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Fall Prevention in the Home

Preventing Falls

By Julie A. Braun, J.D., LL.M.

Falling is the leading cause of death in women and the fourth leading cause of death in men between 65 and 85 years of age. It is the leading cause of death for men and women over age 85. The percentage of falls among community-dwelling older adults increases from 25 percent at age 70 to 35 percent after age 75 and is a growing elderly health risk. Therefore, it makes sense for families and geriatric care managers (GCMs) to incorporate an audit for fall prevention in the home into the assessment process. Most older adults wish to continue to live in their own homes for as long as possible; however, these homes likely are not designed to meet their changing needs as they age. Environmental modifications can promote mobility and reduce the likelihood of falling. This article considers slip and fall accident prevention and modifications relating to lighting conditions throughout the client's home; floor coverings such as carpets, rugs, runners and mats (but not ceramic tiles, linoleum, wood or other floor surfaces); electrical, telephone, extension and other cords; stairs and steps, and the client's bathroom.

PROPER LIGHTING

Tailor lighting to client visual needs. In general, older adults require two to three times more light than younger persons due to normal changes in visual function that accompany the aging process. However, lower levels of lighting may be appropriate for some individuals. For example, enhanced lighting may impair vision and increase fall risk for individuals with cataracts or glaucoma. Ideally, the level of illumination is visually comfortable and safe for mobility. One way a GCM can determine lighting appropriateness is to observe the client in their home environment and record any difficulties the client encounters. These observations may prompt recommendations for increasing, decreasing, or redistributing lighting levels. The geriatric care manager also should tour the client's home. Does the client have effortless physical access to all lighting? Are light switches positioned approximately 32 inches above the floor? Located directly inside or outside doorways and easily visible so the client does not have to traverse a darkened room to activate or grope to find? If appropriately located but not visible, improve detection by using switchplates that contrast in color with the room wall. Purchase switchplates in a different color, remover and re-paint, or apply colored adhesive tape around their borders. Alternatively, substitute existing light switches with a "glow switch" that can be seen in the dark. In addition, client functional status may prompt replacement of traditional toggle switches with user-friendly pressure plate controls. High fall risk locations within the client's home (e.g., path from the bedroom to the bathroom) require special lighting to promote safe mobility and reduce the likelihood of falling. In the bedroom, for instance, the GCM might recommend a bedside table lamp with a sufficient base to prevent it from tipping over positioned to avoid excessive reaching and possible balance loss, convenient headboard lighting, or a nightlight for adequate illumination. Add a working flashlight to the bedside table drawer (as well as other locations throughout the client's home) for access during a power outage. The ability of the aging eye to adapt to sudden changes in lighting intensity decreases with age. A momentary visual loss and an increase in fall risk may occur when the client moves between dark and brightly illuminated areas Therefore, propose installing rheostatic light switches that permit the client to increase or decrease illumination levels as desired. Unlike toggle light switches or pressure plate controls, rheostatic light switches prevent sudden and pronounced shifts in lighting.

Other recommended environmental modifications might include:

  • Replacing burned out light bulbs.
  • Installing additional lighting (e.g., lamps, light fixtures, or nightlights) where appropriate. Passageways between rooms, stairwells, and other heavy traffic areas should be well lit.
  • Using inexpensive nightlights that plug into electrical outlets to illuminate hallways, bedrooms and bathrooms.
  • Installing power failure lights in key areas to prevent walking in the dark. These simple devices can be installed in electrical outlets and are especially helpful near stairs.
  • Using the right type and maximum wattage bulb allowed by the fixture.
  • Reducing sources of glare through frosted bulbs, shades or globes on light fixtures, indirect lighting, partially closing draperies or blinds, tinted mylar shades or polarized window glass.

CARPETS, RUGS, RUNNERS AND MATS

Hospital emergency room personnel routinely treat adults over 65 years of age for injuries sustained after a fall-related event in their home that such older individuals commonly describe as a slip, stumble, trip, loss of footing or near fall involving a carpet, rug, runner or mat. Consequently, the geriatric care manager must consider these floor coverings when performing a fall hazard assessment of the client's current physical environment. The geriatric care manager might begin the assessment process by asking the client or, if present, their family members and friends about any known falls associated with carpets, rungs, runners or mats. In addition, the geriatric care manager can use his or her own observations as a guide when advising of environmental risk factors and home modification recommendations. For example, are the floor coverings in good repair or noticeably worn and torn? Also valuable is the GCM's own experience while walking on the client's carpets, rugs, runners or mats. For instance, do the floor coverings bunch up or slide when the GCM walks on them?

Home modifications might include, among other possibilities:

  • Removing and replacing any carpet, rug, runner, or mat that tends to bunch up or slide underfoot.
  • Avoiding throw rugs.
  • Purchasing only carpets, rugs, runners and mats featuring slip-resistant backing or padding. Remember that such material can become less effective after repeated washings and, therefore, may require replacement occasionally. If the client's budget makes new purchases unlikely, ensuring that offending carpets, rugs, runners, and mats are slip-resistant by, among other options, applying double-faced adhesive carpet tape to the item's reverse side

  • Caption: Applying double-faced adhesive carpet tape to reverse side of carpets, rugs, runners, and mats is one way to ensure slip-resistance, or adding rubber matting beneath the product. Adhesive tape and rubber matting that can be cut to size typically are available at local flooring and carpet outlets as well as home improvement stores. Periodically check whether new tape or rubber matting is needed because the adhesive on the tape can wear away over time and the rubber matting can deteriorate leaving a powdery substance on the bare floor.
  • Making certain that carpets, rugs, runners and mats lie flat and are placed on even floor surfaces.

    Choosing aesthetically pleasing carpets, rugs, runners and mats that complement client preferences must be balanced with functional floor coverings that promote safe navigation. Consider, for example, a client's lifelong preference for wall-to-wall shag carpeting that may snag canes, walkers or wheelchairs causing the client or a visitor to fall. The GCM should recommend a more sensible uncut low pile product and suggest that the replacement floor covering retain the color of the shag carpet unless the color choice also presents a potential fall hazard. As people age, a number of normal changes in the eye's anatomy occur as can several common visual disorders such as difficulty in focusing, delayed glare recovery, decreased sensitivity to light, delay in dark/light adaptation, decreased contrast sensitivity, loss of depth perception, and constriction of peripheral vision. Keep these factors in mind when proposing colors for flooring (walls or furnishings). Floral or checkered configurations may lead to misjudgment of spatial distances, for example, while black on a blue background may be difficult to distinguish for an older adult with decreased contrast sensitivity and carpeting with bold patterns may be disorienting for older adults with limited depth perception. The GCM cannot ignore the fall hazards presented by surface changes that occur throughout the client's home (e.g., carpeting in the living room to linoleum in the kitchen). Changes in surface can cause a loss of balance unless easily distinguishable by the older adult. Floor coverings in contrasting colors can visually cue the client to the boundary between the surfaces as well as the floor and wall. The assessment of the client's carpeting, rugs, runners and mats must be considered within a broader context of the client's comprehensive assessment. A client with shaky hands or loss of some or all control over bladder function, for example, may prefer stain resistant easy-to-clean carpeting.

    ELECTRICAL, TELEPHONE, EXTENSION AND OTHER CORDS

    The geriatric care manager should walk through the client's house and note placement of all electrical, telephone, extension and other cords.

    Avenues of inquiry might include:
    • Are cords positioned out of the flow of foot traffic where they might cause someone to trip over them even if such possibility is remote?
    • Are one or more cords lying underneath and/or protruding out from beneath a piece of furniture creating a fall hazard (along with fire and shock hazards if furniture weight has damaged cords)?
    • Are any cords lying underneath and/or protruding out from or a carpet, rug, runner or mat where they may cause a fall (or a fire)?
    Home modifications might involve:
    • Finding a new location for the offending cords, preferably along a wall and not under the furniture, carpeting, rugs, runners or mats;
    • Re-arranging furniture so that electrical outlets are available for lamps and appliances without need for extension cords;
    • Placing cords on the floor out of the way (e.g., against a wall) where people can not trip over them or fastening up extra cordage with a twist tie;
    • Removing cords from under furniture or carpeting;
    • Moving the telephone so that its cords are out of walking paths yet remain accessible if client has to call for help if he or she falls.

    STAIRS & STEPS

    The geriatric care manager should ask the client if he or she has difficulty with steps or stairs? For all stairways, the GCM should check lighting, handrails, and the condition of the individual steps and their coverings. Lighting is an important factor in preventing falls even amongst persons familiar with the stairs. Are two-way light switches located at the top as well as the bottom of inside stairs? Are the switches accessible? The client should be able to turn on the lights from either end before using the stairway. Stairs should be well lit so that each step, particularly step edges, is clearly seen while going up and down stairs. The lighting should not produce glare or shadows along the stairway. Consider installing motion-detector lights that turn on automatically and light the stairway whenever the client approaches. Handrails are an important addition to any stairway and the client should be educated on the importance of their routine use. Do all stairs in the client's home feature sturdy handrails fastened securely on both sides of the stairway about 30 inches above the stairs? Do handrails run continuously from the top to the bottom (i.e., full length) of the entire flight of stairs and slightly beyond the steps? If not, the client may incorrectly perceive that he or she has arrived at the last step when the handrail stops. Misjudging the last step can trigger a fall. Are the handrails comfortable to grip? Environmental modifications involving handrails might include repairing broken handrails, tightening the fixtures that secure the handrails to the wall, installing at least one handrail (on the right side as the client faces down the stairs) if no handrails are present, or replacing a short handrail with a longer one. The GCM next shifts attention to the stair steps and their coverings, if any. Are steps even (i.e., same size and height)? A small difference in step surface or riser height can lead to falls. Mark any steps that are especially narrow or have risers higher or lower than the others. Do the steps allow secure footing? Consider placing non-slip adhesive treads on each bare step to improve traction. Are step edges clearly visible? Can the client detect the outline of each step as well as top and bottom landings with the light on? A fall may occur if step edges appear blurred or are difficult to spot. Replace any patterned, dark or deep-pile carpeting with a tightly woven carpet in solid color to better highlight step edges. Are all steps in good condition (i.e., not loose, broken or missing)? If no, repair or replace loose, broken or missing boards immediately. Do stair coverings (i.e., rugs or treads) show signs of wear? Worn, torn or loose coverings can lead to insecure footing, resulting in slips or falls.

    Thus, recommend repair or removal and replacement of any stair coverings in disrepair. Is anything stored on the stairway, even temporarily? The client may trip over any objects left on stairs, particularly in an emergency (e.g., fire) or when racing to answer the telephone. Accordingly, remove all items from the stairway and remind client to keep stairs free of clutter.

    BATHROOMS Using Fixtures for Balance Support May Contribute to Falls

    A client with balance dysfunction or one who is unable to use a walker in the bathroom because of space limitations may rely upon the towel bar, wall surfaces, and sink top for support. This habit may cause a fall, particularly if the client's hand slips. Modifications to provide balance support include substituting a grab bar for the towel bar or installing a grab rail around the perimeter of the bathroom wall. Further, applying non-slip adhesive strips along sink surface (in a color similar to the sink to avoid visual confusion) will prevent the client's hands from sliding when sink area is grasped. Toilet Height Must Meet Client Needs Toilet height can cause a fall and influence an older adult's ability to physiologically use the toilet. Sitting instability may happen if the older adult cannot place his or her feet on the bathroom floor while aboard the toilet. Maintaining feet flat on floor or hips at or below knee height facilitates bladder emptying and bowel evacuation Toilet height must satisfy client needs. For example, an older adult recovering from a fractured hip must sustain a sitting position with hips higher than the knees so temporarily adapt the fixture by using a toilet seat riser, thick seat or filler ring. Some ambulatory disabled persons likewise find higher seat heights an advantage. Not so for persons in wheelchairs. The toilet seat should be constructed of sturdy material to provide sufficient support. Furthermore, the seat should act as an absorptive cushion (e.g., made of soft vinyl plastic) to reduce risk of pelvic or hip fracture in persons who tend to drop onto the toilet seat. Low height toilets may pose transfer problems and as a result cause the client to fall. One corrective modification is the raised toilet seat in a fixed or adjustable height to ensure proper toilet sitting height. Another modification that seeks to maintain the client's balance during toilet transfers requires grab bar installation on the walls adjacent to and behind the toilet or attachment of a double armrest grab bar system to the toilet. Some older adults find that the double armrest system provides optimal transferring support since the maximum amount of force exerted during transfers is a straight downward movement of the arms. In contrast, wall mounted grab bars offer less support because the older adult must reach to the side and bend forward during the transfer process to grab the bar losing the benefit of a downward thrust offered by the double armrest system. As an additional cautionary measure, adhere non-slip adhesive strips in a non-contrasting color to the floor in front of the toilet to secure client footing during transfer, only use bathroom rugs with nonskid backing, or install non-slip vinyl flooring throughout the bathroom in a non-slip surface with a padded foundation to minimize fractures in the event the client falls.

    Toilet Grab Bar Type and Placement Is Critical Despite their potential value in preventing falls, community-dwelling older adults underutilize grab bars. Tailor grab bar type and placement to client needs, their disability, and the environment. For example, it is difficult for persons with hemiplegia to use grab bars located on their dysfunctional side; persons of short statute or limited reach find grab bars at heights convenient for the average person unsatisfactory as the bars are beyond their reach; and some older adults (e.g., older women who are generally shorter and possess less upper body strength than men) prefer an angled grab bar to the standard horizontal bar because they can grab the angled bar at the lower position and move up the bar. Select grab bars in a color that contrasts with the bathroom wall to improve their visibility and attach them to wall studs no more than 1½ inches from the wall to prevent the client's arm from slipping between the bar and wall. Toilet Seat Color Improves Visibility Toilet seat color is important. The seat itself must contrast in color to the toilet and the surrounding bathroom area to facilitate proper sitting placement on the toilet, particularly for older adults dependent on visual cueing. Older adults with poor color discrimination, for instance, may encounter problems and even fall trying to locate a white toilet seat where the bathroom flooring is white (or a light color) and it may be difficult for older males to void into a white toilet while standing without significant color differences between the toilet and flooring. Bathroom Doors Some older adults with a poor grasp open and close pocket style doors (i.e., those that slide like patio doors and disappear into a vertical slot in the wall) more easily than the traditional barn style doors that require more effort and may cause a fall. House design will determine if installation of pocket style doors is feasible. In addition, lever-type handles are much easier to grasp than doorknobs. The doorway should be wide enough to accommodate an assistive device (e.g., walker). The threshold should be clearly marked and the difference in height between the two surfaces should be no greater than ¼ inch. Remind the client to leave the bathroom door unlocked, so it can be opened from both sides. A locked bathroom door will delay help in reaching client who sustains a fall. Bathtubs and Shower Areas Does the bathtub/shower area have at least one grab bar? Grab bars aid the client in getting into and out of the tub or shower, and can help prevent falls. If yes, check existing bars for strength and stability, and repair if necessary. If no, attach grab bars, through the tile, to structural supports in the wall, or install bars specifically designed to attach to the sides of the bathtub. Alternatively, consider use of a tub bench, chair, or stool with non-skid tips as a seat while showering or bathing if the client is unsteady and unable to shower while standing or lower him or herself to the floor of the bathtub. Purchase a handheld shower attachment as well and install it on an adjustable rod or high-low mounting brackets. The bench, chair, or stool must be large enough to allow the older adult to use a flexible showerhead while seated. A cautionary measure includes mounting a liquid soap dispenser on the bathtub/shower wall so client does not fall while attempting to retrieve soap. Wet soapy tile or porcelain surfaces are especially slippery and may contribute to falls. Accordingly, place a nonskid rubber mat or apply nonskid textured adhesive strips, decals or appliqués on the bathtub or shower floor. Also replace glass shower enclosures with non-shattering material and add a slip-resistant rug adjacent to the bathtub for safer exit and entry.

    CONCLUSION The purpose of a comprehensive room-by-room environmental assessment is to identify and remove potential fall hazards and to modify the environment to maximize safe, functional mobility. Interventions aimed at modifying environmental conditions relevant to falls offers the geriatric care manager an appealing approach to falls prevention.

    Julie A. Braun, J.D., LL.M., an internationally recognized expert in long-term care, is a Chicago-based attorney and writer. Ms. Braun, braun@newnorth.net, is a visiting professor at various legal and medical institutions, including Emory University in Atlanta and the Universities of Osnabrueck and Witten in Germany. She is the editor of the ElderLaw Portfolio Series, co-author of Litigating Injuries in the Elderly (forthcoming 2003), advisory board member for Medical Malpractice Law & Strategy, and past editor of the Long-Term Care Litigation and the Pharmaceutical & Medical Device Law Bulletin newsletters. Recent publications include Julie A. Braun et al., Legal Issues in Long-Term Care in Principles of Geriatric Medicine & Gerontology (5th ed., William R. Hazzard et al., forthcoming 2003). Ms. Braun chairs the legal subcommittee of the Food and Drug Administration's (FDA) hospital bed safety workgroup and is a co-investigator in an FDA-funded study exploring the legal liability issues of siderail use. She also is a co-recipient of a Borchard Foundation Center on Law & Aging grant, a former chair of the American Bar Association (ABA) Medicine & Law Committee, and former vice chair of the ABA Seniors' Issues Committee. Ms. Braun is admitted to the bar of the Supreme Court of Illinois, U.S. District Court for the Northern District of Illinois, Seventh Circuit Court of Appeals, and the Supreme Court of the United States.

    Copyright, National Association of Professional Geriatric Care Managers, 2003

    USAGE AGREEMENT

    An agreement made this day, April 23, 2004, between ElderIssues, LLC ("Publisher") and Julie A. Braun ("Author").

    1. Assignment of Rights

    The Author hereby grants Publisher usage rights for Home Safe Home: Preventing Falls Through Environmental Assessment & Modification ("Work") which originally appeared as Julie A. Braun, Home Safe Home: Preventing Falls Through Environmental Assessment & Modification in GERIATRIC CARE MANAGEMENT JOURNAL 8-12 (Julie A. Braun & Steven Charles Castled eds., Summer/Fall 2003). The use of the Author's name with the manuscript is authorized by the Author. The Publisher shall have the right throughout the universe in all languages and in perpetuity to post the work on providing the following credit appears at the end of the Work:

    This article originally appeared as Julie A. Braun, Home Safe Home: Preventing Falls Through Environmental Assessment & Modification in GERIATRIC CARE MANAGEMENT JOURNAL 8-12 (Julie A. Braun & Steven Charles Castled eds., Summer/Fall 2003) and is republished with permission of Julie A. Braun, J.D., LL.M. Copyright 2003, Julie A. Braun. All rights reserved.

    2. Author's Warranty

    The Author warrants to the Publisher that: a) the Author is the sole author of the Work; b) the Work is original; c) the work does not violate any copyright law; d) the Work does not infringe in any way the literary property of another; e) the Work contains no matter that is scandalous, libelous, in violation of any right of privacy or otherwise contrary to law.

    Author:

    Julie A. Braun, J.D., LL.M. Law Offices of Julie A. Braun 446 North Wells Street Chicago, Illinois 60610 (715) 649-3244 Fax: (715) 649-3254 braun@newnorth.net

    This article was last updated on: 07/24/2010
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