Stand By Me—Preventing Falls

ASSISTED LIVING COLUMN Richard G. Stefanacci Dan Haimowitz Stand By MedPreventing Falls Richard G. Stefanacci, DO, MGH, MBA, AGSF, CMD, and Dan Haimowitz, MD, FACP, CMD Assisted living, by its very definition, provides assistance in living. One area where this is increasingly needed for AL residents involves fall prevention. Unfortunately, this same concern has also been an increasing focus of malpractice liability to AL communities. As a result of this need and focus, ALs would be well served to develop an aggressive plan of action in managing resident fall risks. This process starts with careful assessment of each residents fall risk, development of a well-thought-out care plan to address these risks, followed by implementation of the plan of care to ensure that residents receive the assistance they require. Assessment of Risk Assessment of AL residents fall risk begins at the initial assessment of each resident as well as with any change in condition that would warrant concern that the previous care plan is no longer appropriate. As identified by the American Geriatric Society (AGS), this initial assessment should include the following:  Ask whether the resident has fallen (in the past year); if so, ask about the frequency and circumstances of the fall(s).  Ask if the resident experiences difficulties with walking or balance.  Evaluate gait and balance with a multifactorial fall risk assessment.  Complete a fall risk assessment. Part of the fall risk assessment should include assessing the risk for both a fall and level of trauma. This classification into 1 of 4 groups can allow the AL staff members to focus their efforts on those residents at greatest risk for a traumatic fall (see Figure 1). This classification focuses on likelihood of a fall as well as trauma. As with most fall risk assessments, the 134 likelihood of a fall is affected by such factors as gait stability, cognition, and level of ambulation. The risk for trauma focuses on the level of osteoporosis and anticoagulation because fractures and bleeds are the most significant consequences from a fall. This 4-class grouping can utilize existing risk assessments such as that developed by the AGS, which directs focus in the following critical areas: Focused History a. History of falls: detailed description of the circumstances of the fall(s), frequency, symptoms at time of fall, injuries, other consequences b. Medication review: all prescribed and overthe-counter medications with dosages c. History of relevant risk factors: acute or chronic medical problems, (e.g., osteoporosis, urinary incontinence, cardiovascular disease) Physical Examinations d. Detailed assessment of gait, balance, and mobility levels and lower extremity joint function e. Neurological function: cognitive evaluation, lower extremity peripheral nerves, proprioception, reflexes, tests of cortical, extrapyramidal and cerebellar function f. Muscle strength (lower extremities) g. Cardiovascular status: heart rate and rhythm, postural pulse, blood pressure, and, if appropriate, heart rate and blood pressure responses to carotid sinus stimulation h. Assessment of visual acuity i. Examination of the feet and footwear Geriatric Nursing, Volume 33, Number 2 Functional Assessment j. Assessment of activities of daily living skills including use of adaptive equipment and mobility aids, as appropriate k. Assessment of the individual’s perceived functional ability and fear related to falling (assessment of current activity levels with attention to the extent to which concerns about falling are protective [i.e., appropriate given abilities] or contributing to deconditioning and/or compromised quality of life [i.e., individual is curtailing involvement in activities he or she is safely able to perform due to fear of falling]) Environmental Assessment l. Environmental assessment including home safety Development of a Care Plan Once an AL resident has been assessed for fall risk, his or her care plan comes directly out of these identified risks. These AGS interventions included here have been evaluated and judged to be those that clinicians should provide to eligible patients. So, for those residents identified at being at risk for falling, the following interventions should be taken: 1. The multifactorial fall risk assessment should be followed by direct interventions tailored to the identified risk factors, coupled with an appropriate exercise program. Trauma Likelihood - anticoagulation - osteoporosis Fall Likelihood - ambulation - cognition Figure 1. Classification of fall and trauma likelihood to determine needed aggressiveness of intervention. Geriatric Nursing, Volume 33, Number 2 2. A strategy to reduce the risk of falls should include multifactorial assessment of known fall risk factors and management of the risk factors identified. 3. The components most commonly included in efficacious interventions were the following: a. Adaptation or modification of home environment b. Withdrawal or minimization of psychoactive medications c. Exercise, particularly balance, strength, and gait training 4. All older adults who are at risk of falling should be offered an exercise program incorporating balance, gait, and strength training. Flexibility and endurance training should also be offered but not as sole components of the program. 5. The health professional or team conducting the fall risk assessment should directly implement the interventions or should ensure that the interventions are carried out by other qualified health care professionals. 6. Psychoactive medications (including sedative hypnotics, anxiolytics, antidepressants) and antipsychotics (including new antidepressants or antipsychotics) should be minimized or withdrawn, with appropriate tapering if indicated. 7. A reduction in the total number of medications or dose of individual medications should be pursued. All medications should be reviewed and minimized or withdrawn. 8. Exercise should be included as a component of multifactorial interventions for fall prevention in community-residing older persons. 9. An exercise program that targets strength, gait, and balance, such as tai chi or physical therapy, is recommended as an effective intervention to reduce falls. 10. Exercise may be performed in groups or as individual (home) exercises, because both are effective in preventing falls. 11. In older adults in whom cataract surgery is indicated, surgery should be expedited because it reduces the risk of falling. 12. Assessment and treatment of postural hypotension should be included as components of multifactorial interventions to prevent falls in older persons. 13. Dual chamber cardiac pacing should be considered for older persons with cardioinhibitory 135 14. 15. 16. 17. carotid sinus hypersensitivity who experience unexplained recurrent falls. Vitamin D supplements of at least 800 IU per day should be provided to older persons with proven vitamin D deficiency. Some experts are recommending dosages of 50,000 to 100,000 IU of Vitamin D3 on a monthly basis. Vitamin D supplements of at least 800 IU per day should be considered for people with suspected vitamin D deficiency or who are otherwise at increased risk for falls. Home environment assessment and intervention carried out by a health care professional should be included in a multifactorial assessment and intervention for older persons who have fallen or who have risk factors for falling. The intervention should include mitigation of identified hazards in the home and evaluation and interventions to promote the safe performance of daily activities. When developing a plan of care specific for treating fall risk, realize that successful implementation will require involvement of the entire team. Many of the above points will need physician evaluation and orders. Activity staff will lead efforts in balance training and exercise. Consultant pharmacy expertise may be crucial to help identify potentially dangerous medications. Resident and family education is vital. Administrative and medical director leadership, along with nursing coordination, should help drive the process. Outside of these recommendations, it is important for the AL staff not to fall into the trap of assisting so much that they are enablers of “bad” behavior. There is a careful balance in assisted living between assisting residents and enabling bad behavior. Enabling behavior is born out of our instinct for love. Although enabling of bad or dangerous behavior is often thought of in terms of drug or alcohol addiction, it can also apply to health care professionals. Think about attempts to protect an AL resident from falling such that the staff places a resident in a wheelchair rather than encouraging ambulation (which may lead to a resident no longer 136 walking independently, with subsequent dependence and decreased quality of life). The danger is the AL staff could be working to enable their residents to persist in selfdestructive behavior by providing excuses or by making it possible to avoid the consequences of such behavior. The danger, of course, is that the consequences of a fall could be traumatic. Use of the 4 classifications could help in identification those residents who could do well with standby observation with minimal assistance, such as those at low risk for a traumatic fall versus those needing more aggressive interventions because of their being at high risk for a traumatic fall. Implementation of the Care Plan Of course assessment and development of a care plan will have no impact if implementation of the care plan is not accomplished. The implementation of a fall prevention care plan requires several elements starting with identification of a change champion. This change champion within the AL must be given the authority and resources to accomplish his or her objectives. This champion will need to educate the entire interdisciplinary team and provide a system for reminders and identification. Then, to ensure that the process is working properly, a system of audits and feedback will be needed. Through this comprehensive approach, a fall prevention system can be successfully implemented within an AL community. RICHARD G. STEFANACCI, DO, MGH, MBA, AGSF, CMD, is an Associate Professor in Health Policy at the University of the Sciences in Philadelphia, PA. He also serves as Chief Medical Officer of The Access Group and maintains an active clinical practice in PACEda Program of All-Inclusive Care for the Elderlydin Philadelphia, PA. DAN HAIMOWITZ, MD, FACP, CMD, is an Internist/Geriatrician in private practice in Levittown PA, and Assisted Living Medical Director at Arden Courts of Yardley, PA, and Brunswick at Attleboro in Langhorne, PA. 0197-4572/$ - see front matter Ó 2012 Mosby, Inc. All rights reserved. doi:10.1016/j.gerinurse.2012.02.003 Geriatric Nursing, Volume 33, Number 2