Falls are a common clinical problem affecting nearly one third of community-dwelling older adults and more than half of institutionalized older persons in the United States. Falling is a major health problem for those older than 65 (Hausdorff, Rios, &Edelber, 2001). In 2005, 15,800 people 65 or older died from injuries related to unintentional falls; about 1.8 million people 65 or older were treated in emergency departments for nonfatal injuries from falls, and more than 433,000 of these patients were hospitalized (Centers for Disease Control and Prevention [CDC], 2005b). Falling occurs among people of all ages, but falling results in higher rates of morbidity and mortality among those older than 75 because of the higher incidence of frailty and a limited physiologic reserve among the aging population (CDC, 2005b). After age 75, white men have the highest fall-related fatality rates, followed by white women, black men, and black women; non-Hispanics have a higher fatal fall rate than Hispanics (CDC, 2005b). In terms of serious injury, falls are the leading cause of hip fractures, accounting for more than 270,000 occurrences annually. In 2000, traumatic brain injury accounted for 46% of fatal falls among older adults (Stevens, 2006). Older individuals who fall are also more likely than other age groups to be hospitalized or institutionalized as a result of the fall or a concomitant serious injury. Fall-related injuries account for 5.3% of all hospitalizations for those 65 years or older (Bell, Talbot-Stern, & Hennessy, 2000; Jager et al, 2000). Women sustain about 80% of all hip fractures (Stevens & Sogolow, 2005). In a research study by Tideiksaar (2005), falls accounted for nursing facility placement in 40% of the population seeking institutionalization.

Falling has numerous antecedents and consequences that can be identified and managed. Most clinical research demonstrates a reduction in fall frequency as a result of intervention strategies to modify risk factors. Clinical programs targeting high-risk older adults have incorporated intervention strategies aimed at medication modification, environmental improvements, and behavioral modification. Clinical research findings demonstrate variability in the effectiveness of these interventions. Not all falls are preventable; therefore goals for individuals who fall frequently are fall reduction, prevention of serious injury, and modification of significant risk factors.

It is also important to note that because falls are multifactorial, not all individuals fall as a result of the same antecedents. For instance, an older woman may lose her balance and fall when hurrying to answer the telephone and then experience a second fall the next morning when getting up from bed too quickly. In this example there are two distinct causes of falling, both of which can be modified through education and behavioral modification. Thus, because falls tend to be multifactorial in this age group, care must be taken to perform a comprehensive assessment of individuals who have fallen; this includes a detailed history and physical examination.

Client education is the cornerstone of fall prevention and management. The gerontologic nurse must explore client beliefs and misconceptions about falling. Older individuals may consider falling to be a normal part of the aging process. For some, it is an expectation of growing old. Individuals who hold these stereotypes must be educated about the normal aging process, which is distinct from diseases and the adverse effects of medications. It is important to tell older adults that the etiology of falling can most often be determined by a health care professional who has expertise in fall assessment and that falls can be reduced and even prevented through some simple interventions (Box 12–1). The treatable causes of falling must also be emphasized in continuing education and staff development programs in all health care settings. Once the clients’ and staff’s knowledge of falling improves, the reporting of falls in an effort to seek treatment may improve.

BOX 12–1 GENERAL FALL PREVENTION GUIDELINES

General Care

• Wear low-heeled shoes with small wedge platforms.

• Wear leather- or rubber-soled shoes.

• Leave nightlights on at night.

• Keep items within reach to avoid overreaching.

• Check the tips of canes and walkers for evenness.

• Paint the last step a different color, indoors and outdoors.

• Dangle the legs between positional changes and rise slowly.

• Avoid the use of alcohol.

• Avoid rushing.

• Avoid risky behavior, such as standing on ladders unaided.

Steps and Floor Surfaces

• Be careful to avoid slippery floors and frayed carpets.

• Watch for the last step when descending the stairs.

• Count the number of steps as a cue while ascending and descending the stairs.

• Install and use sturdy banisters on both sides of staircases.

• Tack down throw rugs or remove them entirely.

• Remove obstacles in the path of traffic.

• Use carpeting on landing surfaces that has color contrast.

Bathroom

• Install grab bars in the tub and shower and near the toilet.

• Avoid throw rugs; install carpeting.

• Avoid bar soaps; use liquid soap from a dispenser mounted in the shower.

Falling Defined

It is crucial for the gerontologic nurse to recognize that older individuals define falling in variable ways and are influenced by perceptions of aging and disease and the context of the situation. For instance, older individuals may not perceive a slip that results in a fall to the floor to be an actual “fall”; rather it may be termed a slip, trip, or accident but not a fall. Box 12–2 illustrates some common reasons given by older adults to explain the fall. The falling event needs to be reviewed in detail to determine whether the person fell to the lowest level (i.e., the ground). Moreover, how individuals define falling is likely to influence the reporting of falls. A fall can be anything that causes a person to unintentionally move from one level plane to another. An example of this is a sudden and unexpected drop from standing upright into a seat or onto the floor. Injuries such as bruising, sprains, strains, or fractures can result from minimal height drops.

BOX 12–2 COMMON EXPLANATIONS FOR FALLING GIVEN BY OLDER ADULTS

• “I think I slipped.”

• “I don’t remember what happened.”

• “I was in a hurry.”

• “I tripped.”

• “I lost my balance.”

History taking should be detailed enough for the examiner to envision the details leading to the fall. Refer to the later section Evaluation of Clients Who Fall for specific questions to ask during history taking (Tideiksaar, 2005).

Meaning of Falling to Older Adults

Falling, in a broad sense, is a concept that holds negative connotations because it is associated with a decline, drop, or descent to a lower level. As it relates specifically to client falling, the same negative connotation appears to hold true, as evidenced by the plethora of research that presents the significant negative consequences of falling. However, to clients, falling may mean something entirely different. It may not be associated with an actual dropping to a lower level, such as the ground; falling might mean a perceived loss in status. In a research investigation of community-dwelling older adults’ statements about falls, the extent to which the fall was attributed to a person’s own limitations instead of the environment depended on self-rated health, among other variables (Arfken et al, 1994; Sterling, O’Connor, & Bonadies, 2001). Thus the meaning of falling involves several related variables and most likely is determined according to an individual perception of how serious the fall is in terms of daily living.

The health care professional may equate a fall with a decline in client health or function or a worsening of a client’s condition. Falling may be viewed as a marker of future decline. In fact, the concept of prodromal falling refers to a series of falls that occurs before the onset of illness or disease, as a prelude (or prodrome). Events such as infections are classic examples of medical conditions associated with falling.

Normal Age-Related Changes Contributing to Falling

Fall Risk

Overall, most published research on falls and falling pertains to determining fall risk. There are clearly identified antecedents (e.g., diseases such as stroke, delirium, dementia, or urinary incontinence) that can lead to falls (Box 12–3), but many individuals with these disease-related risk factors do not fall. Thus fall risk is not determined solely on the basis of the number and kind of diseases but also on how these risk factors influence an older adult’s functional ability, specifically in the areas of mobility, transferring, and negotiating within the environment.

BOX 12–3 TREATABLE CAUSES OF FALLING IN OLDER ADULTS

• Orthostatic hypotension

• Dehydration

• Profound anemia

• Cardiac arrhythmia (e.g., bradyarrhythmia, tachyarrhythmia, sick sinus syndrome)

• Overdosing with medication or alcohol

• Urinary tract infection

• Vitamin B₁₂ deficiency

• Osteoporosis

• Hypoglycemia

• Seizures

• Carotid hypersensitivity

• Carotid stenosis

• Delirium ^∗

^∗∗Mental status is an important determinant of fall risk because changes in mental status, such as those incurred with delirium, can cause older individuals to have difficulty negotiating within the environment. Delirium causes individuals to misperceive sensory input, as well as stimuli and objects in the environment.

Fall risk is best determined by observation of mobility. Fall risk can be categorized according to intrinsic (illness or disease-related) or extrinsic (environmental) risk. A risk for falling according to these categories is different from the intrinsic or extrinsic causes of falling. Risk is determined by the clinician and is a term that reflects a judgment, based on a thorough evaluation of a client, known hazards for falling, and foreseeable events. Older clients at “risk” for falling may not experience a fall at all. There are numerous extrinsic risks for falling, such as lack of color contrast on curbs, poor lighting, frayed carpeting, and unsteady furniture. Intrinsic risks for falling include conditions such as orthostatic hypotension, blindness, or advanced dementia. The presence of these risk factors, however, does not mean that an older client will actually fall—just that he or she is likely to fall given certain circumstances. In fact, some individuals who are at risk for falling, as evidenced by the presence of these risk factors, do not fall. Some of the circumstances that can lead to falling in older adults include unsteady gait or balance instability, delirium or side effects of medications causing unsteadiness, and an inability to right themselves when footing is lost or balance is unstable.

As mentioned, risk for falling is different from actual intrinsic or extrinsic causes of falling. In the latter case, a fall has actually occurred and is the result of either intrinsic disease, extrinsic causes in the environment, or a combination of the two. These falls are likely to occur among those deemed at “risk for falling.” The workup seeks to identify the underlying cause so that it can be treated, thus ultimately preventing or reducing recurrent falling. One aim of fall management is the reduction of risk factors to promote safety while still respecting client autonomy. Because falling is individually determined and not always preventable or predictable, it is important to avoid classifying clients according to the clinician’s perception of their risk for falling (i.e., high risk versus low risk). As previously discussed, falling does not necessarily occur among individuals who are deemed at greatest risk. The effect of functional ability has significance as it relates to older individuals who fall. Research has shown that the individual with frailty and physical functional limitations is at greatest risk for falling (Tideiksaar, 2005).

Intrinsic Risk

Intrinsic risk for falling refers to the combined effect of normal age-related changes and concurrent disease. The most salient observations for intrinsic risk relate to gait, balance, stability, and cognition. This requires the gerontologic nurse to observe and analyze older individuals’ gait and balance and determine whether impairment exists. Measurement tools have been developed to rate both gait and balance. These tools identify key components of gait such as step length and height, step symmetry, and path. Important areas of balance assessment include sitting and standing balance, turning, and the ability to sit without loss of balance. The Tinetti Gait and Tinetti Balance instruments are measurement tools that quantitatively score gait and balance. These tools have been tested through clinical research and hold acceptable validity and reliability ratings (Tinetti, 1986). Before managing gait or balance impairments with assistive aids or physical therapy, older individuals require medical workups for treatable causes of gait and balance abnormalities (Table 12–1).

TABLE 12–1

TREATABLE CAUSES OF GAIT AND BALANCE ABNORMALITIES

PHYSICAL EXAMINATION FINDING	POSSIBLE ASSOCIATED GAIT OR BALANCE IMPAIRMENT
Peripheral neuropathy	Inability to feel feet on the floor
Charcot’s joint	Foot instability and/or foot pain
Loss of proprioception	Foot placement on floor altered
Hemiparesis	Leaning to one side; gait instability
Hammer toe	Foot pain during weight bearing
Decreased steppage height	Shuffling gait; tripping

Extrinsic Risk

Numerous environmental hazards, both indoors and outdoors, can predispose individuals to falling. Research has found that older persons continue to perform the same types of risk-taking behaviors in their later years of life as before. Modification of risky behaviors in the face of functional impairment can prevent accidental falls in and around the home. Instruction in home safety tips should be incorporated into health encounters with older individuals who experience falling.

The modification of environmental risk factors is also critical for fall prevention. Environmental hazards are those that contribute to accidental falls. Research has found that about 30% of falls can be prevented through environmental modification (Warde, 1997). The key areas that require evaluation for safety are steps, floor surfaces, edges and curbs, lighting, and grab rails; nursing interventions are directed at environmental assessment of the indoor living space in these key areas. Whenever possible, steps that are uneven should be repaired or at least have a sturdy handrail to hold onto for support. Floor surfaces should have low-pile carpeting in good repair. Tears should be sewn to prevent shoe heels from becoming caught. Throw rugs should be eliminated because they are a tripping hazard. Curbs and cement landing surfaces should be painted with a contrasting color to outline edges. Lighting should be adequate in high-traffic and dimly lit areas. On a more global scale, a community effort to notify the local Housing Commission of areas needing improvement is an important step in the design of future homes that are safe for older adults.

Steps

The most commonly cited place where falls occur in the home is the last step of a staircase. The last step is a problem area primarily because of visual changes or functional impairment. Handrails should be present on both sides of a staircase or series of steps. The handrail typically ends at the second to last step; if a person descending the stairs is using the handrail as a guide for the landing surface, it will place the individual at the second to last step. Interventions to correct this include educating clients about this situation, teaching individuals to count the steps (i.e., keeping a mental tally of the number of steps ascending or descending), and reinstalling handrails that meet individuals’ needs. Another problematic area on the staircase is an unevenness of steps (Fig. 12–1). Observation and correction of this phenomenon may be the first step toward fall prevention in the home.

FIG 12–1 Steep stairs with handrail missing on the right. (Courtesy of Deanna Gray-Miceli.)

Floor surfaces

Floors that have been waxed or polished are common slippery surfaces that are a safety risk for older adults, especially persons with visual impairments. Carpeting that is frayed or torn can also catch heels. Throw rugs can lead to tripping or sliding (if on a hardwood or tile surface). In general, it is advisable to tack down throw rugs or remove them altogether. Floor surfaces should also be clutter free, as clutter can lead to tripping and accidental falls.

Edges and curbs

Edging that lacks a contrasting color can lead to falls because surfaces tend to blend together. In the interior of the home, carpeting on the staircase and landing surface that are the same color can lead to falling. In the exterior of the home, concrete steps that are homogeneous in color can lead to misperceptions and subsequent falling. Uneven pavement outdoors can cause falling. Curbs that are not clearly marked with a bold contrast in color can also cause falling. Simple modifications include painting the outdoor steps a contrasting color at the landing surface and using carpet borders in a contrasting color (or adhesive tape) to distinguish changing indoor surfaces.

Lighting

Dimly lit rooms cause difficulty for aging eyes and also for those with low levels of vision or impaired vision. Bright lights can lead to glare and temporary visual impairment. Lighting should ideally be evenly distributed and have consistent brightness. Diffuse overhead lighting is often preferable to one bright light source.

Grab bars or rails

Grab bars and rails can aid those with functional impairments and serve those who accidentally slip in the tub or shower. Grab bars to steady balance can be placed around the toilet, in the shower, or on the tub. Grab bars should be strategically placed to be most beneficial for the person with the impairment. Misplaced grab bars, which cause older persons to reach, can actually lead to falls. Tubs and showers should have adhesive mats, be well lit, and be free of bar soap that can lead to accidental falls during showering.

Risk for Serious Injury

A small percentage of older individuals who fall are at the greatest risk for serious physical injury (Box 12–4). It is vital for the gerontologic nurse to identify these individuals because they possess intrinsic risk factors that can be identified and often modified to prevent serious injury. Additionally, recognition and treatment of these individuals are part of the gerontologic nurse’s role in preventing foreseeable accidents. Serious injuries such as hip fractures, head trauma, and internal bleeding affect only a relatively small percentage of older individuals who fall. Although falls are the leading cause of hip fractures, only about 5% to 6% of older individuals who fall sustain them (CDC, 2004). There is a high mortality rate associated with hip fractures, and the cost of their treatment places great economic strain on society for rehabilitation and other ancillary services (Liporace et al, 2005).

BOX 12–4 CONDITIONS ASSOCIATED WITH GREATEST RISK FOR SERIOUS INJURY

• Mental status changes (e.g., those related to delirium and dementia)

• Osteoporosis

• Gait or balance instability

• Concurrent fractures (e.g., of the hip, pelvis, humerus, or ulna)

• Restraint use

In addition, the use of physical restraints can increase the risk for serious injury. Individuals who are physically restrained can injure themselves attempting to remove the restraints. Incidents of strangulation and asphyxiation have been reported secondary to restraint use. The elevation of both side rails can cause demented or delirious older adults to fall in their attempts to climb over the side rails. These individuals are at risk for serious injury because of the height of the fall; thus the impact is greater than if the side rails had not been elevated. Physical restraint use does not prevent falls and therefore should never be employed for “safety precautions.”

Reducing the risk of serious injury

Behavioral modification is a broad term applied to interventions that alter behavior to effect positive outcomes. The gerontologic nurse is in a pivotal position to educate older individuals, especially those at risk for serious injury from falling, about fall prevention measures. Older individuals’ knowledge base and receptivity to changing behavior are important aspects for the gerontologic nurse to assess before initiating a teaching program. Specific teaching points will vary individually, but general guidelines for fall prevention and home safety can be illustrated through a pictorial display of high-risk environmental hazards or by issuing a handout with teaching points. As they relate to those conditions most likely to result in serious injury, specific interventions can be reinforced (Table 12–2).

TABLE 12–2

BEHAVIORAL INTERVENTIONS TO PREVENT SERIOUS INJURY

CONDITION	CLIENT INTERVENTIONS
Osteoporosis	Take medications prescribed for increasing bone mineral density.
	Take vitamin D and calcium supplements.
	Eat well-balanced, nutritious meals high in calcium.
	Perform moderate weight-bearing exercises on a routine basis.
	Avoid smoking.
	Avoid excessive alcohol ingestion.
	Avoid strain on the spine (e.g., heavy lifting, bending).
Gait instability	Wear footwear with nonskid soles.
	Use mobility aids and assistive devices as prescribed.
	Make deliberate attempts to scan the environment while walking to look for possible hazards.
	Participate in an exercise program that includes muscle strengthening and gait training.
	Make environmental modifications as needed.
Balance instability	Change positions slowly and carefully.
	Stabilize position before moving.
	Use mobility aids and assistive devices as prescribed.
	Assume a seated position during high-risk activities, such as bathing and dressing.

Behavioral modification and instruction, such as teaching an older client who has orthostatic hypotension to rise slowly or an individual with dizziness who moves too quickly to slow down, may not be as easy as it seems. Behavior modification first requires older clients to recognize behaviors that are contributing to problems. Often, the causes and effects of these behaviors need to be pointed out to clients in a clear and concise manner. However, this is not a foolproof method because while clients are modifying behaviors falls might not occur. The client’s behavior may thus be negatively reinforced, and he or she may feel justified in continuing to perform the same behaviors. Behavioral modification requires older clients to make conscious attempts, whenever a behavior is performed, to change or alter it. Much of what the nurse teaches must be remembered for later action; the use of notes and tape recorders as daily reminders can help.

Disease or condition modification to reduce the risk of serious injury from falls includes appropriate treatment of the actual disease. In the case of osteoporosis, agents to prevent bone demineralization and build bone mass are prescribed and used with calcium and vitamin D supplements. The nurse plays a key role in teaching clients with osteoporosis about the importance of calcium-rich foods and ways to incorporate these foods into the diet on a daily basis. Teaching about the risk factors associated with the development of osteoporosis is also important.

In cases of delirium, condition modification includes a determination of the underlying etiology; unless the cause is identified and treated, the condition will not resolve and clients will remain at increased risk of serious injury from a fall. It is imperative for the nurse to recognize that the etiology is often multifactorial, thus requiring a variety of interventions based on the identified causes. While the delirium is resolving, injury can be prevented through additional nursing interventions, including padding of side rails, increased surveillance, assistance with activities of daily living (ADLs), and measures to promote a calm and reassuring environment.

Fall Antecedents and Fall Classification

Falling occurs when persons are upright and walking, termed bipedal or ambulatory, or when they are sitting or lying down, termed nonbipedal. Falls may also be considered serious or nonserious, depending on the consequences for clients. Individuals who fall but not to the lowest level (the ground) and those who catch themselves are considered to be experiencing “near falls”; those who actually fall to the ground are experiencing true falls. Falling can be classified according to the cause of the fall (intrinsic, extrinsic, or multifactorial), frequency of falling, and the timing of falling in relation to other diseases. Most falls in the older adult are multifactorial in etiology, that is, a combination of both intrinsic and extrinsic factors. Because so many different circumstances lead to falls in older adults, it is important to determine the type of fall according to a classification system (Box 12–5).

BOX 12–5 FALL CLASSIFICATION

• Multifactorial

• Extrinsic (environmental)

• Intrinsic (illness or disease related)

Isolated falling refers to a one-time event that was most likely purely accidental. The term accidental fall has been avoided in the literature during the last decade because most falls are not accidental but rather indicate specific disease processes or conditions.

Cluster falls can be observed among individuals with specific diseases who decompensate. The classic example is an older individual with congestive heart failure who falls with the onset of oxygen desaturation or cerebral hypoperfusion associated with overexertion. Usually several falls occur over a short period and are markers of a decline in health.

Premonitory falls are those produced by specific medical illnesses. These types of falls have key symptoms that can be elicited on history taking; physical examination findings and diagnostic tests may also confirm this type of falling. Classic examples of premonitory falls are those in individuals with the new onset of stroke, seizure activity, hypoglycemia, or positional vertigo.

Prodromal falling refers to the onset of frequent falling heralding an acute medical problem; thus falling is a prodrome to later disease onset. An infectious disease typically causes this type of fall. Falls have also been associated with a clinical syndrome called drop attack. A drop attack has been defined as sudden leg weakness without loss of consciousness. Drop attacks are diagnosed when all other medical illness and environmental conditions have been excluded and clients continue to fall.

Intentional falls refer to falls by individuals who fall on purpose, possibly with a desire to do harm. Older clients with significant depression or suicidal ideation may throw themselves down to cause bodily harm. Other types of intentional falls include when one resident pushes another resident to the ground. This is frequently observed among demented residents in long-term care institutions.

Thus classifications of falls will often aid in determining the underlying causes of the falls. Box 12–6 illustrates the risk factors associated with the various types of falls. It is important to note that individuals can experience any one of these types of falls singularly or in combination. If an older resident experiences a premonitory fall on one occasion, the next fall may be from a different cause altogether. Because falls are often unpredictable and therefore not always preventable, it behooves the clinician to start the evaluation with the goal of identifying and managing those falls that are treatable.

BOX 12–6 THE MULTIFACTORIAL AND INTERACTING CAUSES OF FALLS

Intrinsic Risk Factors

• Gait and balance impairment

• Peripheral neuropathy

• Vestibular dysfunction

Extrinsic Risk Factors

• Environmental hazards

Modified from Rubenstein LZ, Josephson KR: Falls and their prevention in elderly people: what does the evidence show? Med Clin North Am 90:807–824, 2006.