Reducing Fall Risk in Long-Term Care Residents Through the Interdisciplinary Approach
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Falls among long-term care (LTC) residents are associated with increased morbidity and mortality due to a high prevalence of co-morbidities such as osteoporosis and neurological disorders. Although we cannot eliminate all falls among frail LTC residents, we can reduce their risk for falls by conducting a thorough interdisciplinary falls evaluation and by minimizing amendable risk factors.1,2 This article will provide insight into fall etiology and a format for coordination between members of the interdisciplinary team (IDT) to reduce fall risk. Whenever possible, the strength of scientific support for our recommendations will be described (Table I).2 It is not the intent of this article to create a standard of care, but rather to provide an approach to reduce fall risk.
Although the definition of recurrent fallers may vary, a systemic approach and work-up for fall prevention should be considered with all individuals who fall or who are at risk for falling in LTC facilities (Table II). The first section of this article discusses multiple comorbid conditions that impact upon fall risk, and the various interventions that, when coordinated through the IDT and appropriately implemented, can reduce such risk. The subsequent section describes institution-wide approaches to reducing fall risk, and presents roles to be considered for the different members of the administrative team in reviewing fall risk. Quality assurance (QA) meetings, as well as care planning, restraint reduction committees, and assessments of high-risk residents, are appropriate venues in which to review recurrent fallers.
LTC RESIDENTS AT RISK FOR FALLS
Medical Conditions
Medical conditions may impact upon fall risk and include both chronic and acute clinical issues. Endocrinopathies, such as hypothyroid states and adrenal insufficiency, may increase the propensity for falls. Type II diabetes mellitus increases fracture-risk.3 Inadequately treated seizures have a direct and obvious effect on falls, as do gait disorders and other neurological conditions. Parkinson’s disease increases fracture risk.3 Cognitive impairment increases the risk for falls,4 as does delirium. Protein-calorie malnutrition reduces sustainable strength, reserve strength, and balance. In contrast, postprandial hypotension may contribute to fall risk in some cases.5
Acute (or subacute) clinical problems that may increase the risk for weakness and falls include infections (eg, urinary tract infections, pneumonia), anemia, hypoxia, dehydration (and/or volume depletion), pulmonary emboli, exacerbation of chronic obstructive pulmonary disease, impaction, and urinary retention. These risk factors should be worked up according to the patient’s clinical presentation. Recent occult fractures should always be suspected for sudden changes in gait associated with falls, as should subdural hematoma with recent history of head trauma accompanied by changes in gait, mentation, and/or function. This is particularly crucial in residents who are anticoagulated. If appropriate, chronic subdural hematomas and normal pressure hydrocephalus should be considered in residents with more protracted clinical courses.
It is helpful to review falls and fall etiology with the facility medical director, whose focus is clinical quality issues, systems integrity as related to clinical outcomes, process review, policy participation, and education.6 The medical director provides a resource for review and education for falls assessment and strategies to reduce risk. Residents who fall are considered “high-risk” and should be reviewed on a regular basis during IDT care planning and continuing quality improvement (CQI) meetings.7 In addition, the medical director should encourage identification and treatment of comorbidities associated with falls morbidity, such as osteoporosis.
References
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