Prevent Those Slips and Falls: Tips for Assessment and Strategies to Prevent Falls • Peggy McConnell, GNP-BC • Rhonda Brodrick, MSN, RN College of Nursing • Mike Stoots, Ed. D. College of Public Health East Tennessee State University This project was partially supported by grant number UB4HP19051-02-00 from the Department of Health and Human Services Health Resources and Services Administration (HRSA). Contents are solely the responsibility of the authors and do not necessarily represent the official views of HRSA. 1 Some Falls are funny! 2 Most Falls are Not 3 Objectives At the conclusion of this session, participants will be able to: • Describe the reasons falls are of special concern in the older adult population. • Identify the possible results of falls in the older adult population. • Identify intrinsic and extrinsic factors that increase the older adults' risks for falls. • Describe Level A and Level B categories of evidence-based interventions that reduce fall risk in older adults. • Recognize resources that will help provider/agency build a stronger fall prevention program. 4 Definition of Fall A fall is defined as unintentionally coming to rest on the ground or other lower level in a way that is not the result of a major intrinsic event (i.e., heart attack, stroke, or seizure) or an overwhelming external hazard (i.e., hit by a vehicle). 5 Why are falls important? The answer to this question incorporates data from several sources: • • • • • Demographics Significance of falls Healthy People 2020 Results of falls Potential for Prevention 6 By 2030 almost 70 million which is double the 35 million in 2000 Population over 65 (In millions) 80 2010 – First baby boomers hit 65 70 1900 1920 60 1940 1960 50 1970 1980 40 2000 2010 30 20 2020 10 2030 0 E L N E 1900 1920 1940 1960 1970 1980 2000 2010 2020 2030 C Year Administration on Aging, 2000 7 Demographics • All nations are facing an aging population. Increasing life expectancy in the U.S. (Male/Female) U.S. National Center for Health Statistics U.S. Census Bureau prediction “The world is aging so fast that within a decade there will be more people 65 and older than children under 5 for the first time” 8 Demographics In the United States, the elderly population is expected to be 20% of the total population by 2030. The Old-Old (greater than 85) cohort is the fastest growing cohort. 9 How significant is the problem? • Falls are the leading cause of injury death and nonfatal injury in older adults. • One out of three people age 65 and older living in the community will fall each year • Those who fall at least twice are twice as likely to fall again • The majority of those who fall do not seek medical attention • Fall risk increases as age increases. 10 How significant is the problem? • Of those who fall, 20% to 30% suffer moderate to severe injuries that make it hard for them to get around or live independently and increase their chances of early death • Falls are the most common cause of traumatic brain injuries • The most common fractures are of the spine, hip, forearm, leg, ankle, pelvis, upper arm, and hand • Complications resulting from falls are the number one cause of death from injury in both men and women aged 65 and older. 11 Quiz 12 Click the Quiz button to edit this quiz Growing Public Health Concern • Healthy People 2020 identifies fall prevention as a major focus. • Also identified as major focus by National Council on Aging (NCOA), Administration on Aging (AoA), American Geriatrics Society (AGS), Center for Disease Control (CDC), Medicare and Medicaid (CMS), US Preventive Services Task Force 13 Results of Falls • Morbidity • Health Care Utilization • Mortality • Physical Function • Independence 14 Fear of Falling Many people who fall, even those who are not injured, develop a fear of falling. This fear may cause them to limit their activities, leading to reduced mobility and physical fitness, which increases their actual risk of falling. 15 Results of Falls Hip fractures are the most frequent type of fallrelated fractures. • The cost of hospitalization for hip fracture averaged about $18,000 and accounted for 44% of direct medical costs for hip fractures. • After a hip fracture • 2-3 times more likely to die within one year • 25% in a nursing home one year later 16 Results of Falls • According to the CDC • In 2000, the total direct medical costs of all fall injuries for people 65 and older exceeded $19 billion: $0.2 billion for fatal falls, and $19 billion for nonfatal falls. • Costs are expected to increase as the population ages. • By 2020, the annual direct and indirect cost of fall injuries is expected to reach $54.9 billion (in 2007 dollars). 17 So Why Do Older Adults Fall? • Because of their comorbidities, causes of falls in older adults are rarely due to a single cause. • Two Major Cause Categories • Intrinsic (inside the body or personal) • Extrinsic (environmental) • Most falls result from a complex interaction between individual and environmental factors 18 Intrinsic (Individual) Risk Factors for Falls • Gender • females at greater risk than males • Age • risk increases significantly for 80 and older • Impaired information interpretation and/or judgment • mild cognitive impairment, dementia, Alzheimer disease • Impaired sensory input • diminished vision and/or hearing • Functional impairment • lower extremity weakness, alterations in gait and balance, diminished reflexes, delayed reaction response 19 Intrinsic (Individual) Risk Factors for Falls • Medical Conditions: • Diabetes • Cardiovascular - Orthostatic or post-prandial hypotension, Hypertension, Dysrhythmias, Heart Failure • Pulmonary – pneumonia, COPD • Foot problems - bunion, callous, toenails • Neurological – Stroke, Parkinson disease • Nutrition Deficits - Low body mass index, decreased intake of protein and nutrients • Altered urinary function – infection, incontinence • Depression 20 Extrinsic (Environmental) Risk Factors for Falls • About half of falls are precipitated by an environmental hazard 21 Extrinsic (Environmental) Risk Factors for Falls • Medications • As the number of medications increases, the risk of medication reactions, interactions, and side effects increases. • Fall risk increases with polypharmacy (use of 4 or more medications) and the use of psychoactive medications (tranquilizers, antidepressants) Alcohol Consumption Increased risk of interaction between medications and alcohol Heavy alcohol consumption (> 14 drinks/week) shown to be associated with increased falls 22 Extrinsic (Environmental) Risk Factors for Falls Courtesy Walt Disney Studios The majority of older adults desire to remain in their own homes ‣ Most live in “Peter Pan” Homes - Designed for those that never grow old! ‣ The majority of older homes have multiple hazards. ‣ Older adults are often unaware of the hazards in their homes. ‣ Biggest challenges for older adults are multiple steps/stairs and unsafe bathrooms. 23 Extrinsic (Environmental) Risk Factors for Falls Environmental hazards: • Poor lighting • Slippery surfaces • High-gloss floors • Stair hazards • Clutter • Storage problems • Tripping hazards • Pets/pet-related objects • Improper use of equipment 24 Farming and Falls 40% of farmers in US are above the age of 55 25 Older Farmers • Webinar on “Older Farmers and Falls” at the following OVAR/GEC web download: http://www.mc.uky.edu/aging/documents/gec/Webinar%203 %20Mental%20Health%20-Reed51112.pptx • Information on agricultural safety as it pertains to preventing fall related injuries in farm workers http://www.nasdonline.org/document/208/d000006/pre venting-injuries-from-slips-trips-and-falls.html 26 Risk Factors for Falls • Research has shown that fall risk increases greatly when the number of risk factors increases from 1 to 4 or more. • Age related changes can decrease the ability to avoid a fall after encountering a hazard or unexpected trip. 27 Quiz 28 Click the Quiz button to edit this quiz What Can We Do? Newly published evidence based guidelines: ‣ January 2010 - American Geriatric Society and the British Geriatric Society published the most current AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons ‣ December, 2010 - US Preventive Services Task Force addressed primary care interventions to prevent falls in older adults Michael YL, et al "Primary care–relevant interventions to prevent falling in older adults: A systematic evidence review for the U.S. Preventive Services Task Force" Ann Intern Med 2010; 153: 815-825. 29 What Can We Do? Evidence-based guidelines stress: • Recognition of the risk factors that lead to increased falls • Assessment to identify those at risk for falls. • Intervening to address the modifiable risk factors 30 Screening for Falls in the Acute and Long Term Care Environments Complete scheduled assessments with the screening tools designated by the facility’s fall protocol Two frequently used fall screening tools ◦ Hendrich II Fall Risk Module ◦ Morse Falls Scale 31 Screening for Falls in the Community The American Geriatric Society (AGS) recommends providers ask about falls at least once a year Have you: ◦ Fallen two or more times? ◦ Fallen and hurt yourself? ◦ Been afraid that you would fall because of a balance or walking problem? If the answer is yes to any of these questions, a multifactorial fall risk assessment should be completed. The report of a single fall requires (at minimum) a gait and balance evaluation. 32 Positive Screening . . . Now what? • Regardless of whether the client is in an inpatient facility or in the community, more information is needed • In order to intervene effectively, an in-depth assessment is needed to identify the problem area(s) What is included in a multi-factorial fall assessment? 33 Client’s Fall History History of falls – Have you fallen before? What were the circumstances of your fall(s)? Have you had injuries resulting from a fall? Medication review – What prescription and over the counter medications do you take? Do you use any herbal supplements? History of relevant risk factors – Do you have acute or chronic medical problems such as an infection or arthritis? 34 Physical Observations • Cognitive Function – judgment, evidence of acute or chronic confusion • Sensory Deficits – vision and hearing • Cardiovascular Function – heart rate and rhythm, postural pulse, postural blood pressure • Musculoskeletal Function - muscle strength, gait, balance, mobility levels, reflexes, lower extremity joint function • Extremities – signs of trauma, examination of the feet and footwear 35 Functional Assessment • Independence in activities of daily living (ADL) skills • Katz Index of Independence of ADL • Need for assistive devices • Appropriate use of assistive devices currently in use • Exploration of fear related to falling 36 Environmental Assessment • Check for Safety: A Home Fall Prevention Checklist for Older Adults Developed by the CDC through support from the CDC and MetLife Foundations Retrieved at: http://www.cdc.gov/HomeandRecreationalSafety/F alls/CheckListForSafety.html 1/28/13 Check for Safety PDF 37 Gait Assessment Frequently used tests of gait or balance include: Get up and Go test (Mathias, (1986); Timed Up and Go test (Podsiadlo et al,1991), Berg Balance Scale (Berg et al, 1989), Performance-Oriented Mobility Assessment (Tinetti 1986; Tinetti et al 1988). Gait and Balance can readily be assessed by the “Get Up and Go Test” which is demonstrated on the following slide. 38 Gait Assessment 39 Gait Assessment • Patients who take less than 10 seconds are usually considered normal. • Patients who take longer than 30 seconds tend to need assistance with many mobility tasks. 40 Gait Abnormalities Inability to stand without use of hands Unsteadiness upon standing Short steps Asymmetry Wide-based gait Slow gait Deconditioning, hip or knee pain Orthostatic hypotension, balance problems, weakness Weakness, Parkinson disease Stroke, Arthritis Fear, balance problems Fear of Falling, weakness, PVD, COPD, CHF 41 Quiz 42 Click the Quiz button to edit this quiz General Interventions for Fall Prevention Acute or Long Term Care ◦ Scheduled screenings to identify those at risk ◦ Environmental Assessment to identify/correct hazards ◦ Maintain client mobility ◦ Educate caregivers (staff & family) ◦ Individualized safety measures Community ◦ Annual screening (at minimum) ◦ Medication review ◦ Home hazard assessment ◦ Educate client/caregivers ◦ Address visual deficits 43 American Geriatric Society Clinical Practice Guideline Interventions Level “A” Evidence Based Practice Level “A” Interventions (Good evidence was found that the intervention improves health outcomes and the conclusion is that benefits substantially outweigh harm.) ◦ ◦ ◦ ◦ ◦ ◦ ◦ Individualized Fall Risk Assessment Identify Fall Risks Home Environment Assessment by HCP Home Environment Modification Direct Implementation of Interventions by HCP Exercise Vitamin D Supplementation 44 American Geriatric Society Clinical Practice Guideline Interventions Level “B” • Evidence Based Practice Level “B” Interventions (At least fair evidence was found that the intervention improves health outcomes and the conclusion is that benefits outweigh harm.) • • • • Medication Modification Cataract Surgery if Indicated Treatment of Postural Hypertension Dual Chamber Pacing if Indicated • To prevent syncope • PDF Version of Guidelines 45 US Preventive Services Task Force Community-dwelling adults: • In older, community-dwelling adults, interventions that appear effective in preventing falls include exercise or physical therapy and vitamin D supplementation. • In older, community-dwelling adults, interventions to prevent falls are not associated with significant adverse events. • Source link USPSTF 46 Exercise Programs (Level A) Strong recommendation for activities that increase balance, strength and gait training (AGS & USPSTF) • Numerous studies support the use of exercise programs in conjunction with other interventions • Campbell (1999), Steinberg (2000), Tinetti (1994), Clemson (2004), and Day (2002) • Exercise needs to be sustained for at least 6 months to be effective • AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons, January 2010. retrieved at http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendati ons/2010/ 3-15-10 47 Exercise Programs • Physical Therapy for strengthening and balance and gait training • Evidenced based community health promotion programs such as A Matter of Balance, Otago, Stepping On, and Tai Chi: Moving for Better Balance • Others http://www.ncoa.org/improve-health/center-for-healthy-aging/fallsprevention/community-programs.html 48 Exercise Programs (Level A) http://go4life.nia.nih.gov/exercise-guide-video http://www.nia.nih.gov/HealthInformation/Publications/ExerciseGuide/default.htm 49 Exercise Programs (Level A) Yoga There is growing evidence that yoga can improve physical well-being, including balance, range of motion, blood pressure, pain, fatigue, and general health. 50 Other Evidence-Based Community Exercise Programs Supported by Administration on Aging (AoA) • Tai Chi Moving for Better Balance http://www.ncoa.org/improvehealth/center-for-healthy-aging/tai-chi-moving-for-better.html • A Matter of Balance http://www.mmc.org/mh_body.cfm?id=432 • Stepping on http://steppingon.com/ • Otago http://www.cdc.gov/HomeandRecreationalSafety/Falls/compendiu m/1.2_otago.html 51 Tai Chi and Qigong Recent updates to the American Geriatrics Society show that activities such as Tai Chi are recommended as part of the exercise component of fall prevention interventions. 52 Benefits of Tai Chi Benefits of targeted, meditative movements may include: • Increased physical activity, improved balance and quality of life • Delayed functional decline • Improvement in chronic health conditions (arthritis, blood pressure) • Perceived improvements in psychological well-being and quality of life • Increased social support 53 Tai Chi 54 Games to Improve Muscle Strength and Balance • Wii Fit • Wii Games such as bowling 55 Vitamin D Supplements (Level A) AGS & USPSTF • Vitamin D deficiency impairs muscle strength and neuromuscular functioning • At least 800 IU per day for those with proven Vitamin D deficiency • Consider a supplement if a deficiency is suspected or the client is at risk for fall The American Geriatrics Society. (2010). AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons 56 Modify Home Environment (Level A) • Arrange for a home environmental assessment by a health care provider (HCP) • Structural Challenges • Safety Hazards 57 Modifying “Peter Pan” Housing 58 Modifying “Peter Pan” Housing • Limit throw rugs • Remove extension cords and other tripping hazards • Make sure stairs have handrails and are safe • Installation of safety equipment • Lowered light switches, raised outlets, wider doors, ramps, grab bars 59 Things are not always as they seem! ‣ Moving furniture is generally not recommended unless it poses a definite fallrisk hazard. ‣ We have "cognitive maps" of our environment; that is, we are able to maneuver in our home environment with eyes closed. 60 Bathroom Modifications Large percentage of falls occur in the bathroom • • • • Grab bars Non-skid rugs Shower adapters Elevated seating surfaces 61 Medication Modification (Level B) AGS Keep the total number of medications (prescription and over the counter) as low as possible. Eliminate or replace medications that are known to be associated with increased falls. 62 Medications Associated with Increased Falls (Level B) • • • • • • Antipsychotics Antidepressants Benzodiazepines Some Antihypertensives Diuretics NSAIDS • Woolcott, J. (2009). Meta-analysis of the Impact of 9 Medication Classes on Falls in Elderly Persons. Archives of Internal Medicine 169, 1952-1960. 63 Improve Visual Acuity (Level B) AGS • Assess vision at regular intervals • Expedite cataract surgery • Educate older adults NOT to wear multifocal lenses while descending stairs • In a study by Harwood et al. (2005) there was a 40% decrease in falls post cataract surgery 64 Manage Postural Hypotension (Level B) AGS • Encourage older adults to increase fluid intake if not contraindicated by chronic health issues • Remind older adults to change positions slowly • Sit for few minutes before standing • Stand for a few minutes before walking • Regularly review blood pressure medications • Use of multiple BP medications may increase risk of falls 65 What else can we do? • Educate the older adult population • Pain Management • Manage foot problems/footwear • Stay informed of new information and technology 66 When Targeting Older Adults • • • • • Keep messaging positive Don’t use fear-based messaging Stress maintaining independence Avoid using term “exercise” Keep fall prevention tips – easy, fun, doable, inexpensive • Frame as a “life span issue” not an aging issue • Debunk fall myths Schneider, E.C. (2009). Falls Prevention Awareness: Findings and Lessons Learned from State Coalitions on Falls Prevention. National Council on Aging, Washington, D.C. http://www.ncoa.org/improve-health/center-for-healthy-aging for publication 67 Education • Education about fall prevention needs to be tailored to the individual • Do not focus on single interventions Educate on safe performance of daily activities Individually tailored exercise programs Learn how to fall Create a fall safe environment 68 Everyone falls so learning to fall safely is vital. 69 70 Education: Learn How to Get Up After A Fall If everyone falls, then we must learn to get up safely. 71 Education: Learn How to Get Up After A Fall 72 Education: Assistive Devices • Often used incorrectly by older adults • Ask where the device came from (PT, family member, neighbor, etc.) • Canes should be used on the “good” side • Height of walkers and canes should be about the level of the wrist 73 • May need a referral to PT for evaluation and training in correct use. Pain Management • Leveille et. al. (2009) • Pain is associated with a 1.5 fold increase in falls. • Chronic pain produces more falls than acute pain. • Those with two or more sites of pain had higher rates of falls. • In In comparison to pain free people, those in severe pain have a 77% increased risk of falls and those with mild pain have a 36% increased risk of falls. 74 Pain Management • How do you treat the pain without causing higher risk of falls? • Do we have an answer? • No, finding a balance between pain relief and increasing fall risk is very difficult! 75 Manage foot problems/Footwear • Bunions, toe deformities, ulcers, and deformed nails predispose the elderly to falls (Tinetti et al., 1988) • Elderly may have trouble knowing foot position 76 Manage foot problems/Footwear • Inspect feet regularly for problem areas. • Wear shoes that fit and are laced or buckled. • Avoid high heels, backless or slip-on shoes, and shoes with worn soles. 77 • Use anti-slip pads on soles. Quiz 78 Click the Quiz button to edit this quiz Multifactorial Intervention to Prevent Falls 79 Falls Case for Community Setting 78 y o Ms. J. fell early this morning in her bathroom. She lives alone in a small one bedroom apartment in public housing. She did not have a fracture but did develop a large bruise on her right thigh. Ms. J. is recovering from pneumonia and had recently returned from the hospital where she received 3 days of IV antibiotics and then was discharged home to complete the antibiotics orally. She has a medical history of hypertension as well as Type 2 Diabetes Mellitus. She is on multiple medications including a diuretic. She uses a walker sometimes. She said that since returning from the hospital she has had difficulty sleeping because of her cough and has been taking Benadryl 25 mg which she picked up over the counter several months ago. 80 As clinician, drawback to following AGS recommendations • Lack of knowledge of available assessment tools • Lack of knowledge of evidence based interventions • Time factor in short office visit setting • Cost • Resources • Lack of adequate reimbursement 81 Examples of New Technologies and Devices that address injury reduction • Nonskid socks: http://www.rehabmart.com/category.asp?cat=Fall_Prevention • Safe environments: http://www.environmentalgeriatrics.com/ • Smart Homes: • Georgia Tech Aware Home • ADT QuietCare 82 Other Resources • A Matter of Balance: Managing Concerns about Falls www.mainehealth.org/pfha or call your local Area Agency on Aging at 1-877-353-3771 (toll free) A Tool Kit to Prevent Senior Falls www.cdc.gov/ncipc/pub-res/toolkit/toolkit.htm , fall fact sheets, brochures, publications from the CDC. • No Falls Kentucky http://www.nofalls.org/ website offers resources for seniors and their families as well as professionals 83 Other Resources • Falls Free Initiative National Council on Aging http://www.ncoa.org/improve-health/center-forhealthy-aging/falls-prevention/falls-free-initiative.html • Easy-Exercise and Screening for youwww.easyforyou.info • Fall Prevention Center of Excellence- www.stopfalls.org • Home Safety Council - www.homesafetycouncil.org 84 Other Resources • National Council on the Aging-Center for Healthy Aginghttp://www.ncoa.org/improve-health/center-forhealthy-aging/ • National Institute on Aging Information Center • www.nia.nih.gov/healthinformation/publications • http://go4life.nia.nih.gov/exercise-guide-video • National Institute on Health Senior Healthwww.nihseniorhealth.gov • National Resource Center for Safe Agingwww.safeaging.org/default.asp 85 Falls Free Coalitions (HCP, public health, aging services and others to address fall prevention) 42 states: www.ncoa.org/fallsmap 86 Things to watch for in future • Falls Prevention Awareness Day, first day of Fall each September – this year 46 states participated. Theme “Standing Together to Prevent Falls” • Stopping Elderly Accidents, Deaths, and Injuries 2012 (STEADI Tool Kit) based on AGS clinical guidelines CDC STEADI Site This toolkit will have resources for self assessment, clinicians and education. • View Ehrenreich-NCOA-Webinar-08-14-2012(PDF) • Geriatric Education Center initiatives on Falls Prevention • NCOA, CDC, AoA, Archstone activities and research to decrease falls • Welcome to Medicare Physical and Yearly Physicals for Medicare participants 87 National Falls Prevention Awareness Day • National Falls Prevention Awareness Day is observed the first day of Fall (September 22 , 2012) to promote and increase public awareness about how to prevent and reduce falls among older adults. (46 states this year) Website has multiple promotion resources www.ncoa.org/FPAD • Falls Prevention Awareness: Findings and Lessons Learned from State Coalitions on Falls Prevention. National Council on Aging View PDF • www.stopfalls.org Falls Prevention Center of Excellence with fall prevention ideas and resources 88 STEADI Tool Kit “What is it?” • The Stopping Elderly Accidents, Deaths, and Injuries (STEADI) toolkit is a evidence-based comprehensive approach to reducing falls in the elderly through clinicians based on American Geriatrics Society Guidelines (AGS). • The STEADI toolkit contains suggestions on how to talk to patients, training materials, provider resources, and patient educational materials for both assessment and intervention strategies to prevent falls in the community. • Scheduled to be available December 2012 : http://www.cdc.gov/homeandrecreationalsafety/Falls/steadi/i ndex.html • Centers for Disease Control. (August 28, 2012). Using STEADI for Screening, Fall Risk Assessment, and Care Management (webinar): View PDF 89 Falls are a growing public health issue During this hour presentation: • Two Older Adults died due to a fall. • 240 Older Adults were treated in the ED for fallrelated injury …But many falls are preventable! Interventions can successfully reduce the rate of falls and improve quality of life for our older adults. National Council on Aging, May 2012 90