Prevention of Falls in Older Adults: Evidence Based Practices By Mary Louise Zernicke,MS MPH RD Consultant, Alameda County EMS/AAA

Physiology of Normal Aging and Falls Risk Heart and arteries Lungs Brain Postural Instability Bladder Body wt and body fat Muscular-skeletal Sight and hearing

Acute and Chronic Conditions and Falls Risk Arthritis Stroke Parkinson’s Dementia Neuropathy Cardiac Osteoporosis

Population by Age: US Census

Leading Causes of Death: Heart Disease 2. Cancer 3. Stroke 4. COPD/Pulmonary disease 5. UNINTENTIONAL INJURIES

Top Causes of Injury Among Older Adults, CA Falls Suicide Motor Vehicle Accidents

Hospitalizations Due to Unintentional Injuries by Age in Alameda County 2000 Data, CA Dept of H & HS

Unintentional Injuries: 60+ Alameda County 77% from falls

What is a fall? A fall is defined as an unintentional loss of balance that leads to failure of postural stability ( Nelson and Amin 1009 ) Recurrent fallers are those that have fallen 2 or more times in either 6 or 12 months ( Studentski et all 1994, Gregg et all 2000 )

Health Care: What is a fall? A fall is a sudden and unexpected change in position, usually resulting in landing on the floor. Finding a patient on the floor or lowering or assisting a person to the floor is considered a fall and needs to be documented as such.

Myths about falling… Due to carelessness. A normal process of aging. They “just happen”. Cannot be predicted or anticipated.

Facts About Falling… 1/3 of community dwelling older adults fall annually: % in nursing homes. 95% of hip fractures result from a fall. Of those who fall, 25% suffer injuries that reduce mobility and independence. 50% of those who sustain injury from a fall can no longer live independently.

Facts About Hip Fractures 1 in 7 women will break hip. 25% will regain full functional ability. 50% will end up in nursing home. 25% will die within one year. Risk of dying from osteoporosis = Risk of dying from breast cancer

Why Do People Fall? summary of 12 studies Accident/environment- 31% Gait/balance problem – 17% Dizziness/vertigo – 10% Confusion – 4% Postural hypo-tension –3% Vision –3% Other and unknown –20%

Where do people fall? For those % happen at home - 30% occur in public places - 10% in health care institutions

Facts About Falls and Hospitals . 6 –2.9 falls per bed annually in hospitals; ( Rubenstein 2000)  14% of d/c pts. fall the first month after discharge;  falls are the BEST predictor of nursing home placement;  40% of nursing home placements due in some way related to a fall.

Cost of falls  8% of those over 70 visit ER annually for a fall.  1/3 of these are hospitalized.  5.3% of hospitalizations of those over 65 are directly due to falls.  Ave. cost per fall for 65+= $19,440 (excluding MD). Rizzo 1998  Cost to US-estimate: $20B $32B.

Cost of Falls in Nursing Homes “Falls in nursing homes once again make up the largest number of claims against nursing homes insured by St Paul Medical Service.” The St Paul Annual Report to Shareholders

Falls are Predictable: Risk Factors for Falls Impairments in… Cognition. Vision or hearing. Feet. Lower extremity strength. Balance or gait. Postural hypo-tension. Syncope and arrhythmia.

Risk Factors for falls, cont. Medication use Total number over 4 AND/OR - Sedatives: confusion, motor dysfunction - Anti-psychotics: hypotension - Anti-depressants: hypotension - Anti-hypertensives: postural hypo-tension - Anti-anxiety: Confusion - Diuretics: Urinary urgency resulting in a fall

Risk Factors for Falls, cont. Alcohol intake. Dehydration. Poor Nutrition. - Vitamin D - Calcium

Falls Risk,Extrinsic Factors Poor lighting. Uneven or slippery surfaces. Loose rugs. Steep stairs. Clutter/pets in pathway. Lack of handrails (inc bathroom). Furniture wrong height. Long bathrobe.

Falls in the Hospital: Client Risk Factors Postural hypo-tension. Lowest weight percentile. Medications: 4+ or sedatives. Previous fall. Impaired arm strength or range of motion. Uneven gait. Unable to move from bed to bath without assistance.

Falls in the Hospital: Institutional Risk Factors Recent admission. Furniture placement. Slick and/or hard floors. Unsupervised activities.

Falls in the Hospital: cont… Institutional Risk Factors Reduced # of nurses. Meal times. Absent handrails. Poor lighting.

ED Assessment of falls ( Aannals of internal meds 1997 Things to consider in the History & Physical Elder abuse Alcohol abuse Medication review Falls in preceding months Hydration Malnutrition Eye exams in past year Gait, strength and balance Environmental hazards

Validated Falls Risk Assessment Tools In-patient STRATIFY Morse Develop your own!! Success is wildly mixed in research studies 75% of RN’s from 150 institutions wanted more falls prevention support.

STRATIFY as an example: Predicts up to 93% of falls Did patient present with a fall? Has s/he fallen since admission? Is patient agitated? Patient severely visually impaired? Patient needs frequent toileting? Transfer and mobility ability?

Special Considerations for high risk patients 1. ID bracelets or sticker on chart 2. Bed alarms 3. Special flooring 4. Hip protectors 5. “Toileting rounds” at shift change 6. Terry slippers 7. Motion sensing lights 8. Work with PT’s 9. Patient closer to nursing station

Educate the patient and their family Videos: in-house and at home “Sit and be fit” Written materials Community referrals BMD screening Pharmacists “Call before you fall”

More than one cause…… more than one solution: Avoiding falls in the community Physical Activity Support “THE FOUNTAIN OF YOUTH”  Strength  Balance  Fear of falling  Osteoporosis  Arthritis  CHD  DM

More solutions….. Change behaviors. Manage medications. Proper nutrition. Home modification.

Community Resources…. Area Agency on Aging Senior Centers Falls prevention focus groups Vital-Link FORE Local pharmacist GET A BUDDY!

Packet and Resources