What can PT, OT, Activities and Nursing What can PT, OT, Activities and Nursing Staff do to Reduce Falls?Staff do to Reduce Falls?

Melinda Jaeger, PTmjaeger@empira.org

REACHINGREACHING for your goal for your goalTaking a Taking a STANDSTAND on FALLS on FALLS

ObjectivesObjectives1.1. Explain how the Empira Falls Prevention program Explain how the Empira Falls Prevention program

reduced the prevalence of resident falls between 20% reduced the prevalence of resident falls between 20% and 30% in 16 long term care facilities.and 30% in 16 long term care facilities.

2.2. Identify successful strategies of promoting Identify successful strategies of promoting movement and offering opportunities to reach and movement and offering opportunities to reach and stand. stand.

3.3. Share the journey of the Empira Falls Prevention Share the journey of the Empira Falls Prevention program- specifically the collaboration of PT program- specifically the collaboration of PT and and

OT and Therapeutic Rec (Activities Department)OT and Therapeutic Rec (Activities Department)4.4. Review approaches that can be incorporated in Review approaches that can be incorporated in your facility to reduce falls. your facility to reduce falls.

 

AgendaAgenda•Provide an overview of the Empira Falls Program•Share PT/OT fall assessment tools •Review the important role of Therapeutic Recreation /Activity Staff in the prevention of falls

•Demonstrate how all staff can incorporate reaching and standing in daily cares to reduce falls

Background & ProcessBackground & Process Empira awarded 3-year MN DHS PIPP grant, began 10/1/08Empira awarded 3-year MN DHS PIPP grant, began 10/1/08

~ A project implementing best practices from evidence based studies ~ A project implementing best practices from evidence based studies

~ Goal: Reduce CMS QI/QMs; Falls, Depression & Anxiety, ~ Goal: Reduce CMS QI/QMs; Falls, Depression & Anxiety, Decline in LL ADL, Decline in Decline in LL ADL, Decline in

movementmovement ~ Reduction Goal: 5% first year, 15% second year, 20% third year~ Reduction Goal: 5% first year, 15% second year, 20% third year

16 SNFs, 4 companies participate in PIPP 16 SNFs, 4 companies participate in PIPP Fall Prevent projectFall Prevent project

Facility–wide Program: Facility–wide Program: All departmentsAll departments, residents, family, MD, residents, family, MD Investigation and Interventions based on Root Cause AnalysisInvestigation and Interventions based on Root Cause Analysis

Fall Risk Coordinator in each SNF reports to administratorFall Risk Coordinator in each SNF reports to administrator

who oversees the program – it’s not a nursing program!who oversees the program – it’s not a nursing program!

Project completion date: 10/1/11Project completion date: 10/1/11

Results after 2½ yearsResults after 2½ years• Prevalence of Falls (number of residents who have Prevalence of Falls (number of residents who have

fallen) – fallen) – decreased by 31%decreased by 31% (QI 1.2)(QI 1.2)

• Incidence of Depression – decreased 20%Incidence of Depression – decreased 20% (QI 2.1) (QI 2.1)

• Incidence Worsened ADLs – decreased 17% Incidence Worsened ADLs – decreased 17% (QI 9.1) (QI 9.1)

• Incidence Worsened Room Move – decreased 12%Incidence Worsened Room Move – decreased 12% (QI (QI

9.3)9.3)

• Falls per 1000 resident days (number of falls that Falls per 1000 resident days (number of falls that occurred) – decreased by 14%occurred) – decreased by 14%

• Recurrent Falls – double digits to single digitRecurrent Falls – double digits to single digit

* Compared to a baseline from July 1, 2006 to June 30, 2007* Compared to a baseline from July 1, 2006 to June 30, 2007

Key Components To The Empira Key Components To The Empira Falls ProgramFalls Program•All staff are responsible to reduce falls. This is NOT just a nursing program

•Promote movement and increase functional mobility offering opportunities for residents to reach and stand throughout their day

•Don’t do more…..do things different

Physical Changes As We Age…Physical Changes As We Age…Posture ROM StrengthPosture ROM Strength

Reaction Time Slows

Visual Changes With Aging• Acuity

•Depth Perception

•Contrast Sensitivity

•P eripheral Visio n

Somatosensory ChangesSomatosensory Changes

• Proprioception (position sense)Proprioception (position sense) Ability to walk in the darkAbility to walk in the dark• Sensation Sensation Diabetic changes, numbness, tinglingDiabetic changes, numbness, tingling• Vestibular Vestibular Works with vision to determine whether the world or Works with vision to determine whether the world or

we are moving. Activated in the inner ear when we we are moving. Activated in the inner ear when we move our head. Dizzy with position change. move our head. Dizzy with position change.

• Pain Pain

Affects all movement Affects all movement

BALANCEBALANCE

•Combination of posture, Combination of posture, ROM, strength, reaction ROM, strength, reaction time, visual perception time, visual perception somatosensory and painsomatosensory and pain

“Balance Exercise Reduces Risk of Falling”Balance Exercise Reduces Risk of Falling”

Journal of the American Geriatrics Society, December 2008

Strength training alone may not effectively reduce falls since impaired balance is a stronger risk factor for falls than poor muscle strength.

Walking programs did not appear to have much effect in preventing falls.

The greatest effect in preventing falls were seen with exercises that challenged balance.

How can YOU encourage Standing

•Stand at the sink•Pause during the transfer•Allow standing for a moment

Little time but BIG rewards

TRANSFER POLE

ENCOURAGESTANDING

Fitting Balance During ADLs and Fitting Balance During ADLs and CaresCares

• Wheel chair lockedAdapt if necessary with extenders, tennis balls, or auto lock if they forget to use brakesEncourage to self propel • Feet flat on floor Bed at proper heightEncourage ankle strengthening by tapping feet• Change position SlowlyCount to 4 stay off the floor• Encourage reaching, turning and weight shifting during caresImproves balance and flexibility

Reaching and Turning in Reaching and Turning in ADL’sADL’s

•Turn to get toilet paper and do self hygiene•Reach for towel at sink•Turn and reach for clothing items once set up•Lift arms and lift head to assist with dressing•When offering something to resident have them reach- kleenex, snack, toothbrush, ?????

•Encourage self propel wheelchair (works lots of muscles, posture, balance and independence)

Ambulation Ambulation ProgramsPrograms• Stand TALL• Keep walker close • Good shoes • Stepping: Length and height of step• Use distraction • Parkinson’s walk past destination to decrease

freezing in place• Stand in place and shift weight from leg to leg

•FOCUS ON STANDING AND BALANCE

EVERYONEEVERYONE IS RESPONSIBLE TO IS RESPONSIBLE TO REDUCE FALLSREDUCE FALLS

•ACTIVITY STAFF WERE KEY TO OFFER OPPORTUNITY TO REACH AND STAND TO REDUCE FALLS…..

•Here’s how we implemented this strategy.

Copyright restrictions may apply.

Tinetti, M. E. et al. JAMA 2010;303:258-266.

Independent Risk Factors for Falling Among Community-Living Older Adultsa,b

PT_FALL_RISK_ASSESSMENT.xlsx

Name ____________________________________________ Med Record# ____________Room________________

Recommendation for Ther Rec Program *Static balance *Dynamic balanceAD indoors_________

⃞ hands free ⃞ hands freeAD

outdoors________

*Static Balance: front reach while upright ⃞ 1 hand support ⃞ 1 hand support I A gait

*Dynamic Balance : kick, bend, ⃞ 2 hand support ⃞ 2 hand support I A curb

reach overhead, retro gait ⃞ Assist by staff ⃞ Assist by staff I A stair with rail

I A van/bus step

⃞ seated programming only W/C only for outing

Precautions:

Therapist initial ________________________________ Date______________________

The A, B, C’sThe A, B, C’s

AMBULATE AMBULATE

BALANCEBALANCE

CHAIR CHAIR

Offering Opportunities Offering Opportunities to REACHto REACH

Wheel chair bound can improve balance•Promote core strengthing•Improves balance•Practical in everyday activities- reach for items

•Let’s try it….sit ups and balance seated

Balance ChallengesBalance ChallengesEasy……………..DifficultEasy……………..Difficult

Head straight Head turned Head lift Eyes closed

Reach Push Pull Overhead Turn

Wide stance Feet together Tandem One leg

Reaching and Turning in Reaching and Turning in ADL’sADL’s

•Turn to get toilet paper and do self hygiene•Reach for towel at sink•Turn and reach for clothing items once set up•Lift arms and lift head to assist with dressing•When offering something to resident have them reach- kleenex, snack, toothbrush, ?????

•Encourage self propel wheelchair (works lots of muscles, posture, balance and independence)

SAFETY SAFETY

Wheelchair brakes lock Chair sturdy with arms Table secure Using Assistive device as appropriate Wearing glasses, hearing aide Proper footwear STOP if pale, shaky, dizzy, Report any change in demeanor If in room, make sure bed is correct height

Your Activity CalendarYour Activity Calendar

Do the Activities Promote Standing and Balance?

• Hammer• Wave flag• Rolling pin• Hold the pole on the bus- stand on toes, rock back on heels

• Cast the fishing pole• Catch the fish• Paddle the canoe• Lawrence Welk band

conductor• Iron the clothes• Stir the soup

• Make an X in the air• Sword fight across the table• Statue of Liberty• Shakers• One side of table put down their

noodles, do tug of war across• Steering wheel **free hand balance• Open drawer ** free hand balance • Close drawer ** free hand balance• Marching band director and march • Twirl the baton• Helicopter

STAND UP↑Charades Noodlin’ (Exercising the brain and body)

Have the resident stand in front of a table with a chair behind, leg rests removed. Pass out noodles, alternate colors. Say the action and have the residents act out the action with the noodles.

Song: New York… New YorkSlide to middle of chair so 4” is between chair and resident, feet flat on floor. Sit TALL. Have resident pass noodle to neighbor high or low. Switch it up.Hold noodle at arm’s length. Tap feet through out: Start the music and have fun!

1. Push and Pull 2. Push Left – Center – Right while kicking alternate legs3. Twist right hand on top – Twist left hand on top (Steering wheel)4. Turn head and swing left – center – Turn head and swing right5. Lift alternate knee to noodle6. Paddle left – Paddle right7. Kick noodle with alternate feet while switching noodle in hands8. Tap noodle in front to left –to right while tapping feet9. Sway noodle overhead while looking upward10. Touch head- shoulder- knee- shin-knee-shoulder -head11. Draw circle in air several times then draw big X several times 12. Sway side to side ……end with holding noodle out and shaking it!! When turning in the noodles have those with red noodles stand and pass theirs in. Then yellow stand and pass....

Exercise With Complex ActivityExercise With Complex Activity

•Increases neurotransmitters•Stimulates neuron growth•Strengthens and expands brain network

Challenging Leisure ActivitiesChallenging Leisure Activities

•Dancing, of all kinds, is the most effective activity as far as decreasing risk of dementia and cognitive decline.

•Playing board games and musical instruments, doing word puzzles and reading also decrease your risk.

(Cohen, 2005)

Meaningful Activities Meaningful Activities Personally Relevant/Important, Contribute to Wellbeing

• Brings back good memories• Relaxing• Enjoyable• Makes you laugh• Makes you feel healthy • Makes you feel good about yourself• Let you try something new or get better at something• Helps you express your feelings, • Validates life experiences

Diagnosis Specific StrategiesDiagnosis Specific Strategies Parkinson’s - direct past destination, count or

encourage long steps to ↓ shuffle, work on posture

MS - don’t overtire, heat intolerant Arthritis - encourage ROM, awareness of flare

ups, avoid heavy weights Osteoporosis – avoid flexion and weights Macular Degeneration – avoid bright light, poor

central vision, poor contrast, ↓ face recognition Dementia – ↓ distractions, use calm, reassuring

manner, familiar activities

•A personal invitation and the support of family and friends will encourage older adults to take part in fall prevention programs.

Stepping It Up

• Golf Putting• Bean Bag Toss• Bowling• Wii• Ball Toss• Dance to Music

• Cooking • Art • Walk Through Europeor Walk to Hutchinson• Massage• Tai Chi

Community Involvement

• Quilting• Card Club• Book Club• Gardeners Club• Art Class• Tai Chi – Chair Yoga• Support Group: Grief/Loss, Parkinson’sStroke, Diabetes, MS

Bright Light promotes the Bright Light promotes the secretion of Serotoninsecretion of Serotonin

• Serotonin is the “happy, feel goodSerotonin is the “happy, feel good” biochemical.” biochemical.

• It regulates mood and provides a sense of well-being and It regulates mood and provides a sense of well-being and happiness. happiness.

• It also helps to regulate appetite, wakefulness, sleep, and It also helps to regulate appetite, wakefulness, sleep, and the cognitive functions of memory and learning.the cognitive functions of memory and learning.

• Serotonin is also a growth factor for some cellsSerotonin is also a growth factor for some cells, , which which gives it a role in healing, especially wound and skin healing. gives it a role in healing, especially wound and skin healing.

• Serotonin is triggered by the presence of bright light. Serotonin is triggered by the presence of bright light. More light = more serotonin produced More light = more serotonin produced Less light = less serotonin Less light = less serotonin produced. produced.

LIGHT METER TO MEASURE LIGHTLIGHT METER TO MEASURE LIGHT

$33 on Amazon

500- 1000 lux for 120 min (Indoors)10000 lux for 30 minutes (Out Doors)

Happy Light …It outputs up to 2500 lux (150 watts) of Natural Spectrum® daylight from a cool burning 26 watt bulb.Measures 9" H x 4 3/4" W x 2 1/4" D. UL listed. $39.00

OR.. Open the blinds and let the sun in!!

NO BENDINGNO BENDING•Use reacher•Use long handle shoe horn•Use elastic shoe laces or easy shoes to put on•Keep room accessible so resident does not bend•Keep items out of low drawers •Keep floor clean

Incorrect Footwear- Slippers…Gripper socks a real hazard on carpet!Lets try it out

Shoe Brochure On Admission

Falls Trending Report

• What is it

• What does it mean to TR

August 2012 Falls In One of Our August 2012 Falls In One of Our NHNH

# of falls

Time of day

R- August 2012 Fall Summary

Critical times to provide activities1-3 p.m. • Routine time for naps- Naps rob the sleep bank

How long does it take to put a resident down for a nap?..The NAR can use this time instead to engage the resident. Activity staff can focus on activities during traditional nap times to reduce boredom.

Nap

NIGHT SLEEP

Purpose: Purpose: To provide active, purposeful engagement for residents to reduce boredom(apathy), napping and pharmacological treatment for behaviors which disrupts sleep.

Focus on the Dementia resident who is unable to initiate self driven activities.

CMS NATIONAL GOAL CMS NATIONAL GOAL REDUCE ANTIPSYCHOTICS BY REDUCE ANTIPSYCHOTICS BY 15%15%

• Nursing Homes antipsychotic drug use is available on Nursing Home Compare

• Antipsychotics increase fall risk in elders

• CMS is emphasizing non-pharmacological alternatives for nursing home residents including: consistent staff assignments, increased exercise of time outdoors, monitoring and managing pain and planning individualized activities.

Activity Improves Sleep and Activity Improves Sleep and Decreases AgitationDecreases Agitation

• 1 nursing home 29 residents over 14 weeks• Sleep efficiency improved from baseline of 51.7% to

62.5% (17% improvement)• Control group Sleep efficiency was 66.3 at baseline,

after 14 weeks 67% (no change)• 7 of 15 residents who had activities during 14 weeks

had decrease in observed agitation • Control group only 1 of 14 had decrease in observed

agitation. Alessi CA, Yoon EJ, Schnell J et al. A randomized trail of a combined physical

activity and environment al intervention in nursing home residents: do sleep and agitation improve” J am Geriatr Soc 1999 47:784-91

ACTIVE ENGAGEMENTACTIVE ENGAGEMENT

• Pulls participants out of a passive state, expending energy, providing pleasure and movement opportunities, and reducing other neuropsychiatric symptoms”

(Buettner, Fitzsimmons & Dudley, 2010)

Need to reduce apathy to reduce agitation

INTEREST BOX IDEASINTEREST BOX IDEAS

• Fishing Box• Jewelry Box• Recipe Card/Spices• Sales Receipt Box• Envelope and Stamp • Scratch and Sniff Sticker • Playing Card Box, dominoes• Sports/Gardening • Key and Lock• PVC pipe fitting •Your Ideas

Share Activity Ideas – What can I Share Activity Ideas – What can I implement tomorrow????implement tomorrow????

•What should go in the activity bin for NARs to engage the resident during traditional nap hours? Simple, easy set up, cross cultural and gender

•What will TR Dept provide during nap hours?

Engaged (busy) Residents Engaged (busy) Residents

•Sleep better•Have less falls•Have less depression•Have less behaviors

August 2012 Falls In One of Our NH

# of falls

Time of day

R- August 2012 Fall Summary

Critical times to provide activitiesCritical times to provide activities

6- 8 p.m.

• Delay the bed time for residents so they do not awaken at 2-3 a.m.- promotes restorative sleep

• Utilize managerial staff talents to “entertain” engage the residents. Great opportunity for management and non clinical staff. Wonderful modeling for NARs.

How can we all participate in How can we all participate in engaging the residents?engaging the residents?

• Nonclinical staff- housekeeping , maintenance, business office,

• Managers• SW, Chaplains• TR• NAR• Nurses, LPN, TMA• Families• Volunteers volunteermatch.org• Other Residents

What did you see?What did you see?

Resident is leading this activity

SHARING & CARINGPIPP RSVP Project

Facility Managers Share their Talents to Improve Care of our Dementia Residents

Providing Meaningful Engagement

WIFM- What’s in it for WIFM- What’s in it for me? me?

• One flex day per month to come in later and work through 7 p.m. Morning free to schedule appointments.

• The rewards of sharing your talents, skills with the residents of your facility. An opportunity to build relationships.

• Budget neutral- doesn’t cost the facility $ but provides programming for the resident.

• Gives management an opportunity to review evening shift practices and systems.

• Great visibility to the NAR and front line staff. They feel supported in their role of caring for the resident.

• Meets CMS directive to provide non-pharmacological alternatives for dementia Nursing Home residents.

WHAT WILL I DO?WHAT WILL I DO?• 6-7 pm will fill the void after dinner and before bed. The residents need an

activity• Share your talent

• Musical- piano, harmonica, sing, guitar • Read poems, discuss POSITIVE events in the newspaper, use the

resource bin with books on elder nostalgia, trivia• Talk about a recent trip, your garden, your recent smart phone apps,

bring in props for residents to see and touch• Use magazines to create collage, draw together• Play dominoes, shake dice, shuffle and sort cards• Use the resource bin on the unit which has hand lotion for hand

massages, horseshoes and bean bag toss for physical games, lots of activities provided for you

• Also have the 101 activities resource for ideas in this folder

1. Make collage from magazine2. Put together nuts and bolts3. Bake cookies4. Read paper5. Invite children to visit6. Read a letter out loud7. Listen to music8. Parachute game9. Color/Paint10. Make lemonade11. Wipe off table12. Talk about gardening13. Make Pigs-in-a-Blanket14. Spelling bee15. Readers Digest16. Fold clothes, sort socks17. Pet visit18. Cut out cards19. Wash silverware20. Bake bread21. Sort objects22. Sing Christmas songs23. Life Review24. Put silver away25. Make a Valentine's collage26. Sing songs27. Look out window, what do you see?28. Make a pie29. Read a poem30. Dye Easter eggs31. Sort socks32. Take a walk33. String fruit loops34. String cranberries35. SNOEZELEN ®36. Look at photos37. Reminisce38. Clip coupons39. Sort poker chips40. Count things41. Fold towels42. Afternoon Tea43. Reminisce/Inventions44. Play a game45. Paint46. Cut out paper dolls47. Identify states and capitols48. Make a family tree49. Color American Flag50. Cook hot dogs51. Grow magic rocks52. Water house plants

53. Reminisce - first kiss 54. Play horseshoes55. Dance56. Sing a hymn57. Make ice cream58. Plant bulbs59. Make cards60. Sort cards by suit61. Write a letter62. Dress in team colors-talk sports63. Pop popcorn64. Name the U.S. Presidents65. Give a manicure, hand massage with scented lotion66. Music, Movement & Props67. Plant or weed68. Make a may basket70. Finish a famous saying71. Feed the ducks72. Mold dough73. Picture books74. Put a simple puzzle together75. Sand wood76. Rub on hand lotion77. Decorate place mats78. Arrange fresh flowers in a vase79. Remember famous people80. Rake leaves81. Make a fruit salad82. Sweep the patio or room83. Talk about famous events84. Nursery Rhymes. You start85. Make sandwiches86. Dust furniture87. Cut up paper/ Tear paper88. Take care of bird cage/fish tank.89. Trace/cut leaves90. Simple trivia questions91. Finish Bible quotes92. Paint with string93. Cut out pictures94. Read/listen to a short story95. Put coins in a jar96. Sew sewing cards97. Put seed in bird feeder98. Clean out pumpkin99. Roll yarn100. Reminisce about vacation101. Make a cake

.

101 Things to do with a person with Alzheimer's and Dementia DiseaseProvide existence with meaning. Make each activity success oriented, failure free, purposeful and meaningful

Exercise and Brain HealthExercise and Brain Health• Inactivity kills our brains-physically shrinking them. • If your brain isn’t actively growing, then it is dying.• Toxic levels of stress and chronic depression erode the connections

between billions of nerve cells and shrinks certain areas of the brain. • Exercise has a profound impact on cognitive abilities and mental

health.• Because the aging brain is more vulnerable to damage, anything you do to strengthen it has a more pronounced

effect than it would on a young adult.• Exercise is preventive medicine as well as an antidote.

Good Strategies to Reduce FallsGood Strategies to Reduce Falls

• Keep awake with bright light, in front of windows or outdoors. Residents are bored….not sleepy!

• Keep it simple, no distractions (clutter free, quiet)• Make eye contact and use body language that is

positive (I want to be here, I have time, you are important)

•Follow Human Biological Clock • Stimulate the senses- Smell, Visual, Touch,

Proprioceptive, Vestibular, Auditory (sound) and Taste

Serotonin secretion starts

20:00 Serotonin secretion stops(8:00PM)

Human Biological Clock: Ideal 24 HoursHuman Biological Clock: Ideal 24 Hours

Lowest blood pressure

Greatest healing and growth occurs

(3:30 PM)

(6:00 PM)

AromatherapyAromatherapy

• Aroma targets different neuro-chemicals in Aroma targets different neuro-chemicals in the brainthe brain

AromatherapyAromatherapy• Certain studies involving brain wave frequency

indicated that smelling lavender increases alpha waves in the back of the head which calm and reduce falls

• The fragrance of jasmine and citrus increases beta waves in the front of the head, which are associated with a more alert state.

• Peppermint applied topically causes nerves to be less stimulated and pain relieved

J Am Geriatr Soc. 2012 Jun;60(6):1005-11. doi: 10.1111/j.1532-5415.2012.03977.x. Epub 2012 May 30.

Fall prevention using olfactory stimulation with lavender odor in elderly nursing home residents: a randomized controlled trial. Sakamoto Y1, Ebihara S, Ebihara T, Tomita N, Toba K, Freeman S, Arai H, Kohzuki M

PUTTING IT ALL TOGETHERPUTTING IT ALL TOGETHER

EVIDENCE BASED PROGRAMEVIDENCE BASED PROGRAM

• “Balance Training Program is Highly Effective in Improving Functional Status and Reducing the Risk of Falls in Elderly Women with Osteoporosis.” MM. Madureira, PhD., et al., Osteoporosis International, Vol. 18, pp. 419 – 425, 2007.

• “Effective Exercise for the Prevention of Falls in Older People: A Systematic Review and Meta-Analysis.” Catherine Sherrington, PhD., et al., Journal of American Geriatric Society, Vol. 56, pp. 2234 – 2243, 2008.

• “Not Preventing Falls – Promoting Function,” Elizabeth Capezuti, RN, PhD, et al., Geriatric Nursing, Vol. 32, No. 1, p. 55 - 57. January/February 2011.

We all have a role in We all have a role in managing fallsmanaging falls

•No alarms, •Standing, Reaching, Balance! •Bright light during the day to promote wakefulness. •NO naps. Provide engagement at key times

•What will you do to prevent falls when you get back to your facility?

Workshop Wrap UpWorkshop Wrap Up

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214 Bed Home Average Quarterly Fallsper 1000 Resident Days