Preventing Falls in Elderly Patients

Four years ago, Cleveland Clinic began a geriatric falls clinic run by an advanced practice nurse to offer in-depth assessments of patients’ fall risk factors. “In geriatrics, we see a lot of people who fall,” says Anne Vanderbilt, MSN, RN, CNS, CNP, who runs the clinic on Cleveland Clinic’s main campus. “We developed this clinic to help primary care physicians and their patients. Their patients come here, and we delve much deeper into all aspects of the fall.”

Assessing a patient’s fall risk

Vanderbilt and a geriatric medical assistant hold the falls clinic on Fridays, with patients slotted in 90-minute appointments. During the first part of the appointment, the medical assistant conducts a basic screening: She reviews the patient’s medication and eating habits, takes orthostatic vital signs and conducts vision, cognition and depression screenings. Next, Vanderbilt gets an in-depth history of the patient’s falls. “I look for patterns,” she says. “Are there certain things contributing to the falls? There’s rarely one thing causing falls: It’s usually a combination of things.”

Vanderbilt recently saw an 87-year-old woman with some dementia who had fallen several times in the past few months and ended up in the emergency department. “With the help of her daughter, I was able to ascertain that her falls are related to changing positions,” says Vanderbilt. The woman fell getting out of bed and out of chairs.

Next, Vanderbilt reviews the patient’s medication, which can sometimes factor into falls. For example, hypertension medication can lower blood pressure to a point where patients are at risk for falls. “They may have fabulously controlled blood pressure, but they are falling all the time,” says Vanderbilt. (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.)

Vanderbilt also reviews the patient’s medical conditions and conducts a physical exam focused on neurologic strength. She uses three standardized tests recommended in the Center for Disease Control and Prevention (CDC) STEADI toolkit:

1. The Timed Up and Go Test assesses mobility: Patients stand up from a chair, walk to a line on the floor 10 feet away, then walk back to the chair and sit down.
2. 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. Then they rise to a full standing position and sit back down, repeating the exercise for 30 seconds.
3. 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.

After the exam, Vanderbilt makes recommendations, which may include changing medications and modifying the home environment. She encourages patients to take vitamin D. “There is increasing evidence that vitamin D helps not only with bone health, but also with balance and strength,” she says.

She also advocates exercise. If balance is a primary issue, she suggests Tai Chi. If the patient is weak, then she recommends physical therapy. Sometimes she hands out the National Institute on Aging’s Go4Life exercise DVD.

“The No. 1 thing we try to do is reduce falls,” says Vanderbilt. “You can’t stop every fall, so we also have recommendations that reduce injuries from falls.”

Advice for nurses

Approximately four patients visit Cleveland Clinic’s geriatric falls clinic each week. Most are referred by their primary care physicians, orthopaedic specialists or the emergency department. While not all elderly patients require in-depth falls risk assessments, Vanderbilt encourages nurses in primary care to do the following:

• Ask about falls. “The biggest predictor of a fall is a history of a previous fall,” she says. “And older adults in particular will not tell you voluntarily. They are afraid you will take them out of their homes.” The American Geriatrics Society recommends that older adults who have had more than one fall per year, a fall with an injury, or a change to their balance or gait receive an in-depth assessment.
• Delve into the circumstances of any fall. The patient may need to modify his or her home by removing throw rugs, adding handrails to stairs, placing non-slip strips in the shower, placing nightlights in the hallways and so on.
• Conduct a simple vision screening or ask patients when they last had their vision checked. Vanderbilt recently examined a patient who did poorly on the vision test. When questioned, the woman said she wasn’t wearing her glasses and admitted she never used them when walking. Vanderbilt talked to the patient about the importance of wearing glasses when moving around.
• Use tools in the CDC’s STEADI toolkit. In addition to the three mentioned earlier, the toolkit offers guidance on measuring orthostatic blood pressure, a fall risk algorithm for triaging patients, a fall risk checklist and more.
• Encourage patients to remain active. “What I see most frequently is that older adults who are falling have become inactive,” says Vanderbilt.

One out of three adults aged 65 and over falls each year, according to the CDC. Cleveland Clinic’s geriatric falls clinic aims to prevent some of those falls and reduce related injuries. Sept. 23 – the first day of the fall season – is Falls Prevention Awareness Day. “What a great time to focus on fall risks and commit to helping keep elderly patients safe,” says Vanderbilt.