Topic: Falls & Fall Risk Reduction.

Fall.FallRiskReductioninElderly.docxFalls

Falls are one of the most important geriatric syndromes and the leading cause of morbidity and mortality for people older than 65 years of age. In the United States, falls occur in one-third of adults 65 and older. Among older adults, falls are the leading cause of both fatal and nonfatal injuries and the most common cause of hospital admissions for trauma. Approximately 20% to 30% of people who fall suffer moderate to severe injuries (lacerations, hip fracture, traumatic brain injury [TBI]) (Centers for Disease Control and Prevention [CDC], 2015a; Gray-Micelli & Quigley, 2012). Estimates are that up to two-thirds of falls may be preventable (Lach, 2010).

Box 15.1 presents further data on falls.

Statistics on Falls and Fall-Related Concerns

· Up to 50% of hospitalized patients are at risk for falls and almost half of those who fall suffer an injury. Between 50% and 75% of nursing home residents fall annually, twice the rate of community-dwelling older adults.

· The death rate from falls is 40% higher for men than women.

· Rates of fall-related fractures among older adults are more than twice as high for women as for men.

· More than 95% of hip fractures among older adults are caused by falls. White women have significantly higher hip fracture rates than black women.

· Up to 25% of adults who lived independently before their hip fracture have to stay in a nursing home for at least 1 year after their injury.

· The direct medical costs of fall injuries are $31 billion annually. Hospital costs account for two-thirds of the total costs.

· Falls are considered a nursing-sensitive quality indicator.

Falls are considered a nursing-sensitive quality indicator. In acute care hospitals, patient falls are the most common incidents reported (Zhao & Kim, 2015). All falls in skilled nursing facilities are considered sentinel events and must be reported to the Centers for Medicare and Medicaid Services (CMS). The Joint Commission (TJC) has established national patient safety goals (NPSG) for fall reduction in all TJC-approved institutions across the health care continuum. CMS implemented a new policy in 2008 that eliminated the reimbursement to hospitals for treatment of injuries 202resulting from falls occurring during hospitalization (Zhao & Kim, 2015). Healthy People 2020 includes several goals related to falls (Box 15.2).

Safety Alert

Education on falls and fall risk reduction is an important consideration in the Quality and Safety Education for Nurses (QSEN) safety competency, which addresses the need to minimize risk of harm to patients and providers through both system effectiveness and individual performance. Safe and effective transfer techniques are an important component of safety measures.

Box 15.2 Healthy People 2020

Falls, Fall Prevention, Injury

• Reduce the rate of emergency department visits due to falls among older adults.

• Reduce fatal and nonfatal injuries.

• Reduce hospitalizations for nonfatal injuries.

• Reduce emergency department visits for nonfatal injuries.

• Reduce fatal and nonfatal traumatic brain injuries.

Consequences of Falls

Hip Fractures

More than 95% of hip fractures among older adults are caused by falls. Hip fracture is the second leading cause of hospitalization for older people, occurring predominantly in older adults with underlying osteoporosis. Hip fractures are associated with considerable morbidity and mortality. Recovery from hip fractures is complicated by the presence of multiple comorbid conditions and potentially avoidable problems such as weight loss, delirium, pain, falls, and incontinence (Popejoy et al., 2012).

Only 50% to 60% of patients with hip fractures will recover their pre-fracture ambulation abilities in the first-year post fracture. Older adults who fracture a hip have a five to eight times increased risk of mortality during the first 3 months after hip fracture. This excess mortality persists for 10 years after the fracture and is higher in men. Most research on hip fractures has been conducted with older women, and further studies of both men and racially and culturally diverse older adults are necessary.

Traumatic Brain Injury Older adults (75 years of age and older) have the highest rates of traumatic brain injury (TBI)-related hospitalization and death. Falls are the leading cause of TBI for older adults. Advancing age negatively affects the outcome after TBI, even with relatively minor head injuries.

Factors that place the older adult at greater risk for TBI include the presence of comorbid conditions, use of aspirin and anticoagulants, and changes in the brain with age. Brain changes with age, although clinically insignificant, do increase the risk of TBIs and especially subdural hematomas, which are much more common in older adults.

There is a decreased adherence of the dura mater to the skull, increased fragility of bridging cerebral veins, and increased subarachnoid space and atrophy of the brain, which results in more space within the cranial vault for blood to accumulate before symptoms appear (Timmons & Menaker, 2010).

While most TBIs occur from falls, older people may experience TBI with seemingly more minor incidents (e.g., sharp turns or jarring movement of the head). Some patients may not even remember the incident. In cases of moderate to severe TBI, there will be cognitive and physical sequelae obvious at the time of injury or shortly afterward that will require emergency treatment. However, older adults who experience a minor incident with seemingly lesser trauma to the head often present with more insidious and delayed symptom onset. Because of changes in the aging brain, there is an increased risk for slowly expanding subdural hematomas. Health professionals should have a high suspicion of TBI in an older adult who falls and strikes the head or experiences even a more minor event, such as sudden twisting of the head. For older adults who are receiving anticoagulant therapy and experience minor head injury with a negative computed tomography (CT) scan, a protocol of 24-hour observation followed by a second CT scan is recommended (Mendito et al., 2012).

Manifestations of TBI are often misinterpreted as signs of dementia, which can lead to inaccurate prognoses and limit implementation of appropriate treatment. Box 15.4 presents signs and symptoms of TBI.

Signs and Symptoms of Traumatic Brain Injury (TBI) in Older

· Adults Symptoms of Mild TBI

· Low-grade headache that will not dissipate

· Having more trouble than usual remembering things, paying attention or concentrating, organizing daily tasks, or making decisions and solving problems

· Slowness in thinking, speaking, acting, or reading

· Getting lost or easily confused

· Feeling tired all of the time, lack of energy or motivation

· Change in sleep pattern (sleeping much longer than usual, having trouble sleeping)

· Loss of balance, feeling light-headed or dizzy

· Increased sensitivity to sounds, lights, distractions

· Blurred vision or eyes that tire easily

· Loss of sense of taste or smell

· Ringing in the ears

· Change in sex drive

· Mood changes (feeling sad, anxious, listless, or becoming easily irritated or angry for little or no reason) Symptoms of Moderate to Severe TBI • Severe headache that gets worse or does not disappear

· Repeated vomiting or nausea

· Seizures

· Inability to wake from sleep

· Dilation of one or both pupils

· Slurred speech

· Weakness or numbness in the arms or legs

· Loss of coordination

· Increased confusion, restlessness, or agitation NOTE: Older adults taking blood thinners should be seen immediately by a health care provider if they have a bump or blow to the head, even if they do not have any of the symptoms listed here.

Fallophobia “ Fear of falling”

Even if a fall does not result in injury, falls contribute to a loss of confidence that leads to reduced physical activity, increased dependency, and social withdrawal.

(fallophobia) may cause a person to restrict his or her physical and social activities, leading to further functional decline, depression, social isolation, and decreased quality of life (Zhao & Kim, 2015).

Fear of falling is an important predictor of general functional decline and a risk factor for future falls (Hill et al., 2010; Rubenstein et al., 2003).

Nursing staff may also contribute to fear of falling in their patients by telling them not to get up by themselves or by using restrictive devices to keep them from independently moving. More appropriate nursing responses include assessing fall risk and designing individual interventions and safety plans that will enhance mobility and independence, as well as reduce fall risk.

Fall Risk Factors

Falls are a symptom of a problem and are rarely benign in older people. The etiology of falls is multifactorial; falls may indicate neurological, sensory, cardiac, cognitive, medication, or musculoskeletal problems or impending illness. Episodes of acute illness, infection, or exacerbations of chronic illness are times of high fall risk (Fig. 15.1).

Safety Alert

A history of falls is an important risk factor and individuals who have fallen have three times the risk of falling again compared with persons who did not fall in the past year. Recurrent falls are often the result of the same underlying cause but can also be an indication of disease progression (e.g., heart failure, Parkinson’s disease) or a new acute problem (e.g., infection, dehydration) (Rubenstein & Dillard, 2014).

 Risk factors can be categorized as either intrinsic or extrinsic. Intrinsic risk factors are unique to each individual and are associated with factors such as reduced vision and hearing, unsteady gait, cognitive impairment, acute and chronic illnesses, and effects of medications. Extrinsic risk factors are external to the individual and related to the physical environment and include lack of support equipment for bathtubs and toilets, height of beds, condition of floors, poor lighting, inappropriate footwear, and improper use of assistive devices.

Falls in the young-old and the more healthy old occur more frequently because of external reasons; however, with increasing age and comorbid conditions, internal and locomotor reasons become increasingly prevalent as factors contributing to falls. The risk of falling increases as the number of risk factors increases, and the majority of falls occur from a combination of intrinsic and extrinsic factors that combine at a certain point in time. “Most falls in hospitals result from interactions between person-specific risk factors, the physical environment, the riskiness of a person’s behavior, and the interactions between the patient and the hospital staff” (Basic & Hartwell, 2015, p. 1637).

In institutional settings, extrinsic factors such as limited staffing, the lack of toileting programs, and the use of restraints and side rails also interact to increase fall risk. In hospitals, inadequate staff communication and training, incomplete patient assessments and reassessments, environmental issues, incomplete care planning or delayed care provision, and an inadequate organizational culture of safety have been reported as factors contributing to falls.

Gait Disturbance

Gait disturbances affect between 20% and 50% of people older than 65 years, and are associated with a threefold increase in fall risk (Alexander, 2014). Marked gait disorders are not normally a consequence of aging alone but are more likely indicative of an underlying pathological condition. Arthritis of the knee may result in ligamentous weakness and instability, causing the legs to give way or collapse. Diabetes, dementia, Parkinson’s disease, stroke, alcoholism, and vitamin B deficiencies 205may cause neurological damage and resultant gait problems. The Hendrich II Fall Risk Model (Mathias et al., 1986) (Fig. 15.2) includes the Get-Up-and-Go Test, which can be used to assess mobility, gait, and gait speed. This test is useful in fall risk assessment as well. It is a practical assessment tool that can be adapted to any setting. The client is asked to rise from a straight-backed chair, stand briefly, walk forward about 10 feet, turn, walk back to the chair, turn around, and sit down. The test can be timed as well, and gait speed has been found to be a predictor of mobility. On the basis of the results of initial screening, older adults may need further evaluation.

Foot Deformities

Foot deformities and ill-fitting footwear also contribute to gait problems and potential for falls. Care of the feet is an important aspect of mobility, comfort, and a stable gait and is often neglected. Little attention is given to 206one’s feet until they interfere with walking and moving and ultimately the ability to remain independent. Foot problems are often unrecognized and untreated, leading to considerable dysfunction. As we age, feet are subjected to a lifetime of stress and may not be able to continue to adapt, and inflammatory changes in bone and soft tissue can occur. Many individuals are limited by foot problems; approximately 90% of adults 65 and older have some form of altered foot integrity such as nail fungus, dry skin, and corns and calluses (Andersen et al., 2010). Some older persons are unable to walk comfortably, or at all, because of neglect of corns, bunions, and overgrown nails. The ability to perform self-care of the feet may be difficult for elders with functional or cognitive impairments or vision problems. Other causes of problems may be traced to loss of fat cushioning and resilience with aging, diabetes, ill-fitting shoes, poor arch support, excessively repetitious weight-bearing activities, obesity, or uneven distribution of weight on the feet. Both diabetes and peripheral vascular disease (PVD) commonly cause problems in the lower extremities that can quickly become life-threatening. Estimates are that 20% of individuals with diabetes are admitted to hospitals because of foot problems and more than 60% of nontraumatic lower-limb amputations are performed in people with diabetes (Tewary et al., 2013).

Implications for Gerontological Nursing and Healthy Aging

Care of the foot takes a team approach, including the person, the nurse, the podiatrist, and the primary health care provider. Nursing care of the person with foot problems should be directed toward providing optimal comfort and function, removing possible mechanical irritants, and decreasing the likelihood of infection.

The nurse has the important function of assessing the feet for clues of functional ability and their owner’s well-being (Box 15.5).

Nurses can identify potential and actual problems and make referrals or seek assistance as needed from the primary care provider or podiatrist for any changes in the feet.

Foot Assessment Observation of Mobility

· Gait

· Use of assistive devices

· Footwear type and pattern of wear Past Medical History

· Neuropathies

· Musculoskeletal limitations

· Peripheral vascular disease (PVD)

· Vision problems

· History of falls

· Pain affecting movement Bilateral Assessment

· Color

· Circulation and warmth

· Pulses

· Structural deformities

· Skin lesions

· Lower-extremity edema

· Evidence of scratching

· Abrasions and other lesions

· Rash or excessive dryness

· Condition and color of toenails

Orthostatic and Postprandial Hypotension

Declines in depth perception, proprioception, and normotensive response to postural changes are important factors that contribute to falls. Clinically significant orthostatic hypotension (OH) is a common clinical finding in frail older adults. Among cognitively impaired individuals who reside in skilled nursing facilities, estimates are that 50% to 60% experience OH (Momeyer, 2014). Asymptomatic OH is common. Gray-Micelli and colleagues (2012) reported that loss of balance may be predictive of OH and should trigger assessment.

Orthostatic hypotension is considered a decrease of 20 mm Hg (or more) in systolic pressure or a decrease of 10 mm Hg (or more) in diastolic pressure with position change from lying or sitting to standing. However, these criteria may be too restrictive for some older adults (Gray-Micelli et al., 2012). The detection of orthostatic hypotension (OH) is of clinical importance to fall prevention because OH is treatable. Evidence-based standards of care for fall prevention require OH blood pressure assessment among older adults.

Postprandial hypotension (PPH) occurs after ingestion of a carbohydrate meal and may be related to the release of a vasodilatory peptide. PPH is more common in people with diabetes and Parkinson’s disease but has been found in approximately 25% of persons who fall. Lifestyle modifications such as increasing water intake before eating or substituting six smaller meals daily for three larger meals may be effective, but further research is needed (Luciano et al., 2010). All older persons should be cautioned against sudden rising from sitting or supine positions, particularly after eating.

Cognitive Impairment The presence of neurocognitive disorders, such as dementia and delirium, increases risk for falls twofold, and individuals with dementia are also at increased risk of major injuries (fracture) related to falls. Fall risk assessments may need to include more specific cognitive risk factors, and cognitive assessment measures, especially for delirium, may need to be more frequently scheduled for at-risk individuals (Eshkoor et al., 2014; Gray-Micelli et al., 2010).

Vision and Hearing

Formal vision assessment is also an important intervention to identify remediable visual problems. Although a significant relationship exists between visual problems and falls and fractures, little research has been conducted on interventions for visual problems as part of fall risk–reduction programs. Poor visual acuity, reduced contrast sensitivity, decreased visual field, cataracts, and use of nonmitotic glaucoma medications have all been associated with falls. Hearing ability is also directly related to fall risk. For someone with only a mild hearing loss, there is a threefold increased chance of having falls (Lin & Ferrucci, 2012).

Medications

Medications implicated in increasing fall risk include those causing potentially dangerous side effects including drowsiness, mental confusion, problems with balance, loss of urinary control, and sudden drops in blood pressure with standing. These include psychotropics (benzodiazepines, sedative-hypnotics, antidepressants, neuroleptics), opioids, antiarrhythmics, digoxin, antihypertensives, and diuretics (Gray-Micelli & Quigley, 2012; Tinetti et al., 2014). All medications, including over the counter (OTC) and herbal medications, should be reviewed and limited to those that are absolutely essential. Patient teaching should be provided related to fall risk, appropriate dosing, and drug-drug and drug-alcohol interactions.

Implications for Gerontological Nursing and Healthy Aging

Screening and Assessment

The American Geriatrics Society/British Geriatrics Society Clinical Practice Guideline: Prevention of Falls in Older Persons (2010) recommends that fall risk assessment be an integral part of primary health care for the older person. All older individuals should be asked whether they have fallen in the past year and whether they experience difficulties with walking or balance. In addition, ask about falls that did not result in an injury and the circumstances of a near-fall, mishap, or misstep because this may provide important information for prevention of future falls. Older people may be reluctant to share information about falls for fear of losing independence, so the nurse must use judgment and empathy in eliciting information about falls, assuring the person that there are many modifiable factors to increase safety and help maintain independence. Comprehensive fall assessments include the following components: cognitive, nutrition, environment, medications, pathological conditions, functional assessment, gait, feet and footwear, home safety, and a complete physical examination (including vision and hearing, as well as musculoskeletal and cardiovascular status).

Screening and Assessment in Hospital/Long-Term Care

Individuals admitted to acute or long-term care settings should have an initial fall assessment on admission, after any change in condition, and at regular intervals during their stay. Assessment is an ongoing process that includes multiple and continual types of assessment, reassessment, and evaluation following a fall or intervention to reduce the risk of a fall. “

Assessment includes:

(1) assessment of the older adult at risk

(2) nursing assessment of the patient following a fall

(3) assessment of the environment and other situational circumstances upon admission to a health care facility

(4) assessment of the older adult’s knowledge of falls and their prevention, including willingness to change behavior, if necessary, to prevent falls” (Gray-Micelli, 2008, p. 164) (Table 15.1).

Assessment Strategy Behavior

(1) History Obtain background about unsafe behavior from patient, family, and prior caregivers (e.g., nursing home staff).

(2) Physiological factors Assess for sedation levels; pain; electrolyte disturbances; infection; orthostatic hypotension; syncope; urinary symptoms or urinary or fecal retention; inadequate sleep; and difficulties with walking, balance, or mobility.

(3) Psychological concerns Assess communication ability (i.e., in regard to stroke, dementia, and different primary language); depression; anxiety; impulsivity; agitation; fear; grief; posttraumatic stress disorder; substance abuse, including drugs, alcohol, or nicotine; and stressors, support systems, and coping strategies.

(4) Medications Identify medications that may contribute to confusion, delirium, movement disorders, and falls, such as reaction to a new medication or adverse reaction or drug interaction.

(5) Environment Examine bed appropriateness and safety, medical devices and necessity of use (e.g., ventilator tube, IV, urinary catheter), equipment and furniture (e.g., IV pole, bedside commode, bedside chair, tables, trapeze), lighting, noise levels, room temperature, and floor surface.

An interprofessional team (physician or nurse practitioner, nurse, risk manager, physical and occupational therapists, and other designated staff) should be involved in planning care on the basis of findings from an individualized assessment. Nurses bring expert knowledge of patient activities, abilities, and needs from a 24-hours-per-day, 7-days-per week perspective to help the team implement the most appropriate interventions and evaluate outcomes.

Fall Risk Assessment Instruments

Fall risk is formally assessed through administration of fall risk tools. However, current literature (Degelau et al., 2012) supports using the following three questions to determine fall risk:

(1) Has the patient fallen in the past year?

(2) Does the patient look like he or she is going to fall (does the patient have clinically detected gait/balance abnormalities)?

(3) Does the patient have 208additional risk factors for injurious falls (e.g., osteoporosis, anticoagulant therapy)?

Fall risk assessment instruments are still commonly included in fall prevention interventions; instruments that are utilized need to be reliable and valid and nurses need to use them judiciously (Gray-Micelli & Quigley, 2012). Often, these instruments are completed in a routine manner and risk factors are not identified or may not be known because of lack of assessment and knowledge of the individual’s history. Additionally, so many patients are identified as high risk that nurses may become desensitized and have difficulty prioritizing interventions (Harrison et al., 2010; Lach, 2010).

The National Center for Patient Safety recommends the Morse Falls Scale, but not for use in long-term care (Box 15.3).

The Performance-Oriented Mobility Assessment (Tinetti, 1986) is a well-validated tool. The Hendrich II Fall Risk Model (Hendrich et al., 2003) (see Fig. 15.2) is recommended by the Hartford Foundation for Geriatric Nursing. This instrument has been validated with skilled nursing and rehabilitation populations and is also easy to use in the outpatient setting. In the skilled nursing facility, the Minimum Data Set (MDS 3.0) includes information about history of falls and hip fractures, as well as an assessment of balance during transitions and walking (moving from seated to standing, walking, turning around, moving on and off toilet, and transfers between bed and chair or wheelchair) (see Chapter 8).

Fall risk assessments provide first-level assessment data as the basis for comprehensive assessment, but comprehensive post fall assessments (PFAs) (Box 15.6) must be used to identify multifactorial risk factors as well as complex fall and injury risk factors in those who have fallen (Gray-Micelli & Quigley, 2012). It is very important that all assessment data reported concerning an individual’s risk for falls be tailored with individual assessment so that appropriate fall risk–reduction interventions can be developed, and modifiable risk factors identified and managed.

Post fall Assessment Suggestions

Initiate emergency measures as indicated.

· History

· Description of the fall from the individual or witness

· Individual’s opinion of the cause of the fall

· Circumstances of the fall (trip or slip)

· Person’s activity at the time of the fall

· Presence of comorbid conditions, such as a previous stroke, Parkinson’s disease, osteoporosis, seizure disorder, sensory deficit, joint abnormalities, depression, cardiac disease

· Medication review

· Associated symptoms, such as chest pain, palpitations, light-headedness, vertigo, loss of balance, fainting, weakness, confusion, incontinence, or dyspnea

· Time of day and location of the fall

· Presence of acute illness

Physical Examination

· Vital signs: postural blood pressure changes, fever, or hypothermia

· Head and neck: visual impairment, hearing impairment, nystagmus, bruit

· Heart: arrhythmias or valvular dysfunction

· Neurological signs: altered mental status, focal deficits, peripheral neuropathy, muscle weakness, rigidity or tremor, impaired balance

· Musculoskeletal signs: arthritic changes, range of motion (ROM) changes, podiatric deformities or problems, swelling, redness or bruises, abrasions, pain on movement, shortening and external rotation of lower extremities

Functional Assessment

· Functional gait and balance: observe resident rising from chair, walking, turning, and sitting

· Balance test, mobility, use of assistive devices or personal assistance, extent of ambulation, restraint use, prosthetic equipment

· Activities of daily living: bathing, dressing, transferring, toileting

Environmental Assessment

· Staffing patterns, unsafe practice in transferring, delay in response to call light

· Faulty equipment

· Use of bed, chair alarm

· Call light within reach

· Wheelchair, bed locked

· Adequate supervision

· Clutter, walking paths not clear

· Dim lighting

· Glare

· Uneven flooring

· Wet, slippery floors

· Poorly fitted seating devices

· Inappropriate footwear

· Inappropriate eyewear

Post fall Assessment

Determination of the reason(s) a fall occurred (post fall assessment [PFA]) is vital and provides information on underlying fall etiologies so that appropriate plans of care can be instituted. Incomplete analysis of the reasons for a fall can result in repeated incidents. The purpose of the PFA is to identify the clinical status of the person, verify and treat injuries, identify underlying causes of the fall when possible, and assist in implementing appropriate individualized risk-reduction interventions. For falls that happen outside the hospital or skilled nursing facility, individuals can complete the “Story of Your Falls” (see Box 15.3) to provide post fall assessment information.

Components of the PFA

PFAs include a fall-focused history; fall circumstances; medical problems; medication review; mobility assessment; vision and hearing assessment; neurological examination (including cognitive assessment); and cardiovascular assessment (orthostatic blood pressure [BP], cardiac rhythm irregularities) (Gray-Micelli & Quigley, 2012). If the older adult cannot tell you about 209the circumstances of the fall, information should be obtained from staff or witnesses. Because complications of falls may not occur immediately, all patients should be observed for 48 hours after a fall and vital signs and neurological status monitored for 7 days or more, as clinically indicated. Standard “incident report” forms do not provide adequate post fall assessment information. The Department of Veterans Affairs National Center for Patient Safety provides comprehensive information about fall assessment, fall risk reduction, and policies and procedures (Box 15.3).

Interventions

Lach (2010) reminds us that “while there is much that the nurse can do to manage falls, it may be unrealistic to think that they can be eliminated” (p. 151). Fall risk–reduction programs are a shared responsibility of all health care providers caring for older adults. Choosing the most appropriate interventions to reduce the risk of falls depends on appropriate assessment at various intervals depending on the person’s changing condition and tailoring interventions to individual cognitive function and language (American Geriatrics Society and British Geriatrics Society, 2010a,b). A one-size-fits-all approach is not effective and further research is needed to determine the type, frequency, and timing of interventions best suited for specific populations. Education about fall prevention is an important nursing intervention for patients, families, and the community. The CDC’s STEADI (Stopping Elderly Accidents, Deaths & Injuries) Tool Kit is a valuable resource for providers and older adults and includes excellent teaching materials and fall prevention information (http://www.cdc.gov/steadi/about.html) (Box 15.3).

Fall Risk–Reduction Programs

There is some evidence to support the effectiveness of multicomponent fall risk–reduction strategies in many settings to reduce fall risks (Alexander, 2014; Cameron et al., 2010; Gillespie et al., 2012; Lee et al., 2013; Miake-Lye et al., 2013; Quigley & White, 2013; Tinetti et al., 2008). Randomized controlled trial evidence also suggests that single targeted interventions (e.g., exercise 210programs) might be as effective as multifactorial interventions (Campbell & Robertson, 2013). Frick and colleagues (2010) agree and suggest that multifactorial approaches aimed at all older people, or high-risk elders, are not necessarily more cost-effective or more efficacious than focused intervention approaches and further research is needed. The optimal bundle of interventions is not established, but common components include risk assessment, patient and staff education, bedside signs and wristband alerts, footwear assessment, scheduled and supervised toileting programs, and medication reviews (Miake-Lye et al., 2013).

The components most commonly included in efficacious interventions are shown in Box 15.7

Suggested Components of Fall Risk–Reduction Interventions

• Adaptation or modification of the home environment

• Withdrawal or minimization of psychoactive medications

• Withdrawal or minimization of other medications

• Management of orthostatic hypotension

• Continence programs such as prompted voiding

• Management of foot problems and footwear

• Exercise, particularly balance, strength, and gait training

• Staff and patient education

Each institution should design strategies to meet organizational needs and to match patient population needs and clinical realities of the staff (Ireland et al., 2010). Programs that utilize a system-level quality improvement approach, including educational programs for staff, realized a decrease in fall rate of 5.8% in hospitals (Box 15.8). Examples of effective programs include Acute Care of the Elderly (ACE) units, Nurses Improving Care for Healthsystem Elders (NICHE), and the Geriatric Resource Nurse (GRN) model (Gray-Micelli & Quigley, 2012) (see Chapter 5).

The Hospital Elder Life Program (HELP) is another valuable resource in fall prevention in the hospital (see Box 15.3).

System-Level Interventions for Fall Risk Reduction in Acute Care

· Nurse Champions

· Teach Backs (all patients and families receive education about their fall and injury risks)

· Comfort Care and Safety Rounds

· Safety Huddle Post Fall

· Protective Bundles: Patients with risk factors for serious injury, such as osteoporosis, anticoagulant use, and history of head injury or falls, are automatically placed on high fall risk precautions and interventions to reduce risk of serious injury

· Bundles may include interventions such as bedside mat on floor at side of bed, height-adjustable bed, helmet use, hip protectors, comfort and safety rounds

Environmental Modifications

Environmental modifications alone have not been shown to reduce falls, but when included as part of a multifactorial program, they may be of benefit in risk reduction. However, a home safety assessment and modification interventions have been shown to be effective in reducing the rates of falls in community-dwelling older adults, especially for individuals at high risk of falling and those with visual impairments. It is recommended that home safety interventions be delivered by an occupational therapist (American Geriatrics Society/British Geriatrics Society, 2010a,b; Gillespie et al., 2012).

The CDC provides a home fall prevention checklist (Box 15.3).

In institutional settings, the patient care environment should be assessed routinely for extrinsic factors that may contribute to falls and corrective action taken. Patient activities that contribute to falls include walking, transferring, and urinary and bowel elimination needs (Zhao & Kim, 2015). The majority of falls in acute care occur in patient rooms followed by bathrooms and hallways. Patients should be able to access the bathroom or be provided with a bedside commode, routine assistance to toilet, and programs such as prompted voiding (see Chapter 12). Shift change periods and evening and night shifts have also been associated with increased inpatient falls and supervision must be available during these times.

Assistive Devices

Research on multifactorial interventions including the use of assistive devices has demonstrated benefits in fall risk reduction. Many devices are available that are designed for specific conditions and limitations. Physical therapists provide training on use of assistive devices, and nurses can supervise correct use. Improper use of these devices can lead to increased fall risk. For the community-dwelling individual, Medicare may cover up to 80% of the cost of assistive devices with a written prescription. New technologies such as canes that “talk” and provide feedback to the user, sensors that detect 211when falls have occurred or when risk of falling is increasing, and other developing assistive technologies hold the potential to significantly improve functional ability, safety, and independence for older people (Rantz et al., 2008) (see Chapter 16).

Safe Patient

Handling Lifting, transferring, and repositioning patients are the most common tasks that lead to injury for health care staff and patients in hospital and nursing home environments. Handling and moving patients offer multiple challenges because of variations in size, physical abilities, cognitive function, level of cooperation, and changes in condition.

Nelson and Baptiste (2004) recommend the following evidence-based practices for safe patient handling:

(1) patient handling equipment/devices;

(2) patient-care ergonomic assessment protocols;

(3) no-lift policies;

(4) training on proper use of patient handling equipment/devices; and

(5) patient lift teams.

Key aspects of patient assessment to improve safety for patients and staff are presented in Box 15.9.

Box 15.9 Tips for Best Practice Assessment of Safe Patient Handling

· Ability of the patient to provide assistance

· Ability of the patient to bear weight

· Upper extremity strength of the patient

· Ability of the patient to cooperate and follow instructions

· Patient height and weight

· Special circumstances likely to affect transfer or repositioning tasks, such as abdominal wounds, contractures, pressure ulcers, presence of tubes

· Specific physician orders or physical therapy recommendations that relate to transferring or repositioning patients (e.g., knee or hip replacement precautions).

Wheelchairs

Wheelchairs are a necessary adjunct at some level of immobility and for some individuals, but they are overused in nursing homes, with up to 80% of residents spending time sitting in a wheelchair every day. Often, the individual is not assessed for therapeutic treatment and restorative ambulation programs to improve mobility and function. Improperly maintained or ill-fitting wheelchairs can cause pressure ulcers, skin tears, bruises and abrasions, and nerve impingement, and they account for 16% of nursing home falls (Gavin-Dreschnack et al., 2010). It is important that a professional evaluate the wheelchair for proper fit and provide training on proper use, as well as evaluate the resident for more appropriate mobility and seating devices and ambulation programs. There are many new assistive devices that could replace wheelchairs, such as small walkers with wheels and seats. If the person is unable to ambulate without assistance, the person should be seated in a comfortable chair with frequent repositioning and wheelchairs should be used for transport only.

Osteoporosis Treatment/Vitamin D Supplementation

Other potential interventions for fall risk reduction include assessment and treatment of osteoporosis to reduce fracture rates (see Chapter 21). Older people with osteoporosis are more likely to experience serious injury from a fall. The American Geriatrics Society recommends vitamin D supplementation of at least 1000 international units, as well as calcium supplementation, to community-dwelling and older adults residing in institutionalized settings to reduce the risk of fractures and falls (AGS, 2014a).

Hip Protectors

The use of hip protectors for prevention of hip fractures in high-risk individuals may be considered; there is some evidence that hip protectors have an overall effect on rates of hip fracture (Quigley et al., 2010), but further research is needed to determine their effectiveness. Compliance has been a concern related to the ease of removing them quickly enough for toileting, but newer designs that are more attractive and practical may assist with compliance issues (Willy & Osterberg, 2014).

Alarms/Motion Sensors

Alarms, either personal or chair/bed, are often used in fall prevention programs. There has been no research to support their effectiveness in prevention of a fall and “at best, it can shorten ‘rescue time’” (Willy & Osterberg, 2014, p. 29). Some have suggested that the use of these alarms may increase patient agitation, especially in cognitively impaired individuals, impede functional status, and negatively impact feelings of dignity among older adults in nursing homes. The use of alarms may be more for the needs of the staff rather than the patients (Crogan & Dupler, 2014; Willy & Osterberg, 2014). Silent alarms, visual or auditory monitoring systems, motion detectors, and physical staff presence may be more effective. A recent study reported that use of motion sensors inside patient rooms may be a viable, cost-efficient, unobtrusive solution to prevent and detect falls (Rantz et al., 2014).

Restraints and Side Rails. Definition and History

A physical restraint is defined as any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. A chemical restraint is when a drug or medication is used as a restriction to manage the patient’s behavior or restrict the patient’s freedom of movement and is not a standard treatment or dosage for the patient’s condition. Historically, restraints and side rails have been used for the “protection” of the patient and for the security of the patient and staff. Originally, restraints were used to control the behavior of individuals with mental illness considered to be dangerous to themselves or others (Evans & Strumpf, 1989).

Research over the past 30 years by nurses such as Lois Evans, Neville Strumpf, and Elizabeth Capezuti has shown that the practice of physical restraint is ineffective and hazardous. The use of physical restraints in long-term care settings was effectively addressed almost 25 years ago in these facilities. The Joint Commission and the Centers for Medicare and Medicaid Services (CMS) have focused on restraint reduction strategies in acute care over the past 10 to 15 years but studies continue to document that it is routine practice (Lach & Leach, 2016).

Consequences of Restraints

Physical restraints, intended to prevent injury, do not protect patients from falling, wandering, or removing tubes and other medical devices. Physical restraints may actually exacerbate many of the problems for which they are used and can cause serious injury and death, as well as emotional and physical problems. Physical restraints are associated with higher death rates, injurious falls, nosocomial infections, incontinence, contractures, pressure ulcers, agitation, and depression.

The use of restraints is a great source of physical and psychological distress to older adults and may intensify agitation and contribute to depression. For some older people, especially those with a history of trauma (such as that induced by war, rape, or domestic violence), side rails may cause fear and agitation and a feeling of being jailed or caged (Sullivan-Marx, 1995; Talerico & Capezuti, 2001).

Side Rails

Side rails are no longer viewed as simply attachments to a patient’s bed but are considered restraints with all the accompanying concerns just discussed. Side rails are now defined as restraints or restrictive devices when used to impede a person’s ability to voluntarily get out of bed and the person cannot lower them by themselves. Restrictive side rail use is defined as two full-length or four half-length raised side rails. If the patient uses a half- or quarter-length upper side rail to assist in getting in and out of bed, it is not considered a restraint (Talerico & Capezuti, 2001). CMS requires nursing homes to conduct individualized assessments of residents, provide alternatives, or clearly describe the need for restrictive side rails (Box 15.3).

Restraint-Free

Care Restraint-free care is now the standard of practice and an indicator of quality care in all health care settings, although transition to that standard is still in progress, particularly in acute care settings. Physical restraint use in acute care is now predominantly in intensive care units (ICUs), particularly for patients with medical devices and those with delirium. Older adults with delirium have higher risks of being restrained than other patients. Both the American Geriatrics Society and the American Board of Internal Medicine recommend that physical restraints should not be used to manage behavioral symptoms of hospitalized older adults with delirium (American Geriatrics Society, 2014b).

Further research is needed in ICU settings to determine the best strategies to manage delirium (see Chapter 25). Daily evaluation of the necessity of medical devices (intravenous lines, nasogastric tubes, catheters, endotracheal tubes), as well as securing or camouflaging (hiding) the device, is important (American Geriatrics Society/British Geriatrics Society, 2010a,b; Bradas et al., 2012). A decision algorithm for promoting restraint-free care in acute care is presented in Fig. 15.3. Evidence-based protocols on physical restraints and other resources on restraint alternatives can be found in Box 15.3.

Flaherty (2004) remarked that a “restraint-free environment should be held as the standard of care and anything less is substandard. The fact that it is done in some European hospitals (Bradas et al., 2012; de Vries et al., 2004) and in some U.S. hospitals, even among delirious patients, and in skilled nursing facilities should be evidence enough that it can be done everywhere” (p. 919). Implementing best practice nursing in fall risk reduction and restraint-free care is a complex clinical decision-making process and calls for recognition, assessment, and intervention for physical and psychosocial concerns contributing to patient safety, knowledge of restraint alternatives, interdisciplinary teamwork, and institutional commitment.

Removing restraints without careful attention to underlying fall risk factors and alternative strategies can 214jeopardize safety. The use of advanced practice nurse consultation in implementing alternatives to restraints has been most effective (Bourbonniere & Evans, 2002; Capezuti, 2004; Wagner et al., 2007). Important areas of focus derived from research on advanced practice nurse consultation are presented in Box 15.10. Many of the suggestions on safety and fall risk reduction in this chapter can be used to promote a safe and restraint-free environment.

Suggestions from Advanced Practice Nursing Consultation on Restraint-Free Fall Prevention Interventions

· Compensating for memory loss (e.g., improving behavior, anticipating needs, providing visual and physical cues)

· Improving impaired mobility; reducing injury potential

· Evaluating nocturia/incontinence; reducing sleep disturbances

· Implementing restraint-free fall prevention interventions based on conducting careful individualized assessments; what works for one individual may not necessarily be effective for another.

Implications for Gerontological Nursing and Healthy Aging

Falls are a significant geriatric syndrome, and nurses need to be knowledgeable about fall risk factors and fall risk–reduction interventions in all settings. Health promotion interventions to maintain fitness and mobility; appropriate assessment of fall risk; teaching older adults, their caregivers, and staff about fall risk factors; fall risk–reduction interventions; and restraint–free care are important nursing responses. Accidents and injuries among older adults in all settings are significant in terms of morbidity and mortality and using evidence-based practice can ensure improvement of many modifiable and preventable injuries, as well as mobility limitations and functional decline.

Key Concepts

· Falls are one of the most important geriatric syndromes and the leading cause of morbidity and mortality for people older than 65 years of age.

· The risk of falling increases with the number of risk factors. Most falls occur from a combination of intrinsic and extrinsic factors that unite at a certain point in time.

· Fall risk assessments provide first-level assessment data as the basis for a comprehensive assessment. Post fall assessments (PFAs) must be used to identify multifactorial fall risk factors as well as fall risk factors in those who have previously fallen.

· Physical restraints, intended to prevent injury, do not protect patients from falling, wandering, or removing tubes and other medical devices. Physical restraints may actually exacerbate many of the problems for which they are used and can cause serious injury and death, as well as physical and emotional problems.

• Restraint-appropriate care is the standard of practice in all settings and knowledge of restraint alternatives and safety measures is essential for nurses.