Falls Prevention Literature Review

Falls are a major problem for nursing home residents and can lead to serious injury and death. This literature review provides information on fall prevention that can be used to design and eventually implement a fall prevention program as part of routine day-to-day workflow in nursing homes. The framework for grouping articles in the literature review includes four main domains: Medical/Surgical Issues; Mental Status/Emotions/Coping; Physical Function; and Living Environment. 

Contents

Description and Summary of Fall Prevention Literature Review
Medical Domain
Mental Domain
Functional Domain
Environmental Domain
Multiple Interventions and Implementation Strategies
References 

Description and Summary of Fall Prevention Literature Review

Literature Review Description

This literature review focuses mainly on fall prevention literature related to nursing home residents. However, several articles referring to community-dwelling older adults or hospital or emergency department patients are included if they contained factors also relevant to nursing home residents. This review is not a systematic collection of all possible fall-related articles. Its purpose was to find a range of resident and treatment fall risk factors and treatments to reduce risk of injurious falls in nursing homes. This information can be used to design and eventually implement a fall prevention program as part of routine day-to-day workflow in nursing homes.

The framework for grouping articles in the literature review uses the Siebens Domain Management Model (© Hilary C. Siebens, MD, 2005) to categorize the findings into several main domains and subcategories within them. There are four main domains:

  1. Medical/Surgical Issues.
  2. Mental Status/Emotions/Coping.
  3. Physical Function.
  4. Living Environment (© Hilary C. Siebens, MD, 2005).

The final section includes articles that have multiple domains covered.

Each article is included one time, categorized under the domain with the strongest findings from the article. We include articles with single as well as multidimensional interventions and/or risk factors. Results from each article are summarized in the Results section of each article entry.

Within Domains I-III, we further categorize the findings by resident risk factors, treatment risk factors, and treatments implemented to reduce fall risk. Within the living environment domain, we categorize findings by physical risk factors, caregiver issues (e.g., staffing, training), treatment risk factors, and treatments implemented to reduce fall risk.

Methods to identify references for the literature review follow:

  • Search criteria: fall prevention, fall risk factors, treatments to reduce fall risk factors, rehabilitation to reduce fall risk, fractures due to falls, fall prevention strategies.
  • Date criteria: include literature from the last 15 years except for "classic" older articles that are referenced frequently.
  • Priority of peer-reviewed references related to the skilled nursing home population:
    • Journal articles with input from consultant and other project team members, starting with review articles
    • Fall management program references.
  • Additional references to search journals listed in references of other papers reviewed.

Summary of Findings

A summary of resident risk factors, treatment risk factors, and treatments to reduce risk is presented by domain below.

Medical Domain

Resident Risk Factors

We found the following resident risk factors to be associated with greater likelihood of falls:

  • Age ≥85 years old.

Specific medically related risk factors include:

  • Diabetes mellitus.
  • Low bone mineral density (BMD).
  • Orthostatic hypotension.
  • Urinary incontinence/frequency.
  • Weakness.
  • Dizziness.
  • Acute or chronic medical problems.
  • Lower extremity peripheral nerve disorders.
  • Visual impairment.

A major functionally related risk factor, listed here for completeness, is:

  • History of falling; two or more falls in previous year.
Treatment Risk Factors

We found the following treatment risk factors to be associated with greater likelihood of falls:

  • Cardiac and analgesic drugs: residents taking digoxin, type IA antiarrhythmic, or opioid medications.
  • Diuretic medications.
  • Vasodilator.
  • Multiple medications; residents taking more than three or four medications.
  • Medication side effects.
Treatment To Reduce Risk

We found the following treatments to reduce the risk of falls:

  • Vitamin D supplements (1,000 IU/day).
  • Use of toileting schedules.

Mental Domain

Resident Risk Factors

We found the following resident risk factors to be associated with greater likelihood of falls:

  • Dementia, cognitive impairment.
  • Depression.
  • Agitated behaviors.
  • Low Folstein Mini Mental Status Exam score.
Treatment Risk Factors

We found the following treatment risk factors to be associated with greater likelihood of falls:

  • Central nervous system (CNS)-active medications, including benzodiazepines (both short- and long-acting), antidepressants, anticonvulsants, and narcotics (opioids).
  • Psychotropic medications.
Treatment To Reduce Risk

We found the following treatments to reduce the risk of falls:

  • Structured multifactorial general medical assessment and additional specific fall risk evaluation tool that included attention to medications, including psychotropics.

Functional Domain

Resident Risk Factors

We found the following resident risk factors to be associated with greater likelihood of falls:

  • History of falls.
  • Abnormal postural sway, proprioception.
  • Gait dysfunction.
  • Low hand grip strength scores/hand dynamometry.
  • Gait and balance instability.
  • Lower extremity joint function limitations.
  • Mobility limitations/challenges.
  • Age-related changes in muscle and bone.
  • Physiologic systems (somatosensory, vestibular, and visual).
  • Low instrumental activities of daily living scores.
  • Poor physical condition of resident.
Treatment Risk Factors

We found the following treatment risk factors to be associated with greater likelihood of falls:

  • Walking aids: walkers and canes.
  • Wheelchair use.
  • Specific physical activities.
Treatment To Reduce Risk

We found the following treatments to reduce the risk of falls:

  • Exercise programs; moderate intensity group exercise; regular exercise.
  • Gait and balance training.
  • Muscle strengthening exercises.
  • Tai Chi group exercise.

Environmental Domain

Resident Risk Factors

We found the following resident risk factors to be associated with greater likelihood of falls:

  • Pieces of furniture.
  • Poor lighting.
Treatment Risk Factors

We found the following treatment risk factors to be associated with greater likelihood of falls:

  • Restraint reduction.
  • Assistive and protective aids.
Treatment To Reduce Risk

We found the following treatments to reduce the risk of falls:

  • Daily 5- to 10-minute exposure to Nolwenn Leroy CD for 1 month.
  • Staff education regarding fall prevention, implementation of prevention strategies.
  • Use of hip protectors.
  • Visual way to identify residents at risk of falling, such as bracelet or color-coded charts.
  • High nurse aide-to-resident ratio.
  • Facilitywide multidisciplinary team responsible for implementation and evaluation of fall prevention activities.

Multifactorial Treatments To Reduce Falls

  • Flowchart to improve documentation of fall risk factors and characteristics of fall episodes; supports referrals to geriatrician.
  • Menu-driven incident reporting system for falls.
  • Multifactorial fall risk assessment and prevention program.
  • Fall management program.
  • Postfall assessment tools.

Return to Contents

Page last reviewed February 2010
Internet Citation: Falls Prevention Literature Review. February 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/systems/long-term-care/resources/injuries/fallspxlitrev/index.html