things to different people and has diverse causes. True vertigo, a sensation of rotational movement, may indicate a disorder of the vestibular apparatus such as benign positional vertigo, acute labyrinthitis, or Meniere disease. Symptoms described as imbalance on walking often reflect a gait disorder. Many residents describe a vague light-headedness that may reflect cardiovascular problems, hyperventilation, orthostatic hypotension, drug side effect, anxiety, or depression. Accidents, or falls stemming from environmental hazards, are a major cause of reported falls16% of nursing home falls and 41% of community falls. However, the circumstances of accidents are difficult to verify, and many falls in this category may actually stem from interactions between environmental hazards or hazardous activities and increased individual susceptibility to hazards because of aging and disease. Among impaired residents, even normal activities of daily living might be considered hazardous if they are done without assistance or modification. Factors such as decreased lower-extremity strength, poor posture control, and decreased step height all interact to impair the ability to avoid a fall after an unexpected trip or while reaching or bending. Age-associated impairments of vision, hearing, and memory also tend to increase the number of trips. Studies have shown that most falls in nursing homes occurred during transferring from a bed, chair, or wheelchair [3, 11]. Attempting to move to or from the bathroom and nocturia (which necessitates frequent trips to the bathroom) have also been reported to be associated with falls [34, 35] and fall-related fractures [9]. Environmental hazards that frequently contribute to these falls include wet floors caused by episodes of incontinence, poor lighting, bedrails, and improper bed height. Falls have also been reported to increase when nurse staffing is low, such as during breaks and at shift changes [4, 7, 9, 13], presumably because of lack of staff supervision. Confusion and cognitive impairment are frequently cited causes of falls and may reflect an underlying systemic or metabolic process (for example, electrolyte imbalance or fever). Dementia can increase the number of falls by impairing judgment, visual-spatial perception, and ability to orient oneself geographically. Falls also occur when residents with dementia wander, attempt to get out of wheelchairs, or climb over bed siderails. Orthostatic (postural) hypotension, usually defined as a decrease of 20 mm or more of systolic blood pressure after standing, has a 5% to 25% prevalence among normal elderly persons living at home [36]. It is even more common among persons with certain predisposing risk factors, including autonomic dysfunction, hypovolemia, low cardiac output, parkinsonism, metabolic and endocrine disorders, and medications (particularly sedatives, antihypertensives, vasodilators, and antidepressants) [37]. The orthostatic drop may be more pronounced on arising in the morning because the baroreflex response is diminished after prolonged recumbency, as it is after meals and after ingestion of nitroglycerin [38, 39]. Yet, despite its high prevalence, orthostatic hypotension infrequently causes falls, particularly outside of institutions. This is perhaps because of its transient nature, which makes it difficult to detect after the fall, or because most persons with orthostatic hypotension feel light-headed and will deliberately find a seat rather than fall. Drop attacks are defined as sudden falls without loss of consciousness and without dizziness, often precipitated by a sudden change in head position. This syndrome has been attributed to transient vertebrobasilar insufficiency, although it is probably caused by more diverse pathophysiologic mechanisms. Although early descriptions of geriatric falls identified drop attacks as a substantial cause, more recent studies have reported a smaller proportion of perso