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Guide to Action to Prevent Guide to Action to Prevent Falls (GTA)Falls (GTA)
Community version – in useCommunity version – in useCare Home version – under evaluationCare Home version – under evaluationDementia version – in developmentDementia version – in development
Robertson K, Logan P, Conroy S, Dods V, Gordon A, Challands L, et al. Thinking Falls- Taking Action: development of a Guide to Action for Falls Prevention British Journal of Community Nursing 2010;15(8):406 - 410.Robertson K, Logan P, Ward M, Pollard J, Gordon A, Williams W, Watson J. Thinking falls-taking action: a falls prevention tool for care homes.Br J Community Nurs. 2012 May;17(5):206-9Logan, PA; Coupland, CAC; Gladman, JRF, et al Community falls prevention for people who call an emergency ambulance after a fall: randomised controlled trial. . British Medical Journal 2010; 340 c2102
Professor Pip LoganProfessor Pip LoganDivision of Rehabilitation & AgeingDivision of Rehabilitation & AgeingUniversity of NottinghamUniversity of Nottingham
Developing the GTA
Group of clinicians, social services, fire service, local authorities, older people, commissioners, researchers 2008- to date
Incorporates clinical guidelines, research findings, clinical expertise
Checklist outlining 37 risk factors and recommended interventions
Training by falls specialists: Two hours, groups 4-8, interactive session
Intervention manual, GTA forms, falls incident record sheet
FALLS HISTORY√
MEDICAL HISTORY√
MOVEMENT & ENVIRONMENT√
PERSONAL√
History of FallsHistory of falls prior to admission to
the care homeFalls reason for admission to care
home
Medical historyStroke, Parkinson’s Disease, dementia, epilepsy, blackouts, diabetes, short of
breath, heart disease, arthritis, high / low blood pressure
TransfersNeeds help on/off chair, bed,
toiletUnsteady when transferring,
tends to rush
NutritionNeeds encouragement to eat
Poor appetite, Recent weight loss
History of FallsHistory of falls since admission
MedicationOn 4 or more medications,
on sedatives, antidepressants, diuretics
BalanceHolds furniture when moving,
unsteady when walking,loses balance on turning,
cannot walk unsupported due to unsteadiness
ContinenceIncontinent of urine / faeces,
toilet difficult to access, frequency, urgency,
gets up at night to use toilet/commode, concerned about
continence / getting to toilet in time,
difficulty managing clothes, catheter, constipation
Recent Falls2 or more falls in the past 6 months
(A fall is defined as inadvertently coming to rest on the ground or at a lower level, including slipping from
side of bed)Dizziness
Complains of dizziness, dizzy on first standing up
Stumbles or tripsNoted to stumble / trip even if no
obstacle, near misses noted
FracturesHas broken bones as result of fall:Wrist, hip, humerus, pelvis, spine, ribs, collar bone, shoulder, ankle
CognitionDoes not recognise own limitations, poor
understanding of space and distance, unaware of hazards ,
poor short term memory
GaitShuffles, leans to side,
leans backwards, walks fast
FluidDrinks less than 5 cups of
fluid a day, needs encouragement to drink, often leaves drinks
WalkingNeeds supervision when walking, needs assistance of 1 or 2 to walk
Hospital admissionAttended A&E due to fall, Ambulance
called - not taken to hospital ,admitted to hospital due to
fall
BehaviourAgitated, unsettled, anxious,
periods of aggression, risk to others
Walking aidsUses incorrectly,
refuses to use, forgets to use, poor condition
SleepUnsettled at night,
sleeps a lot during the day, feels tired
Other injury due to fallsHead injury, cuts, bruises, skin tears
ComprehensionHas difficulty understanding verbal
instructions / questions
Heating / body temperature Feels cold,
sits for long periods at a time, doesn’t recognise when cold
VisionHas diagnosed sight loss, wears varifocal / bifocal
glassesrefuses to wear glasses
Coping strategiesInability to get up or summon help
MoodLow mood, depression. anxiety, fearful
AlarmUnable to reach alarm, forgets to use,
does not call for assistance
Footwear Unsupportive footwear,
footwear too loose / tight, painful feet
Fear of FallingIs anxious / worried about falling,
lacks confidence, remains seated for much of day due
to fear of falling
CommunicationUnable to express needs verbally, unable
to make self understood,difficulty making self understood clearly
FlooringRugs, clutter, flexes,
Floor coverings, spillages
PainHas specific / general pain,
pain not helped by pain killers,
on meds for pain that cause side effects e.g. constipation,
dizziness, unable to communicate in
pain
LightingPoor lighting day and/or night, location
of light switches
FALLS HISTORY√
MEDICAL HISTORY√
MOVEMENT & ENVIRONMENT
√PERSONAL
√
History of FallsReview all incidents using Incident Analysis
Form, look for any patterns to falls e.g. time of day, activity at time of fall, inform GP of falls
history / recent fallsPostural blood pressure to be checked in lying, sitting and standing - alert GP if drop of more
than 20mmHg,Request medical review to identify any medical causes of falls e.g. infection, stroke, low blood
pressure, heart problemsIdentify any possible causes of falls and take
steps to reduce those risks
Medical historyCheck for signs of acute illness / infection, consider
medical review from GP if condition not been reviewed in last 6 months, if low blood pressure prompt to stand
still on 1st standing up
TransfersConsider use of alternative furniture,
refer to OT for advice if required
NutritionEncourage to eat small amounts regularly, ensure teeth well fitted, review reasons for poor appetite and weight loss - refer to GP,
dietician
MedicationMedication should be reviewed by GP every 6 mths, consider side effects of meds i.e. dizziness, sedation,
confusion. and refer to GP if concerned
BalanceEncourage to stand still on first standing
Advise to keep head and feet in line when turning, increase supervision, consider referral to
physiotherapist
ContinenceEnsure continence assessment completed, refer to comm. nurse or continence service, test urine, assess for constipation, consider
signage to toilet, refer to OT if required, consider commode for night use, check
regularly if requires toiletDizziness
Postural blood pressure to be checked in lying, sitting and standing - alert GP if drop of more than 20mmHg, Advise to move legs and feet before standing and to
stand still and count to 10 on first standing up
Stumbles or tripsDocument incidents, review incidents for time,
location, activity at time. Review possible causes e.g. footwear, eyesight
FracturesAt risk of osteoporosis,
Ask GP to review if person is falling and has had previous fracture(s)
CognitionRefer to GP if not reviewed in last 6 mths, use signage for toilet, bedroom, lounge, use physical gestures and prompts, Repeat information when person unable to
remember, inc super
GaitPrompt to lift feet, stand upright, refer physio
FluidEncourage to drink 6-8 cups of fluid a day,
stay with person whilst having a drink, document poor fluid intake if does not finish drinks, review reasons for poor fluid intake
eg worried about getting to toilet
WalkingRefer to Physiotherapist, assist in completing
exercise programme prescribed
Hospital admissionReview causes of fall, initiate any treatment
recommended, inform GP
BehaviourRefer to GP if medical review required, Mental Health
services,Ensure no acute illness or infection, be aware of risk of
introducing / increasing psychotropic medication
Walking aidsCheck correct height, check ferrules,
prompt to use correctly
SleepEncourage activity during the day, consider
time goes to bed, be aware of risk of medication to aid sleep increasing risk of falls, increase night supervision, consider
use of sensor mats
Other injury due to fallsReview causes of fall, initiate any treatment
recommended, inform GP
ComprehensionSpeak clearly, in short sentences, with simple
instructions, use physical gestures and prompts
Heating / body temperature Ensure draft free environment, consider
temperature if person sitting for long periods, mobilise regularly
VisionEnsure access to regular sight checks (every
2 yrs), ensure adequate lighting day and night, advise against bifocal glasses
Coping strategiesEnsure call buzzer easily accessible and working
Consider use of sensor equipment Increase level of supervision and document
MoodReassure, encourage socialisation,
Be aware of risk of introducing / increasing psychotropic medation
AlarmEnsure able to access alarm call system in rooms,
consider use of sensor equipment, increase supervision
Footwear Advise on suitable footwear, check footcare,
- nails, corns, callouses, refer to podiatry
Fear of FallingConsider reasons for fear of falling, increase
supervision, ensure mobility maintained, encourage and reassure
CommunicationConsider alternative communication methods, physical
gestures, observe behaviour and routines for insight into how the person may be feeling
FlooringEnsure floor free from clutter, rugs and flexes,
avoid patterned flooring, avoid thresholds, keep floors dry at all times
PainRefer to GP if pain poorly controlled, review
medication if side effects to prescribed tablets, observe behaviour and facial
expression for signs of pain if unable to communicate
LightingEnsure good lighting with no glare, consider use of
night light, ensure switches accessible
Feasibility testing of the GtACH
• 20 minutes versus 2 hours for non-training completers.
• 26 residents were assessed
• 179 risk fall factors were identified
• 163 recommended interventions were recorded
• 86 (53%) of these interventions were completed and recorded in the care plan.
• 9/11 participants with abnormal blood pressure received treatment to rectify.
• 7/8 participants who were having difficulties alerting staff when needing help, received a better placed buzzer and sensory alarm mats placed next to the bed.
• 5/10 incontinent participants were given a management plan or referred to the continence service or district nurse
To estimate important parameters that are needed to design the main study.
To test the feasibility of completing an RCT to evaluate a falls prevention intervention (GtACH) in care homes.
To determine whether to proceed with a large trial
To decide the best approach to adopt for the design of the definitive trial
Future directionsFuture directions
Evaluate GTA ?
Implement GTA ?
Lots of interest
Already used locally
Thank youThank [email protected]@nottingham.ac.uk