Peggy McConnell, GNP-BC Rhonda Brodrick, MSN, RN College of Nursing Mike Stoots , Ed. D. College of Public Health Eas

1. Prevent Those Slips and Falls: Tips for Assessment and Strategies to Prevent Falls • Peggy McConnell, GNP-BC • Rhonda Brodrick, MSN, RN College of Nursing • Mike Stoots, Ed. D. College of Public Health East Tennessee State University This project was partially supported by grant number UB4HP19051-02-00 from the Department of Health and Human Services Health Resources and Services Administration (HRSA). Contents are solely the responsibility of the authors and do not necessarily represent the official views of HRSA.

2. Some Falls are funny!

3. Most Falls are Not

4. Objectives At the conclusion of this session, participants will be able to: • Describe the reasons falls are of special concern in the older adult population. • Identify the possible results of falls in the older adult population. • Identify intrinsic and extrinsic factors that increase the older adults' risks for falls. • Describe Level A and Level B categories of evidence-based interventions that reduce fall risk in older adults. • Recognize resources that will help provider/agency build a stronger fall prevention program.

5. Definition of Fall A fall is defined as unintentionally coming to rest on the ground or other lower level in a way that is not the result of a major intrinsic event (i.e., heart attack, stroke, or seizure) or an overwhelming external hazard (i.e., hit by a vehicle).

6. Why are falls important? The answer to this question incorporates data from several sources: • Demographics • Significance of falls • Healthy People 2020 • Results of falls • Potential for Prevention

7. U. S. Population over 65 years By 2030 almost 70 million which is double the 35 million in 2000 2010 – First baby boomers hit 65 Population over 65 (In millions) 1900 1920 1940 1960 1970 1980 2000 2010 2020 2030 Year Administration on Aging, 2000 E L N E C

8. Demographics • All nations are facing an aging population. • Increasing life expectancy in the U.S. (Male/Female) U.S. National Center for Health Statistics • U.S. Census Bureau prediction • “The world is aging so fast that within a decade there will be more people 65 and older than children under 5 for the first time”

9. Demographics In the United States, the elderly population is expected to be 20% of the total population by 2030. The Old-Old (greater than 85) cohort is the fastest growing cohort.

10. How significant is the problem? • Falls are the leading cause of injury death and non-fatal injury in older adults. • One out of three people age 65 and older living in the community will fall each year • Those who fall at least twice are twice as likely to fall again • The majority of those who fall do not seek medical attention • Fall risk increases as age increases.

11. How significant is the problem? • Of those who fall, 20% to 30% suffer moderate to severe injuries that make it hard for them to get around or live independently and increase their chances of early death • Falls are the most common cause of traumatic brain injuries • The most common fractures are of the spine, hip, forearm, leg, ankle, pelvis, upper arm, and hand • Complications resulting from falls are the number one cause of death from injury in both men and women aged 65 and older.

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13. Growing Public Health Concern • Healthy People 2020 identifies fall prevention as a major focus. • Also identified as major focus by National Council on Aging (NCOA), Administration on Aging (AoA), American Geriatrics Society (AGS), Center for Disease Control (CDC), Medicare and Medicaid (CMS), US Preventive Services Task Force

14. Results of Falls Increased Decreased Physical Function Independence • Morbidity • Health Care Utilization • Mortality

15. Fear of Falling Many people who fall, even those who are not injured, develop a fear of falling. This fear may cause them to limit their activities, leading to reduced mobility and physical fitness, which increases their actual risk of falling.

16. Results of Falls Hip fractures are the most frequent type of fall-related fractures. • The cost of hospitalization for hip fracture averaged about $18,000 and accounted for 44% of direct medical costs for hip fractures. • After a hip fracture • 2-3 times more likely to die within one year • 25% in a nursing home one year later

17. Results of Falls • According to the CDC • In 2000, the total direct medical costs of all fall injuries for people 65 and older exceeded $19 billion: $0.2 billion for fatal falls, and $19 billion for nonfatal falls. • Costs are expected to increase as the population ages. • By 2020, the annual direct and indirect cost of fall injuries is expected to reach $54.9 billion (in 2007 dollars).

18. So Why Do Older Adults Fall? • Because of their comorbidities, causes of falls in older adults are rarely due to a single cause. • Two Major Cause Categories • Intrinsic (inside the body or personal) • Extrinsic (environmental) • Most falls result from a complex interaction between individual and environmental factors

19. Intrinsic (Individual) Risk Factors for Falls • Gender • females at greater risk than males • Age • risk increases significantly for 80 and older • Impaired information interpretation and/or judgment • mild cognitive impairment, dementia, Alzheimer disease • Impaired sensory input • diminished vision and/or hearing • Functional impairment • lower extremity weakness, alterations in gait and balance, diminished reflexes, delayed reaction response

20. Intrinsic (Individual)Risk Factors for Falls • Medical Conditions: • Diabetes • Cardiovascular - Orthostatic or post-prandial hypotension, Hypertension, Dysrhythmias, Heart Failure • Pulmonary – pneumonia, COPD • Foot problems - bunion, callous, toenails • Neurological – Stroke, Parkinson disease • Nutrition Deficits - Low body mass index, decreased intake of protein and nutrients • Altered urinary function – infection, incontinence • Depression

21. Extrinsic (Environmental) Risk Factors for Falls • About half of falls are precipitated by an environmental hazard

22. Extrinsic (Environmental)Risk Factors for Falls • Medications • As the number of medications increases, the risk of medication reactions, interactions, and side effects increases. • Fall risk increases with polypharmacy (use of 4 or more medications) and the use of psychoactive medications (tranquilizers, antidepressants) • Alcohol Consumption • Increased risk of interaction between medications and alcohol • Heavy alcohol consumption (> 14 drinks/week) shown to be associated with increased falls

23. Extrinsic (Environmental)Risk Factors for Falls The majority of older adults desire to remain in their own homes Courtesy Walt Disney Studios • Most live in “Peter Pan” Homes - Designed for those that never grow old! • The majority of older homes have multiple hazards. • Older adults are often unaware of the hazards in their homes. • Biggest challenges for older adults are multiple steps/stairs and unsafe bathrooms.

24. Extrinsic (Environmental)Risk Factors for Falls Environmental hazards: • Poor lighting • Slippery surfaces • High-gloss floors • Stair hazards • Clutter • Storage problems • Tripping hazards • Pets/pet-related objects • Improper use of equipment

25. Farming and Falls 40% of farmers in US are above the age of 55

26. Older Farmers • Webinar on “Older Farmers and Falls” at the following OVAR/GEC web download: http://www.mc.uky.edu/aging/documents/gec/Webinar%203%20Mental%20Health%20-Reed51112.pptx • Information on agricultural safety as it pertains to preventing fall related injuries in farm workers http://www.nasdonline.org/document/208/d000006/preventing-injuries-from-slips-trips-and-falls.html

27. Risk Factors for Falls • Research has shown that fall risk increases greatly when the number of risk factors increases from 1 to 4 or more. • Age related changes can decrease the ability to avoid a fall after encountering a hazard or unexpected trip.

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29. What Can We Do? Newly published evidence based guidelines: • January 2010 - American Geriatric Society and the British Geriatric Society published the most current AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons • December, 2010 - US Preventive Services Task Force addressed primary care interventions to prevent falls in older adults Michael YL, et al "Primary care–relevant interventions to prevent falling in older adults: A systematic evidence review for the U.S. Preventive Services Task Force" Ann Intern Med 2010; 153: 815-825.

30. What Can We Do? Evidence-based guidelines stress: • Recognition of the risk factors that lead to increased falls • Assessment to identify those at risk for falls. • Intervening to address the modifiable risk factors

31. Screening for Falls in the Acute and Long Term Care Environments • Complete scheduled assessments with the screening tools designated by the facility’s fall protocol • Two frequently used fall screening tools • Hendrich II Fall Risk Module • Morse Falls Scale

32. Screening for Falls in the Community The American Geriatric Society (AGS) recommends providers ask about falls at least once a year • Have you: • Fallen two or more times? • Fallen and hurt yourself? • Been afraid that you would fall because of a balance or walking problem? If the answer is yes to any of these questions, a multifactorial fall risk assessment should be completed. • The report of a single fall requires (at minimum) a gait and balance evaluation.

33. Positive Screening . . . Now what? Regardless of whether the client is in an inpatient facility or in the community, more information is needed In order to intervene effectively, an in-depth assessment is needed to identify the problem area(s) What is included in a multi-factorial fall assessment?

34. Client’s Fall History • History of falls – Have you fallen before? What were the circumstances of your fall(s)? Have you had injuries resulting from a fall? • Medication review – What prescription and over the counter medications do you take? Do you use any herbal supplements? • History of relevant risk factors – Do you have acute or chronic medical problems such as an infection or arthritis?

35. Physical Observations • Cognitive Function – judgment, evidence of acute or chronic confusion • Sensory Deficits – vision and hearing • Cardiovascular Function – heart rate and rhythm, postural pulse, postural blood pressure • Musculoskeletal Function - muscle strength, gait, balance, mobility levels, reflexes, lower extremity joint function • Extremities – signs of trauma, examination of the feet and footwear

36. Functional Assessment • Independence in activities of daily living (ADL) skills • Katz Index of Independence of ADL • Need for assistive devices • Appropriate use of assistive devices currently in use • Exploration of fear related to falling

37. Environmental Assessment • Check for Safety: A Home Fall Prevention Checklist for Older Adults Developed by the CDC through support from the CDC and MetLife FoundationsRetrieved at: http://www.cdc.gov/HomeandRecreationalSafety/Falls/CheckListForSafety.html1/28/13 Check for Safety PDF

38. Gait Assessment • Frequently used tests of gait or balance include: • Get up and Gotest (Mathias, (1986); • Timed Up and Gotest (Podsiadlo et al,1991), • Berg Balance Scale(Berg et al, 1989), • Performance-Oriented Mobility Assessment(Tinetti 1986; Tinetti et al 1988). • Gait and Balance can readily be assessed by the “Get Up and Go Test” which is demonstrated on the following slide.

39. Gait Assessment

40. Gait Assessment • Patients who take less than 10 seconds are usually considered normal. • Patients who take longer than 30 seconds tend to need assistance with many mobility tasks.

41. Gait Abnormalities • Inability to stand without use of hands • Unsteadiness upon standing • Short steps • Asymmetry • Wide-based gait • Slow gait • Deconditioning, hip or knee pain • Orthostatic hypotension, balance problems, weakness • Weakness, Parkinson disease • Stroke, Arthritis • Fear, balance problems • Fear of Falling, weakness, PVD, COPD, CHF

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43. General Interventions for Fall Prevention • Acute or Long Term Care • Scheduled screenings to identify those at risk • Environmental Assessment to identify/correct hazards • Maintain client mobility • Educate caregivers (staff & family) • Individualized safety measures • Community • Annual screening (at minimum) • Medication review • Home hazard assessment • Educate client/caregivers • Address visual deficits

44. American Geriatric Society Clinical Practice Guideline Interventions - Level “A” • Evidence Based Practice Level “A” Interventions (Good evidence was found that the intervention improves health outcomes and the conclusion is that benefits substantially outweigh harm.) • Individualized Fall Risk Assessment • Identify Fall Risks • Home Environment Assessment by HCP • Home Environment Modification • Direct Implementation of Interventions by HCP • Exercise • Vitamin D Supplementation

45. American Geriatric Society Clinical Practice Guideline Interventions - Level “B” • Evidence Based Practice Level “B” Interventions (At least fair evidence was found that the intervention improves health outcomes and the conclusion is that benefits outweigh harm.) • Medication Modification • Cataract Surgery if Indicated • Treatment of Postural Hypertension • Dual Chamber Pacing if Indicated • To prevent syncope • PDF Version of Guidelines

46. US Preventive Services Task Force Community-dwelling adults: • In older, community-dwelling adults, interventions that appear effective in preventing falls include exercise or physical therapy and vitamin D supplementation. • In older, community-dwelling adults, interventions to prevent falls are not associated with significant adverse events. • Source link USPSTF

47. Exercise Programs (Level A) Strong recommendation for activities that increase balance, strength and gait training (AGS & USPSTF) • Numerous studies support the use of exercise programs in conjunction with other interventions • Campbell (1999), Steinberg (2000), Tinetti (1994), Clemson (2004), and Day (2002) • Exercise needs to be sustained for at least 6 months to be effective • AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons, January 2010. retrieved at http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2010/3-15-10

48. Exercise Programs • Physical Therapy for strengthening and balance and gait training • Evidenced based community health promotion programs such as A Matter of Balance, Otago, Stepping On, and Tai Chi: Moving for Better Balance • Others http://www.ncoa.org/improve-health/center-for-healthy-aging/falls-prevention/community-programs.html

49. Exercise Programs (Level A) http://go4life.nia.nih.gov/exercise-guide-video http://www.nia.nih.gov/HealthInformation/Publications/ExerciseGuide/default.htm

50. Exercise Programs (Level A) Yoga There is growing evidence that yoga can improve physical well-being, including balance, range of motion, blood pressure, pain, fatigue, and general health.