Reducing injury from nursing home falls
While many experts consider falls to be preventable, they constitute more than 25% of emergency room visits for nursing home residents. In fact, this number may be well below the true number, as CMS indicates that many falls go unreported. On this week’s episode, nursing home abuse attorney Rob Schenk welcomes Dr. Rein Tideiksaar @drrein1 of Fall Prevent LLC to discuss how the severity of injuries from falls may be reduced or eliminated.
Schenk: Welcome to this episode of the Nursing Home Abuse Podcast and I will be your host and guide through the information and resources you’re about to partake. We are going to be talking about this week reducing injuries from falls in nursing homes. Now we’ve covered preventing falls and we’ll touch on that a little bit, preventing falls. We’ve done preventing falls in previous episodes, but we haven’t really talked about if there is a fall, what are the interventions that can be done that can reduce the likelihood that the injury will be bad.
So we wanted to have a real expert on the show to talk about that and that expert is Dr. Rein Tideiksaar, and let me just say this, that I got his name right the first time I said it. I got an A-plus from him, so I’m saying it right. I think he said it was Scandinavian if I’m not mistaken.
So Dr. Rein Tideiksaar is the president of Fall Prevent LLC, a consulting company that provides educational and legal and marketing services related to fall prevention in the elderly. Dr. Tideiksaar is a gerontologist, a healthcare professional who specializes in working with elderly patients and a geriatric physician’s assistant. He has been active in fall prevention for over 30 years. Dr. Tideiksaar has authored several books on fall prevention, has directed numerous research projects on falls and designed fall prevention programs in the community in institutional settings. And we are absolutely thrilled to have him on the show this week. Dr. Tideiksaar, welcome to the show.
Rein: It’s good to be here.
Schenk: Great. So I don’t know, maybe a few months ago, a few weeks ago, I was looking through the Internet and I saw an article that I think that you had co-authored about falls in nursing homes and smart cell technology, and just kind of a broad understanding of injuries and risks of injuries from falls from nursing homes, and I thought I’ve got to have this person on the show. It was such a great article. So I appreciate you coming on.
We’ve had some episodes dealing with falls, but I kind of wanted to touch on it again because it’s such an important topic and quite frankly, a lot of our clients come to us because of injuries from falls, and I want to better educate them, I want to better educate the community about the risk of falls in a nursing home setting. So that’s kind of the first question. We’ll start off with the generalized question of why are falls so common in nursing homes?
Why are falls so common in nursing homes?
Rein: Well the reason that falls are so common, and when we say common, anywhere from 50 to 75 percent of the nursing home population will experience one or more falls per year. And one of the reasons it’s such a high prevalence of falls is because of the population. It’s a very frail, vulnerable population. People have all sorts of chronic diseases, be it arthritis, Parkinson’s disease, stroke, etc., which affects one’s walking ability and affects one’s balance. Also a fair number of residents up to 30 to 40 percent have varying degrees of dementia. So these individuals may not be able to differentiate between a safe and an unsafe environmental surroundings and can get into trouble that way.
The other reason that falls are common are medications. Older people in nursing homes take an awful lot of medication, sometimes anywhere from five to 10 different medications. So you mix in chronic diseases, some dementia, medications with potential side effects and that all comes together in the ingredients of causing falls.
Rein: And I think the other aspect of falls is because, and we’re probably going to address this with the injury issue is that only maybe 10 percent of falls result in injury, and so it isn’t that one fall results in injury right away, like a hip fracture, although sometimes that does occur, but often people have repeat falls before they have injury. So again, we can do something to prevent not only falls but injury as well.
Schenk: That’s an interesting statistic. I don’t think I’ve heard that before, that out of all the falls that occur, only 10 percent result in injury. So let me ask this then. We understand how the senior population and more specifically the nursing home population is vulnerable and susceptible to falls based on the different factors you’ve laid out, the medication, the prior history of falls, generalized weakness, that type of thing. What are some common ways in your experience that falls, knowing all that, how falls can be prevented?
How can falls in nursing homes be prevented?
Rein: Well first of all, what the facilities have to do is they have to identify which residents are at risk for falls. So clearly some of the risk factors are, which we have gone over already, is people who have poor mobility, difficulty with walking, they have balance impairment, they have mental status or cognitive problems as well. People who have urinary incontinence – and one of the reasons that urinary incontinence is a risk factor is when older people have the urge to urinate, it’s only a short time before they can get to the bathroom, so often they hurry to the bathroom, and in doing so, they exceed their safe ability to get to the bathroom.
So I think one of the most important things facilities can do is to identify who is at risk for falling. Once you have done that, then what you do is you take these risk factors and you refer them to various professionals within the facility. So for instance, if a person has difficulty with walking and balance, that should go as a referral to the resident’s physician to find out what is the underlying diseases or the problems responsible for that, and can we manage that? Can we reverse the problem with walking or balance? And if we can’t, then people need to refer to occupational therapy and physical therapy for exercises that can help in terms of maintaining their walking and balance. So those are some of the things we can do to prevent falls in terms of most important.
Schenk: I think that’s a really interesting point and I think that that’s something that often the family misses but sometimes the staff misses is the concept of the need to go causes the individual that shouldn’t be walking to get up and try to locate the bathroom, and that’s when the fall happens. So from a holistic approach of trying to prevent these falls, it’s good to understand well these falls seem to be happening between 10 p.m. and midnight, and oh, maybe that’s why is because they’re trying to go to the bathroom and so maybe we should do our rounding at about that time and take them to the bathroom. So something like that is a good intervention that’s not that difficult to understand is that they’ve got to go to the bathroom, but I think that’s something the family often misses.
What are some common fall prevention interventions in nursing homes?
Rein: Yeah, and just to sidebar on that is another fall prevention is to inform family members, loved ones, what the risk factors for individual residents are, so therefore now the family, particularly if they’re visiting often, they become the eyes and the ears of the nursing staff. So if they can detect a difference in their loved ones in terms of how they’re behaving, how they’re walking, how their balance is, etc., they can go to the nurses and go, “Look, something’s not right with my mom or dad. Can you take a look?” So that’s another important intervention.
Schenk: Right. So with regard to interventions that are common to prevent falls, are there some that seem to work more than others? I know that in the past, in order to keep somebody from falling from the bed, people used rails, which studies have showed and experience has shown that’s almost always never a good idea due to the strangulation and choking hazards and the associated hazards that go with that, but what are some of the more ways to prevent falls that seem to work more than others, in other words?
How do siderails on beds factor into fall risk safety in nursing homes?
Rein: Well I think that you have to take a look at any facility, you have to look at where do most of our falls occur? And generally they occur in two places in terms of the bedroom, getting out of the bed, and in the bathroom. So in terms of the bed, and you’re absolutely right, siderails do not prevent falls, as a matter of fact, studies have shown repeatedly that they cause more problems in terms of people getting out of bed and they fall from higher elevations, etc., etc. So what can be done for individuals who have a problem with bed falls is, again, refer to the physician. Make sure you have looked at all underlying causes for that person’s mobility problems getting out of bed. Then what you want to do is you want to give a person a bed, like a low bed that they are able to easily get out of, and use maybe a half siderail, not to prohibit the person from getting out of bed, but enabling that person to use that half side rail as a balance support when they’re getting out of bed.
Schenk: And so, not to interrupt you, but so to paint the picture for the person at home listening, that kind of half rail, is that towards the head of the bed or towards the legs of the bed? In other words, that’s just there for support, not restraint essentially.
Rein: It can be either way. Generally it’s the head of the bed, but what I often do in terms of training nursing home staff and everything like that, if you’re going to use a half siderail as an enabler, please observe the person using that, and sometimes people are better off with the half siderail at the head or at the bottom. It depends on whether they’re right-handed, left-handed. I mean there are a lot of factors involved in that. But whenever you have an intervention like that, you want to observe if the person is able to use it safely because if they’re not, then it’s not a good intervention.
Schenk: Right. And I kind of cut you off, I’m sorry. Go ahead.
Rein: Well the other thing is so you have the beds, the low beds, you have the half siderails as enablers and everything like that, and then the most important thing to determine is why is the individual getting out of bed? Are they getting out of bed for need of nutrition, for hydration, for exercise? Often people are getting out of bed to go to the bathroom. Well if a person has frequency going to the bathroom and they have poor balance and poor walking, perhaps you could use a bedside commode there next to the bed instead of having the person go all the way to the bathroom.
Schenk: Exactly. Exactly.
Rein: Yeah. And then the other intervention is to use alarms as well to let the staff know when people are getting out of bed when they shouldn’t be getting out of bed by themselves, and also have nurse aides do rounds every 15 minutes, half hour, every hour to make sure that the individuals who are at risk for bed falls are safe.
Schenk: I feel with the personal alarms or the bed alarms, I feel like it’s on one hand, it alerts the nursing staff this individual has gotten up and perhaps they can do something if they’re able to literally at that moment. On the other hand, you have the idea that oftentimes that alarm that goes off acts as a restraint in itself because the person hears the alarm and just sits back down and maybe that’s not something that we want to do in that nursing home is prevent people from moving around if they want to move around. So it’s kind of I see both – a lot of times people argue on either side of that issue of the alarms.
How are noise alarms a fall prevention method?
Rein: Yeah, I think you bring up there an excellent point. I think alarms, first of all, fall alarms, they do not prevent falls but they just alert nurses that residents are participating in an activity, dangerous, unsafe activity by themselves, which they shouldn’t be doing. And you’re absolutely right. Sometimes the sounding of alarms can be very loud and in essence prohibits individuals from moving about. And in those instances, they are a restraint.
Now companies are very clever because what you can do with these alarms is silence them in the room and have them go off at the nursing station or with a pager that the nurse carries around, so therefore the noise does not create a problem. But again, you have to individualize all your interventions, even with fall alarms. You have to individualize. There are all different types of fall alarms and each one can be targeted to individual problems.
Schenk: That’s right. And again, to reference this article, which is a fantastic article and I’ll put it in the show notes and put it on the screen if people want to see it, but you talk about not necessarily – not just preventing falls but reducing the injuries sustained from the falls, that 10 percent where someone’s injured, we’re trying to reduce that number. And one of the aspects you talk about is carpeted flooring. Can you kind of unpack whether or not carpeted flooring is an advantage or disadvantage to reducing injury, not reducing the likelihood of falls but reducing the injuries from falls.
Rein: Well carpeting – every intervention you have has risk and benefits involved. Carpeting is very good because you have some kind of absorptive padding there, so there if you fall, there’s some kind of absorption that occurs and that reduces injuries.
On the other hand, individuals in a nursing home tend to walk with what’s known as decreased depth of height, which means they don’t lift their feet as readily as they do, so people who have Parkinson’s disease, people who have stroke, people who have arthritis of the knees, they don’t lift their feet up when they walk that much and they tend to shuffle when they walk. Shuffling and carpets can lead to trips.
The other thing is walkers can be difficult to use on carpets depending on the diameter of the wheels. Same thing – canes can be difficult as well. You can sometimes get the tip of the cane caught in pile carpeting. Wheelchairs are difficult to maneuver in different kinds of carpeting as well. So there’s the advantage of carpeting in terms of reducing injury but also it can increase the risk of injury, of falls and possible injury as well. So again, you have to target any intervention, even environmental things like carpeting, with the population that you’re serving.
Schenk: Right. That makes sense. Can you kind of talk about vinyl flooring, like I guess that’s probably bad under any circumstances?
What is vinyl flooring in nursing homes? What are advantages?
Rein: Well vinyl, now, people who have this shuffling gait, that it’s much easier to walk. It’s much easier for walkers to get across vinyl flooring, same thing as wheelchairs. On the other hand as you say, if you fall on vinyl or linoleum flooring, you’re at greater risk of injury and studies have shown that.
The other problem that occurs with vinyl flooring, if there’s any spillage or fluids, if it’s water, juice or even urine, that becomes a wet hazard that can lead to slips in older individuals, where with carpeting, if you spill something, any kind of fluids, it’s okay. It just stains and you can generally remove those stains.
Schenk: Can you speak to the pros and cons of some of these injury reducing interventions that you have on this paper, one of them being hip protectors. I think a lot of people or many people don’t know about hip protectors in general, so can you kind of unpack how they’re used, the benefits and the possible risks?
What are hip protectors and how do they reduce injuries in nursing home falls?
Rein: Yeah. Hip protectors, interesting – hip protectors are used to prevent hip fractures from occurring, and hip fractures can occur in both men and women, and of course, because of osteoporosis, they’re much more common in older women. But there are people, maybe 20 years ago, we noticed that older individuals in the winter time when they slipped and fell, they didn’t really hurt themselves or they didn’t fracture their hips because they were wearing overcoats that went down below the hip. So somebody very clever said, “Geez, why don’t we take that concept and develop these protectors that you wear around both hips?” It’s almost like a girdle, a woman’s girdle, that one would have. Of course, it’s much more aesthetically pleasing.
Schenk: I think that’s what…
Rein: So studies have shown that hip protectors do prevent hip fractures from occurring, but the big problem is noncompliance, is that older people don’t like wearing them, particularly any individuals who have problems with urinary frequency and they have to go often to the bathroom back and forth, also for women who are still very much aware of how they look in terms of appearance. Some hip protectors make older women look very bulky and that. So therefore, the compliance with hip protectors is problematic.
Schenk: Right, I was going to say from my days of playing football when I was kid in junior high, that was part of the thing, a girdle that you fastened two pads to your hips.
Rein: Yep, it’s the same concept. It’s absolutely the same concept.
Schenk: What about the concept of either having a low bed or having the mattress on the floor to reduce the injuries from falls? Can you speak to the pros and cons of that?
Rein: Well the low bed does prevent injuries from occurring because you’re only falling a short distance, so therefore generally will roll out of bed and they might have some scrapes or lacerations at their knees or elbows, but that’s the extent of that injury.
Now mats, again, prevent injuries from occurring because they’re absorptive pads alongside the bed. The only problem with mats is that some mats, not all mats are created equal – let me say that. Some mats actually lead to balance instability in terms of individuals who are standing on the mats because of the soft give that they have. Other mats, basically, they work for a while and then the absorptive ability no longer works, so you have to replace the mat. Then it’s difficult too sometimes for staff to do what they have to do in terms of bed care with a mat in place, so they remove the bed mat, but they don’t put the bed mat back again alongside the bed. So there’s all sorts of individual problems with bed mats.
Schenk: That makes sense. So let’s kind of delve into this topic, but in terms of reducing injuries from falls, what is a SmartCell?
How does smart flooring reduce fall risks in nursing homes?
Rein: SmartCell – this is put out by a company called SATECH, and what they did with the SmartCell, it’s pretty clever stuff, is that the flooring has shock absorptive properties very similar to a floor mat, so therefore if you drop onto the floor, it softens the impact of the floor, of the fall. At the same time, when people are walking on it, it maintains its rigidity as a normal floor, and that’s basically what it is. So during walking conditions, there’s no problem, it acts like a regular floor, like a regular linoleum or wooden floor. But if a person falls on it, it softens and it absorbs the impact of the individual.
Schenk: Is that the concept – and this is me, I guess, thinking of action movies, but is that not the concept behind Kevlar, where it has to do with the amount of force is applied to it and how quickly the force is applied to it is how protective it gets or how rigid it gets, or did I make that up?
Rein: Yeah, very, very similar concept. Very similar.
Schenk: Okay. And so I feel like so a SmartCell is going to kind of reduce the disadvantages of a normal mat in terms of rolling around in a wheelchair or people may have difficulty with the stepping due to arthritis and things like that, but it makes up for it in the fact that it’s stronger when the person falls on it. It’s more softer I should say.
Rein: That’s right.
Schenk: Okay. So what’s the, I mean what’s your understanding as to why the SmartCell isn’t something that’s a little more common? Or is it common nowadays?
Rein: Well I don’t know how common it is. When I wrote the article and everything, I had a lot of conversations in terms of the research the company was doing and everything like that and I was waiting for studies to be produced from there and I’m not sure if the studies were ever done like that. But I think one of the reasons it’s not widely used even though it’s effective is, first of all, money in terms of the expense of it. It’s not cheap. So therefore, what I often recommend is to individuals who are interested in this whole SmartCell technology is try to target where you would like to use the SmartCell. Do you want to use it then alongside the bed just by itself so you can have the SmartCell actually underneath the regular tiles and also the company now also produces a SmartCell that you can have there as well? Or do you want to put the SmartCells in the bathroom by the toilet or by the shower area where a lot of injuries occur as well?
So it’s a matter of looking at your population and what is the prevalence of injury or the amount of injuries that occur, where does the injury occur and then targeting the SmartCells to those areas.
Schenk: I think that if I can catch what you’re throwing down, the overarching theme is that there needs to be a holistic approach to the individual’s care from all angles. Finding out why they’re wandering if they’re wandering. Take every intervention that’s possible. Weigh the advantages and disadvantages and try to prevent the falls that way as opposed to maybe like, well we’ve got SmartCells so now we don’t have to worry about our rounding schedule for her getting up and going to the bathroom, that kind of thing. It’s really one piece of the puzzle to prevent those falls.
Rein: Right. You have to individualize. That’s the most important thing.
Schenk: Well Dr. Tideiksaar, I really appreciate you coming on the show and talking about fall prevention, injury prevention in nursing homes, because like I said at the top of the show, we deal with this a lot. We get a lot of calls about this so as much information we can put out there, the better, and we really appreciate you coming on because we know you authored a lot of articles and publications about fall prevention. So we appreciate your experience and you sharing that with us.
Rein: Okay. It’s been my pleasure. Thank you.
Schenk: Thank you. Dr. Tideiksaar is a leader in fall prevention. He’s written all kinds of articles and books on it and I’m so happy we were able to get him onto the show. I really recommend that everybody goes out and reads the articles that we were quoting from. I’ll put that on the screen and in the show notes so you can check that out.
But just as an FYI, this week, I think Friday, the 21st of February, is National Caregiver Day, so that I believe is a category for anybody who provides care, so you’ve got your nurses, your CNAs, all kinds of people. So give them a hug.
And I think with that, we’re going to conclude this episode. You can catch new episodes every other week two times a month, bi-monthly, dual-monthly, duo-monthly, Nursing Home Abuse Podcast, either on YouTube or on our website, which is NursingHomeAbusePodcast.com, or you can check us out wherever you get your podcast from. And with that, we’ll see you next time.