FALL PREVENTION STRATEGIES

The best strategy to avoid the negative impacts of falls is to prevent them from happening in the first place. It is in the best interests of everyone involved in patient/client care—clinicians, caregivers, facilities, and most importantly, at-risk patients/clients themselves—to consider and adopt comprehensive and individualized strategies and planning to minimize the risk of falls.

Whether in clinical, community, or home-based settings, there are a number of strategies to mitigate risk of patient falls. There is no one-size-fits-all strategy; effective fall prevention planning is highly specific to an individual’s unique situation, environment, and needs.

Interventions Based on Type of Fall Risk in Clinical Settings

In order to design the most effective prevention strategies in the clinical environment, it is helpful to determine which specific type(s) of fall an individual may be most at risk for. The primary types of fall risk include anticipated physiologic falls, unanticipated physiologic falls, and accidental falls.

ANTICIPATED PHYSIOLOGIC FALLS

Anticipated physiologic falls may be predicted when patients have certain known risk factors. Examples of risk factors for anticipated physiologic falls may include:

• Muscle weakness or balance difficulties
• History of falling
• Frequent toileting needs and/or urinary urgency
• Altered mental status, such as dementia, which can lead to disorientation
• Vision or hearing problems
• Certain medications (especially those that have side effects such as dizziness or lightheadedness) or polypharmacy

Intervention strategies for anticipated physiologic falls require careful consideration of a patient’s specific risk factors, both intrinsic (visual impairment, balance, gait, sensory neuropathy, orthostatic hypotension, confusion, etc.) and extrinsic (medications, mobility aids, etc.). To minimize risk of anticipated physiologic falls, the following strategies may be useful:

• Employ interventions tailored to the patient’s identified risk factors.
• Implement consistent toileting schedules and encourage consistent drinking schedules for patients with elimination needs.
• Ensure that patients have access to visual and auditory aids (glasses, hearing aids, etc.) if indicated.
• Consult with medical provider about alternative medication options, if indicated.
• Ensure a safe, consistent environment (e.g., no clutter, mobility aids within reach).
• Referrals to rehabilitation specialists (such as physical, occupational, or speech therapy) may be beneficial for further evaluation of specific concerns related to mobility, assistive equipment, ADL function, cognition, etc.
  (Progress Lifeline, 2021)

UNANTICIPATED PHYSIOLOGIC FALLS

These falls may occur with a temporary change in physical or cognitive function and unfamiliar surroundings. Such falls are considered unanticipated because the patient may be otherwise classified as lower risk for falls. This type of fall may potentially occur with conditions such as seizures, syncopal episodes, delirium, stroke, or heart attack. Due to the unexpected and often sudden nature of these falls, preventative strategies may be difficult to implement, and it is important to consult closely with the patient’s medical provider to address potential underlying medical causes. Following an unanticipated physiologic fall, it may be useful to consider assistive technology options, which may alert caregivers to subsequent falls (Yang, 2023; Progress Lifeline, 2021).

ACCIDENTAL FALLS

This type of fall can stem from slipping, tripping, or other accidents and is frequently linked to extrinsic (and often modifiable) factors such as obstacles, poor lighting, or poorly designed ergonomic features in the immediate environment.

Risk reduction strategies for accidental falls in facility settings include careful assessment of a patient’s physical environment, bedroom and bathroom setup, assistive devices, clothing, footwear, and other physically modifiable potential risk factors. Steps to minimize risk of accidental falls include:

• Providing patients with nonslip, comfortable, well-fitting footwear
• Keeping floor surfaces clean and dry and promptly cleaning any spills
• Providing sturdy handrails in bathrooms, rooms, and hallways
• Keeping wheelchair brakes locked whenever chair is stationary
• Use of night lights or other supplemental lighting
• Keeping patient rooms free of clutter
  (Yang, 2023; Progress Lifeline, 2021)

Rehabilitation for Nonvestibular Balance Deficits

Patients who have experienced more than one fall or who demonstrate any difficulty with initial balance or gait testing should likely be referred to physical therapy for further evaluation and treatment (Merck & Co., 2022a).

BALANCE RETRAINING

For balance deficits determined to be nonvestibular in nature, a physical therapist can provide a comprehensive evaluation and individualized treatment program. (For balance deficits due to specific vestibular dysfunction, see “Vestibular Rehabilitation” later in this course.)

A balance retraining program may include specific interventions to improve static and dynamic balance, reaction time, protective responses, proprioception, and the ability to perform balance tasks under varying environmental conditions—such as on soft surfaces, in high-distraction environments, or while simultaneously performing cognitive tasks.

A balance retraining program is highly specific to an individual’s unique functional strengths and deficits and may contain specific exercises and task to improve gait, balance, functional coordination, and strength. The following are examples of generalized exercises that help to improve or maintain balance:

• Standing march
• Standing three-way kicks
• Sidestepping
• Single-legged standing
• Sit-to-stands
• Tandem standing or walking
  (APTA, 2023a; Physiopedia, 2023a)

Reactive balance training is a whole-body movement type of balance exercise aimed at improving static and dynamic balance, as well as an individual’s ability to react quickly to external balance challenges. A physical therapist applies deliberate, controlled pressure to different parts of a patient’s body (usually the hips or shoulders) from multiple different directions, progressively increasing in speed, to help develop protective stepping response (Physiopedia, 2023f).

Specific exercise recommendations and individualized programs should be made by clinicians with appropriate training and expertise and implemented under appropriate supervision.

THERAPEUTIC EXERCISE

Rigorous evidence exists to indicate that exercise can help reduce risk of falls by up to 25% in community-dwelling older adults (Sherrington et al., 2020). Specific and progressive exercise regimens devised and supervised by a physical therapist target and address specific and individualized deficits that may contribute to falls.

In order to maximize benefit from therapeutic exercise interventions aimed at fall reduction, it is recommended that exercise programs be designed and taught by a trained professional, be specifically tailoring to an individual patient’s areas of weakness/need, be provided for at least four months’ duration, and contain a significant component of balance challenge (Merck & Co., 2022b).

Precautions and recommendations for specific exercise regimens are assessed on a case-by-case basis. While most older people are able to successfully engage in and benefit from some level of physical activity, the following conditions are considered absolute contraindications to exercise:

• Acute myocardial infarction (MI), within 2 days
• Ongoing unstable angina
• Uncontrolled cardiac arrhythmia with hemodynamic compromise
• Active endocarditis
• Symptomatic severe aortic stenosis
• Decompensated heart failure
• Acute pulmonary embolism, pulmonary infarction, or deep vein thrombosis
• Acute myocarditis or pericarditis
• Acute aortic dissection
• Physical disability that precludes safe and adequate exercise
  (Merck & Co., 2022b)

AQUATICS

Water-based programs allow the patient to perform challenging exercises characterized by lower impact, increased resistance and buoyancy, and reduced fear of falling (as may occur with land-based exercise programs). The viscosity of water creates increased drag and sensory stimulation, and functional gains in balance made during exercises practiced in the water may be transferrable to land-based situations. Though more research is needed, there is some evidence to suggest that participating in aquatic exercise programs may be associated with increased balance and decreased risk of falls (Nissim et al., 2020; Inverarity, 2022). Aquatic therapy is provided in a supervised setting by a physical or occupational therapist and is tailored to an individual patient, while aquatic exercise is a more generalized water-based exercise program (often in a group setting) offered in a community setting.

GAIT TRAINING

An atypical or impaired gait pattern may increase an individual’s risk of falling. A physical therapist can provide a comprehensive gait evaluation, including an analysis of an individual’s walking speed, step length, and step symmetry (or lack thereof) as well as evaluation and treatment of any specific gait abnormalities (e.g., antalgic, ataxic, steppage, Parkinsonian, etc.). The treatment of gait deviations may include:

• Specific pre-gait training activities (standing in place, side-to-side weight-shifting, stepping practice)
• Specific gait training activities (retraining how to walk, individualized to each patient)
• Selective neuromuscular re-education
• Balance and coordination retraining
• Evaluation for orthotic, splinting, or assistive device needs
  (APTA, 2023b)

Rehabilitation for Vestibular Dysfunction

Vestibular dysfunction is a common contributor to balance-related issues and falls. An estimated 35.4% of all adults in the United States have some degree of vestibular dysfunction, including 75% of adults over age 70 and more than 85% of adults over age 80. When left unaddressed, vestibular hypofunction can result in subjective dizziness/imbalance, blurred vision with head movements, and postural instability, and the incidence of falls in those with vestibular hypofunction is known to be greater than in age-comparable, community-dwelling healthy individuals (Hall et al., 2022).

Vestibular rehabilitation interventions target aberrant vestibular symptoms and resultant functional limitations and have been demonstrated to diminish dizziness, improve visual acuity, and reduce fall risk. Vestibular rehabilitation is an important subspecialty of physical therapy practice and study.

EXERCISE-BASED INTERVENTIONS

There are four primary components to the exercise-based approach used in vestibular rehabilitation:

• Gaze stability exercises: Exercises to promote vestibular adaptation involve head movements while focusing on an object that may be moving or stationary. Exercises to promote substitution involve the development of alternative strategies (such as smooth-pursuit eye movements or central preprogramming of eye movements) in order to help compensate for deficiencies in vestibular function.
• Habituation exercises: Involves systematic and repeated exposure to symptom-provoking stimuli, with the goal of reducing symptoms over time as the vestibular system becomes gradually accustomed to the stimuli. Examples include optokinetic stimuli, which uses repeated moving patterns, and virtual reality, which puts patients into virtual and visually challenging environments.
• Balance and gait training: Designed to use visual and somatosensory cues as compensation for vestibular deficiencies, this component of vestibular rehabilitation may include balancing exercises under enhanced or altered conditions (such as under distraction, with altered visual input, on foam or moving surfaces, with altered base of support, etc.). Gait activities may be executed while turning the head or performing additional tasks in order to increase challenge. Virtual reality and/or gaming technology may be employed.
• Endurance training: While not an effective treatment for vestibular dysfunction on its own, general endurance training is often included in a vestibular rehabilitation program because many people affected by vestibular dysfunction may self-limit their physical activities in order to avoid eliciting symptoms.
  (Hall et al., 2022)

When vestibular impairments significantly affect an individual’s ability to meaningfully engage in preferred roles, activities, and/or occupations, occupational therapists may also work with patients to modify, remediate, and/or adapt as needed to help affected individuals maximize their participation, performance, self-efficacy, and perceived quality of life (AOTA, 2017b).

MANUAL TECHNIQUES FOR BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV)

One of the most common causes of vestibular dysfunction, BPPV is a condition that occurs when small calcium carbonate crystals (called canaliths or otoliths) move within the semicircular ear canals, leading to dizziness and visual disturbance and increase the risk of falling (VEDA, 2023e). The diagnostic and treatment process for BPPV differs from other vestibular dysfunctions and is generally more focused on specific manual techniques to locate and reposition displaced canaliths.

Diagnosis with Dix-Hallpike Test

The Dix-Hallpike maneuver is a manual test performed to help clinicians determine which specific semicircular canal contains displaced canaliths, as well as whether they are in the canals themselves (canalithiasis) or trapped in the cupola of one of the canals (cupulolithiasis) (VEDA 2023f). To minimize the risk of neck/back injury or worsening of symptoms, this testing maneuver—as well as any of the following treatment techniques—should only be performed by clinicians with appropriate training. The general test progression is as follows:

1. The patient is positioned on the examination table in long-sitting, with the examiner in front of them. The examiner rotates the patient’s head to one side and helps the patient lie quickly with their head hanging off the table in 30° of cervical extension (while maintaining rotation).
2. The examiner asks the patient to look at their nose and simultaneously watches the patient’s eyes for signs of elicited nystagmus. Appearance and timing of any nystagmus can help identify whether the patient’s vertigo is of central (CNS) or peripheral (inner ear) origin.
3. The patient sits up and is given time to recover from any symptoms elicited during the test. The test is then repeated with the patient’s head turned in the opposite direction.
   (Physiopedia. 2023g)

Canalith Repositioning Techniques

If testing indicates the presence of BPPV, the following treatment measures may be indicated to attempt to reposition displaced canaliths out of the semicircular canals. Repositioning techniques have been found to relieve symptoms in a majority of patients with BPPV, although recurrence of symptoms may occur (MFMER, 2023a). Detailed instruction in vestibular rehabilitation is beyond the scope of this course, but the following is a list of more commonly used manual repositioning techniques.

• Modified Epley’s maneuver/canalith repositioning maneuver (CRP): Used to treat BPPV occurring in the anterior or posterior semicircular canals; intended to relocate free-floating canaliths out of the canals in order to reduce or eliminate vertigo
• Semont-Liberatory maneuver: Used to redirect unattached canaliths out of the posterior semicircular canal and into the utricle
• BBQ roll: Used to treat BPPV caused by canaliths in the lateral semicircular canal
• Brandt-Daroff exercises: Adjunct treatment to the above clinician-administered techniques; may be taught to a patient to perform independently at home
  (Physiopedia, 2023g)

Addressing Environmental Safety Hazards in the Home

Falls that occur at home are often the result of environmental factors that may be easy to overlook but comparatively simple to address. Occupational therapists are specifically skilled in helping individuals identify and address potential safety hazards in the home that may increase the likelihood of a fall (AOTA, 2017a).

Specific steps that may improve environmental safety in a patient’s home may include:

• Ensuring that stairs have secure handrails (on both sides, if possible)
• Ensuring that lighting is appropriate and sufficient
• Installing grab bars beside the toilet and inside/outside the shower
• Using nonskid mats or strips on any surfaces that may become wet
• Removing throw rugs (or securing with appropriate, double-sided tape)
• Keeping a phone/charger beside the bed and consider carrying a charged phone with you at all times
• Keeping frequently used kitchen items (dishes, pans, utensils, etc.) in easy-to-reach cabinets or shelves
• Minimizing clutter, which may present trip hazards
• Taping down or bundling up wires away from main walking paths
  (NIA, 2023)

ADL Training

Limitations in one’s ability to perform basic activities and instrumental activities of daily living (ADLs and IADLs)—such as dressing, meal preparation, toileting—may lead to increased risk of falling. Occupational therapists (OTs) are the clinical experts in the evaluation and management of ADL deficits, and a referral to an occupational therapist should be considered if any concerns exist regarding an individual’s functional abilities in these areas.

Occupational therapists work with patients to identify specific ADL and IADL deficits and strengths and assist individuals to design safe and beneficial daily activity programs based on what a patient enjoys (e.g., gardening or walking to promote balance/endurance). OTs can also work with patients at a highly individualized level to help break the cycles of inactivity that can result from fear of falling and, if unaddressed, can increase odds of falling due to decreased physical functioning (AOTA, 2012).

Examples of therapeutic interventions to help address ADL deficits include:

• Functional exercises geared specifically toward performance of ADLs (reaching, stepping up/down, practicing shower transfers, etc.)
• Home safety modifications
• Training a patient/client in the use of specific assistive devices (reachers, tub transfer chairs, dressing aides, etc.)

Devices to Reduce Fall Risk or Injury

There are a number of items—some commonly available and others more specialized—which can help reduce risk of falls if selected and used correctly. Three general categories of such devices include environmental, surveillance/monitoring, and injury prevention.

ENVIRONMENTAL SAFETY DEVICES

There are a number of devices that may be employed to improve environmental safety—both in clinical and home/community settings—and help mitigate the risk of falls in commonly utilized areas of the home. Some examples include:

• Handrails for both sides of stairways (should be sturdily attached)
• Nonslip materials on treads of uncarpeted steps and in the shower
• A raised toilet seat or 3-in-1 commode
• Grab bars for shower or tub
• Shower seat or tub transfer bench
• Hand-held showerhead to allow bathing while seated
  (MFMER, 2023b)

SURVEILLANCE/MONITORING DEVICES

Various devices and technologies are available to monitor patients or individuals at increased risk of falling. Such devices are frequently used in clinical or residential care settings, and some may also be used in a home-based setting to assist caregivers of at-risk individuals. Examples of surveillance devices used in fall prevention include bed alarms, pressure-sensing chair alarms, clip-on personal alarms, wall-mounted motion sensors, and video monitoring equipment.

However, available evidence is somewhat mixed regarding the safety and efficacy of patient monitoring devices of this nature. In particular, a recent systemic review and meta-analysis of patient monitoring devices in the hospital setting actually showed an increase in patient falls when bed or chair alarms were used (versus control groups), in part because sensors placed on beds or chairs do not offer a warning if the patient moves away from the sensor. Portable/wearable monitoring devices, in contrast, were found to be a more viable adjuvant to individualized patient safety plans (Cortés et al., 2021).

Recent years have also brought a host of newer technologies geared toward improving the safety of older adults in the home setting, such as remote data collection of geolocation and/or physiologic data, alarm systems trigged when a fall occurs, and other app-based monitoring systems and wearable or nonwearable sensors. While promising in nature, more evidence is needed to more fully determine the efficacy of these new technologies in preventing falls in the home-based setting (Pech et al., 2021).

INJURY-PREVENTION DEVICES

Despite clinicians’ best efforts, a patient/client fall is not always avoidable. When falls are anticipated despite best practices and vigilant staff and/or caregiver intervention, a number of specialized devices may help mitigate the potential for fall-related physical injury.

As with any specialized device, it is important to carefully determine the proper device and/or strategy for each individual patient and to train staff and caregivers in its correct usage. Up-to-date and standardized care plans, routine in-service training, and appropriate staff orientation and caregiver training can help optimize the safe use of injury-prevention devices and strategies.

Injury-prevention devices provide an environment that minimizes fall potential and/or fall-related injury. Examples include:

• Flooring/matting: Compliant floors or matting provide a softer, shock-absorbing surface that may prevent or minimize risk of injury from a fall. Floor matting is relatively cost effective, portable, and easily cleaned. Mats with beveled edges and luminescent strips may offer increased safety to both patients/clients and staff/caregivers. Floor matting should be in place when a patient is unattended (such as at night) and rolled up during direct patient care (Elderly Fall Prevention, 2023).
• Hip protectors: These garments, available as slip-on briefs or pants, have special padding at the lateral hip areas, which can provide cushioning at areas vulnerable to injury and/or fracture from a fall. Designed for use by one patient only, hip protectors are washable, relatively inexpensive, and may be indicated particularly for frail patients. Studies suggest that the use of hip protectors reduce the risk of hip fractures in older adult patients residing in nursing home or residential care settings (Nolan et al., 2022).
• Helmets/protective caps: These protect the head from falls-related impact and may be full-coverage, headband style (either stand-alone or embedded into other headwear) or involve adding padding into an existing piece of headwear (such as a baseball cap). Compared to helmets used for sporting activities, there is a comparative paucity of safety engineering standards with regard to protective headgear for older adults and what research does exist indicates a wide range in impact attenuation among current devices and also notes that existing options appear to be more effective against back-of-head impacts (Martel et al., 2021).
• Low-floor beds (no longer recommended): Specialized beds that keep the patient positioned as low to the ground as possible in order to mitigate risk of injury in the event of a fall from bed. While these beds were commonly used in the past, more recent research indicates that they may not reduce falls and may even contribute to increased falls incidence in older adults. Therefore, the most current clinical practice guidelines do not recommend the use of low-floor beds for the purpose of falls prevention (Schoberer et al., 2022).

RESTRAINTS

Once common in clinical settings, the use of restraints is now deemed controversial and a measure of absolute last resort for the prevention of patient/resident falls. According to the American Medical Association Code of Ethics, a patient should never be restrained for convenience, as a punitive measure, or without a physician’s specific order (except in rare emergency cases). Additionally, a physician who deems restraint to be the only alternative should seek informed consent of a patient or surrogate, as well as explain the following:

• Why restraint is being recommended
• What type of restraint will be used
• Length of time for which restraint is intended to be used

It is imperative that the need for restraint be regularly reassessed and updated in the patient’s medical record (AMA, 2023).

A restraint is defined by the Centers for Medicare and Medicaid Services as “any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or a drug or medication when it is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition” (ACEP, 2020).

Examples of physical restraints utilized for fall prevention (only as an absolute last resort) may include hand mitts, limb restraints, vests, or belts. Examples of chemical restraints may include benzodiazepines or antipsychotic medications (Shuwarger, 2021).