Falls among the elderly can have severe consequences, including life-threatening hip fractures. As an experienced hospice registered nurse case manager, I understand the importance of fall prevention, especially in private homes, personal care homes, and assisted living facilities. This article aims to provide practical tips for in these settings by following the nursing process: assessment, , planning, implementation, and evaluation.

According to the CDC, over three hundred thousand people over 65 suffer from hip fractures each year due to falls. Those of you who have taken geriatric patients who have had recent broken hips know the seriousness of how this type of injury impacts your patients; often, hip fractures are a death sentence to the elderly. In my own experience, head and femur fractures are just as deadly. Therefore, I find it particularly important to reduce the risk of falls for all my patients. The fall risk is typically lower in the hospital and skilled nursing facilities. Thus, this article will focus on tips to reduce falls in private homes, personal care homes, and assisted living facilities.

As you grow and bloom in your nursing practice, it will benefit you always to remember the nursing process: assessment, , planning, implementation, and evaluation. As it relates to fall prevention, the application of this in general is as follows:

Assessment: Identifying Fall Hazards

  1. Environmental Assessment
    • Identify fall hazards like oxygen tubing, throw rugs, and misplaced equipment.
    • Ensure proper lighting during the day and night.
  2. Patient Assessment
    • Evaluate muscle coordination, gait, strength, vision, and assistive devices.
    • Consider relevant patient diagnoses that may increase fall risk, such as dementia or heart disease.

Diagnosis: Understanding Fall Risks

  1. Frequency of Declines

Planning: Strategies to Reduce Fall Risk

  1. Immediate Fall
    • Discontinue medications like Donepezil and Ativan if they contribute to grogginess or increased falls.
    • Consider the real need for external oxygen if the patient is on oxygen. Treat for comfort, not to resolve numbers.
    • Request a chest x-ray and urinalysis to rule out pneumonia and UTIs.
    • Review medications, like Cipro, to reduce polypharmacy burden.
    • Implement chair and bed alarms.
    • Explore relocating the patient closer to the nursing station.

Implementation and Evaluation: Putting the Plan into Action

  1. Implementation
    • Execute the planned interventions to reduce fall risk.
  2. Evaluation
    • Continually assess the effectiveness of interventions and adjust as needed.

DOGi: A Tool for Critical Thinking

  1. DOGi – A Change of Condition Checklist
    • D = Drugs (Medications): Assess the relevance of medication changes and Beers Criteria.
    • O = Oxygenation (SPaO2): Monitor oxygen levels to address confusion and weakness.
    • G = Glucose: Check glucose levels, considering baseline values.
    • i = Infection: Recognize signs of infection and delirium in the elderly.

A Case Study

Background: A geriatric patient with a terminal illness of senile degeneration of the brain with an unrelated (to the terminal) diagnosis of cervical dystonia where the patient has frequent bilateral upper tremors involving the patient's face, neck, and arms to fingers and COPD. The patient's medications include 325 mg Acetaminophen x2 tabs BID for pain, 250 mg Cipro daily for prophylaxis, 10 mg Donepezil for dementia, and 40 mg Simvastatin for high cholesterol. The patient also has been getting (for years per family) 1 mg Ativan daily and 3 mg Ativan HS. The patient used to be on several high blood pressure medications that were discontinued several months prior related to the medications causing hypotension. The patient is on two liters of continuous oxygen for COPD. The patient uses a rollator for ambulation.

Situation: You were in to see the patient for a regular visit, and you found out that staff had found her on the floor near her chair. Staff reported, “The patient is stubborn and refuses to use the call bell.”

Assessment: You find the patient in their room at 11:00 AM. They have oxygen tubing under one foot and are caught up in the wheels of the rollator as they sit on their chair. They are AOX 2, groggy, and deny any . Your inspection finds no injuries.

Can you identify some immediate fall risks? Let me walk through what our team identified (let me know if you agree, disagree, or find more):

  1. I asked the question about the need for continuous oxygen. Tested hypothesis by getting SPO2 at the start of the visit along with respiration rate and effort. Turn off the oxygen, and one hour later (monitoring the patient throughout), get a current SPO2, respiration rate, and effort. For our test, the patient went from 97% on two liters to 92% on room air without a change in respiration rate or effort; the patient also denied being short of breath. Had the test failed, the next step would have been looking at ways to get the patient off continuous oxygen, such as starting an oral steroid, scheduled DuoNeb treatments, and the like; and should those have failed, looking at using portable oxygen tanks during the day and only using the oxygen concentrator at night.
  2. Obtain orders from the doctor to discontinue Donepezil as this medication is for early-to-mid stage dementia and is on the Beers list for having a side effect of increased falls. Also, ask for the discontinuation of the Ativan due to the patient's grogginess at 11:00 am in the morning while having a reasonable PRN dose of Ativan to help wean the patient off the Ativan.
  3. Obtain orders from the doctor for a chest x-ray two view to rule out pneumonia and to obtain a urinalysis to rule out a .
  4. Now, both tests in number 3 came back negative; therefore, ask the doctor to discontinue Cipro due to polypharmacy burden (beers criteria).
  5. Obtain an order for a chair and bed alarm.
  6. Work with the family and the personal care home to see if the patient can be moved to a room closer to the nursing station.

Would there be anything else that you would recommend or do?

Let me end by sharing an acronym I used to learn how to think critically when a patient's condition changes (please remember that a fall, even without injury, is a change of condition): DOGi. I picture a doggy playing with a ball in the grass.

  • D = Drugs (medications). What new medications were introduced before the change of condition? What medications (even if they have been taking them for years) might contribute to the change of condition? Is mediation on the Beers Criteria?
  • O = What's the patient's oxygenation (SPaO2)? Low oxygenation often leads to confusion, , fatigue, and weakness.
  • G = Glucose. What's the patient's current glucose reading? Are they hypo or hyperglycemic? How does their current reading compare to their baseline? (Let's remember that patients who are chronic diabetics with poor compliance/management may experience hypoglycemia symptoms with numbers we might consider normal, which is why it's so important to compare their current reading to their normal baseline.)
  • i = Infection. When a person has an infection, especially in the geriatric population, they often have signs and symptoms of .

What tools and resources do you use to help you identify fall risks and take steps to reduce the risk of falls?

Conclusion

Preventing falls in personal and private care homes is crucial to ensuring the well-being of elderly patients. By following the nursing process and using tools like DOGi, healthcare professionals can identify fall risks and implement effective strategies to reduce them, providing safer patient care.

Resources

Fall Prevention: 8 Things to Check to Prevent Future Falls for an Older Person (video)

2019 Beers Criteria Printable Pocket Guide

Falls and long-term care: a report from the care by design observational cohort study

Falls Prevention in Public Hospitals and State Government Residential Aged Care Facilities Quality Improvement and Enhancement Program (QIEP)

Preventing Falls Infographic

Preventing falls in hospitalized patients

Pain Assessment in Hospitalized Older Adults With Dementia and Delirium

Pain Assessment in Dementia – International Association for the Study of Pain (IASP)

Pain Assessment in People with Dementia: AJN The American Journal of Nursing

PAINAD Scale Offers Alternative to Assessing Pain in the Dementia Patient – JEMS: EMS, Emergency Medical Services – Training, Paramedic, EMT News

Pain Assessment in Advanced Dementia Scale (PAINAD) – MDCalc

Uncontrolled Pain and Risk for Depression and Behavioral Symptoms in Residents With Dementia

Chronic Pain & Symptom Tracker: A 90-Day Guided Journal: Detailed Daily Pain Assessment Diary, Mood Tracker & Medication Log for Chronic Illness Management

Pain And Symptom Tracker: Daily Pain Tracking Journal Detailed Pain Assessment Diary, Medication, Supplements Food & Activities Log for Chronic Illness Management

Pain Assessment and Pharmacologic Management

Adult Nonverbal Pain Scale (NVPS) Tool for pain assessment

Assessing pain in patients with cognitive impairment in acute care

FLACC Pain Scale

Pain Assessment in Advanced Dementia Scale (PAINAD)

Pain Assessment in Non-Communicative Adult Palliative Care Patients

Pain Assessment in People with Dementia

Tools for Assessment of Pain in Nonverbal Older Adults with Dementia: A State-of-the-Science Review

Understanding the physiological effects of unrelieved pain

Untreated Pain, Narcotics Regulation, and Global Health Ideologies

My Loved One with Dementia

Understanding Dementia (Alzheimer's & Vascular & Frontotemporal & Lewy Body Dementia) (Video)

How Do I Know Which Dementia I'm Looking At? (Video)

Dementia Training material (Free)

Promoting Meaningful Relationships with Dementia Patients through Validation Therapy

Unlocking the Power of Validation Therapy in Compassionate End-of-Life Care

Validation Therapy: A Valuable Tool for Families and Healthcare Teams

Best Practices for Approaching Combative Dementia Patients

Dementia Insights: The Validation Method for Dementia Care

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The Validation Breakthrough: Simple Techniques for Communicating with People with Alzheimer's Disease and Other Dementias

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How Do I Know You? Dementia at the End of Life

The Dementia Caregiver: A Guide to Caring for Someone with Alzheimer's Disease and Other Neurocognitive Disorders (Guides to Caregiving)

Sundown Dementia, Vascular Dementia and Lewy Body Dementia Explained

The Caregiver's Guide to Dementia: Practical Advice for Caring for Yourself and Your Loved One (Caregiver's Guides)

Ahead of Dementia: A Real-World, Upfront, Straightforward, Step-by-Step Guide for Family Caregivers

The Dementia Caregiver's Survival Guide: An 11-Step Plan to Understand the Disease and How To Cope with Financial Challenges, Patient Aggression, and Depression Without Guilt, Overwhelm, or Burnout

Dementia Care Companion: The Complete Handbook of Practical Care from Early to Late Stage

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