Fall Prevention in the PACE Environment

Robin Corsetto PT, MHA, CPHQ

Element Care

References

• Abdel-Rahman, E., Turgut, F., Turkmen, K., & Balogun, R. (2011). Falls in elderly hemodialysispatients. QJM: An International Journal of Medicine , 104: 829-838.

• Currie, L. (April, 2008). Patient Safety and Quality: An Evidence-Based Handbook for Nurses. (R. Hughes, Ed.) Rockville, MD: Agency for Healthcare Research and Quality.

• Dukas, L., Schacht, E., & Runge, M. (2010). Independent from muscle power and balance performance, a creatineine clearance below 65 ml/min is a significant and independet risk factor for falls and fall-related fractures in elderly men and women diagnosed with osteoporosis. Osteoporos Int , 21: 1237-1245.

• Ferris, M. (2008). Fall Prevention in Long-term Care: Practical Advice to Improve Care. Topics in Advanced Practice Nursing eJournal , 8(3).

• Kita, K., Hujino, K., Nasu, T., Kawahara, K., & Sunami, Y. (2007). A simple protocol for preventing falls and fractures in elderly individuals with musculoskeletal disease. Osteoporos Int , 18: 611-619.

• Patil SS, S. S. (2015). Risk factors for falls among elderly: A community-based study. International Journal of Health & Allied Sciences , 4 (3), 135-140.

• Shimada, H. S., Tiedemann, A., Kobayashi, K., Yoshida, H., & Suzuki, T. (2009). Which Neuromuscular or Cognitive Test is the Optimal Screening Tool to Predict Falls in Frail Community-Dwelling Older People? Gerontology , 55, 532-538.

Objectives

• to define the impact of falls on the elderly and describe the unique challenges to and opportunities of the PACE environment

• to describe the importance of a collaborative, interdisciplinary approach to assessment/re-assessment of fall risk factors and individualized interventions

• to recommend focus for data collection and tracking/trending of falls

Negative Effects of

Falls

INJURIES / DISABILITIES

LOSS OF INDEPENDENCE

HIGH COST

DEATH

NURSING HOME PLACEMENT

POOR QUALITY OF

LIFE

Prevention is Key

• Falls are multi-factorial and complex

• Major geriatric public health problem

• Where do we start?

PACE Model

• Opportunities

– Population

– Settings

– Time

• Challenges

– Self reports

– Settings

– Time

Research-Based: Japan

• 65% of falls occur during ambulation or when getting up from a chair or bed

• Best screening tool in frail older people to predict risk of falls

– Setting was similar to PACE

– Non-ambulatory persons excluded

– Feasibility & Validity

Research-Based: Japan

• 6 meter walking speed at a comfortable pace (CWS) best feasibility

• 6 meter walking speed at maximum pace (MWS)• Tandem walking test (TWT) – best independent

predictor; low practicability• Grip strength (GS) • Mental status questionnaire (MSQ)• Timed up-and-go test (TUG)• Chair stand tests (CST)• One leg standing test (OLS)• Functional reach test (FRT)

Japanese Study Conclusion

• Multi-factorial causes of falls

• Single mobility-related screening tool is an unrealistic goal for this population of community-based frail elders

• More research needed

Falls Assessments

• Johns Hopkins

• Morse Falls Scale

• MAHC 10

• Balance Assessments

• Mobility Assessments

Cognitive/ Behavioral

Visual Acuity

Weakness / Balance

Comorbidities

Environmental hazards

Mobility & Assistive Devices

Medications &

polypharmacy

Fall Risk Factors

The KEY to fall prevention is addressing each risk factor for each participant.

Fall Risk Factors: Comorbidities

• Diabetes / diabetic foot ulcer

• Parkinson’s disease

• Stroke

• Syncope

• Alzheimer’s disease

• Anemia

• Vitamin D deficiency (& with low creatinine clearance)

• Recent LE amputation

Fall Risk Factors: Visual Acuity

• Legally blind

• Lack of / not using glasses

• Glaucoma

• Cataracts

Fall Risk Factors: Environmental Hazards

• Trip hazards

– Rugs

– Cords

– Pets

– Poorly placed furniture

• Slip hazards

– Ice/snow

– Water on floor

– Tub/shower

Fall Risk Factors: Weakness & Balance

• Gait problems

• Impaired sensation

• New medical issues

• Postural hypotension

• Inability to perform ADLs

• Poor sitting/standing posture

• ROM impairment

• Decreased muscular strength

Fall Risk Factors: Mobility & Assistive Devices

• Lack of use

• Inappropriate use of

• Prosthesis

• Special shoes

• walker, cane, crutches, wheelchair

Fall Risk Factors: Cognitive/Behavioral

• Cognitive– Confusion

– Impaired orientation

– Misperception of functional ability

• Behavioral– Reckless wheelchair use

– Poor compliance

– Unable to adapt to changing environment

– Fear of falling

Fall Risk Factors: Medications/Polypharmacy

• Use of 4 or more prescription medications

• Use of any benzodiazepine or sedative-hypnotics

• Use of diuretics in hospital setting

Census-Based Research: India

• Clinical Exam with statistically relevant higher incidence of falls

• Medical factors with statistically relevant higher incidence of falls

• Factors that increased risk

• Significant association with use of antidepressants (sedative properties)

Research-Based: Germany

• Osteoporotic elderly men & women with a low creatinine clearance of <65 ml/min

• Significantly poorer performance in muscle and balance tests

• More falls and fractures

• More prone to be frequent fallers

Team Approach

• Medical Providers (MD/NP)– Acute illness– Diagnoses– Medication effects

• Nursing– Change in condition

• Rehab (PT/OT)– Increasing weakness– Gait disorder; need

for DME– Home Safety

• Social Worker/ Behavioral Health

– Substance abuse

– Alcohol use

– Assistance in the community

– Poor decision making

Safety / Falls Care Planning

Tailor the participant’s plan with consideration of:

• vitamin D supplementation

• Balance, strength and gait training

• Medication assessment

• TARGET issues involving any identified risk factors

Why Report Fall Events?

Tracking and trending allows us to recognize:

• Care differences

• Commonalities of culture/behavior

• Comparison with benchmarks

What may be useful for tracking & trending in PACE?

• Standardize definition of fall

• Standardize definition of injury levels

• Track/trend

– Location of Fall

– Root Cause of Falls by categories

– Repeat vs. One time fall

• Connect Outcomes/Cost

Location & Details

• Facilities

– Assisted Living Facility

– Skilled Nursing LTC vs. STC

• Time of day (relevant to shift/meals)

• Private Home

• Elderly Housing

• Community• # Self-reported

Root Cause of Fall

• Cognitive impairment• Poor decision making• Syncope• Medical (orthostatic/ post dialysis fatigue/

hypo-hyperglycemia/ low H&H)• Mechanical slip/trip (weather related?)• Drug / Alcohol• Acute Illness• Medication-related• End-of-Life decline

Outcomes / Cost

• No injury• Minor injury

– Requires monitoring (bruising/abrasions)– Requires first aid / treatment done in-house

• Moderate injury– Sent out for diagnostics (x-ray/CT) with no findings– ER visit required (sutures)

• Major injury– Fractures / head injury– Hospitalization– Level II

Actions Taken

• Home Safety Evaluation with/without modified environment

• Diagnostics• PT/OT evaluation with/without increased services or

equipment• Medication evaluation with/without change• RN assessment/monitoring• MD/NP assessment• Psych assessment• Increased home services• Admitted to skilled facility STR