The Vanderbilt Fall Prevention Program for Long-Term Care: Eight Years of Field Experience with Nursing Home Staff

Fall prevention in nursing homes continues to be one of the most challenging aspects of care not only because of the high frequency of falls but also because of their significant impact on residents, families, staff, and administration. Between 45 to 70% of the estimated 1.7 million nursing home residents fall annually. Of these, 30 to 40% will fall two or more times and 11% will sustain a serious injury as a result of the fall. Consequences of falls can affect the resident through loss of function because of physical trauma as well as psychological trauma most often demonstrated by high levels of fear associated with falling. A common result of falls for medical and nursing staff is the need for increased levels of care provision due to resident changes in function. Increased paperwork and poor survey results are associated with a high incidence of falls as well. Falls also may negatively affect a facility’s relationship with families and the community. Finally, rising monetary awards associated with lawsuits related to falls and high insurance premiums may significantly increase operating costs of the facility. Settled claims vary widely between states with some awards exceeding $500,000. Hip fracture is one of the most serious consequences of falls. Over 300,000 hospitalizations among persons 65 years and older are due to hip fracture each year. Increased morbidity and mortality following hip fracture is well documented. Although patterns of excess deaths attributable to hip fracture vary with different levels of comorbidity and functionality at the time of fracture, an estimated 4 excess deaths per 100 hip fracture patients occur in the first year postfracture. Hip fracture often leads to severe losses in independence and quality of life, and of those able to ambulate independently before a fracture, fewer than one-half will be able to do so one year after the fracture. Multiple intrinsic and extrinsic fall risk factors have been identified in elderly nursing home residents. Intrinsic factors related to aging, acute medical illness, and chronic disease often cause sensory, cognitive, neurologic, and musculoskeletal impairments that have been shown to increase fall risk. About one-half of the residents in nursing homes exhibit some form of dementia, and as a result, unsafe behaviors due to cognitive loss are extremely common. Evidence suggests that residents with dementia have a higher risk of falls and associated injuries. Side effects of many medications have also been shown to increase fall risk in the elderly. In particular, antipsychotics, hypnotic-anxiolytics with long elimination half-lives, and cyclic antidepressants are associated with a significantly higher fall risk. Extrinsic factors in relation to the environment and equipment such as clutter, poor lighting, uneven flooring, and ineffective wheelchair brakes also affect fall risk. As the number of persons residing in nursing homes increases due to the greater life expectancy of persons reaching 65 years of age and the level of care rises due to increases in disability, reduction of falls will continue to be a major public health problem. Although fall prevention efforts for community-dwelling elderly have reported some success, few studies are available in the nursing home population. For this reason, in 1993 the Vanderbilt University Department of Preventive Medicine developed its first fall prevention program to determine its efficacy in long term care. The Vanderbilt Fall Prevention Program includes comprehensive assessment and individualized care plan development for residents who are at high risk of falling as well as inspection and repair of safety problems in the resident’s environment and with equipment. The program is implemented by a multi-disciplinary team and includes training of all facility staff in fall prevention methods. This article describes progression of the Department of Preventive Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee.