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

1. 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

2. Session Objectives • Discuss what is known about falls in elders. • 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 • 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.

3. 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: • 20 Research Studies • 4 Specialty Organization Guidelines • 5 Systematic Reviews (Cochrane and journal publications) • 2 Federal Guidelines • 1 Quality Improvement article

4. 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

5. What is known about falls

6. Falls • Definition from Kellogg supported by the IOM • 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

7. Aging population in Texas

8. Aging Demographics 2006-2010

9. Aging Population Proportion Increasing

10. Falls Fatality ratesTexans 65 and older Females Males

11. Falls Mortality Rates by Race65 and older

12. Falls Mortality in Texas

13. What Happens in Nursing Homes? • Only 5% of elders live in nursing homes or about 1.5 million in the US

14. Potentially preventable ED visits

15. 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. • 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 Initiative.

16. Outcome of falls • Hip fractures are a common occurrence in nursing 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).

17. Minimum Data Set Fall Coding • Notes: • 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

18. Minimum Data Set Fall Coding • Coding (RAI Manual J 27-32): • 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

19. Risk factors for falls

20. 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 Factors • Chronic illness/Post-Stroke • Orthostatic hypotension • Urinary incontinence • Mental/Cognitive deficit • Medication/Polypharmacy • Antidepressants • Antipsychotics: zolpidem • Benzodiazapine • Calcium channel antagonists • Diuretics • Hypoglycemics • Laxatives • Nonsteroidal anti-inflammatory agents • Sedatives/hypnotics

21. Modifiable & Non-ModifiableRisk Factors For Falls Non-Modifiable Risk Factors Modifiable Risk Factors • 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 • Urge Urinary Incontinence • 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

22. 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: • People with NDD, should be frequently reassessed

23. Environmental Risk Factors • Extrinsic Risk Factors • 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

24. Staff Related Falls Risk Factors Content and Process Related • Need for heightened awareness and knowledge (content) • Lack of staff interdependence (process) • 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) • 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

25. Risk assessment tools and prevention guidelines/strategies for falls

26. Fall Risk Assessment Instruments • STRATIFY (St. Thomas Risk Assessment Tool in 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

27. Explanation of terms

28. Measures of Precision for Four Falls Risk Assessment Tools • 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)

29. St. Thomas's Risk Assessment Tool In Falling Elderly Inpatients • STRATIFY is a tool that consists of five questions: • Was the patient admitted to the hospital with a fall or has the patient fallen in the past six months? (yes=1, no=0); • Do you think the patient is agitated? (yes=1, no=0); • Do you think the patient is visually impaired to the extent that everyday function is affected? (yes=1, no=0); • Do you think the patient is in need of frequent toileting? (yes=1, no=0);

30. St. Thomas's Risk Assessment Tool In Falling Elderly Inpatients (contd.) • STRATIFY is a tool that consists of five questions: • 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.

32. 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%

33. 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. No risk – 25, Moderate risk – 26-45, High Risk 46+

34. New York-Presbyterian Fall and Injury Risk Assessment Tool • Fall Risk Item • Falls in past 7 days • Male gender • Impaired cognition • Unsteady gait and not using assistive device • One or more sedatives • Injury Risk Item • History of adult fracture • Metastatic Bone Disease • Osteoporosis • Frailty • Antiplatelet therapy • Anticoagulant therapy • Thrombolytics • Bleeding Times • Decreased Platelet Count • Coagulopathy • Thrombocytopenia

36. Maine Medical Center Patient Education Brochure http://www.mmc.org/workfiles/mh_PFHA/FallsInfoPatients.pdf

38. BMJ Editorial (2007) In Simple Terms… • Key interventions are those that are cornerstones of appropriate care for elderly people. These include: • 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

41. Timed up and go test (TUG)

42. Timed Single Limb Stance • 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 • 70-79 yrs/4.3 ± 3.0s.

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44. http://www.cdc.gov/HomeandRecreationalSafety/images/CDC_Guide-a.pdfhttp://www.cdc.gov/HomeandRecreationalSafety/images/CDC_Guide-a.pdf

45. Specialty organizations • 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 Societyand British Geriatrics Society http://americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2010/

46. 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=2052 • Centers for Disease Control and Prevention http://www.cdc.gov/HomeandRecreationalSafety/Falls/FallsPreventionActivity.html#7

50. 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