siobhan mcmahon rn gnp the college of st. scholastica st. mary’s duluth clinic, elder care the...

SIOBHAN MCMAHON RN GNPTHE COLLEGE OF ST. SCHOLASTICA

ST. MARY’S DULUTH CLINIC, ELDER CARETHE ARROWHEAD AGENCY ON AGING

Interventions to reduce fall risk among older adults

Part I

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 injury32% of those with fall related injury require

assistance with ADL(s)Fear of fallingDecreased physical activityDecreased 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

Behavioral

Socioeconomic

Biological

WHO, 2008

Environmental

ENVIRONMENTAL

Behavioral

Socioeconomic

Biological

Poor building design*

Slippery floors and stairs*

Loose Rugs*Insufficient

lighting*Cracked or uneven

sidewalks*

Risk Factors

WHO, 2008

Biological

• Muscle Weakness*• Gait Changes*• Vision Impairment

(2.5)*• History of previous

fall (3.0)• Age (greater than

80)• Gender

Environmental

Behavioral

Socioeconomic

BIOLOGICAL

Risk Factors

WHO, 2008

Behavioral

• Multiple medication use*

• Use of medication that acts on central nervous system*

• Lack of exercise*• Inappropriate

footwear*

Environmental

BEHAVIORA

L

Socioeconomic

Biological

Risk Factors

WHO, 2008

Socioeconomic

Environmental

Behavioral

SOCIOECONOMIC

Biological

Inadequate housingLack of social

interaction*Lack of community

resources*Limited access to

health and social services*

Risk Factors

WHO, 2008

Causes and Risks of Falls

Environmental

Behaviora

l

Socioeconomic

Biological

WHO, 2008

Risk factors are interactive

1 factor raises risk 27 %

4 factors raise risk 78%

Tinneti, Speechley, & Ginter (1998)

Case Study

Jane DoeRecently 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

• Anticonvulsants (e.g., dilantin)

• Antipsychotics (e.g. risperdal, seroquel, haldol)

• Anxiolytic (e.g. xanex, ativan, klonipin)

• Antiarrhythmics (procan, rhythmol, dig)

• Anti-depressant (e.g., prozac, celexa)

• Hypnotics (e.g. diphenydramine/ benadryl)

• Anti-vertigo or motion sickness (e.g. meclizine, dramamine)

• Pain relieving (e.g. darvocet, percocet)

4 or more medications

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

1. Person being screened starts in a seated position.1. Wearing sensory aids (e.g., glasses)2. Using assistive devices (e.g., walker, cane)

2. Place a visible object 8 feet away from the person being screened.3. 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

Vision

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 RateHeart RhythmBlood PressureOrthostatic Blood Pressure

Feet and Foot-ware

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

ApartmentClutter ?Loose Cords? Loose Rugs?Adequate lighting?

EnvironmentalSafety

Case Study

Jane DoeRecently 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

HistoryLives in assisted living apartment; recently

moved from a home she has owned for 40 years

Widowed one year ago2 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 DoeDescription of the Fall: Early am immediately moving from couch to

tableWearing slippersThinks she may have slipped and then was

unable to break her fallNo dizziness, vertigo, black out

Medications Function

Lisinopril 10mg ASA 81 mg Multi vitamin daily

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: Jane Doe

Physical Exam

BP laying down 122/80BP sitting up 130/70BP standing 118/80Heart rate 72 and

regularCN II-XII grossly intactNo bradykinesia,

tremor or rigiditySpeech is clearSensation intact

Gait is slow (healing hip fx)

TUG: NA (healing hip fx)

Chair stand (unable)Functional range of

motionMini cog: 3/3 recall;

clock draw perfectGeriatric Depression

Score 8/15

Case Study

Environmental

Behaviora

l

Socioeconomic

Biological

• 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?

Falls

Risk factors include :grief related change

in sleep and physical activity patterns

de-conditioning and weakness

use of Benadryl for sleep

history of falls

Environmental

Behavioral

(decreased

activity, use of benadr

yl)

Socioeconomic

Biological

(sleep changes; effects of medicatio

ns; weakness)

Jane Doe

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/ OTPharm D

MDRN

ReferencesCenters 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