Transcript FALLS & THE INSTITUTIONALIZED ELDERLY

FALL PREVENTION &
RESIDENT SAFETY
RISK IDENTIFICATION, ASSESSMENT
& THE FALLS PROGRAM
Nursesharks for CCRX Pharmacy author-Alice
B. Levy RN, BS, CWOCN
OBJECTIVES
1.UNDERSTAND THE RISK FACTORS FOR FALLS IN THE
ELDERLY
2. UNDERSTAND THE RISKS OF INJURY ASSOCIATED WITH
FALLS IN THE ELDERLY
3. BE AWARE OF HOW FALLS ARE DEFINED
4. BE ABLE TO PERFORM A RISK ASSESSMENT FOR FALLS
BOTH POST FALL AND ONGOING
5. BE ABLE TO IDENTIFY CONTRIBUTING FACTORS TO FALLS
IN THE ELDERLY
6. IDENTIFY DRUG RELATED SIDE EFFECTS WHICH CAN
CONTRIBUTE TO FALLS
7. BE ABLE TO DEVELOP A FALLS PREVENTION PROGRAM
8. BE ABLE TO DO ONGOING INVESTIGATION & TRENDING
STATISTICAL DATA







30-40% OF COMMUNITY BASED ELDERLY FALL
50% OF FALLS IN ELDERLY POPULATION OCCUR IN
HOSPITALS OR NURSING HOMES
YOUNG CHILDREN AND ATHLETES FALL MORE OFTEN BUT
WITH INFREQUENT INJURY
20-30% OF FALLS IN THE ELDERLY RESULT IN SERIOUS,
LIFE-CHANGING INJURY WHICH CAN INCREASE ANXIETY,
DEPRESSION, AND SOCIAL ISOLATION, AS WELL AS
RESTRICTING MOBILITY
THE INCIDENCE OF FALLS RISES AS ONE APPROACHES
MIDDLE AGE AND PEAKS AT 75-80 YEARS OF AGE
2/3 OF ELDERLY WHO FALL, FALL AGAIN IN 6 MONTHS
WOMEN HAVE GREATER INCIDENCE OF FALLS
RISK FACTORS





ADMISSION TO A LONG TERM CARE FACILITY
IMMEDIATELY PLACES THE ELDERLY PERSON AT
RISK
IF A FALL HAS OCCURRED, THE ELDERLY
PERSON IS LIKELY TO FALL AGAIN
THERE ARE BOTH INTRINSIC AND EXTRINSIC
RISK FACTORS
THE RISK FOR FALLS INCREASES AS THE
NUMBER OF RISK FACTORS INCREASE
THE RELATIONSHIP BETWEEN RISK FACTORS IS
MORE SIGNIFICANT THAN THE INDIVIDUAL RISK
FACTORS IN THE ELDERLY
RISK FACTORS

INTRINSIC RISK FACTORS:
ADVANCED AGE>80
MUSCLE WEAKNESS
GAIT & BALANCE DIFFICULTY
ARTHRITIC CHANGES
OSTEOPOROSIS*
DECLINE IN ACTIVITIES OF DAILY LIVING
SLOWING OF REFLEXES
LACK OF PHYSICAL ACTIVITY*
DECREASED COGNITION
DEPRESSION
VISUAL IMPAIRMENT*
COMORBID MEDICAL DIAGNOSESE
RISK FACTORS

EXTRINSIC RISK FACTORS:
ENVIRONMENTAL FACTORS
OBSTRUCTIONS IN PATH
POOR LIGHTING, SLIPPERY SURFACES
MATTRESS OVERLAYS FOR WOUNDS
MEDICATION SIDE EFFECTS
DIZZINESS, VERITGO, SYNCOPE
BRADYCARDIA,
POSTURAL HYPOTENSION
CONFUSION
RISK FACTORS
 SITUATIONAL:
RUNNING TO THE BATHROOM
REACHING TO TURN OFF AN
ALARM
NOT BEING FULLY AWAKE
UNFAMILIAR ENVIRONMENT
BUMPING INTO OBJECTS
BEING BUMPED BY OBJECT OR OTHER
INDIVIDUAL
FALLS AND INJURY



UNINTENTIONAL INJURY IS 5TH LEADING
CAUSE OF DEATH IN ELDERLY
BECAUSE OF SLOWER REFLEXES, THE
ELDERLY OFTEN RECEIVE FACIAL
INJURIES DURING A FALL
INJURIES INCURRED DURING A FALL CAN
SEVERELY DECREASE PHYSICAL
FUNCTIONING AND SUBSEQUENTLY
AFFECT THE QUALITY OF LIFE FOR THE
INDIVIDUAL
FALLS DEFINED
ACCORDING TO THE MERCK MANUEL OF
GERIATRICS AND THE DEPARTMENT OF
HEALTH:
A FALL IS ANY DROP FROM A
HIGHER TO A LOWER POSITION
COMPONANTS OF A RISK ASSESSMENT








REVIEW PAST FALLS
REVIEW PREVIOUSLY MENTIONED RISK
FACTORS
COMPLETE A HISTORY AND PHYSICAL
SCREEN ROUTINELY; I.E. WHEN MDS DUE
TRACK AND REVIEW THE CIRCUMSTANCES
SURROUNDING EACH FALL
REVIEW MEDICATION CHANGES
REVIEW NEED FOR ALARMS OR OTHER DEVICES
DISCOURAGE THE USE OF RESTRAINTS
POST FALL ASSESSMENT







VITAL SIGNS AND IMMEDIATE PHYSICAL
ASSESSMENT BY RN (INCLUDE OTHOSTATIC
BPS, TEMP)
DETAILS FROM ANY WITNESSES
DETAILS FROM RESIDENT
ENVIRONMENTAL FACTORS (LIGHTING,
OBSTRUCTIONS TO MOVEMENT)
CHANGES IN FUNCTIONAL STATUS
MEDICATION CHANGES
INTENT THAT CAUSED FALL (GOING TO
BATHROOM, REACHING FOR ITEM ON FLOOR)
ONGOING ASSESSMENTS
TRACK RECURRENT FALLS
 DETERMINE SHIFT OR TIME OF DAY
TRENDS
 DETERMINE TRENDS R/T CAREGIVER
 REVIEW MEDICATION ADMINISTRATION
TIMES R/T FALLS
 DETERMINE RELATIONSHIP TO ILLNESS
OR SIGNIFICANT CHANGE

ADDITIONAL POST FALL INFORMATION









RESIDENT DID NOT USE ASSISTIVE DEVICE
RESIDENT LOST BALANCE
RESIDENT LOST CONSCIOUSNESS
RESIDENT WAS DIZZY BEFORE OR DURING FALL
RESIDENT HAD DIFFICULTY SEEING WHERE HE/SHE WAS
GOING
RESIDENT WAS CONFUSED AT TIME OF THE FALL
RESIDENT WAS NEW TO THE ENVIRONMENT (NEW
RESIDENT OR ROOM CHANGE)
RESIDENT HAD BEEN GIVEN A LAXITIVE OR DIURETIC
PRIOR TO THE FALL
RESIDENT DID NOT HAVE CALL BELL IN REACH
OTHER CONTRIBUTORY
CONSIDERATIONS R/T FALLS

DIABETES:
1.PERIPHERAL NEUROPATHY-CAN’T FEEL
FOOT PLACEMENT, PAINFUL FEET,
DEFORMITIES MAKING WALKING
DIFFICULT, DIABETIC FOOT ULCERS
2. RETINOPATHY-VISUAL DECLINE
3. AUTONOMIC NEUROPATHYORTHOSTATIC HYPOTENSION
4. HYPOGLYCEMIC EVENT-LOSS OF
CONSCIOSNESS
5. HYPERGLYCEMIC POLYURIA-NEED TO
URINATE QUICKLY
OTHER CONTRIBUTORY
CONSIDERATIONS R/T FALLS

EFFECTS OF MEDICATIONS
1. DECLINE IN ELDERLY-GI, HEPATIC
& RENAL FAILURE
2. FRAIL ELDERLY OFTEN HAVE MULTISYSTEM DECLINE
3. POLYPHARMACY IN ELDERLY
4. DRUG ACCUMULATION
5. DRUG INDUCED DELERIUM AS
OPPOSED TO DEMENTIA
SIDE EFFECTS OF DRUGS R/T FALLS
BENZODIAZEPINES (ATIVAN, XANAX),
NARCOTICS, NEUROLEPTICS, ANY DRUG
WITH ANTICHOLINERGIC EFFECTS
(TRYCYCLIC ANTIDEPRESSENTS & SIME
INCONTINENCE DRUGS-OXYBUTININE)
CAN CAUSE COGNITIVE IMPAIRMENT &
CONFUSION
SIDE EFFECTS OF DRUGS R/T FALLS
ANTICONVULSANTS, ANTIDEPRESSENTS,
BENZODIAZAPINES, NARCOTICS,
NEUROLEPTICS(ANTIPSYCHOTICS); CAN CAUSE
DIZZINESS, ORTHOSTATIC HYPOTENSION, SEDATION,
DROWSINESS
BETA BLOCKKERS, NITRATES, VASODILATORS; CAN
CAUSE SYNCOPE
ANTICONVULSANTS, BENZODIAZEPINES, NEUROLEPTICS;
CAN CAUSE BALANCE PROBLEMS
SIDE EFFECTS OF DRUGS R/T FALLS
ANTIDEPRESSENTS,METOCLOPRAMIDE
(REGLAN), NEUROLEPTICS ; CAN CAUSE
ABNORMALITIES OF GAIT
ANTIHYPERTENSIVES; CAN CAUSE
ORTHOSTATIC HYPOTENSION
ANTIARRHYTHMICS; CAN CAUSE ARRYTHMIAS
DIURETICS; CAN INCREASE URGENCY
SIDE EFFECTS OF DRUGS R/T FALLS
NEUROLEPTICS & ANY DRUG WITH
ANTICHOLINERGIC EFFECTS
CAN CAUSE VISUAL DISTURBANCES
ANTIDEPRESSENTS,(SSRI,
TRICYCLICS) NEUROLEPTICS,
STIMULANTS, CAFFIENE
CAN INCREASE AGITATION
PROCESSES FOR PREVENTION
EXERCISE TRAINING
1.IMPROVES STRENGTH AND BALANCE
2.WEIGHT BEARING TO DECREASE
RISK FOR FRACTURE
3.DO AS AN ACTIVITY TO INCREASE
PSYCHOLOGICAL WELL BEING
4. TEACH MOVEMENT IN STEPS AND
GOOD SAFETY AWARENESS
5. CONTINUE WITH EFFECTIVE
RESTORATIVE & MAINTENANCE
PROGRAMING
PROCESSES FOR PREVENTION
MEDICATION INTERVENTION
1. CALCIUM, VITAMIN D, FOSOMAX,
HORMONE REPLACEMENT IN TREATMENT
OF OSTEOPOROSIS
2. MANAGING GLYCEMIC
MEDICATIONS AND DIET FOR DIABETICS
3. MANAGING PSYCHOTROPHIC
MEDICATIONS AND SIDE EFFECTS
4. CARDIOVASCULAR MEDICATIONS
AND/OR PACEMAKER
PROCESSES FOR PREVENTION
MEDICATIONS
PERIODIC PHYSICIAN
REVIEW FOR:
POLYPHARMACY
SIDE EFFECTS
ADMINISTRATION TIME AND
WAKEFULNESS/URINATION
ALLERGIES
DELERIUM
PROCESSES FOR PREVENTION
MANAGING DECLINING VISION
1. ROUTINE VISION TESTING
2. USING CONTRASTING COLORS
IN HANDRAILS, WALKWAYS ETC.
3. EFFECTIVE LIGHTING IN
RESIDENT ROOMS
4. KEEPING GLASSES CLEAN AND
ACCESSABLE
PROCESSES FOR PREVENTION
CONSIDER CONDITION CHANGES:
1. MONITER LABS-CBC, GLUCOSE, HGB A1C,
ELECTROLYTES
2. CHANGES IN DISEASE STATUS &
MEDICATION CHANGES-WORSENING
GAIT IN PARKINSONS DISEASE
3. WORSENING PAINFUL MOVEMENT IN
ARTTHRITIC CONDITIONS OR
OSTEOPOROSIS (PRONE TO PATHOLOGICAL
FRACTURE THAT MAY CAUSE FALL)
4. NEW ONSET FEVER, INFECTION
PROCESSES FOR PREVENTION
CONSIDER CONDITION CHANGES:
5. ORTHOSTATIC BP DROP CAUSED BY NEW
MEDICATION, CHANGE IN
CARDIOVASCULAR STATUS
6. MONITER O2 LEVELS FOR
CONFUSION, LOSS OF CONSCIOUSNESS R/T
HYPOXIA
7. MONITER APICAL PULSE FOR
CHANGES IN RATE/RHYTHM OF HEART
8. CONSIDER A UTI IF MENTAL STATUS
CHANGE AND/OR WEAKNESS (FALL MAY BE
ONLY SX OF UTI)
PROCESSES FOR PREVENTION
LOOK AT THE ENVIRONMENT:
LIGHTING
CLUTTER
FLOORS & MATS
THRESHHOLDS & UNEVEN
SURFACES
HEIGHT OF CHAIRS/TOILET SEATS
HEIGHT OF BED
ITEMS WITHIN REACH
EXCESSIVE DISTRACTING NOISE
PROCESSES FOR PREVENTION
ASSISTIVE DEVICES:
WALKERS, CANES, WHEELCHAIRS
MERRYWALKERS
HANDRAILS
SPECIALTY FOOTWEAR
HIP PROTECTORS
ALARMS? ASSISTIVE OR CAUSE
AGITATION?
RESTRAINTS DO NOT PREVENT FALLS
INCLUDING SIDE RAILS
ONGOING SUPPORT AND FOLLOW
THROUGH
MUST HAVE AN EFFECTIVE PROCESS
TO EVALUATE IMMEDIATELY, WHEN
THE FALL OCCURS,
AND ONGOING, TO DETERMINE
TRENDS FOR POSSIBLE
RECURRENCE
F/U ONGOING
KEEP TRACK OF REPORTS ON FALLS AND AUDIT
FOR IMMMEDIATE REPONSE FOR
INTERVENTIONS
WEEKLY MEETINGS TO INCLUDE NURSING STAFF
INCLUDING AIDS, THERAPY AND RESTORATIVE,
RNAC OR MDS COORDINATOR; MEDICAL
DIRECTOR, RESIDENT AND/OR FAMILY MAY
ALSO BE BENEFICIAL
CONSIDER USE OF ALARMS, CORRECT
PLACEMENT AND RESPONSE TO (INCLUDING
HOW RESIDENT REACTS)
INVESTIGATION AND TRENDING
BASIC INFORMATION FOR TRENDING:
TIME OF DAY
DAY OF WEEK
HALL OR WING
CNA ASSIGNMENT
PRESENCE OF TOILETING
DEPENDENCE AND PROGRAMS IN PLACE
FUNCTIONING AND USE/MISUSE OF
ALARMS
USE/DAMAGE OF ASSISTIVE DEVICES
FALLS ARE EVERYONE’S
RESPONSIBILITY
INVOLVE THE WHOLE TEAM
*INCLUDE THE RESIDENT
*AVOID INJURY
*BE AWARE OF CHANGES
IN THE RESIDENT
*BE AWARE OF
ENVIRONMENTAL
CHANGE
ASK FOR HELP
PARRI
PENNSYLVANIA RESTRAINT
REDUCTION INITIATIVE
DEVELOPED WITH CMS AND IS
A PROGRAM O KENDAL
OUTREACH, LLC
REFERENCES
1.
2.
3.
4.
RIEFKOHL, ELSARIS Z., PHARMD;ET AL. MEDICATIONS AND
FALLS IN THE ELDERLY: A REVIEW OF THE EVIDENCE AND
PRACTICAL CONSIDERATIONS. P&T, NOVEMBER
2003,VOL28.NO.11;724-733
TREMBLAY, K.R.JR., AND BARBER, C.E. PREVENTING FALLS IN
THE ELDERLY, NO. 10.242, COLORADO STATE
UNIVERSITY;WWW.EXT.COLOSTATE.EDU/PUBS/CONSUMER/10
242.HML
AMERICAN GREIATRICS SOCIETY, BRITISH GERIATRICS
SOCIETY, AND AMERICAN ACADEMY OF ORTHOPAEDIC
SURGEONS PANEL ON FALLS PREVENTION. GUIDELINE FOR
THE PREVENTION OF FALLS IN OLDER PERSONS.JAGS 49:664672, 2001
CDC INJURY CENTER. FALLS IN NURSING HOMES FACT SHEET.
2/19/2009;
WWW.CDC.GOV/NCIPC/FACTSHEETS/NURSING.HTM
REFERENCES
5. MAURER, MATHEW S., BURCHAM, JOYCE AND HUAI CHENG.
DIABETES MELLITUS IS ASSOCIATED WITH AND INCREASED
RISK OF FALLS IN ELDERLY RESIDENTS OF A LONG-TERM CARE
FACILITY. THE JOURNALS OF GERONTOLOGY SERIES A:
BIOLOGICAL SCIENCES AND MEDICAL SCIENCES 60:11571162(2205) THE GERONTOLOGICAL SOCIETY OF AMERICA
6. FALLS, THE MERCK MANUEL OF GERIATRICS, CHAPTER 20,
SECTION 2;
WWW.MERCK.COM/MKGR/MMG/SEC2/CH20/CH20A.JSP
7. RUDDOCK, BRENT. MEDICATIONS AND FALLS IN THE ELDERLY.
DRUG INFORMATION AND RESEARCH CENTER, CPJ/RPC,
JULY/AUGUST 2004, VOL. 137, NO. 6
8. CRITERIA FOR URINARY TRACT INFECTION IN THE ELDERLY,
ONLINE CME FROM MDESCAPE;
WWW.MEDSCAPE.COM/VIEWARTICLE/481627_2
9. HTTP:PARRI.KENDALOUTREACH.ORG/CONTACT.ASPX