COPYRIGHT PAMELA NYE

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2 If You Had a Crystal Ball, And Knew Who Would Fall, What Would You Do? Pamela Jane Nye, RN, MS, SCRN, CNRN University of California, Los Angeles, Santa Monica campus

3 Sure, I know impulsivity is related to falls But, what is impulsivity, really?

4 Fall Literature A total of 183 patients fell during the study period. The average age of patients who fell was 63.4 years (range 17 to 96). Many falls were unassisted (79%) and occurred in the patient's room (85%), during the evening/overnight (59%), and during ambulation (19%). Half of the falls (50%) were elimination related, which was more common in patients over 65 years old (83% vs 48%; P <.001). Elimination-related falls increased the risk of fall-related injury (adjusted odds ratio, 2.4; 95% confidence interval 1.1 to 5.3). The medicine and neurology services had the highest fall rates (both were 6.12 falls per 1,000 patient-days), and the highest patient to nurse ratios (6.5 and 5.3, respectively).

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6 Morse Score: Useful or Outdated Antique?

7 Talking to the Nurse Why do you think your patient fell? He was trying to go to the bathroom without help. He under-estimated his ability. I told him not to get up without me, he just did it anyway. He s impulsive, I caught him trying to get out of bed several times today.

8 What is Impulsivity? Doing things or tending to do things suddenly and without careful thought (Merriam-Webster Dictionary). Impulsivity is a personality trait or an acquired trait common to the male gender with a well-documented relationship to use of drugs and alcohol. (DSM-5, 2013; Trent, 2012; Weafer & de Wit, 2014). Impulsivity may be a choice or an action. (Weafer & de Wit, 2014; Barker et al, 2015; Urcelay & Dalley, 2012). Choice impulsivity (motor impulsivity) is related to compulsive behavior (Waefer & de Wit, 2014; Urcelay & Dalley, 2012). Impulsivity or ability to suppressive impulsive urges is neurologically based in the pre-frontal gyrus, the seat of executive cerebral function. (Holmes et al, 2014; Oscar-Berman, 2004; Urcelay & Dalley, 2012; Anderberg et al, 2016).

9 Conditions with a Known Component of Impulsivity Attention Deficit Hyperactivity Disorder (ADHD) New studies on adults with childhood ADHD Alcoholism/Substance Abuse Personality Disorder Obsessive Compulsive Disorder Parkinson s Disease Addictive Disorder/Behavior Studies on online addiction, Smartphone addiction, eating disorders, gambling, sexuality, video gaming Immaturity (adolescent frontal brain development) Brain Injury (temporal and/or frontal)

10 Scenario You are about to receive an admission. This is the report you receive from the ED: This is a 45 year old man, who is admitted with acute pancreatitis and is covered with bruises from unknown injuries in the recent past. He has a chronic alcohol problem. VS are stable at 140/84, 88, 14. He is disheveled, and smells of cigarettes. What other information would you want to know about this man?

11 Is Impulsivity Ever a Positive Trait? Police, security, prison guards Nurses, doctors, ambulance drivers Hazardous waste workers Explosives workers Military Dalley et al. 2011; Bureau of Labor Statistics, 2016

12 Rupp et al, 2016

13 Impulse Inhibition Impulsive Action (response inhibition) is failure to inhibit an inappropriate response to stimuli. Impulsive Choice (delayed discounting) preference for smaller immediate rewards over larger delayed rewards. (Rupp et al. 2016) Studies to find inhibitory centers in the brain began in the 1800 s. Current thinking identifies the prefrontal cortex as the seat of inhibition. (Bari & Robbins, 2013)

14 OMG! I think I left food cooking on the stove and left for work! Nah, I never do that. I always turn off the burner and set the pan on the wooden cutting board. Impulse Inhibition, normal thought control.

15 OMG! I think I left food cooking on the stove and left for work! Maybe I didn t.. But, maybe I DID! Impulse inhibition failure I better drive home and check!

16 but she said not to get up without her. I have to go REAL bad. I might wet the bed if I wait. I have to go to the bathroom! I m going to get up just this once.

17 Individuals who experience frequent negative emotions are highly motivated to reduce these negative affect states (i.e., to provide quick and immediate relief of distress). (Klonsky, 2007; Nock, 2010; Suyemoto, 1998), Recent research and theory suggest that individuals who are highly impulsive may be especially motivated to act rashly in the context of negative emotions because long-term benefits become less important than the immediate shortterm gains of emotion regulation The Theory of Urgency, Cyders & Smith, 2008; Tice, Bratslavsky, & Baumeister, 2001). Hamza at al, Meta-analysis, 2015 Using the circumstance of needing to go to the bathroom in hospitalized patients, in patients who have inherent or acquired impulsivity does this increase their likelihood of getting out of bed before waiting for nurse to arrive?

18 The Adult Incontinence Quiz Answer this question: How embarrassed would you be if you lost control of your bladder right now and wet yourself in your clothes? What kind of risks would you be willing to take to hide a really embarrassing problem from a complete stranger?

19 This is tough to admit, but here goes: I m 39 years old and I pee myself on a regular basis. No kidding: it s true. Since I gave birth three years ago (and practically pushed my brains out of my ears in the process), I pee my pants whenever I sneeze, cough, or laugh. It s annoying and demoralizing once I soaked myself when a cat hair got stuck in my throat and triggered a coughing flurry. Um, my toddler s the one who belongs in Pull-Ups, not me.

20 A Small Pilot at UCLA RR In a 1 year retrospective chart review of patients who fell on a neuroscience unit, the follow was found: Total number who fell 38 Mean age 56 years Percent who were men 68% (rounded) Percent of men w/etoh or drugs 71% Percent who were women 31% (rounded) Percent of women w/etoh or drugs 33% Number of falls related to trying to meet toileting needs 30%

21 Another Small Pilot In a 9 month retrospective review of patients who fell in an academic, community based medical center, the following was found: Total falls (Jan-Sept. 2016) <65 yrs old = 49% >65 yrs old = 51% Mean age years Gender distribution Men=49% Women=54% Alcohol or drugs in recent/remote history %

22 In a one month review at UCLA SM How many fell during the month of October 2016? n=18 How many had ETOH in recent/remote history? 11% How many had drugs in recent/remote history? 17% How many were documented by nurses, doctors, therapists, etc. as impulsive in Care Connect? 50%!!

23 Could Risk Factors Apply to Impulsivity? Male <65 years old Alcohol or drug use listed on Physician Problem List or history & physical. Known diseases/conditions associated with impulsive behavior. Observed and documented impulsive behavior by any health professional.

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25 Traditional Methods - that don t work! Hourly rounding Bed Alarms Rationalizing Fall Risk hallway signage Colored socks (red for potential fallers; tan everyone else) Morse score documentation in other words A one size fits all approach!

26 One Method Not a Restraint That MIGHT Work for Motor Impulsivity

27 New Populations New Approach Proactivity works Determine why the patient is trying to get up. Anticipate the need by providing the solution before the problem arises. 30%

28 Proactive Toileting 30%

29 So What Is Proactive Toileting? 30cc/hr cc If the kidney produces 30cc in 1 hour, then in 3hrs, 90cc is in the bladder. If the micturition reflex occurs at , the reflex would not trigger the brain to stimulate the person to get up.

30 This only works when everyone does it the same way, and the patient can trust his/her environment.

31 How Could This Be Done? RN/CP partnership 9am = CP 12noon=RN 3pm = CP 6pm = RN Therefore, a 2-partner team would only have to attend to toileting twice a shift. Adjust times for optimal sleeping at night without sacrificing the concept.

32 What About Stress Incontinence in Women with Low Bladder Capacity? Provide incontinence care products that are likely being used at home & proactive toileting.

33 Questions?

34 CONTACT: