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Strategies to Reduce Risk of Fall-Related Injuries in Rehabilitation Nursing (CE)
Rehabilitation nurses are in a critical position to lead interdisciplinary team fall prevention management, including injury risk reduction. This article provides an update for rehabilitation nurses on evidence-based strategies to reduce patients’ risk of fall-related injuries. This content builds on existing literature by focusing on knowledge to promote patient responses that reduce the risk of falls and ultimately fall-related injuries. Although rehabilitation nurses understand the complex nature of falls, addressing the intrinsic and extrinsic risk factors that increase the risk of fall-related injuries requires both individually based treatment programs and a system-wide commitment. A plethora of literature discusses fall risks and falls, but this article profiles the at-risk patient and describes current and emerging evidence-based interventions to protect patients from fall-related injuries by reducing risk factors. This discussion is limited to exercise, environmental redesign, osteoporosis prevention, and hip protectors.
Falls and fall-related injuries are common, costly, and dangerous, especially for elderly and disabled patients in hospitals and across the continuum of care (Brainsky et al., 1997; Doweiko, 2000; Englander, Hodson, & Terregrossa, 1996; Hoskinn, 1998; Rubenstein, Josephson, & Robbins, 1994; Rubenstein, Powers, & MacLean, 2001). One third to one half of people over 65 years of age fall each year (Kannus et al., 1999). Falls are associated with mortality, morbidity, and reduced function and quality of life. Injuries due to falls are the fifth leading cause of death in older adults, with direct care costs of fall-related injuries among those 65 years and older estimated to exceed $32.4 billion by 2020 (Centers for Disease Control, 2003).
Because of their specialized knowledge, competence, and scope of practice, rehabilitation nurses are in a critical position to lead the interdisciplinary team process needed to assess and treat patients and evaluate their responses to plans of care to reduce fall-related injuries. Although all rehabilitation nurses understand the complex nature of fall risks, addressing the intrinsic and extrinsic risk factors that increase risk for fall-related injuries requires both individually based treatment programs and a system-wide commitment to the reduction of these adverse events. This article profiles the at-risk patient and describes current and emerging evidence-based interventions to protect patients from fall-related injuries. This discussion is limited to exercise, environmental redesign, osteoporosis prevention, and hip protectors. The first two interventions apply globally to the rehabilitation population, and the last two interventions target reduction of fracture risks.
Rehabilitation is a process of maintaining and restoring function while preventing complications due to disease and disability. The rehabilitation population includes those living with functional disabilities and deficits. These functional deficits create fall risks. In addition, rehabilitation patients enter an environment that promotes independence and instills confidence, and patients are encouraged and attempt to complete activities without help or supervision. In other words, people are expected to fall, learn to recover from a fall, and learn safety skills. Thus, our target populations are those who are at risk for an injury if they fall or have a repeat fall. These patients may have cognitive and perceptual deficits, balance and gait disorders, and comorbidities that necessitate polypharmacy. In addition, the rehabilitation population may have low bone density due to osteoporosis or osteopenia. Thus, rehabilitation patients have an extensive and complex fall risk profile that increases their risk for falls. According to Vassallo, Sharma, Briggs, and Allen (2003), “Falls are one of the most frequent complications on rehabilitation wards for elderly patients” (p. 338). Those at risk for fall-related injury are repeat fallers who also have osteopenia or osteoporosis.
As a result, rehabilitation nurses work with interdisciplinary teams to reduce patients’ risks for falls and ultimately fall-related injuries. In a practice setting, the focus is on interdisciplinary approaches to reduce intrinsic fall risk factors and protect patients for whom some risk factors are not modifiable. The most common interdisciplinary intervention to restore functional deficits is exercise.
Exercise has surfaced as a powerful tool in reducing risk of falls, which ultimately reduces injury risk. Mobility status, activity level, balance, and gait have long been singled out as intrinsic modifiable fall risk factors. Gregg, Pereira, and Caspersen (2000) completed an extensive literature review on falls and exercise and found consistent evidence from prospective and case control studies of a 20%–40% lower risk of hip fracture in physically active older adults than in sedentary ones. Additionally, Robertson, Campbell, Gardner, and Devlin (2002) reported a 35% reduction in the number of falls and fall-related injuries in a group of more than 1,000 men and women aged 65–97 who participated in an individually prescribed, home-delivered exercise program that consisted of muscle strengthening and balance retraining.
A key effort to better understand the role of exercise in fall risk reduction was launched by the National Institute on Aging and the National Institute for Nursing Research. These two organizations sponsored a multicenter study called Frailty and Injuries: Cooperative Studies of Intervention Techniques (FICSIT) (Province et al., 1995). The FICSIT trials consisted of a collection of eight independent, randomized, controlled clinical trials throughout the country that assessed the efficacy of a variety of fall risk interventions that included exercise in community-dwelling older adults. Sample size ranged from 100 to 1,323 participants per individual site, which used different types of exercise interventions (i.e., strength, endurance, T’ai Chi, balance training) over various periods of time (10–36 weeks) and analyzed their impact on risk abatement.
Although some of the FICSIT trials also implemented multidisciplinary interventions in association with exercise (Tinetti, McAvay, & Claus, 1996), the positive effects of exercise found in these trials are generally accepted. A planned meta-analysis of the FICSIT trials (Province et al., 1995) found an adjusted fall incidence ratio for exercise treatment arms of .90 (95% confidence limits) and .83 (95% confidence limits) for those that included an element of balance training.
In 2001, “A Guideline for the Prevention of Falls in Older Persons” was developed and published with the collaboration of the American Geriatrics Society, the British Geriatrics Society, and the American Academy of Orthopaedic Surgeons Panel on Falls Prevention (2001). This guideline listed the following recommendations regarding exercise interventions to address fall risk:
Rehabilitation nurses work closely in collaboration with physical therapists to integrate exercise interventions into interdisciplinary plans of care and monitor effectiveness in reducing falls and fall-related injuries.
Successful exercise programs reported in the literature vary widely. Steadman, Donaldson, and Kalra (2003) published positive results of balance-specific training on a sample of 199 older adults. This group compared the effects of a 6-week enhanced balance training program consisting of a series of tasks of increasing difficulty that are related to functional balance with “standard” physical therapy for adults with balance and mobility deficits. Results were encouraging and demonstrated that although both forms of exercise improved mobility, the enhanced balance training group displayed additional benefits in the domains of confidence and quality of life. Fall rates were not collected as a variable for this study. Morgan, Virnig, Duque, Abdel-Moty, and Devito (2004) also demonstrated positive findings on the effects of a low-intensity exercise program on fall incidence and time to first fall in a group of 294 community-based men and women who either had a hospital admission or were on bed rest for a minimum of 2 days in the previous month. Participants were randomly assigned to a control group or an 8-week exercise program that consisted of 45-minute sessions three times per week. Sessions focused on strength, balance, and mobility training. A significant reduction in falls was demonstrated in participants in the exercise group with low levels of physical functioning at baseline.
Finally, Li, Harmer, Fisher, and McAuley (2004) studied the effect of T’ai Chi on functional balance and fall occurrence in a sample of 256 healthy, physically inactive older adults aged 70–92 living in the community. Participants were randomized into either a 26-week T’ai Chi class intervention or an exercise stretching control class. Classes were conducted three times a week for 6 consecutive months; each class session lasted 60 minutes. Various standardized functional balance measures were assessed at baseline, at 3 months, upon termination of the intervention, and 6 months after intervention. Additionally, fall occurrence was recorded throughout the study by participants using a fall calendar. Results showed that T’ai Chi training improved balance and significantly reduced the likelihood of falling during the 6-month postintervention period compared with the stretching control group. This intervention has much promise in reducing falls; however, a T’ai Chi master (one with extensive T’ai Chi training and experience) is needed to facilitate the class.
General consensus and evidence exists that exercise, which includes a component of balance training, does have beneficial effects on fall reduction. Thus, inclusion of exercise as a component of any fall reduction program is strongly advised to rehabilitation nursing professionals. Additionally, integration of habitual exercise into nursing care plans is encouraged.
Environmental redesign is an intervention commonly used in rehabilitation settings to create a safer environment for the disabled. This intervention targets extrinsic fall risk factors such as bed placement, lighting, flooring, equipment placement, and space management. Environmental modifications for reducing fall risks range in scope and costs, depending on the extent of redesign. Rehabilitation nurses work with engineers and safety officers to conduct environmental safety rounds and assess each patient’s environment in relation to his or her abilities and disabilities. Rehabilitation nurses determine the fall risks present and initiate strategies to reduce the risks of injury and falls.
Depending on the clinical setting, involvement of various team members such as therapists, social workers, safety officers, and environmental management staff is necessary to make these changes (Rogers, 1994). Regardless of the setting, the environment must match the overall functional level and individual impairments of the population being served.
This assertion applies to appropriate application and functional use of wheelchairs. Because patients can fall from wheelchairs (Teasell, McRae, Foley, & Bhardwaj, 2002), this equipment can be modified to increase safety by using seat belts, brake extenders, individualized fittings, and removable leg rests. Rehabilitation therapists, nurses, and engineers can redesign wheelchairs to maximize patient use and safety.
Sensory impairments, such as visual deficits and impaired proprioception, are common deficits that are often considered in environmental redesign. For example, redesigning an environment for patients with depth perception deficits is different from redesign for those with visual field cuts, such as homonymous hemianopsia. A clear contrast of colors without glare is effective in helping older adults compensate for and anticipate changes in depth and surface areas. According to Lord and Dayhew (2001), “persons with only moderate visual acuity loss were also at significantly increased risk for falls as were persons with impairments of visual functions more closely related to hazard detection and mobility requirements” (p. 513).
Other adaptations to the environment are also critical components in fall prevention. Such adaptations include proper placement of safety rails, grab bars, lighting, and nonskid flooring. The CDC has free home safety checklists that can be provided to patients and families for use in their home (available at http://www.cdc.gov).
Environmental checklists can be used in the practice setting for environmental safety checks. Valuable information is gathered from these safety rounds, especially when the team includes patients and families. These rounds allow staff to see the environment from the perspective of patients and families and gain objective data about implementation of fall prevention measures. Patient and family involvement in safety is pivotal to successful environmental redesign.
Environmental safety evaluations also provide valuable information used to determine the need to install adaptive equipment that will improve patients’ functional abilities and safety. These adaptations range from moving groceries to low-reach kitchen shelves to installing shower safety grab bars. Ideally, environments are modified before older people fall or become frail.
“While the evidence regarding the effectiveness of environmental modifications as a single intervention is limited, recent findings suggest that it is an effective strategy when combined with other strategies that target intrinsic risk factors.” (Rose, 2002, p. 63)
Consistently the literature posits that a large proportion of falls and fall injuries in older people probably are preventable with careful medical and environmental evaluation and intervention.
People who have cognitive and physical deficits are at higher risk for falls than the average person. A lack of safety awareness, altered judgment, and limited problem-solving skills put them at higher risk for repeat falls and fall-related injuries. Impaired judgment and misinterpretation of environmental safety conditions can result from disordered thought processes associated with dementia, depression, and neurological disorders, such as stroke and multiple sclerosis. A person who wanders and has a gait disturbance is at a very high risk for falls and repeat falls and must be safeguarded while walking. This risk increases in patients who have difficulty with communication, such as those with aphasia, dementia, or hearing impairments. Caregivers use a variety of low-tech environmental strategies to detect movement before a fall, such as wheelchair and bed alarms. However, use of these devices must be matched to the needs of the patient. For example, loud alarms are contraindicated for agitated patients. For wandering patients, global positioning devices are being used to track the position of the person wearing the device (Bakker, 2003).
These devices are still in the testing stages, and clinical evidence of their value in preventing falls is limited. The National Center for Patient Safety of the Veterans Health Administration, Department of Veterans Affairs, produced a National Falls Toolkit (Department of Veterans Affairs, 2004) that includes a fall safe room, designed to reduce risk of falls and fall-related injuries. In addition, the CDC’s National Center for Injury Prevention and Control (Parra & Stevens, 2000) has published a selection of U.S. fall prevention programs in some states that are considered model programs. These models include education, home assessment for environmental hazards, and access to home modifications and repair services. This publication is an environmental safety resource for rehabilitation nurses.
One of the most important interventions to reduce fall-related injuries is to reduce risks for fractures. This risk reduction can occur by primary prevention of osteoporosis through supplemental calcium and vitamin D, screening with dual X-ray absorptiometry, and instituting treatment when indicated. Current guidelines recommend screening postmenopausal women starting at age 65 and men starting at age 70 (International Society for Clinical Densitometry, 2005) or earlier if there are risk factors such as treatment with steroids, history of smoking, or excessive alcohol intake. After osteoporosis is diagnosed, treatment should be started if there are no contraindications. To further reduce fall injury risks, rehabilitation nurses, in collaboration with prescribing providers, should assess patients’ risk for osteoporosis and include prevention in plans of care. This important patient safety intervention targets men as well as women.
The effect of calcium and vitamin D supplementation on falls is still unclear, with multiple studies reporting conflicting results. Levels of vitamin D and muscle strength decline with age (Scharla, 1998; van der Wielen et al., 1995), and low levels of vitamin D are associated with reduced physical performance, muscle strength, and physical function and increased risk for falls in older people based on cross-sectional studies (Bischoff et al., 1999; Mowe, Haug, & Bohmer, 1999; Stein et al., 1999). Because vitamin D is a simple and inexpensive treatment that can be administered frequently, it has potential to improve muscle strength and reduce physical disability and falls in older people, but no clinical trials have demonstrated that vitamin D alone has those desired results.
Some evidence suggests benefit from the combination of vitamin D and calcium. Clinical trials conducted to determine the effect of calcium and vitamin D supplementation on fracture rates in older women residing in nursing homes or apartments showed that after 18 months, participants who received vitamin D with calcium had 43% fewer hip fractures and 32% fewer nonvertebral fractures (Chapuy, Arlot, Delmas, & Meunier, 1994; Chapuy et al., 1992). Because the fractures were reduced in the active group soon after randomization, it was suggested that the effect on fractures might have been due to reduction in falls and improvements in muscle strength and physical function rather than changes in bone turnover, but falls were not directly measured in the study. These findings must be confirmed in a large, well-designed clinical trial with appropriate measurements (strength, function, falls). Based on current evidence, vitamin D alone cannot be recommended for use in clinical practice where the primary aim is to improve muscle strength or physical function or to reduce the risk of falling in frail older people (Latham, Anderson, & Reid, 2003). The most recent study that examined the efficacy of calcium with vitamin D supplementation for preventing hip and other fractures in healthy postmenopausal women found small but significant improvement in hip bone density. Reduction in hip fractures based on the intention-to-treat analysis was not significant, but when analysis was done excluding the subjects who discontinued calcium and vitamin D supplements, the hazard ratio for hip fracture was reduced to .71 (95% confidence interval .52–.97) (Jackson et al., 2006).
Estrogen has been unequivocally established as the major contributor to bone mass retention in women. Based on data from the Women’s Health Initiative (Cauley et al., 2004) and subsequent analyses, it is no longer considered the standard of care to prescribe estrogen replacement as first-line therapy for osteoporosis prevention. Careful assessment of individual risk factors, reduction of modifiable risks, and behavior modification are recommended.
In patients who need pharmacotherapy for the treatment of osteoporosis, bisphosphonates are first-line agents (for both men and women). Most commonly used from this category are drugs such as alendronate (Fosamax) and risedronate (Actonel). Selective estrogen receptor modulators are a class of medications available to women unable to take bisphosphonates. Raloxifene (Evista) is a drug currently available in the United States from this group. They differ from estrogen in that they provide beneficial effects on the heart and skeletal tissues at the same time.
If a patient is diagnosed with osteoporosis, rehabilitation must include interventions to reduce the risk of hip fractures because of their impact on mobility and mortality. Hip protectors are specifically designed to provide a protective barrier between the patient’s body and flooring.
External hip protectors are girdle-like devices, with shells made of polyurethane designed to shunt or absorb the energy of the impact, thereby protecting the person from a hip fracture (Parker, Gillespie, & Gillespie, 2005; Rubenstein, 2000). Studies differ in their findings about the effectiveness of hip protectors. However, the authors do not report any studies that show hip protectors did not work. The problems seem to be high dropout rates of participants and noncompliance in wearing these protective garments. Patient and caregiver compliance in using hip protectors is a significant problem (Becker, Walter-Jung, & Nikolaus, 2000; Cameron, 2002; Parkkari, Heikkila, & Kanus, 1998). In the largest study to date, more than 1,200 patients participated in a clinical trial of hip protectors; however, 31% of those eligible refused to participate, and by the end of the trial almost 50% of participants dropped out (Kannus et al., 2000). Multiple trials have reported positive results, with up to 84% reduction of risk of hip fracture if the protector was worn at the time of fall (Harada et al., 2000; Jensen, Lundin-Olsson, Nyberg, & Gustafson, 2002; Kannus et al., 2000). Summation of the results gave an occurrence of hip fracture of 2.4% in those wearing hip protectors and 6.6% in controls (Parker et al., 2005). Unfortunately, acceptance and compliance over time seem to be a problem. Barriers to compliance must be examined systematically in both patients and healthcare providers in different settings (long-term care, outpatient) and targeted interventions developed to improve patient compliance with hip protector use (Bulat, Powell-Cope, Nelson, & Rubenstein, 2004). In addition, durability of hip protectors must be investigated so that patients and caregivers know when to replace them. The concern is that the protective properties may change over time with prolonged use, and no studies have addressed that issue.
Fall prevention strategies are widely implemented in rehabilitation practice settings. To further improve practice requires that strategies be designed based on the factors that put patients at high risk for falls and fall-related injuries. As leaders of interdisciplinary teams, rehabilitation nurses are universally implementing fall prevention strategies. The strategies presented in this article describe specific interventions. Implementation of these interventions separately and in combination will further increase effectiveness of programs targeting patients already at risk for falls. Reducing fall risks also reduces risks for repeat falls and fall-related injuries. Still, opportunities exist to build knowledge about the effectiveness of these interventions in rehabilitation settings through research. For example, rehabilitation nurses can contribute to interdisciplinary research efforts that fill gaps in knowledge and practice related to effectiveness of exercise programs that evaluate the intensity, duration, and frequency of training specific to patients’ fall risks, effectiveness of environmental redesign based on individual patients’ functional abilities, and strategies to increase patient use of hip protectors.
About the Authors
Patricia A. Quigley, PhD MPH ARNP CRRN FAAN, is the deputy director at the VISN 8 Patient Safety Center. Address correspondence to her at 11605 N. Nebraska Ave., Tampa, FL 33612. Contact her at Patricia.Quigley@med.va.gov.
Tatjana Bulat, MD, is employed at the VISN 8 Patient Safety Center.
Stephanie Hart-Hughes, PT NCS, is employed at the VISN 8 Patient Safety Center.
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