What is a fall
World Health Organization defines a fall as:
- “An event which results in a person coming to rest inadvertently on the ground or floor or other lower level”.
- There’s a challenge to an individual’s balance or strength > Ability to stay upright
Significance of falls
• Falls is a quality indicator for residential care: four selected quality indicators for home and residential care settings, specifically signs and symptoms of depression, pain, pressure ulcers and falls
• On an individual level falls are very significant for the elder, it impacts ADLs
• On a systemic level, falls are used as a quality indicator; once someone falls the hospital has to pay
• Falls are the #1 reason for hospitalizations of older people (81%)
• They can be quite striking; extremely fragile skin and takes a long time to heal
• Falls are also the top reason for injury among seniors seen in the ER
• Falls accounted for 60% of all reported ER visits among seniors, with an estimated 20% admitted to
the hospital
Epidemiology of fall-related injuries in older adults
Hip fractures • 23,000/yr in Canada • 25% die within one year • 50% lose independence • 95% caused by falls
Wrist fractures
• Similar in frequency to hip fractures
• 90% caused by falls
Traumatic brain injuries • 20,000/yr in Canda • 80% caused by falls • 41% of fall deaths • 2-fold increased in past decade
Spinal cord injuries
• 1,800/yr in Canada
• 50% caused by falls
How are falls studied?
- Examining the velocity of falling and how people may fall in certain ways that would lead to injuries of hips and wrists
- Recording how well people recover fro various movement patterns
- Can measure effectiveness of intervention in a controlled setting
Types of falls
Common types of falls
• Slips and trips
• Falls on stairs
• Falls from furniture
People fall when they are • Turning • Incorrect weight shifting • Transferring • Forward walking • Standing quietly • Sitting down
Etiology of falls
- Falls result from complex interactions between intrinsic and extrinsic factors
- Physiological
- Environmental
- Behavioural
Intrinsic risk factors for falls
- Advanced age
- Previous falls
- Muscle weakness
- Gait and balance problems
- Poor vision
- Postural hypotension
- Fear of falling
- Chronic conditions; arthritis, stroke, incontinence, diabetes, Parkinson’s, dementia
Extrinsic risk factors for falls
- Lack of stair handrails
- Poor stair design
- Lack of bathroom grab bars
- Dim lighting or glare
- Obstacles and tripping hazards
- Slippery or uneven surfaces
- Psychoactive medications
- Improper use of assistive devices
GOAL; reduce modifiable risk factors
Modifiable risk factors for falls
Risk factor (relative risk) • Muscle weakness (4.4x) • Gait and balance problems (2.9x) • Vision problems (2.5x) • Psychoactive medications (1.7x)
Multifactorial interventions to address and prevent falls is best
How do drugs contribute to falls?
- Decreased mental alertness
- Impaired cognitive function and/or judgment
- Impaired postural stability
- Hypotension
- Postural Hypotension
- Arrhythmias
Risk factors for significant injury due to falling
1) Current use of anticoagulants
- Slow down rate of clotting in blood to prevent heart attack
- But makes it slower for blood to stop bleeding so increased risk of injury
2) Patients wth osteoporosis
3) Post surgical patients
- Use of ansthesia or anaglesic
4) History of falls
Osteoporosis and falls
- A bone disease that occurs when the body loses too much bone, makes too little bone, or both
- As a result, bones become weak and may break from a fall
Risk factors:
• Older women are much more likely to develop osteoporosis than are men.
• Advanced age. The older you get, the greater your risk of osteoporosis.
• Race. You’re at greatest risk if white or Asian.
• Family history. Having a parent or sibling with osteoporosis
• Body frame size. Men and women who have small body frames tend to have a higher risk because they might have less bone mass to draw from as they age.
Prevention of falls in OAs; clinical practice guidelines
- Screen for Falls or Risk for Falling
- The screening for falls and risk for falling is aimed at preventing or reducing fall risk. - Evaluation of Gait and Balance
- Gait and balance deficits should be evaluated in older individuals reporting a single fall as a screen.
- E.g. Timed Up and Go Test - Determination of Multifactorial Fall Risk.
- A multifactorial fall risk assessment can reveal the factors that put an older adult at risk of falling and can help identify the most appropriate interventions. - Initiate Multifactorial or Multicomponent Interventions
- To Address Identified Risk(s) and Prevent Falls
Multifactorial approach to falls interventions
1) Minimize medications
2) Provide individually tailored exercise program
3) Treat vision impairment
4) Manage postural hypotension
5) Manage heart rate and rhythm abnormalities
6) Supplement vitamin D
7) Manage foot and footwear problems
8) Modify the home environment
9) Provide education and information
Environmental: clinical setting falls risks
- Cluttered path
- Spill on floor
- Cords
- Lighting too bright or too low
- Table far away from bed
- Bed at high awkward height
- Brake not one equipment and/or table or bed
- Sheets or blanket hanging off the bed loosely
Environmental: home setting falls risks
• Rugs • Bed skirts hanging on the ground • Glare from windows • Cluttered night stands with no room for light sources, or assistive devices (glasses) • Things that are out of reach • Toys/objects on the ground • Things in high places out of reach • Unsteady furniture • No hand rails or grab bars • Toilet too low • Too dim
Practice tips to reduce falls
- Ensure brakes are on for all gait aids
- When standing up a patient; slow and stabilize
- When transferring ask the patient “can you feel the chair behind your knees?” before allowing them to sit. They can also reach back and hold onto the arm rests
- Tell them what you’re doing
- Choose a chair with a firm back and arm rests so the older adults can easily get back out of the chair (e.g. appropriate height, width, etc.)
- We know when and why falls happen; be there to ensure safety.
Technologies to study and prevent falls
1) video camera that can do fall detection
2) Hip protectors; like goalie pads that sit on hips, when they fall hips are protected- can reduce injury with falls up to 40% but people don’t like the wear them
3) compliant flooring - cushioned flooring so when they fall they won’t experience significant injury because it has some give. expensive to do, a lot fo retrofitting to be done, not that common
4) wearable sensors, most popular technology for older adults; button you wear on necklace. But 75% of OA don’t like wearing it, identifer that they need help (stigma); they also don’t want to push the button, might mean they’ll never come home again
5) visual capabilities; falls detection using computer systems and sensors (in video cameras); systems separate fore from background and identify the ratio of the person with regards to the background; to see if person as fell and if they’re on the ground. issues with privacy, storage of information, ownership
Key messages from a fall risk reduction program
- Fall prevention is everyone’s responsibility
- Maintain a safe environment
- All inpatients are assessed for fall risk at admission
- Activate individualized interventions
- Use an inter-professional team approach
- Monitor for changes and reassess as needed
- Document and report any changes or fall events
- Educate the patient and family/SDM about fall prevention
Consequences of falls
- lasting discomfort
- decreased function
- imposing family and societal care burdens
- interventions for fall prevention can interfere with patient’s independence
- inability to rise, resulting in dehydration, pressure ulcers, and rhabdomyolysis
- functional decline
- healthcare utilization
How to translate falls evidence into patient care
- Should screen people over 65 for risk of falls if they have a history of falls or have unsteady gait or balance (up-and-go test, performance-oriented mobility assessment)
- assess and manage any risk factors the patient has for falling
- physical therapy and home safety modifications
- support for caregivers
- is a trade-off between safety for the person that is at risk for falls and maintenance of functional independence
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Geriatric nursing today37
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Frailty and functional decline44
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Common geriatric cases in the ER7
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Dehydration in older adults22
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Geriatric palliative care26
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Pain assessment and management in geriatric care41
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Falls21
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Urinary incontinence in older persons25
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Transitions from acute care to the community for OAs17
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Delirium, dementia, and depression83
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Older adults and cannabis use18
