Angie SzumlinskiThere has been some exciting research in the pursuit of identifying the root cause of falls.

A study recently published in the December issue of Neurology finds that people whose brains work the hardest when they try to walk and talk at the same time may have a higher risk of falling in the future than those who can do both with ease. The ability to multi-task is directly related to what is considered “executive function” and/or “dual-task performance.” What makes this truly exciting is that it appears to be the first study to link brain activity changes that precede behavioral changes to risk of falls.

In this study, researchers asked the participants to perform three tasks: walking at a normal pace, reciting alternate letters of the alphabet while standing, and reciting alternate letters of the alphabet while walking at a normal pace. They then measured the brain activity and oxygen levels in the frontal lobe of the brain and found oxygen levels rose when the brain worked harder.

Although more research is needed to identify interventions that may influence brain activity during complex walking conditions as a way to prevent falls, this study does identify changes in brain activity and oxygen levels, which is more scientific than anything being used today.

So what does this really mean in predicting a resident’s risk for falls in a proactive manner? People who are able to multi-task, including walking and talking at the same time, will likely fall less frequently than people who struggle with it.

Long term and post-acute care (LT/PAC) providers should take note. According to the Centers for Disease Control and Prevention, more than one in four seniors fall each year, and falls are a leading cause of death and disability in seniors.

Investigating the Resident’s History

For LT/PAC providers responsible for evaluating residents at risk for falls, a first step to manage risk is to investigate. If little is known about the resident’s risk for falls, consider asking questions of the resident and/or family; be inquisitive about previous lifestyles and employment.

There are differences in brain activity and function for people who work in “change on a dime” dynamic positions versus positions requiring rote/single-thought process activities.

Going Beyond the Standard to Reduce Fall Risk

Staff should also consider initiating standards for fall-risk identification and reduction such as balance and strength training, medication reviews, or checking for appropriate footwear. Then, think outside of the paradigm that clinicians are often caught up in.

For example, the “homelike environment,” “clutter-free environment,” and “therapeutic milieu” are all great additions to the care plan, but they may sound to some like “canned” interventions, and, sometimes, they are.

Be Sensitive to Distractions

Say a resident at risk for falls ambulates in a common area that is distracting. To assess the person’s risk, consider what types of distractions might interfere with the resident’s ability to ambulate safely.

Noise, raised voices, other residents calling out, chair/bed alarms, door alarms, telephones ringing, overhead paging, clutter around seating areas, staff moving about with medication carts and supplies are all distractions that require the resident to multi-task while walking.

Even if the resident tries to “tune out” distractions, it isn’t always possible. It is likely the resident will listen to other conversations, respond to alarms sounding, turn to respond to their name being called, or will be required to step around items on the floor: This constitutes multi-tasking.

While these distractions may not affect everyone, these situations can increase the risk of falls if a person has difficulty processing multiple stimuli while walking. Being alert to these situations may assist in maintaining a calm, therapeutic environment with a decreased risk for falls for all residents.

To Maintain a Calm Environment, Be the Customer

Some fixes can be quite simple. One thing that is critically important is for the management team to “be the customer.” Quietly visit resident care areas, common areas, activity rooms, dining rooms, and therapy gyms. Bring a critical eye, and be hypersensitive to noise levels and clutter.

The typical “rounds” don’t really identify these areas of risk, and many centers are so tuned into the day-to-day operations that these scenarios are considered the “norm.”

Then, observe the residents as they ambulate about the center. Observe for unspoken levels of stress, which is often presented as hesitancy while ambulating, turning their heads toward noise, attempting to respond to external stimuli, hand fidgeting, and reaching out to support themselves on furniture or walls.

If management observes a resident exhibiting these unspoken signs of stress or distress, consider referring the person to skilled therapy for evaluation. The therapist may assist in determining whether the resident would benefit from an environment with decreased stimulation.

Taking an Interdisciplinary Approach

If needed, a resident who is at risk for falls could be identified for staff members. A color-coded arm band on the walker is one way to signal staff to be considerate of the resident’s need for a calm environment. The process of implementing any method of fall prevention should be interdisciplinary and requires education on the part of staff. More important, the outcomes would benefit the residents.
Consider these other ideas to help cut residents’ risks of falls:
  • Request referrals for resident assessment and evaluation by skilled therapy staff to determine if there is a connection between distraction and poor balance/gait stability;
  • Create a list of residents who may be affected by distractions, noise, or clutter;
  • Establish a Performance Improvement Plan (PIP) through the Quality Assurance and Performance Improvement (QAPI) committee to develop a plan for decreasing noise and clutter throughout the center and/or identifying ways to assist the specific residents affected;
  • Review the plan with the full QAPI committee, adjust as needed, and establish an implementation plan;
  • Circle back and evaluate the plan through ongoing monitoring, auditing,  and tracking and trending fall rates;
  • Review outcomes at the quarterly QAPI committee meeting and adjust the plan if needed; and
  • If the center has struggled with higher fall statistics, consider initiating a History of Past Non-Compliance to avoid regulatory citations.

Keeping the Goal in Mind

Although there is no magic formula to reduce falls and residents may continue to experience them, the goal is to identify the specific cause(s). This is usually very individual to each resident. Thinking about this study gives reason for pause, as many centers are a buzz of activity with different noises, alarms, and so on.

The impact of these seemingly harmless, “normal” noises on residents at risk could be significant, and centers may become “numb” to the noise.

Take the time to be the observer. Stop, look, and listen. Share resources with sister facilities, “mystery shop” different centers, and give constructive feedback. Remember, it may make the difference in resident outcomes, fall rates, quality measure results, star rating, and scope and severity of citations.
Angie Szumlinski, NHA, RN-BC, RAC-CT, BS, is director at HealthCap Risk Management Services. She can be reached at