Question

Need an Executive Summary/Thesis on: reduction of fall related injuries in memory care residents in a nursing home setting.

Answer 1

Falls and fall-related injuries among older, institutionalized adults are common problems, resulting in serious physical, psychological, and financial consequences for the people who have fallen, their family and friends, nursing home staff, and the larger community.

Around 30% of people aged 65 years or older living in the community and more than 50% of those living in residential care facilities or nursing homes fall every year and about 50% of these fall repeatedly. Nursing home residents older than 65 years of age and recording a rate of falls (falls/bed/year) of 1.5 are approximately three times more likely to fall than their community-dwelling peers.

Recognizing that risk factors for falls are multifactorial and interacting, providers require guidance on the components, intensity, dose, and duration for an effective fall and fall injury prevention program. Administrators of health care facilities require guidance on resources needed for these programs. Clear guidance does not exist for specifying the right combination of interventions to adequately protect specific at-risk populations, such as nursing home residents with dementia or osteoporosis. Staff education about fall prevention and resident fall risk assessment and reassessments has become part of standards of practice; however, the selection, specificity, and combination of fall prevention and injury protection interventions are not standardized.

Falls often lead to reduced functioning, which increases morbidity and mortality: around 20% of falls need medical attention, 5% result in fractures, severe head injuries, joint distortions and dislocations, and 5-10% in soft-tissue contusions and lacerations. Fall-induced injuries are the fifth leading cause of death in elderly adults and are one of the most common causes of longstanding pain and disability in this population: falls account for over 80% of injury-related admissions to hospital of people older than 65 years. Between 10% and 25% of nursing home falls result in fractures or hospital admissions.

The risk of falling increases dramatically with a number of risk factors, such as musculoskeletal problems, neurological diseases, psychosocial characteristics, functional dependency and drug use. Prevention is not easy because falls are complex events caused by a combination of intrinsic impairments and disabilities and, sometimes, environmental hazards.

Exposure to environmental hazards account for approximately 27% of all falls in long-term care. The most common fall hazards in Long Term Care (LTC) homes are: beds that are too high, poor lighting, slippery floors, lack of rest areas, and a lack of kick space under the bed, which is important for maintaining balance when rising to standing from a sitting position. It is logical to conclude that this may be a factor explaining why so many institutional falls occur in and around the bed.

The bedside is the most common location for falls, followed by the bathroom. Many falls are associated with transfers around the bed, and with toileting. The majority of falls happen during the day, mostly during times when care providers are less available, either due to peak care demands, or processes such as shift change. A high percentage of falls are un-witnessed. Men tend to fall more in long-term care, but women have higher rates of fracture associated with falls.

Fall management is an important part of a larger effort to move toward a more social model of care (i.e., person centered care) that acknowledges that quality of life is as important as (if not more important than) simply extending life.

Identifying risk and risk factors is very important to efficient targeting of falls prevention interventions. Application of a comprehensive falls risk assessment can be the basis for effective falls prevention for individuals, particularly those at increased risk.

Assessment Recommendations:
1. Prevention of Falls and Fall Injuries in the Older Adult
1. Assess fall risk on admission.
2. Risk factors to assess include:
• history of previous fall
• age
• gender
• medical conditions
• cognitive impairment
• balance
• gait
• ambulatory aids
• environmental hazards
• vision
• systolic hypotension, and
• total number of risk factors
3. Assess fall risk after a fall.
4. Conduct periodic medication reviews: residents taking psychotropic drugs or more than five medications should be identified as high risk.

2. Guidelines for the Prevention of Falls in Older Persons
1. Those who report a fall or recurrent falls, or demonstrate abnormalities of gait and/or balance should have a fall evaluation performed.
2. The fall evaluation should assess the following:
• history of fall circumstances
• identification of acute or chronic medical conditions
• medication review
• sensory evaluation (vision, neurological, lower limb sensation)
• environmental assessment and modification
• assistive device / walking aid review
• continence management
• gait, balance, mobility, and lower extremity muscle strength
• cardiovascular status: heart rate and rhythm, postural pulse and
pressure.

3. Prevention of Falls in Long-Term Care Facilities
1. Residents should be assessed on admission and re-assessed after a fall.
2. All persons admitted to LTC should undergo a comprehensive and individualized risk assessment of the broad range of intrinsic and extrinsic risk factors.
3. Assessment of medication history, cognition, strength, and balance, nutrition, meds and environmental hazards requires a multidisciplinary approach
4. Quick screening procedures or risk scales are not sufficient for LTC settings

Falls Risk Assessment:
There are two main goals for conducting a fall risk assessment:
1. To tailor interventions to individual risk profiles
2. To maximize resources by targeting interventions to those at greatest risk

Three Basic Categories of Fall Risk Assessment Tools
1. Multifactorial tools: series of questions that cover a wide range of risk factors
2. Functional mobility tools: assessment of gait, strength and/or balance
3. Environmental hazard checklists: potential hazards in a resident’s room or in the facility that are associated with slips, trips, and falls

Interventions That Decrease the Risk of Ralls and/or Fractures

Environmental modification
Older persons at increased risk of falls should have an environmental assessment of their room.

Periodic Medication Review and Withdrawal of Psychotropics
Residents who have fallen or are at risk for falling should have their medications reviewed. Those taking four or more medications, or taking psychotropic medications, should be classified as “high risk for falls”. Reduction of medications is an effective and prominent component of fall reducing interventions in long-term care and community-based studies. Benzodiazepines should be tapered and discontinued and doses of antipsychotics should be reduced if possible.

Assistive Devices
Assistive devices such as canes, walkers, safety poles or bathroom grab bars have demonstrated benefit when used as a component of multifactorial interventions. It is important that the resident is assessed for the proper type of devices, and receives training in correct use.

Vision care
Residents should have their vision formally assessed if they report any visual problems. Wearing corrective eyewear and treating remediable visual abnormalities can decrease the fall and fracture risk. In addition, environmental changes can be implemented which can compensate for vision problems; for example: a nightlight, motion light, bathroom light, or outlining the path to the bathroom with fluorescent tape.

Footwear
Improper footwear is responsible for about 20% of falls in long-term care. Slippers, high-heeled or narrow-soled shoes, bare feet, nylons, or sock feet can increase the risk of falls. There are certain footwear features that can decrease the risk of falls including, low-heel, hard-sole, lightweight walking or athletic shoes. In addition, non-slip socks are available for wearing to bed to decrease the risk of slipping for residents who get up through the night.
Residents should also be screened for foot pain and other foot problems, receive education and info about foot care and be referred to a podiatrist where indicated. A common misperception for safe footwear for an older adult is one with a thick sole.
In reality, a thinner sole with a good tread is preferable as the ability to sense the walking surface with the foot is reduced as a consequence of aging.

Resident and Family Education
Education has not demonstrated effectiveness as a single intervention to reduce falls and fractures in long-term care, but it is an essential component in an overall strategy. Residents and families should receive education on their level of fall risk, and interventions that can reduce their risk of falls and fractures, such as hip protectors, calcium, Vitamin D, bisphosphonates, proper footwear, and exercise.

Exercise
Individualized exercise programs, as a component of a multifactorial risk reduction strategy, can improve balance, strength, and bone density which leads to a decreased risk of falls and fractures. Lower limb strengthening combined with balance exercises has demonstrated the most effectiveness. Tai Chi is the only single exercise intervention effective for improving balance and decreasing falls.

Hip protectors
Hip protectors are effective in reducing the risk of hip fractures in older individuals but they do not decrease the risk of falling. It is recommended that those at risk for falls and fractures, and those with a fear of falling wear hip protectors. However, there are many barriers to using hip protectors, causing a low adherence rate. Many individuals report discomfort, In addition, there is a potential for skin irritation and breakdown. The user may not clearly understand the linkage between falls and hip protectors as a
form of prevention, which may explain the high dropout rate. Expert knowledge supports the position that wearing hip protectors can lead to incontinence. The adherence rate is improved by staff education.

Who should wear a hip protector?
• Osteoporosis and / or arthritis in the hip
• Fallen or at high risk for falls
• Previous hip fracture
• Unsteady walking; independent transfer
• And/or dementia

Bowel and Bladder Management Program
It is recommended that residents have an individualized toileting program to reduce the occurrence of unassisted transfers, the risks of infections or skin breakdown, and to prevent slipping in urine.

Staff Education
Contrary to findings in community-based falls prevention programs, staff education programs for falls prevention in long-term care are a beneficial component of a global falls prevention strategy.

Other interventions that may be of benefit in fall and fracture prevention
ID Bracelets, Signs or Tags for High-Risk Residents
There is currently insufficient information to conclude whether ID bracelets as a single intervention are effective in decreasing falls risk. However, no potential harm for its use has been identified and the costs for implementation are minimal. The use of ID bracelets and/or falls icons is an accepted practice in identifying high-risk residents as part of a multi-factorial risk reduction strategy.

Bed alarms
There is currently insufficient evidence regarding the effectiveness of bed alarms; however, there is no potential harm associated with their use. Bed and chair alarms are often recommended for use with cognitively impaired individuals and/or those who wander and/or those who cannot call for assistance with transfers or ambulation.