“I’m getting way fewer calls about falls,” says Barbara Resnick, RN, PhD, CRNP, Sonya Ziporkin Gershowitz chair in gerontology at the University of Maryland School of Nursing, but that doesn’t mean that this issue shouldn’t remain a priority.

While falls may be down because residents are in isolation as a result of the sweeping COVID-19 pandemic and less physically active, deconditioning and muscle weakening is likely on the rise, and this could lead to a spike in falls as residents become more active when restrictions are lifted. Forward-thinking team members at all levels are taking innovative steps to protect their residents from falls and maximize their strength and flexibility, even as they are isolated or quarantined.

“We are seeing less trauma right now because people aren’t as active and have less exposure to random obstacles,” says Lew Schon, MD, FAAOS, FACS, director of orthopedic innovation at The Institute for Foot and Ankle Reconstruction at Mercy Medical Center in Baltimore.

“Once the acute respiratory or systemic issues have been resolved and lockdowns and isolations are lifted, we will have deconditioned and compromised patients. These patients who were sick don’t necessarily realize the full impact of their new disabilities and will be physically weaker.”

Schon says a high percentage of COVID patients will have neurological issues—some have already reported balance problems and dizziness, which contribute to falls. “I suspect that minor falls are being undetected right now because people aren’t reporting them as they’re happening in the privacy of their home or apartment,” he says. “We need to prioritize ways to keep people as physically strong as possible now and in the future to prevent falls and fall-related injuries.”

Back to Basics

There is a reason that addressing falls in older adults is always a priority. One in four Americans age 65 and older experiences a fall every year, and falls result in 2.8 million injuries and an emergency room visit every 11 seconds, according to the National Council on Aging. Falls also are a major cause of disability in this population and cause 27,000 deaths annually. Add to that the cost of falls—more than $50 billion per year, and it’s clear why this is a top concern in all care settings, but none more so than in post-acute and long term care, the council says.

There are many risk factors for falls, including older age, chronic diseases, low vitamin D level, urinary incontinence, gait/balance disorders, orthostatic hypotension, chronic pain, and altered sensory perception. There also are behavioral or lifestyle factors, including lack of exercise, fear of falling, feelings of anxiety, depression, low self-efficacy, cognitive impairment, and a history of falls.

Medications are a significant contributor to falls. These include psychoactive medications such as anticonvulsants, antidepressants, antipsychotics, benzodiazepines, opioids, and sedatives-hypnotics. It also is important to review over-the-counter medications that residents are taking, including herbal supplements, that may cause dizziness, sedation, confusion, blurred vision, or orthostatic hypotension. Among these are antihistamines and sleep aids.

Prescribing practitioners and pharmacists can work together to make needed changes to medication regimens and monitor for side effects. Other strategies may include implementing nonpharmacological options to manage conditions and reduce the risk of falls.

Elsewhere, there are environmental factors such as inappropriate or ill-fitting footwear, improper use of assistive devices, and hazards such as loose wires or cords, slippery floors, throw rugs, and poor lighting. There also are numerous instances of people tripping over a pet or getting a leash tangled around their legs while walking a dog.

Health conditions such as certain eye or ear disorders can increase the risk of falls. At the same time, arthritis or other conditions that cause pain and stiffness or affect gait can contribute to falls.

Fall Risk: Looks Can Be Deceiving

“Frailty is a major contributor to falls, and this may not be readily apparent or easy to identify. Two residents can look alike, have similar backgrounds, etc., but they make have different levels of frailty,” says Steven Buslovich, MD, MSHCPM, CMD, co-founder and chief executive officer of Patient Pattern in New York. “As a result, if they both experience a fall, they could have very different outcomes.”

Assessing frailty isn’t a new concept, he says, but it needs to be incorporated into clinical management strategies. By assessing frailty risk, it is possible to identify and address issues contributing to vulnerability.

“Frailty assessment allows us to understand the level of risk a resident has for falling. That physiological risk helps us to establish expectations and set realistic goals. We can use this information to communicate with families to set expectations before a fall occurs,” Buslovich says. “Families need to know about how their loved one’s frailty may contribute to problems such as falls and what can be done to prevent such accidents and avoid serious injury if a fall does occur. Keeping them informed and involving them in attempted solutions increases family satisfaction and engagement,” he says.

Kevin O’Neil, MD, CMD, chief medical officer of Affinity Living Group, headquartered in Hickory, N.C., agrees, noting, “If a person has been falling at home before they enter a facility, they will still be at risk for falls. However, we can assess them and mitigate the risk.”

When a fall does happen, O’Neil says, transparency is key. “We need to be honest about what happened, express our concern, and discuss how we can prevent similar situations from occurring in the future.”

Challenges in Isolation

The more engaged the family is, the better, says Buslovich. Engaging families can help keep residents physically strong, even when they can’t visit.

Arif Hussain, DO, a physiatrist with Chicago-based Community Physicians, suggests, “Tell families what you are doing to maintain conditioning. Then encourage their involvement. If they are having a Skype call, for example, they can get their loved one to wave or clap.”

Families can feel helpless because they can’t be there in person with their loved ones, Hussain says. “Engaging them in helping to keep mom or dad active can make them feel like they’re doing something useful.”

Physical activity is an important means of fall prevention. Activities such as walking, water aerobics, stretching, and even dancing help reduce the fall risk by improving strength, balance, coordination, and flexibility. Under normal conditions, these activities are widely available and generally routine. However, during the COVID-19 pandemic, most residents are subject to lockdowns, quarantines, and social isolation, much as is the general public.

“I anticipate there will be a good bit of deconditioning because of the pandemic,” says Resnick. To address this, she suggests focusing on functioning and physical activity in innovative ways. For instance, dancing or doing exercises with residents from a safe distance in the doorway or coordinated activities with residents at a distance stimulates muscles.

“We need to make sure caregivers are optimizing what people do—let them raise their arms to put on a shirt, put the brush in their hand and let them brush their own hair, or let them wash their own face. We need to keep them functioning and as active as possible,” Resnick says. “Make it fun. There are lots of fun easy activities you can do with people. For instance, put on some music and have them sit and stand for a few minutes.”

Encourage Residents to Stay Active

It is important for physicians and other providers to regularly encourage residents to stay as active as possible.

“Depending on their ability and status, they can do simple things in a repetitive fashion like lift a book, stand up and sit down, do leg extensions, or reach over their heads,” says Schon. These are suggestions that practitioners can make via telemedicine visits, he says. “We are engaged in developing creative strategies to help patients more efficiently, given the new challenges.”

Tiffany Rose, MSN, NP-C, a nurse practitioner with the Department of Geriatrics at Wake Forest Baptist Health in Winston-Salem, N.C., says, “We need to be working as a team to prevent falls now and six months from now. If a nurse, nursing assistant, or housekeeper notices someone who isn’t engaged or is more withdrawn, we need to know about this now. We may be able to arrange for them to participate in an activity in their room or in another space with safe distance from other residents.”

Physical therapists can conduct evaluations and identify those residents who can participate in and will most benefit from some physical therapy—provided via telehealth if appropriate, Rose says.

“Make the team feel like part of the solution. Ask their opinions and have them suggest ideas for safely keeping people active. I’m big on ensuring that my team knows they can come to me with their ideas,” she says. “I’ve gotten some wonderful ideas from the housekeeper and engineering departments—things I wouldn’t have thought about.”

Train Staff to be Alert to Problems

Educate all staff about how they can help, says O’Neil. “We can train all staff to watch for and report signs such as limping or shuffling, changes in gait, indications of pain such as a resident moaning, rocking, rubbing, or grimacing. Those who see the residents the most and know them the best can help us address these issues before they result in a fall.”

For residents who are used to being social and physically active, limited mobility may be especially difficult. Staff should identify these individuals and work with the team to consider ways to make them more comfortable staying in their rooms. “We would love to substitute unrestricted physical movement with controlled activity, but that’s not always possible,” Schon says. “We have robust media and entertainment available, and we can make sure that they have access to their favorite shows, movies, and music. This may keep people, especially those with cognitive impairment, from getting restless or agitated and wandering.”

Hidden Pandemic

Deconditioning is the “hidden pandemic,” says Geoffrey Hoffman, PhD, assistant professor at the University of Michigan School of Nursing. “The COVID crisis has exposed some gaps in policy. We’ve never thought about people not being able to exercise or get physical therapy. Social isolation in the elderly has become a big issue, but we didn’t envision what would happen if we had to impose it on them for periods of time,” he says. “We need to think of solutions and ways to reshape policies to optimize aging in the most challenging of circumstances. Now is the time for all hands on deck to think about opportunities for change and innovation.”

Addressing residents’ risk of falls in the coming months is essential, Hoffman says, especially considering that “fall-related injuries are a leading reason for hospital readmission in older patients, particularly for at-risk individuals discharged home.”

Targeting at-risk older adults, especially those recently discharged from the hospital, is a worthwhile focus, with the potential to reduce readmissions and improve patient care and outcomes, he says.

Looking ahead, Hoffman suggests that there may be more intergenerational programs and opportunities for younger and older people to live together or engage in more meaningful ways. “This could result in programs and interactions that promote physical activity,” he says.

“Think of how many yoga instructors and personal trainers are out there. Now imagine if Medicare says they will hire them to work with older patients. Imagine if we did this for people who are desperate for work and want to make a difference. Then we let them provide some of these services via telehealth consultations.” There’s no reason this couldn’t be done, Hoffman says: It would be mutually beneficial, and it would save money in the long run.

How Residents are Coping

“Many of our residents are dealing with the current situation quite marvelously,” Hussain says. “They’re handling it for the most part and working with practitioners and staff to stay active and engaged as much as possible.” However, he stresses the need to be vigilant.

For many people, it’s difficult not to see family members, and Community Physicians is seeing a rise in depression. “We need to utilize social workers and others in the facility to help deal with the emotional stresses of social distancing and changes to their routines,” Hussain says. “We need multidisciplinary strategies to get and stay ahead of the curve. This may mean enabling video conferencing with family members, showing videos of pets, or aromatherapy with comforting scents such as cinnamon or freshly baked bread.”

Creativity is the name of the game, Hussain says, “as we continue to face something we’ve never experienced before.” This is especially true as physical therapists and activities directors can’t conduct business as usual.

However, therapy can be provided virtually in some cases or in person at a safe distance. While these sessions may not be able to be optimally rigorous or frequent, they can keep residents on track and making limited progress until regular therapy can resume.

“We don’t want to push people beyond what they are capable of, but we can all take some steps to help people gain or maintain function, strength, and conditioning so they don’t fall at some point in the future,” Hussain says.
Schon stresses the importance of team training. “We want people with adequate training on the front lines. We need to provide innovative tools and solutions. These are stimulating times for change, and if we train and empower team members, some exciting innovations are likely to result.”

Attend to Falls All Year Long

While any situation that contributes to residents’ risk of deconditioning, immobility, and fall risk requires attention, preventing falls is a year-round commitment. For instance, O’Neil says, “We follow the Go4Life campaign and encourage our residents to engage in fitness activities, including walking, swimming, cycling, and resistance exercises.”

Launched nearly 10 years ago by the National Institute on Aging (NIA), Go4Life (www.nia.nih.gov/health/exercise-physical-activity) encourages older adults to reap health benefits by making physical activity part of their daily lives. The program is based on studies that demonstrate the beneficial effects of exercise and physical activity for older adults, including those with chronic health conditions.

Affinity Living Group also evaluates residents’ environments annually, looking for loose rugs and wires, slippery floors, and other hazards that can contribute to falls.

“We make sure the environment is as safe as possible, but we also encourage residents to avoid risky behaviors and take actions to reduce their fall risk, such as wearing well-fitting shoes and getting their vision checked annually,” O’Neil says.

Residents often don’t realize the potential danger of falls and may see these accidents as a sign of weakness or physical decline. As a result, they may hesitate to self-report a fall, even if they are injured. “Education is an important piece. We need people to understand how common falls are and that they can happen to people even when they are healthy and cautious,” says O’Neil. “We let our residents know that it’s important for them to report a fall and that, by evaluating the situation, we often can resolve the problem and prevent them from falling again and possibly getting injured.”

Looking Ahead

“While we don’t know what the impact of isolation and quarantines will be, we will see the impact of deconditioning later. We may see an influx of falls if we don’t address this now,” Schon says.

Buslovich agrees, saying, “We know that our residents can lose up to 1 percent of muscle mass per day if they are sedentary. That means they can lose up to 10 to 15 percent in a couple of weeks. This is especially problematic when you consider that most residents don’t have much of a muscle mass reserve to begin with. We need to address this now, or we will see a much greater prevalence of falls in the next quarter or two.”

Establishing and maintaining a healthy organizational culture will go a long way toward a positive fall prevention program. Buslovich says facilities need a feedback mechanism and positive reinforcement for good behaviors. Staff shouldn’t fear punishment for reporting a fall, he says. Instead, the focus should be on finding a root cause for the fall and identifying what changes are necessary to prevent similar events in the future.

“A punitive culture isn’t ultimately effective,” O’Neil says. “We need staff who are proactive and confident enough to suggest new ideas and ask for training or help when they need it. Our staff work so hard; we need to let them know when they are doing good work,” he says. “We have to get away from the blame game. It’s really important not to shame staff when a fall happens and to encourage and recognize ‘good catches.’”

Tagging the Tradeoffs

Falls prevention can be a bit of a Catch-22. When people are more active, there are more opportunities for them to fall. However, according to a recent study, a higher level of activity may actually be protective in the event of a fall. The study, published in The Journal of Applied Gerontology, showed that physically active U.S. veterans were more likely to fall but less likely to be injured when they do. Compared with inactive older adults without a military history, the vets had 11 percent more falls but 28 percent fewer fall-related injuries.

Particularly as people age, there are risks associated with activity. However, Hoffman notes, “A lifetime of habits is hard to break. If people have always viewed themselves as active and independent, suddenly shifting to limited activity can be hard.”

However, he says, it’s important to share information with residents and their families about the risks and benefits associated with being active and the tradeoffs involved. For a lot of people, it will be worth the risk, and, in reality, “nothing is zero risk.”

Buslovich agrees, adding, “Patients who are active and mobile will fall unless they are in a bubble. We need to balance resident autonomy with efforts to maximize their safety. In the end, our goal should be to prevent falls and fall-related injuries as much as possible while maximizing each person’s quality of life.”

Read More: Putting Tech on the Table

Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Va.​