Prepared by Julia Poole

CNC Aged CareRNSH

September 2007

The Changing Paradigm in Falls

Implications in Acute Care

Cost of fall injury to older people Total lifetime cost of falls $644 million ($333

million direct costs & $311 million mortality & morbidity costs) in NSW

If current admission rates continue, by 2050 NSW will need 800 new acute care beds and 1200 new aged care places to manage the impact of the demographic change.

A serious fall frequently becomes the precipitating event into permanent residential care for a frail older person.

Falls Facts for Acute/Sub-acute Care

In Australian Hospitals 1/3rd of all patient incidents involve a fall.

Most people who have a fall in hospital are over 65 years of age.

Falls in hospital are being given a high priority as they are considered to be generally predictable and often preventable within a scheme of falls prevention activities.

Risk Factors for Falls In Hospital

History of falls prior to coming in to hospital or has fallen in hospital

Patient is confused or agitated - can be long standing eg dementia or can be made worse on admission to unfamiliar environment, confusion post operatively or from acute infection (delirium).

Mobility and transfers are unsafe. May have a walking aid such as a frame.

Risk Factors for Falls In Hospital (cont’d)

Needs to go to the toilet frequently or is incontinent

Takes medications associated with increased risk of falls eg psychoactive, diuretics, antihypertensives

Has poor vision, such that everyday function in the ward is impaired

Consequences of FallsFalls in hospital are associated with:

Increased mortality

Increased length of stay

Serious injury eg hip fractures, cerebral haemorrhage

Change in discharge living arrangements

Consequences of Falls Other consequences of falls:

Fear of falling and loss of confidence, correlates with depression and social isolation.

Reduces older persons' confidence to return home and function independently.

Falls per 1,000 Bed Days in the Acute Aged Care Ward 2001-2004

7.8 7.3

11.911.9

9.26

21.6

13.1

15.813.5

9.2

14.8

20.8

11.7

7.2

10.58.2

13.4

9.4 9.1

17.4

7.2

3.82

17.8

5

14 15

7.1 8

12.1

5.4

11.7

6.5 6.8

20.120

14.716.616.5

21.6

14.4

4.6 4.8

10.8

18.6

11.4

0

5

10

15

20

25

Months

Fall

Rate

s

2001 2002 2003 2004

Volunteer Companions, IPS

2001 - 2 # NOF, 1 # Ondontoid, 21 skin tears2002 - 2 # NOF, 1 # Radius, 14 skin tears2003 -1 # NOF, 1 # Humerus, 18 skin tears2004 - 1 # humerus, 1 # scaphoid, 16 skin tears

Delirium, the major risk factor for fall in an acute aged care ward (unpublished) Poole J and Ogle S

n = 312

File audit

‘confusion’ documented in 96% of notes

DEMENTIA

The word “Dementia” is used widely to describe a group of diseases which affects the brain and cause a progressive decline in a person’s abilities to remember, think and learn. The main abilities affected are:

Judgement

Orientation

Emotions

Memory

Thinking

WHAT CAUSES DEMENTIA?

There are different forms of dementia and each has its own causes. Some of the most common forms of dementia are:

Alzheimer’s Disease

Vascular dementia

Frontal Lobe dementia

Dementia with Lewy Bodies

(see www.alzvic.asn.au)

What is Delirium?

an acute organic mental disorder characterised by confusion, restlessness, incoherence, anxiety or hallucinations which may be reversible with treatment

Sometimes known as :– Acute Confusion– Acute confusional state– Acute brain disorder– Acute brain syndrome

Gelder, Mayou & Geddes (1999); Moran & Dorevitch (2001); Inouye (2006);

DSM-IV 1994 Delirium is characterised by a disturbance of consciousness and a

change in cognition that develop over a short period of time American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th Ed).Washington: American

Psychiatric Association.

ICD-10-AM Diseases 2003– F05 -Delirium, not induced by alcohol and other psychoactive

substances

– non specific organic cerebral syndrome

– concurrent disturbances of consciousness and attention, perception, thinking, memory, psychomotor behaviour, emotion, and the sleep-wake schedule

– F05.1 Delirium superimposed on dementia

Pathophysiology of Delirium

Multiple mechanisms Inouye 2006 The NEJ M 354:1157-65.

– Neurotransmission, Inflammation, Chronic stress

Moran 2001 The Australian Journal of Hospital Pharmacy. 31(1):35-40.

– decreased cerebral oxidative metabolism causing altered neurotransmitter levels

– stress-induced increased plasma cortisol levels causing altered neurotransmitter activity

Yokata et al.2003 Psychiatry and Clinical Neurosciences.75(3):337-339.

– cerebral hypo-perfusion in the frontal, temporal & occipital cortex

Delirium Risk AssessmentWeber et al. 2004 Internal Medicine Journal. 34:115-121.

Predisposing

Vision/hearing impairment

Severe illness

Cognitive deficit

– AMTS < 7/10

– MMSE < 25/30

Dehydration

Precipitating

‘Mechanical’ restraint

Malnutrition/dehydration

3 new medications

IDC

Unpleasant event/s – surgical procedure

– med. toxicity

– falls

– infections

– faecal impaction

– etc

Prevention of Delirium Inouye et al. 1999 NEJM 340(9):669-676.

Cognitive impairment

Orientation, therapeutic activities

Sleep deprivation Pain relief, non-pharmacological sleep enhancement protocol

Immobility early mobilisation, minimal use of immobilising equipment

Sensory impairment

vision & hearing protocols

Dehydration volume repletion

Delirium Maher & Almeida 2002 Current Therapeutics. March:39-43.

Is a medical emergency

Incidence of up to 56% in hospitalised elderly

Independent predictor of adverse outcomes

– falls

– incontinence

– pressure sores

– decreased functional levels

– increased mortality

– increased LOS in acute care

– INCREASED COSTS

“Think about when you have looked after an agitated older patient - tell us about it?”

Registered and enrolled nurses in a large teaching hospital were asked to discuss their feelings and actions in regard to caring for agitated older patients

– six taped focus groups, n = 36

thematically coded and analysed.

Poole, J. and Mott, S. (2003) Agitated Older Patients – nurse’s perceptions and reality. International Journal Of Nursing Practice, 9:306-312.

1. See (to understand)cont’d

-ve - ‘you think you’ve calmed them down and they seem sweet or whatever, people can just change’ , ‘Doctor would chart a minuscule amount...didn’t touch her’, ‘won’t even numb a little finger’

Particular concern- ‘sometimes it (restraint) makes them more agitated but you’d rather that so you can get out and get some of the other work done and come back to them later and calm them down’

3. Span of time

The burden placed on staff by agitated patients was clear - ‘trying to work out how to get the rest of the jobs done’ and ‘nothing else gets done’.

‘if I’ve been with one patient, I get complaints from other patients and relatives because I haven’t been with them and then it sort of snowballs and you get more agitated and frustrated ... because you can’t give everyone the same care’.

FALL RISK ASSESSMENT SCORE to be completed on admission or transfer in, DAILY and where so warranted by a change in the patient’s condition (Mercer 1997)

Characteristics Value Age equal to or over 70yrs

5

History / admission diagnosis related to falls / seizures / stroke

3

Disorientation / Confusion / Agitation OR Impaired memory OR judgement OR

Unable to understand OR follow instructions (no score if patient unconscious &/or unable

to move)

10

Significantly impaired sight, hearing OR sensation

1

Impaired Co-ordination or unsteady gait limb weakness OR uses walking aid OR may be tripped by equipment (IV poles, catheters

etc)

3

On one or more of the following medication Sedatives ( including benzodiazepines) Psychotropics Hypoglycaemics Narcotic analgesia Antihypertensives Antidepressants Anticonvulsants Antiparkinsonians Diuretics

1 for each medication

Incontinent or change in continence status eg removal of a catheter,

Urgency, Frequency, Nocturia Recent aperient use/ administration

1 for each

Less than 24hrs post op or confinement

1

Add up score, document according to characteristics

TOTAL score

SUGGESTED STRATEGIES FOR FALL PREVENTION

L

Low risk 0-4

1. Keep environment clear and floor dry 2. Tell patient/family about fall risk and give

Fall Risk Leaflet. 3. Put call bell and light switches within

reach at all times. 4. Put patient's glasses and hearing aid

on. 5. Insist on use of non slip footwear. 6. Position bed at the lowest height with the

brake on except during direct clinical care.

M

Medium risk 5-14

All of the above plus: 7. Refer patient to medical and allied health

team for review. 8. Assist / supervise all patient mobility 9. Consider individual toilet schedule 10. Assess and document individualised bed

rail position. 11. Discuss patients at risk in nursing

handover.

H

HIGH RISK 15 +

All of the above plus: 12. Flag patient on Care Plan with orange

falls sticker. 13. Increase frequency of observation by: supervision by family, IPS, Volunteer

&/or sit in room to write notes place patient closer to the nurses station. 14. Consider suitability of single room (reduce

stimulus) or 4 bed room (increase supervision).

15. Consider the use of restraints adhering to the restraints policy.

Take Home Messages

Increasing numbers of older sicker patients in hospitals

Older patients have

– increased predisposition for delirium and/or dementia

– increased predisposition for falls

– increased predisposition for injury from falls

– increased predisposition for death from falls

Falls are COSTLY for everyone

The best way to manage delirium and prevent falls is to increase patient support & surveillance (NOT RESTRAINT)

Hospitals must be designed to enable surveillance of patients eg windows, glass walls etc