Falls prevention for people living with dementia: Education session for home care workers

1. Falls prevention for people living with dementia:Education session for home care workers Professor Keith Hill, Head, School of Physiotherapy and Exercise Science, Curtin University– Keith.Hill@urtin.edu.au Gippsland (Victoria): September 2014

2. Overview • How common are falls among older people • What are the effects of falls on an older person • Why do older people fall • What effect does dementia have on falls • What should an older person do if they have a fall • How can a home care worker help clients to avoid falls • Case studies • Resources to help older people who fall

3. Falls in older people – Is it a problem??? • One third of people over 65 years of age fall each year • 10% cause a serious injury such as a fractured bone • Even falls that don’t cause an injury can cause loss of confidence in walking

4. Other factors • implicated in up to 40% of admissions to residential care • quality of life issues • independence • community living • active life-style • other

5. There are many possible causes of falls Health problems Intrinsic factors Ageing Environment Medications Activity related risks Extrinsic factors

6. Health problems contributing to risk of falling Dementia Poor eyesight Dizziness Incontinence Arthritis in the legs • Also includes: • - other medical conditions such as stroke, Parkinson’s disease • pain (low back and legs) • low blood pressure

7. Number of risk factors Modifiable and non-modifiable risk factors

8. There are many possible causes of falls Health problems Intrinsic factors Ageing Environment Medications Activity related risks Extrinsic factors

9. Environmental problems contributing to risk of falling Poor lighting Poor footwear Loose mat or slippery / uneven surface

10. The biggest risk for having a future fall is ……. ….. having had a recent fall

11. However many older people who fall do not tell a Doctor or other health professional • Why is this important? • The Doctor can • assess the cause of the falls • provide treatment to reduce risk of a further fall • But if the Doctor is not aware of the fall • there will be no actions put in place to reduce ongoing risk of falls • another fall is likely to occur

12. What effect does dementia have on a person’s risk of falling? • Reduced awareness of environment and safety • Agitation • Wandering • Increased unsteadiness Even greater risk of falling

13. But the person with dementia may also have other falls risk factors… Poor eyesight Dizziness Incontinence Arthritis in the legs • OFTEN THESE CAN BE TREATED • Poor eyesight • Dizziness • Incontinence • Arthritis • etc • Poor eyesight • Dizziness • Incontinence • Arthritis • etc

14. Case: Mary • 85 yo lady • Lives at home alone, has a home care worker visit twice weekly • Has a personal alarm • Has been falling for more than 10 years • Multiple fractures from falls • Medical past history includes osteoporosis, diabetes, depression, osteoarthritis, cataracts • Medications include sleeping tablets, antidepressants, and several others • Increasing unsteadiness in past few months • Had a recent fall, has not seen Doctor about falls • Environmental hazards

15. Early identification of risk: Mary                

16. Case: Mary – what might the home care worker observe? • 85 yo lady • Lives at home alone, has a home care worker visit twice weekly • Has a personal alarm • Has been falling for more than 10 years • Multiple fractures from falls • Medical past history includes osteoporosis, diabetes, depression, osteoarthritis, cataracts • Medications include sleeping tablets, antidepressants, and several others • Increasing unsteadiness • Had a recent fall, has not seen Doctor about falls • Environmental hazards

17. Can the risk of falls among older people be reduced? YES!

18. What can help to reduce an older person’s risk of falls: 1. See the doctor or other health professional • If a person has a fall - even if they think it was just an accident • If a person is feeling more unsteady when walking / turning • Commences using a different walking aid • If a person is reducing their activities

19. What can help an older person to reduce their risk of falls: 2. Exercise

20. Evidence of what works in exercise in falls prevention • Group exercise programs • Home exercise programs (often prescribed by a physiotherapist) • Tai Chi- (note: different types of Tai Chi may have different effects) • Foot and ankle exercise as part of podiatric multi-faceted program (Spink et al, 2011)

21. Many older people have an exercise program to do at home • Usually under intermittent supervision of physiotherapist or accredited exercise physiologist • Often need for encouragement to maintain participation

23. What can an older person do to reduce their risk of falls: 3. Medication review • Keep medications to the minimum needed • Take medications as prescribed • Have medications reviewed by the doctor regularly • Try to avoid / minimise use of sleeping tablets, anti anxiety tablets etc Largest effect of any falls prevention study involved weaning people off sleeping / anxiety medications

24. What can an older person do to reduce their risk of falls: 4. Vision check • Regular vision review • Cataract surgery • First eye effective • Bifocals and multi-focal glasses– can be a problem

25. What can an older person do to reduce their risk of falls: 5. Home safety • Removing environmental hazards will reduce risk of falls • If having falls should have an occupational therapy home assessment

26. What can an older person do to reduce their risk of falls and fall injuries: Vitamin D and calcium • Many older people have low levels of vitamin D • Main sources of vitamin D are: • Sunlight (approx 20 min/day) • Some foods (eg sardines) • Supplements • Vitamin D and calcium together have been shown to reduce fractures and falls (in high risk samples)

27. What can an older person do to reduce their risk of falls injuries: Hip protectors • Useful if falling frequently, and / or if bones are weak • Will reduce risk of hip fracture substantially, if worn... • Several different types • Hard shields • Foam

28. Other interventions from best practice guidelines Safe footwear Education Change walking aid Treat postural hypotension Treat incontinence

29. Case: Mary – how can her falls risk be reduced? • Use her personal alarm if a fall occurs and cannot get up • Discuss hip protectors / vitamin D / possibly bone-strengthening medications • Review re cataracts-?surgery • Review medications, in particular sleeping tablets • Physiotherapy assessment of balance and mobility - ?exercise program • Have a medical review AND report the fall • Home safety assessment by occupational therapist • 85 yo lady • Lives at home alone, has a home care worker visit twice weekly • Has a personal alarm • Has been falling for more than 10 years • Multiple fractures from falls • Medical past history includes osteoporosis, diabetes, depression, osteoarthritis, cataracts • Medications include sleeping tablets, antidepressants, and several others • Increasing unsteadiness in past few months • Had a recent fall, has not seen Doctor about falls • Environmental hazards

30. Case: if Mary also had dementia… • POSSIBLE OPTIONS TO REDUCE RISK OF FALLS • Use her personal alarm if a fall occurs and cannot get up • Discuss hip protectors / medications to strengthen bones • Review re cataracts-?surgery • Review medications, in particular sleeping tablets • Physiotherapy assessment of balance and mobility, and to provide an exercise program • Have a review by a Doctor AND report the fall • Home safety assessment by occupational therapist • 85 yo lady • Lives at home alone, has a home care worker visit twice weekly • Has a personal alarm • Has been falling for more than 10 years • Multiple fractures from falls • Medical past history includes osteoporosis, diabetes, depression, osteoarthritis, cataracts • Medications include sleeping tablets, antidepressants, and several others • Increasing unsteadiness in past few months • Had a recent fall, has not seen Doctor about falls • Environmental hazards • Dementia friendly environment • Ensure consideration of causes and management of agitation • Other …..

31. Exercise to reduce falls in people with dementia • Home exercise programs for people with dementia, supported by a carer, have been shown to reduce falls • Need for assessment by physiotherapist and provision of exercise program • Followup home visits, support from others (eg home care workers) to encourage ongoing participation image

32. Successful case studies from Gippsland region (1) • David: • 70 year old • Inoperable hydrocephalus • Frequent falls • Unable to get up after a fall – needed ambulance call out • Treatments • Home based physiotherapy commenced (low compliance so physio home visits, as wife and carers were unable to persuade participation) • OUTCOMES • Maintained mobility • No falls • Able to remain at home for extended period before further decline and need for Nursing Home

33. Successful case studies from Gippsland region (2) • James: • 70 years old • Alzhiemer’s disease • Lived on hobby farm • Previously active and enjoyed daily walks • As dementia progressed, activity reduced and needed prompting / supervision • Treatments • Not suitable for community Rehab because of high level of prompting and supervision needed • Home based physio exercise program introduced • Wife and home care worker monitored and supported exercises • OUTCOMES • 1.5 years later, balance had been maintained, continuing with supervised walking but small decline in endurance

34. Ways a home care worker can assist in reducing client’s risk of falling • Look for indicators of increased risk: • Signs of a fall (eg bruises) • Increased unsteadiness (furniture walking) • Change in type of walking aid used • Increased difficulty getting out of a chair • Increased environmental hazards in the home increasing risk of trips Report to your manager

35. Ways a home care worker can assist in reducing client’s risk of falling • If the client has a home exercise program: • ask the client about the program • encourage regular completion of the exercise program Report to your Manager or the physiotherapist

36. Summary • Falls are common among older people, especially in people with dementia, and can cause serious injuries and loss of confidence • All falls should be reported to a doctor • There are a number of ways that falls risk can be reduced • Home care workers can play an important role in identifying potential risks for falling among their client, and supporting participation in recommended fall prevention activities