1. Fall Prevention in Nursing Homes Nursing Team Module
Developed by: Duke University Medical Center School of Nursing, Center for Aging and Human Development, and the Durham VA GRECC

2. Contact: colon001@mc.duke.edu
Preventing Falls
After taking this course you will be able to:
Describe the high rate of falls and their consequences in older adults
Identify patients who are at high risk for falls
Assess and intervene in five fall risk areas in high risk patients
Describe your role in the fall prevention team
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3. Fall Rates and Consequences: Scenario 1
You are orienting a new Nurse who has not worked in a nursing home before. She wants to know why there is so much emphasis on fall prevention. You tell her…
Write down the numbers that are true.
Half of nursing home residents fall each year, and one third fall multiple times.
1 in every 10 falls results in a major injury.
Falls are the most common cause of injury-related deaths in older adults.
Falls can cause decreased ability to function and lower quality of life in older adults.
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4. Contact: cathleen.colon-emeric@va.gov
Answers
Half of nursing home residents fall each year and one third fall multiple times. Right.
1 in every 10 falls results in a major injury. Correct. Major injuries include fractures, lacerations, and head injuries.
Falls are the most common cause of injury-related deaths in older adults. True.
Falls can cause decreased ability to function and lower quality of life in older adults. Right. A “fear of falling” causes patients to restrict their mobility and further lose function.
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5. Identifying Fall Risk Factors Scenario 2
Later that day you admit a new patient, Mr. Jones. Which of the following factors increase his chance of having a fall?
Write down the numbers that are true.
His wife tells you he has fallen several times at home.
He has Parkinson’s Disease.
He has dementia.
He has intermittent urinary incontinence.
He has broken his wrist in the past.
His vision is poor due to macular degeneration.
He shuffles when he walks, and holds onto furniture.
He has heart failure.
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6. Contact: cathleen.colon-emeric@va.gov
Answers
History of falls. Right. Previous falls are one of the strongest risk factors for more falls.
Parkinson’s Disease. Correct. Many neurologic diseases including stroke, seizures, and neuropathy cause falls.
Dementia. Yes. Cognitive impairment can lead to unsafe behavior and is often associated with gait problems.
Urinary Incontinence. Right. Many falls happen while patients are rushing to toilet themselves.
Prior fracture. No. Prior fractures and osteoporosis don’t increase falls but do indicate a high risk for more broken bones if the patient does fall.
Low vision. Yes! Both vision and hearing impairment are associated with falls.
Gait disorder. Right. Abnormal gait, and especially “furniture surfing,” indicate a high risk for falls.
Heart disease. No, heart disease in itself isn’t a falls risk factor, but cardiac medications may cause bradycardia or orthostatic hypotension that can lead to falls.
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7. Why is it Important to Identify Risk Factors?
It helps you to estimate his risk of falling. The more risk factors he has, the higher the chance that he will fall.
It helps you figure out which interventions are most likely to help prevent his falls.
The next section will review interventions that have been shown to prevent falls.
You have identified a number of risk factors for falls in Mr. Jones.
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8. Intervening: Medications Scenario 3
You decide that Mr. Jones is at very high risk for falls and want to intervene. You start by looking at his medications. Which of the following would you consider reducing or discontinuing?
Write down all numbers that are correct.
Citalopram 20 mg daily for depression
Lorezapam 1 mg twice daily for anxiety
Baclofen 10 mg twice daily for back pain
Digoxin 0.25 mg daily for heart failure
Zolpidem 5 mg at bedtime for sleep
Risperdal 0.5 mg as needed for agitation
Oxycodone 5 mg every 6 hours for pain
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9. Contact: cathleen.colon-emeric@va.gov
Answers
Citalopram. Maybe. All antidepressants increase falls, but treating depression is important too. Work with the care team to use the lowest effective dose.
Lorezapam. Right. Benzodiazepines increase falls risk and should be avoided or used at the lowest effective dose.
Baclofen. Definitely. Muscle relaxants have anticholinergic side effects that increase falls risk.
Digoxin.Yes. Digoxin has a narrow therapeutic window and needs to be monitored regularly for toxicity.
Zolpidem. Yes. Sedative-hypnotics probably increase falls and should be used cautiously. Are there non-pharmacologic strategies the team could use to help Mr. Jones sleep?
Risperdal. Definitely. Atypical antipsychotics increase falls risk and have a black box warning. Use only when necessary and try tapering often.
Oxycodone. No. Analgesics including opiates are surprisingly not associated with falls.
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10. Intervention: Medications
Many classes of medications are associated with increased fall risk
Digoxin
Some antiarrhythmic drugs
Diuretics
Psychotropics
Benzodiazepines
Antidepressants
Drugs with anticholinergic side effects
Consider tapering or discontinuing these drugs in patients at high risk for falls.
For summaries of meta-analyses of drugs and falls, refer to the following:
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11. Intervention: Medications Scenario 4
You talk with the facility pharmacist about tapering some of Mr. Jones’ medications. He asks if you have considered whether Mr. Jones might be vitamin D deficient. Which of the following statements are true about vitamin D in nursing home residents?
Write down all numbers that are correct.
One half to two-thirds of nursing home residents are vitamin D deficient.
The best test to assess for vitamin D sufficiency is serum 1,25(OH) vitamin D.
Vitamin D supplements strengthen bone, but do not prevent falls in nursing home residents.
Calcium and vitamin D supplements reduce hip fractures in older adults.
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12. Contact: cathleen.colon-emeric@va.gov
Answers
One half to two-thirds of nursing home residents are vitamin D deficient. Correct.
The best test to assess for vitamin D sufficiency is serum 1,25(OH) vitamin D. No. The body maintains the active 1,25(OH) form of vitamin D at stable levels until deficiency is far advanced. 25(OH) Vitamin D is a better assessment of Vitamin D stores.
Vitamin D supplements strengthen bone, but does not prevent falls in nursing home residents. No. Vitamin D supplements have been shown to reduce falls in a dose-response manner.
Calcium and vitamin D supplements reduce hip fractures in older adults. Right. They reduce fracture risk by about 25%.
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13. Intervention: Orthostatic Hypotension Scenario 5
You ask the Nurse’s Aid to check Mr. Jones’
orthostatic blood pressure and pulse. The Nurse’s
Aid is slightly annoyed by the request, so you
explain why older people like Mr. Jones often
have large drops in blood pressure that result in falls.
Write down all numbers that are correct.
They are on medications that cause orthostasis.
They have Parkinson’s disease.
They are more likely to become dehydrated.
Blood pressure tends to decrease as you age.
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14. Contact: cathleen.colon-emeric@va.gov
Answers
They are on medications that cause orthostasis. Right. Frequent culprits are cardiac medicines (especially clonidine and hydralazine), prostate medications (especially terazosin and doxazosin), anticholinergic medicines (like benadryl, muscle relaxants, antihistamines) and diuretics.
They have Parkinson’s disease. Yes. Parkinson’s is often associated with autonomic insufficiency. Other causes include diabetes, hepatic diseases, B12 deficiency, uremia, and alcoholism.
They are more likely to become dehydrated. Correct. Older people may not drink enough because of decreased feelings of thirst, dementia, or difficulty getting to water.
Blood pressure tends to decrease as you age. Actually, blood pressure tends to increase with age. However, even patients with high blood pressure can have symptomatic orthostasis.
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15. Intervention: Orthostatic Hypotension Scenario 6
The Nurse’s Aid reports that Mr. Jones’ systolic blood pressure falls from 160 to 125 mm Hg when he stands up.
Write down at least 3 things that you would consider to evaluate or treat Mr. Jones’ orthostasis.
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16. Contact: cathleen.colon-emeric@va.gov
Answers
Exclude dehydration and acute blood loss.
Review medications for potential culprits.
Consider treatable causes like adrenal insufficiency and B12 deficiency.
Talk with the Nurses about putting on compression stockings every morning.
Talk with the Nurses to ensure easy access to fluids and regular encouragement to drink.
Consider prescribing fludrocortisone for symptomatic orthostasis not responding to other measures.
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17. Intervention: Vision Impairment
During your admission assessment, you note that Mr. Jones’ vision is impaired. In addition to making sure he has had a recent eye exam, what else can be done to decrease his falls risk?
(write down the numbers that are true)
Increase the lighting in his room and bathroom
Add high contrast strips to stairs and curbs
Increase the glare in the room
Talk to the Nurses’ Aids about keeping his eyeglasses within reach at all times and encouraging him to wear them
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18. Contact: cathleen.colon-emeric@va.gov
Answers
Increase the lighting in his room and bathroom. Yes, make sure the maximum wattage bulb is used, or add additional lights.
Add high contrast strips to stairs and curbs. Good idea!
Increase the glare in the room. No, glare makes poor vision worse. Make sure there are shades or covers over the light fixtures and windows.
Talk to the Nurses’ Aids about keeping his eyeglasses within reach at all times and encouraging him to wear them. Yes, they need to understand how important good vision is to reducing falls risk.
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19. Intervention: Mobility Scenario 8
You ask Mr. Jones to do an “Up and Go” test for you. (Click the box to the right)
Is his gait safe or unsafe, and why? Decide what you would do next.
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20. Scene 6: Intervening - Mobility
Mr. Jones has weakness on one side, decreased arm swing, unequal step length, and a foot drop. You call the Physical Therapist, who will evaluate him for an assistive device and exercises. What other interventions might help reduce his risk of falling due to his unsteady gait? (write down the numbers that are true)
Use a lap belt to keep him in his chair
Check the height of his bed, toilet seat, and chairs
Consider bathroom safety
Talk to staff about increasing assistance during particular times
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21. Contact: cathleen.colon-emeric@va.gov
Answers
Use a lap belt to keep him in his chair. No. Restraints increase the risk of injurious falls, and do not promote independence and quality of life
Check the height of his bed, toilet seat, and chairs. Yes! To help patients transfer safely, seating height should be % of lower leg height. The next slide will illustrate how to check this
Consider bathroom safety. Good. Make sure there is adequate handrail support, nonskid flooring, and that the patient has easy to manage clothes
Talk to staff about increasing assistance during particular times. Yes, Mr. Jones needs increased assistance in the mornings, during transfers, to and from the toilet, and during ambulation
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22. Correct seating height is 100-120% of lower leg height
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23. Intervention: Unsafe Behavior Scenario 9
Mr. Jones has poor judgment due to his dementia. The nurses ask for your suggestions in managing some of his unsafe behaviors, such as pacing, trying to climb over bed rails, and trying to transfer without help.
Write down at least 1 idea for each of these categories.
Increasing assistance and surveillance
Reducing risk of injury
Increasing comfort
The following slides show options for each of these areas.
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24. Increasing Assistance and Surveillance
Use position alarms and motion sensors
Toilet at regular intervals
Increase activities involvement
Locate patient near nursing station
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25. Contact: cathleen.colon-emeric@va.gov
Reduce Risk of Injury
Low bed, floor mat
Lower or remove side rails
Non-skid socks or footwear
Non-skid strips or mat
Hip protectors, Calcium, Vitamin D
Screen for and treat osteoporosis when indicated
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26. Contact: cathleen.colon-emeric@va.gov
Increase Comfort
Pain management
Recliner or rocking chair
Exercise
Cradle mattress, sheepskin, air mattress or pillows
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27. Summary of Falls Intervention Areas
Evaluate risk
Resident:
High Risk
areas
Calcium + D
Review and
Medications
Taper
Hypotension
Orthostatic
Stockings
Measure
Fluids
Glasses
Lighting
Vision
Glare
Seat height
Mobility
Toileting PT
Unsafe Behavior
Prevent Injury
Comfort
Assistance

28. The Falls Prevention Team
Recall how many disciplines have been involved in the effort to keep Mr. Jones from falling. In your CLC, how many of these people do you routinely talk with about your patients’ fall risk? Coordination is vital, and you have a key role in sharing information and ideas. Don’t forget to include the patient and family in the discussions, too.
The nurses’ assistants
The floor nurses
The Rehabilitation staff
The pharmacist
Housekeeping and Maintenance
Activities Director
Patients and Families
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29. If you want to learn more about preventing falls…
Visit the web sites listed below….
AHRQ innovations site
Falls Management Program
NIH Age Page–Preventing Falls and Fractures (patient handout)
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30. Please close this presentation
The End
Please close this presentation
and begin the quiz.
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