Transcript Fall Prevention in Nursing Homes Nursing Team Module

Fall Prevention in Nursing Homes
Nursing Team Module
Developed by: Duke University Medical
Center School of Nursing, Center for Aging
and Human Development, and the Durham
VA GRECC
Preventing Falls
• After taking this course you will be
able to:
– Describe the high rate of falls and their
consequences in older adults
– Identify patients who are at high risk for falls
– Assess and intervene in five fall risk areas in
high risk patients
– Describe your role in the fall prevention team
Developed: 08-31-09
Contact: [email protected]
2
Fall Rates and Consequences:
Scenario 1
You are orienting a new Nurse who has not worked in a
nursing home before. She wants to know why there is so
much emphasis on fall prevention. You tell her…
Write down the numbers that are true.
1. Half of nursing home residents fall each year, and one
third fall multiple times.
2. 1 in every 10 falls results in a major injury.
3. Falls are the most common cause of injury-related
deaths in older adults.
4. Falls can cause decreased ability to function and lower
quality of life in older adults.
Developed: 08-31-09
Contact: [email protected]
3
Answers
1. Half of nursing home residents fall each year and one
third fall multiple times. Right.
2. 1 in every 10 falls results in a major injury. Correct.
Major injuries include fractures, lacerations, and
head injuries.
3. Falls are the most common cause of injury-related
deaths in older adults. True.
4. Falls can cause decreased ability to function and lower
quality of life in older adults. Right. A “fear of falling”
causes patients to restrict their mobility and further
lose function.
Developed: 08-31-09
Contact: [email protected]
4
Identifying Fall Risk Factors
Scenario 2
Later that day you admit a new patient, Mr. Jones. Which of
the following factors increase his chance of having a fall?
Write down the numbers that are true.
1.
2.
3.
4.
5.
6.
7.
8.
His wife tells you he has fallen several times at home.
He has Parkinson’s Disease.
He has dementia.
He has intermittent urinary incontinence.
He has broken his wrist in the past.
His vision is poor due to macular degeneration.
He shuffles when he walks, and holds onto furniture.
He has heart failure.
Developed: 08-31-09
Contact: [email protected]
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Answers
1.
2.
3.
4.
5.
6.
7.
8.
History of falls. Right. Previous falls are one of the strongest risk
factors for more falls.
Parkinson’s Disease. Correct. Many neurologic diseases including
stroke, seizures, and neuropathy cause falls.
Dementia. Yes. Cognitive impairment can lead to unsafe behavior
and is often associated with gait problems.
Urinary Incontinence. Right. Many falls happen while patients are
rushing to toilet themselves.
Prior fracture. No. Prior fractures and osteoporosis don’t increase
falls but do indicate a high risk for more broken bones if the
patient does fall.
Low vision. Yes! Both vision and hearing impairment are
associated with falls.
Gait disorder. Right. Abnormal gait, and especially “furniture
surfing,” indicate a high risk for falls.
Heart disease. No, heart disease in itself isn’t a falls risk factor,
but cardiac medications may cause bradycardia or orthostatic
hypotension that can lead to falls.
Developed: 08-31-09
Contact: [email protected]
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Why is it Important to Identify Risk
Factors?
1. It helps you to estimate his risk of falling.
The more risk factors he has, the higher
the chance that he will fall.
2. It helps you figure out which
interventions are most likely to help
prevent his falls.
•
The next section will review interventions that
have been shown to prevent falls.
Developed: 08-31-09
Contact: [email protected]
7
Intervening: Medications
Scenario 3
You decide that Mr. Jones is at very high risk for falls and
want to intervene. You start by looking at his
medications. Which of the following would you consider
reducing or discontinuing?
Write down all numbers that are correct.
1.
2.
3.
4.
5.
6.
7.
Citalopram 20 mg daily for depression
Lorezapam 1 mg twice daily for anxiety
Baclofen 10 mg twice daily for back pain
Digoxin 0.25 mg daily for heart failure
Zolpidem 5 mg at bedtime for sleep
Risperdal 0.5 mg as needed for agitation
Oxycodone 5 mg every 6 hours for pain
Developed: 08-31-09
Contact: [email protected]
8
Answers
1.
2.
3.
4.
5.
6.
7.
Citalopram. Maybe. All antidepressants increase falls, but treating
depression is important too. Work with the care team to use the
lowest effective dose.
Lorezapam. Right. Benzodiazepines increase falls risk and should be
avoided or used at the lowest effective dose.
Baclofen. Definitely. Muscle relaxants have anticholinergic side
effects that increase falls risk.
Digoxin.Yes. Digoxin has a narrow therapeutic window and needs to
be monitored regularly for toxicity.
Zolpidem. Yes. Sedative-hypnotics probably increase falls and
should be used cautiously. Are there non-pharmacologic strategies
the team could use to help Mr. Jones sleep?
Risperdal. Definitely. Atypical antipsychotics increase falls risk and
have a black box warning. Use only when necessary and try
tapering often.
Oxycodone. No. Analgesics including opiates are surprisingly not
associated with falls.
Developed: 08-31-09
Contact: [email protected]
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Intervention: Medications
• Many classes of medications are associated with increased fall risk
– Digoxin
– Some antiarrhythmic drugs
– Diuretics
– Psychotropics
– Benzodiazepines
– Antidepressants
– Drugs with anticholinergic side effects
• Consider tapering or discontinuing these drugs in patients at high
risk for falls.
• For summaries of meta-analyses of drugs and falls, refer to the
following:
– http://www.ncbi.nlm.nih.gov/pubmed/9920228
– http://www.ncbi.nlm.nih.gov/pubmed/9920227
Developed: 08-31-09
Contact: [email protected]
10
Intervention: Medications
Scenario 4
You talk with the facility pharmacist about
tapering some of Mr. Jones’ medications. He
asks if you have considered whether Mr. Jones
might be vitamin D deficient. Which of the
following statements are true about vitamin D
in nursing home residents?
Write down all numbers that are correct.
1.
2.
3.
4.
One half to two-thirds of nursing home residents are vitamin D
deficient.
The best test to assess for vitamin D sufficiency is serum 1,25(OH)
vitamin D.
Vitamin D supplements strengthen bone, but do not prevent falls in
nursing home residents.
Calcium and vitamin D supplements reduce hip fractures in older
adults.
Developed: 08-31-09
Contact: [email protected]
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Answers
1.
2.
3.
4.
One half to two-thirds of nursing home residents are
vitamin D deficient. Correct.
The best test to assess for vitamin D sufficiency is serum
1,25(OH) vitamin D. No. The body maintains the active
1,25(OH) form of vitamin D at stable levels until
deficiency is far advanced. 25(OH) Vitamin D is a
better assessment of Vitamin D stores.
Vitamin D supplements strengthen bone, but does not
prevent falls in nursing home residents. No. Vitamin D
supplements have been shown to reduce falls in a
dose-response manner.
Calcium and vitamin D supplements reduce hip fractures
in older adults. Right. They reduce fracture risk by
about 25%.
Developed: 08-31-09
Contact: [email protected]
12
Intervention: Orthostatic Hypotension
Scenario 5
You ask the Nurse’s Aid to check Mr. Jones’
orthostatic blood pressure and pulse. The Nurse’s
Aid is slightly annoyed by the request, so you
explain why older people like Mr. Jones often
have large drops in blood pressure that result in falls.
Write down all numbers that are correct.
1.
2.
3.
4.
They are on medications that cause orthostasis.
They have Parkinson’s disease.
They are more likely to become dehydrated.
Blood pressure tends to decrease as you age.
Developed: 08-31-09
Contact: [email protected]
13
Answers
1.
2.
3.
4.
They are on medications that cause orthostasis. Right. Frequent
culprits are cardiac medicines (especially clonidine and hydralazine),
prostate medications (especially terazosin and doxazosin),
anticholinergic medicines (like benadryl, muscle relaxants,
antihistamines) and diuretics.
They have Parkinson’s disease. Yes. Parkinson’s is often associated
with autonomic insufficiency. Other causes include diabetes,
hepatic diseases, B12 deficiency, uremia, and alcoholism.
They are more likely to become dehydrated. Correct. Older people may
not drink enough because of decreased feelings of thirst, dementia,
or difficulty getting to water.
Blood pressure tends to decrease as you age. Actually, blood pressure
tends to increase with age. However, even patients with high blood
pressure can have symptomatic orthostasis.
Developed: 08-31-09
Contact: [email protected]
14
Intervention: Orthostatic Hypotension
Scenario 6
•
The Nurse’s Aid reports that Mr. Jones’ systolic
blood pressure falls from 160 to 125 mm Hg
when he stands up.
•
Write down at least 3 things that you would
consider to evaluate or treat Mr. Jones’
orthostasis.
Developed: 08-31-09
Contact: [email protected]
15
Answers
1.
2.
3.
4.
5.
6.
Exclude dehydration and acute blood loss.
Review medications for potential culprits.
Consider treatable causes like adrenal insufficiency
and B12 deficiency.
Talk with the Nurses about putting on compression
stockings every morning.
Talk with the Nurses to ensure easy access to fluids
and regular encouragement to drink.
Consider prescribing fludrocortisone for symptomatic
orthostasis not responding to other measures.
Developed: 08-31-09
Contact: [email protected]
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Intervention:
Vision Impairment
• During your admission assessment, you note that Mr.
Jones’ vision is impaired. In addition to making sure he
has had a recent eye exam, what else can be done to
decrease his falls risk?
(write down the numbers that are true)
1. Increase the lighting in his room and bathroom
2. Add high contrast strips to stairs and curbs
3. Increase the glare in the room
4. Talk to the Nurses’ Aids about keeping his eyeglasses
within reach at all times and encouraging him to wear
them
Developed: 08-31-09
Contact: [email protected]
17
Answers
1.
2.
3.
4.
Increase the lighting in his room and bathroom. Yes,
make sure the maximum wattage bulb is used, or
add additional lights.
Add high contrast strips to stairs and curbs. Good
idea!
Increase the glare in the room. No, glare makes poor
vision worse. Make sure there are shades or
covers over the light fixtures and windows.
Talk to the Nurses’ Aids about keeping his eyeglasses
within reach at all times and encouraging him to wear
them. Yes, they need to understand how important
good vision is to reducing falls risk.
Developed: 08-31-09
Contact: [email protected]
18
Intervention: Mobility
Scenario 8
• You ask Mr. Jones to
do an “Up and Go”
test for you. (Click
the box to the right)
• Is his gait safe or
unsafe, and why?
Decide what you
would do next.
Developed: 08-31-09
Contact: [email protected]
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Scene 6: Intervening - Mobility
•
Mr. Jones has weakness on one side, decreased arm
swing, unequal step length, and a foot drop. You call
the Physical Therapist, who will evaluate him for an
assistive device and exercises. What other
interventions might help reduce his risk of falling due to
his unsteady gait? (write down the numbers that are true)
1.
2.
3.
4.
Use a lap belt to keep him in his chair
Check the height of his bed, toilet seat, and chairs
Consider bathroom safety
Talk to staff about increasing assistance during particular times
Developed: 08-31-09
Contact: [email protected]
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Answers
1.
2.
3.
4.
Use a lap belt to keep him in his chair. No. Restraints increase
the risk of injurious falls, and do not promote independence
and quality of life
Check the height of his bed, toilet seat, and chairs. Yes! To help
patients transfer safely, seating height should be 100-120%
of lower leg height. The next slide will illustrate how to check
this
Consider bathroom safety. Good. Make sure there is adequate
handrail support, nonskid flooring, and that the patient has
easy to manage clothes
Talk to staff about increasing assistance during particular times.
Yes, Mr. Jones needs increased assistance in the mornings,
during transfers, to and from the toilet, and during
ambulation
Developed: 08-31-09
Contact: [email protected]
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Correct seating height is 100-120%
of lower leg height
www.contextualise.com/image/img/Sticktostand.jpg
Developed: 08-31-09
Contact: [email protected]
22
Intervention: Unsafe Behavior
Scenario 9
Mr. Jones has poor judgment due to his dementia. The
nurses ask for your suggestions in managing some of
his unsafe behaviors, such as pacing, trying to climb
over bed rails, and trying to transfer without help.
Write down at least 1 idea for each of these categories.
–
–
–
Increasing assistance and surveillance
Reducing risk of injury
Increasing comfort
The following slides show options for each of these areas.
Developed: 08-31-09
Contact: [email protected]
23
Increasing Assistance and
Surveillance
•
•
•
•
Use position alarms and motion sensors
Toilet at regular intervals
Increase activities involvement
Locate patient near nursing station
Developed: 08-31-09
Contact: [email protected]
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Reduce Risk of Injury
•
•
•
•
•
•
Low bed, floor mat
Lower or remove side rails
Non-skid socks or footwear
Non-skid strips or mat
Hip protectors, Calcium, Vitamin D
Screen for and treat osteoporosis when indicated
Developed: 08-31-09
Contact: [email protected]
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Increase Comfort
•
•
•
•
Pain management
Recliner or rocking chair
Exercise
Cradle mattress, sheepskin, air mattress
or pillows
Developed: 08-31-09
Contact: [email protected]
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Summary of Falls Intervention
Areas
Medications
•Review and
Taper
•Calcium + D
Unsafe Behavior
•Assistance
•Prevent Injury
•Comfort
Mobility
•PT
•Seat height
•Toileting
Orthostatic
Hypotension
•Measure
•Medications
•Fluids
•Stockings
High Risk
Resident:
Evaluate
risk
areas
Vision
•Lighting
•Glasses
•Glare
The Falls Prevention Team
Recall how many disciplines have been involved in the effort to
keep Mr. Jones from falling. In your CLC, how many of these
people do you routinely talk with about your patients’ fall risk?
Coordination is vital, and you have a key role in sharing
information and ideas. Don’t forget to include the patient and
family in the discussions, too.
1.
2.
3.
4.
5.
6.
7.
The nurses’ assistants
The floor nurses
The Rehabilitation staff
The pharmacist
Housekeeping and Maintenance
Activities Director
Patients and Families
Developed: 08-31-09
Contact: [email protected]
28
If you want to learn more about
preventing falls…
Visit the web sites listed below….
• AHRQ innovations site
http://www.innovations.ahrq.gov/content.aspx?id=2052
• Falls Management Program
http://www.qualitynet.org/dcs/ContentServer?cid=1136495771104&pag
ename=Medqic/MQTools/ToolTemplate&c=MQTools
• NIH Age Page–Preventing Falls and Fractures
(patient handout)
http://www.nia.nih.gov/HealthInformation/Publications/falls.htm
Developed: 08-31-09
Contact: [email protected]
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The End
Please close this presentation
and begin the quiz.
Developed: 08-31-09
Contact: [email protected]
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