Given the increasing rates of Alzheimer’s disease in long-term care, it is vital for facilities to develop a proactive approach to fall prevention.

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lzheimer’s disease (AD), the most common form of dementing illness, is a common condition in long-term care facilities. Approximately 50% of residents in both assisted living facilities and nursing homes suffer from AD.^1-3 Falls are one of the most common safety problems in long-term care facilities—as many as 60% of residents experience one or more falls annually). Individuals with AD are twice as likely to experience a fall as are those without AD. These residents are not only at increased risk of falling but involved in the majority of falls occurring in long-term facilities.
       Of even greater importance, the fall-related morbidity associated with AD is significant. About 25% of residents with AD who fall sustain fractures. Hip fractures are the most common, often resulting in decreased ambulation and immobilization. In addition, residents with AD who fall have a poorer prognosis than do cognitively intact fallers; they are less likely to make a satisfactory recovery from injury. If caregivers are aware of the issues surrounding fall prevention in residents with AD, many falls can be avoided. The purpose of this article is to provide facilities with practical guidance on developing an approach to fall prevention in residents with AD.

Why Residents With Alzheimer’s Disease Fall

       It is often believed that falls are a normal part of AD, due solely to cognitive deficits. Moreover, many think that there is no effective treatment for falls in residents with AD. These beliefs, however, represent a myth. As with any resident, falls in AD are often precipitated by a number of risk factors, including:
       Previous falls. A history of one or more falls in the preceding six months is a strong predictor of future falls. The majority of falls occur during four time periods: mid-afternoon, at change of staff shift, just after a resident rises in the morning, and just before bedtime in the evening).
       Medication. The number and type of drugs influence the risk of falling. The combination of four or more drugs and/or the use of cardiovascular and psychotropic drugs double the risk of falls in AD. Common drug side effects associated with fall risk in AD include drowsiness, dizziness, unstable blood pressure, and worsening confusion.
       Mobility. Mobility includes altered bed and chair and transfers and impaired gait/balance, which increase the risk of falling. These impairments are more marked in residents with AD who fall. Specific impairments include:
• Disturbed balance/transfers (ie, inability to maintain stability during postural changes)
• Impaired ambulation (ie, a small-stepping and shuffling gait)
• Cautious gait (ie, flexed posture, slowness of walking, and uncertainty of foot placement).
       Cognition. A loss of cognitive function can lead to:
• Lack of understanding and awareness of potential for falls and need for help
• Inability to ask for help or assistance with mobility because of communication problems (eg, aphasia)
• Judgment errors (ie, inability to recognize the difference between safe and hazardous mobility and misperception of environmental hazards)
• Overestimation of capacity for safe mobility (ie, “I can do it myself”); as a result, individuals attempt to accomplish tasks they are no longer capable of performing safely by themselves.
• Failing to remember limitations in daily activities (ie, forgetting that they cannot walk by themselves)
• Behavioral manifestations (eg, wandering, pacing, agitation, restlessness, disorientation, hallucinations, etc.) that can result in attention deficits and worsening cognition
• Sundowning (ie, disruptive behaviors that appear during late afternoon or night).
       Vision. Important visual problems in AD include:
• Restriction of visual fields (ie, loss of peripheral vision)
• Decrease in visiospatial function (ie, the ability to judge distances/relationships among objects in visual field), which may lead them to misjudge where the edge of a chair or edge of their bed is located
• Decline in depth perception (ie, the ability to judge distances and relationship among objects)
• Loss of contrast ability (ie, the ability to perceive spatial detail and contrast between objects)
• Agnosia (ie, decreased recognition of familiar objects/places).
       Environment. Environmental obstacles and design features associated with fall risk in AD include:
• Lighting problems (eg, low lighting, a lack of night lights, and added glare)
• Floor problems (eg, clutter and slippery surfaces/rugs)
• Furniture problems (eg, a low seating height of beds and chairs)
• Bathroom problems (eg, a low toilet seat and lack of grab-rail support)
• Storage problems (eg, low and/or high shelves).
       Assistive devices and protective equipment. The choice and the use of assistive devices (eg, canes/walkers and transfer aids) and protective equipment (eg, hip protectors and fall alarms) have to be correct in order to create safe conditions for the resident with AD. Incorrect choice and/or use enhance fall risk.
       In view of the multifactorial fall risk factors in residents with AD, a successful intervention strategy to reduce falls should be multidisciplinary and address the risk factors and specific causes of falls identified as being important in AD.

Approaches to Preventing Falls in Alzheimer’s Disease

       The approach advocated to preventing falls in cognitively intact residents is appropriate for residents with AD as well. Assessing the risk of falls represents an important starting point in attempting to reduce falls. The main purpose of risk assessment is to identify those residents with AD most likely to fall. The rationale for this assessment is that if residents at high fall risk can be identified, appropriate interventions can be instituted to minimize their risk of falling. An effective fall risk assessment is one that identifies the relevant risk factors for falls in residents with AD (eg, previous falls, cognitive status, disturbed vision, muscle weakness, unsteady gait and balance, elimination problems, chronic diseases affecting mobility, medications, correct use of ambulatory aids, and environmental hazards).
       It is also important to assess the resident’s mobility (eg, asking the resident to walk with his or her cane or walker, if needed, and transfer from his or her bed, chairs, and toilet, and noting any difficulties encountered). Observing a resident’s mobility in relation to his or her surrounding environmental conditions is the best way to determine whether external factors (eg, lighting, floor conditions, furnishings, assistive walking devices, footwear, etc.) are appropriate and safe or hazardous and unsafe.
       Fall risk assessments should be completed upon admission or at the time of move-in. Since residents are subject to a change of condition (eg, onset of medical illness, medication adjustments, cognitive impairment), fall risk factors can change as well. As a result, reassessment of fall risk must be ongoing and completed whenever residents have a new medical condition and/or begin taking new medications. They should occur daily and/or every shift for certain high-risk residents (eg, those with recent confusion, those taking sedatives, those with a recent fall and/or temporary acute illness, etc.) and immediately post-fall. The purpose of this assessment is to discover what caused the fall and to prevent another fall from occurring.
       After completing a fall risk assessment and identifying specific risk factors, an attempt should be made to identify the underlying cause(s) of all risk factors identified. Since residents with AD may have multiple risk factors, multidisciplinary referral and evaluation is vital. Identified risk factors and the results of subsequent multidisciplinary evaluations serve as the basis for selection of interventions or strategies aimed at reducing fall risk. The most successful interventions are those that are designed to meet the individual needs of residents with AD. To follow are suggested approaches to reduce fall risk.

Medications

       Monitor medications on a regular basis, specifically cardiovascular and psychotropic drugs (eg, benzodiazepines and antidepressants), which have been implicated as risk factors for falls in residents with AD. Teach staff to observe for cardiovascular and psychotropic drug side effects (eg, drowsiness, dizziness, unstable blood pressure, and confusion) that can increase fall risk. Most importantly, observe residents on new medications, looking for side effects that may lead to falls.

Mobility

       Observe mobility during daily activities; judgment of the resident’s mobility by caregivers can provide important information about possible problems with standing, walking, activities of daily living (ADLs), and transfers. If residents exhibit risky behavior, provide appropriate supervision. Conduct regular resident checks during high fall-risk times (ie, shift changes, just after a resident rises in the morning, and just before bedtime in the evening). Provide anticipatory care (ie, anticipate a resident’s toileting needs, hunger, thirst, etc., and meet needs as appropriate). Utilize a gait belt (ie, a broad belt with handles worn by the resident) to assist with bed, chair, and toilet transfers in those high-risk fallers with impaired transfers and balance. This device may help caregivers to avoid a fall in progress, since the gait belt allows the caregiver to bring any episodes of unsteady balance under control.
       Promote mobility through daily floor ambulation, walking groups, and/or general exercise programs. It is important to offer exercise programs that are specifically targeted to the needs of the resident with AD (ie, select a program that improves a resident’s mobility and is not beyond his or her cognitive and physical capabilities). Encourage residents with AD to wear properly fitting shoes rather than loose-fitting slippers or socks. The best shoe designs are those that are easy to get on and off, are snug-fitting without being too tight, have low heels, and have soles that are slip-resistant. Non-skid socks (ie, snug-fitting socks with rubberized treads) are particularly good for residents who get up frequently in the night.

Assistive Devices and Protective Equipment

       Assistive devices (eg, ambulation and transfer aids) and protective equipment (eg, hip protectors and fall alarms) can be of benefit in preventing falls and/or injury. It is important to carefully assess the need for both and promote their correct use. The evaluation of correct choice and use of assistive devices and protective equipment should consider the resident’s physical and cognitive abilities. It is also important to gauge whether caregivers are using the devices and equipment correctly.
       Ambulation aids (eg, canes and walkers) are of great benefit in helping to maintain safe ambulation. Different types of canes and walkers are available, but not all types are appropriate for residents with AD. In some cases, the wrong type can create a fall hazard. All residents requiring an ambulation aid should be referred to a physical therapist for proper evaluation. While residents with AD can be at increased fall risk while using canes or walkers, it is a mistake to generalize. Some residents will experience no difficulties with their cane or walker, while others will not use their walking device correctly, forget to use it, or not understand what it is for.
       Caregivers should regularly assess and monitor whether residents are properly using their ambulation aid. Some residents with AD will use walls and furnishings, rather than ambulation aids, for balance support. In this instance, it is important to make sure that all pathways are clear of clutter and that furnishings (eg, chairs, table tops, etc.) used by individuals for balance support are stable enough to actually support balance when leaned upon.
       Transfers aids (eg, quarter-length side rails) can by employed as an assistive device (sometimes referred to as “enablers”) to support bed transfers in residents with AD with poor balance. When used to facilitate in-bed mobility and/or bed transfers, transfer aids meet the definition of an enabling device that supports bed mobility and are not considered restraints. Any decision to use transfer aids must occur within a framework of individual resident assessment that identifies the purpose of using a transfer aid and weighs the risks and probable effects of using transfer aids against the risk and probable effects of other interventions. When considering the use of transfer aids as an enabling device, it is important to observe whether they assist the resident in getting up safely from bed. Hip protectors are devices designed to ease the impact of a fall on the hip bone and prevent hip fractures. They consist of two basic types: absorptive hip protectors, which consist of soft foam pads that are held in place at the hips with specially designed removable briefs or underwear (ie, the pads are either sewn into or inserted inside pockets located over each hip), and energy-shunting protectors, which consist of hard shells contained in special pants (eg, removable briefs or underwear).
       Hip protectors come in a variety of designs, including specially designed protectors for those with incontinence. The compliance with absorptive hip protectors may be higher for residents with AD due to the comfort of the pads versus the hard shells. The best use of a hip protector is in residents with AD at greatest hip fracture risk (eg, those who are highly medicated, balance-impaired, or brittle and/or those have suffered multiple falls).
       Electronic surveillance systems or fall alarms are particularly helpful in monitoring high-risk residents with AD. These consist of position sensors on beds or chairs or sensors attached to a resident’s leg. They are designed to alert staff of potentially dangerous resident movement. For example, a system can be set to alert caregivers that the resident is getting out of bed so that the caregiver can be there to help. Many fall alarm models have features that deter removal and/or tampering by residents with AD. Lastly, to ensure that fall alarms are used correctly, it is important for caregivers to know what fall alarms are and how to use them properly.

       Editor’s note: The second part of this article, beginning with a look at environmental modifications to reduce fall risk, will be published in the “Wandering/Fall Management” section of the July/August ECPN.