MARY Z. “KELLY” DUNN, PHD, RN, PHCNS, BCASSOCIATE PROFESSOR

UTHSCSA SCHOOL OF NURSING

RACHEL BROWN, HONORS STATISTICS STUDENTUTSA

Falling in Older Adults:Evidence, Best Practices, and

Management

Session Objectives

• Discuss what is known about falls in elders.• Definition of falls• Statistics on falls among the elderly• Outcome of falls (mortality, disability, cost, quality of life )• Documenting falls: coding scheme

• Describe risk factors for falls• Individual factors• Factors related to staff• Environmental factors

• Describe available risk assessment tools and prevention strategies/guidelines

• Participate in group discussion of experiences with falls and implementing interventions to prevent falls.

Method

• We conducted a review of research studies and the internet using the terms aging, falls, falls assessment, nursing homes, and falls prevention

• We worked in a nursing home to understand falls as explained by administration, nurses, and middle management

• We found:• 20 Research Studies• 4 Specialty Organization Guidelines• 5 Systematic Reviews (Cochrane and journal publications)• 2 Federal Guidelines• 1 Quality Improvement article

Results

• Multiple instruments are used to evaluate fall risks

• None contain all risk factors• The AGS / BGS algorithm lacks precision• England, Germany, the Netherlands and

Australia promote comprehensive assessments of outpatients

New studies are being published regularly

What is known about falls

Falls

• Definition from Kellogg supported by the IOM

• An event which results in a person coming to rest inadvertently on the ground or other level and other than as a consequence of the following: sustaining a violent blow, loss of consciousness, and sudden onset of paralysis, as in a stroke or an epileptic seizure

Aging population in Texas

Year 65-69 

70-74

 

75-79

 

80-84

 

85+

2003 633,686 541,464 442,347 306,927 255,164

2004 647,653 543,899 446,019 320,092 262,282

2005 659,743 550,242 454,266 328,897 275,737

2006 686,224 561,708 463,215 339,404 291,461

2007 713,475 568,985 466,497 345,017 305,226

Aging Demographics 2006-2010Subject Bexar County, Texas Total 65 years and over

Total population 1,650,052 167,756 (10%)Male 48.9% 42.0%Female 51.1% 58.0%Median Age 32.7 74.1Race (% of total rounded)    

White 72 82Black or Af. Am. 7 6Amer. Ind. or Alaskan 0.7 0.3Asian 2 2Some other Race 15 9Two or more Races 3 1

Marital Status    Married, but separated 48 52Widowed 5 29Divorced 5 29Never married 32 5

Education    Less than 12 years 19 69High school or more 80 21

Citizenship    Not a US Citizen 61 32

Language at Home    Not English 43 46

Income    Mean Earnings 62,431 40,593Social Security 13,365 14,639At 100% poverty 17 13At 100 to 149% poverty 11 12

Aging Population Proportion Increasing

Falls Fatality ratesTexans 65 and older

Males Females

Falls Mortality Rates by Race65 and older

Falls Mortality in Texas

  2003 2004 2005 2006 2007 Total

Cause of Death No. Rate No. Rate No. Rate No. Rate No. Rate No. Rate

Fall on Same Level (W00-W09, W18)

246 1.4 255 1.4 305 1.7 322 1.7 365 1.9 1,493 1.6

Fall From One Level to Another (W10-W17)

118 0.6 138 0.7 141 0.7 132 0.6 138 0.6 667 0.6

Unspecified Fall (W19)

533 3.1 647 3.7 728 4.1 849 4.6 929 4.9 3,686 4.1Total for Selection 897 5.1 1,040 5.8 1,174 6.5 1,303 6.9 1,432 7.5 5,846 6.4

What Happens in Nursing Homes?

• Only 5% of elders live in nursing homes or about 1.5 million in the US

Potentially preventable ED visits

Falls and Fractures in nursing homes

• Half of nursing home residents fall annually with incidence rates of 0.6-3.6 falls per bed, twice the rate of community dwelling elders. • 24% of these falls are due to balance and gait problems

• The incidence rate for hospital inpatients is 2.2-17.1 per 1000 patient days.

• Mortality risk increases in 6 months following hip fractures.

• Prevalence of hip fractures in care homes is estimated at 50.8/1000 person-years in women and 32.7/1000 in men.

• In November 2002, the Centers for Medicare and Medicaid Services launched the Nursing Home Quality Initiative.

Outcome of falls

• Hip fractures are a common occurrence in nursing homes with an incidence rate of 4% (range 2%-6%).

• After a hip fracture, elderly NH residents have a 40% mortality risk within a year and a 6-12% risk of another fracture.

• Most never return to pre-fracture function, and 2/3 cannot be independently mobile (Crotty et al., 2000)(Rapp et al., 2008).

• The one-year cost of a NH hip fracture is about $30K, most involving hospital costs. Balance this with changes in QoL, and the cost is prohibitive.

• In those > 65 years, accidental falls are the 5th leading cause of death (Rubenstein, 2006).

Minimum Data Set Fall Coding

• Notes: • The fall may be witnessed, reported by the resident or

an observer or identified when a resident is found on the floor or ground.

• Falls include any fall (home, community, in an acute hospital, or a nursing home).

• Falls are not a result of an overwhelming external force (e.g., a resident pushes another resident).

• An intercepted fall occurs when the resident would have fallen if he or she had not caught him/herself or had not been intercepted by another person—this is still considered a fall. (RAI Manual J-27)

Source: University of MO-Columbia, Sinclair School of Nursing – March 2011

Minimum Data Set Fall Coding

• Coding (RAI Manual J 27-32):1. J1700A – Did the resident have a fall any time in the last

month prior to admission?2. J1700B – Did the resident have a fall any time in the last

2-6 months prior to admission?3. J1700C – Did the resident have any fracture related to a

fall in the 6 months prior to admission?4. J1800 – Any falls since admission or prior assessment

(OBRA or PPS) whichever is more recent.5. J1900 – Number of falls since admission or prior

assessment (OBRA or PPS) whichever is more recent.6. J1900A – No injury7. J1900B – Injury (Except major)8. J1900C – Major Injury

Source: University of MO-Columbia, Sinclair School of Nursing – March 2011

Risk factors for falls

Individual Risk Factors Related to Falling

Intrinsic Risk Factors in Order of High to Low Risk• Lower extremity weakness• History of falls• Gait/Balance deficits• Use of assistive devices• Vision deficit• Arthritis• Impaired ADLs• Depression• Agitation and Wandering• Fear of Falling

• Additional Intrinsic Risk Factors

• Chronic illness/Post-Stroke• Orthostatic hypotension• Urinary incontinence• Mental/Cognitive deficit• Medication/Polypharmacy

• Antidepressants• Antipsychotics: zolpidem• Benzodiazapine• Calcium channel antagonists• Diuretics• Hypoglycemics• Laxatives• Nonsteroidal anti-

inflammatory agents• Sedatives/hypnotics

Non-Modifiable Risk Factors Modifiable Risk Factors

• Sex• Age• Diagnosed with LBD• Dementia Duration• Lives in a LTC• History of falls over 12

months• Sarcopenia• Brain White Matter

Hyperintensities• Functional Disability: Use of

an assistive Device• Visual Impairment• Urge Urinary Incontinence

• Cardioactive medications• Psychotropic Medications• Gait and Balance• Agitation• Pain• Depression• Autonomic Symptoms• Orthostatic Hypotension• ADL’s and IADL’s• Fear of Falling• Inappropriate Footwear• Physical Restraint Use

Modifiable & Non-ModifiableRisk Factors For Falls

Individual risk factors: other conditions

• Neurodegenerative disorders (NDDs) (all dementias, PD) more common in the aging population. By 2020, there will be 42 million people with dementia, a risk factor for falls (Ang et al., 2010).

• People with dementia have tough recoveries from falls and falls with injuries.

• While falls risks and management strategies may be known, we need policies and processes in all NHs:• People with NDD, should be frequently reassessed

Environmental Risk Factors

• Extrinsic Risk Factors• Lack of grab bars in the bath or toilet and hallways• Poor lighting• Height of bed or chairs• Improper use of assistive devices• Inadequate assistive devices• Poor condition of flooring surfaces• Improper footwear• Clutter, slippery throw rugs• Electrical cords in walking path• Lack of non-slip shower surfaces

Staff Related Falls Risk Factors

Content and Process Related• Need for heightened awareness and knowledge

(content)• Lack of staff interdependence (process)

• Learning from each other• Frequent collaborations• Participation in decision making• Team building• Need for mentorship and guidance

• Need for staffing numbers, activities and stability (process)• Studies show staff “team” building improves quality care• Hourly toileting rounds, root cause analyses of falls,

other?• Staff turnover in nursing homes is very high

Risk assessment tools and prevention guidelines/strategies

for falls

Fall Risk Assessment Instruments

• STRATIFY (St. Thomas Risk Assessment Tool in Falling Elderly Inpatients

• Hendrich II Fall Risk Model• Morse Fall Scale• New York-Presbyterian Fall and Injury Risk

Assessment Tool• Maine Medical Center Falls Risk

Assessment/Interventions

Explanation of terms

Count

Fell

Yes No

High Fall Risk Yes a b

No c d

Measures of Precision for Four Falls Risk Assessment Tools

Assessment Tool Sensitivity (%) Specificity (%) Negative Predictive Value (%)

Positive Predictive Value (%)

MMC 64.9 65.8 98.0 6.8

NY 78.9 58.4 98.6 6.9

Morse 77.2 72.8 98.8 9.9

Hendrich II 64.9 69.0 98.1 7.5

STRATIFY 57 72 95 15

• MMC= Maine Medical Center, Falls Risk Assessment/Interventions (Maine Medical Center 2005)

• NY= New York-Presbyterian Fall and Injury Risk Assessment Tool (Currie et al. 2004, Currie 2006)

• Morse= Morse Fall Scale (Morse et al. 1989)• Hendrich II= Hendrich II Fall Risk Model (Hendrich 2006)

St. Thomas's Risk Assessment Tool In Falling Elderly Inpatients

• STRATIFY is a tool that consists of five questions:1. Was the patient admitted to the hospital with a fall or

has the patient fallen in the past six months? (yes=1, no=0);

2. Do you think the patient is agitated? (yes=1, no=0);3. Do you think the patient is visually impaired to the

extent that everyday function is affected? (yes=1, no=0);

4. Do you think the patient is in need of frequent toileting? (yes=1, no=0);

St. Thomas's Risk Assessment Tool In Falling Elderly Inpatients (contd.)

• STRATIFY is a tool that consists of five questions:5. Does the patient have a transfer and mobility score

of 3 or 4? (yes=1, no=0. Transfer is scored as follows: 0=unable, 1=major help needed (1–2 helpers and/or physical aids needed), 2=minor help needed (verbal or physical), 3=independent. Mobility is scored as follows: 0=immobile, 1=independent with the aid of wheelchair, 2=walks with the help of one person, 3=independent.)

• The total STRATIFY score corresponds to the sum of all present risk factors and can range between 0 and 5. The higher the score, the greater the risk a patient has of falling.

Validity MeasuresAdditional testing completed by Eagle et al. (1999) on a sample of elderly inpatientsindicated the following:

➢ Sensitivity (ability to detect falls when they are present) = 72% ➢ Specificity (ability to identify correctly the absence of falls) = 51% ➢ Positive Predictive Value (how well test predicted compared to actual number of

falls) = 38% ➢ Negative Predictive Value (how well negative test correctly predicts absence of falls)

= 81% ➢ Accuracy (overall rate of agreement between the test and the actual number of falls) =

57% ➢ Prevalence (ratio of the number of people who have fallen divided by the total

number of people at risk for falling) = 30%

Morse fall scale

(see next slide)

Variables Numeric Values

Score

1. History of falling No 0 Yes 25

  _______

2. Secondary diagnosis No 0 Yes 15

  _______

3. Ambulatory aid None/bed rest/nurse assist Crutches/cane/walker Furniture

  0 15 30

    _______ 

4. IV or IV Access No 0 Yes 20

  _______

5. Gait Normal/bed rest/wheelchair Weak Impaired 

  0 10 20

    _______

6. Mental status Oriented to own ability Overestimates or forgets limitations

  0 15

   _______ 

Morse Fall Scale Score Total ____

Morse Fall Scale for the Acute Inpatient SettingProcedure:•Obtain a Morse Fall Scale Score by using the variables and numeric values listed in the “Morse Fall Scale” table below. (Note: Each variable is given a score and the sum of the scores is the Morse Fall Scale Score. Do not omit or change any of the variables. Use only the numeric values listed for each variable. Making changes in this scale will result in a loss of validity. Descriptions of each variable and hints on how to score them are provided below.) The “Total” value obtained must be recorded in the patient’s medical record.

No risk – 25, Moderate risk – 26-45, High Risk 46+

New York-Presbyterian Fall and Injury Risk Assessment Tool

• Fall Risk Item• Falls in past 7 days• Male gender• Impaired cognition• Unsteady gait and not using assistive device• One or more sedatives

• Injury Risk Item• History of adult fracture• Metastatic Bone Disease• Osteoporosis• Frailty• Antiplatelet therapy• Anticoagulant therapy• Thrombolytics• Bleeding Times• Decreased Platelet Count• Coagulopathy• Thrombocytopenia

No falls • No further assessment or referral is needed. • Encourage older adult to exercise daily • Encourage older adult to take action and prevent

a fall

Yes - Single fall • Recommend visit to primary care provider for falls assessment and treatment of risk factors

• Primary care provider will assess for gait and/or balance problems. The Timed Get Up and Go can be used to identify gait and/or balance problems. Older adults who demonstrate no difficultly or unsteadiness need no further assessment. Those who have difficulty or unsteadiness require further assessment.

• Encourage older adult to take action and prevent a fall Yes - Multiple falls and/or Impairment of gait and/or

balance •Recommend visit to primary care provider for falls assessment and treatment of risk factors.•Assessment should be performed by professional with appropriate skills and experience.•Encourage older adult to take action and prevent a fall

Yes - Fear of falling • Recommend visit to primary care provider to discuss fear of falling.

• Encourage older adult to take action and prevent a fall

Maine Medical Center Patient Education Brochure

http://www.mmc.org/workfiles/mh_PFHA/FallsInfoPatients.pdf

BMJ Editorial (2007)

In Simple Terms…

• Key interventions are those that are cornerstones of appropriate care for elderly people. These include:• adequate supervision• encouragement of supervised mobility and exercise• individually prescribed mobility and safety aids• a safe institutional environment• avoidance of psychotropic drugs where possible• recognition of changes in health status that predispose

to falls, such as delirium.

But in Reality, Interventions are Very Complex

Intervention Recommendations

Identifying gait and balance problems using TUG and the timed SLS (CDC, Morse, and others)

Acceptable for NH residents who are ambulatory. Take precautions with the SLS. May use aides during TUG.

Monitoring medications using clinical informatics tool, GRAM (Lapane)

Found to reduce the incidence of falls, delirium, and hospitalization

Respiridone 1 mg. for elders with dementia who wander (are agitated)Pain management reduces agitation

Used in one study but reduced falls significantly, and in another study, agitated residents were 3 times as likely to have fractures

Reduce walking aides to 1 Those who used wheelchairs and either canes or walkers fell more

Staff education and fall case discussions Netherlands researchers found this important

Environmental modification and resident focused interventions

Low bed height, obstacle removal, w/c maintenance, resident-specific exercise program, hip protectors

High ratio of CNAs to residents Significantly lowered risk of falls

Evaluate for Orthostatic Hypotension Found important in more than 2 studies

Vitamin D and Calcium Reduces fractures, but could cause kidney calculi

Timed up and go test (TUG)

Timed Single Limb Stance

• The One-Legged Stance Test measures postural stability (i.e., balance) and is more difficult to perform due to the narrow base of support required to do the test. Along with five other tests of balance and mobility, reliability of the One-Legged Stance Test was examined for 45 healthy females 55 to 71 years old and found to have "good" intraclass correlations coefficients (ICC range = .95 to .099). Within raters ICC ranged from 0.73 to 0.93.

•

• To perform the test, the patient is instructed to stand on one leg without support of the upper extremities or bracing of the unweighted leg against the stance leg. The patient begins the test with the eyes open, practicing once or twice on each side with his gaze fixed straight ahead.

•

• The patient is then instructed to close his eyes and maintain balance for up to 30 seconds.

•

• The number of seconds that the patient/client is able to maintain this position is recorded. Termination or a fail test is recorded if 1) the foot touches the support leg; 2) hopping occurs; 3) the foot touches the floor, or 4) the arms touch something for support.

•

• Normal ranges with eyes open are:

• 60-69 yrs/22.5 ± 8.6s

• 70-79 yrs/14.2 ± 9.3s

• Normal ranges for eyes closed are:

• 60-69 yrs/10.2 ± 8.6s

• 70-79 yrs/4.3 ± 3.0s.

Hip Protectors

Regain Confidence - Prevent Inactivity!

One-Piece System is the most comfortable to wear men's hip protector. This popular SOFT HIProtector SafeHip is easy to put on and comfortable to wear

They don’t seem to work

http://www.cdc.gov/HomeandRecreationalSafety/images/CDC_Guide-a.pdf

Specialty organizations

• National Gerontological Nursing AssociationLueckenotte, A.G. & Conley, D.M. (2009). A study guide for evidence-based approach to fall assessment and management. Geriatric Nursing 30(3), 207-216.

•American Nurses AssociationJorgensen, J. (2011). Reducing patient falls: A call to action. Supplement to American Nurse Today Special Report: Best Practices for Falls Reduction, A Practical Guide, 2-20.

• American Geriatrics Society and British Geriatrics Societyhttp://americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2010/

Federal Guidelines

• Agency for Healthcare Research and QualityFall Management Guidelinehttp://www.guideline.gov/content.aspx?id=13484http://www.innovations.ahrq.gov/content.aspx?id=2052

• Centers for Disease Control and Preventionhttp://www.cdc.gov/HomeandRecreationalSafety/Falls/FallsPreventionActivity.html#7

For People We Serve

• National Institutes of Health(NIH) SeniorHealth http://nihseniorhealth.gov/falls/toc.html

• National Institute on Aging – Age Page Falls and Fractures www.nia.nih.gov/HealthInformation/Publications/falls.htm

• Centers for Disease Control and Prevention www.cdc.gov/injury

• National Center for Injury Prevention and Control www.cdc.gov/ncipc

• American Geriatrics Society Patient Education Forum www.gericareonline.net

• UCLA Division of Geriatrics – Patient Education www.geronet.ucla.edu/centers/acove/patient_education.htm

• Your falls experiences• What you do to prevent falls• What you do after falls• What you recommend that has

worked to Prevent falls

Discussion

• Contact:• Kelly Dunn• 830 446 6507• Or • dunnm@uthscsa.edu

For More Information