1. Fall Prevention in Nursing Homes Medical Team Module Developed by: Duke University Medical Center School of Nursing, Center for Aging and Human Development, and the Durham VA GRECC

2. 2 Fall Prevention: Objectives As a result of completing this module, you will be able to: –Describe the high rate of falls and their consequences in nursing home residents –Identify residents who are at high risk for falls –Assess and intervene in four fall risk areas in high risk patients –Describe the roles of other staff in the fall prevention team Developed: 08-31-09 Contact: cathleen.colon- emeric@va.gov

3. 3 You are orienting a new Nurse Practitioner who has not worked with older adults before. She wants to know why there is so much emphasis on fall prevention. You tell her… You are orienting a new Nurse Practitioner who has not worked with older adults 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 Prevention: Rates and Consequences: Scenario 1 Developed: 08-31-09 Contact: cathleen.colon- emeric@va.gov

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- emeric@va.gov

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. –His wife tells you he has fallen several times at home. –He has Parkinson’s Disease. –He has dementia. –He has intermittent urinary incontinence. –He has broken his wrist in the past. –His vision is poor due to macular degeneration. –He shuffles when he walks, and holds onto furniture. –He has heart failure. Identifying Fall Risks Scenario 2 Developed: 08-31-09 Contact: cathleen.colon- emeric@va.gov

6. 6Answers 1.History of falls. Right. Previous falls are one of the strongest risk factors for more falls. 2.Parkinson’s 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 in the bathroom while patients are rushing to toilet themselves. 5.Prior fracture. No. Prior fractures and osteoporosis don’t 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 isn’t 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- emeric@va.gov

7. 7 Identifying Fall Risks Identifying falls risk factors in each patient is important because:Identifying falls risk factors in each patient is important because: 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- emeric@va.gov

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 Interventions: Medications Scenario 3 Developed: 08-31-09 Contact: cathleen.colon- emeric@va.gov

9. 9Answers 1.Citalopram. Maybe. All antidepressants increase the risk of 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. Yes. Muscle relaxants don’t work well for back pain and 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 which can result in falls. 5.Zolpidem. Yes. Sedative-hypnotics probably increase falls risk 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 besides. Use only when necessary and try tapering often. 7.Oxycodone. No. Analgesics including opiates are surprisingly not associated with falls in meta-analyses. Developed: 08-31-09 Contact: cathleen.colon- emeric@va.gov

10. 10 Interventions: Medications Many classes of medications are associated with increased fall riskMany classes of medications are associated with increased fall risk –Digoxin –Some antiarrythmics –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- emeric@va.gov

11. Interventions: Medications Scenario 4 You talk with the facility pharmacist about tapering some of Mr. Jones’ medications. He asks if you have considered evaluating and treating vitamin D deficiency in Mr. Jones. 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- emeric@va.gov

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 provides 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- emeric@va.gov

13. Fall Prevention: Medical Intervention Fall Prevention: Medical Intervention Calcium and Vitamin D Current guidelines recommend target 25(OH)Vitamin D levels of >30 ng/ml in older adults. –Deficiency can usually be corrected with 50,000 IU Ergocalciferol weekly x 12 wks. Randomized controlled trials of vitamin D supplements in nursing homes show a reduction in falls of 72% at doses of 800 IU or more daily. –http://www.ncbi.nlm.nih.gov/pubmed/17302660http://www.ncbi.nlm.nih.gov/pubmed/17302660 Recent meta-analyses suggest that calcium and Vitamin D supplements also reduce fractures and possibly mortality in older adults. –http://www.ncbi.nlm.nih.gov/pubmed/17846391http://www.ncbi.nlm.nih.gov/pubmed/17846391 13 Developed: 08-31-09 Contact: cathleen.colon- emeric@va.gov

14. 14 You ask the Nurse’s Aid to check Mr. Jones’ orthostatic blood pressure and pulse. The Nurse’s 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 Parkinson’s disease. 3.They are more likely to become dehydrated. 4.Blood pressure tends to decrease as you age. Interventions: Orthostatic Hypotension Scenario 5 Developed: 08-31-09 Contact: cathleen.colon- emeric@va.gov

15. 15 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 Parkinson’s disease. Yes. Parkinson’s 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- emeric@va.gov

16. 16 The Nurse’s Aid reports that Mr. Jones’ systolic blood pressure falls from 160 to 125 mm Hg when he stands up.The Nurse’s 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. Interventions: Orthostatic Hypotension Scenario 6 Developed: 08-31-09 Contact: cathleen.colon- emeric@va.gov

17. 17 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- emeric@va.gov

18. Interventions: Other Risk Factors On Mr. Jones’ physical exam, you note the following: –Low vision due to macular degeneration –Difficulty rising from the chair and bed –Abnormal gait (click on the box) –Poor judgment, restlessness, agitation 18 Developed: 08-31-09 Contact: cathleen.colon- emeric@va.gov

19. Interventions: Low Vision Scenario 7 You realize that his low vision will increase his risk of falls, and brainstorm strategies to handle it with his floor nurse and CNA. Which of the following ideas would you support? 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 other Nurses’ Aids about keeping his eyeglasses within reach at all times and encouraging him to wear them. 19 Developed: 08-31-09 Contact: cathleen.colon- emeric@va.gov

20. 20 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- emeric@va.gov

21. 21 Mr. Jones is experiencing difficulty rising from his chair, hemiparesis, decreased arm swing; unequal step length; and a foot drop. You call the Physical and Occupational Therapist. Which of the following interventions do you agree on? Mr. Jones is experiencing difficulty rising from his chair, hemiparesis, decreased arm swing; unequal step length; and a foot drop. You call the Physical and Occupational Therapist. Which of the following interventions do you agree on? Write down the numbers that are true. 1.Trial of an ankle-foot orthosis (AFO). 2.Make the height of his bed, toilet seat, and chairs shorter than his lower leg length. 3.Implement a toileting schedule. 4.Talk to staff about increasing assistance during particular times. Intervention: Mobility Scenario 8 Developed: 08-31-09 Contact: cathleen.colon- emeric@va.gov

22. 22 Answers 1.Trial of an ankle-foot orthosis. Yes, patients with a foot drop may need an AFO (a brace which keeps their foot in dorsiflexion) to help their toes clear the floor. 2.Make the height of his bed, toilet seat, and chairs shorter than his lower leg length. No. To help patients transfer safely, seating height should be 100-120% of lower leg height. 3.Implement a toileting schedule. Good. Many patients fall while trying to toilet themselves. Also 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. Developed: 08-31-09 Contact: cathleen.colon- emeric@va.gov

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- emeric@va.gov

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- emeric@va.gov

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- emeric@va.gov

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- emeric@va.gov

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

28. 28 Recall how many disciplines have been involved in the effort to keep Mr. Jones from falling. 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 with the falls prevention team. Don’t forget to include the patient and family in the discussions, too. Recall how many disciplines have been involved in the effort to keep Mr. Jones from falling. 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 with the falls prevention team. Don’t 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- emeric@va.gov

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 Page–Preventing Falls and Fractures (patient handout)NIH Age Page–Preventing Falls and Fractures (patient handout) http://www.nia.nih.gov/HealthInformation/Publications/falls.htm Developed: 08-31-09 Contact: cathleen.colon- emeric@va.gov

30. 30 The End Please close this presentation and begin the quiz. Developed: 08-31-09 Contact: cathleen.colon- emeric@va.gov