Running head: REASONS FOR FALLS IN ELDERLY

Reasons for Falls in the Elderly: An Evidence Based Practice Analysis

Rita Daniels, Ashley DenHartigh, Sharon Lumbert, Angie Robl
Ferris State University

REASONS FOR FALLS IN ELDERLY

Abstract
The purpose of this paper is to review available literature on the topic of causes of falls in the
elderly. National estimates from 2000 place health care cost resulting from fatal and non-fatal
falls in older adults at approximately $19.2 billion (as cited in Hill et al., 2009, p. 287). Due to
constraints, four articles were chosen to summarize and critique. One previous literature review
of the subject, a Centers for Disease Control and Prevention (CDC) overview of statistical
information, one qualitative study based in nursing homes, and one randomized clinical trial are
included. Implications on nursing practice are presented. The conclusion includes
recommendations for the use of research based evidence.
Keywords: geriatrics, elderly, older adult, fall(s), slips, injury, safety, risk, prevention,
hospitalization

REASONS FOR FALLS IN ELDERLY

Reasons for Falls in the Elderly: An Evidence Based Practice Analysis

According to the Centers for Disease Control and Prevention (CDC), Each year, one in
every three adults age 65 and older falls. Falls can cause moderate to severe injuries, such as hip
fractures and head traumas, and can increase the risk of early death, (para 1, 2011). The risk
for injury and death make it necessary to understand the causes behind falls. In 2008, 19,700
older adults died from inadvertent falls; in 2009, 2.2 million were treated in emergency rooms
and 581,000 were hospitalized due to falls, (CDC, 2011). By recognizing the reasons that people
fall, interventions can be put in place to reduce or eliminate a persons cause for falling. This
leads to the question of, what does the evidence say about the reasons for falls in the elderly?
Looking at research studies that have explored falling amongst the elderly can provide insight to
the problem and determine interventions that can prevent future falls.
Summary of the Evidence
Article One
Comprehensive Fall Prevention Programs Across Settings: A Review of the Literature
covers fall prevention and management, with information on national programs and resources for
the elderly. MacCulloch, Gardner, & Bonner (2007) cited 59 references in their article to look at
risk factors for falls, examined the costs and mortality rate, called for assessments on older adults
and described intervention to decrease falls. The study looked at intrinsic factors that contribute
to falls, such as physiological illness, lower extremity weakness, poor grip strength, balance
disorders, visual defects, cognitive impairment, and polypharmacy, (MacCulloch et al., 2007, p.
306). The article also noted extrinsic factors for falls like lighting, faulty assistive devices, and
wet or cluttered floor surfaces, (MacCulloch et al., 2007, p. 306). A fall risk assessment was
recommended that involved evaluating patients rising from a chair without assistance, walking

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several steps, turning around and returning to sit in the chair again. Interventions included
exercise and medication management. The concept of multidimensional interventions was
discussed, because often falls occur due to multiple causes, rather than one factor.
Multidimensional interventions address multiple risk factors, (MacCulloch et al., 2007). Injury
prevention was mentioned; including devices to protect people when they fall, enhancement of
beds, non-skid foot wear, and motion detectors, (MacCulloch et al., 2007). Finally, specific
programs regarding falls and fall safety across settings were described.
Article Two
In the article Falls Among Older Adults: An Overview, the CDC (2011) has recognized
four ways to reduce chances of falling amongst older adults while at home or out in the
community which include exercising, reviewing medications, getting a yearly eye exam, and
reducing tripping hazards. Without addressing these four areas, a person would be at higher risk
for falls. Exercise can increase strength and balance. Exercise programs should increase in
intensity over time to continue to build on these traits. In effort to reduce falls due to dizziness
or drowsiness, older adults should have their physician look over their medication list to discover
drugs that may cause these side effects or interactions (CDC, 2011). A persons vision should be
at their highest potential to reduce the risks of falling. Yearly eye exams make certain that older
adults are seeing as clear as possible to lessen the danger tripping over objects that would have
otherwise been overlooked (CDC, 2011). Lastly, the CDC recommends that older adults can
make their homes safer by reducing tripping hazards, adding grab bars inside and outside the
tub or shower and next to the toilet, adding stair railings and improving the lighting in their
homes, (CDC, 2011, para 6).
Article Three

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The article Person-Environment Interaction Contributing to Nursing Home Resident

Falls, by Hill et al. (2009), is a report of a qualitative study. This study identifies a gap in
research regarding the causes for falls by nursing home residents. The purpose outlined, was to
explore, from the perspective of the nursing staff, the person risk factors, environmental
circumstances and the interaction of the two surrounding nursing home falls, (Hill et al., 2009,
p. 289). Lawtons Ecological Model of Aging was used as a theoretical framework (Hill et al.,
2009). Hill et al. (2009) formed four focus groups, made of licensed and unlicensed nursing
staff, to collect information. Issues adding to falls included the design of the residents rooms,
lack of space within the rooms, obstacles that are created due to limited space, equipment misuse
and malfunction, and also staffing (Hill et al., 2009). This study found that the nursing home
environment has an impact on rates of falls. Hill et al. (2009) found this to be important because
of all the factors that contribute to falls in the elderly, the environment is the easiest to
manipulate.
Article Four
The article Fall Prevention in Acute Care Hospital by Dykes et al. (2010) is the
publishing of a cluster randomized study investigating the benefits of implementing a Fall
Prevention Tool Kit (FPTK) using health information technology (HIT). The intervention is a
computer program that builds on an already proven fall risk assessment tool, (Dykes, 2010). The
FPTK program generates patient specific interventions and produces bedside posters, patient
education handouts and plans of care, (Dykes et al., 2010). The study was conducted in four
urban hospitals; each hospital utilized one unit as a control group and one unit as an intervention
unit, (Dykes et al., 2010). The primary goal was to reduce falls with a secondary goal of
reducing falls with injury, (Dykes et al., 2010). Data was collected over six months, every

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patient that was cared for on the study units were included in the study. The results showed a
positive correlation between the use of the FPTK program and a decreased in the fall rates
(Dykes et al., 2010). Dykes et al. (2010) also noted through statistical analysis that the FPTK
had a greater impact on the population over 65 years old. The projected impact indicates that,
the FPTK could potentially prevent 1 fall every 4 days, 7.5 falls each month, and about 90 falls
each year in the study units alone, (Dykes et al., 2010).
Analysis of the Evidence
Article One
The literature review, by MacCulloch et al. (2007), is very complete. The review is
thorough and the articles are all relevant to the topic at hand, each has been written within the
last fifteen years. The information gained from the review is up to date and very useful. A good
literature review allows the reader to absorb a wealth of knowledge about a subject from one
single reading, rather than hours of sifting through multiple articles. MacCulloch et al. (2007)
has compiled information from many studies and organized it clearly. The sources are also cited
correctly, which ensures the reader the articles are dependable. Overall, this article offers strong
evidence in regards to falls, because the information is reliable, current, and comprehensive.
Article Two
The CDC does not look at one particular study in this article. Instead the article compiles
statistics from the results of a variety of studies. The results are broad, covering a wide range of
topics, yet concise enough to stay on the subject of falls amongst elderly. Information regarding
how the results of the studies were collected is not included within the article; however all of the
sources are correctly cited. It would be feasible, yet time consuming, for the reader to refer to
the primary sources to see how the results were gathered.

REASONS FOR FALLS IN ELDERLY

In general, the CDC as a whole is considered a reliable, credible source. Although it is

not easy to quickly see the number of participants within the sample or evaluate the research
designs, the CDC can be credited for their history of utilizing and conducting dependable studies.
Even though the reader is not able to gather a rapid opinion on the credibility of the research
itself, the reader is able to trust the source from which the information is coming from. The
article offers readers a quick glimpse at the evidence, while providing useful interventions for
improving fall risks, which makes this article overall very useful.
Article Three
The study by Hill et al. (2009) is a strong addition to evidence based nursing research.
The evidence suggests that there is a strong relationship between a persons environment and
risks of falls. The thorough literature review and the use of a theoretical framework reinforce the
credibility and of usefulness of this study. Through use of the theory framework, Ecological
Model of Aging (EMA), Hill et al. (2009) link this study to one previous study which used an
EMA framework and note that the results of this study are being used to form a, PersonEnvironment After Fall Assessment (PEAFA), (p. 288). This shows the importance of the
study as the research is able to be applied to improve nursing practice.
The article is clearly written with the problem statement and significance of the problem
is easily identifiable. A gap in knowledge was noted as relatively few studies have examined
environmental factors, such as poor lighting, faulty equipment, and slippery floor surfaces, as
potential risk factors for falls by nursing home residents, (as cited in Hill et al., 2009, p. 288).
Also, the research subjects, licensed, and unlicensed nursing staff are an underutilized source of
information that have valuable input for identifying causes of falls, (Hill, 2009).
Article Four

REASONS FOR FALLS IN ELDERLY

Dykes et al. (2010) looked at a known problem in the health care industry, the physical
and financial cost of falls in acute care hospitals. They also highlighted a gap in knowledge in
nursing practice, the use of health care technology to prevent falls. Dykes et al. (2010) note that
there have not been previous clinical trials using specific HIT interventions for fall prevention in
acute care settings. This is a look into a new way to use technology to promote safety and
decrease costs in the acute care setting.
The report is clearly presented. The process before the clinical study is outlined and the
statistical analysis is clearly presented. To overcome weakness of previous randomized
controlled trials of fall prevention Dykes et al., used the Institute for Healthcare Improvements
Framework for Spread to promote unit-level buy-in. The FPTK included an adherence
dashboard to facilitate monitoring, (2010, p. 1914). A weakness identified is the limits of the
program, the FPTK was designed specifically to reduce falls, (Dykes et al., 2010). It was not
found to be effective in reducing falls in injury or repeat falls. Dykes et al. indicate that further
research is needed to address these issues.
How Does the Evidence Effect Practicing Nurses?
Nurses help ensure patient safety, including prevention of falls and fall-related injuries.
Patient falls are one of the top five sentinel events for hospitals, long term care, and home care
agencies because of loss of function and injury that results (Quigley, Neily, Watson, Wright, &
Strobel, 2007). Avoiding injury by falls is significant to every nurse in every practice setting.
Averting further harm is just as important, if not more important, as healing current health
problems. By incorporating what the evidence has shown, nurses can reduce their patients risks
for falling. Also, when a fall does occur, the nurse should take time to fully understand what led
that patient to fall. This can lead to further prevention in similar situations in the future.

REASONS FOR FALLS IN ELDERLY

Patients most often understand the need to decrease their risks for falls. In most
situations, patients are willing to learn exercises that will improve balance, make appropriate
changes to their medication list to decrease drowsiness or dizziness, maintain eye care to keep
vision clear, and modify their environments to reduce fall risks and tripping hazards. However,
there are patients with mental illness, dementia, poor education, deficient resources, and even
lack of will. These patients make utilizing the evidence more difficult. In these circumstances,
nurses need to be persistent and creative in applying interventions.
Values drive the need for change. Safety, wellness, and being fiscally responsible are all
values within our health care system. Applying the evidence on falls improves safety. The
evidence presented by Hill et al. (2009), in regard to how interactions with the environment can
increase or decrease fall rates can be applied to areas other than nursing homes. The
environment risk factor in falls is currently being assessed in homes and hospitals. Home care
nurses assess the environment their patients live in for safety. Nurses and support staff in the
hospital are continually assessing falls incidents and looking for what was missing that could
have prevented a fall. Exercising, stretching, and improving balance are encouraged to improve
a persons state of wellness. It is an added benefit that these activities will decrease the risk for
falls as well. Controlling the cost of health care is a continual struggle that affects every aspect
of healthcare. The evidence based nursing research into the causes of falls in the elderly has the
potential to help the health care industry save money, prevent debilitating injuries, decrease
hospital lengths of stay, and even avoid deaths.
Overall, applying the evidence will improve health outcomes for patients, which is a
benefit to nurses. The added interventions may increase the number of tasks the nurse must
complete, the number of phone calls made, and the number of patient education sessions held

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with the patient or family. In general, the extra work will be worth the added safety, improved
wellness, and decreased costs to the health care system.
Conclusion and Recommendations
Utilizing the evidence to reduce the risk of falls benefits both patients and nurses.
Patients reduce their risk for injury or death and nurses improve health outcomes when
appropriate interventions are performed. To improve patient outcomes nurses should do the
following

Use fall risk assessments to examine the patient and think of ways to decrease the
patients risks immediately;

Talk with patients about appropriate exercise to improve balance and make suggestions
that are appropriate for the patients health status, as well as find resources for the patient
to engage in wellness programs within their community;

Review medication lists for drugs that cause drowsiness or dizziness and talk with
physicians about these medications to see if any modifications can be made;

Assess the need for eye exams and any barriers that may exist, also see what can be done
to help the patient access resources, find transportation, or make appointments;

Modify the patients home before discharge by having family members remove mats that
are tripping hazards, install grab bars or railings where appropriate, and so on;

Reflect on why a patient has fallen, after the fall occurs to determine additional
interventions;

Look into possible Fall Prevention Tool Kits that could be utilized and bring options to
managements attention where appropriate.

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There is no detriment to incorporating these interventions. The only negative aspect is
that the nurse will have to put forth effort. Sometimes, utilizing the evidence will be quick and
easy. Other times, the nurse will have to overcome obstacles and barriers, or make
modifications. By being imaginative, the nurse should be able to improve fall risks for every
patient across each practice setting.

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References

Centers for Disease Control and Prevention. (2011, September 16). Falls among older adults: An
overview. Retrieved from
http://www.cdc.gov/HomeandRecreationalSafety/Falls/adultfalls.html
Dykes, P. C., Carroll, D. L., Hurley, A., Lipsitz, S., Benoit, A., Chang, F.,Middleton, B.
(2010). Fall prevention in acute care hospitals: A randomized trial. JAMA, 304(17), 19121918. doi:10.1001/jama.2010.1567
Hill, E. E., Nguyen, T. H., Shaha, M., Wenzel, J. A., DeForge, B. R., & Spellbring, A. M.
(2009). Person-environment interactions contributing to nursing home resident falls. Res
Gerontol Nurs., 2(4), 287-296. doi:10.3928/19404921-20090527-02
MacCulloch, P. A., Gardner, T., & Bonner, A. (2007). Comprehensive fall prevention programs
across settings: A review of the literature. Geriatric Nursing, 28(5), 306-311. doi:
10.1016/j.gerinurse.2007.03.001
Quigley, P., Neily, J., Watson, M., Wright, M., & Strobel, K. (2007). Measuring fall program
outcomes. Online Journal of Nursing, 12(2).