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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


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.


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.


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.


Sample Falls Prevention Checklist

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I think your article is great, and this is a real multidiscplinary approach, with this on going problem of preventing falls in Nursing homes.
Anjani Deodhar
Pomona, NewYork USA Summit park Hospital&Nursing care centerTuesday, July 06, 2010 at 10:10:24 (EDT), IP Address: 124232130
Conventional wisdom dicates less movement is safer and would result in fewer falls. Your approach suggests jsut the opposite. Makes sense to me.
Ray Dailey
Canton, MS USA Florida CareTuesday, March 09, 2010 at 09:48:16 (CST), IP Address: 989510167
Thanks for the info. I am glad I found it, and I will bring it up during our next fall committee meeting.
Terry Guy
S, Plainfield, NJ USA AristaCare - Saturday, October 13, 2007 at 19:59:10 (CDT), IP Address:
What we did my wife and I put together a fitness and rehab device that patient can use in or out of bed,easy to adjust from 0-70pds good foam grips and a foot strap Nice. We are looking for help to put this New Program together in bed. To help patient from falling out of bed. I hope we can help
Kathy & Brent Taylor
Erie, Pa USA Day & Night Inc Wellness and Fitnesss manufacture Monday, November 20, 2006 at 09:24:57 (CST)
more info on documentation and splints
Friday, July 28, 2006 at 14:31:48 (CDT)
this is great info. another good thing to preventing to use restraints in nursing homes is to use bean bag chairs for positioning this as decreased our uses of restrants and falls. we had inuse of approx. 14 to 2 had have inserviced the familys to risk of using restraints and how restraints can increase falls and injuries.great matierial. now can you please help me with a good restrotive feeding program and some good info. for a bowel and bladder progrgam i have a program now be could you help me with some more matrierial. please
evelyn fussell
porter, texzas USA pine shadow retreat Friday, May 26, 2006 at 10:15:11 (CDT)
Alot of information,we have recently had an increase in falls at our facility.I'm a Restorative Aide and would love more info on any fall prevention and also dining programs .Thanks,Donna
Donna Spellman
Springfield, ohio USA Oakwood Village Retirement Saturday, April 08, 2006 at 08:37:35 (CDT)
im looking for so good idieas for my residents in our 124 bed long term facility.
evelyn fussell
Tuesday, December 27, 2005 at 22:53:20 (CST)
I work in the rehab therapy and I am looking for some great idieas for my residents to do. Can you help me with this.
evelyn fussell
porter, texas USA pine shadow retreat nursing facility Tuesday, December 27, 2005 at 22:52:18 (CST)
I am a CTRS working in the Dementia Unit at the NH Veterans Home. I would like to incorporate therabands into my exercise program. Where can I get info on exercising with therabands?
Angelique Mosher
Concord, NH USA NHVH Wednesday, October 05, 2005 at 05:19:30 (CDT)
I'm writing a research proposal for my grad. class on recreational therapy and its impact on the prevention of falls among the elderly. Your article was helpful and if there is any other resources you know could help I would appreciate your time for response. Thank you again!
Amy Rote
Harrisburg, PA USA Penn State University Sunday, September 11, 2005 at 08:06:34 (CDT)
iam a restorative aide at a long term facility. could you please e-mail me information on exercises for resedents who are wheelchair boundand ambulatory. DH
delores hill
camden, nj USA cna/restorative Tuesday, July 26, 2005 at 18:46:37 (CDT)
I have my degree in health and fitness and been hired to work at a nursing home as a resoritive/program coordinator. I have created a strenth training class for wheelchair/chair bound residents. The residence love it! i also have been incharge of making sure that every able ambulatory person gets daily walks. I have been very involoved with the falls at the nursing home. I am now incharge of that committee as well, what i am woundering is if you have any information on fall prevention and safety i would love to read.
Waltham, Ma USA Tuesday, May 17, 2005 at 09:14:26 (CDT)
Well I'm an Doctor(M.D) working on my MHA Degree, Information here is helpful Thanks alot for providing it!!!
Dr. Sandeep Singh
Wichita Falls, Tx USA Midwestern State University Tuesday, May 03, 2005 at 21:53:47 (CDT)
I am a Fitness Director interested in exercises to help prevent falls in the Assisted Living and Nursing Center facility. Please provide me with exercises for those residents who are ambulatory and also wheelchair bound.
Ellen Stambaugh
Newville, PA USA Green Ridge Village Friday, March 18, 2005 at 12:25:36 (CST)
I am the CarePlan coorinator, I am interested in setting up individle programs to help prevent falls, using our restorative program, any help would be greatly appreciated. Stacey Goodwin
stacey goodwin
osage city, ks USA Peterson Health Care Wednesday, March 09, 2005 at 12:46:23 (CST)
Hello, Looking for a simple restoritve Dining program that can be initiated by OT and carried by Nursing
jo Morrison OTR/L
Gilberville, Ma USA Radius Mgmt Monday, January 31, 2005 at 13:59:02 (CST)
iam a restoritive cna and need feedback on games, exercises,and preventive falls, alsofor wheelchairs i need all the information i can get on the job of a restoritive aide thank you frankie
crystal river, fl. USA brentwood retirement community Tuesday, January 04, 2005 at 17:33:29 (CST)
I am a nurse at an assisted living facility. I would love to start a program to help the residents. My questions were in regards to the residents in wc, please email me I want to start this immediately. I believe cognitive therapy is needed badly. I see so many residents totally bored, come to breakfast, lunch, dinner then back to rooms. I will save this sight and check in soon for any responses. Thank You
, AL USA Friday, December 31, 2004 at 18:36:20 (CST)
I am a CTRS and currently working in a nursing home. I have been elected to run my own root cause analysis program in preventing falls. Im repsonsible to plan and organize recreational programs through out the facility. I wondering if you could email me some suggestions on what kind of programs would be benefical. And who else can be apart of this program. We are very supportive facility and all have the same goal in mind. The benefit of the resident. We also have the fallen star program also. Any that you suggest would be very much appreciated. Thank you
Bay Shore, NY USA Student Saturday, October 16, 2004 at 15:38:57 (CDT)
need policy on falling stars, hip protector
dusty rowan
eddy, tx USA Sunday, July 04, 2004 at 16:57:58 (CDT)
Im the restortive cna and im doing an inservice on restortive care and preventing falls.I would loke more information on this subject.Thank-You
Lena Raygadas
broken bow, ok USA mc curtain manor nursing center Friday, April 02, 2004 at 19:16:29 (CST)
I am a Director of Nursing at a long-term facility. I have a Restoritive CNA who assists in range of motion exercises and ambulation. I would like to plan an activity program individualized for each resident, including those in wheelchairs, using the Restoritve CNA. Can you help me in this decision?
Libby Ward
Dyersburg, Tn USA Lauderdale Community Living Center Monday, March 08, 2004 at 20:46:26 (CST)
I am an Activity Director/Recreation Therapist for a Nursing Home. Our home has the "Falling Stars" Program and a Restortive RN who is in charge of the program. We also have a Physical and Occupational Therapists, but they are only here to do their work and then they leave. I would love to do a Rec Therapy Falls Program, but I really do not think the Occupational Therapist will be able to assist. I would also like to incorporate Tai Chi, but most of my residents are in wheelchairs and I have yet to find a Tai Chi video for them. Can you help????
Michelle Reynolds CTRS/Activity Director
Cincinnati, Ohio USA Ivy Woods Care Center Friday, October 17, 2003 at 13:13:19 (CDT)
I teach Body Recall and I'm interested in sharing my experiences with seniors. I find they are afraid to learn recovery techniques, because they must get on the floor in order to learn to get back up. Also, in using stretch bands what exercises are your participants doing? This is a new area for me and I need ideas.
GREENVILLE, SC USA YWCA Tuesday, October 14, 2003 at 16:50:19 (CDT)
I am currently working on a research proposal regarding the impact of scheduled therapeutic recreation program and the incidence of falls on people with dementia in a nursing home setting. Can you send me more information or is this the whole research on line? Any advice? Great resource for literature review.
Annemarie Wilson
Falls Church, VA USA Goodwin House West Tuesday, February 11, 2003 at 16:18:32 (CST)
I enjoyed your article and thought it was very interesting. I am a student and am presenting an inservice on incorporating SI into the rehab setting. Can you send me more information on your study. Thank you
Lisa Feist
USA University of Mary Thursday, October 24, 2002 at 15:22:14 (CDT)
ATRA has a special publication now available from our recent research on preventing falls on the special care unit. under Book Store. Linda Buettner
Dr. Linda L. Buettner, CTRS
Tuesday, May 14, 2002 at 13:42:46 (CDT)
This article was very helpful and I am taking it to our Falls Prevention Workgroup as a resource. Some of our nursing staff have inquired about baby dolls for some of our more anxious and restless (high risk for falls) residents as a way to pacify them. I was concerned about the age appropriate guidelines and thought that stuffed animals may be more suitable. Do you know of any State of Michigan guidelines that this may cross, if so what are they? I couldn't find anything specifically about a "baby doll" issue.
Rochester Hills, MI USA Mercy Bellbrook Friday, January 04, 2002 at 13:06:22 (CST)
I have been searching for ways of screening the elderly so as to determine their risk of falling as part of my final year project.Please can you send any other info to me that you think might be of some assistance.Thanks
Trinidad&Tobago School of Physical Thaeapy (Jamaica) Saturday, August 12, 2000 at 10:22:24 (CDT)
Can you email me information on a falls prevention program for acute care. A Medical ward . Thanks . Also Iam interested in travel to conferences that cover aged care .
Jan Williams
Old Bar Australia, Australia Wednesday, July 05, 2000 at 06:21:20 (CDT)
I am working on both an acute rehab unit and Nursing center which we have a "Fall Committee" in place. Your article was very helpful in highlighting the education of the residents/patients in fall risks and safety awareness. This is an area which I want to expand on to help decrease the number of falls in our facility. Please send any more info you may have. LRMC Recreation Therapy Dept. 700 N. Palmetto Dr. Leesburg, FL 34748
Annabella Benfield
Leesburg, FL USA Leesburg Regional Medical Center - SNF Wednesday, March 22, 2000 at 20:31:04 (CST)
excellent article to assist those working with the frail elderly population. I have also found, hanging a very bright colored poster with the word SAFE on it, above the individuals' bed and in strategic places helps in the prevention of falls. SAFE stand for: Staff Against Falls Everywhere.
Yvonne Bliss
Moab, Utah USA Spanish Valley Adult Day Care Thursday, October 28, 1999 at 09:18:33 (CDT)
Dr. Buettner; I recently gave a copy of the abstract on Preventing Falls in LTC: A Model Recreation Therapy Program to our Senior Director of Nursing and she thought it was wonderful. Thank you! I am requesting a copy of the original paper if that is possible. We recently have been having more falls than usual and would like to put this program in to effect as soon as possible. I hope you can help us out.
Mickey Rodak, CTRS
Brockport , NY USA Park Hope Nursing Home Wednesday, March 31, 1999 at 19:54:04 (CST)
I think this issue is very intersting and I'd like to know more about it. Please, send all information aviable.
Maria Amalia Gonzalez Lorente
Corrientes, 3400, Corrientes Argentina Nueva Imagen Tuesday, March 16, 1999 at 19:46:51 (CST)
please send me a copy of this article so i may share it w/ fellow catrd members thank you
michele petruzzi
Tuesday, January 26, 1999 at 17:43:52 (CST)

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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