Falls in the Elderly Deanna Abbott-McNeil, BScPT, Dip. CPA Resource Consultant Center for Studies in Aging & Health Providence Care
Learning Objectives By the end of the session you will be able to: 1. State the prevalence of falls in the community 2. List risk factors for falls from 4 categories 3. Describe screening questions for fall risk. 4. Describe the Timed Up & Go test and why it is used 5. Name medications associated with increased fall risk 6. Describe potential interventions to decrease fall risk for patients / clients
Outline 1. Falls facts 2. Risk factors for falls 3. Best practices for seniors fall prevention Screening Assessment Risk factor identification Multifactorial, interprofessional management 4. Resources 5. Your ideas for preventing falls in your setting
Falls are common Every year 1/3 of community-dwelling seniors 65 will have at least one fall Incidence of falls increases with age: 65 years 35% 80 years 40% Division of Aging and Seniors (2005). Report on seniors falls in Canada.
Injuries are more severe with Age ½ - minor injury Up to ¼ - serious injury (fracture, sprain, death) Division of Aging and Seniors (2005). Report on seniors falls in Canada.
Serious Injuries from a Fall: A profile Female 80+ years Alone widowed / divorced Low income (Division of Aging and Seniors, 2005)
Consequences not just physical Even without injury Loss of confidence Curtailment of activities: Decline in health, function, and quality of life Risk of future falls Division of Aging and Seniors (2005). Report on seniors falls in Canada.
Most falls happen in or near Home 50% of falls due to slip, trip, stumble Common locations: Bathrooms Stairs Ice/snow Division of Aging and Seniors (2005). Report on seniors falls in Canada.
ER Missed Opportunities 50% of patients presenting with a fall have vision and balance impairments Majority (70-90%) will have no modification of risk factors 40% likely to sustain a fracture within 12 months
Hip Fractures cause significant Morbidity and Mortality Approx 1/2 fall-related injuries are to femur, pelvis, hip, or thigh Majority of these injuries are hip fractures Only 1/3 will regain prior functional level Hospitalization: 7% will die within 30 days 20-30% will die within one year Division of Aging and Seniors (2005). Report on seniors falls in Canada.
Disproportionate fall-related Admissions from LTC Seniors hospitalized due to falls: ½ from home ¼ from residential institution*** (only 7% of senior population live in LTC) Division of Aging and Seniors (2005). Report on seniors falls in Canada.
Falling in Hospital Predictable Patterns Up to 84% of inpatient incidents Most during day: 0630-1600 Most from or near bed transferring from one location to another eg bathroom Division of Aging and Seniors (2005). Report on seniors falls in Canada.
LTC High Rates of Falls and Injuries 40% of LTC admissions are a result of falls 50% residents fall each year 40% LTC fallers have 2 or more falls / year 10% result in serious injury Less than 15% who fracture hip regain pre-fracture ambulation status Division of Aging and Seniors (2005). Report on seniors falls in Canada.
Avoidable Catastrophes! Despite the high personal and system costs Most falls are predictable and preventable
Risk Factors Interact and Compound Falls caused by interaction of multiple risk factors, not single cause Cumulative effect of risk factors: More risk factors = greater likelihood of falling and injury 4 risk factors = 80% chance of falling Division of Aging and Seniors (2005). Report on seniors falls in Canada.
Risk Factors Four Main Categories 1. Biological / medical 2. Intrinsic 3. Extrinsic 4. Socio-economic Division of Aging and Seniors (2005). Report on seniors falls in Canada.
Risk Factors 1. Biological and Medical normal aging changes and pathology Sensory changes, altered reflexes Gender women > men Advanced age Muscle weakness (esp lower body), reduced fitness Impaired balance and gait Vision changes acuity, light/dark, depth perception Chronic illness arthritis, stroke, Parkinson s, low BP, osteoporosis, incontinence, arrhythmias Acute illness infection (weakness, dizziness) Cognitive impairment confusion, dementia, delirium Depression chicken versus egg Division of Aging and Seniors (2005). Report on seniors falls in Canada.
Risk Factors 2. Behavioural History of previous falls (increases risk 3-fold) Risk-taking ki behaviour Footwear, clothing, handbags Inactivity / inadequate diet Fear of falling Medications Polypharmacy (5 or more) - adverse drug reactions Certain medications alertness, judgment, coordination, blood pressure, dizziness, balance: Benzodiazepines i Psychotropics paxil/zoloft, etc?nsaids Alcohol (14 or more drinks per week) Division of Aging and Seniors (2005). Report on seniors falls in Canada.
3. Environmental Spot the 14 Hazards (Adapted from Public Health Agency of Canada, 2008)
Risk Factors 3. Environmental Stairs - no handrails, poor lighting, no contrast for stair edges, non-uniform steps or not to code, slippery surfaces Loose rugs, poor night lighting, no light switches at room entrance, clutter, etc Pets Sidewalks Bed heights, floor surfaces Division of Aging and Seniors (2005). Report on seniors falls in Canada.
Risk Factors 4. Socio-economic Low income Low education Inadequate housing Lack of support networks Lack of access to appropriate p health or social services Division of Aging and Seniors (2005). Report on seniors falls in Canada.
Best Practices for Fall Prevention 1. Screen for high risk 2. Comprehensive assessment (high risk) 3. Risk factor identification 4. Risk factor management Interprofessional Registered Nurses Association of Ontario (2005). Prevention of Falls and Fall Injuries in the Older Adult.
Best Practices 1. Screening for Fall Risk Seniors 65 ask three questions: 1. Have you fallen in the past 12 months? 2. Did you seek medical attention due to your fall? 3. Are you afraid of falling? High risk = 1. Recurrent falls (2 or more) 2. Sought medical attention 3. Fear of falling American Geriatrics Society (2001). Guideline for the Prevention of Falls in Older Persons. JAGS, 49, 664 672672
Best Practices 1. Screening Timed Up & Go (TUG) If 65+ with single fall past 12 months: Perform the Timed Up & Go (TUG) Test To distinguish normal fall from high risk Chair with arms, 3 meter line, stop watch Get up, walk to line, sit back down HIGH RISK= 14 seconds or more Gait or balance abnormalities
Best Practices 1. Screening - Timed Up & Go Test http://www.saskatoonhealthregion.ca/your_health/ps_ip_falls_screening_tools.htm Saskatoon Falls Prevention Consortium (2008). Timed up and go test: by Julie Landeryou. Saskatoon Health Region. Video file, reproduced with permission. Retrieved July 21, 2008, from http://www.saskatoonhealthregion.ca/your _ health/ps _ ip_ falls_ screening_ tools.htm
Best Practices 1. Screening - Other high risk characteristics Lower limb disability Serious foot problems Lower extremity weakness Cognitive / memory problems 4 or more medications Physical inactivity Multiple trips to primary care team Registered Nurses Association of Ontario (2005). Prevention of Falls and Fall Injuries in the Older Adult.
Best Practices 2. Comprehensive Assessment 1. History Falls history and circumstances 2. Physical assessment Gait, balance, strength (leg), mobility Osteoporosis risk Vision Medication review Acute/chronic health problems infection; diabetes, incontinence, stroke, etc. Cardiovascular hypotension, arrhythmias Perceived functional ability / fear of falling Home hazard assessment (CCAC OT) Registered Nurses Association of Ontario (2005). Prevention of Falls and Fall Injuries in the Older Adult.
Best Practices 3. Risk Factor Identification 1. Medical / biological 2. Intrinsic 3. Extrinsic 4. Socio-economic Division of Aging and Seniors (2005). Report on seniors falls in Canada.
Best Practices 4. Risk Factor Management (Interprofessional) No single profession can manage falls adequately Involve patient/client and family stress the need to prevent falls to maintain independence Quick wins first medication adjustment, footwear, vision correction, gait aids Include long-range strategies environmental modification, ongoing education, exercise balance and leg strengthening
Best Practices 4. Risk Factor Management (Interprofessional) 1. Exercise 2. Behaviour 3. Medication reduce #; use Beers Criteria 4. Treat acute/chronic health conditions 5. Assistive devices 6. Environmental Modification 7. Education Division of Aging and Seniors (2005). Report on seniors falls in Canada.
Best Practices Risk Factor Management Exercise Need balance and leg strengthening Tai Chi CCAC physiotherapist VON SMART exercise program
Best Practices Risk Factor Management Behaviour Modification Education Minimize alcohol Risk-taking ladders, step stools, etc Footwear Inactivity Diet Vit D. CCAC Occupational Therapist KFLA Falls Prevention Programs
Best Practices Risk Factor Management Medication Beware polypharmacy / Adverse Drug Reactions Eliminate / replace (use Beers Criteria): Psychotropics especially benzodiazepines Antidepressants tricyclics, SSRIs;antipsychotics, anticonvulsants, etc Anti-Parkinsonian meds Antihypertensives Narcotics Hypoglycemics Diuretics and laxativesati OTC sleeping pills, muscle relaxants Consider Vit D, calcium, osteoporosis meds
Best Practices Risk Factor Management Acute / Chronic Health Conditions Infection Orthostatic hypotension Arrhythmias Vision Osteoporosis Incontinence Diabetes Stroke / Parkinson s disease
Best Practices Risk Factor Management Assistive Devices Canes, walkers, wheelchairs, scooters Transfer poles Bathroom grab bars Foot drop splints Hip pprotectors Safety call device e.g. Lifeline E.g. OT / PT (CCAC) Assistive Devices Program government subsidizes 75% cost of device
Best Practices Risk Factor Management Environmental Modification Small modifications lighting, railings, rugs, clutter, bed/chair height, ht footwear, emergency call system, shower/tub safety, etc. Larger modifications grants available through Canada Mortgage and Housing Corporation Handout home safety yquestionnaire CCAC OT Can conduct detailed Home Safety Assessment and make recommendations Can help individual apply for funding for larger modifications if required
Best Practices Risk Factor Management Education Adjunct to other interventions Not effective as a stand-alone intervention Many seniors are not aware of their increased risk of falls and/or injury Many seniors overestimate fitness level Many seniors underestimate loss of visual acuity Seniors are receptive to education about risk factor modification - emphasize maintain independence
Fall Prevention Resources HELP (Hospital Elder Life Program) and Everybody Gets It QHC Belleville GH KFLA Falls Prevention Coalition (http://www.stepsafe.com ) SMART (Seniors Maintaining Active Roles Together) In-home exercise program for home-bound seniors (www.von.ca ) Sagelink information for providers, resources/ handouts for patients and families www.sagelink.ca RNAO Best Practice Guideline (2005): Prevention of Falls and Fall Injuries in the Older Adult www.rnao.org/bestpractices
What are your Ideas for incorporating Best Practices into your Setting? Clinician Management / administration Educator if you can t change something big, change something small
Example Interventions Ask about history of falls Medication review Lowering bed height Lowering bed rails Minimize physical / chemical restraints Fall symbol at bedside Leave light on in bathroom Assistive devices and ensure appropriate and used properly Commodes or raised toilet seats Move to area of high visibility OT/PT assessment Footwear: Avoid socks, bare feet, flip flops, slippers, loose-fitting Best is light weight walker with non-slip sole Cognitive issues family monitoring, move closer to reception station Hip protectors?
References American Geriatrics Society (2001). Guideline for the Prevention of Falls in Older Persons. JAGS, 49, 664 672. British Columbia Ministry of Health (2006). Falls can be prevented. BC Health Files, Issue 78. Division i i of Aging and Seniors (2005). Report on seniors falls in Canada. Minister i of Public Works and Government Services, Public Health Agency of Canada. Ottawa, Ontario. Retrieved, July 4, 2008, fromhttp://www.phac-aspc.gc.ca/seniors-aines/pubs/seniors_falls/index.htm. Laird, R.D. & Robinson, B.E. (2006). Falls in Older Adults: Evaluation and Management in Primary Practice 3 rd Edition. In The Practicing Physician Education Project Tools for the Evaluation and Management of Geriatric Patients in Primary Practice. Robinson, B.E. & Levine, S. A. (Eds). Merck Institute of Aging and Health. Public Health Agency of Canada (2008). Stay Safe (poster). Retrieved July 29, 2008, from http://www.phacaspc.gc.ca/seniors aines/pubs/safety_poster/safety_poster_e.htm. Registered Nurses Association of Ontario (2005). Prevention of Falls and Fall Injuries in the Older Adult. Retrieved March 18, 2009 from www.rnao.org/bestpractices. Saskatoon Falls Prevention Consortium (2008). Timed up and go test: by Julie Landeryou. Saskatoon Health Region. Video file, reproduced with permission. Retrieved July 21, 2008, from http://www.saskatoonhealthregion.ca/your_health/ps_ip_falls_screening_tools.htm. Shumway-Cook, A., Brauer, S. & Woolacott, M. (2000). Predicting the probability for falls in communitydwelling older adults using the Timed Up & Go Test. Phys Ther, 80:896-903. Statistics Canada (2007). A portrait of seniors in Canada. Minister of Industry: Ottawa, Ontario. Retrieved July 28, 2008, from http://www.statcan.ca/english/freepub/89-519-xie/89-519-xie2006001.pdf.