The Clinical Issue and Research Questions Developed Using PICOT

EVIDENCE- BASED CARE SHEET

ICD-9 E888

ICD-10 W19

Authors Tanja Schub, BS

Cinahl Information Systems, Glendale, CA

Helle Heering, RN, CRRN Cinahl Information Systems, Glendale, CA

Reviewers Darlene Strayer, RN, MBA

Cinahl Information Systems, Glendale, CA

JenniferEdit Kornusky, RN, MS Cinahl Information Systems, Glendale, CA

Nursing Practice Council Glendale Adventist Medical Center,

Glendale, CA

Editor Diane Pravikoff, RN, PhD, FAAN

Cinahl Information Systems, Glendale, CA

August 20, 2021

Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2021, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206

Falls, Accidental: Resulting in Injury

What We Know › A fall is defined as an event in which a person unintentionally drops from an upright or

other fixed, secure position to a lower or less erect position on the floor or the ground for reasons that are not related to sudden onset of a medical condition such as syncope orseizure(5)

• The incidence of falls and the severity of fall-related complications increase with advanced age; falls are common in older adults and represent a significant cause of morbidity and mortality in this patient population(5)

–Each year, approximately 30–40% of community-dwelling older adults and 50% of nursing home residents fall at least once(5)

–More than half of falls result in injury, most of which are not serious (e.g., abrasions, contusions)(5)

- However, falls can result in serious injury (e.g., hip fracture, head and internal injury, lacerations) and fall-related injuries account for about 5% of hospitalizations of older adults(5)

- In the U.S. in 2018, falls resulted in an estimated 3 million ED visits and more than 950,000 hospitalizations or interfacility transfers(4)

–Falls are an important cause of immobility and dependence; indeed falls contribute to more than 40% of nursing home admissions(5)

–Falls represent the leading cause of accidental death and the 7th leading cause of death in persons aged 65 years and older(4,5)

- In 2018, falls accounted for approximately 32,000 deaths in older adults in the U.S.(4)

–After falling once, fear of falling again is common, and severe complications related to falling can have debilitating psychological effects(5)

› Balance and walking require complex cognitive, neuromuscular, and cardiovascular functions; most falls have a multifactorial etiology. Risk factors for falling can be categorized as intrinsic, medication-related, and environmental(3,5)

• Intrinsic risk factors pertain to the physical and cognitive status of the individual, and include aging, female sex, history of falls (increased risk of future fall two- to sixfold), cardiac conditions (e.g., arrhythmias), neurologic conditions (e.g., Parkinson disease, dementia), musculoskeletal factors (e.g., lower extremity weakness, deconditioning, arthritis, foot abnormalities), vascular conditions (e.g., vertebrobasilar insufficiency, hypotension), visual impairment (e.g., stereopsis, poor depth perception, poorly-fittingglasses), metabolic abnormalities (e.g., hypoglycemia, hypothyroidism, hyponatremia), and psychiatric conditions (e.g., depression)(3,5)

• Polypharmacy and the use of certain medications can increase fall risk in older adults(3,5)

–Fall risk increases with the number of medications used(5)

–Psychoactive drugs (e.g., antidepressants, antipsychotics, benzodiazepines) are medications most blamed for increasing fall risk. Other types of medication associated

with increased fall risk include analgesics (especially opioids), antiarrhythmics, anticholinergics, antihypertensives, diuretics, laxatives, and sleep medications(3,5)

• Environmental risk factors include inadequate lighting, poorly-fitting shoes, loose carpet, slippery floors, lack of handrails, and uneven stairs(3,5)

› In assessing a person’s fall risk, it is important to remember that most falls are the result of the interaction of multiple risk factors(5)

• Risk assessment tools are available for use in quantifying a person’s risk of falling. (For information regarding the use of tools for risk assessment, see Evidence-Based Care Sheet: Falls, Accidental: Risk Assessment )

› Although there is no single, all-encompassing strategy that prevents falls, a number of strategies can be instituted to reduce the risk for falls(5,7)

• Exercise interventions, such as balance, strength, and gait training may reduce fall risk in older adults(3,6,7)

–The U.S. Preventive Services Task Force (USPSTF) recommends exercise interventions for prevention of falls in community-dwelling older adults at increased risk for falls(7)

–Cochrane reviewers analyzed data from 108 RCTs including 23,407 participants and found that exercise reduces the rate of falls by 23% compared with no exercise(6)

• Some older adults at increased fall risk benefit from use of assistive devices, such as canes or walkers(5)

• Patients at increased fall risk due to medication effects may benefit from medication cessation, dose reduction, or substitution, when possible(1,5)

• Fall risk related to certain medical conditions (e.g., Parkinson disease, vision problems) can be reduced via proper medical management of the underlying condition(3,5)

• Home environment modifications that can reduce fall risk include improving lighting, removing or replacing torn carpet, using rugs with nonskid backs, removing clutter and arranging furniture to provide unobstructed paths, and installing shower grab bars and handrails on both sides of stairways(1,5)

• Multifactorial interventions may reduce fall risk(2)

–The USPSTF recommends selective use of multifactorial interventions for preventing falls in this patient population(7)

–Authors of a recent meta-analysis of data from 20 trials found that multifactorial interventions reduce the rate of falls by 21%, but have little or no effect on fall-relatedoutcomes(2)

What We Can Do › Learn about accidental falls resulting in injury so you can accurately assess your patients’ personal characteristics and health

education needs; share this information with your colleagues › Learn about risk factors for falls, including intrinsic, medication-related,and environmental risk factors › Assess your patients fall risk on admission, following a change in status, on transfer to a new unit, and after a fall

• If available, use a risk assessment tool that has been validated for use in specific patient populations and settings (e.g., acute care, skilled facilities)

• Use a standardized environmental checklist to screen for environmental hazards › Request referral to physical therapy for patient evaluation and strength and balance training, if appropriate › Educate patient and family members about environmental strategies that can be initiated to prevent falls, including removal

of loose rugs or cords, use of adequate lighting, and installation of safety equipment › Review your patient’s prescribed medication regimen and when appropriate, request a substitute medication to eliminate the

use of a drug that is associated with increased fall risk › Follow facility protocols for general safety precautions to maintain patient safety (e.g., airway, circulation, and prevention of

injury)

Coding Matrix References are rated using the following codes, listed in order of strength:

M Published meta-analysis

SR Published systematic or integrative literature review

RCT Published research (randomized controlled trial)

R Published research (not randomized controlled trial)

C Case histories, case studies

G Published guidelines

RV Published review of the literature

RU Published research utilization report

QI Published quality improvement report

L Legislation

PGR Published government report

PFR Published funded report

PP Policies, procedures, protocols

X Practice exemplars, stories, opinions

GI General or background information/texts/reports

U Unpublished research, reviews, poster presentations or other such materials

CP Conference proceedings, abstracts, presentation

References 1. Centers for Disease Control and Prevention. (2019). Algorithm for fall risk screening, assessment, and intervention. Retrieved June 28, 2021, from

https://www.cdc.gov/steadi/pdf/STEADI-Algorithm-508.pdf (G)

2. Hopewell, S., Copsey, B., Nicolson, P., Adedire, B., Boniface, G., & Lamb, S. (2020). Multifactorial interventions for preventing falls in older people living in the community: A systematic review and meta-analysis of 41 trials and almost 20 000 participants. British Journal of Sports Medicine, 54(22), 1340–1350. doi:10.1136/bjsports-2019-100732 (M)

3. Moncada, L.V.V., & Mire, L.G. (2017). Preventing falls in older persons. American Family Physician, 96(4), 240-247. (RV)

4. Moreland, B., Kakara, R., & Henry, A. (2020). Trends in nonfatal falls and fall-related injuries among adults aged #65 years - United States, 2012-2018. MMWR, 69(27), 875–881. doi:10.15585/mmwr.mm6927a5 (PGR)

5. Rubenstein, L.Z. (2021, April). Falls in older people. Merck Manual Professional Version. Retrieved from https://www.merckmanuals.com/professional/geriatrics/falls-in-older-people/falls-in-older-people (GI)

6. Sherrington, C., Fairhall, N.J., ... Wallbank, G.K. (2019). Exercise for preventing falls in older people living in the community. Cochrane Database Syst Rev, (1), CD012424. doi:10.1002/14651858.CD012424.pub2 (M)

7. US Preventive Services Task Force. (2018). Interventions to prevent falls in community-dwelling older adults: US Preventive Services Task Force recommendation statement. JAMA, 319(16), 1696–1704. doi:10.1001/jama.2018.3097 (G)