Approaches for Falls Prevention in Hospitals and Nursing Home Settings

  • Jesse Zanker
  • Gustavo DuqueEmail author


Falls in older people are a common problem and carry significant consequences for individuals and society. Falls can result in serious injury, hospitalization, death, anxiety and depression, and reduction in quality of life. The risk of falls and falls-related complications is associated with age, and given the population is aging, the incidence of falls is expected to rise. Older people living in long-term care facilities, or nursing homes, and those who are hospitalized are at significantly higher risk than the general population and commonly are cognitively impaired. This chapter will review the specific risk factors for falls in these populations focusing in cognitively impaired populations. Interventions to assess falls risk and initiate falls-prevention interventions will be discussed.


Falls Older persons In-hospital Nursing homes Risk factors Vitamin D Exercise 


  1. 1.
    Gill TM, Murphy TE, Gahbauer EA, Allore HG. Association of injurious falls with disability outcomes and nursing home admissions in community-living older persons. Am J Epidemiol. 2013;178(3):418–25.PubMedPubMedCentralCrossRefGoogle Scholar
  2. 2.
    Siracuse JJ, Odell DD, Gondek SP, et al. Health care and socioeconomic impact of falls in the elderly. Am J Surg. 2012;203(3):335–8.PubMedCrossRefPubMedCentralGoogle Scholar
  3. 3.
    Kumar A, Carpenter H, Morris R, et al. Which factors are associated with fear of falling in community-dwelling older people? Age Ageing. 2014;43(1):76–84.PubMedCrossRefGoogle Scholar
  4. 4.
    Burns ER, Stevens JA, Lee R. The direct costs of fatal and non-fatal falls among older adults - United States. J Saf Res. 2016;58:99–103.CrossRefGoogle Scholar
  5. 5.
    Nurmi I, Luthje P. Incidence and costs of falls and fall injuries among elderly in institutional care. Scand J Prim Health Care. 2002;20(2):118–22.PubMedCrossRefGoogle Scholar
  6. 6.
    Rubenstein LZ, Josephson KR, Robbins AS. Falls in the nursing home. Ann Int Med. 1994;121(6):442–51.PubMedCrossRefGoogle Scholar
  7. 7.
    Nyberg L, Gustafson Y, Janson A, et al. Incidence of falls in three different types of geriatric care. A Swedish prospective study. Scand J Social Med. 1997;25(1):8–13.CrossRefGoogle Scholar
  8. 8.
    Rapp K, Becker C, Cameron ID, et al. Epidemiology of falls in residential aged care: analysis of more than 70,000 falls from residents of Bavarian nursing homes. J Am Med Dir Assoc. 2012;13(2):187.e1–6.CrossRefGoogle Scholar
  9. 9.
    Lord SR, March LM, Cameron ID, et al. Differing risk factors for falls in nursing home and intermediate-care residents who can and cannot stand unaided. J Am Geriatr Soc. 2003;51(11):1645–50.PubMedCrossRefGoogle Scholar
  10. 10.
    Oliver D, Daly F, Martin FC, McMurdo ME. Risk factors and risk assessment tools for falls in hospital in-patients: a systematic review. Age Ageing. 2004;33(2):122–30.PubMedCrossRefGoogle Scholar
  11. 11.
    Vieira ER, Freund-Heritage R, da Costa BR. Risk factors for geriatric patient falls in rehabilitation hospital settings: a systematic review. Clin Rehabil. 2011;25(9):788–99.PubMedCrossRefGoogle Scholar
  12. 12.
    Chartered Society of Physiotherapy. Falls prevention economic model. http://www.Csp.Org.Uk/professional-union/practice/your-business/evidence-base/cost-falls. Accessed 15 Jan 2018.
  13. 13.
    Kojima G, Kendrick D, Skelton DA, et al. Frailty predicts short-term incidence of future falls among british community-dwelling older people: a prospective cohort study nested within a randomised controlled trial. BMC Geriatr. 2015;15:155.PubMedPubMedCentralCrossRefGoogle Scholar
  14. 14.
    Cooper R. Reducing falls in a care home. BMJ Qual Improv Rep. 2017;6(1):u214186.w5626.PubMedPubMedCentralCrossRefGoogle Scholar
  15. 15.
    Cameron ID, Dyer SM, Panagoda CE, et al. Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Datab Sys Rev. 2018;(9):Cd005465.Google Scholar
  16. 16.
    Tricco AC, Thomas SM, Veroniki AA, et al. Comparisons of interventions for preventing falls in older adults: a systematic review and meta-analysis. JAMA. 2017;318(17):1687–99.PubMedPubMedCentralCrossRefGoogle Scholar
  17. 17.
    Shimada H, Obuchi S, Furuna T, Suzuki T. New intervention program for preventing falls among frail elderly people: the effects of perturbed walking exercise using a bilateral separated treadmill. Am J Phys Med Rehabil. 2004;83(7):493–9.PubMedCrossRefGoogle Scholar
  18. 18.
    Sihvonen S, Sipila S, Taskinen S, Era P. Fall incidence in frail older women after individualized visual feedback-based balance training. Gerontol. 2004;50(6):411–6.CrossRefGoogle Scholar
  19. 19.
    Sakamoto K, Nakamura T, Hagino H, et al. Effects of unipedal standing balance exercise on the prevention of falls and hip fracture among clinically defined high-risk elderly individuals: a randomized controlled trial. J Orthop Sci. 2005;11(5):467–72.CrossRefGoogle Scholar
  20. 20.
    Faber MJ, Bosscher RJ, Chin APMJ, van Wieringen PC. Effects of exercise programs on falls and mobility in frail and pre-frail older adults: a multicenter randomized controlled trial. Arch Phys Med Rehabil. 2006;87(7):885–96.PubMedCrossRefGoogle Scholar
  21. 21.
    Kerse N, Peri K, Robinson E, et al. Does a functional activity programme improve function, quality of life, and falls for residents in long term care? Cluster Randomised Controlled Trial. BMJ. 2008;337:a1445.PubMedPubMedCentralCrossRefGoogle Scholar
  22. 22.
    Choi JH, Moon JS, Song R. Effects of sun-style tai chi exercise on physical fitness and fall prevention in fall-prone older adults. J Advanc Nurs. 2005;51(2):150–7.CrossRefGoogle Scholar
  23. 23.
    Nowalk MP, Prendergast JM, Bayles CM, et al. A randomized trial of exercise programs among older individuals living in two long-term care facilities: the fallsfree program. J Am Geriatr Soc. 2001;49(7):859–65.PubMedCrossRefGoogle Scholar
  24. 24.
    Mulrow CD, Gerety MB, Kanten D, et al. Effects of physical therapy on functional status of nursing home residents. J Am Geriatr Soc. 1993;41(3):326–8.PubMedCrossRefGoogle Scholar
  25. 25.
    Littbrand H, Carlsson M, Lundin-Olsson L, et al. Effect of a high-intensity functional exercise program on functional balance: preplanned subgroup analyses of a randomized controlled trial in residential care facilities. J Am Geriatr Soc. 2011;59(7):1274–82.PubMedCrossRefGoogle Scholar
  26. 26.
    Schoenfelder DP. A fall prevention program for elderly individuals. Exercise in long-term care settings. J Gerontol Nurs. 2000;26(3):43–51.PubMedCrossRefGoogle Scholar
  27. 27.
    Serra-Rexach JA, Bustamante-Ara N, Hierro Villaran M, et al. Short-term, light- to moderate-intensity exercise training improves leg muscle strength in the oldest old: a randomized controlled trial. J Am Geriatr Soc. 2011;59(4):594–602.PubMedCrossRefGoogle Scholar
  28. 28.
    Toulotte C, Fabre C, Dangremont B, et al. Effects of physical training on the physical capacity of frail, demented patients with a history of falling: a randomised controlled trial. Age Ageing. 2003;32(1):67–73.PubMedCrossRefGoogle Scholar
  29. 29.
    Crotty M, Rowett D, Spurling L, et al. Does the addition of a pharmacist transition coordinator improve evidence-based medication management and health outcomes in older adults moving from the hospital to a long-term care facility? Results of a randomized, controlled trial. Am J Geriatr Pharmacother. 2004;2(4):257–64.PubMedCrossRefGoogle Scholar
  30. 30.
    Lapane KL, Hughes CM, Daiello LA, et al. Effect of a pharmacist-led multicomponent intervention focusing on the medication monitoring phase to prevent potential adverse drug events in nursing homes. J Am Geriatr Soc. 2011;59(7):1238–45.PubMedPubMedCentralCrossRefGoogle Scholar
  31. 31.
    Zermansky AG, Alldred DP, Petty DR, et al. Clinical medication review by a pharmacist of elderly people living in care homes--randomised controlled trial. Age Ageing. 2006;35(6):586–91.PubMedCrossRefGoogle Scholar
  32. 32.
    Patterson SM, Hughes CM, Crealey G, et al. An evaluation of an adapted US model of pharmaceutical care to improve psychoactive prescribing for nursing home residents in northern Ireland. J Am Geriatr Soc. 2010;58(1):44–53.PubMedCrossRefGoogle Scholar
  33. 33.
    Wallerstedt SM, Kindblom JM, Nylen K, et al. Medication reviews for nursing home residents to reduce mortality and hospitalization: systematic review and meta-analysis. Br J Clin Pharmacol. 2014;78(3):488–97.PubMedPubMedCentralCrossRefGoogle Scholar
  34. 34.
    Holick MF. Vitamin d deficiency. New Eng J Med. 2007;357(3):266–81.PubMedCrossRefGoogle Scholar
  35. 35.
    DeLuca GC, Kimball SM, Kolasinski J, et al. Review: the role of vitamin d in nervous system health and disease. Neuropathol Appl Neurobiol. 2013;39(5):458–84.PubMedCrossRefGoogle Scholar
  36. 36.
    Feron F, Burne TH, Brown J, et al. Developmental vitamin d3 deficiency alters the adult rat brain. Brain Res Bull. 2005;65(2):141–8.PubMedCrossRefGoogle Scholar
  37. 37.
    Tomlinson PB, Joseph C, Angioi M. Effects of vitamin d supplementation on upper and lower body muscle strength levels in healthy individuals. A systematic review with meta-analysis. J Sci Med Sport. 2015;18(5):575–80.PubMedCrossRefGoogle Scholar
  38. 38.
    Bischoff HA, Stahelin HB, Dick W, et al. Effects of vitamin d and calcium supplementation on falls: a randomized controlled trial. J Bone Min Res. 2003;18(2):343–51.CrossRefGoogle Scholar
  39. 39.
    Broe KE, Chen TC, Weinberg J, et al. A higher dose of vitamin d reduces the risk of falls in nursing home residents: a randomized, multiple-dose study. J Am Geriatr Soc. 2007;55(2):234–9.PubMedCrossRefGoogle Scholar
  40. 40.
    Chapuy MC, Pamphile R, Paris E, et al. Combined calcium and vitamin d3 supplementation in elderly women: confirmation of reversal of secondary hyperparathyroidism and hip fracture risk: the decalyos II study. Osteoporos Int. 2002;13(3):257–64.PubMedCrossRefGoogle Scholar
  41. 41.
    Flicker L, MacInnis RJ, Stein MS, et al. Should older people in residential care receive vitamin d to prevent falls? Results of a randomized trial. J Am Geriatr Soc. 2005;53(11):1881–8.PubMedCrossRefGoogle Scholar
  42. 42.
    Law M, Withers H, Morris J, Anderson F. Vitamin d supplementation and the prevention of fractures and falls: results of a randomised trial in elderly people in residential accommodation. Age Ageing. 2006;35(5):482–6.PubMedCrossRefGoogle Scholar
  43. 43.
    Grieger JA, Nowson CA, Jarman HF, et al. Multivitamin supplementation improves nutritional status and bone quality in aged care residents. Eur J Clin Nutr. 2009;63(4):558–65.PubMedCrossRefGoogle Scholar
  44. 44.
    Cox H, Puffer S, Morton V, et al. Educating nursing home staff on fracture prevention: a cluster randomised trial. Age Ageing. 2008;37(2):167–72.PubMedCrossRefGoogle Scholar
  45. 45.
    Meyer G, Kopke S, Haastert B, Muhlhauser I. Comparison of a fall risk assessment tool with nurses’ judgement alone: a cluster-randomised controlled trial. Age Ageing. 2009;38(4):417–23.PubMedCrossRefGoogle Scholar
  46. 46.
    Ward JA, Harden M, Gibson RE, Byles JE. A cluster randomised controlled trial to prevent injury due to falls in a residential aged care population. Med J Aust. 2010;192(6):319–22.PubMedCrossRefGoogle Scholar
  47. 47.
    Chenoweth L, King MT, Jeon YH, et al. Caring for aged dementia care resident study (cadres) of person-centred care, dementia-care mapping, and usual care in dementia: a cluster-randomised trial. Lancet Neurol. 2009;8(4):317–25.PubMedCrossRefGoogle Scholar
  48. 48.
    Huang TT, Chung ML, Chen FR, et al. Evaluation of a combined cognitive-behavioural and exercise intervention to manage fear of falling among elderly residents in nursing homes. Aging Ment Health. 2016;20(1):2–12.PubMedCrossRefGoogle Scholar
  49. 49.
    van het Reve E, de Bruin ED. Strength-balance supplemented with computerized cognitive training to improve dual task gait and divided attention in older adults: a multicenter randomized-controlled trial. BMC Geriatr. 2014;14:134.CrossRefGoogle Scholar
  50. 50.
    Bates-Jensen BM, Alessi CA, Al-Samarrai NR, Schnelle JF. The effects of an exercise and incontinence intervention on skin health outcomes in nursing home residents. J Am Geriatr Soc. 2003;51(3):348–55.PubMedCrossRefGoogle Scholar
  51. 51.
    Durvasula S, Kok C, Sambrook PN, et al. Sunlight and health: attitudes of older people living in intermediate care facilities in southern Australia. Arch Gerontol Geriatr. 2010;51(3):e94–9.PubMedCrossRefGoogle Scholar
  52. 52.
    Becker C, Kron M, Lindemann U, et al. Effectiveness of a multifaceted intervention on falls in nursing home residents. J Am Geriatr Soc. 2003;51(3):306–13.PubMedCrossRefGoogle Scholar
  53. 53.
    Dyer CA, Taylor GJ, Reed M, et al. Falls prevention in residential care homes: a randomised controlled trial. Age Ageing. 2004;33(6):596–602.PubMedCrossRefGoogle Scholar
  54. 54.
    Jensen J, Lundin-Olsson L, Nyberg L, Gustafson Y. Fall and injury prevention in older people living in residential care facilities. A cluster randomized trial. Ann Int Med. 2002;136(10):733–41.PubMedCrossRefGoogle Scholar
  55. 55.
    Kerse N, Butler M, Robinson E, Todd M. Fall prevention in residential care: a cluster, randomized, controlled trial. J Am Geriatr Soc. 2004;52(4):524–31.PubMedCrossRefGoogle Scholar
  56. 56.
    McMurdo ME, Millar AM, Daly F. A randomized controlled trial of fall prevention strategies in old peoples’ homes. Gerontol. 2000;46(2):83–7.CrossRefGoogle Scholar
  57. 57.
    Neyens JC, Dijcks DP, Twisk J, et al. A multifactorial intervention for the prevention of falls in psychogeriatric nursing home patients, a randomised controlled trial (RCT). Age Ageing. 2009;38(2):194–9.PubMedCrossRefGoogle Scholar
  58. 58.
    Ray WA, Taylor JA, Meador KG, et al. A randomized trial of a consultation service to reduce falls in nursing homes. JAMA. 1997;278(7):557–62.PubMedCrossRefGoogle Scholar
  59. 59.
    Rubenstein LZ, Robbins AS, Josephson KR, et al. The value of assessing falls in an elderly population. A randomized clinical trial. Ann Int Med. 1990;113(4):308–16.PubMedCrossRefGoogle Scholar
  60. 60.
    Shaw FE, Bond J, Richardson DA, et al. Multifactorial intervention after a fall in older people with cognitive impairment and dementia presenting to the accident and emergency department: randomised controlled trial. BMJ. 2003;326(7380):73.PubMedPubMedCentralCrossRefGoogle Scholar
  61. 61.
    Hempel S, Newberry S, Wang Z, et al. Hospital fall prevention: a systematic review of implementation, components, adherence, and effectiveness. J Am Ger Soc. 2013;61(4):483–94.CrossRefGoogle Scholar
  62. 62.
    Growdon ME, Shorr RI, Inouye SK. The tension between promoting mobility and preventing falls in the hospital. JAMA Int Med. 2017;177(6):759–60.CrossRefGoogle Scholar
  63. 63.
    Brown CJ, Redden DT, Flood KL, Allman RM. The underrecognized epidemic of low mobility during hospitalization of older adults. J Am Geriatr Soc. 2009;57(9):1660–5.PubMedCrossRefGoogle Scholar
  64. 64.
    National Institute of Clinical Excellence. Falls in older people. Quality standard: NICE, 2017. Accessed 16 Jan 2018.
  65. 65.
    Morse JM, Black C, Oberle K, Donahue P. A prospective study to identify the fall-prone patient. Soc Sci Med. 1989;28(1):81–6.PubMedCrossRefGoogle Scholar
  66. 66.
    Morse JM, Morse RM, Tylko SJ. Development of a scale to identify the fall-prone patient. Can J Aging. 2010;8(4):366–77.CrossRefGoogle Scholar
  67. 67.
    Donald IP, Pitt K, Armstrong E, Shuttleworth H. Preventing falls on an elderly care rehabilitation ward. Clin Rehabil. 2000;14(2):178–85.PubMedCrossRefGoogle Scholar
  68. 68.
    Jarvis N, Kerr K, Mockett S. Pilot study to explore the feasibility of a randomised controlled trial to determine the dose effect of physiotherapy on patients admitted to hospital following a fall. Prac Evid. 2007;2(2):4–12.Google Scholar
  69. 69.
    Burleigh E, McColl J, Potter J. Does vitamin d stop inpatients falling? A randomised controlled trial. Age Ageing. 2007;36(5):507–13.PubMedCrossRefGoogle Scholar
  70. 70.
    Michalek C, Wehling M, Schlitzer J, et al. Effects of “Fit fOR The Aged” (FORTA) on pharmacotherapy and clinical endpoints - a pilot randomized controlled study. Eur J Clin Pharm. 2014;70(10):1261–7.CrossRefGoogle Scholar
  71. 71.
    Haines TP, Bell RA, Varghese PN. Pragmatic, cluster randomized trial of a policy to introduce low-low beds to hospital wards for the prevention of falls and fall injuries. J Am Geriatr Soc. 2010;58(3):435–41.PubMedCrossRefGoogle Scholar
  72. 72.
    Mayo NE, Gloutney L, Levy AR. A randomized trial of identification bracelets to prevent falls among patients in a rehabilitation hospital. Arch Phys Med Rehabil. 1994;75(12):1302–8.PubMedGoogle Scholar
  73. 73.
    Tideiksaar R, Feiner CF, Maby J. Falls prevention: the efficacy of a bed alarm system in an acute-care setting. Mt Sin J Med. 1993;60(6):522–7.Google Scholar
  74. 74.
    Shorr RI, Chandler AM, Mion LC, et al. Effects of an intervention to increase bed alarm use to prevent falls in hospitalized patients: a cluster randomized trial. Ann Int Med. 2012;157(10):692–9.PubMedCrossRefGoogle Scholar
  75. 75.
    Wolf KH, Hetzer K, Zu Schwabedissen HM, Wiese B, et al. Development and pilot study of a bed-exit alarm based on a body-worn accelerometer. Z Gerontol Geriatr. 2013;46(8):727–33.PubMedCrossRefGoogle Scholar
  76. 76.
    Dykes PC, Carroll DL, Hurley A, et al. Fall prevention in acute care hospitals: a randomized trial. JAMA. 2010;304(17):1912–8.PubMedPubMedCentralCrossRefGoogle Scholar
  77. 77.
    Wald HL, Glasheen JJ, Guerrasio J, et al. Evaluation of a hospitalist-run acute care for the elderly service. J Hosp Med. 2011;6(6):313–21.PubMedCrossRefGoogle Scholar
  78. 78.
    Mador JE, Giles L, Whitehead C, Crotty M. A randomized controlled trial of a behavior advisory service for hospitalized older patients with confusion. Int J Geriatr Psychiatry. 2004;19(9):858–63.PubMedCrossRefGoogle Scholar
  79. 79.
    Koh SL, Hafizah N, Lee JY, et al. Impact of a fall prevention programme in acute hospital settings in Singapore. Singap Med J. 2009;50(4):425–32.Google Scholar
  80. 80.
    van Gaal BG, Schoonhoven L, Mintjes JA, et al. The safe or sorry? Programme. Part ii: Effect on preventive care. Int J Nurs Stud. 2011;48(9):1049–57.PubMedCrossRefGoogle Scholar
  81. 81.
    Ang E, Mordiffi SZ, Wong HB. Evaluating the use of a targeted multiple intervention strategy in reducing patient falls in an acute care hospital: a randomized controlled trial. J Adv Nurs. 2011;67(9):1984–92.PubMedCrossRefGoogle Scholar
  82. 82.
    Haines TP, Hill AM, Hill KD, et al. Patient education to prevent falls among older hospital inpatients: a randomized controlled trial. Arch Int Med. 2011;171(6):516–24.CrossRefGoogle Scholar
  83. 83.
    Haines TP, Bennell KL, Osborne RH, Hill KD. Effectiveness of targeted falls prevention programme in subacute hospital setting: randomised controlled trial. BMJ. 2004;328(7441):676.PubMedPubMedCentralCrossRefGoogle Scholar
  84. 84.
    Stenvall M, Olofsson B, Lundstrom M, et al. A multidisciplinary, multifactorial intervention program reduces postoperative falls and injuries after femoral neck fracture. Osteoporos Int. 2007;18(2):167–75.PubMedCrossRefGoogle Scholar
  85. 85.
    Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. JAMA Int Med. 2015;175(4):512–20.CrossRefGoogle Scholar
  86. 86.
    Aizen E, Lutsyk G, Wainer L, Carmeli S. Effectiveness of individualized fall prevention program in geriatric rehabilitation hospital setting: a cluster randomized trial. Aging Clin Exp Res. 2015;27(5):681–8.PubMedCrossRefGoogle Scholar
  87. 87.
    Barker AL, Morello RT, Ayton DR, et al. Development of an implementation plan for the 6-PACK falls prevention programme as part of a randomised controlled trial: protocol for a series of preimplementation studies. Inj Prevent. 2016;22(6):446–52.CrossRefGoogle Scholar
  88. 88.
    Inouye SK, Bogardus ST, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. New Eng J Med. 1999;340(9):669–76.PubMedCrossRefGoogle Scholar
  89. 89.
    Inouye SK, Bogardus ST, Baker DI, et al. The hospital elder life program: a model of care to prevent cognitive and functional decline in older hospitalized patients. Hospital elder life program. J Am Geriatr Soc. 2000;48(12):1697–706.PubMedCrossRefGoogle Scholar
  90. 90.
    Inouye SK. Prevention of delirium in hospitalized older patients: risk factors and targeted intervention strategies. Ann Med. 2000;32(4):257–63.PubMedCrossRefGoogle Scholar
  91. 91.
    Hshieh TT, Yue J, Oh E, et al. Effectiveness of multi-component non-pharmacologic delirium interventions: a meta-analysis. JAMA Int Med. 2015;175(4):512–20.CrossRefGoogle Scholar
  92. 92.
    Brown CJ, Foley KT, Lowman JD, et al. Comparison of posthospitalization function and community mobility in hospital mobility program and usual care patients: a randomized clinical trial. JAMA Int Med. 2016;176(7):921–7.CrossRefGoogle Scholar

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© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Australian Institute for Musculoskeletal Science (AIMSS), The University of Melbourne and Western HealthSt. AlbansAustralia
  2. 2.Department of Medicine-Western Health, Melbourne Medical School, The University of MelbourneSt. AlbansAustralia
  3. 3.Department of Geriatric Medicine, Western HealthSt. AlbansAustralia

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