Strategies for Reducing Falls in Long-Term Care

January 17, 2014

Betty Willy, PT, MA, CWS • Christine M. Osterberg, RN, BSN



Annals of Long-Term Care: Clinical Care and Aging. 2014;22(1):23-32.

Affiliations: Pathway Health Services, White Bear Lake, MN

Abstract: Preventing falls in nursing homes presents an ongoing challenge to the entire interdisciplinary care team. An essential first step is conducting a thorough falls risk assessment on the first day of admission and then implementing strategies to mitigate any identified risks. Despite best efforts on this front, some falls will continue to occur. These events necessitate a comprehensive root cause analysis that looks beyond the most obvious reasons for falls. Such reviews are essential in developing sustainable and efficacious fall prevention programs and in promoting a culture of safety. In this article, the authors provide two case scenarios that demonstrate why individual risks need to be carefully explored. They also review some common fall risk factors and interventions that can be used to reduce those risks.

Key words: Falls, falls prevention, fractures, root cause analysis, wheelchair use.

Fall prevention in nursing homes continues to be a major focus for quality improvement in patient safety. Although only approximately 5% of adults aged 65 years and older live in nursing homes, this population accounts for approximately 20% of fall-related deaths in this age group.1,2 Between 50% and 75% of nursing home residents fall annually, which is twice the rate of falls in community-dwelling older adults.3 In addition, elderly individuals fall at an average rate of 2.6 falls per person per year.2,4 Falls result in disability, functional decline, reduced quality of life, and even death. In fact, approximately 1800 nursing home residents die from falls each year.2,5 In addition, fear of falling can cause further loss of function, depression, feelings of helplessness, and social isolation.

As these data show, fall prevention is essential; however, this endeavor is challenging, as there is a lack of compelling evidence that any one intervention will reliably decrease the incidence of falls. This is because many falls have multiple etiologies, requiring consideration of multiple physical, cognitive, and environmental factors. Therefore, reducing the risk of falls and fall-related injuries in long-term care (LTC) facilities requires a comprehensive approach that focuses on identifying the myriad conditions that predispose to falls and addressing each resident’s identified risk factors6; this needs to start on each resident’s first day of admission. In addition, when a fall occurs, systemic improvement depends on conducting a thorough root cause analysis of the fall, which includes tracking trends (eg, when, where, and how the fall occurred), the number of falls per unit, and whether any staff members were present.
Implications for Exercise to Prevent or Reduce Falls in the Elderly Population
Care of Patients with Delirium at the End of Life

In this article, we review how to assess falls risk and discuss some key risk factors for falls and potential interventions to mitigate these risks. The interventions we review were based on a combination of research findings reported in the medical literature and in the American Geriatrics Society/British Geriatrics Society (AGS/BGS) Clinical Practice Guideline for Prevention of Falls in Older Persons.7 Despite best efforts to prevent falls, we recognize that they will still occur; however, to promote a culture of safety in the nursing home and optimize the efficacy and sustainability of fall prevention programs, thorough root cause analysis is essential when any falls occur. 

How to Assess and Mitigate Falls Risk 

The interdisciplinary care team must begin the process of falls prevention before the first fall occurs by identifying an individual’s risk factors and fall risk screeninghistory of falls at home. This can be achieved by using any number of evidence-based fall risk screening tools on the first day of admission (Table). A thorough multifactorial risk assessment is essential, as many potential falls may be related to medication and/or cardiac conditions. This assessment should include a focused history review that considers a patient’s history of falls, medication use (including changes to the medication regimen), and comorbidities, such as osteoporosis, incontinence, cardiovascular disease, and uncontrolled pain. It also includes a comprehensive physical examination that evaluates mobility, joint function, cognitive/neurologic function, muscle strength, visual acuity, cardiovascular status, and feet/footwear, as well as a functional assessment that considers a patient’s ability to perform activities of daily living and gauges his or her fear of falling (eg, via the Falls Efficacy Scale). In addition, for patients who have experienced multiple falls or report gait and/or balance problems, focusing on a tool that specifically assesses gait and balance, such as the Tinetti Assessment Tool, is helpful.7

Once a comprehensive fall risk assessment is completed, the team must plan care interventions to reverse or address each risk identified on the falls assessment instrument. Effective use of fall risk assessment tools is dependent upon identifying each risk factor that can be the cause of a fall.8 During these assessments, the whole person must be considered, which requires careful examination of all relevant social, psychological, and medical history that may influence the risk of falling. For example, an individual’s total fall risk score may reflect low fall risk, but it may also reveal that the individual has a history of syncope due to cardiac issues, which by itself places this person at a high risk for a fall. Therefore, this risk factor must be addressed to reduce its impact.

Many conditions can compound the risk for falls and make it more challenging to intervene effectively. Poor oral health, for example, can lead to nutrition and hydration deficits that in turn may cause weakness, cognitive changes, and poor healing of infections, among other issues. What follows are the illustrative cases of Harold and Ruth, two LTC residents who fell despite the use of fall prevention interventions. In both of these cases, the cause of falling was initially misidentified due to poor root cause analysis.

Harold’s Case  

Upon admission to our LTC facility, Harold was identified to have multiple risk factors for falls. Harold’s primary diagnosis was Parkinson’s disease, and he initially required assistance walking to and from the dining room for meals. Walking eventually became more difficult for him, so staff members started transporting him to and from the dining room by wheelchair. The loss of independence seemed to upset him, and one day he attempted to rise from his wheelchair in an effort to walk, which resulted in a fall.

Using root cause analysis, the antigravity team started with the following main question: “Why did Harold fall?” The answer seemed simple: “He tried to get up.” Staff members often stop at the first question and answer and determine that they will try to prevent falls by keeping the patient seated with the use of alarms, call light reminders, or even restraints. Proceeding beyond the first question and answer, however, and involving the interdisciplinary team in the root cause analysis reveals there is much more behind Harold’s fall:

falls, long-term care, root cause analysis, wheelchairs

















Based on this dialogue, we determined that Harold’s mouth sore made it difficult for him to eat, which in turn caused him to lose weight and become weak. This compounded his increasing stiffness and emotional upset about his loss of independence, which put him at increased risk for falls. By having a deeper understanding of the factors predisposing Harold to falls, the following care interventions were made to prevent Harold from falling again:

•     Conduct comprehensive oral assessment and treat his oral impairment.

•     Modify his diet to improve his nutritional status.

•     Schedule a neurologic consultation to assess and treat
advancements of his Parkinson’s disease symptoms.

•     Schedule a physical therapy consultation to provide muscle strengthening and improve balance.

Ruth’s Case 

Ruth was a tall, lanky woman who had been a professional tennis player in her younger years. She was interested in everyone and everything until she developed dementia as she aged and became nonverbal and wheelchair-bound, leading to her LTC admission. Her caregivers became extremely frustrated in their attempts to keep her safe in her wheelchair, as she would repeatedly slide forward asymmetrically into the sacral sitting position, pushing her right leg forward until she was on the front edge of the chair. Ruth would often attempt to rise from her chair when she was unsupervised, which resulted in her falling to the floor.

Rather than seeking the answer as to why Ruth was moving away from the back of her wheelchair and therefore pushing her right hip into extension, the interdisciplinary team focused on how to keep her in her chair and prevent her from falling. Staff members resorted first to using a lap buddy, a cushion that is placed into the wheelchair and across the lap of the individual to prevent him or her from trying to stand unassisted while providing upper body support and posture assistance. After she figured out how to remove the lap buddy, the team tried using an antithrust cushion and pelvic seat belt with the clasp in the back of her chair, as recommended by the occupational therapist. Despite these interventions, she continued her attempts to slide forward, causing her to slip off the wheelchair seat to the floor. 

The interdisciplinary team had exhausted all of the easy answers as to the cause of Ruth’s behavior. When they reexamined their basic assumptions, reviewed her medical history, and spoke with her family, they learned that Ruth had incurred multiple injuries to her right hip during her active career as a tennis player and that these injuries were treated with steroid injections. Subsequent radiographs and magnetic resonance imaging scans revealed an avascular necrotic femoral head as the cause of her right hip pain with weight bearing in a flexed position in the wheelchair. Unfortunately, the caregivers’ initial solutions to her sliding had strapped her further into a position of pain, which she was unable to communicate verbally. The family opted against a total hip replacement due to her advanced dementia, and the problem was addressed by using a specialty cushion to offload the pressure under her hip, a recliner chair to decrease the hip flexion angle while sitting, and appropriate pain medication.

What Harold’s and Ruth’s Cases Teach Us

Although root cause analysis of falls is now common practice in LTC facilities, it is often done superficially due to time constraints, but as Harold’s and Ruth’s cases demonstrate, detailed root cause analysis is essential in properly identifying the cause of falls and in improving quality of life for the resident. In Harold’s case, a variety of health problems worked collectively to lead to his fall, whereas in Ruth’s case, the reason behind her fall was buried in her medical history. In addition, in Ruth’s case, the staff sought ways to keep her in her wheelchair, rather than determining why she was trying to get out of it in the first place. The team interpreted Ruth’s body language of sliding to the front of the chair as a dementia-related behavioral problem instead of a symptom of pain, and their initial interventions led her to experience even more pain. As these cases show, post-fall huddles with an honest discussion of the circumstances surrounding the fall with the entire interdisciplinary care team and even the resident’s family members is critical, as each of these individuals may have important information that may help shed light on the actual cause(s) behind the fall.   

Documenting these discussions and tracking falls data enable trends to be identified that will contribute valuable information as to when, where, and how each fall occured. In addition, the interventions initiated to address fall risk factors must be monitored to determine their impact on the safety culture of the facility and the individual resident’s safety and then modified until effective sustainable programs are in place. The use of quality improvement tools, such as the Plan-Do-Study-Act (PDSA) cycle, can assist facilities with this task.9 The PDSA tests a change by developing a plan to test the change (Plan), carrying out the test (Do), observing and learning from the results (Study), and determining what modifications should be made (Act). A comprehensive discussion of how to apply the PDSA in fall prevention programs is beyond the scope of this article, but what follows is a review of several factors that can contribute to falls among LTC residents and ways that these risks can be mitigated.

Fall Risk Factors and Interventions

A variety of resident and facility issues may lead to falls. Although many of these risk factors are well reported in the literature, they may be overlooked, particularly as facilities struggle with staffing issues and time constraints, leading to more superficial reviews when conducting fall risk assessments and root cause analyses. In the section that follows, we review some common factors that contribute to falls in LTC facilities, along with interventions that can be used to reduce injuries. Investigation should begin at the time of the event, with staff on shift, to provide the most accurate data collection.

Preventing Syncope

Approximately 30% of patients 65 years and older who have experienced syncope will not be aware that they have fainted, but will instead report that they have fallen.10 Therefore, the prevalence and incidence figures for syncope in older adults are confounded by an overlap with presentations classified as falls11; however, population-based studies indicate that approximately 40% of adults have experienced syncope, with women being more likely to report a syncopal event.12 The cause of syncope can be multifactorial or a single cardinal event. Some common medical causes include carotid stenosis, orthostatic hypotension (also known as postural hypotension), postural orthostatic tachycardia syndrome, and diabetes. Vasovagal syncope, one of the most common types of syncope, occurs when a person faints in response to a sudden drop in heart rate and blood pressure. A common cause of vasovagal syncope is orthostatic hypotension, a condition marked by a sudden drop in blood pressure after standing up quickly. Although it has become routine in LTC facilities to include orthostatic hypotension assessments during the resident’s initial intake process and after each fall incident, they are often administered by nursing assistants, who may be unaware of the resident’s recent changes in medication or history of heart arrhythmias; however, even when the assessments are administered by licensed practical nurses or other members of the care team, results may not be accurate due to measurements being taken at incorrect time intervals. Common errors include the following:

•     Not allowing the resident to spend 5 minutes in a supine position before recording his or her blood pressure.

•     Allowing the resident to sit for a period while the gait belt is applied before he or she rises to a standing position.

•     Not repeating the test while the resident is in a standing position within 1 minute of rising and then again within 5 minutes of rising.

These errors often lead to postural hypotension being erroneously discounted as the cause of syncope. Provision of a “fill-in-the-blank” chart format for each position and appropriate training of staff can significantly reduce these errors. The Centers for Disease Control and Prevention website provides a helpful instruction and documentation tool for measuring blood pressure with position changes as part of their falls prevention package, the STEADI (Stopping Elderly Accidents, Deaths & Injuries) Tool Kit for Health Care Providers, which can be ordered online.

Syncope can also be associated with certain drug classes, including diuretics, calcium antagonists, angiotensin-converting enzyme inhibitors, nitrates, antipsychotics, antihistamines, central nervous system agents (eg, levodopa), narcotics, and alcohol. Any modification to how these drugs are used should be communicated to the nursing assistants, who are charged with assisting residents to rise safely from the supine or sitting positions. This information will alert the nursing assistants that these residents are at high risk of falling during the medication adjustment period, enabling them to take appropriate precautions, such as having residents rest in sitting positions and performing ankle exercises before moving from supine to standing. In addition, they should be instructed that special care must be provided to otherwise independent residents during the first 72 hours following any medication modification. Staff members become accustomed to these residents being independently safe during position changes, but these individuals are at higher risk for falls during this time period.

Recognizing Pain, Discomfort, and a Desire to Move  

When the interdisciplinary team discovers that a resident fell after sliding into a sacral sitting position or attempting to transfer from a wheelchair while unsupervised, they often look for a urinary tract infection, attribute it to a need to use the toilet, or blame the resident for having a behavioral problem that causes him or her not to wait for staff assistance. As Ruth’s case demonstrates, however, they need to look deeper.

To increase the likelihood that individuals will remain seated, they must be comfortable and engaged in life around them. Life observation tells us that we as humans have a physiologic need to move. Everyone moves away from painful stimulus and toward comfort. We often move just for self-stimulation or to keep the “juices flowing.” When we are bored or in pain, we may become restless and attempt to change positions more frequently or move to a more comfortable or more stimulating environment.

In 2007, an Australian study found that participants with enough pain to cause moderate to severe interference with their ability to perform activities of daily living were more likely to report any falls or multiple falls in the 12-month study period compared with participants reporting no pain.13 The association was stronger for multiple falls than for any single fall. A 2012 study published in the Journal of the American Geriatrics Society found that depressive symptoms are associated with fall risk in older adults and are mediated in part by chronic pain.14 Although the study focused on community-dwelling persons, it is likely that a similar relationship would be found in the LTC setting.

To address issues of pain and boredom, which can lead to depression, several steps can be taken. First and foremost, residents should be regularly evaluated for pain or discomfort, even if they are unable to properly express their pain. This is especially essential when a resident appears agitated or distressed or actually communicates experiencing pain. Based on the findings of the pain assessment, strategies should be implemented to alleviate the pain, focusing on nonpharmacologic interventions first. Such interventions could include provision of a comfortable environment that is not too hot or cold and that reduces overstimulation from noise and bright lights; engaging the resident in appropriate social activities to prevent boredom; using appropriate cushioning and assistive devices; and ensuring proper nutrition. If these measures do not alleviate the pain, pharmacologic measures can be considered, starting with mild analgesics.

Using Visual and Environmental Factors to Address Visual and Cognitive Deficits 

Although vision deficits, such as macular degeneration, diabetic retinopathy, and cataracts, are recognized as risk factors for falls, there is currently no compelling evidence that demonstrates the effectiveness of vision correction in falls reduction for LTC residents, with the exception of first eye cataract surgery.15 It is postulated that this is due primarily to the lack of well-designed, randomized studies that control for other variables. In practice, contrasting colors for doorways, phones, water jugs, wheelchair arm pads, toilet seats, and call lights make a difference for targeted individuals. In addition, strong lighting without glare, nightlights, and lighted pathways to the toilet are good common practices in many facilities.

Patients with dementia and other cognitive impairments may be prone to wandering, which can also increase the risk of falls. One practice reported experiencing a reduction in wandering after they relocated to a space that was more home-like and followed some of the design guidelines outlined in Geriatric Care by Design: A Clinician’s Handbook to Meet the Needs of Older Adults Through Environmental and Practice Redesign.16,17 This included using light to medium floor colors with no or simple patterns and low color contrast to improve perception; offering a variety of seating areas with firm or
medium-firm cushions, ensuring comfort, facilitating repositioning, and promoting the ability to move between seating and other areas; and using sound-absorbing materials, such as drapes, low-pile carpeting, and wall and ceiling panels to reduce background noise. The authors note that the previous environment was more institutionalized and clinical, which “made [their] cognitively impaired patients feel restless and uncomfortable, and they appeared to be powerfully motivated to leave.”16 As the culture-change movement continues and nursing homes work to become more home-like, they need to carefully consider the impact of their design choices.

Avoiding Auditory Clutter

Another common mistake that interdisciplinary teams make in the interest of reducing falls is to apply a personal alarm to individuals who have a history of repeated falls. Staff response to an alarm sounding seldom results in the prevention of a fall.18 At best, it can shorten the “rescue time.” The purpose of an alarm is to notify those in the immediate surroundings of imminent danger, such as a fire or tornado. Over their lifetime, people are conditioned to respond to alarms in their environment by fleeing the area; thus, it is inconceivable that applying alarms to individuals with cognitive deficits would cause them to correct their unsafe behavior by sitting down. Chaotic noise in an environment causes agitation even in healthy individuals. We know that babies have a strong physiologic response to alarms and noise in their environment. As their neurologic system grows and matures, their tolerance improves and they develop the ability to self-soothe. As they become teenagers, they seem to have a hunger for stimulation, such as loud cacophony in their music and dance, and a need to multitask using electronic media. As humans move through middle age and into their elder years, their tolerance for noise and clutter in their environment diminishes to the extent that they become agitated in its presence. In persons with dementia, alarms from unknown sources result in defensive responses, such as agitated behaviors, calling out, physical aggression, physical attempts to escape the stimulation, or shutting down and withdrawing from the stimulation.19 And yet, as an industry, we continue to use “personal alarms” as an intervention to help keep our residents safe.

Arguments for the use of noise-producing alarms are based on the perceived needs of the staff, not the actual needs of the elderly person. Replacing them with silent alarms, visual or auditory monitoring systems, motion detectors, and physical staff presence to increase vigilance makes more sense. In a webinar for Stratis Health from April 2012, Sue Ann Guildermann presented the unpublished results of a grant in which 16 nursing homes participated in a noise-reduction program in an attempt to reduce falls.20 The results strongly indicated that noise in the environment was the primary contributor to falls. Most facilities are restricting the use of overhead paging systems to make the building more home-like with their move toward “culture change.” The elimination of the use of auditory personal alarms should be added to this strategy.

Sleep deprivation as a contributing factor for falls is difficult to single out for study. It is reasonable to assume, however, that a good night’s sleep uninterrupted by personal alarms and loud conversations would have a favorable effect. And, in fact, the fall patterns reported in Guildermann’s study20 indicate that this is true; they found that no residents fell between 7:00 am and 10:00 am in facilities that had turned off all personal alarms during the night.

Using Gravity-Assisted Seating 

Some wheelchair-bound individuals are more likely to fall than others, and an ill-fitting chair (eg, seat too high, seat not deep enough, seat angled improperly) can contribute to a slide to the floor. For instance, it can be challenging for staff to prevent a fall in residents with dementia who habitually reach for unseen objects on the floor in front of their wheelchair while seated. Using gravity to enhance the safety of their seating eliminates this problem,21 and this can be achieved as follows:

•     Placing the seat low enough to enable the person’s feet to be flat on the floor.

•     Ensuring the seat is deep enough to allow no more than two fingers of width between the back of the person’s knee and the front of the chair. To keep the center of mass within the wheelchair base of support, the individual’s nipple line should not fall in front of the seat edge when he or she leans forward (Figure 1).21

falls, long-term care

•    Tilting the angle of the seat by changing the wheel positions, lowering the back of the seat, and raising the front of the seat to enable gravity to assist with pelvic stability while maintaining a 90-degree angle between the seat and the back of the chair.21

A person with severe kyphotic deformity of his or her back tends to fall forward while seated because the center of gravity of his or her torso and head is in front of the hip joints. Making the aforementioned changes and substituting a wheelchair back that conforms to the curve of the kyphotic deformity will enable the individual’s trunk to stabilize behind the hip joint, preventing a forward fall head first from the chair. Tilting the angle of the seat by changing the wheel positions, lowering the back of the seat, and raising the front will bring the person’s face into a more vertical alignment and will encourage socialization and eye contact, and enable safer swallowing (Figure 2).21

falls, long-term care

Finally, while most nursing homes provide wheelchairs that are wide enough for morbidly obese residents, many do not recognize the need for chairs that are deep enough to accommodate tall individuals as they lean forward. The biomechanics of maintaining one’s balance when seated and propelling a wheelchair requires that the person’s center of gravity remains within the wheelbase of the chair as he or she leans forward. Appropriately sized wheelchairs are necessary to achieve this.

Using wheelchairs with the back reclined puts residents at risk of sliding to the floor. Often, the only thing keeping them in the chair is their feet braced on raised foot pedals. Most of these individuals can be safely seated in a standard wheelchair in which the angle of the seat back and the seat is kept at 90 degrees and the seat itself is tilted so that gravity is pushing the sacrum to the rear of the seat. If they self-propel the chair with their feet, it may be necessary to start with a lower wheelchair frame in which the seat is closer to the ground to ensure that when the front of the seat is raised, their feet can still remain flat on the floor.21

Considering Vitamin D and Calcium Supplementation

Because nursing home residents have little or no sun exposure, it can be assumed that their vitamin D levels are lower than that found in the general population, particularly because it is difficult to get enough of this nutrient through diet. Yet good evidence suggests that vitamin D supplementation in older adults can improve the uptake of calcium to reduce osteoporosis and prevent sarcopenia (loss of muscle mass),22 both of which can contribute to falls. In addition, good evidence suggests that the benefits of vitamin D on fall prevention are distinct from its positive effects on bone health.7 Subsequently, the new consensus statement from the AGS recommends that healthcare providers review older patients’ vitamin D intake from all sources, including diet, sunlight exposure, and supplements, and work to achieve a total vitamin D input of 4000 international units daily (IU/day).23 The statement indicates that this will enable 90% of patients to achieve recommended vitamin D levels and minimize their risks of falls and fall-related injuries.  

Historically, vitamin D and calcium have been administered concomitantly as a means of improving bone health. Although both of these nutrients are essential for healthy bones, some controversy regarding these supplements arose in 2013 after the US Preventive Services Task Force issued a statement concluding that the current evidence is insufficient to assess the balance of the benefits and harms of daily supplementation with more than 400 IU of vitamin D3 and more than 1000 mg of calcium for the primary prevention of fractures in younger men and women (premenopausal) and in noninstitutionalized postmenopausal women.24 Although these guidelines did not extend to the institutionalized elderly, they still raised questions as to whether supplementation should also be altered for this population. Currently, the evidence favors the continued use of vitamin D for falls prevention in these individuals, particularly because the costs of supplementation are low and there is little risk of toxicity.25

In contrast, calcium poses some risks, particularly for persons who do not need it. For example, calcium can be constipating, and calcium carbonate (the most common preparation available and also the most constipating26) requires an acid medium in the stomach for absorption.25 Constipation, in turn, can increase the risk of falls by causing the person to strain during a bowel movement.27 In addition, straining can lead to a vasovagal response, further increasing the risk of falls; however, the new AGS consensus statement indicates that there is insufficient data to support a recommendation for increased vitamin D supplementation without calcium for older people.23 The statement indicates that most studies advocate calcium doses ranging between 500 and 1200 mg daily, yet at the same time acknowledge that the depth of the evidence in this area will expand over the next 5 to 10 years. Until we have better evidence to support coupling these supplements, we recommend that LTC facilities consider each of these supplements separately, deciding for each individual resident whether the benefits of calcium supplementation outweigh the potential risks.25

Equipping Residents With Protective Gear

Use of several items that are worn by residents should be carefully considered, as they may help prevent falls and/or reduce the severity of injuries should a fall occur. These include proper footwear, helmets, and hip protectors.

Footwear. According to a 2011 report from the Mayo Clinic, surveys indicate that old shoes and old habits can contribute to falls in older adults.28 Elderly individuals are less likely to fall in their homes if they wear athletic shoes as opposed to going barefoot or wearing socks or slippers, and they are less likely to fall outside of the home if they opt for supportive shoes, such as lace-up or strap-on shoes with a snug fit, rather than wearing slip-on shoes. These same principles apply in the LTC setting. Not only can ill-fitting or worn-out shoes contribute to falls, but they can also increase the likelihood of developing painful bunions, corns, and blisters.28 The exception to this would be individuals with a festinating gait pattern, such as ambulatory residents with Parkinson’s disease. In these individuals, the festinating gait pattern prevents them from clearing the floor as they step forward; thus, these individuals should avoid wearing treaded shoes to prevent catching their feet on rug surfaces and falling forward.

People with peripheral neuropathies or peripheral arterial disease of the lower extremities are at high risk for falls and the development of diabetic or arterial ulcers. These individuals may be unable to detect uneven walking surfaces due to the lack of pressure and position sensations in the foot and ankle, presenting a real danger, particularly when paired with diminished sight and depth perception. The use of stable, secure footwear may increase these residents’ stability during ambulation. In addition, to prevent skin breakdown and provide proper support to residents with orthopedic foot deformities from diabetic peripheral neuropathies, a consultation with an orthopedist for custom-molded diabetic shoes may be warranted.

Although the AGS/BGS guidelines7 discuss the importance of foot screenings and footwear evaluations for all older adults, they do not specifically make any recommendations for LTC patients. However, best practice would dictate that a foot screening be completed upon admission to an LTC facility and at least quarterly thereafter to ensure that any skin integrity issues are identified early and addressed. These screenings should be accompanied by a review of the resident’s footwear to identify any poor fitting, broken, and unsafe shoes, such as those with wedge heels and slick bottoms.

Helmets. In LTC settings, consideration should be given as to when it is ethically appropriate to discontinue the use of blood thinners, including aspirin, for individuals with advanced dementia, poor balance, and lapses in safety judgment.29 For those high-risk ambulatory elders in whom anticoagulation and antiplatelet therapy is continued, the use of high-impact helmets may be helpful in reducing the risk of subdural hematomas sustained from falls.30 Adherence with this strategy, however, can be difficult. Resistance to wearing helmets can come from numerous sources, including the caregiver, who may assume that the resident will reject it; the cognitively impaired resident, who may be unable to understand and/or accept the unfamiliar; and the cognitively alert and aware resident, who may feel that wearing a helmet is demeaning to his or her self-image and be concerned about how it will appear to others.

Currently, there are no published studies that specifically demonstrate whether use of high-impact helmets can protect older high-risk individuals during a fall, and the AGS/BGS guidelines do not discuss helmets; however, anecdotal reports have been favorable. For example, a pilot program that encouraged patients with a high risk of falling and bleeding to wear protective headgear while hospitalized and after discharge reported that many patients embraced the idea when they fully understood the importance of wearing the helmet, with some even adding artistic flourishes to their helmets.31 More importantly, there were no cases of head bleeding among the patients who embraced the helmets and consistently wore them. If a resident is deemed to be a good candidate for a high-impact helmet, this intervention should be carefully reviewed with the resident and his or her power of attorney and these discussions carefully documented in the resident’s medical chart.

Hip protectors. Although the AGS/BGS guidelines do not make recommendations for or against hip protectors, the Veterans Administration Safety Center has adopted their use as best practice in their centers. Selection of residents for this intervention could be based on a history of unresolved fall risk, presence of moderate to severe osteoporosis, and level of compliance with regard to such devices. A recently published literature review found that compliance with hip protectors in the LTC setting is a challenge, with the authors stating that “compliance issues must be tackled if hip protectors are to be part of a resident-centered approach.”32

Although it remains unclear exactly which factors contribute to poor compliance among the LTC population, a study that assessed the acceptability and compliance with hip protectors in community-dwelling women at high risk of hip fractures found that many who discontinued wearing them attributed this to discomfort, dislike of how the hip protectors made them look, and disagreement about their fracture risk.33 It is likely that many of these same issues may lead to lack of compliance among LTC residents; however, new designs to high-impact pads may change this. These newly designed pads now survive industrial laundering, making them easier to care for, and are more comfortable and less bulky than previous designs. Some of these advances are attributable to the development of new materials, such as polyurethane foam, which can absorb up to 90% of the impact of a fall.34 Although such materials are thinner and feel soft, they become firmer on impact, enabling the pressure to be distributed across a greater area. In addition to thinner protectors, new clothing designs into which these pads are placed have become more attractive and practical, making tasks such as toileting and even walking easier.

Promoting Appropriate Exercises

It is assumed that introducing formal exercise programs into the daily routine of residents in LTC facilities will improve their balance, thereby preventing falls and fractures resulting from falls. A 2012 Cochrane review assessed exercise interventions to improve balance and reduce falls in older people in nursing homes and hospital settings and found the evidence for efficacy to be weak due to poorly designed studies.35 In addition, the AGS/BGS guidelines7 state that there is currently insufficient evidence to recommend for or against the use of individually customized exercise programs to prevent falls in the LTC setting, though they do recommend exercise programs that target strength, gait, and balance for all older community-dwelling persons. It needs to be acknowledged, however, that the majority of the LTC population is often either unable or unwilling to participate in formal group exercise programs; thus, when exercise is promoted, it should be individualized based on the physical therapist’s assessment. This step helps prevent injury and cardiopulmonary decompensation from performing the wrong type of exercise or becoming overexerted.

The integration of active lifestyle concepts into the daily routine of all residents, such as limiting the use of wheelchairs when they are used only to save time and to reduce the effort of the caregiver, enhances the residents’ quality of life and mobility skills. Standing and walking should be maintained to the tolerance of each resident. Wheelchairs are too often assigned to residents with only moderate endurance, strength, and balance deficits, and they immediately become the primary mode of moving these individuals from place to place. In these cases, the resident loses endurance, strength, and balance reactions through benign neglect.

Addressing Staffing Issues

Although resident factors often cause falls, they can also result from facility factors. For example, falls have been linked to nurse staffing patterns.36 The consistent assignment of staff to the same residents allows for staff to have an intimate knowledge of their charges, enabling them to anticipate the residents’ unsafe errors in judgment or high-risk behaviors, to be present in the area of risk, and to have the greatest ability to intervene before a fall occurs.37 Caregivers can be much more effective in their vigilance if they are not moved to different units with each schedule change. In addition, charting near a frequent faller’s room, increasing staff availability, and staffing extra hours to cover a change of shift and during high-risk times of the day, such as the hour just after meals and during “sundowning,” may reduce risk. Using split shifts or management on the floor during high fall incident times identified through analysis of facility trends has also been effective in many facilities. Finally, including all facility staff in making rounds and observing for risks can be helpful, as can adopting a practice of checking on residents regardless of call light use, as these practices further support an environment of heightened safety awareness.


This article provided a review of many—but not all—factors contributing to falls in LTC facilities, along with suggested interventions to reduce injuries. Fall reduction in any organization requires an organized, consistent approach to facilitate change and achieve sustainable outcomes. The honest reporting of fall circumstances, performing root cause analysis that involves the interdisciplinary care team and the patient’s family, and identifying and analyzing trends must go beyond the paper compliance level. In addition, any fall interventions that are used must be matched to each individual’s risk factors and initiated before the fall occurs. Educational and research focus on the creation of sustainable change in LTC facilities is needed to create safer environments for our elders.


1.     Rubenstein LZ, Josephson KR, Robbins AS. Falls in the nursing home. Ann Intern Med. 1994;121(6):442-451.  

2.     Centers for Disease Control and Prevention. Falls in nursing homes. Accessed December 12, 2013.

3.     Rubenstein LZ. Preventing falls in the nursing home. JAMA. 1997;278(7):595-596.

4.     Rubenstein LZ, Robbins AS, Josephson KR, Schulman BL, Osterweil D. The value of assessing falls in an elderly population. A randomized clinical trial. Ann Intern Med. 1990;113(4):308-316.

5.     Rubenstein LZ, Robbins AS, Schulman BL, Rosado J, Osterweil D, Josephson KR. Falls and instability in the elderly. J Am Geriatr Soc. 1988;36(3):266-278.

6.     Leistikow IP, Kalkman CJ, de Bruijn H. Why patient safety is such a tough nut to crack. BMJ. 2011;342:d3447.

7.     Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatric Soc. 2011;59(1):148-157. Accessed December 17, 2013.

8.     Oliver D. Falls risk assessment tools in hospitals: mermaid or manatee? Talk presented at: 2012 Transforming Fall Management Practices Conference; May 2012; Clearwater, FL.

9.     Institute for Healthcare Improvement. How to improve. Updated December 4, 2012. Accessed September 20, 2013.

10.   Syncope Trust And Reflex anoxic Seizures. Syncope and falls in the elderly (SaFE). STARS Website. Accessed December 14, 2013.

11.   Kenny RA, Bhangu J, King-Kallimanis BL. Epidemiology of syncope/collapse in younger and older Western patient populations. Prog Cardiovasc Dis. 2013;55(4):357-363.

12.   Parry SW, Tan MP. An approach to the evaluation and management of syncope in adults. BMJ. 2010;340:c880.

13.   Blyth FM, Cumming R, Mitchell P, Wang JJ. Pain and falls in older people. Eur J Pain. 2007;11(5):564-571.

14.   Eggermont LH, Penninx BW, Jones RN, Leveille SG. Depressive symptoms, chronic pain, and falls in older community-dwelling adults: the MOBILIZE Boston Study. J Am Geriatr Soc. 2012;60(2):230-237.

15.   Harwood RH, Foss AJ, Osborn F, Gregson RM, Zaman A, Masud T. Falls and health status in elderly woman following first eye cataract surgery: a randomized controlled trial. Br J Ophthalmol. 2005;89(1):53-59.

16.   Schlaudecker JD, Moore I. Reducing wandering through improved waiting room design. Annals of Long-Term Care: Clinical Care and Aging. 2013;21(1):30-31.

17.   Bakker R. Environmental design. In: Geriatric Care by Design: A Clinician’s Handbook to Meet the Needs of Older Adults Through Environmental and Practice Redesign. Chicago, IL: American Medical Association; 2011:1-14.

18.   Rader J, Frank B, Brady C. Rethinking the use of position change alarms. Idaho Department of Health and Welfare Website. Published January 4, 2007. Accessed September 20, 2013.

19.   The impact of alarms on patient falls at a VA community center living. Paper presented at: Transforming Fall Management Practices 2010 Annual Conference; May 2010; Clearwater, FL.

20.   Guildermann SA. Effective fall prevention strategies without physical restraints or personal alarms [transcript]. Quality Improvement Organizations, Stratis Health. April 24, 2012. Accessed September 20, 2013.

21.   Willy BA; Centers for Medicare & Medicaid Services Ninth Scope of Work. Wheelchair seating for elders - booklet. Mountain Pacific Quality Health 2010. Accessed December 30, 2013.

22.   Montero-Odasso M, Duque G. Vitamin D in the aging musculoskeletal system: an authentic strength preserving hormone. Mol Aspects Med. 2005;26(3):203-219.

23.   American Geriatrics Society Workgroup on Vitamin D Supplementation for Older Adults. Recommendations abstracted from the American Geriatrics Society consensus statement on vitamin D for prevention of falls and their consequences. Published December 18, 2013. doi: 10.1111/jgs.12631.

24.   US Preventive Services Task Force. Vitamin D and calcium supplementation to prevent fractures. Published February 2013. Accessed December 17, 2013.

25.   Tangalos EG. Vitamin D and calcium recommendations: making sense of the hype and the reality. Annals of Long-Term Care: Clinical Care and Aging. 2013;21(8):36-37.

26.   Mayo Clinic. Calcium and calcium supplements: achieving the right balance. Accessed December 17, 2013.

27.   Loftus S. Fall prevention strategies for people living with Parkinson’s. Accessed December 30, 2013.

28.   Mayo Clinic. Fall prevention: out with the old shoes, old habits. Published June 20, 2011. Accessed September 20, 2013.

29.   Cappuzzo KA. Anticoagulation in elderly patients who fall frequently: a therapeutic dilemma. Consult Pharm. 2005;20(7):601-605.

30.   Quigley P, Hahm B, Sarduy I, et al. Reducing severe injury from falls in two medical surgical units. J Nurs Care Qual. 2009;24(1):33-41.

31.   Donning helmets, patients protect themselves from harmful falls. URMC Today. Published May 29, 2012. Accessed December 17, 2013.

32.   Combes M, Price K. Hip protectors: are they beneficial in protecting older people from fall-related injuries? J Clin Nurs. 2014;23(1-2):13-23.

33.   Patel S, Ogunremi L, Chinappen U. Acceptability and compliance with hip protectors in community-dwelling women at high risk of hip fracture. Rheumatology (Oxford). 2003;42(6):769-772.

34.   Hoyden K. Hip protectors with a sporty look. Sintef Website. Accessed December 17, 2013.

35.   Cameron ID, Gillespie LD, Robertson MC, et al. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database Syst Rev. 2012;12:CD005465. doi:10.1002/14651858.CD005465.pub3.

36.   Implementation guide: goal 2: improving consistent assignment of nursing home staff. Accessed September 20, 2013.

37.   Quigley P, Neily J, Watson M, Wright M, Strobel K. Measuring fall program outcomes. Online J Issues Nurs. 2007;12(2):8.


Disclosures: The authors report no relevant financial relationships.

Address correspondence to:

Betty Willy, PT, MA, CWS;

Christine M. Osterberg, RN, BSN;