Geriatric Care Management Managers

Geriatric Care Management

SUMMER/

FALL 2003

NUMBER 2

VOLUME 13

Published by the

NationalAssociation ofProfessionalGeriatric CareManagers1604 North CountryClub Road

Tucson, Arizona85716-3102

520.881.8008 / phone

520.325.7925 / fax

www.caremanager.org

Guest Editor's MessageBy Julie A. Braun, J.D., LL.M.

page ....................................................................................................................... 2

Guest Editor's MessageBy Steven Charles Castle, M.D.page ....................................................................................................................... 3

Federal Legislation Seeks To Reduce Falls AmongOlder AmericansBy Julie A. Braun, J.D., LL.M.page ....................................................................................................................... 4

Perspective by Senator Michael B. Enzi .................... 4Perspective by Senator Barbara A. Mikulski ............. 5

Home Safe Home: Preventing Falls ThroughEnvironmental Assessment & ModificationBy Julie A. Braun, J.D., LL.M.page ....................................................................................................................... 8

What Professional Geriatric Care Managers Need toKnow: A Nursing Home UpdateBy Julie A. Braun, J.D., LL.M. with an introduction by Marcie Parker, Ph.D., CFLEpage .....................................................................................................................13

Practical Fall Risk Assessment in Older Adults withMultiple Medical Problems and/or Chronic DiseaseBy Steven Charles Castle, M.D. & Dorene Opava-Rutter, M.D.page .....................................................................................................................17

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Falls are the leading cause ofinjury, death and disability amongpersons 65 years of age and older.Therefore, this issue devotes itsattention solely to falls and fall-relatedinjuries.

Geriatric care management takesmany shapes and continues to evolveinto new practice contexts. Conse-quently, professional geriatric caremanagers (PGCMs) should keepabreast of recent legislation, litigationand regulation that may impact theirprofession. This issue begins byreviewing federal legislation, ElderFall Prevention Act of 2003 (S. 1217),that seeks to reduce falls among olderAmericans (page 4) and suppliesperspectives on the subject by billsponsors, U.S. Senators Michael B.Enzi and Barbara A. Mikulski (pages 4and 5, respectively).

The issue continues its efforts toupdate the PGCM's knowledge bysharing results of a web-based surveyreleased in March/April 2003 thathighlights the surge in litigationinvolving nursing homes along withsignificant increases in averagerecovery size for claims involving fall-related injuries, pressure ulcers,dehydration and weight loss, improperuse of physical restraints, medicationerrors, and sexual assault (page 13);conveying findings of a GeneralAccounting Office report (July 17,2003) noting that the proportion ofnursing homes with serious qualityproblems remains unacceptably high,despite a decline in the incidence ofserious problems (page 14); andrelating data from a July 2003 Office ofInspector General report regardingombudsman resident care complaintcategories (page 15). This informationallows the PGCM to identify trends,issues, and concerns in institutionallong-term care making them betteradvocates for their clients.

The issue then shifts topics tohome assessment and modification.According to a May 2003 AARPhousing survey, These Four Walls . . .Americans 45+ Talk About Home and

Guest Editor's MessageBy Julie A. Braun, J.D., LL.M.

Community, http://research.aarp.org/il/four_walls.html, 83 percent of olderAmericans prefer to stay in theircurrent homes for as long as possible.Respondents believe their homescomfortable as well as convenient andemphasize that they feel secure andindependent there. However, aspeople age, their physical and/ormental abilities may change making itdifficult or even impossible to remainin their residence without environmen-tal modifications. PGCMs offer avariety of services that may incorpo-rate an environmental audit into theassessment process. During thisdiagnostic home visit, the PGCMassesses environmental hazards andrecommends modifications tailored tothe client’s unique needs. The goals:to promote mobility, reduce thelikelihood of falling, ensure continuedindependence, and improve quality oflife. Learn more by reading Home SafeHome: Preventing Falls throughEnvironmental Assessment &Modification (page 8).

Next, the issue considers Practi-cal Fall Risk Assessment in OlderAdults with Multiple MedicalProblems and/or Chronic Disease

(page 17). This article offers PGCMsa better understanding of the fallassessment process from a clinicalperspective. It covers, among otherareas, taking a falls history, reviewingfall event(s), underlying medicalconditions that contribute to falls,issues that worsen fall risk, andmedical problems that increaseexposure to falls.

Last, issue content is punctuatedthroughout with brief reminders on therelationship between falls and foot-wear, falls and osteoporosis, and fallsand vision.

Julie A. Braun, J.D., LL.M., guesteditor, thanks Jihane K.Rohrbacker, CommunicationsDirector of the National Associationof Professional Geriatric CareManagers, for her thoughtfulcomments on issue content as well asher assistance, patience and humorduring issue creation, assembly andgeneration. In addition, Ms. Braunappreciated the invaluable editorialinput kindly offered by MarcieParker, Ph.D., CFLE, incomingChair of the GCM Journal EditorialBoard; the generosity of Jeffrey M.Levine, M.D. who shared his wonder-ful photographs; and the opportu-nity to work with Steven CharlesCastle, M.D., a talented internation-ally-recognized falls expert.

EDITORIAL BOARDRona Bartelstone, MSWFort Lauderdale, FL

Lenard W. Kaye, Ph.D.Bryn Mawr, PA

Karen Knutson, MSN, MBA, RNCharlotte, NC

Monika White, Ph.D.Santa Monica, CA

EDITOR--IN CHIEFMarcie Parker, Ph.D., CFLEGolden Valley, MN

COMMUNICATIONSDIRECTORJihane K. RohrbackerTucson, AZ

GRAPHIC DESIGNERKristin L. HagerMcKinney, TX

Published by the:National Association of

Professional Geriatric Care Managers

1604 North Country Club RoadTucson, AZ 85716-3102 * www.caremanager.org

© Copyright 2003

The GCM Journal is published as a membership benefit tomembers of the National Association of Professional GeratricCare Managers. Non-members may subscribe to GCMJournal for $95.00 per year. Send a check for your one-yearsubscription to: Subscription Department, GCM,1604 N. Country Club Road, Tucson, AZ 85716-3102.

Geriatric Care Management

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Guest Editor's MessageBy Steven Charles Castle, MD

Professional geriatric caremanagers (PGCMs) are generallycontacted in times of near crisis for anelder and their families. Part of thereward is making a difference whenfamilies are stressed beyond theirlimits. The PGCM does this byadvocating for the client and helpingthe client to navigate the complexityof geriatric syndromes, and aiding theclient's understanding of the nuancesof continuity of care in many types ofhealth care settings. The crisissituation may center around attemptsat prevention of a serious eventreviewed in this journal: falls. Falls,while often catastrophic, have beenshown to be preventable, and henceone source of the rapid increase inlitigation in the long-term care setting.

Litigation matters are not part ofmost PGCMs' training. At the centerof most litigation matters, outside ofegregious actions, is the debate overwhether the standard of care wasprovided. Improved understanding offall events and falls-related injurieswill improve a care manager's abilityto act as an advocate. The goal is toprovide a more practical understand-ing of the complexity of falls and their

Assessing fall risk in older adults is challenging in any setting.The VA Greater Los Angeles Fall Prevention Clinic Teamtackles the complexity of the issue. Team members picturedleft to right include Ashal Sahai, Dorene Opava-Rutter, M.D.(Physiatrist, Co-Developer), Maria Peralta Manzano, BobWeaver, Parisa Mazandarani, Kyle Patterson, Mona Fiuzat,Pharm.D., Steven Charles Castle, M.D. (Geriatrician, Co-Developer), Michelle Voss-McCarthy, D.P.T. Karen Perell(Biomechanist, Principal Investigator) is not pictured.

outcomes, balanced with informationrelated to the medico-legal liability inthis high-risk area.

This balanced approach will betterenable the PGCM to assist clients andfamilies to ask appropriate questions.A PGCMshouldprovide thesugges-tions,supportandfacilitateaccess toservicesthat are ator exceedthestandard ofcare forpersons atrisk forfalls.Despitethechallenge,there istremen-dousreward intruly

making a difference when it mattersmost, even though untoward eventsmay happen, because you have givenclients and families the confidencethat they have done all that could bedone by considering various ap-proaches to fall management.

Impaired vision is highlyprevalent and notably unreportedin the elderly population particu-larly among older women andnursing home residents. Visualimpairment is a recognized riskfactor for falls and influences therisk of hip fracture makingidentification of such a deficitcritical to the design of anappropriate fall prevention inter-vention. Clinical studies under-score the relationship between

Relationship Between Falls & VisionBy Julie A. Braun, J.D., LL.M.

falls and certain visual factors: poorvisual acuity, impaired contrastsensitivity, decreased visual field,posterior subcapsular cataracts,and nonmiotic topical glaucomamedications. A fall interventionstrategy should incorporate aregular ophthalmic examination todetect, monitor, or treat an olderadult’s vision as low vision may becompounding or causing falls. Anappropriate intervention for an olderadult with reduced retinal sensitivity

and hence impaired dark adapta-tion might include the provision ofa nightlight to offset the influenceof impaired dark adaptation. Achange in an eyeglass prescrip-tion, correcting refractive error,improving stereopsis (i.e. depthperception), or cataract extrac-tion, among other possibilities,may improve visual function andprevent a future fall and fall-related fracture.

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P E R S P E C T I V E

Senator Michael B. Enzi on the

Elder Fall Prevention Act of 2003

Walking—climbing the stairs. Things we may takefor granted. But for many of our nation’s elderly, they area source of anxiety and apprehension.

Anyone with an elderly parent, relative or friendwho lives alone has experienced concern when atelephone call goes unanswered. Our first reactionoften is worry because we know that for many olderadults a fall can result in serious injury. As the

telephone continues to ring we wonder if Mom is upstairs and can’t hearthe phone, whether Dad is in his workshop, or our friend has steppedoutside to catch a breath of fresh air. We hang up, wait a few minutes andplace our call again, often with a greater sense of urgency as we envisionour loved one suffering from the effects of a fall, alone, with no one to helpthem. Then, when the telephone is answered, a huge rush of relief over-comes us as we realize our fears were misplaced.

Wish that every such story would have this happy ending. For toomany older adults, however, it ends tragically as brittle bones and areduction in our sense of balance become a formula for serious injury andconsequent change in quality of life. Although the physical healingprocess after a fall can be long and traumatic, it often pales in comparisonto the psychological effects of a loss of confidence – and therefore activity– of an elderly individual who no longer takes for granted the ability towalk and safely navigate their world without assistance or support.

Fortunately, there are things that can be done to reduce the number ofthese tragic falls and restore the confidence of our loved ones in their

(continued on page 6)

Federal Legislation SeeksTo Reduce Falls Among

Older AmericansBy Julie A. Braun, J.D., LLM.

On June 9, 2003, U.S. SenatorsMichael B. Enzi (R-Wy.) and BarbaraMikulski (D-Md.) introduced the ElderFall Prevention Act of 2003 (S. 1217),a bill that seeks to address falls amongAmerica’s elder population. Subse-quently, the measure was referred tothe Senate Committee on Health,Education, Labor, and Pensions.Senator Tim Hutchinson (R-Ark.) andCongressman Frank Pallone, Jr. (D-N.J.) introduced a similar measure lastyear in the Senate and House,respectively (S. 1922 and H.R. 365).

Falls-Related Statistics

The proposed legislation relatesthe following statistics concerningfalls and fall-related injuries:

� Falls are the leading cause ofinjury deaths among persons 65years of age and older;

� By the year 2030, as the babyboomer generation is added tothe ranks of the elderly, thenumber of people over age 65 isexpected to double, potentiallydoubling the number of elderfalls and by 2050, the number ofindividuals 85 years of age orolder will quadruple;

� In 2000, falls among elderlyindividuals accounted for10,200 deaths and 1,600,000emergency department visits;

� Sixty percent of fall-relateddeaths happen to persons whoare age 75 and older;

� One fourth of elderly personswho sustain a hip fracture diewithin one year;

� Hospital admissions for hipfractures among the elderlyincreased from 231,000 admis-sions in 1988 to 332,000 in 1999with the number of hip fractures

expected to exceed 500,000 by2040;

� Annually, more than 64,000individuals who are over 65years of age sustain a traumaticbrain injury (TBI) as a result ofa fall;

� 40,000 individuals over age 65visit emergency departmentswith TBIs sustained as a resultof a fall each year, of which

16,000 are hospitalized and4,000 die; and

� Rate of fall-induced TBIs forindividuals 80 years of age orolder increased by 60 percentfrom 1989 to 1998.

Bill Overview

The Elder Fall Prevention Act of2003 adopts a national approach toreducing elder falls and focuses onthe daily life of older adults inresidential, institutional, and commu-nity settings. The effort incorporatesa wide range of organizations andindividuals including family members,caregivers, health care providers,social workers, and others who touchthe lives of senior citizens. The billseeks to amend the Public Health


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P E R S P E C T I V E

Senator Barbara A. Mikulski on the

Elder Fall Prevention Act of 2003

Falls don’t discriminate. Kay Graham was thevictim of a fall. Many of us have friends or relativeswho have fallen. A fall can have a devastating impacton a person’s physical, emotional, and mental health.If an older woman loses her footing on her front porchsteps, falls, and suffers a hip fracture, she likely wouldspend about two weeks in the hospital, and there is a50 percent chance that she would not return home or

live independently as a result of her injuries.

Last year, I chaired a hearing of the U.S. Senate Subcommittee onAging on the problem of elder falls. The Subcommittee heard testimonyfrom Lillie Marie Struchen, a 91-year-old woman who had recently fallen inher bathroom when she slipped on the tile. Lillie Marie could not reach thepanic button in her apartment, and it took her some time before she couldget to her feet and call for help. Lille Marie was lucky. She recovered fromher fall and returned to her normal routines. She shared with the Subcom-mittee some steps that she and her family had taken to prevent future falls,knowing that she may not be so lucky next time.

These falls, like the ones that Lillie Marie and thousands of otherssuffer from each year, can be prevented. With some help, there are simpleways that seniors can improve the safety of their homes and make a fall farless likely. Home modifications like handrails in the bathroom, rubber matson slippery tile floors, and cordless telephones that seniors can keepnearby can make a big difference. Well-trained pharmacists can review


Service Act (42 U.S.C. 241 et seq.) todirect the Administration on Agingwithin the Department of Health andHuman Services to oversee anddevelop public education on fallprevention for the elderly and thoseinvolved with the elderly, expandresearch on approaches to fallprevention and treatment, andevaluate the effect of falls on thecosts of Medicare and Medicaid aswell as the potential for reducingthose costs through education,prevention and intervention.

Public EducationCampaign

Federal grant money wouldestablish a three-year nationaleducation campaign by the NationalSafety Council (NSC) and providegrants to state coalitions for localeducation campaigns addressingreduction and prevention of elderfalls. The educational effortsprincipally target elders, theirfamilies, and health care providers.

Research Initiatives

Under the Elder Fall PreventionAct of 2003, the Centers for DiseaseControl and the Agency forHealthcare Research and Qualitywould conduct and support researchto:

� Identify older adults who havea high risk of falling;

� Better data collection andanalysis to identify fall riskand protective factors;

� Design, implement, andevaluate fall preventioninterventions to ascertain themost effective of the numer-ous potential strategiesavailable;

� Improve strategies alreadyproven effective in reducingfalls by tailoring thesestrategies to specific elderlypopulations;

Federal LegislationSeeks To Reduce FallsAmong OlderAmericans

(continued from page 4)

� Maximize the dissemination ofproven, effective fall preventioninterventions;

� Expand proven interventions toprevent elder falls;

� Improve the diagnosis, treat-ment, and rehabilitation ofelderly fall victims; and

� Assess the risk of falls occur-ring in various settings.

Further, the bill recommendsresearch concerning barriers toadopting proven fall interventions(e.g., medication review and visionenhancement); development, imple-mentation and assessment of the mosteffective approaches to reducing fallsamong the very high risk elders livingin assisted living facilities, nursinghomes, and other types of long-termcare facilities; and effectiveness ofcommunity programs in preventing

assisted living and nursing home falls.

Demonstration Projects

In addition, the Elder FallPrevention Act of 2003 authorizesgrants for the NSC and other qualifiedorganizations to conduct demonstra-tion programs in the following areas:

� A multi-state project investigat-ing the utility of targeted fallrisk screening and referralprograms;

� Programs designed for commu-nity-dwelling elderly individu-als that rely upon multi-component fall interventionapproaches, including physicalactivity, medication assessmentand reduction when possible,vision enhancement, and homemodification strategies;


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� Interventions targetingnewly-discharged fall victimswho are at high risk for arepeat fall;

� Private sector and public-private partnerships todevelop technology toprevent falls and prevent orreduce injuries if falls occur;

� Design, implementation, andevaluation of fall preventionprograms using provenintervention strategies inresidential as well as institu-tional settings; and

� A multi-state demonstrationproject to implement fallprevention programs usingproven intervention strate-gies designed for multi-familyresidential settings with highconcentrations of elders thatidentifies high risk popula-tions, evaluates residentialfacilities, conducts screeningto identify high risk individu-als, provides pre-fall counsel-ing, coordinates services withhealth care and social serviceproviders, and harmonizespost-fall treatment andrehabilitation.

Review ofReimbursementPolicies

According to bill content, theestimated total cost for non-fatalTBI-related hospitalizations for fallsin individuals who are 65 years ofage or older is more than$3,250,000,000. Two-thirds of thesecosts are associated with individuals75 years of age or older. The coststo Medicare and Medicaid programsand society as a whole from falls byelderly persons continue to climbmuch faster than inflation andpopulation growth. Direct costsalone will exceed $32,000,000,000 in2020, posing an additional burdenon already strapped Medicare and

Medicaid funding. There-fore, bill sponsors believethat the federal govern-ment should devoteadditional resources toresearch concentrating onthe prevention andtreatment of falls amongolder adults in residential,community and institu-tional settings. Thislegislation supportsproactive and preventiveapproaches to geriatricfalls and contemplates areview of the effects offalls on the costs of theMedicare and Medicaidprograms along with thepotential for reducing suchcosts. Evaluation ofreimbursement policies willconsider coverage ofadditional fall-relatededucation, prevention, andearly intervention servicesand reimbursementguideline modification.

LegislationGarners Broad-Based Support

The Elder FallPrevention Act of 2003has garnered the supportof many advocacy groups,including the congression-ally chartered NSC(www.nsc.org), theEmergency NursesAssociation(www.ena.org), theAssisted Living Federationof America (www.alfa.org),the American GeriatricsSociety(www.americangeriatrics.org),the Brain Injury Associa-tion (www.biausa.org), andthe American Health CareAssociation(www.ahca.org). Thesegroups and others haveagreed to be partners inthis comprehensive effortto address one of theleading causes of deathand disability in theelderly.

ability to once again lead a normal life. In aneffort to address this issue I am introducinglegislation, together with Senator Barbara A.Mikulski (D-Md.), which would take a multi-faceted approach to solving this problem.The Elder Fall Prevention Act of 2003 willexamine every aspect of this matter, fromeducating the elderly about how to “fall-proof” their home, to researching the causesof most falls and trying to find ways to avoidfalls and to provide better treatment to thoserecovering from them.

The largest generation in our country’shistory is rapidly approaching retirement.Passing this bill into law will mean a betterquality of life for them and for all of ournation’s elderly. The sooner we act thesooner we can begin to work to prevent fallsand help our nation’s elderly live safely andin better health.

Source: Excerpted and adapted from 149Cong. Rec. S7554, S7555 (daily ed. June 9,2003) (statement of Sen. Enzi), available at<http://www.gpoaccess.gov/crecord/>.

Contact The Honorable Michael B. Enzi at hisoffices in Washington, D.C. or Wyoming (Casper,Cheyenne, Cody, Gillette and Jackson).

Washington, D.C. OfficeRussell Senate Office Building, Suite 379Washington, D.C. 20510(202) 224-3424Fax: (202) [email protected]

Casper (Wy.) OfficeFederal Center100 East B Street, Suite 3201Casper, WY 82601(307) 261-6572

Cheyenne (Ay.) OfficeFederal Center2120 Capitol Avenue, Suite 2007Cheyenne, WY 82001(307) 772-2477

Cody (Wy.) Office1285 Sheridan Avenue, Suite 210Cody, WY 82414(307) 527-9444

Gillette (Wy.) Office400 S. Kendrick Avenue, Suite 303Gillette, WY 82716(307) 682-6268

Jackson (Wy.) OfficePO Box 12470Jackson, WY 83002(307) 739-9507

Perspective: SenatorMichael B. Enzi


Federal LegislationSeeks To Reduce FallsAmong OlderAmericans


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Perspective: SenatorBarbara A. Mikulski

(continued from page 5)medications to make sure that twodrugs do not interact to causedizziness and throw a senior offbalance.

That’s what the Elder FallPrevention Act of 2003 is about— getting behind our Nation’sseniors and giving help to thosewho practice self-help. This billcreates fall prevention publiceducation campaigns for seniors,their families, and health careproviders. It expands research onelder falls to develop better waysto prevent falls and to improve thetreatment and rehabilitation ofelder falls victims. This legislationalso requires an evaluation of theeffect of falls on Medicare and

Medicaid, to look at potentiallyreducing costs by expanding coverageto include fall-related services.

Reducing the number of falls willhelp seniors live longer, healthier,more independent lives. I lookforward to working with SenatorMichael B. Enzi (R-WY.) and mycolleagues on the Health, Education,Labor, and Pensions Committee to getthis bill signed into law.

Source: Excerpted and adaptedfrom 149 Cong. Rec. S7555 (daily ed.June 9, 2003) (statement of Sen.Mikulski), available at <http://www.gpoaccess.gov/crecord/>.

Contact The Honorable Barbara A.Mikulski at her offices in Washington,D.C. or Maryland (Baltimore, Annapolis,Greenbelt, Hagerstown and Salisbury).

Washington, D.C. OfficeHart Senate Office Building, Suite 709

Washington, D.C. 20510-2003(202) [email protected]

Baltimore (Md.) OfficeBrown’s Wharf1629 Thames Street, Suite 400Baltimore, MD 21231(410) 962-4510

Annapolis (Md.) Office60 West Street; Suite 202Annapolis, MD 21401-2448(410) 263-1805

Greenbelt (Md.) Office6404 Ivy Lane, Suite 406Greenbelt, MD 20770-1407(301) 345-5517

Hagerstown (Md.) Office94 West Washington StreetHagerstown, MD 21740-4804(301) 797-2826

Salisbury (Md.) Office1201 Pemberton DriveSuite 1E, Building BSalisbury, MD 21801-2403(410) 546-7711

Osteoporosis & FallsBy Julie A. Braun, J.D., LLM., Guest Editor

Osteoporosis, a skeletaldisorder characterized by com-promised bone strength predis-posing an individual to an in-creased risk of fracture, affectsmore than 10 million Americansand an additional 18 million havelow bone mass placing them atrisk for this disorder (NIH).According to a National Institutesof Health (NIH) consensusstatement on osteoporosisprevention, diagnosis, andtherapy, residents of long-termcare facilities are at particularhigh risk of fracture. The consen-sus statement advises that mostresidents have low bone mineraldensity as well as a high preva-lence of other risk factors forfracture, including advanced age,poor physical function, lowmuscle strength, decreasedcognition and high rates ofdementia, poor nutrition, and,often, use of multiple medica-tions.

Fracture prevention is aprimary goal in the treatment ofpersons with osteoporosis. An

osteoporotic fracture can be atragic outcome of a fall withsignificant, long-term physical,psychosocial and financial conse-quences. Therefore, managementof osteoporosis is an importantadjunctive approach to caring for aperson who presents with a risk offalls (Campbell 2002). Assortedtreatment modalities are availablefor older adults with osteoporosis,male or female, who have a historyof falls or are assessed as being atrisk for falls. A multifactorialapproach to preventing falls (e.g., aphysical activity program forambulatory older adults thatincorporates Tai Chi) coupled withtreatment for osteoporosis (e.g.,hormone replacement therapy,calcium intake obtained through dietor supplements, vitamin D andantiresorptive agents) may reducethe likelihood of a fall-related os-teoporotic fracture (AGS 2001;Agency for Healthcare Research andQuality 2000A and 2000B; Stevens1997).

References

Agency for Healthcare Research andQuality. Osteoporosis Guidelines.National Guideline Clearinghouse(2000A), http://www.guideline.gov.

Agency for Healthcare Research andQuality. Hormone Replacement TherapyGuidelines. National Guideline Clearing-house (2000B), http://www.guideline.gov.

American Geriatrics Society (AGS),British Geriatrics Society, and AmericanAcademy of Orthopaedic Surgeons Panelon Falls Prevention. “Guideline for thePrevention of Falls in Older Persons."Journal of the American Geriatrics Society2001;49:664–72.

Campbell, A.J. “Commentary. PreventingFractures by Preventing Falls in OlderWomen." Canadian Medical AssociationJournal 2002 Oct 29;167(9):1005-05.

Osteoporosis Prevention, Diagnosis, andTherapy. National Institutes of Health(NIH) Consensus Statement Online 2000March 27-29; 17(1):1-36, <http://www.consensus.nih.gov/cons/111/111_statement.htm>.

Stevens, J.A. “The Association ofCalcium Intake and Exercise with HipFracture Risk among Older Adults"[Dissertation]. Atlanta (GA): EmoryUniversity: 1997.

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Falling is the leading cause ofdeath in women and the fourth leadingcause of death in men between 65 and85 years of age. It is the leading causeof death for men and women over age85. The percentage of falls amongcommunity-dwelling older adultsincreases from 25 percent at age 70 to35 percent after age 75. Therefore, itmakes sense for geriatric care manag-ers (PGCMs) to incorporate anenvironmental audit into the assess-ment process. Most older adults wishto continue to live in their own homesfor as long as possible; however, thesehomes likely are not designed to meettheir changing needs. Environmentalmodifications can promote mobilityand reduce the likelihood of falling.This article considers environmentalassessment and modification relatingto lighting conditions throughout theclient’s home; floor coverings such ascarpets, rugs, runners and mats (butnot ceramic tiles, linoleum, wood orother floor surfaces); electrical,telephone, extension and other cords;stairs and steps; and the client’sbathroom.

Proper Lighting

Tailor lighting to client visualneeds. In general, older adults requiretwo to three times more light thanyounger persons due to normalchanges in visual function thataccompany the aging process.However, lower levels of lighting maybe appropriate for some individuals.For example, enhanced lighting mayimpair vision and increase fall risk for

Home Safe Home:Preventing

Falls ThroughEnvironmentalAssessment &Modification

By Julie A. Braun, J.D., LL.M.

individuals with cataracts or glau-coma. Ideally, the level of illuminationis visually comfortable and safe formobility.

One way a PGCM can determinelighting appropriateness is to observethe client in their home environmentand record any difficulties the clientencounters. These observations mayprompt recommendations for increas-ing, decreasing, or redistributinglighting levels. The GCM also shouldtour the client’s home. Does the clienthave effortless physical access to alllighting? Are light switches posi-

tioned approximately 32 inches abovethe floor? Located directly inside oroutside doorways and easily visibleso the client does not have to traversea darkened room to activate or gropeto find? If appropriately located butnot visible, improve detection byusing switchplates that contrast incolor with the room wall. Purchaseswitchplates in a different color,remove existing switchplates and re-paint, or apply colored adhesive tapearound their borders. Alternatively,substitute existing light switches witha “glow switch” that can be seen inthe dark. In addition, client functionalstatus may prompt replacement oftraditional toggle switches with user-friendly pressure plate controls.

High fall risk locations within theclient’s home (e.g., path from thebedroom to the bathroom) requirespecial lighting to promote safemobility and reduce the likelihood offalling. In the bedroom, for instance,the PGCM might recommend a bedsidetable lamp with a sufficient base toprevent it from tipping over positionedto avoid excessive reaching andpossible balance loss, convenientheadboard lighting, or a nightlight foradequate illumination. Add a workingflashlight to the bedside table drawer(as well as other locations throughoutthe client’s home) for quick, easyaccess during a power outage.

The ability of the aging eye toadapt to sudden changes in lightingintensity decreases with age. Amomentary visual loss and an increasein fall risk may occur when the clientmoves between dark and brightlyilluminated areas. Therefore, proposeinstalling rheostatic light switchesthat permit the client to increase ordecrease illumination levels asdesired. Unlike toggle light switchesor pressure plate controls, rheostaticlight switches prevent sudden andpronounced shifts in lighting.

Other recommended environmen-tal modifications might include:

� Replacing burned out lightbulbs.

� Installing additional lighting(e.g., lamps, light fixtures, ornightlights) where appropriate.

Falling is the

leading cause of

death in women and

the fourth leading

cause of death in

men between 65

and 85 years of age.

It is the leading

cause of death for

men and women

over age 85.

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Home Safe Home


Passageways between rooms,stairwells, and other heavytraffic areas should be well lit.

� Using inexpensive nightlightsthat plug into electrical outletsto illuminate hallways, bed-rooms and bathrooms.

� Installing power failure lightsin key areas to prevent walkingin the dark. These simpledevices can be installed inelectrical outlets and areespecially helpful near stairs.

� Using the right type andmaximum wattage bulb allowedby the fixture.

� Reducing sources of glarethrough frosted bulbs, shadesor globes on light fixtures,indirect lighting, partiallyclosing draperies or blinds,tinted mylar shades or polar-ized window glass.

Carpets, Rugs, Runnersand Mats

Hospital emergency roompersonnel routinely treat adults over65 years of age for injuries sustainedafter a fall-related event in their homethat such older individuals commonlydescribe as a slip, stumble, trip, lossof footing or near fall involving acarpet, rug, runner or mat. Conse-quently, the geriatric care managermust consider these floor coveringswhen performing a fall hazardassessment of the client’s currentphysical environment.

The PGCM might begin theassessment process by asking theclient or, if present, their familymembers and friends about anyknown falls associated with carpets,rungs, runners or mats. In addition,the PGCM can use his or her ownobservations as a guide whenadvising of environmental risk factorsand home modification recommenda-tions. For example, are the floorcoverings in good repair or notice-ably worn and torn? Also valuable isthe PGCM’s own experience whilewalking on the client’s carpets, rugs,runners or mats. For instance, do the

floor coverings bunchup or slide when thePGCM walks on them?

Home modificationsmight include, amongother possibilities:

� Removing andreplacing anycarpet, rug,runner, or matthat tends tobunch up or slideunderfoot.

� Avoiding throwrugs.

� Purchasing onlycarpets, rugs,runners and matsfeaturing slip-resistant backingor padding.Remember thatsuch material canbecome lesseffective after repeatedwashings and, therefore, mayrequire replacement occa-sionally.

� If the client’s budget makesnew purchases unlikely,ensuring that offendingcarpets, rugs, runners, and matsare slip-resistant by, amongother options, applying double-faced adhesive carpet tape tothe item’s reverse side (seegraphic above) or addingrubber matting beneath theproduct. Adhesive tape andrubber matting that can be cutto size typically are available atlocal flooring and carpet outletsas well as home improvementstores. Periodically checkwhether new tape or rubbermatting is needed because theadhesive on the tape can wearaway over time and the rubbermatting can deteriorate leavinga powdery substance on thebare floor.

� Making certain that carpets,rugs, runners and mats lie flatand are placed on even floorsurfaces.

Choosing aesthetically pleasingcarpets, rugs, runners and mats thatcomplement client preferences must bebalanced with functional floor

Applying double-faced adhesive carpet tape toreverse side of carpets, rugs, runners, and mats isone way to ensure slip-resistance.

The ability of

the aging eye to

adapt to sudden

changes in lighting

intensity decreases

with age.

A momentary visual

loss and an increase

in fall risk may occur

when the client

moves between dark

and brightly

illuminated areas.

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summer/fall 2003

Home Safe Home


coverings that promote safe naviga-tion. Consider, for example, a client’slifelong preference for wall-to-wallshag carpeting that may snag canes,walkers or wheelchairs causing theclient or a visitor to fall. The GCMshould recommend a more sensibleuncut low pile product and suggestthat the replacement floor coveringretain the color of the shag carpetunless the color choice also presents apotential fall hazard.

As people age, a number ofnormal changes in the eye’s anatomyoccur as can several common visualdisorders such as difficulty infocusing, delayed glare recovery,decreased sensitivity to light, delay indark/light adaptation, decreasedcontrast sensitivity, loss of depthperception, and constriction ofperipheral vision. Keep these factorsin mind when proposing colors forfloor coverings (walls or furnishings).Floral or checkered configurationsmay lead to misjudgment of spatialdistances, for example, while black ona blue background may be difficult todistinguish for an older adult withdecreased contrast sensitivity andcarpeting with bold patterns may bedisorienting for older adults withlimited depth perception.

The PGCM cannot ignore the fallhazards presented by surface changesthat occur throughout the client’shome (e.g., transition from carpeting inthe living room to linoleum in thekitchen). Changes in surface cancause a loss of balance unless easilydistinguishable by the older adult.Floor coverings in contrasting colorscan visually cue the client to theboundary between the surfaces aswell as the floor and wall.

The assessment of the client’scarpeting, rugs, runners and matsmust be considered within a broadercontext of the client’s comprehensiveassessment. A client with shakyhands or loss of some or all controlover bladder function, for example,may prefer stain resistant easy-to-clean carpeting.


Electrical, Telephone,Extension and otherCords

The PGCM should walk throughthe client’s house and note placementof all electrical, telephone, extensionand other cords. Avenues of inquirymight include:

� Are cords positioned out of theflow of foot traffic where theymight cause someone to tripover them even if such possibil-ity is remote?

� Are one or more cords lyingunderneath and/or protrudingout from beneath a piece offurniture creating a fall hazard(along with fire and shockhazards if furniture weight hasdamaged cords)?

� Are any cords lying underneathand/or protruding out from or acarpet, rug, runner or mat wherethey may cause a fall (or a fire)?

Home modificationsmight involve:

� Finding a newlocation for theoffending cords,preferably alonga wall and notunder thefurniture,carpeting, rugs,runners or mats;

� Re-arrangingfurniture so thatelectrical outletsare available forlamps andapplianceswithout need forextension cords;

� Placing cords on the floor outof the way (e.g., against a wall)where people cannot trip overthem or fastening up extracordage with a twist tie;

� Removing cords from underfurniture or carpeting;

� Moving the telephone so that itscord is out of walking paths yetremains accessible if client has tocall for help if he or she falls.

Stairs & Steps

The geriatric care manager shouldask the client if he or she has difficultywith steps or stairs? For all stairways,the PGCM should check lighting,handrails, and the condition of theindividual steps and their coverings.Lighting is an important factor inpreventing falls even amongstpersons familiar with the stairs. Aretwo-way light switches located at thetop as well as the bottom of insidestairs? Are the switches accessible?The client should be able to turn onthe lights from either end before usingthe stairway. Stairs should be well litso that each step, particularly stepedges, is clearly seen while going upand down stairs. The lighting shouldnot produce glare or shadows alongthe stairway. Consider installingmotion-detector lights that turn onautomatically and light the stairwaywhenever the client approaches.

Handrails are an importantaddition to any stairway and the clientshould be educated on the importanceof their routine use. Do all stairs inthe client’s home feature sturdyhandrails fastened securely on bothsides of the stairway about 30 inchesabove the stairs? Do handrails runcontinuously from the top to thebottom (i.e., full length) of the entireflight of stairs and slightly beyond thesteps? If not, the client may incor-rectly perceive that he or she has

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summer/fall 2003

arrived at the last step when thehandrail stops. Misjudging the laststep can trigger a fall. Are thehandrails comfortable to grip?Environmental modificationsinvolving handrails might includerepairing broken handrails, tighten-ing the fixtures that secure thehandrails to the wall, installing atleast one handrail (on the right sideas the client faces down the stairs) ifno handrails are present, or replacing ashort handrail with a longer one.

The GCM next shifts attentionto the stair steps and their cover-ings, if any. Are steps even (i.e.,same size and height)? A smalldifference in step surface or riserheight can lead to falls. Mark anysteps that are especially narrow orhave risers higher or lower than theothers. Do the steps allow securefooting? Consider placing non-slipadhesive treads on each bare step toimprove traction. Are step edgesclearly visible? Can the client detectthe outline of each step as well astop and bottom landings with thelight on? A fall may occur if stepedges appear blurred or are difficultto spot. Replace any patterned, darkor deep-pile carpeting with a tightlywoven carpet in solid color to betterhighlight step edges. Are all stepsin good condition (i.e., not loose,broken or missing)? If not, repair orreplace loose, broken or missingboards immediately. Do staircoverings (i.e., rugs or treads) showsigns of wear? Worn, torn or loosecoverings can lead to insecurefooting, resulting in slips or falls.(see graphic on p.10) Thus,recommend repair or removal andreplacement of any stair coverings indisrepair.

Is anything stored on thestairway, even temporarily? Theclient may trip over any objects lefton stairs, particularly in an emer-gency (e.g., fire) or when racing toanswer the telephone. Accordingly,remove all items from the stairwayand remind client to keep stairs freeof clutter.

Home Safe Home


Bathrooms

Using Fixtures for BalanceSupport May Contribute toFalls

A client with balance dysfunctionor one who is unable to use a walkerin the bathroom because of spacelimitations may rely upon the towelbar, wall surfaces, and sink top forsupport. This habit may cause a fall,particularly if the client’s hand slips.Modifications to provide balancesupport include substituting a grabbar for the towel bar or installing agrab rail around the perimeter of thebathroom wall. Further, applying non-slip adhesive strips along sink surface(in a color similar to the sink to avoidvisual confusion) will prevent theclient’s hands fromsliding when sink areais grasped.

Toilet HeightMust MeetClient Needs

Toilet height cancause a fall andinfluence an olderadult’s ability tophysiologically usethe toilet. Sittinginstability mayhappen if the olderadult cannot place hisor her feet on thebathroom floor whileaboard the toilet.Maintaining feet flaton floor or hips at orbelow knee heightfacilitates bladderemptying and bowel evacuation.

Toilet height must satisfy clientneeds. For example, an older adultrecovering from a fractured hip mustsustain a sitting position with hipshigher than the knees so temporarilyadapt the fixture by using a toilet seatriser, thick seat or filler ring. Someambulatory disabled persons likewisefind higher seat heights an advantage.Not so for persons in wheelchairs.

The toilet seat should be con-structed of sturdy material to providesufficient support. Furthermore, theseat should act as an absorptive

cushion (e.g., made of soft vinylplastic) to reduce risk of pelvic or hipfracture in persons who tend to droponto the toilet seat.

Low height toilets may posetransfer problems and as a resultcause the client to fall. One correctivemodification is the raised toilet seat ina fixed or adjustable height to ensureproper toilet sitting height. Anothermodification that seeks to maintain theclient’s balance during toilet transfersrequires grab bar installation on thewalls adjacent to and behind the toiletor attachment of a double armrest grabbar system to the toilet. Some olderadults find that the double armrestsystem provides optimal transferringsupport since the maximum amount offorce exerted during transfers is a

straight downward movement of thearms. In contrast, wall mounted grabbars offer less support because theolder adult must reach to the side andbend forward during the transferprocess to grab the bar losing thebenefit of a downward thrust offeredby the double armrest system. Asadditional cautionary measures,adhere non-slip adhesive strips in anon-contrasting color to the floor infront of the toilet to secure clientfooting during transfer, only usebathroom rugs with nonskid backing,


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summer/fall 2003

or install non-slip vinyl flooringthroughout the bathroom in a non-slipsurface with a padded foundation tominimize fractures in the event theclient falls.

Toilet Grab Bar Type andPlacement Is Critical

Despite their potential value inpreventing falls, community-dwellingolder adults underutilize grab bars.Tailor grab bar type and placement toclient needs, their disability, and theenvironment. For example, it is difficultfor persons with hemiplegia to use grabbars located on their dysfunctionalside; persons of short statute or limitedreach find grab bars at heights conve-nient for the average person unsatis-factory as the bars are beyond theirreach; and some older adults (e.g.,older women who are generally shorterand possess less upper body strengththan men) prefer an angled grab bar tothe standard horizontal bar becausethey can grab the angled bar at thelower position and move up the bar.Select grab bars in a color that con-trasts with the bathroom wall toimprove their visibility and attach themto wall studs no more than 1½ inchesfrom the wall to prevent the client’s armfrom slipping between the bar and wall.

Toilet Seat Color ImprovesVisibility

Toilet seat color is important. Theseat itself must contrast in color to thetoilet and the surrounding bathroomarea to facilitate proper sitting place-ment on the toilet, particularly for olderadults dependent on visual cueing.Older adults with poor color discrimina-tion, for instance, may encounterproblems and even fall trying to locatea white toilet seat where the bathroomflooring is white (or a light color) and itmay be difficult for older males to voidwhile standing into a white toiletwithout significant color differencesbetween the toilet and flooring.

Bathroom Doors

Some older adults with a poorgrasp open and close pocket styledoors (i.e., those that slide like patio

Home Safe Home


doors and disappear into a verticalslot in the wall) more easily than thetraditional barn style doors thatrequire more effort and may cause afall. House design will determine ifinstallation of pocket style doors isfeasible. In addition, lever-typehandles are much easier to graspthan doorknobs. The doorwayshould be wide enough to accommo-date an assistive device (e.g.,walker). The threshold should beclearly marked and the difference inheight between the two surfacesshould be no greater than ¼ inch.Remind the client to leave thebathroom door unlocked, so it can beopened from both sides. A lockedbathroom door will delay help inreaching client who sustains a fall.

Bathtubs and ShowerAreas

Does the bathtub/shower areahave at least one grab bar? Grabbars aid the client in getting into andout of the tub or shower, and canhelp prevent falls. If yes, checkexisting bars for strength andstability, and repair if necessary. Ifno, attach grab bars, through the tile,to structural supports in the wall, orinstall bars specifically designed toattach to the sides of the bathtub.

Alternatively, consider use of atub bench, chair, or stool with non-skid tips as a seat while showering orbathing if the client is unsteady andunable to shower while standing orunable to lower him or herself to thefloor of the bathtub. Purchase ahandheld shower attachment as welland install it on an adjustable rod orhigh-low mounting brackets. Thebench, chair, or stool must be largeenough to allow the older adult touse a flexible showerhead whileseated. A cautionary measureincludes mounting a liquid soapdispenser on the bathtub/showerwall so client does not fall whileattempting to retrieve soap.

Wet soapy tile or porcelainsurfaces are especially slippery andmay contribute to falls. Accordingly,place a nonskid rubber mat or applynonskid textured adhesive strips,decals or appliqués on the bathtub

or shower floor. Also replace glassshower enclosures with non-shatter-ing material and add a slip-resistantrug adjacent to the bathtub for saferexit and entry.

Conclusion

The purpose of a comprehensiveroom-by-room environmental assess-ment is to identify and removepotential fall hazards and to modifythe environment to maximize safe,functional mobility. Interventionsaimed at modifying environmentalconditions relevant to falls offer thegeriatric care manager an appealingapproach to falls prevention.

Julie A. Braun, J.D., LL.M., aninternationally recognized expert inlong-term care, is a Chicago-basedattorney and writer. Ms. Braun,[email protected], is a visitingprofessor at various legal andmedical institutions, including EmoryUniversity in Atlanta and theUniversities of Osnabrueck andWitten in Germany. She is the editorof the ElderLaw Portfolio Series, co-author of Litigating Injuries in theElderly (forthcoming 2003), advisoryboard member for Medical Malprac-tice Law & Strategy, and past editorof the Long-Term Care Litigation andthe Pharmaceutical & MedicalDevice Law Bulletin newsletters.Recent publications include Julie A.Braun et al., Legal Issues in Long-Term Care in Principles of GeriatricMedicine & Gerontology (5th ed.,William R. Hazzard et al., 2003). Ms.Braun chairs the legal subcommitteeof the Food and DrugAdministration’s (FDA) hospital bedsafety workgroup and is a co-investigator in an FDA-funded studyexploring the legal liability issues ofsiderail use. She also is a co-recipi-ent of a Borchard Foundation Centeron Law & Aging grant, a former chairof the American Bar Association(ABA) Medicine & Law Committee,and former vice chair of the ABASeniors’ Issues Committee. Ms. Braunis admitted to the bar of the SupremeCourt of Illinois, U.S. District Courtfor the Northern District of Illinois,Seventh Circuit Court of Appeals,and the Supreme Court of the UnitedStates.

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summer/fall 2003

What ProfessionalGeriatric Care Managers

Need to Know:A Nursing Home Update

By Julie A. Braun, J.D., LL.M.with introduction by Marcie Parker, Ph.D., CFLE

This special theme issue of theGCM Journal looks at falls assess-ment and prevention in all settings,whether home- or community-based orin a long-term care settings. It istherefore important for professionalgeriatric care managers (PGCMs) to beaware of recent legislative andregulatory initiatives that affect theirpractices.

In the three brief pieces thatfollow, we see a rapid increase inlitigation against nursing homes,raising concerns about quality of carefor residents. In some states, there arethousands of pending lawsuitsagainst nursing homes. While manyof these lawsuitsare warranted, inother cases,lawsuits againstnursing homes aswell as thephysicians, nursesand staff such asCNAs whopractice there arecausing nursinghomes to shutdown. In somestates, fewer andfewer physiciansare willing topractice in nursinghomes and as thefacilities shutdown there areincreasingly lessplacement beds forthe families whoneed them.

In the second piece, a recentlycompleted Office of Inspector General(OIG) report shares ombudsmancomplaints about nursing homes.

PGCMs can use this information asone piece of the decision makingprocess to help families contemplatingwhere a loved one should live.

In the third piece, we see that interms of nursing home quality, theprevalence of serious problems isdeclining but that enhanced oversightis still critically needed. We all knowthat services that are excellent oneweek can deteriorate next week withchanges in administration, staffturnover, and squeezed budgets.

We ask you to read these threeshort pieces carefully and decide howthey might affect your own GCMpractice. As always, we try, in this

journal, toprovide you withtheory, researchand actualapplication/implementation,so you will havean answer for the“So what?”question. Howdoes thisresearch influ-ence, change oraffect mypractice? Let usknow what youthink.

Marcie Parker,Ph.D., CFLE,senior qualita-tive researcherwith a large

healthcare firm in Golden Valley,Minnesota; Dr. Parker is incomingChair of the GCM Journal EditorialBoard.

Rapid Increase inLitigation AgainstNursing Homes RaisesConcerns About Qualityof Care For Residents

Professional geriatric caremanagers and others are witnessingan increase in litigation surroundinginjuries received in the long-term caresetting, especially in the context ofpressure ulcers, dehydration andweight loss, fall-related injuries (thesubject of this journal), improper useof physical restraints, medicationerrors, and sexual assault. Results ofa Web-based survey examiningnursing home litigation trendspublished in the March/April 2003issue of Health Affairs reflect a surgein the number of nursing home claimshandled in the past five years as wellas significant increases in averagerecovery size. See David Stevenson &David Studdert, Trends: The Rise ofNursing Home Litigation: Findingsfrom a National Survey of Attorneys,22 Health Affairs 219-29 (Mar/Apr.2003). Available for purchase at<http://www.healthaffairs.org>.

Harvard School of Public Healthresearchers David Stevenson andDavid Studdert base their analysis onresponses of a national sample of 268plaintiff and defense attorneys from 37states who specialize in nursing homelitigation. Most of the responses werefrom attorneys in Florida, Texas, andCalifornia, states with a large volumeof nursing home residents. AlthoughFlorida and Texas have been home tothe majority of litigation activity,states that reported increases in bothclaims volume and average recoveryamounts included Arkansas, Georgia,Louisiana, and Oklahoma.

Attorneys surveyed wereinvolved in litigating nearly 4,700claims in the preceding 12 months andtheir firms handled 8,300 claims. Theaverage recovery amount among paidclaims, whether resolved in or out ofcourt, was about $406,000 per claim.The most striking finding about thedynamics of this litigation is thatnearly 9 out of 10 plaintiffs receivedcompensation. According to re-searcher David Studdert, “[t]his kindof payment rate is off the scale in theworld of personal injury litigation, and


We ask you to

read these

three short

pieces

carefully and

decide how

they might

affect your own

PGCM practice.

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summer/fall 2003


probably reflects a tremendousreluctance to bring this kind of claimbefore a jury.”

More than half the claimsreported nationally were in Florida andTexas, and recovery amounts in thesestates were higher than the nationalaverage. Based on their analysis, theauthors estimate compensationpayments of $2.3 billion to plaintiffsnationally, with claims in Florida andTexas accounting for $1.1 billion and$654 million, respectively. In Texas,punitive damages were significantlymore common than elsewhere.Attorneys in Texas and Floridahandled claims worth more than 15percent of stateside nursing homeexpenditures.

Nursing home claims were largelyfocused in Florida, Texas, and ahandful of other southeastern states,including Georgia. David Stevensonadvises that is “[i]t’s unclear whetherthis phenomenon will become morewidespread, or whether it will remainrelatively concentrated [in thesoutheastern states].”

The survey also looked at othertrends. It found that residents’children are the chief catalyst behindmore than 60 percent of claims andnearly half of all nursing home claimsinvolved wrongful death or pressureulcers or both. In Texas, the propor-tion of claims that alleged death andpressure ulcers were significantlyhigher than the national average; inFlorida, the proportion of claims thatalleged falls was significantly higherthan the national average. A largeproportion of the litigation involvedchronic, long-stay residents.

Determining the extent to whichlitigation trends are related to poorquality care as opposed to otherfactors is difficult. “The litigationdoesn’t seem to track an overalldecline in nursing home quality,”Stevenson believes, “but this doesn’t

mean that individual claims brought byattorneys are inappropriate.”

Nursing Home Quality:Prevalence of SeriousProblems, WhileDeclining, ReinforcesImportance of EnhancedOversight

Case management takes manyshapes and continues to evolve intonew practice contexts. Thus, geriatriccare managers should keep abreast ofthe recent reports concerning thequality of care in our nation’s nursinghomes. According to a report releasedby the General Accounting Office(GAO) on July 17, 2003, the proportionof nursing homes with serious qualityproblems remains unacceptably high,despite a decline in the incidence ofsuch reported problems. Actual harmor more serious deficiencies were citedfor 20 percent or about 3,500 nursinghomes during an 18-month periodending January 2002, compared to 29percent for an earlier period. Fewerdiscrepancies between federal andstate surveys of the same facilitiessuggests that state surveyors aredoing a better job of documentingserious deficiencies and that thedecline in serious quality problems ispotentially real. Despite theseimprovements, the continuing preva-lence of and state surveyor under-statement of actual harm deficienciesis disturbing. For example, 39 percentof 76 state surveys from homes with ahistory of quality-of-care problems—but whose current survey found noactual harm deficiencies—had docu-mented problems that should havebeen classified as actual harm orhigher, such as serious avoidablepressure sores, severe weight loss, andmultiple falls resulting in brokenbones and other injuries.

Weaknesses persist in statesurvey, complaint, and enforcementactivities. According to the Centersfor Medicare and Medicaid Services(CMS) and states, several factorscontribute to the understatement ofserious quality problems, includingpoor investigation and documentationof deficiencies, limited quality assur-

ance systems, and a large number ofinexperienced surveyors in somestates. In addition, the GAO foundthat about one-third of the most recentstate surveys nationwide remainedpredictable in their timing, allowingfacilities to conceal problems if theychose to do so. Considerable statevariation remains regarding the ease offiling a complaint, the appropriatenessof the investigation priorities, and thetimeliness of investigations. Somestates attributed timeliness problemsto inadequate staff and an increase inthe number of complaints. Althoughthe agency strengthened enforcementpolicy by requiring states to refer forimmediate sanction homes that hadrepeatedly harmed residents, the GAOfound that states failed to refer asubstantial number of such facilities,significantly undermining the policy’sintended deterrent effect.

CMS oversight of state surveyactivities has improved but requirescontinued attention to help ensurecompliance with federal requirements.While CMS strengthened oversightby initiating annual state performancereviews, officials acknowledged thatthe reviews’ effectiveness could beimproved. For the initial fiscal year2001 review, officials said they lackedthe capability to systematicallydistinguish between minor lapses andmore serious problems that requiredintervention. CMS oversight also ishampered by continuing databaselimitations, the inability of some CMSregions to use available data tomonitor state activities, and inad-equate oversight in areas such assurvey predictability and state referralof homes for enforcement. Three keyCMS initiatives have been signifi-cantly delayed—strengthening thesurvey methodology, improvingsurveyor guidance for determining thescope and severity of deficiencies,and producing greater standardizationin state complaint processes. Theseinitiatives are critical to reducing thesubjectivity evident in current statesurvey and complaint activities.

What ProfessionalGeriatric Care ManagersNeed to Know: A NursingHome Update


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summer/fall 2003


Retrieve 104-page text of “NursingHome Quality: Prevalence of SeriousProblems, While Declining, ReinforcesImportance of Enhanced Oversight”(GAO-03- 561, July 15, 2003) from<http://www.gao.gov/cgi-bin/getrpt?GAO-03-561>.

Retrieve related 19-page testimonyby Dara Corrigan, Acting PrincipalDeputy Inspector General, before theU.S. Senate Committee on Finance(July 17, 2003) from <http://www.gao.gov/cgi-bin/getrpt?GAO-03-1016T>.

OIG Report SharesOmbudsman ComplaintsAbout Nursing Homes

Professional geriatric care manag-ers, among others, can use ombudsmancomplaint data to identify trends,issues, and concerns in institutionallong-term care making them betteradvocates for their clients. In July2003, the Office of Inspector General(OIG) published its findings using themost recent information available.

Background

Congress established the StateLong Term Care Ombudsman Programin the Older Americans Act Amend-ments of 1978. The Administration onAging (AoA) within the U.S. Depart-ment of Health and Human Servicesadministers the program. Ombudsmenattempt to resolve problems of indi-vidual nursing home residents and tobring about changes to improvenursing home care at the local, state,and national levels. They helpresidents and their families understandand exercise rights that are guaranteedby federal and state laws.

The Older Americans Act, 42 USC§ 3001-3058ee, requires states tocollect ombudsman complaint data andfor state ombudsman to report aggre-gate data to the AoA. In 1995, theAoA implemented the NationalOmbudsman Reporting System(NORS), an ombudsman complaint

reporting system, which consists of128 complaint categories divided intofive major groups.

Methodology

The OIG gathered data andinformation for1996 through2000 fromNORS statisti-cal reports,annual ombuds-man narrativecommentssubmitted withthe NORS data,and interviewsundertaken withstate and localombudsmenfrom Alabama,California,Connecticut,Maryland,Missouri, NewYork, SouthCarolina, SouthDakota andTexas. Thesenine geographi-cally diversestates representa cross sectionof ombudsmanprograms fromlarge urbanareas to smallrural communi-ties and accountfor approxi-mately 30percent of thenursing homebeds within theUnited States.

ReportFindings

Nationally,the total numberof nursing homecomplaints grewfrom approxi-mately 145,000in 1996 toapproximately186,000 in 2000.During the sameperiod, the

number of complaints per 1,000 bedsrose from 78.4 to 102.1. This corre-sponds to a 28 percent increase in thenumber of complaints and a 30 percentincrease in the number of complaintsper thousand beds.



Top Ombudsman ComplaintCategories, 1996-2000

Complaint Categories withLargest Growth, 1996-2000

Complaints 1996 1996 2000 2000 PercentTotal Rank Total Rank Growth

1996-2000

Accidents 6,661 1 7,675 2 15.2%

Request for Assistance 5,441 2 8,676 1 59.5%

Personal Hygiene 5,301 3 7,279 5 37.3%

Dignity, Respect-StaffAttitudes 4,882 4 7,351 4 50.1%

Care Plan 4,453 5 7,550 3 69.5%

Staff Shortage 4,352 6 6,625 6 53.0%

Physical Abuse 4,321 7 4,350 11 0.7%

Menu Quality 4,295 8 5,540 8 29.0%

Discharge, Eviction 4,110 9 5,762 7 40.2%

Personal Property 3,598 10 4,227 12 17.5%

Meds Administration 3,123 11 4,914 9 57.3%

Symptoms Unattended 3,196 12 4,617 10 44.4%

Complaint 1996 Total 2000 Total PercentGrowth1996-2000

Staff Turn-Over 330 1,015 207.6%

Dehydration 1,122 2,219 97.8%

Infection Control 562 1,074 91.1%

Supervision 1,825 3,326 82.2%

Exercise Choice and/or Civil Rights 2,211 3,803 72.0%

Cleanliness, Pests 2,242 3,832 70.9%

Care Plan/Assessment 4,453 7,550 69.5%

Call Lights/Requests for 5,441 8,676 59.5%

Medications-Administration 3,123 4,914 57.3%

Staff Unresponsive, Unavailable 2,376 3,700 55.7%

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summer/fall 2003

The most frequent complaintsinvolved resident care such as afailure to respond to call lights orrequests for assistance, accidents andimproper handling of residents, lack ofadequate care plans and residentassessments, inadequate administra-tion of medications, unattendedresident symptoms, and poor personalhygiene. Resident care complaints



grew 37 percent from 1996 to 2000compared to a 21 percent growth forcomplaints involving resident rights(e.g., abuse, access to information andtransfer and discharge issues).

The NORS complaint categorywith the highest national growth was,not surprisingly, staff turnover withan increase of approximately 208percent between 1996 and 2000.

The NORS complaint categoriesunder the umbrella of abuse includephysical abuse, resident-to-residentabuse, verbal/mental abuse, grossneglect, other abuse or exploitation,financial exploitation, and sexual

Types of Abuse Complaints, 1996-2000

abuse. According to OIG findings, thenumber of abuse cases reported toNORS peaked in 1998 and havedeclined about 3 percent since then.The total for all reported abuse casesrose from 13,469 in 1996 to 15,501 in1998, and declined to 15,010 in 2000.During that period, among seven typesof abuse categories, physical abusewas the most common type reported.

Retrieve full text of Dep’t Health &Human Servs., Office of InspectorGeneral, “State Ombudsman Data:Nursing Home Complaints” (OEI-09-02-00160, July 2003) from <http://oig.hhs.gov/oei/reports/oei-02-01-00600.pdf>.

6,000

5,000

4,000

3,000

2,000

1,000

0

Nu

mb

er o

f C

om

pla

ints

1996

1997

1998

1999

2000

PhysicalAbuse

Residentto residentabuse

Verbal/mentalabuse

Grossneglect

OtherAbuse orExploitation

Financialexploitation

Sexualabuse

Abuse Types

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summer/fall 2003

Practical Fall RiskAssessment in OlderAdults with Multiple

Medical Problems and/orChronic Disease

By Steven Charles Castle, M.D. &Dorene Opava-Rutter, M.D.

Reviewing ClinicalStandards of Falls RiskAssessment

A number of controlled trials findthat detecting a history of falls orchange in gait and balance andperforming a fall-related assessmentlikely reduces future falls whencoupled with appropriate interven-tions (Rubenstein 2001). The QualityIndicators for Assessing Care of

Vulnerable Elders (ACOVE) projectidentifies six indicators in this domain(Rubenstein 2001). The ACOVE studyrelied upon a structured literaturereview and expert panel process(Shekelle 2001). Table I detailsACOVE Project recommendations.

The six indicators of care pro-cesses detailed in Table I are judgedsufficiently valid as indicators ofquality care in the management of falland mobility disorders for vulnerable

elders defined as persons over65 years of age with a greaterlikelihood of death or decline infunction over a two-yearperiod. Accordingly, a healthcare provider (e.g., geriatriccare manager) who fulfills thesecriteria provides quality care,improves the chance ofpreventing a preventable fall,and reduces the risk of seriousinjury in non-preventable falls.

Taking a FallsHistory

It is important for healthcare providers to understandthe natural human instinct tocharacterize a fall as anaccident. Parties involved in afall incident often are embar-rassed and prefer to believe thefall “an accident.” This misidentification of the eventmistakenly implies that it willnot recur and represents asignificant clinical hurdle toovercome. A pioneer ofgeriatric medicine, Bernard

T A B L E I

Quality Indicators forManagement & Preventionof Falls

1. Document Fall Inquiries Annually orMore Frequently As Appropriate

• Falls often are undetected

• Risk of recurrence/injury is higher

• Preventable components

• Effectiveness of screening likely nottested

2. Evaluate for Balance and GaitDisturbance At Least Once

• Abnormality often undetected

• Clear increased risk of fall andprogression of immobility

• Case finding and assessment todetect mobility problems and theircorrection

3. Basic Fall Evaluation

IF: >2 falls in past yr. OR 1 fall withserious injury

THEN: Basic fall evaluation is definedas:

• Medication review includingidentification of acute and chronicproblems;

• Physical examination (e.g.,orthostatic vital signs, vision, gaitand balance, lower extremityfunction);

• Neurological exam;

• Environmental assessment;

• Summary of physician’s impression

• Detail recommended medications

• Drug review (e.g., ascertain ongoingneed and lowest effective dose)

4. Gait-Mobility and Balance Evaluation

IF: New or worsening ambulation,balance, mobility

THEN: Gait, mobility and balanceevaluation within six months that resultsin diagnostic and treatment recommen-dations

BECAUSE: Use of assistive devicesand exercise reduce likelihood of futurefalls and complications; however,assessment for need and proper use isrequired for optimal use. Indirectevidence relates the assessmentcomponent of programs with improvedsurvival and function accompanied byless healthcare use.

5. Exercise and Assistive Device FORBalance Problems

(continued on page 18)(continued on page 18)

Steven Charles Castle, M.D., GCM JournalGuest Editor, and 98-year-old Benjamin Korb,one of Steve’s fall prevention patients. Mr.Korb fought in the Aleutians during WWII andwas among the first of our troops to encounteractive resistance.

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Isaacs, remarks that “the first step inpreventing a fall is to fall yourself.Everyone is a potential faller; andeveryone needs to abandon faith in

foundational issues which, if notaddressed, may increase the exposureor risk of fall or injury associated with afall. In general, these aspects tend tobe more or less preventable ones thatby their nature compound inherent gaitand balance deficits.

Severe, irreversible aspects of fallsshift the fall management approachtoward injury preventive or protectivestrategies. For instance, alwaysscrutinize the role medication(s) mayplay in the fall event(s). Queries mightinclude, among other possibilities:

� Do prescription or over-the-counter medications contributeto falls and/or gait instability?

� How effective or necessary arethe medications being taken inrelationship to the intendedprescribed use?

� Do the medications have a low,medium or high risk of contribut-ing to a patient’s fall and/or fallrisk?

� What would happen if themedication(s) is/are stopped?

� What might be the impact of adose change? Can an alternativeagent be prescribed?

It is common for older adults whoexperience recurrent falls to remain onmedications that contribute to the fallincident(s). This presents clinicalchallenges as well as potential legalliability, especially in the long-term caresetting. Therefore, assess patientsquarterly or sooner if there is a changein condition. Failure to considerwhether medications contribute to anolder adult’s fall(s) is a risky practicethat may expose the health careprovider and the institution to legalliability.

Classifying MedicalConditions thatContribute to Falls

The authors rely upon andrecommend a practical classification ofmedical conditions that contribute tofalls and have established a diagnosisin over 90 percent of the cases referredto their falls prevention clinic. Clinicalstudies demonstrate that even with

IF: abnormal balance/proprioception, orincreased postural sway,

THEN: Evaluate for exercise andassistive device

BECAUSE: Balance problemscontribute to falls risk and medicationwill reduce likelihood of fall

• Improves mobility-related tasks

• Improves balance if peripheralneuropathy/vestibular abnormalitydetected

• Problem if impulsive, cognitiveimpairment

6. Exercise Prescription for GaitProblems and Weakness

IF: Problems with gait, weakness (<4/5manual muscle test, need to use arms)or decreased endurance

THEN: Offer exercise program

BECAUSE: Exercise improves orameliorates risk factors, and reducesrisk of falls and fall-related injuries.

• Decreased muscle strength isassociated with functional gaitimpairment.

• 7 Randomized Clinical Trials - exercise on gait variables in elders.

2 - no effect of strength trainingon gait velocity.

2 - lower extremity strengtheningimproved velocity, endurance,stability.

3 - on walking-endurance programin community elders (mean ageof 70 years), increase ofambulatoryfunction between 5and 15 percent after 8 to12weeks.

Adapted by authors from Rubenstein, L.Z.& Kenny, R.A. “Guideline for thePrevention of Falls in Older Persons.”Journal of the American Geriatric Society49 (2001):664-672.

T A B L E I


personal invulnerability” (Isaacs 1996).In the authors’ experience, older adultsamazingly possess little or no insightinto their own invincibility despitemultiple falls and recurrent balanceproblems. This is particularly truewhere a dementia-related illness limits aclinician’s ability to obtain an accuratefalls history. In this situation, theauthors recommend using a structuredapproach to acquiring a history, eitherby patient/ caregiver self-report orthrough patient interview.

Another challenging aspect in fallsassessment involves the complexity offalls and their inherent multi-factorialnature. Falls often are not caused ortriggered by the same factor. Accord-ingly, scrutinize each falls incidentalong with any accidents or eventsdescribed as slips, stumbles, trips, ornear falls. Dr. Bernard Isaac focuseson two inquiries when reviewing a fallincident (Isaac 1996). First, whatcaused the displacement and secondwhat prevented its correction (Isaac1996). If it is impossible to answerthese two questions, shift attention tothe intended activity and relate it to thepatient’s gait and balance problems.

Reviewing the ActualFalls Event

Analysis relating to the actual fallsevent varies with some overlapdepending on the specific health caresetting (e.g., long-term, acute or homecare) and the older adult’s uniquecharacteristics. For example, Dr. ReinTideiksaar, Senior Vice President,ElderCare Companies, Inc. (Philadel-phia, PA), employs a practical pneu-monic (Tideiksaar 1998):

S Symptoms experienced at timeof fall.

P Previous number of falls or nearfalls.

L Location of falls.A Activity engaged in or at-

tempted at time of fall.T Time (hour) of day.

T Trauma (e.g., physical or psycho-logical) associated with falls.

Remember to ask questions fromthe perspective of a practical classifica-tion of medical conditions thatcontribute to falls and to tackle

Practical Fall RiskAssessment in OlderAdults with MultipleMedical Problems and/orChronic Disease



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thorough neurocardiac assessment,approximately 20 percent of falls donot have a clear etiology and 20percent have multiple etiologies(Lawson 1999), suggesting that thepractical approach described in thisarticle lends itself to more individual-ized interventions.

Cardiovascular Causes

Diagnoses: Carotid sinushypersensitivity, vasovagal, orthos-tatic hypotension.

Common Symptoms: Feeling lightheaded upon standing, feeling likepassing out if you do not sit down,symptoms after prolonged standing,any other common cardiac symptoms.

Nuances: Older adults are proneto dysregulation of the autonomicnervous system and hence getexcessive waves of parasympathetictone that normally follow sympatheticoutpouring in a flight or fight arousal,but can occur on a lesser level ofstimulation. The concept of excessiveparasympathetic tone followingsympathetic is why people becomeincontinent when excessively scared.The scare produces a large outpouringof sympathetic tone (i.e., tightenssphincters and reduces detrussor tonewhich maintain continence) followedby an increased parasympathetic toneto maintain autonomic regulation (i.e.,diminished sphincter with contractionof detrusor resulting in incontinence ifstrong enough parasympathetic tone).Thus, autonomic dysregulation resultsin excessive parasympathetic tonefollowing mild sympathetic stimula-tion, causing a drop in blood pressureand a drop in heart rate (Tea 1996).Prolonged tilt table testing or stress-ing a response with acute administra-tion of a diuretic or nitroglycerin mayuncover this (Kenny 2000). There is aspectrum of Parkinsonian patients,called multiple system atrophy, withmultiple contributors to gait andbalance problems including cardiovas-

cular causes that can be very complexto manage (Goldstein 2000). In thiscircumstance, refer patients to aninternist, geriatrician, neurologist orcardiologist with experience inmanaging neurocariogenic syncope/near syncope.

Vertigo, AbnormalSensation of Motion

Diagnoses: Peripheral causesinclude inner ear disorders, includingbenign positional vertigo, vestibularneuronitis, or Meniere’s disease.Central causes are from poor circula-tion to the posterior aspects of thebrain, includingvertebral-basilarinsufficiency, ischemic lesion to thebrainstem or basal ganglion, andmigraine headaches.

Common Symptoms: Symptomsinclude the classic room-spinning orthe feeling of being pulled to one sideor downward, sometimes referred to asimpulsion. Acute care and emergencyroom personnel witness thesesymptoms more often when comparedto falls referral clinics or long-termcare.

Nuances: First, there are someindividuals who have dizzy symptomsassociated with panic attack symp-tomatology. Relaxation therapy withvestibular training or desensitizationis described in the literature andanecdotally has resulted in dramaticimprovement in a few cases (Cowand1998). Second, peripheral vestibularcauses will have rotational vertigowhich occurs often a minute or so afterthe Dix-Hall Pike maneuver, and thissuppresses on repeated testing unlikecentral causes. Benign positionalvertigo tends to be intermittent overdays, but persists for a couple of weeks,while other peripheral causes are moreintense over a shorter duration (Heaton1999; Hoffman 1999).

Dysequilibrium

Diagnoses: Peripheral neuropathy(damage from diabetes, alcoholvitamin deficiencies and othercauses); Parkinsonism/Parkinson’sdisease, multiple system atrophy,cerebral basilar degeneration, subcor-tical white matter ischemia (smallstrokes in the deep parts of the brain),

cervical spondylosis (alignmentproblems of vertebrae in the neck),bilateral carotid artery stenosis, basilarartery migraine (spasm of artery toposterior brain), or lumbar spinalstenosis (narrowing of spinal canalwith impingement on the nerves).

Common Symptoms: Symptomsinclude impairment in any loop ofsensory/motor response and conse-quently an unawareness of being offbalance, and the inability to correctwhen balance is lost. Patients lacksensation (e.g., dizziness or lightheadedness) and may find them-selves on the ground quite perplexed.This condition may feature earlierdiagnoses of drop attacks wherepatients usually can get right back upunless injured. Patients may complainabout comments from family, friends oreven strangers that they look drunkwhen they walk but are not.

Nuances: The effect on gait andbalance of common peripheralneuropathies usually are not appreci-ated by non-physiatrists. Othercommon problems found in somepreviously active individuals includethe presence of spinal stenosis,where symptoms are worse withwalking down hill or down steps.This category has been the largestgroup in the authors’ experience.

Neuromusular/JointWeakness or Pain

Diagnoses:

Nerve – Radiculopathy (pinchednerves), peripheral neuropathy,spinal stenosis, or cerebral vascularaccident (stroke).

Muscular – Myopathy (inflam-mation and breakdown of muscles),deconditioning (loss of strength fromlack of use), or constitutional (wholebody) symptoms (e.g., fever, hy-poglycemia).

Joint – Arthritis, bursitis(inflammation of the joint capsule),deformity, or contractures (frozenjoints).

Foot/ Shoes/Improper AdaptiveEquipment

Symptoms: The typical symptomis the older adult’s knee “giving way”




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or buckling usually when going downstairs or stepping off of a curb. Manypersons can relate to feeling weak inthe knees when they have a highfever, and this probably contributes tofalls in the acute care setting. Inter-mittent hypoglycemia should beconsidered as well but studies tobetter define are lacking. Addition-ally, patients who catch their toes andtrip or stumble may have hip, knee, orankle weakness. Lack of endurance orfatigue also may contribute to the fall.

Nuances: Manual muscle testingdoes not correlate well with actualimpact on gait and balance. Subtleweakness easily can be missed. Gripstrength may provide some globalsense of weakness and/or decondi-tioning. Performance measures mayprovide a more objective measure, suchas the timed get up and go test (i.e.,patient arises from a chair, walks 10 feet,turns around and returns to sitting;normal time is about 14 seconds).

Foundation Issues thatWorsen Fall Risk andMedical Problems ThatIncrease Exposure toFalls

Vision & Hearing

Vision and hearing problemsrepresent obvious problems thatunfortunately are easily overlooked.While preventing falls by correction isassumed, it has not been clearlydemonstrated. However, in certainindividuals it could make a differenceand, therefore, should be included inthe assessment and care plan.

Foot Care and Wear

Likewise, footwear, foot deformi-ties and nail care should be includedin this category. Examine the feet ofanyone with clearly identified gaitimpairment.

Sleep Disorders

An evaluation of sleep disordersis critical given that obstructive sleepapnea (loud snoring with periods ofarrested breathing), restless legsyndrome/periodic leg movements(excessive, uncontrolled movementsof legs during sleep) and sedativehypnotic use (sleeping pills) arecommon and improved managementmay prevent falls. Anyone who hasexperienced a disrupted night of sleepmay attest to catching their toes andcan therefore imagine the impact onsomeone with more impaired gait andbalance. Part of the pathology alsomay relate to depression and dementia(discussed below), and likely involvesimpaired visuomotor processing.Another aspect of sleep disorders isgetting up at night and meandering ina semi-alert state with inadequatelighting. One of the authors, Dr.Steven Charles Castle, finds this lessof a problem than expected and mustbe due to patients’ increased vigilanceand attention.

Urinary Frequency andIncontinence

Urinary frequency, especiallywhen linked with urgency, may resultin increased exposure to falls. Clinicalstudies demonstrate the associationof urinary incontinence (bladdercontrol problems) with falls, but onlyif tied to urgency (Brown 2002).Detailed assessment is critical forpatients with urinary frequency,especially when associated withurgency needs, to ameliorate symp-toms and reduce falls risk exposure.This is common in acute care where aconnection exists between frequencyof urination and many diseases anddisease management. In health careinstitutions, careful attention totoileting schedule is crucial, especiallyin persons with gait impairment andurgency.

Remember that not all nocturia(urination at night) is related toprostatic problems, and may insteadbe symptomatic of a sleep disorder.Consider, for example, an older adultwho awakens due to the sleepdisorder and notices that he or shehas to go to the bathroom. In thisinstance, it is inappropriate to

attribute the disrupted sleep tonocturia (Pressman 1996) when acareful sleep history and referral forsleep studies is proper.

Osteoporosis

Another issue to considerinvolves osteoporosis. If someone isidentified as a falls risk, he or sheshould be assessed for osteoporosisand, if appropriate, be considered forcalcium and vitamin D3 supplementa-tion (Papadimitropoulos 2002).Osteoporosis occurs in men as well,and testosterone deficiency has beenidentified as a risk factor for hipfractures (Jackson 1992).

Psychiatric Problems

Various studies exploring falls orfall risk factors identify depressionand anxiety as associated factors. Thefear of falling is well reported andleads to the downward spiral ofdecondititioning with further impair-ment in gait and balance (Tideiksaar1998; Tinetti 1994). The interaction ofanxiety, depression and dementia,even without the added impact ofappropriate and inappropriatemedications, overlap and significantlyimpact the risk of falling. Althoughbeyond the scope of this article, knowthat there is a bottom line impact onvisuomotor functioning that leads toclearly identified decline in gait andbalance performance, which olderindividuals are more likely to manifest(Brown 2000; Draganich 2001;Whooley 1999).

Case series devoted to dementiaand stroke report depression as anindependent factor associated withfalls (Jorgensen 2002; Lyketsos 1997).It is unclear; however, how much ofthe association between depressionand anxiety have direct or indirecteffects on fall risk. Even in youngerindividuals, inducting fear of fallingby doing toe raises at elevation nearthe edge of a platform modifiesanticipatory postural control (Adkin2002). Part of the mechanism of thesechanges may be associated withhypocapnia, or low carbon dioxide dueto hyperventilation (Clague 2000).The other caveat is that certain types




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of dementia, such as Dementia withLewy bodies (i.e., fluctuation insymptoms, Parkinsonian stiffness, andhallucinations) have a ten-fold higherincidence of falls than Alzheimer’sdementia, again likely due to specificdeficits in visumotor processing whichcould be tested directly (Imamura 2000).

Environmental Issues

Environmental modifications arean important, but complex issue thatmay be tied to finances, personalpreferences, adaptations, and theability to get work completed. Severalexcellent publications offer guidancein this area (AARP 2000; CDC NCIPC1999). Further, findings from a recentprospective study that completed aroom by room assessment of 13potential slip or trip hazards of 1103persons greater than age 72, andwhich controlled for vision, balance/gait and cognition did not support anassociation between environmentalhazard and nonsycopal falls (Gill 2000).

Other practical matters toconsider include whether the oldercommunity dwelling adult takes a busfor transportation, carries heavyobjects, or has pets. A British studyadvises that elder community-dwellingresidents who have dypnea walkingup a hill, live alone, care for pets, orcarry heavy packages have a higherincidence of falls (Bath 2000). Devis-ing strategies on changes in lifestyleare extremely difficult, but likely toimpact falls and fall-related injury.

Recommended PhysicalExamination

The type of physical examinationdepends on the health care settingand whether it is a risk assessment forfalls or a post-fall assessment. SeeTables II and III. The quality indicatoroutlined in the ACOVE study sug-gests performing a basic fall evalua-tion when a vulnerable elder reportstwo or more falls in the past year or

has a significant injury from a fall.The evaluation seeks to identify anytreatable cause and highlight therelationship between fall event andmedications (e.g., use of sedatives orover treatment with antihypertensives)or the presence of a subacute medicalcondition such as postural hypoten-sion, metabolic disorders (includinghypo or hyperglycemia), infections,dehydration or cardiac arrhythmia orprogression of heart failure (Rubenstein2001A; Rubenstein 2001B).

Steven Charles Castle, M.D.,[email protected], hasdeveloped, tested and replicated fallsprevention programs across thecontinuum of care and throughoutthe country. Dr. Castle is a nation-ally recognized expert in standards oflong term care and medico-legalperspectives in long-term care andassisted living as well as interdisci-plinary training in falls prevention.As president and Chief ExecutiveOfficer of ElderCare Experts(www.eldercare-experts.com), hedeveloped a blended-interdiscipli-nary, train-the-trainer programtargeting education of frontline stafffor long-term care and assisted livingfacilities. Using a structured ap-proach and components, anindividual’s fall risk is assessed inthe context of practical interventions.This unique approach focuses on howmedical conditions and/or medica-tions interact with inherent fall risk,encourages participation by frontlinestaff, and enhances communicationwith doctors and therapists resultingin improved follow up of fall riskfactor adjustment as well as bettercommunication about the plan ofcare and outcomes with patients/residents and their families. The goalis to provide higher quality care thatreduces liability and facilitatesresident independence, well beingand success towards aging in place.

Doreen Opava-Rutter, M.D., is afellow of the American Academy ofPhysical Medicine & Rehabilitation.Dr. Opava-Rutter joined UCLA/SantaMonica Orthopedic Associates inJuly 2001 as an Associate ClinicalProfessor of Physiatry. Her areas ofinterest include non-operative

treatment of spine, shoulder and kneedisorders. She also performs elec-tromyographic (EMG) and nerveconduction studies, for which she isboard-eligible. In addition, Dr.



T A B L E I I

RecommendedEvaluation of a Fall inEmergency/UrgentCare

History:

• Review prescription and over-the-counter medications and inquire aboutany recent changes in prescribing aswell as patient compliance withmedication regimen

• Location and situation associated withfall

• Intended activity

• Agitation and/or confusion

• Long lie

• Specific symptoms (e.g.,cardiovascular, vertigo,dysequilibrium, weakness, mixed,none, foundation issues).

• Current and past activity level, falls,slips, trips, stumbles in previous threemonths

• Change in condition - confusion,seizure, pass out, cardiopulmonarystatus, melena, urination (e.g., frequentor diminished)

• Social history such as person’salcohol use, their ability to liveindependently (e.g., perform activitiesof daily living), complex social history(e.g., elder abuse or neglect)

Physical Exam:• Vital signs with orthostatic measures

as tolerated

• Hydration and nutrition status

• Mental status (e.g., orientation,naming, calculation, construction)

• Evidence of trauma (e.g., head, spine,ribs, pelvis, hips, extremity) or long lie

• Rales, gallup or murmur, carotid bruits

• Gait and balance, get up and go test,observational gait

Adapted by authors from Baraff, L.J. etal., “Practice Guidelines for the EDManagement of Falls in Community-Dwelling Elderly Persons.” Ann EmergMed. 30, no.4 (Oct. 1997):480-489.


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Opava-Rutter holds privileges asan Attending Physician at the VAMedical Center at West LosAngeles (GLAHS) with researchand clinical interests in fallprevention in the elderly. She alsohas held positions at the VA as

medical director of the WellnessProgram, Cardiac Rehabilitation,and the Gait Laboratory. Recently,she participated in a two-yearclinical initiative through the VA todevelop a fall prevention continuumof care from the acute, inpatientsetting to an outpatient fallsprevention clinic. She lecturesextensively in fall prevention andthe development of amultidisciplinary fall preventionclinic and frequently on the reha-bilitation of amputations in addi-tion to other rehabilitation topics.

Clague, J.E., Petrie, P.J., Horan,M.A. “Hypocapnia and itsRelation to Fear of Falling.” ArchPhys Med Rehab 81, no.11 (Nov.2000):1485-1488.

Cowand, J.L., Wrisley, D.M.,Walker M., Strasnick, B.,Jacobson, J.T. “Efficacy ofVestibular Rehabilitation.”Otolaryngology - Head & NeckSurgery 118, no.1 (Jan. 1998):49-54.

Draganich, L.F., Zacny, J., Klafta,J., Karrison, T. “The Effects ofAntidepressants on Obstructedand Unobstructed Gait in HealthyElderly People.” Journal ofGerontology Series A: Biologicaland Medical Sciences 56A, no.1(Jan. 2001):M36-M41.

Gill, T.M., Williams, C.S., Tinetti,M.E. “Environmental Hazards andthe Risk of Nonsyncopal Falls inthe Homes of Community-LivingOlder Persons.” Medical Care 38,no.12 (Dec. 2000):1174-1183.

Goldstein, D.S., Holmes, C., Li,S.T., Bruce, S., Metman, L.V.“Cardiac Sympathetic Denervationin Parkinson Disease.” Ann. Internal Medicine 133(2000):338-347.

Heaton, J.M., Barton, J., Ranalli,P., Tyndil, F., Mai, R., Rutka, J.A.“Evaluation of the Dizzy Patient:Experience from aMultidisciplinary NeurotologyClinic.” Journal of Laryngology& Otology 113 (Jan. 1999):19-23.

Hoffman, R., Einstadter, D.,Kroenke, K. “Evaluating Dizzi-ness.” American Journal ofMedicine 107, no.5 (Nov.1999):468-478.

Imamura, T., Hirono, N.,Hashimoto, M., Kazui, H.,Tanimukai, S., Takahara, A., Mori,E. “Fall-Related Injuries inDementia with Lewy Bodies(DLB) and Alzheimer’s Disease.”European Journal of Neurology7, no.1 (Jan. 2000):77-79.

Isaacs, B. “The Prevention ofFalls in Older People.” In Falls,Gait and Balance Disorders inthe Elderly, edited by LaFont, C.13-25. New York: Springer, 1996.




T A B L E I I I

Basic Fall Evaluation

• History of fall circumstance,medication, acute or chronic medicalproblems, and mobility problems(including rate of change).

• Orthostatic vital signs: Establishresting value after 10-15 minutes.Look for drop in systolic >20 ordiastolic > 10 mmHg within 3 minutesof change in position (measureimmediately, then next at one minuteand two minutes), increase in pulse isNOT required and suggests autonomicdysfunction if drop in blood pressureand no increase in pulse.

• Evaluation of vision (i.e., acuity, grossconfrontation, depth perception).

• Gait & Balance: Timed get up and gotest, observe balance, symmetry, pathdeviation, stride length and height,base of support, ability to turn. Testbalance with eyes open, eyes closed,with head turning, and on foam.

• Lower extremity function, footdeformity, nail condition.

• Neurologic evaluation includes mentalstatus, strength, proprioception(number correct/five attempts witheach toe), light touch, and cerebellarfunction.

• Environmental assessment.

• Diagnostic impression, need foradditional testing, therapeuticrecommendations.

Adapted by authors from Rubenstein,L.Z. & Kenny, R.A. “Guideline for thePrevention of Falls in Older Persons.”Journal of the American GeriatricsSociety 49 (2001):664-672.

References

AARP. “Fixing to Stay.” (2000).Available at <http://www.aarp.org>.

Adkin, A.L., Frank J.S., Carpen-ter, M.G., Peysar, G.W. “Fear ofFalling Modifies AnticipatoryPostural Control.” ExperimentalBrain Research 143, no.2 (Mar.2002):160-170.

Bath, J.P.A., Pendleton N.,Morgan K., Clague J.E., HoranM.A., Lucas S.B. “New Ap-proach to Risk Determination:Development of Risk Profile forNew Falls among Community-Dwelling Older People by Useof a Genetic Algorithm NeuralNetwork (GANN).” Journal ofGerontology Series A: Biologi-cal and Medical Sciences, 55, no.1(Jan. 2000):M17-21.

Brown, L.A., Gage, W.H.,Polych M.A., Sleik, R.J.,Winder, T.R. “Central SetInfluences on Gait: Age-Dependent Effects on PosturalThreat.” Experimental BrainResearch 145, no.3 (Aug.2002):286-296.

Centers for Disease Control andPrevention (CDC), NationalCenter for Injury Prevention andControl (NCIPC) Fact Sheet(1999). “A Home Fall Preven-tion Checklist for Older Adults.”

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Jackson, J.A., Riggs, M.W.,Spiekman, A.M. “TestosteroneDeficiency as a Risk Factor for HipFractures in Men: A Case-ControlStudy.” American Journal ofMedical Sciences 304, no.1 (July1992):4-8.

Jorgensen, L., Engstad, T.,Jacobsen, B.K. “Higher Incidenceof Fall in Long-Term StrokeSurvivors than in PopulationControls: Depressive SymptomsPredict Falls after Stroke.” Stroke33, no.2 (Feb. 2002):542-547.

Kenny, R.A., O’Shea D., ParryS.W. “The Newcastle Protocolsfor Head-Up Tilt Table Testing inthe Diagnosis of VasovagalSyncope, Carotid Sinus Hypersen-sitivity, and Related Disorders.”Heart 83, no.5 (May 1, 2000):564-569.

Lawson, J., Fitzgerald, J., Birchall,J., Aldren, M.A., Kenny, R.A.Diagnosis of Geriatric Patientswith Severe Dizziness.” Journal ofthe American Geriatrics Society1999; 47:12-17.

Lyketsos, C.G., Steele, C., Baker,L., Galik, E., Kopunek, S.,Steinberg, M., Warren, A. “Majorand Minor Depression inAlzheimer’s Disease: Prevalenceand Impact.” Journal of Neurop-sychiatric Clinical Neurosciences9, no.4 (Fall 1997):556-561.

Papadimitropoulos, E., Wells, G.,Shea, B., Gillespie, W., Weaver, B.,Zytaruk, N., Cranney, A., Adachi,J., Tugwell, P., Josse, R., Green-wood, C., Guyatt, G. “The Os-teoporosis Methodology Groupand The Osteoporosis ResearchAdvisory Group. Meta-Analysesof Therapies for PostmenopausalOsteoporosis. VIII: Meta-Analysisof the Efficacy of Vitamin DTreatment in Preventing Os-teoporosis in PostmenopausalWomen.” Endocrine Reviews. 23,no. 4(Aug. 2002):560-569.

Pressman, M. R., Figueroa, W. G.,Kendrick-Mohamed, J.,Greenspon, L. W., Peterson, D. D.“Nocturia: A Rarely RecognizedSymptom of Sleep Apnea andOther Occult Sleep Disorders.”Archives of Internal Medicine156, no.5 (Mar. 11, 1996):545-550.

Rubenstein, L.Z., Kenny, R.A.“Guideline for the Prevention ofFalls in Older Persons.” Journal ofthe American Geriatric Society2001A;49:664-672.

Rubenstein, L.Z., Powers, C.M.,MacLean, C.H. “Quality Indicatorsfor the Management and Preven-tion of Falls and Mobility Prob-lems in Vulnerable Elders.” AnnIntern Med 2001B:135;686-693.

Shekelle, P.G., MacLean, C.H.,Morton, S.C., Wenger, N.S.“Assessing Care of VulnerableElders: Methods for DevelopingQuality Indicators.” Ann InternMed 2001:135;647-652.

Tea, S.H., Mansuorati, J.,L’Heveder, G., Mabin, D., Blanc,J.J. “New Insights into thePathophysiology of Carotid SinusSyndrome.” Circulation 93, no.7(Apr. 1, 1996):1411-1416.

Tideiksaar, R. Falls in OlderPersons, Prevention and Manage-ment (2d ed.). Baltimore, MD: HealthProfessions Press, Inc, 1998.

Tinetti, M.E., Mendes de Leon,C.F., Doucette, J.T., Baker, D.I.“Fear of Falling and Fall-RelatedEfficacy in Relationship toFunctioning among Community-Living Elders.” Journal ofGerontology Biological andMedical Sciences 49, no.3(1994):M140-M147.

Whooley, M.A., Kip, K.E., Cauley,J.A., Ensrud, K.E., Nevitt, M.C.,Browner, W.S. “Depression, Falls,and Risk of Fracture in OlderWomen.” Arch Intern Med 159,no.5 (Mar. 8, 1999):484-490.

Footwear & FallsBy Julie A. Braun, J.D., LL.M. ,Guest Editor

No experimental studies of footwear examine falls as anoutcome. However, some trials report that specific footwearfeatures influence balance and sway in older adults. Anappropriate footwear intervention may improve balance andgait tasks in older women, for example. Better results infunctional reach and timed mobility tests occurred whenfemale subjects aged 65 to 93 years wore walking shoes ascompared to being barefoot. Further, static and dynamicbalance among women aged 60 to 89 years were better inlow-heeled, walking shoes versus high-heeled shoes whichconstituted a balance hazard. In men, foot position aware-ness is related to stability and declines with advancing years.In men, stability is best with high mid-sole hardness or lowmid-sole thickness and static balance is best in hard-soled,low resistance shoes. In older men and women, inadequatecasual footwear may contribute to slipping accidents over arange of surfaces (in both dry and wet conditions) such asbathroom tile, concrete or vinyl flooring.

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Geriatric Care Managers

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