Elderly Falls

     Elderly adults are a significant group of patients who need ‘specific nurse care’ and this need is the basis of geriatric nursing practice. The older adults are more prone to falls and injury than other patients due to their age and accompanying disease symptoms. Their cognitive impairments further add up to their chances of a fall and subsequent serious injuries. A fall can be defined as a sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor, or the ground (Feder et.al, 2000). Several preventive strategies have proven effective to reduce the occurrence of falling and the nurse plays a preventive role by reducing the rate of falling in the elderly community. Falls and fall injuries in elderly population results in functional decline and meets all the criteria for prevention like high frequency, evidence of preventability, and high burden of morbidity (Tinetti et.al, 1998). A physical examination and focus on the patient history after a fall reveal both the immediate underlying causes of the fall and contributing risk factors. Regular evaluations also help identify high risk patients (Rubenstein et.al, 1994).

The Nurses' Awareness and Preventative Role

    Elderly falls can be effectively prevented by multifaceted interventions that reduce falls in older people, home assessment of older people at risk of falls and assessment of high risk residents in nursing homes with relevant referral. Identification, assessment and modification of risk factors in elders who had a previous fall and the provision of hip protectors have also been shown to be effective (Feder et.al,2000). A Cluster Randomized Controlled Nonblinded Trial in residential care facilities to investigate if a multifactorial intervention program would reduce falls and fall-related injuries in older patients has shown that an interdisciplinary and multifactorial prevention program targeting residents, nurses and the environment reduces falls and femoral fractures (Jensen et.al,2002). The use of a physiological profile approach to elderly fall risk assessment and prevention has been elucidated recently. This Physiological Profile Assessment (PPA) with a series of simple tests of vision, peripheral sensation, muscle force, reaction time, and postural sway can be used effectively by nurses to differentiate people who are at risk for falls from people who are not at risk for falls (Lord et.al, 2003). A qualitative study designed to explore nurses’ perceptions of the use of physical restraints on elderly patients by Content analysis of semi-structured interviews with 20 registered nurses working in geriatric settings has revealed that nurses had an overriding concern to ensure elderly patients’ safety and use of restraints provided them with a sense of security (Diana, 1999). A recent study to evaluate the effectiveness of research-based nurse interventions in preventing falls has shown that these interventions based on research studies, experts' opinions, and a pilot study are effective in reducing falls. The study has also identified bedside as the most common site for falls and has shown that falls occurred more frequently during walking, climbing over the siderails and accidentally rolling out of bed (Mosley et.al, 1998).A 20-month, population-based, prospective, observational study to determine the temporal relationship between falls and fear of falling, and to see if these two outcomes share predictors has shown falls at baseline as an independent predictor of developing fear of falling 20 months later and fear of falling at baseline as a predictor of falling at 20 months taking us to the conclusion that individuals who develop one of these outcomes are at risk for developing the other (Susan,2002).
     Multiple logistic regression analysis in a study population of elderly has shown that short-term memory loss, transfer assistance, urinary incontinence, positive fall history, and use of trunk restraints as predictors of elderly falls. Further, logistic regression analysis has also shown that depressive symptoms, transfer assistance, urinary incontinence and positive fall history are associated with frequent falls. These risk indicators help nurses to identify frequent fallers (Kron et.al, 2003).
     A research study to determine if the Berg Balance Test could be used by nurses to predict an elderly person's risk of falling in a sample population of sixty-six residents aged between 69 to 94 using a questionnaire pertaining to their fall history and activity level has shown that the test demonstrated poor sensitivity for predicting falls (Thorbahn et.al, 1996).But a similar study aimed at assessing the fall-prediction accuracy of an easily administered fall risk index in stroke rehabilitation in a consecutive series of 135 patients admitted to a geriatric stroke rehabilitation unit has shown a moderately high correlation between the predicted and the observed risk of falls in stroke rehabilitation with the Downton fall risk index (Nyberg et.al, 1996).
     A recent study to analyze the potential value of adverse event prevention programs using quality management methods to prevent elderly falls in hospital has shown that organizational causes have been responsible for 66% of the documented falls and  organizational management changes can reduce the number of falls (Sennelier et.al, 2002). For a nurse to effectively prevent falls, it is necessary to identify measurable predictors of falls and frequent falls. A study to identify easily measurable predictors for falls, recurrent falls, and fractures using a population-based prospective cohort study has shown that urinary incontinence, impaired mobility, use of analgesics, and antiepileptic drugs as the predictors most strongly associated with recurrent falls (Tromp et.al,1998).Poor vision has been associated with increased risk of elderly falls and risk of fractures (Harwood et.al,2005).A study to assess the effectiveness of a targeted, multiple intervention falls prevention programme in reducing falls and injuries related to falls in a subacute hospital has shown that a targeted multiple intervention falls prevention programme reduces the incidence of elderly falls (Haines et.al,2004).
     Studies have proved that dementia is a risk factor for falling and residents with dementia fall more often than their counterparts without dementia leaving them with a higher overall risk of sustaining injurious falls over time. A study to evaluate the association between use/dosage of risperidone (RIS) and falls in a residential-care dementia population has demonstrated that at 1 mg/day, RIS was associated with decreased falls, especially in patients who exhibit wandering and at 2 mg/day, it increases the risk of falls in ambulatory individuals with low levels of wandering (Katz et.al, 2004).Psychoactive drugs do play a role in elderly falls. Research studies to explore risk factors associated with falls and to evaluate a strategy used by nurses to predict and prevent falls in a hospitalised cohort of such elderly patients has shown that 46% (84 of 181) of the fallers were taking one or more benzodiazepines compared with 27% (48 of 181) of the control patients (p<0.001). More fallers 20% (34 of 181) had their benzodiazepines prescribed during their current admission compared with 7% (13 of 181) of the control patients (p<0.001) taking us to the conclusion that an alternative to benzodiazepines should be sought for night sedation for such older patients (Frels et.al, 2002).A study to assess the effectiveness of trained nurses based in general practices individually prescribing a home exercise programme to reduce falls and injuries in elderly people and to estimate the cost effectiveness of the programme has demonstrated that an individually tailored exercise programme, delivered by trained nurses from within general practices is effective in reducing falls (Robertson, et.al, 2001). Oral supplementation of vitamin D between 700 to 800 IU/d have been shown to reduce the risk of hip and any nonvertebral fractures in ambulatory or institutionalized elderly persons (Heike et.al,2005).

Conclusion

     Implementing fall prevention and intervention programs for the elderly presents nurses with a number of challenges and a fall prevention program that uses multidisciplinary interventions has been proved to be more effective. But there is a need for more reliable instruments that will predict falls and recurrent falls for the nurses to predict and intervene more effectively to prevent elderly falls.

Reference

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