Guide to Action to Prevent Guide to Action to Prevent Falls (GTA)Falls (GTA)

Community version – in useCommunity version – in useCare Home version – under evaluationCare Home version – under evaluationDementia version – in developmentDementia version – in development

Robertson K, Logan P, Conroy S, Dods V, Gordon A, Challands L, et al. Thinking Falls- Taking Action: development of a Guide to Action for Falls Prevention British Journal of Community Nursing 2010;15(8):406 - 410.Robertson K, Logan P, Ward M, Pollard J, Gordon A, Williams W, Watson J. Thinking falls-taking action: a falls prevention tool for care homes.Br J Community Nurs. 2012 May;17(5):206-9Logan, PA; Coupland, CAC; Gladman, JRF, et al Community falls prevention for people who call an emergency ambulance after a fall: randomised controlled trial. . British Medical Journal 2010; 340 c2102

Professor Pip LoganProfessor Pip LoganDivision of Rehabilitation & AgeingDivision of Rehabilitation & AgeingUniversity of NottinghamUniversity of Nottingham

Developing the GTA

Group of clinicians, social services, fire service, local authorities, older people, commissioners, researchers 2008- to date

Incorporates clinical guidelines, research findings, clinical expertise

Checklist outlining 37 risk factors and recommended interventions

Training by falls specialists: Two hours, groups 4-8, interactive session

Intervention manual, GTA forms, falls incident record sheet

FALLS HISTORY√

MEDICAL HISTORY√

MOVEMENT & ENVIRONMENT√

PERSONAL√

History of FallsHistory of falls prior to admission to

the care homeFalls reason for admission to care

home

Medical historyStroke, Parkinson’s Disease, dementia, epilepsy, blackouts, diabetes, short of

breath, heart disease, arthritis, high / low blood pressure

TransfersNeeds help on/off chair, bed,

toiletUnsteady when transferring,

tends to rush

NutritionNeeds encouragement to eat

Poor appetite, Recent weight loss

History of FallsHistory of falls since admission

MedicationOn 4 or more medications,

on sedatives, antidepressants, diuretics

BalanceHolds furniture when moving,

unsteady when walking,loses balance on turning,

cannot walk unsupported due to unsteadiness

ContinenceIncontinent of urine / faeces,

toilet difficult to access, frequency, urgency,

gets up at night to use toilet/commode, concerned about

continence / getting to toilet in time,

difficulty managing clothes, catheter, constipation

Recent Falls2 or more falls in the past 6 months

(A fall is defined as inadvertently coming to rest on the ground or at a lower level, including slipping from

side of bed)Dizziness

Complains of dizziness, dizzy on first standing up

Stumbles or tripsNoted to stumble / trip even if no

obstacle, near misses noted

FracturesHas broken bones as result of fall:Wrist, hip, humerus, pelvis, spine, ribs, collar bone, shoulder, ankle

CognitionDoes not recognise own limitations, poor

understanding of space and distance, unaware of hazards ,

poor short term memory

GaitShuffles, leans to side,

leans backwards, walks fast

FluidDrinks less than 5 cups of

fluid a day, needs encouragement to drink, often leaves drinks

WalkingNeeds supervision when walking, needs assistance of 1 or 2 to walk

Hospital admissionAttended A&E due to fall, Ambulance

called - not taken to hospital ,admitted to hospital due to

fall

BehaviourAgitated, unsettled, anxious,

periods of aggression, risk to others

Walking aidsUses incorrectly,

refuses to use, forgets to use, poor condition

SleepUnsettled at night,

sleeps a lot during the day, feels tired

Other injury due to fallsHead injury, cuts, bruises, skin tears

ComprehensionHas difficulty understanding verbal

instructions / questions

Heating / body temperature Feels cold,

sits for long periods at a time, doesn’t recognise when cold

VisionHas diagnosed sight loss, wears varifocal / bifocal

glassesrefuses to wear glasses

Coping strategiesInability to get up or summon help

MoodLow mood, depression. anxiety, fearful

AlarmUnable to reach alarm, forgets to use,

does not call for assistance

Footwear Unsupportive footwear,

footwear too loose / tight, painful feet

Fear of FallingIs anxious / worried about falling,

lacks confidence, remains seated for much of day due

to fear of falling

CommunicationUnable to express needs verbally, unable

to make self understood,difficulty making self understood clearly

FlooringRugs, clutter, flexes,

Floor coverings, spillages

PainHas specific / general pain,

pain not helped by pain killers,

on meds for pain that cause side effects e.g. constipation,

dizziness, unable to communicate in

pain

LightingPoor lighting day and/or night, location

of light switches

FALLS HISTORY√

MEDICAL HISTORY√

MOVEMENT & ENVIRONMENT

√PERSONAL

√

History of FallsReview all incidents using Incident Analysis

Form, look for any patterns to falls e.g. time of day, activity at time of fall, inform GP of falls

history / recent fallsPostural blood pressure to be checked in lying, sitting and standing - alert GP if drop of more

than 20mmHg,Request medical review to identify any medical causes of falls e.g. infection, stroke, low blood

pressure, heart problemsIdentify any possible causes of falls and take

steps to reduce those risks

Medical historyCheck for signs of acute illness / infection, consider

medical review from GP if condition not been reviewed in last 6 months, if low blood pressure prompt to stand

still on 1st standing up

TransfersConsider use of alternative furniture,

refer to OT for advice if required

NutritionEncourage to eat small amounts regularly, ensure teeth well fitted, review reasons for poor appetite and weight loss - refer to GP,

dietician

MedicationMedication should be reviewed by GP every 6 mths, consider side effects of meds i.e. dizziness, sedation,

confusion. and refer to GP if concerned

BalanceEncourage to stand still on first standing

Advise to keep head and feet in line when turning, increase supervision, consider referral to

physiotherapist

ContinenceEnsure continence assessment completed, refer to comm. nurse or continence service, test urine, assess for constipation, consider

signage to toilet, refer to OT if required, consider commode for night use, check

regularly if requires toiletDizziness

Postural blood pressure to be checked in lying, sitting and standing - alert GP if drop of more than 20mmHg, Advise to move legs and feet before standing and to

stand still and count to 10 on first standing up

Stumbles or tripsDocument incidents, review incidents for time,

location, activity at time. Review possible causes e.g. footwear, eyesight

FracturesAt risk of osteoporosis,

Ask GP to review if person is falling and has had previous fracture(s)

CognitionRefer to GP if not reviewed in last 6 mths, use signage for toilet, bedroom, lounge, use physical gestures and prompts, Repeat information when person unable to

remember, inc super

GaitPrompt to lift feet, stand upright, refer physio

FluidEncourage to drink 6-8 cups of fluid a day,

stay with person whilst having a drink, document poor fluid intake if does not finish drinks, review reasons for poor fluid intake

eg worried about getting to toilet

WalkingRefer to Physiotherapist, assist in completing

exercise programme prescribed

Hospital admissionReview causes of fall, initiate any treatment

recommended, inform GP

BehaviourRefer to GP if medical review required, Mental Health

services,Ensure no acute illness or infection, be aware of risk of

introducing / increasing psychotropic medication

Walking aidsCheck correct height, check ferrules,

prompt to use correctly

SleepEncourage activity during the day, consider

time goes to bed, be aware of risk of medication to aid sleep increasing risk of falls, increase night supervision, consider

use of sensor mats

Other injury due to fallsReview causes of fall, initiate any treatment

recommended, inform GP

ComprehensionSpeak clearly, in short sentences, with simple

instructions, use physical gestures and prompts

Heating / body temperature Ensure draft free environment, consider

temperature if person sitting for long periods, mobilise regularly

VisionEnsure access to regular sight checks (every

2 yrs), ensure adequate lighting day and night, advise against bifocal glasses

Coping strategiesEnsure call buzzer easily accessible and working

Consider use of sensor equipment Increase level of supervision and document

MoodReassure, encourage socialisation,

Be aware of risk of introducing / increasing psychotropic medation

AlarmEnsure able to access alarm call system in rooms,

consider use of sensor equipment, increase supervision

Footwear Advise on suitable footwear, check footcare,

- nails, corns, callouses, refer to podiatry

Fear of FallingConsider reasons for fear of falling, increase

supervision, ensure mobility maintained, encourage and reassure

CommunicationConsider alternative communication methods, physical

gestures, observe behaviour and routines for insight into how the person may be feeling

FlooringEnsure floor free from clutter, rugs and flexes,

avoid patterned flooring, avoid thresholds, keep floors dry at all times

PainRefer to GP if pain poorly controlled, review

medication if side effects to prescribed tablets, observe behaviour and facial

expression for signs of pain if unable to communicate

LightingEnsure good lighting with no glare, consider use of

night light, ensure switches accessible

Feasibility testing of the GtACH

• 20 minutes versus 2 hours for non-training completers.

• 26 residents were assessed

• 179 risk fall factors were identified

• 163 recommended interventions were recorded

• 86 (53%) of these interventions were completed and recorded in the care plan.

• 9/11 participants with abnormal blood pressure received treatment to rectify.

• 7/8 participants who were having difficulties alerting staff when needing help, received a better placed buzzer and sensory alarm mats placed next to the bed.

• 5/10 incontinent participants were given a management plan or referred to the continence service or district nurse

To estimate important parameters that are needed to design the main study.

To test the feasibility of completing an RCT to evaluate a falls prevention intervention (GtACH) in care homes.

To determine whether to proceed with a large trial

To decide the best approach to adopt for the design of the definitive trial

Future directionsFuture directions

Evaluate GTA ?

Implement GTA ?

Lots of interest

Already used locally

Thank youThank youPip.logan@nottingham.ac.ukPip.logan@nottingham.ac.uk