Falls - factors to consider

If a patient has a history of falls then they are more likely to fall again, particularly when in hospital. Healthcare professionals must routinely ask the people they come in to contact with whether they have fallen in the past 6 months and where applicable asked about the frequency, context and characteristics of the fall/s (NICE, 2013). Recurrent falls are considered to be two or more in the previous 12 months (AGS/BGS Clinical Practice Guideline, 2010).

A good falls history can help prevent future falls as you can identify patterns of falls, frequency of falls and any triggers for a fall (deterioration/reason for admission to hospital, change in medication, life events, and functional decline).

Providing good support for people with cognitive impairment is imperative given the association with falls prevention.

It is recognised that the safety of patients with cognitive impairment can be adversely affected by increased changes in ward environment (changing ward/hospital or even moving bed space); therefore this movement must be minimised.

If the person has dementia, explore what is normal for the person and ask the family and carers to complete the ‘Getting to Know Me’ document with the person.

Cognitive Impairment is a known major risk factor for contributing to a patient experiencing a fall and any cause for distress and agitation should be investigated and managed.

If a patient is presenting with symptoms of stress and distress (such as verbal and physical aggression, anxiety, agitation etc.) then refer to and use the Distressed Behaviour Care plan to support the de-escalation and management of stressed and distressed behaviour. In mental health settings there should be a detailed care plan in place to manage stress and distress. Where there is a behavioural component to falls this should be stated in the behavioural management plan and interventions to manage falls included.

Stress and distress may be an indicator of postural hypotension and this could be a key reason for falls. If an individual displays stress and distress during functional activity such as transfers it is recommended to review lying and standing blood pressure.

Consideration should be given to the effects of alcohol withdrawal combined with risk taking behaviour and mobility.

The 4AT is a screening instrument designed for rapid and sensitive initial assessment of cognitive impairment and delirium. If delirium is identified, an assessment, treatment and management plan must be put in place -TIME Bundle. Maintain a calm, relaxed manner and use the person’s name when working with them as this will help reassure them. Engage with patient / family or carers and explain what delirium is and how it is affecting the person and provide information.

As part of the Delirium pathway there is the Delirium Immediate care guidance - TIME Bundle. Access Athena for more information and guidance on delirium management and to access the 4ATscreening instrument for cognitive impairment and delirium.

During hospitalisation, older people may experience significant functional decline which impairs their future independence and quality of life. Even a minor illness can have a significant impact on functional decline, recovery time and ability to regain full independence. Muscle strength is vital for activities such as walking, getting up from a chair, out of bed or climbing stairs. Physical activity and exercise can help combat the loss of essential muscle and bone density which accompanies ageing. Encouraging people to take part in functional activities of daily living such as washing, dressing, sitting up for meals etc. can help people maintain independence while they are in hospital.

Recovery, independence and rehabilitation must be considered throughout the patient journey. Appendix 2 highlights the importance of early mobilisation to help to build a patients confidence and maintain or regain their mobility. A mobility assessment must be completed as part of the care plan at the earliest opportunity during admission.

Mobility should be prioritised and patient placement on the ward considered, to encourage mobility to the toilet. Patients should be encouraged to change position (sit to stand) and move as part of their care rounding. Ward safety briefs should incorporate a discussion about active wards and encouraging mobility.

In mental health settings similar challenges can arise due to acute mental illness leading to lethargy, poor motivation, withdrawal and inactivity. This can lead to long periods of inactivity in a seated position and a reluctance to mobilise or pursue activity. Every opportunity should be taken to encourage mobility/activity as this can have a direct impact on improving both physical and mental health.

To maintain/regain mobility, independence and prevention of falls, consideration must be given to condition of feet. Neglected nails, skin pathologies including thickened nails, painful corns, callus and foot wounds must be referred to podiatry for immediate assessment, advice and/or treatment.

Staff can participate in Basic Footcare Awareness Training for Nurses Presentation supported by Podiatry.

Dual task activities such as walking and talking to staff at the same time can increase the risk of falls. This is particularly significant if a patient has a visual, hearing or cognitive impairment.

• Falls prevention messages must be shared in a positive way; emphasising the benefits of interventions – enhancing health, independence and quality of life.
• Make sure if appropriate they have walking aids and suitable footwear available.
• Plan a routine to encourage activity as research shows that breaking long periods of sitting at least every hour has a positive effect on health.
• If someone has lost confidence or has problems with mobility or balance involve the physiotherapist if required for a full assessment.
• Interventions which will provide benefit on discharge from hospital must be initiated and introduced while the patient is in hospital care.
• Discuss community falls services (e.g. further rehabilitation, Community strength and balance classes run by local Leisure services) with the person and multidisciplinary team and ensure appropriate falls prevention and management follow up is in place.

Older people reporting a fall or considered at risk of falling must be observed for balance and gait deficits and considered for their ability to benefit from interventions to improve strength and balance (NICE, 2013).

In the wider context of Ayrshire & Arran the falls pathway relates to ‘The Prevention and Management of Falls in the Community; A Framework for Action for Scotland 2014/2016’ 

Ayrshire and Arran Community Falls Pathways are also available.

Fear of falling could potentially negatively influence mobility, physical activity and functional performance in adults. An active ward where mobility is encouraged can help to build a patients confidence in a supported environment. This will help their recovery and ability to return home.

Fear of falling can affect activities of daily living and occupational engagement. The multifactorial nature of falls prevention and management means that referral to an appropriate service to meet the patient’s needs is often required. If someone has lost confidence, has a fear of falling or has problems with mobility or balance, you must consider this in the discharge planning.

Patient information leaflets are available with advice for patients and relatives on Up and About Taking Positive steps to avoid trips and falls (healthscotland.com) 

Certain medications can have an impact on a patient’s risk of falling; therefore, medication history must be reviewed by medical staff / ANP or pharmacy staff.

Proactive medication review must take place for all patients with a view to reducing inappropriate prescribing and identifying medication implicated in falls (Appendix 1).

Polypharmacy guidance realistic prescribing 

Patients who have continence related issues must have an appropriate plan in place and be cared for in an area close to toileting facilities if appropriate/available. Toileting equipment and rails of an appropriate height must be available for patients who require them. Stay in close proximity if the person needs assistance or is known to take risks with their mobility.

Utilise patient centred care and comfort rounding to support toileting needs and ensure functional independence where possible.

It is important to ensure that the patient is supported to have their glasses with them and wear them appropriately, and that spectacles are safe and clean.

Postural (orthostatic) hypotension can be a common cause of falls. Signs and symptoms include:

• dizziness, light-headedness, unsteadiness
• visual disturbance
• stress/distress on movement
• just goes down
• falls after standing up.

Orthostatic (postural) hypotension is defined by a drop in arterial BP of at least 20 mmHg for systolic BP and 10 mmHg for diastolic BP after standing (Royal Marsden, 2015).

Clinical examination may be required to identify any possible causes (for example dehydration or medications).

Orthostatic blood pressure measurement may be indicated if the patient has a history of dizziness or syncope on changing position:

• The patient needs to rest on a bed in the supine position for 10 minutes prior to the initial blood pressure measurement being taken, and then they must stand upright and have their blood pressure taken again within 3 minutes.
• While in the standing position, the practitioner must support the patient's arm at the elbow, to maintain it at the correct level and ensure accuracy.

Post prandial hypotension can occur in to 1:3 people over 65 after eating. This is more common when an individual is diabetic or pre-diabetes.

There are many causes of postural hypotension. Medical conditions, certain medications that help treat blood pressure, depression and urinary problems. Dehydration, eating large meals, heat, standing too long in one position and lying flat for long periods of time can all cause a drop in blood pressure. It is important to check for postural hypotension as part of an MDT approach to falls prevention.

There are several techniques to help a person cope with the drop in blood pressure and help to reduce their chances of falling. Encourage the person:

• to avoid quick changes in position. When changing from lying to standing, first go from lying to sitting on the edge of the bed, sit for a minute or two and then slowly stand up.
• to circle their ankles and ‘march’ their legs gently before standing up.
• to wait a few seconds before moving, as the dizziness can start in the first few minutes.
• to have drink fluids throughout the day, in particular water or decaffeinated drinks.

Falls are not a risk factor for osteoporosis but are a powerful predictor of fracture risk in patients with osteoporosis.

Patients with high risk of osteoporosis such as per SIGN 142 Management of osteoporosis and the prevention of fragility fractures (March 2021)  must be assessed and considered for DEXA Scan and / or bone protection.

The risk factors include:

• previous fracture; parental history of osteoporosis
• history of early menopause (under 45)
• low body mass index (<20 kg/m)
• smoking
• low bone mineral density
• heavy alcohol intake (more than 3.5 units daily) or
• have causative factors from co-existing diseases e.g. diabetes or drug therapy (e.g. long term antidepressants)

Malnutrition and dehydration are individual risk factors for falls. There is evidence to suggest that ensuring that patients have adequate fluid intake can reduce the risk. Including this in to the care and comfort rounding will help to prevent falls.

There is also evidence to suggest that Vitamin D supplementation for vulnerable groups can reduce falls.

Glycaemic control is a risk factor for falls.

It is important to ensure that the patient is supported to wear their working hearing aid, if applicable. Batteries can be obtained from hospital volunteers or the audiology department. Check hearing aid/environment re hearing. Consider placement on the ward.

Consider onward referral to audiology if further information or support is required.

Patients who are risk assessed as requiring higher level supervision must have this in place. The supervision can range from nurse / family presence in the room at all times (cohort supervision) to nurse presence with the patient at all times i.e. 1:1 supervision.

In mental health setting enhanced observation is determined as per the Safe and Supportive Clinical Observation Guideline.

Providing increased supervision within existing resources may result in the need to alter staff allocation / workload within the ward to accommodate and reduce the identified risk. There are times where additional staff will be required to support the increased activity within the ward which is a consequence of staff providing essential supervision. The staffing shortfall should be escalated in the usual way
Patients assessed at high risk of falls should be cared for in an observable area within the ward that is within easy view of staff to maximise supervision or where staff are visible.

Improving staff visibility to patients throughout ward area e.g. nurse based within the room or, for lower risk patients, the use of observation windows can alleviate patient anxiety and allow easier discussion by patients about their needs. Consideration must also be given when appropriate to Technology Enabled Care systems to enhance observation and supervision.

For more information refer to GO78 Guideline for Higher Level Supervision of patients.

For mental health settings see the Safe and Supportive Clinical Observation Guideline.

Unsafe footwear can further compound a falls risk, especially those patients with gait, balance, lower limb and proprioceptive problems. Staff must ensure the patient’s footwear is appropriate and well fitting.

Where possible family must bring indoor footwear (shoes/trainers) and patients should be encouraged to wear this when mobilising.

‘Pillow Paws’ foam slippers must not be used for patients at risk of falls as they do not provide the necessary support and damage easily, contributing further to the falls risk. Consider anti-slip slipper socks (Medline) as an alternative if patient has no suitable footwear.

Guidance for assessing in-patient footwear

Staff must ensure that patients have safe and comfortable footwear prior to walking or transferring. To achieve this:

• Patients must be encouraged to bring in or have brought in, suitable footwear. It may be helpful to ask family and carers to bring in appropriate footwear if necessary.
• Patients with long term medical foot problems, which cannot be accommodated by ‘off the shelf’ foot wear, must have an appliance request form completed, requesting an assessment by the Orthotist for suitable footwear.

Consider the following questions:

• Does the patient have their own slippers or shoes?
• Do they appear to fit?
• Can the patient put on their own footwear?
• Is the footwear in good condition e.g. not worn down or flattened and are all fastenings, laces in good order?
• Is the footwear likely to require to be washed and if so does the patient have alternative suitable footwear?
• If they have dressings on their feet or oedema does this prevent them from wearing commercially available shoes or slippers?
• Does the patient’s footwear contribute to their instability?
• Where the patient refuses to provide or to wear appropriate footwear or clothing this should be stated in the patients care plan.
• Readiness to change may impact on an individual’s falls risk where some patients will not accept advice regarding risk factors for falls (this can be related to the person’s mental state, impaired capacity or judgement of risk)

Ensure clothing hazards are minimal; this can be reduced by not wearing clothing that is too big or loose or clothing that trails on the floor. Liaise with family, relatives and/or carers regarding bringing appropriate footwear and clothing in from the patient’s home, as required.

Care and Comfort Rounds

Regular observation as assessed by professional judgement and checks on patients to fulfil and evidence the delivery of fundamental care – checking if patients are comfortable, offering the use of the toilet, and ensuring they feel supported and have everything they need within reach may also have the potential to reduce falls.

Personal possessions:

• Glasses and hearing aids are kept clean, working and available
• Drinks, tissues or other personal possessions within easy reach
• Patient alert buzzer in reach for patients able to use them
• Catheters, intravenous lines and oxygen tubing secure and not trailing.

Furniture:

• Chairs must be available in a range of heights and types, including riser recliners and appropriate bariatric seating.
• Hoists, slings, stand aids and bariatric equipment should be available at ward level to facilitate early mobilisation and rehabilitation and minimise unnecessary and as such, harmful, bed rest.
• Beds must be kept at the correct height for safe standing for mobile patients; when delivering care variable bed height can be used, but must be lowered on completion of care.
• Some pressure relieving mattresses elevate the bed height, so must only be used for pressure area prevention or treatment.
• If using a low bed provided with mats then follow instructions on how to manage any ‘crash mats’ provided with these beds to avoid creating a trip hazard.
• Brakes must always be applied to beds and wheeled chairs/commodes.
• Placement of patient/furniture.

Bedrails - may reduce the risk of a person accidentally slipping or sliding falling or rolling out of bed, however they may also increase the risk of someone falling if that person tries to climb over or around them.

Bed rails must only be used after a considered individual risk assessment using the Bed Rails Risk Assessment and decision making tool.

Mobilising – walking aids at the correct height and type, must be well maintained and kept within easy reach.

Regular environmental checks/walks must be carried out around the ward area and patients rooms to reduce clutter and other trip hazards.

Signposting - Ensure toilets are easy to find with signage suitable for those with visual impairment, cognitive problems, or language barriers.

Lighting – must be adequate and even, avoiding glare where possible.

Flooring – must be nonslip with prompt cleaning of spillages. Flooring must avoid patterns that create the illusion of slopes or steps for people with visual impairment and proprioceptive problems.

Technology Enabled Care (TEC) - . A wide variety of technology enabled care (TEC) equipment is becoming increasingly available - Movement alarms (bed or chair monitor alarms) are designed to detect patient movement and alert staff with an audible buzzer or via a pager bleep.

Bed and bedside chair pressure sensors as a single intervention strategy do not reduce in-patient bedside falls; however, alarms may be useful in multifaceted approaches to reduce inpatient falls.

Not all TEC is suitable for all people and some may be counterproductive for some patients. Individual assessment and choice of equipment must be undertaken prior to any TEC being used.

Housekeeping - on the ward housekeeping is extremely important particularly to promote an active ward. Staff must ensure that areas are clear and clutter free.