Summary of factors contributing to falls in older adults and nursing implications

Background and significance One-third of adults over 65 years of age fall every year.18In the older adult population, falls are the most common cause of trau-matic brain injury,4and of in

NGNA Section

Summary of factors contributing to falls in older adults and nursing

implications

Carol Enderlin, PhD, RN, FNGNAa,*, Janet Rooker, MNSc, RNPa,h,

a University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA

b University of Arkansas Community College at Batesville, USA

c Pinnacle Health System in Harrisburg, PA, USA

d National Gerontological Nursing Association, APRN Collaborative Community Practice, USA

e St Monica Manor, Philadelphia, PA, USA

f University of Utah College of Nursing, Salt Lake City, UT, USA

g University of Central Arkansas, Conway, AR, USA

Keywords:

Falls

Fall risk

Fall risk screening

a b s t r a c t Falls are a common cause of serious injury and injury-related death in the older adult population, and may be associated with multiple risks such as age, history of falls, impaired mobility, balance and gait problems, and medications Sensory and environmental factors as well as the fear of falling may also increase the risk of falls The purpose of this article is to review current best practice on screening fall risks and fear of falling, fall prevention strategies, and fall prevention resources to assist gerontological nurses in reducing falls by their older adult clients

Ó 2015 Elsevier Inc All rights reserved

Introduction

Falls, defined as unplanned descents to the floor or lower level

with or without injury,1are a frequent and devastating occurrence

in older adults The incidence of falls and injuries increases with

age Between 30 and 40 percent of community-dwelling people over the age of 65 years sustain at least one fall per year,2increasing

to about 50 percent for those 80 years and older.3Twenty to thirty percent of older adults who fall suffer moderate to severe injuries.4 Frequently, significant sustained negative outcomes occur in this population as a result of a fall, including a decline in function, an increased likelihood of nursing home placement, and an increased utilization of medical services and costs.5e7

The fear of falling, commonly understood as the level of concern

a person has about falling, or the degree of confidence a person has

in performing common activities without falling, is also a concern Fear of falling affects approximately 50e60% of community-dwelling older adults,8and is particularly prevalent among those who have previously fallen, occurring in as many as 70% after a fall.9 Gait, mobility and vision issues are related to fear of falling, which is

* Corresponding author University of Arkansas for Medical Sciences, 4301 W.

Markham, Slot 529, Little Rock, AR 72205, USA Tel.: þ1 501 526 7845.

E-mail address: caenderlin@uams.edu (C Enderlin).

h Tel.: þ1 501 526 7035.

i Tel.: þ1 501 412 4318.

j Tel.: þ1 716 657 7576.

k Tel.: þ1 267 312 8555.

l Tel.: þ1 801 585 9583.

m Tel.: þ1 501 450 5517.

Contents lists available atScienceDirect Geriatric Nursing

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Geriatric Nursing xx (2015) 1e10

a marker of gait variability.10Greater fear of falling has also been

associated with age-related macular degeneration and vision loss,11

and with fear-related restriction of activity mitigated by visual

acuity and contrast sensitivity.12Fear of falling is a psychological

barrier to performing physical activities,13 and often results in

decreased activities of daily living, which may lead to decreased

muscle strength and tone, loss of mobility and decreased quality of

life.14e16Consequently, fear of falling may also play a role in future

falls.17

The issue of falls in older adults often goes unnoticed by health

care professionals for a variety of reasons which may include: 1) the

older adult does not discuss falling because of fearing loss of

in-dependence; 2) at the time of the fall, little or no injury was

incurred therefore the fall goes undocumented; 3) health care

professionals fail to bring up the issue (or history of falls); 4) those

involved (patient, family, health care professionals) think‘falling’ is

part of the aging process Nurses have the opportunity to play an

essential role in preventing falls in older adults through application

of best practices

Background and significance

One-third of adults over 65 years of age fall every year.18In the

older adult population, falls are the most common cause of

trau-matic brain injury,4and of injury-related death,19costing billions of

dollars yearly in preventable health care expenditures.20 Age, a

history of falls, impaired mobility, balance and gait problems,

specific medications and polypharmacy have all been identified as

risk factors for falls.21

Currently, both single and multidisciplinary approaches are

used to assess the risk of falls, employing a wide variety of

in-struments.22,23There are also a variety of evidence-based fall

pre-vention interpre-ventions including exercise or physical therapy,

psychotropic medication withdrawal, and falls education

Collabo-rative care by an occupational therapist, ophthalmologist,

podia-trist, or cardiologist for problems related to home safety, cataracts,

foot pain, or cardiac arrhythmias is also recommended.24

Conse-quently, the purpose of this article is to review the current best

practice evidence on screening fall risks and fear of falling, fall

prevention strategies, and fall prevention resources to assist

gerontological nurses in reducing falls by their older adult clients

Fall risk screening tools

Determining the risk for falls is complex and involves many

factors It is difficult for the nurse to screen multiple risks

adequately without using a systematic method At a minimum,

simple yearly screening for a history of falls and medications

(particularly those with central nervous system side effects) is

recommended.25Assessment of cognition should also be

consid-ered, since research findings suggest that cognitive decline is

associated with unsafe performance of mobility activities, thereby

increasing the risk of falls.26 Specific fall-related concerns in

community-dwelling older adults can be addressed through the

use of a variety of screening tools related to vision, balance, gait, leg

strength, fear of falling, and home environmental safety The

following summarized tools require limited training, equipment,

cost and time for administration (Table 1)

Incorporating the use of a general fall risk assessment tool such

as The Hendrich II Fall Risk ModelÔ45is recommended as a best

practice approach in caring for older adults admitted to acute care

for primary fall prevention screening and in post-fall assessment

and secondary fall prevention.46This tool, along with documented

evidence and directions for its use are readily available through the

Hartford Institute for Geriatric Nursing.46Using the“4 W’s” (What,

When, Where & Why) framework as part of the post-fall assess-ment may provide important insights into the previous fall and identify risks for future falls Asking the client how he/she was feeling at the time of the fall and about the physical and emotional impact of the fall are also important data to gather in the post-fall assessment.47

Fall risk factors Risk factors which increase the likelihood of a fall in older adults can be divided into extrinsic and intrinsic categories.48Extrinsic factors are those that are external to the individual, such as uneven and slippery surfaces, poor lighting, loose rugs and clutter on the floor, and unsafe footwear Intrinsic factors are those age-related changes and health related internal factors which affect the sys-tems involved in effective balance performance and mobility These can include things such as sensory loss (sight or hearing), chronic health conditions such as heart disease, diabetes, stroke, Parkin-son’s disease, arthritis, cardiac and antihypertensive medications,

or polypharmacy.49Specific vision risk factors include binocular vision (strabismus, amblyopia, diplopia and nystagmus)50and self-reported poor vision (fair or poor distance vision) regardless of actual visual acuity.51,52Other major intrinsic health-related risks for falls in active older adults have been identified as vertigo, which may accompany vestibular failure, peripheral neuropathy, and poor postural stability with associated movement intolerance.53Among community-dwelling older adults, orthostatic hypotension and carotid sinus hypersensitivity were reported as commonly associ-ated with falls.54Medication-related mechanisms which increase fall risk include orthostatic hypotension, sedation, sleep distur-bance, confusion, dizziness and other central nervous system side effects.55

Research focused on falls and mental health problems other than dementia is very limited, although a positive association has been identified.56 Older adults with cancer who are receiving neurotoxic agents, especially those who receive multiple agents, are also at an increased risk of falls and fall-related injuries.57Often these fall risk factors do not exist in isolation, but are additive, such

as a sensory deficit worsening an already unsafe environment or multiple central nervous system-active medications impairing postural balance

Fall risk reduction strategies The Centers for Disease Control18and the National Institute on Aging58 have published general fall reduction strategies with commonalities focusing on exercise, home/environmental modi-fication, medical screening and management of sensory deficits and medication evaluation The American Geriatric Society25 made more specific recommendations including exercise (bal-ance, strength, gait-training), management of foot problems and footwear, the withdrawal or minimization of psychoactive medi-cations, management of postural hypotension, and vitamin D supplementation of 800 IU/day for those with deficiency or risk of falls A recent systematic review further emphasized sarcopenia, frailty, polypharmacy, multi-morbidity, vitamin D status and home hazards as risks, noting that risk reduction strategies should

be individualized and applied in combination to be optimally effective.59

Exercise Based on a Cochrane Review,24Tai Chi was the single type of exercise which was found to significantly reduce the risk of falls, but this reduction applied to those at low risk of falling only Tai Chi

C Enderlin et al / Geriatric Nursing xx (2015) 1e10

2

has been associated with decreased falls for older adults with

Parkinson’s disease.60 Group exercise and home-based exercise

with multiple components significantly reduced the rate and risk of

falls in those at both a low and high risk of falling.24Exercise classes

plus home exercise, rather than home exercise alone, demonstrated

a significant reduction in falls rates for community-dwelling older

adults.61A combination intervention of physical activity with risk

and home safety components was also associated with a reduction

in falls in community-dwelling older adults.62Physical exercise in

general was associated with a significant effect on fall prevention in

cognitively impaired older adults.63However, a systematic review

of exercise in residential care settings noted that, while exercise

improved some physical functions which are risk factors for falls,

the actual impact upon falls is less clear.64Among sporting

activ-ities participated in by older men, swimming has been associated

with significantly lower risk of falling.65 The United States

Department of Health and Human Services recommends a

mini-mum of 150 min per week of moderate-intensity or 75 min per

week of vigorous-intensity aerobic physical activity plus muscle

strengthening activities twice per week, in addition to balance

training three or more days per week for older adults at risk for falling.66

Home and environmental modification Overall, home safety assessment and modification in-terventions, including the use of assistive devices, were found to reduce the rate of falling.24An occupational therapist plus nurse or physical therapist home visit intervention, including home assessment for environmental hazards, information regarding changes, facilitation of modifications, and training for technical and mobility aids was effective in reducing the rate of falls in community-dwelling older adults at high-risk for falling.67Falls were also reduced in older adults with a history of falling following environmental assessment and modification by an occupational therapist (OT), although the same results were not found with us-ing a trained assessor.68A single home visit from a research nurse with offers of a home hazard assessment, information on hazard reduction and installation of safety devices was ineffective in reducing falls in older adults, and this failure was attributed to its

Table 1

Selected fall risks screening tools used in older adults in the community setting.

Screening tool & risk factor Administration

time

Older adult population & psychometrics Sensory function

Snellen eye test

(visual acuity) 27 <10 min Community-dwelling adults 65 years and older

 Visual acuity of better eye <6/12 (odds ratio [OR], 2.47; 95% CI, 1.18e5.18; p < 0.001) were significantly associated with falls 28

 High reliability (r ¼ 0.99) 29

 Reliability dependent upon correct distance and lighting with testing 30

Physical function

Berg balance scale

(functional balance) 31

<20 min Community-dwelling independent-living adults 65 years and older with & without history of falls

 A score of 40 or < is associated with a fall risk approaching 100%

 A score of 56 or > associated with a 10% probability of falls 32

 Inconsistent falls prediction with cut score of 45 in community-dwelling older adults 33

Dynamic gait index

(balance and gait function) 32 20e30 min Community-dwelling independent-living adults 65 years and older with & without history of falls

 Sensitivity 91% & specificity 82% with best model including 2 factors: balance þ self-report measure of imbalance history

 Score of 19 or below predictive of falls 32

Functional reach test 34 <5 min Community-dwelling males 70e104 years

 Reach < or ¼6 inches predictive of falls (OR ¼ 4.02, 1.84e8.77) 35

 High test-retest reliability (ICC ¼ 0.81) 34

Timed sit to stand

(leg strength) 36,37

<10 min Community-dwelling independent-living adults

Norms available by gender and age group (60e94 years)

 Predictive of falls (OR ¼ 4.03) 38

 Discriminates between persons with recurrent, single and no falls (OR ¼ 2.0)

 >15 s to complete task associated with 74% increase in risk of recurrent falls 39

Timed up and go

(functional mobility) 40,41 <5 min Community-dwelling adults mean age 79.5 years

 Predictive of ability to go outside alone safely

 Correlates well with log-transformed Berg Balance Scale (r ¼ 0.81), gait speed (r ¼ 0.61), & Barthel Index of activities of daily living (r ¼ 0.78)

 Inter- and intra-rater reliabilities (ICC ¼ 0.99 both)

 Scores 30 s or > indicate assistance for many mobility tasks & slow gait speed

 Scores < than 20 s indicate independent mobility or with a cane, reasonable balance, & functional gait speed 41

Psychological function

(fear of falling)

Falls Efficacy Scale:

international version

(fear of falling) 42

<10 min Community-dwelling adults 60e95 years

 Discriminates older adults with history of falls from those without history of falls

 Excellent internal validity (Cronbach’s alpha ¼ 0.96)

 High test-retest reliability (ICC ¼ 0.96) 42

6-item Activity-specific

Balance Confidence Scale

(ABC-6) (balance confidence

and fear of falling in

performance of ADLs) 43

<10 min Older adults 66e83 years (3 groups: higher level gait disorders [HLGDs], Parkinson’s disease [PD], healthy controls)

 Internal consistency high in 3 groups ranging from 0.81 to 0.90

 Sensitivity 91% for higher level gait disorders and 53% for Parkinson’s disease

 Test-retest reliability between original ABC-16 and ABC-6 ICC ¼ 0.88 (HLGDs), 0.83 (PDs), 0.78 (controls) 43

Home

Home Falls and Accident

Screening Tool (Home FAST) 44

20 min Community-dwelling older adults, two sites with mean ages of 79.7 and 78.1 years

 Sensitivity ¼ 69% for proportion of people with hazards

 Specificity ¼ 90% for proportion of people who do not have hazards identified by expert & second raters

 Cronbach’s alpha ¼ 0.62 for overall checklist 44

Adapted from Fabre JM, Ellis R, Kosma M, Wood RH Falls risk factors and a compendium of falls risk screening instruments J Geriatr Phys Ther 2010;33:184e197.

C Enderlin et al / Geriatric Nursing xx (2015) 1e10 3

limited effect upon the hazards which remained within the

home.69 Including home hazard education and modification in

multifactorial health promotion home programs also resulted in

reduced overall falls and indoor falls for older adults, which was

significant in those 75 years and older.70Interventions involving

specific home modifications including handrails for outside steps

and internal stairs, grab rails for bathrooms, outside lighting,

edg-ing for outside steps, and slip-resistant surfacedg-ing for outside areas

such as decks and porches, were associated with reducing

fall-related injuries by over 33%.71 Single environmental modi

fica-tions such as placement of high-contrast edge highlighters on stairs

improved foot clearance and foot placement significantly, reducing

the risk of stairway falls.72Thus, there is some evidence to support

home programs which include hazard awareness and modi

fica-tions, specific single modifications to high fall risk areas such as

stairs, and OT-led interventions in reducing falls Working

collab-oratively with OTs to achieve home modifications may then be the

optimal way for nurses to help achieve fall reduction in older

adults

Screening and management of sensory deficits

Replacement of multifocal lens with a single lens in glasses used

for indoor/outdoor activities significantly reduced all falls for an

active subgroup of older adults,73which may be very meaningful

for older adults who choose to walk outdoors for exercise and thus

are more vulnerable to external environmental risk factors Older

adults with bilaterial cataracts were found to be at high risk for

falls, based on self-report, especially women who lived alone.74

Vision correction itself was associated inconsistently with a

reduction in risk of falls.75Earlier studies found that cataract

sur-gery on thefirst eye was significantly associated with a reduction

in the rate of falls, but not in the risk of falling,76while cataract

surgery on the second eye had no effect upon the rate or the risk of

falling.77However, a large recent study reported a doubled risk of

falls between the time of thefirst and second-eye cataract surgery,

and a 34% increase in falls requiring hospitalization during the 2

years following the second-eye cataract surgery when compared

with two years prior to surgery.78Neither visual acuity assessment

nor referral were associated with a reduction in the rate of falls,79

while vision assessment, eye exam, and referral for mobility

training and canes was actually associated with an increased rate of

falls.80 In older men with poor vision, status of large muscle

function was suggested to mediate fall risks, although this was not

so of older women.81Thus vision and related vision correction,

mobility and the use of mobility devices, and large muscle

func-tioning should all be considered when evaluating fall risks in older

adults

Peripheral sensation was also suggested as part of every

stan-dard fall risk assessment.82Multifaceted podiatry including

foot-wear review, customized orthoses, foot and ankle exercises, and fall

prevention education in addition to standard podiatry care were

found to significantly reduce the rate of falls in persons with

disabling foot pain.83A non-slip device worn on outdoor shoes in

hazardous winter conditions also resulted in a significantly reduced

rate of outdoor falls.84This could be important to the large numbers

of older adults who suffer with diabetes and arthritis-related foot

problems

Vitamin D supplementation

Vitamin D was found to benefit muscle strength and balance,85

although vitamin D supplementation reduced the risk and rate of

falls in those with low vitamin D only.24 Combining 800 IU of

vitamin D (cholecalciferol) per day plus calcium 1000 mg was

shown to be superior to calcium alone in reducing the number of falls in community-dwelling older adults.86A slightly higher dose

of 1000 IU of vitamin D (ergocalciferol) plus 1000 mg of calcium per day was associated with a fall reduction of 19% in community-dwelling older women with vitamin D insufficiency and a history

of falling, primarily in the winter months.87In an effort to improve medication adherence, research of high-dose, intermittent dosing

of oral vitamin D (cholecalciferol) of 150,000 IU every three months found neither a beneficial nor an adverse effect on falls in older women.88Overall, vitamin D supplementation appears to be the most beneficial for fall reduction in older adults with insufficient levels of vitamin D

Medication modification Research investigating medication review and modification combined with an educational component for family practitioners significantly reduced the risk of falling.89 However, medication review and modification alone as a single strategy was ineffective.90 Nurses could have an impact on the risk for falling by either reviewing or facilitating medication reconciliation This is of particular concern regarding medications with central nervous system side effects, such as psychotropics or those which influence blood pressure When reviewing medications, nurses can compare the client’s medications against the Beers Criteria91 to identify potentially inappropriate medications which are associated with a high risk of adverse side effects such as orthostatic hypotension and/or falls Particular categories of drugs with these high risks include tertiary tricyclic antidepressants, benzodiazepines, non-benzodiazepine hypnotics, alpha blockers, and alpha agonists.91 This article reviews the noted high risk medication categories as well as other commonly used medications related to risk for falls

Psychotropic medications and falls risks Psychotropic medications are defined as those which cross the blood brain barrier and act directly on the central nervous system (CNS).49These drugs are also called CNS active or psychoactive drugs The use of some classes of psychotropic medications in older adults has been shown to pose significant risk for falls Research indicates that over 20% of community dwelling older adults are prescribed psychotropic medications92and over 80% of older adults living in residential care settings take at least one psychotropic medication.93,94 Moreover, these same adults often have other comorbidities or medications that, when added to their psycho-tropic medication regimen, significantly increase their risks Com-munity dwelling older adults taking one psychotropic medication have a 1.5 fold increased risk of falls, and those taking two or more have a 2.5 fold increased risk of falls compared to non-users.95The highest risk is associated with antipsychotic medications followed

by antidepressants and then benzodiazepines.96 Psychotropic drug subcategories that have been linked to increased fall risk include antidepressants drugs (OR 1.36; 95% CI, 1.13e1.76), drugs used to treat bipolar disorder, anxiolytics or hypnotics, drugs used in dementia therapy, and antipsychotics (OR 95% CI, 0.94e2.00) When data from 6 of 22 studies included in a meta-analysis on falls and medications were analyzed, it was noted that sedative hypnotics, antipsychotics and anxiolytics significantly increased the likelihood of falling While most of these studies examined data from community-dwelling older adults, similar re-sults were noted in residential care settings.96

C Enderlin et al / Geriatric Nursing xx (2015) 1e10

4

Roughly 16% of community dwelling older adults use

antide-pressant medications, and in nursing homes this number rises to

between 18 and 27%.94,97 Antidepressants as a class have been

found to be among the most prescribed fall risk-increasing drugs.98

Antidepressants have also been identified as among the most

common medications associated with falls by older adults treated

in the emergency department.99Tricyclic antidepressants (TCAs)

have been related to orthostatic hypotension and a widening QT

interval, particularly due to the anti-cholinergic side effects The

most commonly used are doxepin and amitriptyline.100,101TCAs are

associated with a 51% increase in fall risk (OR 1.51, 95% CI, 1.14e

2.00) Selective serotonin reuptake inhibitors (SSRIs) also increase

the risk of falls due to anti-cholinergic effects (OR 1.72, 95% CI, 1.40e

2.11).96,102 These medications also have the potential to cause

extrapyramidal effects and sedation SSRIs are associated with

reduced bone mineral density and higher risk for fractures These

drugs are widely advertised but they are not benign

medications.101,103

Medications for bipolar disorder

The most commonly used medication in the treatment of

bi-polar disorder is lithium Although, lithium is not associated with

falls directly, increased fall risk is associated with the side effects

which include blurred vision, fatigue, tremor and vertigo

Thera-peutic ranges for older adults are somewhat lower than they are for

younger adults because of the reduced kidney function found in

older adults, and toxic levels are reached much quicker Other

medications that are used to treat bipolar disorder include mood

stabilizers These are also known as anti-seizure medications and

include carbamazepine, valproic acid and lamotrigine While not

directly associated with increased fall risk, they may increase risk

due to dose-related ataxia Neurontin, often given to treat

periph-eral neuropathy in diabetics and sometimes used as a mood

sta-bilizer in violent patients, can increase the risk for falls due to

dizziness and confusion, especially in the morning.104

Anxiolytics

Medications used in the treatment of anxiety, including such

medications as hydroxyzine, benzodiazepines, and antihistamines,

increase the overall fall risk due to the increase in confusion

experienced with age Anxiolytics produce side effects that are

more prominent in older adults, and increases in fall risk up to 44%

have been reported in nursing home residents.105 In addition to

antidepressants, anxiolytics are one of the two most prescribed fall

risk-increasing medication categories,98 and the longer acting

benzodiazepines have the greatest risks Side effects such as slower

thought processes and reaction time as well as increased confusion/

delirium have been reported.49,106

Medications for Alzheimer’s disease

There are limited data available on the effects of medications

specifically used to treat Alzheimer’s Disease and other dementias

Aricept (donepezil), the most commonly used medication for

de-mentia, has side effects which include dizziness, drowsiness,

fa-tigue, ataxia, and syncope, all of which could increase the risk of

falls.107However, improvements in cognition early in the treatment

can reduce fall risk for those suffering early dementia.108 It is

necessary, therefore, to balance the treatment effects versus risk

factors involved when treating dementia with these drugs

Antipsychotics Antipsychotic medications have been categorized as either typical (older) antipsychotics such as haloperidol and chlor-promazine, or atypical (newer) antipsychotics such as olanzapine and risperidone Typical low potency antipsychotics such as chlorpromazine, still used to bring about rapid behavioral control

in violent patients, have a higher occurrence of anti-cholinergic symptoms such as urinary retention, constipation, blurred vision and orthostatic hypotension Medications such as halo-peridol and thioridizine, higher potency typical antipsychotics, have higher rates of drug-induced Parkinsonism and extrapyra-midal side effect (EPS) symptoms which can increase gait ab-normalities and balance as well as coordination difficulties.109 After a 1-month follow-up study,110an increased fall risk with olanzepine (hazard ratio [HR] 1.74 95% CI, 1.04e2.90) and ris-peridone (HR 5.05, 95% CI, 1.4e17.75) was reported, after adjusting for the effects of Parkinson’s disease Atypical anti-psychotic drugs have fewer side effects but still produce side effects which can increase all fall risk include sedation and orthostatic hypotension.49,96 Additionally, several studies found that both typical and atypical antipsychotics increased the risk of fall-related fractures in dementia patients especially during the first week of treatment,111although the risk remained higher for

a longer period with the use of typical antipsychotics Drugs such

as diphenhydramine and benzotropine given to combat EPS often contribute to the fall risk by increasing confusion Any antipsy-chotic drug has been reported to increase the overall fall risk by approximately 59% (OR 95%, CI, 1.37e1.83).96Antipsychotics have also been identified as among the most common medications associated with falls resulting in emergency department visits.99 Although the atypical antipsychotics may produce fewer overall adverse side effects, they do not appear to be any safer than typical antipsychotics in terms of mitigating fall risks

In conclusion, the use of psychotropic medications across all settings poses a significant threat to the safety and health of older adults because of the increase in fall risk A thorough physical, behavioral, and environmental evaluation is a must before any of these medications are prescribed Astute observation by nursing staff and other caregivers will help to mitigate injury related to use

of these medications However, it seems advisable to avoid the use

of psychotropic medications whenever possible To reduce the fall risk for patients requiring psychotropic medications, it is advisable

to consider several of the following issues:

1 What is the patient’s initial fall risk?

2 What other risk factors does this patient have that need to be considered?

3 What alternatives are there to the use of antipsychotic medications?

4 Are psychotropic medications essential in this situation?

5 When were the indicators for beginning a particular psycho-tropic medication last evaluated?

Reducing the dosage, length of therapy or withdrawing the high-risk medications altogether has been associated with a reduced risk of falls and other adverse events in the older popu-lation Non-pharmacologic measures should always be triedfirst If medications are used, they should be reviewed frequently so that when opportunities arise dosages can be reduced or medications discontinued over time Fall risk assessments should be completed

as needed to identify other risk factors in order to reduce the risk of subsequent falls and related injuries in patients who must take psychotropic medications

C Enderlin et al / Geriatric Nursing xx (2015) 1e10 5

Pharmacological and non-pharmacological sleep therapies

and falls

Sleep problems are associated with falls in older adults aged 64e

99 years.112Forty-four percent of older adults experience one or

more insomnia symptoms a few nights per week or more, and older

adults take more prescription and over-the-counter sleep

medica-tions than any other age group.101,113 International research has

focused on the problem of falls in older adults and sleep

medica-tions, particularly drugs classified as sedative-hypnotics including

benzodiazepines,“Z” compounds, and antihistamines As a class,

sedative-hypnotics are thought to increase the risk of falls through

their CNS side effects, particularly those related to balance, sedation

and anti-cholinergic properties, which would include orthostatic

hypotension (low blood pressure on arising).114Across a variety of

older adult settings (community, residential, acute care,

rehabili-tation) sedative-hypnotics increase the odds of falling by almost

one-half (pooled Bayesian OR 1.47 [95% CI, 1.35e1.62]).70,96,102

Sedative-hypnotics

Sedative-hypnotics have been specifically categorized as “fall

risk increasing drugs” and are positively correlated with an

increased incidence of injuries including falls in a study of frail

German elderly 65 years and older.115Although sedative-hypnotics

increase the odds of falling for all age groups, there is a

“dose-response” relationship only among the elderly, conferring a unique

vulnerability to this age group based on a Swedish national

study.116This vulnerability is most pronounced in nursing home

residents whose risk of falling increased with even low doses of

sedative-hypnotic drugs, as reported in a study of nursing home

residents in the Netherlands.117Further, exposure to sedative and

anti-cholinergic medications (measured as the Drug Burden Index)

was significantly and independently associated with falls in

Australian aged care facility residents,118suggesting that regardless

of other fall risks these medications alone increased the risk of

falling

Benzodiazepines

Benzodiazepines, a type of sedative-hypnotic, has been one of

the most common drugs traditionally used for the medical

man-agement of sleep problems and has fallen out of favor in the care of

older adults due to CNS side effects Increased postural sway and

loss of balance,119 is thought to increase the risk of falls, and is

worsened by a loss of position-sense in the toes,101,120a condition

common to those with peripheral neuropathy or similar sensory

disorders As a type of sedative-hypnotic, benzodiazepines increase

the odds of falling by slightly over one-half (Bayesian OR 1.57 [95%

CI, 1.42e1.72]).96 Although there has been a shift towards a

reduction in benzodiazepine prescribing practices, the decreased

use has not resulted in a decrease in hip fractures from falls,121,122

suggesting that falls are multifactorial in nature Dose of

benzodi-azepine has also been suggested as more important than

half-life,123suggesting that shorter-acting formulations may not be as

effective as lower doses in preventing falls Although one might

expect thefinding that fall risk is higher during the first two weeks

of a new prescription,124the fact that the fall risk remains elevated

after 30 days105 is alarming, suggesting that older adults do not

“acclimate” to CNS side effects Last, although families and health

care providers often think of the hospital as a safer place than the

home, exposure to benzodiazepines (controlling for cancer,

zolpi-dem, antihistamines and narcotics) more than doubled the odds of

falling in this setting (OR 2.26, 95% CI, 1.21e4.23) in a

case-controlled study of older adult inpatients.125 Benzodiazepines

with a shorter duration of action were once thought to be a safe alternative for older adults; however, short-acting benzodiazepines have been found to strongly increase the frequency of falls in older adults and should thus be avoided, especially by older adults with other fall risk factors.126

Non-benzodiazepines What about the“Z” drugs, and are they a safer alternative for older adults with sleep problems? These medications significantly impair body balance in a dose-dependent manner as well Based on

a review of randomized controlled trials of hypnotics and Z-drug effects on body balance and standing steadiness, zolpidem and zopiclone have demonstrated similar impairments as benzodiaze-pines, and zaleplon significantly impairs balance up to 2 h after administration.127One small randomized controlled trial of zolpi-dem, which investigated the impact of sleep inertia (grogginess on awakening) on walking and cognition after awakening from sleep, reported that there were clinically significant balance and cognitive impairments, with one tandem walk failure per 1.7 older adults treated.128Although a small study, this suggested that for every two older adults treated, one would have difficulty with walking after taking zolpidem (while still under its effects)

Narcotics While narcotics are not sleep medications, they are taken by many older adults to assist with chronic pain relief at bedtime Taken alone, this class of medications is not suggested to increase the risk of falls.129 However, narcotics may potentiate gait and balance changes when they are taken together with other CNS-active medications.114Exposure to narcotics as well as benzodiaz-epines was associated with falls during hospitalization,125which emphasizes the potential for falls during a time when older adults are likely to be exposed to the cumulative CNS side effects of multiple medications while in pain and in an unfamiliar environment

Antihistamines Antihistamines, most commonly found in over-the-counter sleep aids, have also been associated with falls in the hospital setting.125These medications are frequently administered to con-trol adverse side effects of other medications such as itching, or to control symptoms such as nausea and, although often considered

by older adults to be“innocuous”, have CNS side effects on cogni-tion which can be more pronounced in older adults.130The use of antihistamines such as diphenhydramine and doxylamine succi-nate are not recommended for older adults in general,91but when they are used, their potential influence and additive influence on fall risks should be taken into consideration

Herbals Melatonin, a melatonin receptor agonist often used for sleep, does not differ in safety for older compared to younger adults and does not have the CNS side effects found with benzodiazepines and

“Z” drugs,131although dizziness is listed as a possible side effect.132 Over-the-counter melatonin formulations are short-acting, but longer-acting forms are available by prescription, and are designed

to mimic the pattern of naturally-produced melatonin European studies of prolonged-release melatonin reported no adverse effects

on cognition or postural stability and found a 31% discontinuation rate of benzodiazepines or“Z” drugs by older adults with insomnia prescribed the herbal alternative.133Although studies of campaigns

C Enderlin et al / Geriatric Nursing xx (2015) 1e10

6

to reduce benzodiazepine and“Z” drug use and to promote

pro-longed release-melatonin use found they were not largely

suc-cessful in nine European countries, this was attributed to factors

related to market availability and uptake.134

Cognitive behavioral therapy

Due to the CNS side effects of so many sleep medications,

non-pharmacologic sleep interventions may be safer alternatives for

many older adults Cognitive behavioral therapy is actually

considered thefirst-line of therapy for insomnia, to be equal in

effectiveness and to have more sustained effectiveness over time

than medications.135 Non-pharmacologic interventions, such as

stimulus control therapy which focuses on the re-association of the

bed and bedroom with sleep,136,137and relaxation therapy which

focuses on reducing cognitive arousal and somatic (muscle)

ten-sion,138may promote sleep without increasing fall risk Although

not recommended as a single intervention, sleep hygiene

educa-tion, which aims to increase client knowledge of the sleep process

and sleep-promoting behaviors, such as the importance of a regular

sleep-wake schedule, may help improve sleep and thus decrease

fall risk.139,140 Sleep hygiene education is consistent with the

teaching role of nursing and engages the client to be an informed

and active participant in his/her own care Sleep hygiene is also

considered most effective when individually tailored, which is also

consistent with nurses’ views of clients as having unique personal

and cultural preferences and needs

In summary, sleep medications have been suggested to increase

the risk of falls in older adults through impaired balance, sedation

and other side effects such as orthostatic hypotension in a

dose-dependent manner Older adults with dementia, hospitalized

older adults and those taking multiple CNS-active medications

appear to be at particular risk for falls when taking sleep

medica-tions Melatonin and non-pharmacologic sleep interventions may

be safer, effective alternatives to benzodiazepines,“Z” drugs and

antihistamines for older adults who need sleep medications

Nurses should not only be aware of prescription and

over-the-counter sleep medications their clients take, but should assess

the following in older adults: balance, gait, toe sensation, and blood

pressure on rising Sleep hygiene should be routinely included in

client education, and individualized to the client

Non-pharmacologic interventions should be considered“first choice”,

but if medication is necessary, the lowest dose possible for the

needed effect should be given Melatonin may also be considered as

an alternative medication The concurrent use of multiple

CNS-active medications should be avoided if at all possible and, where

unavoidable, additional fall precautions should be implemented to

increase safety

Syncope and falls

Falls and syncope have been addressed as two common and

interrelated geriatric syndromes that cause considerable mortality

and morbidity among older adults.141Syncope is described as“a temporary and sudden loss of consciousness, typically due to transient cerebral hypoperfusion or a decline in bloodflow to the brain.”142Because brain cells require adequate bloodflow to pro-vide a constant supply of energy, an interruption of cerebral perfusion for only 3e5 s can result in syncope It can be caused by a decrease in cardiac output, high blood pressure, a sudden drop in blood pressure or other neurologic factors Syncope can also occur without reduced cerebral blood flow in response to changes in blood sugar or oxygen levels.143 Conditions such as orthostatic hypotension, cardiac arrhythmias, cardiopulmonary or cerebro-vascular disease may be factors underlying syncope.143Other car-diac conditions associated with syncope and/or falls include heart murmurs, angina, heart failure and myocardial infarction.144 Med-ications such as blood pressure-reducing agents, or drugs affecting electrolytes or the central nervous system may also contribute to syncope.142

Syncope is characteristically rapid in onset, short in duration and spontaneous in recovery Consequently, older adults may not even realize they are losing consciousness until they regain awareness tofind themselves on the ground.145In retrospect, some older adults may recall warning symptoms of a syncopal episode such as: dizziness, light-headedness, visual disturbances, cold/ clammy skin, nausea, or sweating Weakness, loss of postural tone,

a“drop” to the floor, or losing consciousness may also be remem-bered It is important to note how quickly the older adult lost and regained consciousness, along with the presence of confusion and if

he or she fell Cardiac or stroke-like symptoms should also be explored further The nurse should ask what the older adult was doing immediately before the event (e.g resting, exertion, cough-ing, voiding or standing).143 Finally, a complete medication list should be reviewed.146 Positive responses on the post-syncopal assessment are“red flags” and should be shared with the older adult’s primary care provider (PCP) to assist in determining the likely cause/s of the syncope

Educating older adults and their families about syncope cannot

be over-emphasized An at-risk older adult should know how to recognize it and to discuss suspected syncope with a PCP Keeping the PCP apprised of all medications taken should also be stressed to prevent polypharmacy and allow consideration of possible adverse effects which could contribute to syncope and falls

Conclusion Preventing older adults from falling will become an increasing challenge with the growth of an older population Yet, the number

of falls and the severity of injuries can be decreased by identifying, removing and/or modifying various risk factors and implementing risk reduction interventions Nurses caring for this population across all settings are in an important position to screen, educate and intervene for better outcomes With implementation of evidenced-based practices and continued research related to fall prevention, we can anticipate new approaches to decrease falls and

Table 2

Falls prevention resources.

Resource and author Website

Prevention of falls in community-dwelling older adults:

U.S Preventive Services Task Force recommendation statement 2

http://www.guideline.gov/content.aspx?id¼37219&search¼fallþprevention

AGS/BGS clinical practice guideline prevention of falls in older persons 25 http://americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_

recommendations/2010/

STEADI (Stopping Elderly Accidents, Deaths & Injuries) tool kit

for health care providers 147

http://www.cdc.gov/homeandrecreationalsafety/Falls/steadi/index.html

NIH senior health: falls and older people 148 http://nihseniorhealth.gov/falls/aboutfalls/01.html

Falls toolkit 149 http://www.patientsafety.va.gov/professionals/onthejob/falls.asp

C Enderlin et al / Geriatric Nursing xx (2015) 1e10 7

injuries sustained by an aging population The responsibility to not

only provide optimal care for older adults, but also to utilize

existing information and resources (Table 2) as we collaborate with

all other health care professionals to optimize safety in an aging

population is paramount

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