an inTeRlink feature article
5-7-97

Preventing Falls in Long-term Care: A Model Recreation Therapy Program

Linda L. Buettner, C.T.R.S., Ph.D. and Janet Waitkavicz, B.S., RN

Authors can be reached at Decker School of Nursing, Binghamton University, Box 6000, Binghamton, NY 13902-6000

Abstract

This paper identifies and explores the programmatic issue of prevention of falls for older adults in the long-term care system. It identifies three primary areas of involvement for recreation therapists in the prevention of falls. The recreation therapist has the opportunity to help alleviate a major risk to leisure in this setting by addressing this problem through careful assessment of both the environment and the participant, through education, and through a model fall prevention program.

Keywords: Older adults, falls, long-term care, recreation therapy programs, prevention.

The number of older adults in the United States is growing, and falls among the older adult population are a serious and significant problem (Commodore, 1995). Approximately 33 percent of older adults 65 years of age and older fall at least once each year (Koski, Luukinene, Laippala, & Kivela, 1996). Injuries caused from a fall are a predisposing factor in 40 percent of the events leading to long-term nursing home placement among older adults. In the long-term care setting, two thirds of older adult residents fall once a year on average (Commodore, 1995). The survival rate of long-term care residents who have had to be hospitalized for injuries resulting from a fall has been estimated to be only 63 percent (Janitti, Pykko, & Laippala, 1995). Approximately 47 percent of residents die during their hospital stay for a fall.

Although recreation therapists provide a variety of services across the long-term care spectrum, few comprehensive therapeutic programs address the problem of falls in this setting. It is essential that the recreation therapist be able to address the area of falls prevention since injury- causing falls have serious consequences requiring medical attention, hospitalization, and limitations in activity (Luukinen, Koski, Honkanen, & Kivela, 1995).

The purpose of this article is threefold: (a) to increase awareness of the incidence and consequences of falls in long-term care settings, (b) to assist the therapist in assessing and alleviating risks for falls in recreation program areas, and (c) to present a model fall prevention program for long-term care residents.

Literature review

Research studies have shown that multiple factors contribute to the older adult's risk of falling (King & Tinetti, 1995). The main grouping of risk factors for falls identified in the literature is as follows: (a) intrinsic or host factors related to normal changes of aging or impairments due to disease, (b) extrinsic or environmental factors, and (c) the level of activity during the time of the fall (Galindo-Ciocon, Ciocon, & Galindo, 1995; Tinetti & Speechley, 1989).

Intrinsic risks

Intrinsic factors that have been most related to falls in long-term care are impairments in musculoskeletal function, cognitive impairment, and increased use of medications (Galindo-Ciocon, Ciocon, & Galindo, 1995). Some examples of medications found to be risk factors for injurious falls include: sedatives, diuretics, psychotropics, short-acting benzodiazpeines, and drugs causing hypotension such as antihypertensives (Koski, Luukinen, Laippala, & Kivela, 1996).

Among ambulatory nursing home residents, those receiving psychotropic medications have been found to be at the greatest risk of falling (Thapa, Brockman, Gideon, Fought, & Ray, 1996). Nonambulatory residents who are not bed-bound but who have the capacity for independent transfer have been found to be at the greatest risk of falling.

Additional intrinsic factors that place older adult participants at an increased risk of falling in programming areas include: slow walking speed, reduced quadriceps strength, poor vision and hearing, podiatric conditions such as bunions, and multiple medical diagnoses (Luukinen, Koski, Laippala, & Kivela, 1995). Medical diagnoses commonly associated with falls include: dementia, cardiovascular disease, diabetes, depression, dehydration, orthopedic disorders, acute illness of any kind, and neurological problems such as stroke, Transient Ischemic Attack (TIA), or Parkinson's disease.

Extrinsic risks

The importance of the interaction of the older adult with his or her environment was first identified and described by Lawton (1974). Older adults are especially vulnerable to negative environmental influences in a concept known as environmental press. The more disabled the older adult using the recreation environment, the more critical the environment, because individuals' with disabilities are so dependent upon the supports of the environment to achieve the highest possible level of functioning. Environmental problem areas of concern in the long-term care setting include the presence of glossy floors, inadequate lighting, unstable furniture, unlocked wheelchairs, unsecured rug edges, ill-fitting walking aids or footwear, excessive clutter, and a lack of adapted equipment in the program area (Buettner & Martin, 1995).

For older adults with cognitive impairments the provision of a modified environment is based on the progressively lowered stress threshold model (Hall & Buckwalter, 1987). It proposes that individuals with dementia need environmental demands modified to match their cognitive and functional abilities. Both environmental stressors and internal stressors can cause the individual to become anxious and agitated. In this model if the stressful stimuli are allowed to continue or increase, behavior becomes increasingly dysfunctional (Gerdner, Hall, & Buckwalter, 1996). This dysfunctional behavior reduces the individual's ability to adapt to the environment and can lead to a fall.

Level and type of activity

Most falls occur when the older adult is completing his or her usual activities of daily living such as walking or changing position (Tinetti & Speechley, 1989). Only a small number of falls have been found to occur when the older adult is engaging in recreational activities. Other studies have demonstrated that social and physical activity are inversely related to reported falls (Cwikel, Fried, Galinsky, & Ring, 1995). It has also been found that most falls in long-term care settings occur first thing in the morning and in the evening, when few structured recreation therapy programs are scheduled (Luukinen, Koski, Honkanen, & Kivela, 1995).

Intervention studies have shown that certain types of therapeutic activities can reduce the occurrences of falls among long-term care residents. In an cooperative intervention study of over 1,000 older adults who lived in the community and in nursing home settings, participants were selected for independent, randomized, controlled clinical trials to determine if short-term exercise could reduce falls (Province, et al., 1995). Two nursing homes and three community based HMOs were used as training sites. Training was performed using one or more of these components: endurance, balance, flexibility, and resistance. The main outcome of this intervention study was that fall incidents were significantly less for groups receiving general exercise and for those receiving balance activities. It was concluded that general exercise was the most important treatment component for reducing falls, followed by activities for balance.

Another program investigated the efficacy of two exercise approaches, Tai Chi and computerized balance training while a control group received only education (Wolf, Barnhart, Kutner, McNely, Coogler, & Xu, 1996). The intervention length was 15 weeks, with primary outcomes measured before and after interventions and at a 4-month follow-up. Falls were monitored continuously throughout the study. The Tai Chi group showed lowered blood pressure, improved lower extremity range of motion, and a reduced fear of falling. The Tai Chi group was also found to have a 47.5% reduced risk of multiple falls in the four-month follow-up period.

Description of the falls prevention program

The interdisciplinary falls prevention program described here was designed for frail older adults with cognitive and psychiatric impairments who resided in a long term health care facility in New York State. The program was developed by a recreation therapist, an occupational therapist, and a nurse (Buettner, Kernan, and Carroll, 1990). Part one of the program involved evaluating extrinsic risk factors involved in falls. When, where, and how the falls occurred were carefully examined after each incidence report. If the fall occurred because the patient was bored or looking for something to do, an individualized program of independent activities was established for the individual. If environmental risk factors played a role in the falls, a full environmental evaluation was completed by the staff member responsible for that particular environmental area. The recreation therapist was responsible for an environmental evaluation of the independent leisure areas on each unit, as well as the other areas used inside and outside the building used for therapeutic recreation programs.

Assessing the program area and participant

A quality assurance fall risk assessment checklist (figure 1.) was completed randomly one time monthly in each program to assist the therapist and program aides in the identification of risk factors. This was completed as a peer review, and the program staff was provided with results on a quarterly basis. The therapist then developed a plan to alleviate extrinsic risk factors for falls in the recreation programs identified.

Entrance and exit criteria

Part two of the program was designed to enhance functioning of older adults with frequent falls. This part of the program had specific entrance and exit criteria for participation (Kernan, 1989). If an older adult suffered two falls in one month, or one fall in two consecutive months, he or she was recommended for the program. If the treatment team determined that individual needed functional rehabilitation due to repeated falls, he or she received a interdisciplinary program of activities to enhance endurance, strength, and balance . To be discharged from the program the individual had to be free of falls for three months.

The intervention program

In planning the intervention program the staff carefully examined time of day and location of most falls. The intervention program was then planned to include increased activities at those times, in nearby settings. The first part the program involved a graded cardiovascular ambulation program before breakfast in the hallways leading to the dining rooms (Kernan, 1989). The older adult walked a prescribed distance each morning with a therapist or a therapy aide. Heart rate, blood pressure, and distance walked was monitored on a daily basis, with the goal of increased endurance.

The second part of the activities program involved a late afternoon session of sensory integration and balance activities provided by an occupational and recreational therapist (Buettner, Kernan, & Carroll, 1990). The goal of this part of the program was to improve protective responses and general balance. Special equipment was used in this segment of the program to heighten body awareness and promote movements like putting a hand-arm out to stop an off-balance situation from turning into a fall.

The third activities program was called exercise to music and was designed to improve strength, balance, and flexibility (Buettner, Kernan, & Carroll, 1990). The exercise program was provided in a co-treatment setting with an occupational therapist and a recreational therapist in the evening after dinner. The program included specific sensorimotor activities set to music. Upper extremity, lower extremity, and trunk movements were used to give opportunities for postural adjustment. Weights and stretchbands were added to the exercise routine as the group improved.

Finally, the participant was provided with ongoing education about falls and opportunities to move about in a variety of recreational settings inside and outside the facility and the community (Buettner, Kernan, & Carroll, 1990). Education for the older adult in a recreation therapy program included discussions about the fear of falling and common misconceptions that often limited the individual's activities. The participants were instructed, reminded, and cued on the use of adaptive equipment, avoiding unnecessary risks, and modifying activities for safety. Assertiveness training was provided to help the individuals who might otherwise hesitate to ask for assistance. Education was also provided about allowing enough time to get to and from recreation programs so the individual did not feel rushed. Finally, education programs for program participants and staff promoted the idea that the probability of falling was reduced by risk awareness, and active involvement to maintain skills.

Evaluation

Individuals who took part in the falls prevention program were monitored weekly on distance walked during the morning ambulation program. A distance chart was maintained for the group. Average distance covered in one minute increased from 28.6 feet to 52.2 feet during the first six months of the program. Strength was assessed monthly during exercise group using a bulb-type hand dynamometer. Average grip strength increased from 2.9 pounds to 6.72 pounds in first six months of the program.

The entire program was evaluated by the number of fall related incident reports in the facility per month. The average number of fall incidents per month in the facility before the program began was forty. After six months of the falls prevention program, the monthly average of fall incidents dropped to seven (Buettner, Kernan, & Carroll, 1990). This was a 76 percent reduction in falls.

Summary

In summary, falling is a common and serious health problem among older adults living in a long-term care setting. All health care professionals, including recreation therapists, should be alert to and aware of the risks associated with falls in older adults in this setting and know how to prevent them. It is imperative that therapists become involved in coordinating fall education programs, monitoring and alleviating risks in programming areas, and implementing comprehensive programs that help to prevent falls. Recreation therapists can have a significant impact on preventing this potentially life threatening problem in long-term care settings.

References

Sample Falls Prevention Checklist

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READ COMMENTS BY VISITORS:

I'm a student at the university of Northern Colorado my major is human rehabilitation services, the minor is therapeutic recreation. I spent four years in the military in the medical field. This is a great article about the elderly and their fragile state when they above 65yrs. Not much is really in place for them like it is for us in our younger years. Some are not able to get around like they use to. Which is very scary for me as I get older. However I know how important it is to stay in shape. Just taking a walk strengthens the very nature of our cardiovasculer system which is very important as we age. More should be done like this to improve one's agility and movement our whole selves as a unit.
Michael F. Blair
Greeley , Co. USA University of Northern Colorado - Sunday, November 15, 1998 at 12:39:31 (CST)

Excellent written information. The checklist is very helpful. I wonder about making this information more applicable to an older adult interested in fall prevention for themself. Can this be made more laymans language?
Heather Lever, richboro, pa USA - Tuesday, October 21, 1997 at 12:24:15 (PDT)

I just want to let you know that I find your article very interresting And I used it for an analysis in one of my class. I think there should be more research articles on the web about therapeutic recreation.
Marie Claude, Piedmont, Quebec Canada - Friday, November 14, 1997 at 08:02:42 (PST)

I am a CTRS at a skilled nursing facility. I am a member of the "Falling Stars" committee. I often find it difficult to provide interventions due to the time of the falls. (many occur after hours) I have started leaving activities at the nurses station in the evenings so they can attempt to prevent residents from wandering and falling. I have a class called Motions to Music daily to help increase strength and we are in the process of formulating a co-treatment program between RT and PT. I also encourage participation in activites during the day so as to prevent boredom.
Deann Ruckman, Tampa, FL USA - Sunday, April 05, 1998 at 17:24:56 (PDT)

Well. I?am a member of the workshop of falls od the Sociedad Espanola de Geriatria y Gerontologia. It?s very important the comunication of different groups for the prevention of falls in the world.
francisco garcia, Madrid, Spain Spain - Friday, April 10, 1998 at 23:16:35 (PDT

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