Falls are very common among older people. Previous literature has reported a mean fall rate of 1.7 falls per person-year (range, 0.6–3.6) for those who live in nursing homes (Rubenstein et al, 1994) and a rate of 0.65 (range, 0.3–1.6) for those living in the community (Rubenstein, 2006). A more recent study of 70,000 falls in Bavarian nursing homes has reported a similar fall rate (1.6 per person-year), with the rate being higher among men (Rapp et al, 2012). The higher fall rate among older people in nursing homes compared to the rest of the community is expected, and falls are a major reason for admission into nursing homes. One non-injurious fall carries a 3.1 times relative risk of admission into a nursing home, while a fall accompanied by serious injuries is associated with a 10.2 times higher relative risk (Tinetti and Williams, 1997). Even though the majority of falls in nursing homes do not result in serious injury, 10–25% result in hospital admission and/or fractures (Vu et al, 2004). With such a high prevalence, falls, unsurprisingly, result in 81.5% of external (defined as premature, usually injury related and potentially preventable) causes of deaths among nursing home residents (Ibrahim et al, 2017).
Multiple factors related to falls are associated with patients in nursing homes. Most common of these are frailty, loss of muscle mass/balance, medications and dementia (Rubenstein et al, 1994; van Doorn et al, 2003; French et al, 2007; Struksnes et al, 2011; Nursing Home Abuse Center, 2018). Dementia is of particular importance: a previous study reported that the unadjusted fall rate for residents in nursing homes with dementia was 4.05 per year compared with the 2.33 falls per year for residents without dementia (P < 0.0001) (van Doorn et al, 2003).
A recent systematic review of falls prevention in nursing homes demonstrated that there was a lack of good quality evidence available for guiding staff practice (Cameron et al, 2018). The highest level of evidence is only moderate, recommending vitamin D supplementation among residents with low vitamin D levels. Vitamin D supplementation reduced the falls rate in the examined group of residents by 28% (RaR, 0.72; 95% CI=0.55–0.95). The review concluded that the effect of multifactorial interventions in nursing homes is uncertain and that several other interventions that are effective for community patients may not necessarily show clear evidence supporting their application in nursing home residents.
Caution should be exercised in generalising the findings of the aforementioned systematic review as it focusses on randomised control trials (RCTs). As succinctly summarised by Frieden (2017), although RCTs have better internal validity, they have some limitations: they are more difficult to plan and implement, and their external validity or generalisability may be questionable because of their exclusions. Often, in a tightly controlled, well-funded RCT, any positive results may not be reproducible in another RCT setting or in the real-world setting. Further, studies with complex or multifactorial interventions may fall into a category which is not easily implementable in nursing homes, which are chronically under-resourced. Nursing homes in the real-world setting may require interventions that are simple and less labour intensive to implement. However, such interventions have proven elusive, especially for frail, ambulatory nursing home residents with dementia.
Important general issues to consider about falls in nursing homes
A recent systematic review identified common barriers to as well as facilitators of implementing procedures for falls prevention in nursing homes. The most commonly cited barriers were limited knowledge and skills, staff concerns regarding their ability to control falls management, staffing issues and poor communication, while the most commonly cited facilitators were good communication and the availability of suitable equipment (Vlaeyen et al, 2017).
Falls have many complex, interacting predisposing and precipitating factors. Therefore, it is understandable that nursing staff may find the acquisition of adequate knowledge and management skills in falls prevention to be an area of concern. Although the prevalence of various predisposing or precipitating factors varies between different populations of older people (e.g. dementia is a more prevalent risk factor in nursing homes than in the community), some basic facts about falls remain the same irrespective of the setting and these can be found in most textbooks on geriatric care.
Some conditions that require nursing actions to improve ambulation safety in nursing home settings are easy to facilitate. These include the provision of good lighting, glasses, walking aids or transfer assistance. However, residents' conditions affecting ambulation safety may be more complex and require good clinical assessment. This is because residents' conditions would change from reasonably safe to ambulate to unsafe because of a change in blood pressure (which can be caused by the introduction of antihypertensives/diuretics or reduced fluid intake and dehydration) or the development of acute conditions such as urinary tract infections complicated by delirium. In such scenarios, sound knowledge and training may aid in the detection of factors precipitating falls. Since nursing staff members are the predominant carers for nursing home residents, they are most likely to discover these factors early; this may facilitate prompt intervention, either by themselves or in conjunction with other professional groups, including doctors.
Specific challenges to managing the high falls risk in residents' rooms or bathrooms
From past and present studies, there has been a consensus that the most common place for falls among nursing home residents is their bedrooms. This has remained consistent over the years (Jantti et al, 1993; Lester et al, 2008; Rapp et al, 2012). In a recent study, around 75% of falls were found to occur in the residents' rooms or in the adjoining bathrooms, and only 22% were reported in the common areas (Rapp et al, 2012). High falls rates were particularly observed among residents with low and medium care needs (Rapp et al, 2012). These figures suggest that many fallers may belong to a category of ambulatory residents who attempt to self-ambulate within their own rooms. They may lack good judgement of their ambulatory capability and/or they may disregard safety issues (possibly, they may not use walking aids or ask for help with transfers when alone). Poor judgement has indeed been found to be associated with falls among cognitively impaired older persons in institutional settings (Ko et al, 2012; Chan et al, 2013).
According to the study by Rapp (2012), 41% of falls occurred during a transfer. Since most occur in the residents' own rooms or bathrooms, bed or chair motion alarms have been trialled. However, the results of the trials are variable, and overall support for these alarms is not strong (Luk et al, 2015; Oliver, 2018). Therefore, innovative ideas are needed to reduce the falls risk, particularly for cognitively impaired residents who try to stand and ambulate from beds or chairs without seeking aid while alone in their own rooms or bathrooms.
Management of cognitively impaired fallers in nursing home settings
Traditional methods such as multifactorial interventions have limitations for cognitively impaired and frail older residents. For instance, many nursing homes have limited staff that can provide or supervise exercise programs for residents, although exercise (muscle/balance training) and education are often found to be useful in the community setting for falls prevention (Hopewell et al, 2018). Additionally, cognitively impaired residents may forget verbal instructions while being educated about risky behaviour. Further, these residents may lack good judgement regarding their ambulatory capabilities (Chan et al, 2013). Increased direct supervision of these groups of residents may not be practical as this will increase the cost of care or take away from the care time dedicated to other needy residents.
A recent study based in a hospital setting has provided preliminary results with an optimistic outlook on educating patients about the importance of seeking supervision or aid for ambulation while in the hospital (Chan et al, 2018). The study used video clips as the education tool: those that showed the correct way of asking for help/supervision before ambulation were marked with a tick, while those that showed the incorrect way of going alone were marked with a cross. The message was reinforced using clips that showed broken bones that would require surgery, to gently reinforce the right action on an emotional basis. The pilot results included 33% of cognitively impaired patients and showed a 50% numerical reduction in falls (although this did not reach statistical significance because of the small sample size). In dementia, verbal memory is affected earlier than visual memory is—a face may be recalled more easily than a name (Cohen et al, 2009). Moreover, memory involving an emotional component is usually better retained than memory without an emotional component (Wiglesworth and Mosqueda, 2011; Dolcos et al, 2012). Therefore, using a video to communicate how to reduce the risk of falls may be a more practical adjunctive approach to strengthen information retention in cognitively impaired patients.
We do need to stress that the aforementioned study is only a pilot, and its preliminary results will need to be confirmed through adequately powered studies in the nursing home setting. Further, the cost effectiveness of the method recommended by the study will need assessment.
Conclusion
Falls in nursing homes remain a challenge. In particular, impulsive ambulatory behaviour among cognitively impaired patients remains unresolved, and much more research on this topic is needed to improve falls prevention in nursing homes. Looking at the positive side of things, these challenges are opportunities that await keen researchers. Indeed, research opportunities in the field of geriatrics and gerontology are bountiful (Chan and Chan, 2018), and it is only a matter of time before the risk of falls becomes better managed in nursing homes.