Falls in Dementia: Root Cause Analysis and Interventions

Root Cause Analysis of Falls in Dementia
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Determining the Root Cause of Falls

When people with Alzheimer's or another kind of dementia fall, it's important that we spend time to determine the root cause for that fall. This process is called root cause analysis. Root cause analysis means to dig deep and attempt to determine the underlying cause of the fall. Once we identify that root cause, we can then figure out an appropriate intervention that hopefully reduces that chance that this person will fall again.

Those with dementia have a higher risk for falls, often due to poor visual-spatial abilities, impaired judgment, impulsivity or a decline in walking and balance. The root cause, however, often goes deeper than those contributing factors.

Root cause analysis asks the questions of "What?", "How?" and "Why?" repeatedly until we drill down to the primary cause of the fall. Additionally, some experts recommend the "5 Whys" approach, which is asking the question "Why?" five times about the different pieces of information, such as the location of the fall (Why there?), the environment surrounding the fall (Why was the floor wet?), the possible reason that the individual was walking around (Why was he headed across the hall?), etc.

A Case Study

John is a 82 year old resident of the secure dementia unit in a long term care facility. He was moved there because he was wandering into other residents' rooms and because staff had determined that he would likely benefit from the activities that target his mid-stage dementia.

However, he has fallen twice in the last week.

When asking why John fell, you might look at some of the following questions for each of his falls:

  • Why did he get up?
  • What was he doing?
  • Where was he going?
  • Has he become weaker lately?
  • Did he lose his balance?
  • Did he bump into something?
  • What clues can we gather from his body language and facial expressions?
  • Did we ask him why he got up?
  • Did he need to use the bathroom?
  • Was he hungry?
  • Was he thirsty?
  • Was he bored?
  • Did he need to stretch his legs?
  • Has he been sitting too long?
  • Was he tired?
  • Was he in pain?

If, for example, John bumped into something, you need to ask "Why?". If you have determined that he is weaker now than he used to be, ask the "Why?" question. If he appeared restless, ask "Why?". Your answers to these questions will help you determine if John simply was restless and needed to walk around, if John was bored and was looking for something to do, or if he had declined and become weaker.

Note that environmental factors also need to be considered even if they aren't always the root cause. If John fell on the floor that was just mopped, the wet floor contributed to his fall. But, we still need to consider why John was getting up or where he was going. Was he headed to use the bathroom? Or, was he hungry and looking for a snack?

Identifying Interventions that Relate to the Root Cause

The answers to the questions above help us identify what kind of intervention will be the most effective in preventing future falls.

If we've concluded that John was hungry and looking for a snack, our intervention should relate to that issue. We could decide to offer John a snack at 2:00pm if his fall was at 2:30pm. Or, if he fell because he lost some strength, we could provide some physical therapy  after determining that his weakness may be related to his recent illness.

The key is to implement the interventions that truly address the underlying cause of John's fall so that we are hopefully eliminating the trigger, and thus the next potential fall.

While there are often multiple factors that may have contributed to the fall rather than one simple root cause, the process of deliberately asking questions and applying related interventions is often effective and can decrease falls. A decrease in falls can help maintain quality of life and overall functioning.

Sources:

Annals of Long Term Care.Volume 22 - Issue 1 - January 2014. Strategies for Reducing Falls in Long-Term Care. http://www.annalsoflongtermcare.com/article/strategies-for-reducing-falls-long-term-care

Windsor, J. Portsmouth Hospitals. Root Cause Analysis: Guidance for Falls Link Champions. September 9, 2014. 

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