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Falls in the Environment, Part I: Faulty Footwear or Footing? An Interdisciplinary Case-Based Perspective
This article is the first in a three-part series from the author on environmental falls.
Falls by older nursing home residents are common, estimated at 2.6 falls per person per year.1 To adequately address the problem requires a concerted effort and team approach by all healthcare professionals and providers who enter the healthcare setting, consistent with the creation of a culture of patient safety,2 and as required by federal regulations3 and national accrediting bodies.4,5 Although not under federal mandate, administrative management of facilities, such as residential homes or those comprising a Continuing Care Retirement Community (CCRC), have the responsibility to provide due diligence in preventing falls among their residents.
Of all of the multifactorial etiologies linked to falls in older adults, those due to environmental hazards are probably the simplest type of falls to recognize and prevent. According to the Consumer Product Safety Commission and National Safety Network Report (1991-2002), consumer products found in the environment are responsible for many falls among older adults who enter the Emergency Room for fall-related injuries.6
This three-part series focuses on some of the more commonly observed environmental-type falls, drawn from anecdotal patient reports from practice experience, to illustrate their contribution, if at all, to fall development. If at all is emphasized, as falls in older people may appear to be due to an environmental factor, when in fact they may occur from other significant events, unbeknownst to the observer. Because falls are observed and recorded to occur in a recognized “place” (eg, down the step, off the bed, in the bathroom), it is easy for the untrained observer, and a mistake, to attribute where the fall occurred as an explanation for why it occurred.
Healthcare professionals trained to assess the older adult ask decisive questions of underlying events and precipitating causes. This line of inquiry is essential, as an untrained provider or the older adult him/herself may attribute the fall to an “accident” or maybe old age. The case presented here illustrates this point. Only through a focused, comprehensive post-fall assessment of the person and the environment can likely underlying causes be identified. Complementing the post-fall assessment is the practice of “due diligence” by all healthcare professionals and providers of healthcare to avert additional falls.
Application of due diligence in the healthcare setting embraces both healthcare providers (staff) and professionals. Healthcare professionals and healthcare facilities that adopt national and professional guidelines for fall prevention (American Geriatrics Society [AGS]/British Geriatrics Society [BGS]7; AMDA8) in their practice and follow standards of care provide tangible examples of due diligence. Due diligence belies the professional code of ethics, professional accountability in the healthcare setting, and is an integral component of patient safety. It is also an unspoken expectation of the care recipients, our patients.
Interdisciplinary Team Member and Patient Perspectives of a Fall
The following excerpt conveys a resident’s personal account and the team’s account of a fall assumed to be due to environmental hazards. Plans of care were developed accordingly and were revisited when falls unexpectedly continued.
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Case Presentation
Footing and Footwear Issues: Reports from One Older Adult
An 89-year-old, cognitively intact, married female residing in a two-bedroom apartment in the residential section of a CCRC reports in response to her fall, “I tripped over my own foot!”
RN assessment: Resident found lying on the kitchen floor near a puddle of water, dazed, vital signs stable. No overt injuries, moves all extremities well, wearing slippers.
Medical assessment: Following review of incident report and medical review of the record, the physician notes fall due to chronic gait instability due to neurological disease.
Nursing aide: Resident trips over own feet frequently.
Physical therapist: Unable to comment; resident has a history of these types of falls.
Interdisciplinary team recommendations: Avoid slippers, wear shoes with supportive soles, transfer and mobility with assistance from husband; environmental assessment of living space; refer to physical therapy for evaluation.
Follow-up evaluation 2 weeks later: Resident continues to fall up to twice weekly in her home. Environmental assessment performed by a licensed occupational therapist identified no hazards in the kitchen or living space, well-lit areas, no throw rugs, no small pets, no assistive devices, one floor level, no frayed carpet.
Re-evaluation of care plan and follow-up team meeting 1 month later: Falling continues for this 89-year-old resident. Team decides that an in-depth post-fall assessment is required.
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Discussion
To the team, this fall appeared to be an environmental type, due to an external event. Yet, further assessment revealed that the water spilled after the resident tripped over her foot. By reviewing and verifying the resident’s historical account in more explicit detail, we learn of this important, previously overlooked detail. This level of detail gets to the heart of what a post-fall assessment can reveal. This is an important detail because it indicates that the environment was dry, not wet, and so therefore the emphasis of the post-fall evaluation should be placed on other potential contributory events aside from the environment. For instance, a greater focus on the resident’s intrinsic factors is needed. When important details are overlooked, missing information leads to an inappropriate plan of care.
Further illustrating this point are the results from the environmental assessment (ie, the kitchen failed to produce any identifiable known extrinsic risks to fall). Missing from the patient accounts are a complete review of systems that often will identify important symptoms associated with the fall requiring medical attention. Note that the place of occurrence is assumed to be the underlying cause, although one does not know whether intrinsic events or faulty footwear or equipment were responsible. Comprehensive post-fall assessments emphasize detailed historical accounts of the fall in addition to fall-focused questions of antecedent symptoms along with focused physical assessments, all directing the plan of care.9 Determining the timing for re-evaluation by the team is critical. For many reasons, it should be as close to the fall event as possible.
Realistic concerns for mobile older adults who fall include questions about footwear and foot placement on the floor. Getting up can be a problem if shoes are not supportive or fit properly. Transferring can be difficult if the soles are slippery or do not allow pivoting. Chronic neurological disease, as pointed out by the physician, may compound the problem of mobility and transferring—especially if the older adult’s capacity to lift his/her foot to clear a surface edge is impaired. Therefore, the type of footwear selected to provide safe mobility becomes a very important aspect of the resident’s plan of care. This highlights the added value of the occupational and physical therapists’ opinions.
Common-sense observation indicates that stocking feet or slippers provide no structural support to the foot or ankle required for ambulation. Depending on the surface area, stocking feet or slippers contribute to slips and falls. In one study, bare feet and stocking feet were associated with a sharply increased risk of fall, even when health status was controlled for.10 Research of footwear worn at the time of a fall-related hip fracture indicates that older persons wearing slippers or shoes without fixation may be associated with increased risk of tripping.11 Evidence on footwear and risk of falls in older adults shows that athletic and canvas shoes (Figure) provide the lowest risk of a fall and are the best choice in this case scenario.10
Based on the resident’s own statements, further medical assessment of her feet and issues of foot placement on the floor, as well as footwear, were addressed. An occupational therapist consultation was initiated, and, ultimately, form-fitting orthotic footwear was purchased and worn by the resident for walking. The addition of “bells” on her shoelaces made it easier to discern her foot placement on the floor increasing awareness of each step taken. Other follow-up measures included a more thorough medical assessment checking for sensory loss of the lower limbs, foot drop, leg limb discrepancy, and/or musculoskeletal issues.
Because falls can have a psychological impact on older adults (eg, engendering feelings of loss of confidence,12 or fear of falling,13 or other emotions14), it is important to achieve a balance between the promotion of patient safety by the healthcare team and maintenance of physical independence in living and autonomy (personal decision making by the resident). The team recommendation for the patient's spouse to aid with transferring or mobility may actually be an overprotective response by staff, who are concerned with “patient safety” at all times, and one that could be refused by a resident who does not wish to be or become dependent on another person or object (eg, assistive device).
The need to prescribe additional walking aids is done carefully and at the suggestion of the primary care practitioner, who weighs the risks and benefits about mobility and safety for each patient. A “quick fix” by staff may be to provide a wheelchair for long-distance mobility or to recommend the use of a cane. While mobility can be aided temporarily, reliance on an assistive device may mask a treatable medical condition. Many diseases manifest with symptoms affecting the lower extremity or hip girdle, such as weakness, myalgia, or neuralgia. For example, thyroid disease, polymyalgia rheumatica, and Lyme disease can present with these symptoms.
Reliance on an assistive device may also affect the older adult’s perception of his/her health and adversely affect emotional health. Aids and devices can be a visual signal to the resident of becoming “dependent.” Follow-up discussions with the resident should discern whether these interventions might evoke this type of response, and if they are consistent with his/her personal choice. Monitoring the resident for emotional health issues such as increasing fear, feeling sad or blue, and adjustment to the device are important emotional aspects of any treatment option that could create dependence on a device for mobility.
Due Diligence for Fall Prevention
As it relates to this 89-year-old resident, cognitively intact and living with spouse, who falls frequently and wishes to remain in residential living, a few questions surface as her falling continues:
1. What can staff implement to help prevent an accidental-type fall from occurring in the resident’s home while respecting autonomy and independence? (The onus of responsibility here is on healthcare staff as resident advocates.)
2. What can the resident herself do to prevent further falls at home? (The onus of responsibility here is on resident recognition and participation in her healthcare plan to minimize reoccurrence of falls.)
3. What can healthcare professionals implement as interventions to help prevent additional fall events ? (The onus of responsibility here is on healthcare professional responsibility [addressed in the next section].)
Response to Question 1: What can residential staff implement as an intervention to help prevent a fall in the home?
Many residential facilities set administrative precedent through policies and procedures to provide due diligence by helping residents maintain independence in daily living in their current living space. Staff—including members of housekeeping and maintenance, as well as nursing assistants—are assigned tasks related to surveillance and maintaining constant monitoring and communication with one other. As resident advocates, they provide surveillance of the outdoor and indoor environments, and detect and correct environmental hazards that could lead to falls by the following:
• frequent surveillance of the outdoor and indoor grounds, hallways, and corridors (eg, walking rounds, where clutter or spills in pathways are identified and removed)
• calling the resident’s apartment to “check in” at prearranged times
• personally escorting the resident around the grounds, if needed
• reminding the resident to wear designated shoes for mobility
• providing assistance to change footwear if inappropriate footwear is detected
• performing regular environmental checks of residential apartments for frayed or torn carpet or cluttered areas; do safety evaluation of equipment using a checklist
When procedures are sanctioned as important by administration and performed diligently by staff at regular intervals, a degree of oversight and supervision of residents occurs. An important caveat is that check-off sheets be available for use by staff and that they are completed. This level of detail helps to verify that healthcare staff are doing everything possible to keep the residential grounds free of hazards so that the resident can remain independent for as long as possible. For communication purposes, monitoring checklists for environmental hazards should be kept in a location accessible to residents as well. A complete listing of recommendations for environmental modifications is available in the standard of practice recommendations for fall prevention in older adults7,8 and the Centers for Disease Control and Prevention’s (CDC) Check for Safety: A Home Fall Prevention Checklist for Older Adults.15
Response to Question 2: What can the resident do to prevent additional falls in his/her home?
Since this resident recognizes falling as a problem in her life and wishes to minimize its reoccurrence, there are many proactive activities she can engage in. The U.S. Preventive Services Task Force recommends that all persons over age 75 years with known risk for falling be counseled about specific measures to prevent falls.16 Home Safety Fall Toolkits providing detailed home modifications and environmental checklists are available for older adult consumers through the CDC’s National Center for Injury Prevention and Control. These checklists are downloadable forms to print out and have been translated into Spanish and Chinese languages. This resident should, in addition to staff, identify and report a list of environmental hazards to the healthcare facility administration for correction. This resident can follow the recommended footwear when walking and seek further evaluation as recommended by the healthcare professionals and physician directed at potentially treatable medical factors contributing to her falls. Since falls have been multiple, it is important to help the resident identify any important symptoms occurring at the time of the fall and report them to the primary provider. Use of a diary can help the resident identify time, activity, and symptoms at the time of the fall. Further, a complete fall assessment is required. Preparing the older adult for an evaluation that searches for treatable aspects of falling is critical, thereby demystifying the notion of falls due to old age.
During the fall evaluation process, the resident could benefit from monitoring devices to alert his/her spouse should a fall occur. Many portable devices are available for the home that link to emergency response services. Monitoring surveillance systems are commercially available as well, operating through the absence of motion (motion-detection systems).
Response to Question 3: What can healthcare professionals implement as interventions to help minimize fall episodes?
Due Diligence by Healthcare Professionals:
This resident has fallen several times, and the physician reports that she has a neurological condition predisposing to chronic gait instability, which poses certain risks while walking in her home environment. Although we do not know the progression of the gait instability or the resident’s diagnosis or prognosis, due diligence by the healthcare professionals includes following the medical standard of care for fall prevention. This case requires a follow-up geriatric assessment by which the risks imposed by her condition can be individually addressed. As a part of this evaluation, post-fall evaluation searching for treatable events related to gait instability may or may not be indicated, depending on prior evaluation and designation of “chronic gait instability” and prognosis. However, other fall risks such as visual impairment may exist and, if discerned, treated.
Specific issues, which have remained unexplored, include the assessment and treatment for osteoporosis in persons who fall,17 foot evaluation, and laboratory assays looking for treatable causes of falls. Because this resident remains mobile but continues to fall, risk for fracture needs to be discussed in relation to viable treatment options and exploration of whether to use hip pads/protectors as a preventive measure, although research evidence is conflicting. In addition to assessment of footwear, those at high risk for falls can benefit from assessment of foot pathology. In one descriptive study, a large percentage had foot pathology, many requiring podiatric medical management.18 Many CCRCs have consultants on staff who provide shoewear and foot assessments. The Footwear Assessment Form is also available to clinicians, which is a reliable clinical tool to assess shoe type, heel height, and stiffness and tread pattern, among others.19 Based on recent evidence of vitamin D and falling, determination of vitamin D deficiency is warranted.
Outcome of the Post-Fall Evaluation
The post-fall evaluation revealed falls to be due to use of slippers, foot drop, and gait instability from hemiparesis. The resident’s falls were not accidental, but rather due to a combination of faulty footing worsened by inappropriate footwear. There were no overt visual or hearing impairments and no evidence of orthostatic hypotension or cardiovascular abnormalities. Neurological assessment showed decreased musculoskeletal strength of the right lower extremity and foot drop. The resident refused serological studies looking for possible etiologies of the right lower-extremity weakness and foot drop, such as thyroid function studies, vitamin B12 and D levels, and a bone densitometry. The past medical record revealed a questionable transient ischemic attack 20 years earlier. The cause of the falls was attributed to the right lower-extremity weakness and right foot drop, presumably due to an old stroke, and the resident consented to several weeks of active physical therapy. The occupational therapist fitted the resident for high-top sneakers, and her ability to walk improved greatly. The combination of the last two interventions was believed to be responsible for the prevention of additional falls. The resident agreed to follow up in the primary healthcare clinic for assessment of cardiovascular risk factors. She remarked that she preferred not to ask her husband for assistance with mobility and wanted to be completely independent, even if she might fall. She replied, “I am used to falling, and I am used to getting up again.”
Conclusion
Fall management is complex and challenging for all team members who continually intervene and re-evaluate plans of care in hopes of reducing falls. Our standard of practice rests on rendering educated guesses and approximations of likely suspected fall causes based on review and analysis of available data (historical accounts, medical records and incident reports) and post-fall evaluations so that preventive measures can be instituted. It is a dynamic process subject to change, pending new findings. Critical analysis of fall events within an interdisciplinary team approach often unveils various explanations for a fall event. Falls are not always due to environmental accidents. Physical assessment of the older adult’s foot and use of footwear at the time of the fall is very important to ascertain. Most often, we can offer older adults an explanation for their falling. Once they are mindful of events that can precipitate additional falls, they too can be proactive in their attempts to detect correctable problems. When suggesting interventions to older adults, clinicians and therapists should take into account psychological effects, such as the person’s feeling of disability, dependence, and sense of autonomy. The practice of due diligence by all healthcare staff and professionals is critical in order to prevent accidental-type falls in the environment.
The author reports no relevant financial relationships. Dr. Gray-Miceli is Associate Professor, Widener University School of Nursing, Chester, PA.
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