Interventions to reduce fall risk among older adults

Report
Interventions to reduce fall risk
among older adults
Part I
SIOBHAN MCMAHON RN GNP
THE COLLEGE OF ST. SCHOLASTICA
ST. MARY’S DULUTH CLINIC, ELDER CARE
THE ARROWHEAD AGENCY ON AGING
Objectives
• Review common risk factors of falls
• Assess older adults for presence of fall risk
factors
• Review Interventions that have been proven to
reduce fall risk
• Implement additional fall-preventive interventions
in patient population you serve.
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
 Poor building design*
ENVIRONMENTAL
Biological
Behavioral
Socioeconomic
WHO, 2008
 Slippery floors and
stairs*
 Loose Rugs*
 Insufficient lighting*
 Cracked or uneven
sidewalks*
Risk Factors
Biological
• Muscle Weakness*
Environmental
• Gait Changes*
• Vision Impairment
(2.5)*
• History of previous
fall (3.0)
• Age (greater than 80)
WHO, 2008
• Gender
BIOLOGICAL
Behavioral
Socioeconomic
Risk Factors
Behavioral
• Multiple medication
use*
• Use of medication
that acts on central
nervous system*
• Lack of exercise*
• Inappropriate
footwear*
WHO, 2008
Environmental
BEHAVIOR
AL
Biological
Socioeconomic
Risk Factors
Socioeconomic
 Inadequate housing
Environmental
Biological
 Lack of social
Behavioral
SOCIOECONOMIC
WHO, 2008
interaction*
 Lack of community
resources*
 Limited access to
health and social
services*
Causes and Risks of Falls
Risk factors are
interactive
Environmental
1 factor raises risk 27 %
Biological
Behavioral
4 factors raise risk 78%
Socioeconomic
WHO, 2008
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?
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-ware
• 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
4 or more medications
•
Anticonvulsants (e.g.,
dilantin)
•
Anti-depressant (e.g., prozac,
celexa)
•
Antipsychotics (e.g.
risperdal, seroquel, haldol)
•
Hypnotics (e.g. diphenydramine/
benadryl)
•
Anti-vertigo or motion sickness
(e.g. meclizine, dramamine)
•
Pain relieving (e.g. darvocet,
percocet)
•
•
Anxiolytic (e.g. xanex, ativan,
klonipin)
Antiarrhythmics (procan,
rhythmol, dig)
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?
– Sitting down in a chair?
– Standing up from a chair?
Timed Get up and Go
Person being screened starts in a seated position.
1.
1.
2.
2.
3.
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.
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
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
Vital Signs
Vital Signs
Heart Rate
Heart Rhythm
Blood Pressure
Orthostatic Blood Pressure
Feet and Footware
Feet and Foot-ware
 Sensation
 Skin/Nails
 Circulation
 Shoes (fit, soles, comfort ?)
 Slippers (non-skid ?)
Environmental
Safety
Apartment
 Clutter ?
 Loose 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
Function





Tylenol PM 2 q HS

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
• What is your
Environmental
Biological
Behavioral
Socioeconomic
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
Environmental
Falls
Risk factors
include :
grief related change
in sleep and
physical activity
patterns
Biological
(sleep
changes;
effects of
medications;
weakness)
Behavioral
(decreased
activity, use
of benadryl)
de-conditioning and
weakness
use of Benadryl for
sleep
history of falls
Socioeconomic
Conclusions
• 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
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

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