Transcript Falling in Older Adults: Evidence, Best Practices, and

Falling in Older Adults:
Evidence, Best Practices, and
Management
MARY Z. “KELLY” DUNN, PHD, RN, PHCNS, BC
ASSOCIATE PROFESSOR
UTHSCSA SCHOOL OF NURSING
RACHEL BROWN, HONORS STATISTICS STUDENT
UTSA
Session Objectives
• Discuss what is known about falls in elders.
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Definition of falls
Statistics on falls among the elderly
Outcome of falls (mortality, disability, cost, quality of life )
Documenting falls: coding scheme
• Describe risk factors for falls
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Individual factors
Factors related to staff
Environmental factors
• Describe available risk assessment tools and prevention
strategies/guidelines
• Participate in group discussion of experiences with falls
and implementing interventions to prevent falls.
Method
• We conducted a review of research studies and the
internet using the terms aging, falls, falls assessment,
nursing homes, and falls prevention
• We worked in a nursing home to understand falls as
explained by administration, nurses, and middle
management
• We found:
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20 Research Studies
4 Specialty Organization Guidelines
5 Systematic Reviews (Cochrane and journal publications)
2 Federal Guidelines
1 Quality Improvement article
Results
• Multiple instruments are used to evaluate fall risks
• None contain all risk factors
• The AGS / BGS algorithm lacks precision
• England, Germany, the Netherlands and Australia
promote comprehensive assessments of outpatients
New studies are being published regularly
What is known about falls
Falls
• Definition from Kellogg supported by the IOM
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An event which results in a person coming to rest inadvertently
on the ground or other level and other than as a consequence
of the following: sustaining a violent blow, loss of
consciousness, and sudden onset of paralysis, as in a stroke or
an epileptic seizure
Aging population in Texas
Year
65-69
70-74
75-79
80-84
85+
2003
633,686
541,464
442,347
306,927
255,164
2004
647,653
543,899
446,019
320,092
262,282
2005
659,743
550,242
454,266
328,897
275,737
2006
686,224
561,708
463,215
339,404
291,461
2007
713,475
568,985
466,497
345,017
305,226
Aging Demographics 2006-2010
Subject
Total population
Male
Female
Median Age
Race (% of total rounded)
White
Black or Af. Am.
Amer. Ind. or Alaskan
Asian
Some other Race
Two or more Races
Marital Status
Married, but separated
Widowed
Divorced
Never married
Education
Less than 12 years
High school or more
Citizenship
Not a US Citizen
Language at Home
Not English
Income
Mean Earnings
Social Security
At 100% poverty
Bexar County, Texas
Total 65 years and over
1,650,052
48.9%
51.1%
32.7
167,756 (10%)
42.0%
58.0%
74.1
72
7
0.7
2
15
3
82
6
0.3
2
9
1
48
5
5
32
52
29
29
5
19
80
69
21
61
32
43
46
62,431
13,365
17
40,593
14,639
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Aging Population Proportion Increasing
Falls Fatality rates
Texans 65 and older
Males
Females
Falls Mortality Rates by Race
65 and older
Falls Mortality in Texas
2003
Cause of Death
No.
2004
Rate
No.
2005
Rate
No.
2006
Rate
No.
2007
Rate
No.
Total
Rate
No.
Rate
Fall on Same
Level (W00W09, W18)
Fall From One
Level to
Another (W10W17)
246
1.4
255
1.4
305
1.7
322
1.7
365
1.9
1,493
1.6
118
0.6
138
0.7
141
0.7
132
0.6
138
0.6
667
0.6
533
3.1
647
3.7
728
4.1
849
4.6
929
4.9
3,686
4.1
897
5.1
1,040
5.8
1,174
6.5
1,303
6.9
1,432
7.5
5,846
6.4
Unspecified Fall
(W19)
Total for
Selection
What Happens in Nursing Homes?
• Only 5% of elders live in nursing homes or about 1.5
million in the US
Potentially preventable ED visits
Falls and Fractures in nursing homes
• Half of nursing home residents fall annually with
incidence rates of 0.6-3.6 falls per bed, twice the rate of
community dwelling elders.
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24% of these falls are due to balance and gait problems
• The incidence rate for hospital inpatients is 2.2-17.1 per
1000 patient days.
• Mortality risk increases in 6 months following hip
fractures.
• Prevalence of hip fractures in care homes is estimated at
50.8/1000 person-years in women and 32.7/1000 in
men.
• In November 2002, the Centers for Medicare and
Medicaid Services launched the Nursing Home Quality
Outcome of falls
• Hip fractures are a common occurrence in nursing
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homes with an incidence rate of 4% (range 2%-6%).
After a hip fracture, elderly NH residents have a 40%
mortality risk within a year and a 6-12% risk of another
fracture.
Most never return to pre-fracture function, and 2/3
cannot be independently mobile (Crotty et al.,
2000)(Rapp et al., 2008).
The one-year cost of a NH hip fracture is about $30K,
most involving hospital costs. Balance this with changes
in QoL, and the cost is prohibitive.
In those > 65 years, accidental falls are the 5th leading
cause of death (Rubenstein, 2006).
Minimum Data Set Fall Coding
• Notes:
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The fall may be witnessed, reported by the resident or an
observer or identified when a resident is found on the floor or
ground.
Falls include any fall (home, community, in an acute hospital,
or a nursing home).
Falls are not a result of an overwhelming external force (e.g., a
resident pushes another resident).
An intercepted fall occurs when the resident would
have fallen if he or she had not caught him/herself or
had not been intercepted by another person—this is
still considered a fall. (RAI Manual J-27)
Source: University of MO-Columbia, Sinclair School of Nursing – March 2011
Minimum Data Set Fall Coding
• Coding (RAI Manual J 27-32):
1.
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6.
7.
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J1700A – Did the resident have a fall any time in the last month
prior to admission?
J1700B – Did the resident have a fall any time in the last 2-6
months prior to admission?
J1700C – Did the resident have any fracture related to a fall in the
6 months prior to admission?
J1800 – Any falls since admission or prior assessment (OBRA or
PPS) whichever is more recent.
J1900 – Number of falls since admission or prior assessment
(OBRA or PPS) whichever is more recent.
J1900A – No injury
J1900B – Injury (Except major)
J1900C – Major Injury
Source: University of MO-Columbia, Sinclair School of Nursing – March 2011
Risk factors for falls
Individual Risk Factors Related to Falling
Intrinsic Risk Factors in
Order of High to Low Risk
• Lower extremity weakness
• History of falls
• Gait/Balance deficits
• Use of assistive devices
• Vision deficit
• Arthritis
• Impaired ADLs
• Depression
• Agitation and Wandering
• Fear of Falling
• Additional Intrinsic Risk
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Factors
Chronic illness/Post-Stroke
Orthostatic hypotension
Urinary incontinence
Mental/Cognitive deficit
Medication/Polypharmacy
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Antidepressants
Antipsychotics: zolpidem
Benzodiazapine
Calcium channel antagonists
Diuretics
Hypoglycemics
Laxatives
Nonsteroidal anti-inflammatory
agents
Sedatives/hypnotics
Modifiable & Non-ModifiableRisk Factors For
Falls
Non-Modifiable Risk
Factors
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Sex
Age
Diagnosed with LBD
Dementia Duration
Lives in a LTC
History of falls over 12 months
Sarcopenia
Brain White Matter
Hyperintensities
Functional Disability: Use of an
assistive Device
Visual Impairment
Modifiable Risk Factors
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Cardioactive medications
Psychotropic Medications
Gait and Balance
Agitation
Pain
Depression
Autonomic Symptoms
Orthostatic Hypotension
ADL’s and IADL’s
Fear of Falling
Inappropriate Footwear
Physical Restraint Use
Individual risk factors: other conditions
• Neurodegenerative disorders (NDDs) (all dementias,
PD) more common in the aging population. By 2020,
there will be 42 million people with dementia, a risk
factor for falls (Ang et al., 2010).
• People with dementia have tough recoveries from
falls and falls with injuries.
• While falls risks and management strategies may be
known, we need policies and processes in all NHs:
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People with NDD, should be frequently reassessed
Environmental Risk Factors
• Extrinsic Risk Factors
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Lack of grab bars in the bath or toilet and hallways
Poor lighting
Height of bed or chairs
Improper use of assistive devices
Inadequate assistive devices
Poor condition of flooring surfaces
Improper footwear
Clutter, slippery throw rugs
Electrical cords in walking path
Lack of non-slip shower surfaces
Staff Related Falls Risk Factors
Content and Process Related
• Need for heightened awareness and knowledge (content)
• Lack of staff interdependence (process)
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Learning from each other
Frequent collaborations
Participation in decision making
Team building
Need for mentorship and guidance
• Need for staffing numbers, activities and stability
(process)
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Studies show staff “team” building improves quality care
Hourly toileting rounds, root cause analyses of falls, other?
Staff turnover in nursing homes is very high
Risk assessment tools and prevention
guidelines/strategies for falls
Fall Risk Assessment Instruments
• STRATIFY (St. Thomas Risk Assessment Tool in
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Falling Elderly Inpatients
Hendrich II Fall Risk Model
Morse Fall Scale
New York-Presbyterian Fall and Injury Risk
Assessment Tool
Maine Medical Center Falls Risk
Assessment/Interventions
Explanation of terms
Count
Fell
High Fall Risk
Yes
No
Yes
a
b
No
c
d
Measures of Precision for Four Falls Risk
Assessment Tools
Assessment Tool
Sensitivity (%)
Specificity (%)
Negative
Predictive Value
(%)
Positive Predictive
Value (%)
MMC
64.9
65.8
98.0
6.8
NY
78.9
58.4
98.6
6.9
Morse
77.2
72.8
98.8
9.9
Hendrich II
64.9
69.0
98.1
7.5
STRATIFY
57
72
95
15
• MMC= Maine Medical Center, Falls Risk Assessment/Interventions (Maine
Medical Center 2005)
• NY= New York-Presbyterian Fall and Injury Risk Assessment Tool (Currie et al.
2004, Currie 2006)
• Morse= Morse Fall Scale (Morse et al. 1989)
• Hendrich II= Hendrich II Fall Risk Model (Hendrich 2006)
St. Thomas's Risk Assessment Tool In Falling
Elderly Inpatients
• STRATIFY is a tool that consists of five questions:
1. Was the patient admitted to the hospital with a fall or has the
patient fallen in the past six months? (yes=1, no=0);
2. Do you think the patient is agitated? (yes=1, no=0);
3. Do you think the patient is visually impaired to the extent
that everyday function is affected? (yes=1, no=0);
4. Do you think the patient is in need of frequent toileting?
(yes=1, no=0);
St. Thomas's Risk Assessment Tool In Falling
Elderly Inpatients (contd.)
• STRATIFY is a tool that consists of five questions:
5. Does the patient have a transfer and mobility score of 3 or 4?
(yes=1, no=0. Transfer is scored as follows: 0=unable,
1=major help needed (1–2 helpers and/or physical aids
needed), 2=minor help needed (verbal or physical),
3=independent. Mobility is scored as follows: 0=immobile,
1=independent with the aid of wheelchair, 2=walks with the
help of one person, 3=independent.)
• The total STRATIFY score corresponds to the sum of all
present risk factors and can range between 0 and 5. The higher
the score, the greater the risk a patient has of falling.
Morse fall scale
(see next slide)
Validity Measures
Additional testing completed by Eagle et al. (1999) on a sample of elderly inpatients
indicated the following:
➢ Sensitivity (ability to detect falls when they are present) = 72%
➢ Specificity (ability to identify correctly the absence of falls) = 51%
➢ Positive Predictive Value (how well test predicted compared to actual number of
falls) = 38%
➢ Negative Predictive Value (how well negative test correctly predicts absence of falls)
= 81%
➢ Accuracy (overall rate of agreement between the test and the actual number of falls) =
57%
➢ Prevalence (ratio of the number of people who have fallen divided by the total
number of people at risk for falling) = 30%
Morse Fall Scale for the Acute Inpatient Setting
Procedure:
•Obtain a Morse Fall Scale Score by using the variables and numeric values listed in the “Morse Fall Scale”
table below. (Note: Each variable is given a score and the sum of the scores is the Morse Fall Scale Score. Do
not omit or change any of the variables. Use only the numeric values listed for each variable. Making changes in
this scale will result in a loss of validity. Descriptions of each variable and hints on how to score them are
provided below.) The “Total” value obtained must be recorded in the patient’s medical record.
Variables
1. History of falling
Numeric Values
No
0
2. Secondary diagnosis
Yes
No
25
0
Yes
15
Score
_______
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3. Ambulatory aid
None/bed rest/nurse assist
Crutches/cane/walker
Furniture
4. IV or IV Access
0
15
30
No
0
Yes
20
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5. Gait
Normal/bed rest/wheelchair
Weak
Impaired
0
10
20
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6. Mental status
Oriented to own ability
Overestimates or forgets limitations
0
15
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Morse Fall Scale Score
Total
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No risk – 25, Moderate risk – 26-45, High Risk 46+
New York-Presbyterian Fall and Injury Risk
Assessment Tool
• Fall Risk Item
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Falls in past 7 days
Male gender
Impaired cognition
Unsteady gait and not using assistive device
One or more sedatives
• Injury Risk Item
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History of adult fracture
Metastatic Bone Disease
No falls
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Yes - Single fall
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Yes - Multiple falls and/or Impairment of gait and/or
balance
Yes - Fear of falling
No further assessment or referral is needed.
Encourage older adult to exercise daily
Encourage older adult to take action and prevent
a fall
Recommend visit to primary care provider for
falls assessment and treatment of risk factors
• Primary care provider will assess for gait and/or
balance problems. The Timed Get Up and Go
can be used to identify gait and/or balance
problems. Older adults who demonstrate no
difficultly or unsteadiness need no further
assessment. Those who have difficulty or
unsteadiness require further assessment.
• Encourage older adult to take action and prevent
a fall
•Recommend visit to primary care provider for falls
assessment and treatment of risk factors.
•Assessment should be performed by professional with
appropriate skills and experience.
•Encourage older adult to take action and prevent a fall
• Recommend visit to primary care provider to
discuss fear of falling.
• Encourage older adult to take action and prevent
a fall
Maine Medical Center Patient Education Brochure
http://www.mmc.org/workfiles/mh_PFHA/FallsInfo
Patients.pdf
BMJ Editorial (2007)
In Simple Terms…
• Key interventions are those that are cornerstones of
appropriate care for elderly people. These include:
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adequate supervision
encouragement of supervised mobility and exercise
individually prescribed mobility and safety aids
a safe institutional environment
avoidance of psychotropic drugs where possible
recognition of changes in health status that predispose to falls,
such as delirium.
But in Reality, Interventions are Very Complex
Intervention
Recommendations
Identifying gait and balance problems using
TUG and the timed SLS (CDC, Morse, and
others)
Acceptable for NH residents who are
ambulatory. Take precautions with the SLS.
May use aides during TUG.
Monitoring medications using clinical
informatics tool, GRAM (Lapane)
Found to reduce the incidence of falls,
delirium, and hospitalization
Respiridone 1 mg. for elders with dementia
who wander (are agitated)
Pain management reduces agitation
Used in one study but reduced falls
significantly, and in another study, agitated
residents were 3 times as likely to have
fractures
Reduce walking aides to 1
Those who used wheelchairs and either canes
or walkers fell more
Staff education and fall case discussions
Netherlands researchers found this important
Environmental modification and resident
focused interventions
Low bed height, obstacle removal, w/c
maintenance, resident-specific exercise
program, hip protectors
High ratio of CNAs to residents
Significantly lowered risk of falls
Evaluate for Orthostatic Hypotension
Found important in more than 2 studies
Vitamin D and Calcium
Reduces fractures, but could cause kidney
calculi
Timed up and go test (TUG)
Timed Single Limb Stance
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The One-Legged Stance Test measures postural stability (i.e., balance) and is more difficult to perform due to
the narrow base of support required to do the test. Along with five other tests of balance and mobility,
reliability of the One-Legged Stance Test was examined for 45 healthy females 55 to 71 years old and found to
have "good" intraclass correlations coefficients (ICC range = .95 to .099). Within raters ICC ranged from 0.73
to 0.93.
To perform the test, the patient is instructed to stand on one leg without support of the upper extremities or
bracing of the unweighted leg against the stance leg. The patient begins the test with the eyes open, practicing
once or twice on each side with his gaze fixed straight ahead.
The patient is then instructed to close his eyes and maintain balance for up to 30 seconds.
The number of seconds that the patient/client is able to maintain this position is recorded. Termination or a
fail test is recorded if 1) the foot touches the support leg; 2) hopping occurs; 3) the foot touches the floor, or 4)
the arms touch something for support.
Normal ranges with eyes open are:
60-69 yrs/22.5 ± 8.6s
70-79 yrs/14.2 ± 9.3s
Normal ranges for eyes closed are:
60-69 yrs/10.2 ± 8.6s
Hip Protectors
Regain Confidence - Prevent Inactivity!
They don’t seem to work
One-Piece System is the most comfortable
to wear men's hip protector. This popular
SOFT HIProtector SafeHip is easy to put
on and comfortable to wear
http://www.cdc.gov/HomeandRecreationalSafety/images/CDC_Guide-a.pdf
Specialty organizations
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National Gerontological Nursing Association
Lueckenotte, A.G. & Conley, D.M. (2009). A study guide for
evidence-based approach to fall assessment and management.
Geriatric Nursing 30(3), 207-216.
•American Nurses Association
Jorgensen, J. (2011). Reducing patient falls: A call to action.
Supplement to American Nurse Today Special Report: Best
Practices for Falls Reduction, A Practical Guide, 2-20.
• American Geriatrics Society and British Geriatrics
Society
http://americangeriatrics.org/health_care_professionals/clinic
al_practice/clinical_guidelines_recommendations/2010/
Federal Guidelines
• Agency for Healthcare Research and Quality
Fall Management Guideline
http://www.guideline.gov/content.aspx?id=13484
http://www.innovations.ahrq.gov/content.aspx?id=2
052
• Centers for Disease Control and Prevention
http://www.cdc.gov/HomeandRecreationalSafety/Fal
ls/FallsPreventionActivity.html#7
For People We Serve
• National Institutes of Health(NIH) SeniorHealth
http://nihseniorhealth.gov/falls/toc.html
• National Institute on Aging – Age Page Falls and
Fractures
www.nia.nih.gov/HealthInformation/Publications/falls.htm
• Centers for Disease Control and Prevention
www.cdc.gov/injury
• National Center for Injury Prevention and Control
www.cdc.gov/ncipc
• American Geriatrics Society Patient Education
Forum www.gericareonline.net
• UCLA Division of Geriatrics – Patient Education
www.geronet.ucla.edu/centers/acove/patient_education.htm
Discussion
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Your falls experiences
What you do to prevent falls
What you do after falls
What you recommend that has
worked to Prevent falls
For More Information
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Contact:
Kelly Dunn
830 446 6507
Or
[email protected]