Fall Prevention in Nursing Homes Nursing Team Module Developed
by: Duke University Medical Center School of Nursing, Center for
Aging and Human Development, and the Durham VA GRECC
Slide 2
Developed: 08-31-09 2Contact: [email protected] Preventing
Falls After taking this course you will be able to:After taking
this course you will be able to: Describe the high rate of falls
and their consequences in older adults Identify patients who are at
high risk for falls Assess and intervene in five fall risk areas in
high risk patients Describe your role in the fall prevention
team
Slide 3
3 You are orienting a new Nurse who has not worked in a nursing
home before. She wants to know why there is so much emphasis on
fall prevention. You tell her Write down the numbers that are true.
1.Half of nursing home residents fall each year, and one third fall
multiple times. 2.1 in every 10 falls results in a major injury.
3.Falls are the most common cause of injury-related deaths in older
adults. 4.Falls can cause decreased ability to function and lower
quality of life in older adults. Fall Rates and Consequences:
Scenario 1 Developed: 08-31-09 Contact: cathleen.colon-
[email protected]
Slide 4
4 Answers 1.Half of nursing home residents fall each year and
one third fall multiple times. Right. 2.1 in every 10 falls results
in a major injury. Correct. Major injuries include fractures,
lacerations, and head injuries. 3.Falls are the most common cause
of injury-related deaths in older adults. True. 4.Falls can cause
decreased ability to function and lower quality of life in older
adults. Right. A fear of falling causes patients to restrict their
mobility and further lose function. Developed: 08-31-09 Contact:
cathleen.colon- [email protected]
Slide 5
5 Later that day you admit a new patient, Mr. Jones. Which of
the following factors increase his chance of having a fall? Write
down the numbers that are true. 1.His wife tells you he has fallen
several times at home. 2.He has Parkinsons Disease. 3.He has
dementia. 4.He has intermittent urinary incontinence. 5.He has
broken his wrist in the past. 6.His vision is poor due to macular
degeneration. 7.He shuffles when he walks, and holds onto
furniture. 8.He has heart failure. Identifying Fall Risk Factors
Scenario 2 Developed: 08-31-09 Contact: cathleen.colon-
[email protected]
Slide 6
6Answers 1.History of falls. Right. Previous falls are one of
the strongest risk factors for more falls. 2.Parkinsons Disease.
Correct. Many neurologic diseases including stroke, seizures, and
neuropathy cause falls. 3.Dementia. Yes. Cognitive impairment can
lead to unsafe behavior and is often associated with gait problems.
4.Urinary Incontinence. Right. Many falls happen while patients are
rushing to toilet themselves. 5.Prior fracture. No. Prior fractures
and osteoporosis dont increase falls but do indicate a high risk
for more broken bones if the patient does fall. 6.Low vision. Yes!
Both vision and hearing impairment are associated with falls.
7.Gait disorder. Right. Abnormal gait, and especially furniture
surfing, indicate a high risk for falls. 8.Heart disease. No, heart
disease in itself isnt a falls risk factor, but cardiac medications
may cause bradycardia or orthostatic hypotension that can lead to
falls. Developed: 08-31-09 Contact: cathleen.colon-
[email protected]
Slide 7
7 Why is it Important to Identify Risk Factors? 1.It helps you
to estimate his risk of falling. The more risk factors he has, the
higher the chance that he will fall. 2.It helps you figure out
which interventions are most likely to help prevent his falls. The
next section will review interventions that have been shown to
prevent falls.The next section will review interventions that have
been shown to prevent falls. Developed: 08-31-09 Contact:
cathleen.colon- [email protected]
Slide 8
8 You decide that Mr. Jones is at very high risk for falls and
want to intervene. You start by looking at his medications. Which
of the following would you consider reducing or discontinuing?
Write down all numbers that are correct. 1. Citalopram 20 mg daily
for depression 2. Lorezapam 1 mg twice daily for anxiety 3.
Baclofen 10 mg twice daily for back pain 4. Digoxin 0.25 mg daily
for heart failure 5. Zolpidem 5 mg at bedtime for sleep 6.
Risperdal 0.5 mg as needed for agitation 7. Oxycodone 5 mg every 6
hours for pain Intervening: Medications Scenario 3 Developed:
08-31-09 Contact: cathleen.colon- [email protected]
Slide 9
9Answers 1.Citalopram. Maybe. All antidepressants increase
falls, but treating depression is important too. Work with the care
team to use the lowest effective dose. 2.Lorezapam. Right.
Benzodiazepines increase falls risk and should be avoided or used
at the lowest effective dose. 3.Baclofen. Definitely. Muscle
relaxants have anticholinergic side effects that increase falls
risk. 4.Digoxin.Yes. Digoxin has a narrow therapeutic window and
needs to be monitored regularly for toxicity. 5.Zolpidem. Yes.
Sedative-hypnotics probably increase falls and should be used
cautiously. Are there non-pharmacologic strategies the team could
use to help Mr. Jones sleep? 6.Risperdal. Definitely. Atypical
antipsychotics increase falls risk and have a black box warning.
Use only when necessary and try tapering often. 7.Oxycodone. No.
Analgesics including opiates are surprisingly not associated with
falls. Developed: 08-31-09 Contact: cathleen.colon-
[email protected]
Slide 10
10 Intervention: Medications Many classes of medications are
associated with increased fall riskMany classes of medications are
associated with increased fall risk Digoxin Some antiarrhythmic
drugs Diuretics Psychotropics Benzodiazepines Antidepressants Drugs
with anticholinergic side effects Consider tapering or
discontinuing these drugs in patients at high risk for
falls.Consider tapering or discontinuing these drugs in patients at
high risk for falls. For summaries of meta-analyses of drugs and
falls, refer to the following:For summaries of meta-analyses of
drugs and falls, refer to the following:
http://www.ncbi.nlm.nih.gov/pubmed/9920228
http://www.ncbi.nlm.nih.gov/pubmed/9920228
http://www.ncbi.nlm.nih.gov/pubmed/9920227
http://www.ncbi.nlm.nih.gov/pubmed/9920227 Developed: 08-31-09
Contact: cathleen.colon- [email protected]
Slide 11
Intervention: Medications Scenario 4 whether You talk with the
facility pharmacist about tapering some of Mr. Jones medications.
He asks if you have considered whether Mr. Jones might be vitamin D
deficient. Which of the following statements are true about vitamin
D in nursing home residents? Write down all numbers that are
correct. 1.One half to two-thirds of nursing home residents are
vitamin D deficient. 2.The best test to assess for vitamin D
sufficiency is serum 1,25(OH) vitamin D. 3.Vitamin D supplements
strengthen bone, but do not prevent falls in nursing home
residents. 4.Calcium and vitamin D supplements reduce hip fractures
in older adults. 11 Developed: 08-31-09 Contact: cathleen.colon-
[email protected]
Slide 12
Answers 1.One half to two-thirds of nursing home residents are
vitamin D deficient. Correct. 2.The best test to assess for vitamin
D sufficiency is serum 1,25(OH) vitamin D. No. The body maintains
the active 1,25(OH) form of vitamin D at stable levels until
deficiency is far advanced. 25(OH) Vitamin D is a better assessment
of Vitamin D stores. 3.Vitamin D supplements strengthen bone, but
does not prevent falls in nursing home residents. No. Vitamin D
supplements have been shown to reduce falls in a dose-response
manner. 4.Calcium and vitamin D supplements reduce hip fractures in
older adults. Right. They reduce fracture risk by about 25%. 12
Developed: 08-31-09 Contact: cathleen.colon- [email protected]
Slide 13
13 You ask the Nurses Aid to check Mr. Jones orthostatic blood
pressure and pulse. The Nurses Aid is slightly annoyed by the
request, so you explain why older people like Mr. Jones often have
large drops in blood pressure that result in falls. Write down all
numbers that are correct. 1.They are on medications that cause
orthostasis. 2.They have Parkinsons disease. 3.They are more likely
to become dehydrated. 4.Blood pressure tends to decrease as you
age. Intervention: Orthostatic Hypotension Scenario 5 Developed:
08-31-09 Contact: cathleen.colon- [email protected]
Slide 14
14 Answers 1.They are on medications that cause orthostasis.
Right. Frequent culprits are cardiac medicines (especially
clonidine and hydralazine), prostate medications (especially
terazosin and doxazosin), anticholinergic medicines (like benadryl,
muscle relaxants, antihistamines) and diuretics. 2.They have
Parkinsons disease. Yes. Parkinsons is often associated with
autonomic insufficiency. Other causes include diabetes, hepatic
diseases, B12 deficiency, uremia, and alcoholism. 3.They are more
likely to become dehydrated. Correct. Older people may not drink
enough because of decreased feelings of thirst, dementia, or
difficulty getting to water. 4.Blood pressure tends to decrease as
you age. Actually, blood pressure tends to increase with age.
However, even patients with high blood pressure can have
symptomatic orthostasis. Developed: 08-31-09 Contact:
cathleen.colon- [email protected]
Slide 15
15 The Nurses Aid reports that Mr. Jones systolic blood
pressure falls from 160 to 125 mm Hg when he stands up.The Nurses
Aid reports that Mr. Jones systolic blood pressure falls from 160
to 125 mm Hg when he stands up. Write down at least 3 things that
you would consider to evaluate or treat Mr. Jones orthostasis.Write
down at least 3 things that you would consider to evaluate or treat
Mr. Jones orthostasis. Intervention: Orthostatic Hypotension
Scenario 6 Intervention: Orthostatic Hypotension Scenario 6
Developed: 08-31-09 Contact: cathleen.colon- [email protected]
Slide 16
16 Answers 1.Exclude dehydration and acute blood loss. 2.Review
medications for potential culprits. 3.Consider treatable causes
like adrenal insufficiency and B12 deficiency. 4.Talk with the
Nurses about putting on compression stockings every morning. 5.Talk
with the Nurses to ensure easy access to fluids and regular
encouragement to drink. 6.Consider prescribing fludrocortisone for
symptomatic orthostasis not responding to other measures.
Developed: 08-31-09 Contact: cathleen.colon- [email protected]
Slide 17
Intervention: Vision Impairment During your admission
assessment, you note that Mr. Jones vision is impaired. In addition
to making sure he has had a recent eye exam, what else can be done
to decrease his falls risk?During your admission assessment, you
note that Mr. Jones vision is impaired. In addition to making sure
he has had a recent eye exam, what else can be done to decrease his
falls risk? (write down the numbers that are true) 1.Increase the
lighting in his room and bathroom 2.Add high contrast strips to
stairs and curbs 3.Increase the glare in the room 4.Talk to the
Nurses Aids about keeping his eyeglasses within reach at all times
and encouraging him to wear them 17 Developed: 08-31-09 Contact:
cathleen.colon- [email protected]
Slide 18
18 Answers 1.Increase the lighting in his room and bathroom.
Yes, make sure the maximum wattage bulb is used, or add additional
lights. 2.Add high contrast strips to stairs and curbs. Good idea!
3.Increase the glare in the room. No, glare makes poor vision
worse. Make sure there are shades or covers over the light fixtures
and windows. 4.Talk to the Nurses Aids about keeping his eyeglasses
within reach at all times and encouraging him to wear them. Yes,
they need to understand how important good vision is to reducing
falls risk. Developed: 08-31-09 Contact: cathleen.colon-
[email protected]
Slide 19
Developed: 08-31-09 19 Contact: cathleen.colon- [email protected]
Intervention: Mobility Scenario 8 You ask Mr. Jones to do an Up and
Go test for you. (Click the box to the right)You ask Mr. Jones to
do an Up and Go test for you. (Click the box to the right) Is his
gait safe or unsafe, and why? Decide what you would do next.Is his
gait safe or unsafe, and why? Decide what you would do next.
Slide 20
Developed: 08-31-09 20 Contact: cathleen.colon- [email protected]
Mr. Jones has weakness on one side, decreased arm swing, unequal
step length, and a foot drop. You call the Physical Therapist, who
will evaluate him for an assistive device and exercises. What other
interventions might help reduce his risk of falling due to his
unsteady gait? (write down the numbers that are true)Mr. Jones has
weakness on one side, decreased arm swing, unequal step length, and
a foot drop. You call the Physical Therapist, who will evaluate him
for an assistive device and exercises. What other interventions
might help reduce his risk of falling due to his unsteady gait?
(write down the numbers that are true) 1.Use a lap belt to keep him
in his chair 2.Check the height of his bed, toilet seat, and chairs
3.Consider bathroom safety 4.Talk to staff about increasing
assistance during particular times Scene 6: Intervening -
Mobility
Slide 21
Developed: 08-31-09 21 Contact: cathleen.colon- [email protected]
Answers 1.Use a lap belt to keep him in his chair. No. Restraints
increase the risk of injurious falls, and do not promote
independence and quality of life 2.Check the height of his bed,
toilet seat, and chairs. Yes! To help patients transfer safely,
seating height should be 100-120% of lower leg height. The next
slide will illustrate how to check this 3.Consider bathroom safety.
Good. Make sure there is adequate handrail support, nonskid
flooring, and that the patient has easy to manage clothes 4.Talk to
staff about increasing assistance during particular times. Yes, Mr.
Jones needs increased assistance in the mornings, during transfers,
to and from the toilet, and during ambulation
Slide 22
Developed: 08-31-09 22 Contact: cathleen.colon- [email protected]
Correct seating height is 100-120% of lower leg height
www.contextualise.com/image/img/Sticktostand.jpg
Slide 23
23 Mr. Jones has poor judgment due to his dementia. The nurses
ask for your suggestions in managing some of his unsafe behaviors,
such as pacing, trying to climb over bed rails, and trying to
transfer without help. Mr. Jones has poor judgment due to his
dementia. The nurses ask for your suggestions in managing some of
his unsafe behaviors, such as pacing, trying to climb over bed
rails, and trying to transfer without help. Write down at least 1
idea for each of these categories. Increasing assistance and
surveillance Reducing risk of injury Increasing comfort The
following slides show options for each of these areas. The
following slides show options for each of these areas.
Intervention: Unsafe Behavior Scenario 9 Developed: 08-31-09
Contact: cathleen.colon- [email protected]
Slide 24
24 Increasing Assistance and Surveillance Use position alarms
and motion sensorsUse position alarms and motion sensors Toilet at
regular intervalsToilet at regular intervals Increase activities
involvementIncrease activities involvement Locate patient near
nursing stationLocate patient near nursing station Developed:
08-31-09 Contact: cathleen.colon- [email protected]
Slide 25
25 Reduce Risk of Injury Low bed, floor matLow bed, floor mat
Lower or remove side railsLower or remove side rails Non-skid socks
or footwearNon-skid socks or footwear Non-skid strips or
matNon-skid strips or mat Hip protectors, Calcium, Vitamin DHip
protectors, Calcium, Vitamin D Screen for and treat osteoporosis
when indicatedScreen for and treat osteoporosis when indicated
Developed: 08-31-09 Contact: cathleen.colon- [email protected]
Slide 26
26 Increase Comfort Pain managementPain management Recliner or
rocking chairRecliner or rocking chair ExerciseExercise Cradle
mattress, sheepskin, air mattress or pillowsCradle mattress,
sheepskin, air mattress or pillows Developed: 08-31-09 Contact:
cathleen.colon- [email protected]
Slide 27
Summary of Falls Intervention Areas High Risk Resident:
Evaluate risk areas Medications Review and Taper Calcium + D
Orthostatic Hypotension Measure Medications Fluids Stockings Vision
Lighting Glasses Glare Mobility PT Seat height Toileting Unsafe
Behavior Assistance Prevent Injury Comfort
Slide 28
28 Recall how many disciplines have been involved in the effort
to keep Mr. Jones from falling. In your CLC, how many of these
people do you routinely talk with about your patients fall risk?
Coordination is vital, and you have a key role in sharing
information and ideas. Dont forget to include the patient and
family in the discussions, too. 1.The nurses assistants 2.The floor
nurses 3.The Rehabilitation staff 4.The pharmacist 5.Housekeeping
and Maintenance 6.Activities Director 7.Patients and Families The
Falls Prevention Team Developed: 08-31-09 Contact: cathleen.colon-
[email protected]
Slide 29
29 If you want to learn more about preventing falls Visit the
web sites listed below. AHRQ innovations siteAHRQ innovations site
http://www.innovations.ahrq.gov/content.aspx?id=2052 Falls
Management ProgramFalls Management Program
http://www.qualitynet.org/dcs/ContentServer?cid=1136495771104&pag
ename=Medqic/MQTools/ToolTemplate&c=MQTools
http://www.qualitynet.org/dcs/ContentServer?cid=1136495771104&pag
ename=Medqic/MQTools/ToolTemplate&c=MQTools NIH Age
PagePreventing Falls and Fractures (patient handout)NIH Age
PagePreventing Falls and Fractures (patient handout)
http://www.nia.nih.gov/HealthInformation/Publications/falls.htm
Developed: 08-31-09 Contact: cathleen.colon- [email protected]
Slide 30
30 The End Please close this presentation and begin the quiz.
Developed: 08-31-09 Contact: cathleen.colon- [email protected]