siobhan mcmahon rn gnp the college of st. scholastica st. mary’s duluth clinic, elder care the...
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SIOBHAN MCMAHON RN GNPTHE COLLEGE OF ST. SCHOLASTICA
ST. MARY’S DULUTH CLINIC, ELDER CARETHE ARROWHEAD AGENCY ON AGING
Interventions to reduce fall risk among older adults
Part I
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Objectives
• Review common risk factors of falls• Assess older adults for presence of fall
risk factors• Review Interventions that have been
proven to reduce fall risk • Implement additional fall-preventive
interventions in patient population you serve.
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Falls are a significant cause of injury, disability and death among older adult populations.
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Falls are a significant cause of injury, disability and death among older adult populations.
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Impact of falls
20-30% of those who fall sustain injury32% of those with fall related injury require
assistance with ADL(s)Fear of fallingDecreased physical activityDecreased social activity
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Impact of falls
Cost in 2000 $179 million (fatal falls) $19.3 billion (non fatal injurious falls)
Projected cost in 2020 $43.8 billion annually
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Causes and Risks of Falls
Environmental
Behavioral
Socioeconomic
Biological
WHO, 2008
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Environmental
ENVIRONMENTAL
Behavioral
Socioeconomic
Biological
Poor building design*
Slippery floors and stairs*
Loose Rugs*Insufficient
lighting*Cracked or uneven
sidewalks*
Risk Factors
WHO, 2008
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Biological
• Muscle Weakness*• Gait Changes*• Vision Impairment
(2.5)*• History of previous
fall (3.0)• Age (greater than
80)• Gender
Environmental
Behavioral
Socioeconomic
BIOLOGICAL
Risk Factors
WHO, 2008
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Behavioral
• Multiple medication use*
• Use of medication that acts on central nervous system*
• Lack of exercise*• Inappropriate
footwear*
Environmental
BEHAVIORA
L
Socioeconomic
Biological
Risk Factors
WHO, 2008
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Socioeconomic
Environmental
Behavioral
SOCIOECONOMIC
Biological
Inadequate housingLack of social
interaction*Lack of community
resources*Limited access to
health and social services*
Risk Factors
WHO, 2008
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Causes and Risks of Falls
Environmental
Behaviora
l
Socioeconomic
Biological
WHO, 2008
Risk factors are interactive
1 factor raises risk 27 %
4 factors raise risk 78%
Tinneti, Speechley, & Ginter (1998)
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Case Study
Jane DoeRecently admitted to the hospital via the ER after a fall.
She had planned to get the morning paper, located at the dining room table across the room. She lost her balance as she moved from the couch to the table and fell. She did not lose consciousness but sustained a hip fracture and many bruises.
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Screening
Have you had 2 or more falls in the prior 12 months?
Are you here because of a recent (acute) fall? Have you noticed any difficulty or changes
with your walking or balance?
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History of 1 fall in last year
Evaluate Gait and Balance Timed Up and Go Berg Balance Scale Performance Oriented mobility assessment
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Answers YES to any of the screening questions
• History of falls• Medication review• Gait, balance and mobility• Visual Acuity• Other neurological impairments• Muscle strength• Heart Rate and Rhythm• Feet and foot-ware• Environmental hazards
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Comprehensive Assessment
History of falls Frequency of fall Symptoms at the time of fall Previous injuries of fall
sequelae
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Comprehensive Assessment: Medication Review
• Anticonvulsants (e.g., dilantin)
• Antipsychotics (e.g. risperdal, seroquel, haldol)
• Anxiolytic (e.g. xanex, ativan, klonipin)
• Antiarrhythmics (procan, rhythmol, dig)
• Anti-depressant (e.g., prozac, celexa)
• Hypnotics (e.g. diphenydramine/ benadryl)
• Anti-vertigo or motion sickness (e.g. meclizine, dramamine)
• Pain relieving (e.g. darvocet, percocet)
4 or more medications
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Comprehensive assessment
• Gait, balance and mobility (Timed Get up and Go)– Hesitant start ?– Broad based ?– Path Deviation ?– Heels not clearing floor ?– Heels do not clear other foot ?– Cannot speed up without losing balance? – Turning difficulties?– Gait symmetry? – Sitting down in a chair? – Standing up from a chair?
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Timed Get up and Go
1. Person being screened starts in a seated position.1. Wearing sensory aids (e.g., glasses)2. Using assistive devices (e.g., walker, cane)
2. Place a visible object 8 feet away from the person being screened.3. Ask the person being screened to get up and walk around or to walk
the object 8 feet away (and then turn around) , and sit back down.
Walking time greater than 8.5 seconds or observations of abnormal gait or balance during test are associated with fall risk among
community dwelling older adults.
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Comprehensive Assessment
Vision
History of vision impairment?Regular visits to the
ophthalmologist? Vision aids? Functional vision? (e.g., able
to read magazine print; signs? )
Visual acuity (Snellen)
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Comprehensive assessment Additional neurological exam
Cognitive screen (mini cog) Cranial Nerves LE peripheral nerves Proprioception Reflexes Rigidity, bradykinesia, tremor Coordination
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Comprehensive Assessment
Muscle strength Quad strength
Using arms/ maneuvers to get out of chair? Chair rise (5 chair rises not using hands normally less
than 30 seconds; average is 11.5s) Range of motion
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Vital Signs
Vital Signs
Heart RateHeart RhythmBlood PressureOrthostatic Blood Pressure
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Feet and Foot-ware
Feet and Foot-ware Sensation Skin/Nails Circulation Shoes (fit, soles, comfort ?) Slippers (non-skid ?)
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ApartmentClutter ?Loose Cords? Loose Rugs?Adequate lighting?
EnvironmentalSafety
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Case Study
Jane DoeRecently admitted to the hospital via the ER after a fall. She
had planned to get the morning paper, located at the dining room table across the room. She lost her balance as she moved from the couch to the table and fell. She did not lose consciousness but sustained a hip fracture and many bruises.
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Case Study
HistoryLives in assisted living apartment; recently
moved from a home she has owned for 40 years
Widowed one year ago2 daughters; one in Duluth and another
living in the cities; both very supportive Loves to shop, visit with friends, garden,
walks (did) daily.
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Case Study
Jane DoeDescription of the Fall: Early am immediately moving from couch to
tableWearing slippersThinks she may have slipped and then was
unable to break her fallNo dizziness, vertigo, black out
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Medications Function
Lisinopril 10mg ASA 81 mg Multi vitamin daily
Tylenol PM 2 q HS
Independent with ADLs Independent with most
IADLS (daughter helps with medications and bills)
Continent Sleep pattern is interrupted
by repeated thoughts and memories about her husband (she misses him)
Use to shop a lot and exercise every day but now feeling too tired for that lately
Case Study: Jane Doe
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Physical Exam
BP laying down 122/80BP sitting up 130/70BP standing 118/80Heart rate 72 and
regularCN II-XII grossly intactNo bradykinesia,
tremor or rigiditySpeech is clearSensation intact
Gait is slow (healing hip fx)
TUG: NA (healing hip fx)
Chair stand (unable)Functional range of
motionMini cog: 3/3 recall;
clock draw perfectGeriatric Depression
Score 8/15
Case Study
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Environmental
Behaviora
l
Socioeconomic
Biological
• What is your assessment?
• Name some of the fall risk factors that Jane Has
• Would your evaluation in the Hospital be different for the NH or clinic?
• How will you communicate your assessment on the record?
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Falls
Risk factors include :grief related change
in sleep and physical activity patterns
de-conditioning and weakness
use of Benadryl for sleep
history of falls
Environmental
Behavioral
(decreased
activity, use of benadr
yl)
Socioeconomic
Biological
(sleep changes; effects of medicatio
ns; weakness)
Jane Doe
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Conclusions
• Individualize assessments in accordance with situation.
• Integrate screening and assessment into your everyday work.
• Use your resources to help with assessment. • If you find abnormalities or confusing aspects
of your assessment, collaborate and consult with family and other members of the IDT
PT/ OTPharm D
MDRN
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ReferencesCenters for Disease Control and Prevention. (2010a). Web-based injury statistics query and
reporting system (WISQARS) [online]. NCIPC, CDC (producer). Retrieved July 10, 2009, from www.cdc.gov/ncipc/wisqars
Centers for Disease Control and Prevention. (2010b). Wide-ranging online data for epidemiologic research, DATA2010 the Healthy People 2010 database; focus area: 22-physical activity and fitness. Retrieved July 10, 2009, from http://wonder.cdc.gov/scripts/broker.exe
Gillespie, L. D., Robertson, M. C., Gillespie, W. J., Lamb, S. E., Gates, S., Cumming R. G., et al. (2009). Preventing falls in older people living in the community. Cochrane Database of Systematic Reviews, 2, Art. No.: CD007146. DOI: 10.1002/14651858CD007146.pub2.
McInnes, E., & Askie, L. (2004). Evidence review on older people’s views and experiences of falls prevention strategies. Worldviews on Evidence-Based Nursing, 1(1), 20-37.
Rubenstein, L. Z. (2006). Falls in older people: Epidemiology, risk factors and strategies for prevention. Age and Ageing, 35(Suppl. 2), ii37-ii41.
Sleet, D. A., Moffett, D. B., & Stevens, J. (2008). CDC’s research portfolio in older adult fall prevention: A review of progress, 1985-2005, and future research directions. Journal of Safety Research, 39, 259-267.
Taylor, A. H., Cable, N. T., Faulkner, G., Hillsdon, M., Narici, M., & Van Der Bij, A. K. (2004). Physical activity and older adults: a review of health benefits and the effectiveness of interventions. Journal of Sports Sciences, 22(8), 703-725.
Yardley, L., & Smith, H. (2007a). A prospective study of the relationship between feared consequences of falling and avoidance of activity in community living older people. The Gerontologist, 42(1), 17-23.
World Health Organization. (2008). WHO global report on falls prevention in older age. Retrieved from http://whqlibdoc.who.int/publications/2008/9789241563536_eng.pdf