Every Fall Tells a Story: How a Nurse-Led Clinic Protects Older Adults

A single fall can change everything for an older adult — triggering injury, loss of independence and a cascade of health challenges. Recognizing that many of these incidents are preventable, Cleveland Clinic’s geriatric falls clinic is taking a proactive approach to identifying risk factors, addressing underlying causes and helping older patients stay safely on their feet.

“Falls are often the result of multiple, interconnected issues — and that’s where a specialized assessment makes all the difference,” says Anne Vanderbilt, MSN, RN, CNS, CNP, who runs the weekly clinic on Cleveland Clinic’s Main Campus. “By taking a comprehensive, patient-centered approach, we’re able to identify the root causes and intervene in ways that truly protect our patients’ safety, independence and quality of life.”

Getting the whole story

Vanderbilt’s first order of business during every clinic visit is to get an in-depth history of the patient’s falls. “I’m looking for patterns,” she explains. “Falls can rarely be blamed on one thing, so I ask questions designed to illuminate any contributing factors.”

Vanderbilt recalls a recent case in which an 87-year-old woman with dementia had presented to the emergency department several times for a succession of falls. With the help of the patient’s daughter, Vanderbilt was able to ascertain that her falls were triggered by a change in position – often related to getting out of bed or a chair.

“Every fall has a story,” she says. “Until we understand the why behind it, we’re only treating the outcome, not protecting the patient from the next one.”

Next, Vanderbilt reviews the patient’s medications, which may harbor hidden risks. She notes that drugs prescribed to reduce blood pressure, for example, can lead to falls – especially during positional shifts – by depriving the brain of oxygen-rich blood.(In 2014, the Eighth Joint National Committee released guidelines that relaxed blood pressure goals in adults 60 and older from 140/90 to 150/90.)

After taking a thorough medical history, Vanderbilt evaluates the patient’s physical and neurologic strength with three standardized tests recommended in the Center for Disease Control and Prevention (CDC) STEADI toolkit:

• The Timed Up and Go (TUG) Test assesses mobility by requiring patients to stand up from a chair, walk to a line on the floor 10 feet away, then walk back to the chair and sit down.
• The 30-Second Chair Stand Test assesses leg strength and endurance. Patients sit in a chair with their hands on opposite shoulders and feet flat on the floor. They then rise to a full standing position and sit back down, repeating the exercise for 30 seconds.
• The 4-Stage Balance Test assesses static balance. Patients assume four progressively challenging positions – standing with their feet side-by-side, placing the instep of one foot touching the big toe of another, placing one foot completely in front of the other and standing on one foot.

Based on her findings, Vanderbilt says she frequently recommends medication changes or modifications to the home environment.

In nearly every case, she advocates exercise. If balance is a primary issue, she suggests Tai Chi. Physical therapy is often prescribed for frailer patients. In many cases, Vanderbilt provides exercise guidance from the National Institute on Aging’s Go4Life program.

Clinical preparedness is key

Most patients who visit the geriatric falls clinic are referred by their primary care physicians, orthopaedic specialists or the emergency department. While not all older adults require in-depth falls risk assessments, Vanderbilt encourages primary care nurses to remain vigilant when evaluating geriatric patients.

She urges clinicians to:

1. Ask about falls. “The biggest predictor of a fall is a history of a previous fall,” Vanderbilt explains. “But caregivers should be aware that patients may be reluctant to disclose a fall. Older adults, in particular, may be afraid of losing their independence – or even being taken from their homes.” Of note, the American Geriatrics Society recommends an in-depth assessment for any older adult who has had more than one fall per year, feels unsteady when standing or walking, or is concerned about falling.
2. Delve into the circumstances of any fall. In some cases, simple changes to a patient’s living environment can significantly reduce the risk of falling. Among the modifications Vanderbilt suggests are removing throw rugs, adding handrails to stairs, placing nonslip strips in the shower and installing nightlights in the hallways.
3. Conduct a simple vision screening or determine when patients last had their vision checked. Vanderbilt describes evaluating a patient who did poorly on a vision test. When questioned, the woman admitted to rarely wearing her prescription glasses. “This gave me an opportunity to talk to her about the importance of being able to see — and interpret — everyday obstacles,” Vanderbilt says.
4. Rely on the CDC’s STEADI toolkit. In addition to the three tests mentioned earlier, the toolkit includes a fall-risk checklist, an algorithm for triaging patients and guidelines for measuring orthostatic blood pressure.
5. Encourage patients to remain active. “Inactivity is a common denominator in patients experiencing frequent falls,” Vanderbilt says. “I emphasize that staying physically active is one of the most effective ways to reduce fall risk by strengthening the body systems that keep you steady, coordinated and responsive.”