Interventions to reduce fall risk among older adults Part I

S i o b h a n M c M a h o n R N G N P T h e C o l l e g e o f S t . S c h o l a s t i c a S t . M a r y ’ s D u l u t h C l i n i c , E l d e r C a r e a n d D e b L a i n e P r o g r a m D i r e c t o r T h e A r r o w h e a d A g e n c y o n A g i n g

Objectives

• • • •

Identify common risk factors of falls Integrate risk screening and assessment methods into everyday routines

Identify Interventions that have been proven to reduce fall risk Implement additional fall-preventive interventions into the everyday routines of your work with persons at risk of falls

Falls are a significant cause of injury, disability and death among older adult populations.

Falls are a significant cause of injury, disability and death among older adult populations.

Impact of falls

     20-30% of those who fall sustain injury 32% of those with fall related injury require assistance with ADL(s) Fear of falling Decreased physical activity Decreased social activity

Impact of falls

  Cost in 2000  $179 million (fatal falls)  $19.3 billion (non fatal injurious falls) Projected cost in 2020  $43.8 billion annually

Causes and Risks of Falls

Environmental Biological Behavioral Socioeconomic WHO, 2008

Risk Factors

Environmental ENVIRONMENTAL

Biological Socioeconomic WHO, 2008 Behavioral   Poor building design* Slippery floors and stairs*    Loose Rugs* Insufficient lighting* Cracked or uneven sidewalks*

*Modifiable

Risk Factors

Biological

• • • • • •

Muscle Weakness

*

Gait Changes*

Vision Impairment*

History of previous fall

Age (greater than 80) Gender

*Modifiable

WHO, 2008

BIOLOGICAL

Environmental Socioeconomic Behavioral

Risk Factors

Behavioral

• • • •

Multiple medication use* Use of medication that acts on central nervous system

* Lack of exercise* Inappropriate footwear* WHO, 2008 Biological Environmental Socioeconomic

BEHAVIOR AL

Risk Factors

Socioeconomic

Biological Environmental

SOCIOECONOMIC

WHO, 2008 Behavioral   Inadequate housing Lack of social interaction*  Lack of community resources*  Limited access to health and social services*

Causes and Risks of Falls

Biological Environmental Risk factors are

interactive

1 factor raises risk 27 %

Behavioral

4 factors raise risk 78%

WHO, 2008 Socioeconomic Tinneti, Speechley, & Ginter (1998)

Case Study

Jane Doe Recently admitted to the hospital via the ER after a fall. She had planned to get the morning paper, located at the dining room table across the room. She lost her balance as she moved from the couch to the table and fell. She did not lose consciousness but sustained a hip fracture and many bruises.

Screening

   Have you had 2 or more falls in the prior 12 months? Are you here because of a recent (acute) fall? Have you noticed any difficulty or changes with your walking or balance?  Do you fear falling?

History of 1 fall in last year

 Evaluate Gait and Balance  Timed Up and Go   Berg Balance Scale Performance Oriented mobility assessment

Answers YES to any of the screening questions

• • • • • • • • • History of falls Medication review Gait, balance and mobility Visual Acuity Other neurological impairments Muscle strength Heart Rate and Rhythm Feet and foot-wear Environmental hazards

Comprehensive Assessment

History of falls



Frequency of fall

 

Symptoms at the time of fall Previous injuries of fall sequelae

Comprehensive Assessment: Medication Review

• • • Anticonvulsants (e.g., dilantin)

4 or more medications

• Anti-depressant (e.g., prozac, celexa) • Antipsychotics (e.g. risperdal, seroquel, haldol) • Hypnotics (e.g. diphenydramine/ benadryl) Anxiolytic (e.g. xanex, ativan, klonipin) Antiarrhythmics (procan, rhythmol, dig) • Anti-vertigo or motion sickness (e.g. meclizine, dramamine) • Pain relieving (e.g. darvocet, percocet)

Comprehensive assessment

• Gait, balance and mobility (Timed Get up and Go) – Hesitant start ?

– – Broad based ?

Path Deviation ?

– – – – – Heels not clearing floor ?

Heels do not clear other foot ?

Cannot speed up without losing balance? Turning difficulties?

Gait symmetry?

Timed Get up and Go

1.

2.

3.

  Person being screened starts in a seated position.

Wearing sensory aids (e.g., glasses) Using assistive devices (e.g., walker, cane) Place a visible object 8 feet away from the person being screened.

Ask the person being screened to get up and walk around or to walk the object 8 feet away (and then turn around) , and sit back down.

Walking time greater than 8.5 seconds or observations of abnormal gait or balance during test are associated with fall risk among community dwelling older adults.

Comprehensive Assessment

Muscle strength  Quad strength   Using arms/ maneuvers to get out of chair? Chair rise (5 chair rises not using hands normally less than 30 seconds; average is 11.5s)  Range of motion

Vision Comprehensive Assessment

History of vision impairment?

Regular visits to the ophthalmologist? Vision aids? Functional vision? (e.g., able to read magazine print; signs? ) Visual acuity (Snellen)

Comprehensive assessment

       Additional neurological exam Cognitive screen (mini cog) Cranial Nerves LE peripheral nerves Proprioception Reflexes Rigidity, bradykinesia, tremor Coordination

Vital Signs

Vital Signs Heart Rate Heart Rhythm Blood Pressure Orthostatic Blood Pressure

Feet and Foot ware

Feet and Footwear  Sensation  Skin/Nails    Circulation Shoes (fit, soles, comfort ?) Slippers (non-skid ?)

Environmental Safety

Apartment  Clutter ?

 Electrical Cords?   Loose Rugs?

Adequate Lighting?

Case Study

Jane Doe Recently admitted to the hospital via the ER after a fall. She had planned to get the morning paper, located at the dining room table across the room. She lost her balance as she moved from the couch to the table and fell. She did not lose consciousness but sustained a hip fracture and many bruises.

Case Study

History  Lives in assisted living apartment; recently moved from a home she has owned for 40 years    Widowed one year ago 2 daughters; one in Duluth and another living in the cities; both very supportive Loves to shop, visit with friends, garden, walks (did) daily.

Case Study

Jane Doe Description of the Fall:     Early am immediately moving from couch to table Wearing slippers Thinks she may have slipped and then was unable to break her fall No dizziness, vertigo, black out

Case Study: Jane Doe

Medications

   Lisinopril 10mg ASA 81 mg Multi vitamin daily  Tylenol PM 2 q HS

Function

     Independent with ADLs Independent with most IADLS (daughter helps with medications and bills) Continent Sleep pattern is interrupted by repeated thoughts and memories about her husband (she misses him) Use to shop a lot and exercise every day but now feeling too tired for that lately

Case Study

Physical Exam

        BP laying down 122/80 BP sitting up 130/70 BP standing 118/80 Heart rate 72 and regular CN II-XII grossly intact No bradykinesia, tremor or rigidity Speech is clear Sensation intact       Gait is slow (healing hip fx) TUG: NA (healing hip fx) Chair stand (unable) Functional range of motion Mini cog: 3/3 recall; clock draw perfect Geriatric Depression Score  8/15

Biological Environmental Socioeconomic Behavioral • • • • What is your assessment? Name some of the fall risk factors that Jane Has Would your evaluation in the Hospital be different for the NH or clinic? How will you communicate your assessment on the record?

Jane Doe Falls Risk factors include : Grief related change in sleep and physical activity patterns Situational depression De-conditioning and weakness Benadryl for sleep history of falls Biological

(sleep changes; effects of medications; weakness) Environmental Socioeconomic

Behavioral

(decreased activity, use of benadryl)

Conclusions

Interventions to reduce fall risk among older adults Part I • • • • Individualize assessments in accordance with situation.

Integrate screening and assessment into your everyday work.

Use your resources to help with assessment. If you find abnormalities or confusing aspects of your assessment, collaborate and consult with family and other members of the IDT PT/ OT Pharm D MD RN

Practice Guidelines

• Minnesota falls web-site:

http://www.mnfallsprevention.org/professional/index.html

• American Geriatrics Society Fall prevention Guideline: http://www.medcats.com/FALLS/frameset.htm

• Consult Geri RN (great for inpatient and nursing home environment strategies) http://consultgerirn.org/topics/falls/want_to_know_more • ICSI Acute Care Guideline: http://www.icsi.org/guidelines_and_more/protocols_/patient_s afety___reliability_protocols/falls__acute_care___prevention_ of__protocol_/falls__acute_care___prevention_of__protocol_ _24254.html

References

Centers for Disease Control and Prevention. (2010a). Web-based injury statistics query and reporting system (WISQARS) [online]. NCIPC, CDC (producer). Retrieved July 10, 2009, from www.cdc.gov/ncipc/wisqars Centers for Disease Control and Prevention. (2010b). Wide-ranging online data for epidemiologic

research, DATA2010 the Healthy People 2010 database; focus area: 22-physical activity and

fitness. Retrieved July 10, 2009, from http://wonder.cdc.gov/scripts /broker.exe

Gillespie, L. D., Robertson, M. C., Gillespie, W. J., Lamb, S. E., Gates, S., Cumming R. G., et al. (2009). Preventing falls in older people living in the community. Cochrane Database of Systematic Reviews, 2, Art. No.: CD007146. DOI: 10.1002/14651858CD007146.pub2.

McInnes, E., & Askie, L. (2004). Evidence review on older people’s views and experiences of falls prevention strategies. Worldviews on Evidence-Based Nursing, 1(1), 20-37.

Rubenstein, L. Z. (2006). Falls in older people: Epidemiology, risk factors and strategies for prevention. Age and Ageing, 35(Suppl. 2), ii37-ii41. Sleet, D. A., Moffett, D. B., & Stevens, J. (2008). CDC’s research portfolio in older adult fall prevention: A review of progress, 1985-2005, and future research directions. Journal of Safety Research, 39, 259-267.

Taylor, A. H., Cable, N. T., Faulkner, G., Hillsdon, M., Narici, M., & Van Der Bij, A. K. (2004). Physical activity and older adults: a review of health benefits and the effectiveness of interventions. Journal of Sports Sciences, 22(8), 703-725.

Yardley, L., & Smith, H. (2007a). A prospective study of the relationship between feared consequences of falling and avoidance of activity in community living older people. The Gerontologist, 42(1), 17-23. World Health Organization. (2008). WHO global report on falls prevention in older age. Retrieved from http://whqlibdoc.who.int/publications/2008/9789241563536_eng.pdf