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Falls prevention for people living with dementia: Education session for HACC Assessment Officers and District Nurses. Professor Keith Hill, Head, School of Physiotherapy and Exercise Science, Curtin University – [email protected]. Gippsland (Victoria): September 2014. Overview. - PowerPoint PPT Presentation
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Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
Professor Keith Hill,
Head, School of Physiotherapy and Exercise Science,
Curtin University – [email protected]
Falls prevention for people living with dementia:
Education session for HACC Assessment Officers
and District Nurses
Gippsland (Victoria): September 2014
Overview How common are falls among older people
What are the effects of falls on an older person
Why do older people fall
What effect does dementia have on falls
What should an older person do if they have a fall
Case study
How can HACC Assessment Officers and District Nurses help clients (with and without dementia) to avoid falls
Introduction to the Gippsland Falls Prevention Pathway for People Living With Dementia
Resources to help older people who fall
Hospital separations due to injury and poisoning, Australia 2008-9
Australian Institute of Health and Welfare, 2012
Falls as a National IssueTransportation related hospitalisations – 55,457
Falls related hospitalisations – 153,170
Hospital separations due to injury and poisoning, Australia 2003-4
Falls as a National Issue
Australian Institute of Health and Welfare, 2007
Other factors
implicated in up to 40% of admissions to residential care
quality of life issues◦ independence◦ community living◦ active life-style◦ other
Falls are multi factorial
Intrinsic factors
Extrinsic factors
Medications
Healthproblems
Ageing
Environment
Activityrelatedrisks
eg.psychoactive meds
Factors commonly associated with fallers:previous fallslower extremity weaknessarthritis (hips / knees)gait / balance disorderscognitive disorders (depression / dementia /
poor judgement...)visual disorderspostural hypotensionbladder dysfunction (frequency / urgency /
nocturia / incontinence...)medications (psychotropics/ sedatives /
hypnotics / antihypertensives...)
Tideiksaar, 1995
Identifying who is at risk of falls…
0
10
20
30
40
50
60
70
80
0 1 2 3 4+
Number of risk factors
Per
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fel
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Tinetti et al, 1988
Number of risk factors
Modifiable and non-modifiable risk factors
Falls risk assessment
Systematic process of identifying an individual’s intrinsic falls risk factors (...to tailor an intervention)
Falls risk screening
Systematic process of identifying an individual’s level of falls risk (eg low, medium, high)
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
The falls prevention pathway for people living with dementia in Gippsland
Tools:Falls risk screening tool (FROP-Com* screen)
FROP-Com = Falls Risk for Older People: Community version:Screen available from-http://www.mednwh.unimelb.edu.au/nari_tools/nari_tools_falls.html
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
The falls prevention pathway for people living with dementia in Gippsland
Tools:Eg Falls risk assessment tool (FROP-Com*)
FROP-Com = Falls Risk for Older People: Community version:Assessment tool available from-http://www.mednwh.unimelb.edu.au/nari_tools/nari_tools_falls.html
Environmental problems contributing to risk of falling
Poor lighting
Loose mat or slippery / uneven surface
Poor footwear
….. having had a recent fall
The biggest risk for having a future fall is …….
Why is this important?◦ The Doctor can
assess the cause of the falls provide treatment to reduce
risk of a further fall◦ But if the Doctor is not
aware of the fall there will be no actions put
in place to reduce ongoing risk of falls
another fall is likely to occur
However many older people who fall do not tell a Doctor or other health professional
American Geriatrics Society / British Geriatrics Society guidelines:JAGS 2011, 59: 148-157
Case: Mary
85 yo lady Lives at home alone, has a home care worker visit twice weekly Has a personal alarm Has been falling for more than 10 years Multiple fractures from falls Medical past history includes osteoporosis, diabetes, depression,
osteoarthritis, cataracts Medications include sleeping tablets, antidepressants, and
several others Increasing unsteadiness in past few months Had a recent fall, has not seen Doctor about falls Environmental hazards
Early identification of risk: Mary
Reduced awareness of environment and safety
Agitation
Wandering
Increased unsteadiness
What effect does dementia have on a person’s risk of falling?
Even greater risk of falling
But the person with dementia may also have other falls risk factors…
Poor eyesight
Arthritis in the legs
Incontinence
Dizziness
• Poor eyesight• Dizziness• Incontinence• Arthritis • etc
OFTEN THESE CAN BE TREATED• Poor eyesight• Dizziness• Incontinence• Arthritis • etc
Can the risk of falls among older people be
reduced?
YES!
What can help to reduce an older person’s risk of falls: 1. See the doctor or other health
professional
If a person has a fall - even if they think it was just an accident
If a person is feeling more unsteady when walking / turning
Commences using a different walking aid
If a person is reducing their activities
What can help an older person to reduce their risk of falls: 2. Exercise
What can an older person do to reduce their risk of falls: 2.
Exercise COCHRANE REVIEW: “Multiple-component group exercise significantly reduced rate of falls …….. and risk of falling ….., as did multiple-component home-based exercise …... For Tai Chi, the reduction in rate of falls bordered on statistical significance …… but
Tai Chi did significantly reduce risk of falling ……. Overall, exercise interventionssignificantly reduced the risk of sustaining a fall-related fracture …….”.
Cochrane review: Gillespie et al, 2012
Exercise / physical activity
Most researched single intervention in falls prevention
Majority of research in the community setting
Meta-analysis of >50 RCTs identified key elements for success in reducing falls (Sherrington et al, (JAGS, 2011):◦ Balance component◦ Moderate intensityNOTE: Exercise programs usually have a range
of other benefits as well as falls prevention
Usually under intermittent supervision of physiotherapist or accredited exercise physiologist
Often need for encouragement to maintain participation
Many older people have an exercise program to do at home
What can an older person do to reduce their risk of falls: 3.
Medication review Keep medications to the
minimum needed
Take medications as prescribed
Have medications reviewed by the doctor regularly
Try to avoid / minimise use of sleeping tablets, anti anxiety tablets etc
Largest effect of any falls prevention study involved weaning people off
sleeping / anxiety medications
What can an older person do to reduce their risk of falls: 4. Vision
check
Regular vision review
Cataract surgery
◦ First eye effective
Bifocals and multi-focal glasses– can be a problem
What can an older person do to reduce their risk of falls: 5. Home
safety
Removing environmental hazards will reduce risk of falls
If having falls should have an occupational therapy home assessment
Outcomes associated with level of adherence with recommendations
What can an older person do to reduce their risk of falls and fall injuries: Vitamin D and calcium
Many older people have low levels of vitamin D
Main sources of vitamin D are:◦ Sunlight (approx 20 min/day)◦ Some foods (eg sardines)◦ Supplements
Vitamin D and calcium together have been shown to reduce fractures and falls (in high risk samples)
Effect of vitamin D on falls
Cochrane review: Gillespie et al, 2012
COCHRANE REVIEW: “Overall, vitamin D did not reduce rate of falls ……. or risk of falling ……, but may do so in people with lower vitamin D levels before treatment..”
Complex series of studies to interpret because of:• different types of vitamin D (D2 and D3)• different dosages• different samples in terms of vit D deficiency• supplementation of vitamin D with calcium• outcomes of fractures as well as falls
What can an older person do to reduce their risk of falls injuries: Hip protectors
Useful if falling frequently, and / or if bones are weak
Will reduce risk of hip fracture substantially, if worn...
Several different types◦ Hard shields◦ Foam
33
Factors influencing low adherence with hip protectors
Design and style
Fashion / concern about “extra width on hips”
Cost
Impact of:◦ Reduced dexterity◦ Incontinence (some come with continence pads)
Staff / family not reinforcing value of hip protectors
Other interventions from best practice guidelines
Safe footwear
Treat posturalhypotension
Education
Treat incontinence
Change walking aid
Case: Mary – how can her falls risk be reduced?
85 yo lady Lives at home alone, has a home care
worker visit twice weekly Has a personal alarm
Has been falling for more than 10 years Multiple fractures from falls
Medical past history includes osteoporosis, diabetes, depression, osteoarthritis, cataracts
Medications include sleeping tablets, antidepressants, and several others
Increasing unsteadiness in past few months
Had a recent fall, has not seen Doctor about falls
Environmental hazards
Use her personal alarm if a fall occurs and cannot get up
Discuss hip protectors / vitamin D / possibly antiresorptive medications
Review re cataracts-?surgery Review medications, in particular
sleeping tablets Physiotherapy assessment of balance
and mobility - ?exercise program Have a medical review AND report the
fall Home safety assessment by
occupational therapist
Case: if Mary also had dementia…
85 yo lady Lives at home alone, has a home care
worker visit twice weekly Has a personal alarm Has been falling for more than 10 years Multiple fractures from falls Medical past history includes osteoporosis,
diabetes, depression, osteoarthritis, cataracts Medications include sleeping tablets,
antidepressants, and several others Increasing unsteadiness in past few months Had a recent fall, has not seen Doctor about
falls Environmental hazards
POSSIBLE OPTIONS TO REDUCE RISK OF FALLS Use her personal alarm if a fall occurs and
cannot get up Discuss hip protectors / vitamin D / possibly
antiresorptive medications Review re cataracts-?surgery Review medications, in particular sleeping
tablets Physiotherapy assessment of balance and
mobility - ?exercise program Have a medical review AND report the fall Home safety assessment by occupational
therapist
• Dementia friendly environment• Consider any additional carer burden in interventions• Ensure consideration of causes and management of agitation• Other …..
Falls risk can change quickly◦ Acute health problems such as urinary tract /
chest infections
Transitions between settings appear to increase risk of falls (eg home to hospital, home to respite)
Greater level of care / falls risk management at these times
Additional considerations
Summary of what works: falls prevention interventions in the
community setting for people with dementia (randomised controlled
trials)
Exclusion criteria for most community falls prevention randomised trials
Difficult area of research
Limitations in few randomised trials to date (mainly replicating approaches found successful for people who don’t have dementia)
Reasons for lack of research evidence …
Home based exercise for people with mild to moderate dementia◦ Prescribed by a physiotherapist◦ Individualised exercise program, based on balance
and mobility assessment findings◦ Key role of carer in supporting / encouraging
exercise participation by the person with dementia (sometimes doing the exercises together)
◦ Regular review and update by physiotherapist (6 times in 6 months)
Improved balance, mobility and falls risk after 6 months
An area with recent promising results
Suttanon et al, Clinical Rehabilitation, 2013
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
The falls prevention pathway for people living with dementia in Gippsland
Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J
The falls prevention pathway for people living with dementia in Gippsland
Identification of falls risk and referral / screen• Many people accept falls as an inevitable part of ageing (irrespective of
cognitive impairment)
• Only a quarter of older people who fall report the fall to a Dr or health professional
• Many falls risk factors are not identified or managed optimally (eg guideline care in Emergency Departments)
• Need for multiple access / referring points
Timing• Consider falls risk screening
• in early stages of dementia, and
• intermittent review, especially if increased unsteadiness, falls or near falls
Observe for signs of increased falls risk Ask the client to complete a falls risk self assessment
(eg: http://www.health.wa.gov.au/stayonyourfeet/docs/2857_SOYF.pdf)
Encourage:1. Medical review if falls, near falls, unsteadiness, change in
mobility2. Participation in recommended interventions (exercise, use of
gait aid, home modifications, etc)3. Home care workers to report changes in potential level of risk4. If provided with training, encourage home care workers to
observe and encourage participation in home exercise programs
Ways nursing or assessment staff can assist in reducing risk of falling for a client with dementia
Falls are common among older people and can cause serious injuries and loss of confidence
All falls should be reported to a doctor
There are a number of ways that falls risk can be reduced
Home care assessment staff, home nursing staff and other health professionals can play an important role in identifying potential risks for falling among their clients
Consider the Gippsland falls prevention pathway for people with dementia in assessment and management of clients with dementia
Summary
45
Falls prevention resources
National Falls Prevention Guidelines for Community setting (UPDATED – Nov 2009):http://www.safetyandquality.gov.au/our-work/falls-prevention/falls-
prevention-community/
Victorian Government Dept of Health– website of falls prevention resources for community and residential aged care settings (UPDATED 2009)http://health.vic.gov.au/agedcare/maintaining/falls_dev/index.htm