Transcript The Changing Paradigm in Falls – Implications in Acute Care

The Changing Paradigm in Falls
Implications in Acute Care
Prepared by Julia Poole
CNC Aged Care
RNSH
September 2007
Cost of fall injury
to older people
 Total lifetime cost of falls $644 million ($333
million direct costs & $311 million mortality &
morbidity costs) in NSW
 If current admission rates continue, by 2050
NSW will need 800 new acute care beds and 1200
new aged care places to manage the impact of the
demographic change.
 A serious fall frequently becomes the
precipitating event into permanent residential
care for a frail older person.
Falls Facts for
Acute/Sub-acute Care
 In Australian Hospitals 1/3rd of all patient
incidents involve a fall.
 Most people who have a fall in hospital are
over 65 years of age.
 Falls in hospital are being given a high
priority as they are considered to be
generally predictable and often preventable
within a scheme of falls prevention activities.
Risk Factors for
Falls In Hospital
 History of falls prior to coming in to hospital
or has fallen in hospital
 Patient is confused or agitated - can be long
standing eg dementia or can be made worse
on admission to unfamiliar environment,
confusion post operatively or from acute
infection (delirium).
 Mobility and transfers are unsafe. May have
a walking aid such as a frame.
Risk Factors for
Falls In Hospital (cont’d)
 Needs to go to the toilet frequently or
is incontinent
 Takes medications associated with
increased risk of falls eg psychoactive,
diuretics, antihypertensives
 Has poor vision, such that everyday
function in the ward is impaired
Consequences of Falls
 Falls in hospital are associated with:
 Increased mortality
 Increased length of stay
 Serious injury eg hip fractures, cerebral
haemorrhage
 Change in discharge living arrangements
Consequences of Falls
 Other consequences of falls:
 Fear of falling and loss of
confidence, correlates with
depression and social isolation.
 Reduces older persons' confidence
to return home and function
independently.
2001 - 2 # NOF, 1 # Ondontoid, 21 skin tears
2002 - 2 # NOF, 1 # Radius, 14 skin tears
2003 -1 # NOF, 1 # Humerus, 18 skin tears
2004 - 1 # humerus, 1 # scaphoid, 16 skin tears
Volunteer
Companions, IPS
Delirium, the major risk
factor for fall in an acute aged care ward
(unpublished) Poole J and Ogle S
 n = 312
 File audit
 ‘confusion’ documented in 96% of notes
DEMENTIA
The word “Dementia” is used widely to describe a group of diseases
which affects the brain and cause a progressive decline in a person’s
abilities to remember, think and learn. The main abilities affected are:
 Judgement
 Orientation
 Emotions
 Memory
 Thinking
WHAT CAUSES DEMENTIA?
 There are different forms of dementia and each has its own
causes. Some of the most common forms of dementia are:
 Alzheimer’s Disease
 Vascular dementia
 Frontal Lobe dementia
 Dementia with Lewy Bodies
(see www.alzvic.asn.au)
What is Delirium?
 an acute organic mental disorder characterised by
confusion, restlessness, incoherence, anxiety or
hallucinations which may be reversible with treatment
Sometimes known as :
– Acute Confusion
– Acute confusional state
– Acute brain disorder
– Acute brain syndrome
Gelder, Mayou & Geddes (1999); Moran & Dorevitch (2001); Inouye (2006);
DSM-IV 1994
 Delirium is characterised by a disturbance of consciousness and a
change in cognition that develop over a short period of time

American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th Ed).Washington: American
Psychiatric Association.
 ICD-10-AM Diseases 2003
– F05 -Delirium, not induced by alcohol and other psychoactive
substances
– non specific organic cerebral syndrome
– concurrent disturbances of consciousness and attention,
perception, thinking, memory, psychomotor behaviour,
emotion, and the sleep-wake schedule
– F05.1 Delirium superimposed on dementia
Pathophysiology of Delirium
 Multiple mechanisms
Inouye 2006 The NEJ M 354:1157-65.
– Neurotransmission, Inflammation, Chronic stress
Moran 2001 The Australian Journal of Hospital Pharmacy. 31(1):35-40.
– decreased cerebral oxidative metabolism causing altered
neurotransmitter levels
– stress-induced increased plasma cortisol levels causing altered
neurotransmitter activity
Yokata et al.2003 Psychiatry and Clinical Neurosciences.75(3):337-339.
– cerebral hypo-perfusion in the frontal, temporal & occipital cortex
Delirium Risk Assessment
Weber et al. 2004 Internal Medicine Journal. 34:115-121.
Predisposing
 Vision/hearing impairment
 Severe illness
 Cognitive deficit
– AMTS < 7/10
– MMSE < 25/30
 Dehydration
Precipitating
 ‘Mechanical’ restraint
 Malnutrition/dehydration
 3 new medications
 IDC
 Unpleasant event/s
– surgical procedure
– med. toxicity
– falls
– infections
– faecal impaction
– etc
Prevention of Delirium
Inouye et al. 1999 NEJM 340(9):669-676.
Cognitive
impairment
Orientation, therapeutic activities
Sleep deprivation
Pain relief, non-pharmacological sleep
enhancement protocol
Immobility
early mobilisation, minimal use of
immobilising equipment
Sensory
impairment
vision & hearing protocols
Dehydration
volume repletion
Delirium
Maher & Almeida 2002 Current Therapeutics. March:39-43.
 Is a medical emergency
 Incidence of up to 56% in hospitalised elderly
 Independent predictor of adverse outcomes
– falls
– incontinence
– pressure sores
– decreased functional levels
– increased mortality
– increased LOS in acute care
– INCREASED COSTS
“Think about when you have looked after an agitated
older patient - tell us about it?”
Registered and enrolled nurses in a large teaching hospital were
asked to discuss their feelings and actions in regard to caring for
agitated older patients
– six taped focus groups, n = 36
thematically coded and analysed.
Poole, J. and Mott, S. (2003) Agitated Older Patients – nurse’s perceptions and
reality. International Journal Of Nursing Practice, 9:306-312.
1. See (to understand)cont’d
 -ve - ‘you think you’ve calmed them down and they seem sweet
or whatever, people can just change’ , ‘Doctor would chart a
minuscule amount...didn’t touch her’, ‘won’t even numb a little
finger’
 Particular concern- ‘sometimes it (restraint) makes them more
agitated but you’d rather that so you can get out and get some
of the other work done and come back to them later and calm
them down’
3. Span of time
 The burden placed on staff by agitated patients was clear - ‘trying
to work out how to get the rest of the jobs done’ and ‘nothing else
gets done’.
 ‘if I’ve been with one patient, I get complaints from other patients
and relatives because I haven’t been with them and then it sort of
snowballs and you get more agitated and frustrated ... because
you can’t give everyone the same care’.
FALL RISK ASSESSMENT SCORE
to be completed on admission or transfer in, DAILY and where so
warranted by a change in the patient’s condition (Mercer 1997)
Characteristics
Value
Age equal to or over 70yrs
5
History / admission diagnosis related to
falls / seizures / stroke
3
Disorientation / Confusion / Agitation OR
Impaired memory OR judgement OR
Unable to understand OR follow instructions
(no score if patient unconscious &/or unable
to move)
Significantly impaired sight, hearing
OR sensation
10
Impaired Co-ordination or unsteady gait
limb weakness OR uses walking aid OR may
be tripped by equipment (IV poles, catheters
etc)
3
On one or more of the following medication
Sedatives ( including benzodiazepines)
Psychotropics
Hypoglycaemics
Narcotic analgesia
Antihypertensives
Antidepressants
Anticonvulsants
Antiparkinsonians
Diuretics
1 for each
medication
Incontinent or change in continence status
eg removal of a catheter,
Urgency, Frequency, Nocturia
Recent aperient use/ administration
1 for each
Less than 24hrs post op or confinement
1
1
Add up score, document according to characteristics
TOTAL
score
L
Low
risk
0-4
SUGGESTED STRATEGIES FOR FALL
PREVENTION
1. Keep environment clear and floor dry
2. Tell patient/family about fall risk and give
Fall Risk Leaflet.
3. Put call bell and light switches within
reach at all times.
4. Put patient's glasses and hearing aid
on.
5. Insist on use of non slip footwear.
6. Position bed at the lowest height with the
brake on except during direct clinical care.
M
All of the above plus:
7. Refer patient to medical and allied health
team for review.
Medium 8. Assist / supervise all patient mobility
risk
9. Consider individual toilet schedule
5-14
10. Assess and document individualised bed
rail position.
11. Discuss patients at risk in nursing
handover.
H
All of the above plus:
12. Flag patient on Care Plan with orange
falls sticker.
13. Increase frequency of observation by:
 supervision by family, IPS, Volunteer
&/or sit in room to write notes
 place patient closer to the nurses station.
14. Consider suitability of single room (reduce
stimulus) or 4 bed room (increase
supervision).
15. Consider the use of restraints adhering to
the restraints policy.
HIGH
RISK
15 +
Take Home Messages
 Increasing numbers of older sicker patients in hospitals
 Older patients have
– increased predisposition for delirium and/or dementia
– increased predisposition for falls
– increased predisposition for injury from falls
– increased predisposition for death from falls
 Falls are COSTLY for everyone
 The best way to manage delirium and prevent falls is to increase
patient support & surveillance (NOT RESTRAINT)
 Hospitals must be designed to enable surveillance
of patients eg windows, glass walls etc