Risk assessment tools for falls

Due to the ageing population and the increase of falls among older adults, I choose to investigate how home care nurses use risk assessment tools to prevent falls. Approximately 9,500 deaths in older Americans are associated with falls each year. The elderly account for seventy-five percent of deaths from falls. [1] A majority of older adults spend nearly all of their time in their home, and for this reason one-half to two-thirds of all falls occur in or around the home. [2] Due to the ageing population, more demands are going to be made on health care services specifically dealing with older adults. With my previous experience working at a nursing home for three years, I have witnessed many residents who have fallen. Falls have a huge impact on the older adults and diminish their quality of life. Working with elderly people has inspired me to continue on in life working with elderly patients as a geriatric nurse. My career goal is to pursue a bachelor’s degree in nursing, and earn my Registered Nursing license. Helping and aiding older adults in daily tasks is very rewarding to me. Seeing older adult residents fall is very upsetting to me, especially when they have a hard recovery. I am further interested in exploring what nurses can do to help prevent these horrendous falls. There are three different kinds of falls, Accidental Falls, Anticipated Physiological Falls, and Unanticipated Physiological Falls. I would like to look into the risk assessment tools used to identify patients at risk of falling, and what prevention home care nurses advise for each type of fall.

In the last two decades, precautionary programs have been developed aiming at reducing health care cost and improving the independent functioning of elderly people. One of such programs is home visitation by public health nurses of elderly people living in the community. This aims to maintain or improve the functional abilities and well-being of elderly people and reduce the use of institutional care services. Many elderly people try to avoid entering a nursing home at all cost, so they try to stay in their own home as long as possible. A fall is an unexpected event in which the individual comes to rest on the ground, floor, or lower level.( Consultgerim.org) The role of a home care nurse is to conduct a fall risk assessment test, which provides a scale that identifies which patients are at risk of a fall.(Scott,Lord,Donaldson,Khan, 2006) This tool helps to recognize which type of fall the older adult is at risk of and helps to plan strategies for prevention. Many different things may cause a fall. The causes of falls are known as risk factors. There is not a single risk factor that causes all falls, the greater the number of risk factors to which an older adult is exposed, the greater probability of a fall. According to Tinetti, with one or no risk factors seniors will have approximately 27% risk of falling each year. In addition to the previous statistic, Tinetti also concluded that older adults with 4 or more risk factors have a 78% chance of falling.(Tinetti, 1998) Many of these risk factors are preventable. The most key fall risk factors include medical and past fall history, cognitive impairment, bladder dysfunction, gait/balance disturbances, poor vision and medications. Once a patient’s risk of falling has been identified, then a plan can be put in place to prevent future falls.

Home care nurses role in protecting older adult patients from falls is significant and the first step to prevention is to assess the patient with a fall risk assessment evaluation. The first evaluation is to discuss the patient’s history of falls. Studies have cited a history of falls as a significant factor associated with patients being more likely to fall again. (www.premierinc.com) A home care nurse should converse about any previous falls that may have happened, when they happened, where, and why. Home care nurses should be aware of any previous medical history due to falls. General health is another risk factor that home care nurses should discuss. This includes if the patient has any chronic or acute illnesses such as, Parkinson’s disease, cardiovascular disease, diabetes, or any history of loss of consciousness, dizziness.

It’s generally established that patient falls are caused by multiple risk factors, both intrinsic and extrinsic. Extrinsic risk factors are safety hazards within the environment that predispose one to slipping and tripping. (Rice,1994) The way home care nurses evaluate and older adults’ environment is by a home hazard assessment. Home hazard assessment looks at every room of the house and evaluates the safety. Home care nurses us a standardized environmental checklist to screen risk factors. Home care nurses look for risk factors such as poor lighting, slippery floors, inappropriate height of chairs and toilets, stairs that have no rails, lack of grab bars or poorly located/mounted grab bars, unsteady furniture, improper fitting shoes and throw rugs. Bathrooms are a particularly highly risk part of the home for falls. It can be difficult for elders patients to get on an off a low toilet and many falls take place when a person is rushing to get to the toilet. Crutches, canes or walkers can increase fall risk. Patients often fall when rising from a chair to reach for a walker, or when a cane catches on a loose floor or floor covering. (Costal Training Technologies, 2006) An additional way home care nurses can advise their patients is to have communication devices, such as a cell phone, telephone in every room, or a life alert button. Older adults should have communication with the outside world so that incase of a fall they can communicate with medical professionals quickly. Environmental factors account for up to one-half of all falls among seniors. (Gillespie, 2009). Most falls happen at home where the patient spends most of their time and can be easily correctable with a aid of a home hazard evaluation preformed by a trained home care nurse who can identify home risk factors and recommend appropriate actions.

The second type of fall risk classification intrinsic risk factors. Intrinsic risk factors are internal conditions that affect one’s ability to maintain his or her balance. (Rice, 1994) The most common intrinsic risk factors for falls are a history of falls, muscle weakness, gait and balance problems, use of assistive devices, visual deficits, and sleep disturbances. (Grady, Lamb, 2008) Medications are a major risk factor for falls. Many older adults take multiple medications to treat health conditions. Taking four or more medications significantly increases the risk for falling because there are a greater number of side effects associated with multiple medication use and the side effects are more intense. Interactions between medications can also cause side effects. (Hamilton County) As a home care nurse performs the assessment, they would obtain a list of current medications that their patient is taking and review the medications and dosage that was administered from a physician. Gait and balance abnormalities are also a good predictor for risk factors for falls: difficulty with rising or sitting down, instability immediately after standing, staggering on turns or walking with short, discontinuous steps. (Tideiksaar, 2008) Dealing with patients who have mobility troubles, a home care nurse would perform a “Get up and Go test” which can be used to quickly assess gait and balance. As adults age their vision and body systems age along with them. Intrinsic factors also include vision problems, diseases, and troubles with the musculoskeletal and cardiovascular system. (Zelinsky, 2009)

In summary, fall prevention is really about carefully recognizing and assessing the needs of each older patient. A fall risk assessment program that evaluates, communicates and attempts to diminish fall risk on a regular basis, can be very effective in preventing falls.(Tideiksaar, 2009)

From the interviews with the older adults I intend to discover many issues regarding falls and how the older adults can relate to fall risk assessment. The variety of interview questions I wrote all deal with fall risk assessment and relate to the assessment home care nurses perform on elderly people. I aspire to learn if older adults are in fact taking advantage of the home care services and if so, does my research match up with assessments they may have experienced. Medication revision, Home Hazard Assessment, and the Get up and Go test, are among the various components of a fall risk assessment test. I also am determined to learn if older adults are aware of issues causing them to fall, and how they would feel if a home care nurse evaluated them with different procedures. With any luck I hope from these interviews it may make the older adults a little more aware of what home care nurses do and that falling is a huge occurrence among elderly people.

I am very eager to interview a professional home care nurse given that I seek to work in the nursing, medical field one day. Especially considering home care nurses deal with older adults and that is an interest of mine from working at a Nursing home for many years. The questions I put together for the professional home care nurse deal with the actual fall risk assessment procedures and how to deal with people who suffer from risk factors of falling. Together, our group wanted to ask a professional about the three different kinds of falls, accidental, anticipated, physiological, and how they would go about dealing with these types of falls. I am very eager to see what the professional home care nurse has to say about these three types of falls because I myself did not know that there were three different types.

From the interviews with the older adults I have learned that older adults have very different views on home care nurses and tools to help prevent falls. In one of my interviews, the older adult was very unenthusiastic about having a home care nurse come into to her home, she was a very independent lady and wanted to do everything herself. Although with the help from her sons she did make adjustments to her home to reduce the chances of falling. On another note, the other two older adults I interviewed willing to have a home care nurse assess them. The one older adult I interviewed was very healthy and has not had any medical problems in her old age. Although she was very willing to have a home care nurse help her when that time comes in her life. The final older adult I interviewed has had many experiences with home care nurses. She said that every time she was dismissed from the hospital, the hospital made sure that a home care nurse came home to assess her home to make sure it was safe for her. She appreciated the home care nurses assess her home because it made her feel safe. Overall, all three older adults I interviewed had different mental and physical abilities, and had different opinions on having home care nurses assess them.

As for the interview with the professional home care nurse she reassured a lot of my research that I did to assist me in writing this paper. The interview made me very excited to get out into the medical world and use the skills and knowledge that I have learned.

MARY ROSE MCSHANE

AGE

GENDER

MARITAL STATUS

LIVING ARRANGEMENTS

Mary Rose McShane was my first interview for the older adults. She has been a neighbor to my Grandma for a few years now. I do not know her but my Grandma has told me many stories about her and with her living in the same home for many years and being as old as she is, I thought I would get good quality answers to the variety of questions I had.

Mrs. McShane was very pleasant and was willing to answer all the questions I had. The interview took place inside Mrs. McShane’s home, with my Grandma by my side. The topic of my paper is all about accessing elders for falling and how home care nurses go about doing that. Mrs. McShane was very hesitant to have a home care nurse accesses her in the many procedures I talked about. She seemed like a very independent woman and reassured me many times that she would be staying in her home for as long as possible

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ROSEMARY PIZZULI

AGE

GENDER

MARITAL STATUS

LIVING ARRANGEMENTS

Rosemary Pizzuli is a new resident at Emerald Village where I have been working in dietary service for three years. I noticed that she uses a walker to get around the complex, so I thought she would be a good candidate for my questions. She lives in a one bedroom apartment, with a kitchen, living room, and bathroom. She says that it’s just enough space for her and she really enjoys living at Emerald Village.

The interview took place in her apartment at Emerald Village. Even though she is a new resident she was very enthusiastic about having me interview her and willing to help young people who are interested in older adults. She answered my questions very thoroughly, and had much experience with home care nurses because after being dismissed from the hospital a home care came to evaluate her living quarters.

ELIZABETH GRENTZER

AGE

GENDER

MARITAL STATUS

LIVING ARRANGEMENTS

My mom is an accountant and does Elizabeth Grentzer’s taxes. My mom said the Mrs. Grentzer is a very healthy lady and I thought that diversity in biological aging would be a good addition to my research. She lives in ranch home in North Ridgeville, Ohio, by self. She told me she enjoys gardening and doing yard work in the summer. Mrs. Grentzer even showed me the ten pound weights she lifts daily so she can life her bags of mulch.

The interview took place at her home, I was accompanied by my mom. Mrs. Grentzer is in good physical shape and is very social. She enjoys taking part in Seniors, where she plays bingo and cards throughout the week with her lady friends.

Joyce Rettig

AGE

GENDER

MARITAL STATUS

LIVING ARRANGEMENTS/EMPLOYMENT

Joyce Rettig was a registered nurse for 32 years and worked in the gastrointestinal unit and MetroHealth Hospital and later retired to work as a home care nurse. She is currently employed for Heritage Health Care Services and has worked there for ten years. Given that she is getting older herself, she is working about fifteen hours a week just to keep her busy. I chose Joyce to interview because she works with my Aunt at Heritage Health Care Services, and was told she had a lot of experience dealing with older adults.

The interview took place in Independence, Ohio, at Heritage Health Care in an office. Joyce was very thorough in answering my questions and defiantly knew her information on older adults. It was very interesting interviewing her considering this career may possibly be in my future.

In general from the interviews I conducted, what amazed me the most was that some elderly adults were not in favor of having a home care nurse assess them for falls. Before I performed the interviews I thought that every older adult would be appreciative of a home care nurse come in and perform an assessment test to reduce the chances of a serious injury. Home care nurses try to prevent serious injuries that can lead to a lifetime in a nursing home. Home care nurses try and keep you in your home as long as possible. Out of three interviews only two women, RoseMary Pizzuli and Elizabeth Grentzer were willing and grateful to take advantage of home care nurses assistance. As for Mary Rose McShane, she said, “I will be staying in my home for as long as possible with assistance from my sons.” Mary Rose McShane appeared to be very independent women, although she admitted she needed help as she is getting older, but the help would not come from a home care nurse.

In addition to my findings I was stunned by my interview with Mrs. Grentzer, at the age of 82 she still maintains her yard and gardens. She also walks two miles on a regular basis and lifts ten pound weights in the winter so that she can lift mulch bags in the summer. I was not aware that older adults in their 80’s are in exceptional physical condition.

All of my interviews with the older adults took place inside their own home, and each house hold was very different from my observations. Among the older adults, the oldest women, Mary Rose McShane, lived in a two story home by herself. Although she had moved her bed from the second story to her family room on the first story, so she would no longer have to go up and down the stairs. She also said that receives a great deal of assistance from her sons and is going to keep living in her home as long as possible. The next two older women were very close in age but had two entirely different living arrangements. Rosemany Pizzuli, is 83 years old and living in a retirement community, and her living quarters was a one bedroom apartment with a small kitchen, living room, and bathroom. In her facility she made me aware that she hires someone to clean her room, all meals are provided by dietary services, shopping trips to the grocery store were arranged, and she rarely leaves the facility. Mrs. Pizzuli needs assistance with instrumental activities of daily living (IADLs). In comparison with Mrs. Pizzuli, Mrs. Grentzer lives in a three bedroom ranch house by herself. Mrs. Grentzer cooks her own meals, cleans her own home, and is still able to drive the grocery store. Mrs.Grentzer was also very more mobile and more lively than Mrs. Pizzuli. It was very astounding to me that two women so close in chronological age were so different in biological age. It was fascinating to see that comparison with my own eyes, and from the research I concluded.

From previous knowledge, I knew that many women outlive their husbands. In more developed countries, the average life expectancy at birth is 79 years for women, 72 years for men.(Jones, 2001) The interviews that I carried out proved this fact, all of the ladies were over 80 years old and have been a widow for many years. “A longer life doesn’t necessarily mean a healthier life, however. While men succumb to fatal illnesses like heart disease, stroke, and cancer, women live on with non-fatal conditions such as arthritis, osteoporosis, and diabetes. “While men die from their diseases, women live with them,” said by Pearls.(Pearls, Cromie, 1998) I currently work at Emerald Village, a retirement community, and 90% of the residents are women. It was very interesting to prove this fact myself from my observations and research.

As for the interview with the professional home care nurse, Joyce Rettig, it made me very eager to finish nursing school and get out into the real world and help older adults. She defiantly passionate about her job working with older adults.

For the future of older adults and home care nurses, in the next twenty years the older population is going to increase quickly because of the Baby Boomers. Baby boomers are people who were born between (and including) 1946 and 1964. (Baby Boomer website http://www.bbhq.com/whatsabm.htm)

Currently in 2010, baby boomers are between 46 and 64 years old. There are about 75 million baby boomers in the U.S. and represent about 29% of the United States population. (Baby Boomer Website http://www.bbhq.com/whatsabm.htm)

) In 2030, the Baby Boomers will be aged 66 to 84 years old, and will be considered the “young old”. The Baby Boomers with make up 61 million people in the United States. In addition to the Baby Boomers, those born prior to 1946, with will make up the “oldest old” and will make up 9 million people in 2030.(Knickman, Snell, 2002) With this information, there is going to be a great demand for home care nurses and long-term care facilities in the near future.

To elaborate on the demand for nurses, America will not only need more nurses, but highly skilled nurses trained specifically in dealing with the care of older adults. Science has shown how the human body changes with aging. With aging comes changes that drive the need to totally change the way nurses assess, plan, deliver and evaluate nursing care. The American Journal of Nursing (AJN) recognizes that nurses today will care for more adults over 65 than any other patient population. Caring for older adults requires specific expertise, knowledge and skills that the majority of nurses did not learn in school, and for which less than one percent have had specialized training or certification. (http://www.nursingcenter.com/library/static.asp?pageid=730388) Caring for older adults is far more complex than the majority of today’s nurses and other healthcare providers ever learned in school, and the majority of faculty in any schools of nursing are prepared to teach their students. In fact, lack of knowledge about care of older adults among the teachers, students and working graduates of nursing programs results in inadequate assessment skills. These are skills that are the foundation of good geriatric care and ultimately are missed or incorrect diagnoses, treatments that can harm rather than heal, and a reduced quality of life among those 65 years of age and older. (http://www.nursingcenter.com/library/static.asp?pageid=730390)

For the reason that I am aspiring to be a nurse and specifically deal with older adults, I believe that Nurses/Practitioners should be working with experts in gerontology to update the nursing care given to older adults. Older adult’s bodies are completely different any other age groups, and require special care. Their bodies are changing physiologically due to aging, and the way the human body responds to treatment, medications, injuries, etc. has changed. From my interviews with older adults I observed how each and every older adult is different and requires specific individual care for their needs. No matter what age they are every older adult’s body ages at a different rate, therefore having a different biological age in comparison to their chronological age.

As for nursing students, like myself, I think a course specifically dealing with nursing care for older adults should be part of a nurse’s degree. In this course training in dealing with falls, extrinsic and intrinsic factors that lead to falls, and how to conduct a fall risk assessment are among the many major topics that should be educated to aspiring nurses. From my research I have concluded that assessment is the most important step in determining appropriate care for an older adult. Nurses must be able to perform an accurate fall risk assessment in order to develop the proper care needed for a patient. In my opinion a well rounded nurse should be trained for dealing with every different age group, and with the number of older adults rising nursing care for older adults should be heavily studied.

APPENDIX

Mary Rose McShane (Older Adult)

87 Years Old

Living in a two-story house in Fairview Park

Falls do not have to happen. They are predictable, and if you can predict a fall, you can prevent it. Have you had a home care nurse perform a Home Hazard Assessment to evaluate the safety of the household you are living in? If not, how would you feel about having a home care nurse help assess your household?

Yes, after I had my knee surgery a home care nurse came out and looked through my house. The nurse did not like the stairs in my home and advised me to install a elevator to take me up the stairs. The home care nurse also advised me to move my wash machine from downstairs to the first floor. Because my house is two stories, I moved my bed down the to first floor. Also she recommended that I install grab bars at the doorways and in the bathrooms.

The first and easiest test a home care nurse can have the patient perform is the “Get up and Go Test.” This test requires the home care nurse to observe the patient as they stand up from a chair without using their arms, and walk several paces and return to their seat. As an older adult how would you feel about having a home care nurse helping you with this evaluation?

Reluctant, but would do the “Get up and Go Test” if had to by a home care nurse.

By observation, Mary Rose would be a good candidate for the test, because she is rather uneasy.

A common cause for falls results from the type of medication older adults are taking. Side affects of certain medications can be dizziness, drowsiness, and confusion. Would you as an older adult find it helpful for a home care nurse to assess your medications and help you become aware of the side effects?

My son currently looks and my medication, and counts out my pills for the week. The side effects are clearly written on the bottle for me. Also, my doctor reviews the side effects with me. I also make sure to take my pills when I eat a meal. One of my high blood pressure medicines cause my hair to fall out. At one holiday I did become dizzy from drinking a glass of wine, because of mixing medication with alcohol.

One of the most common causes of falls is when an older adult uses the restroom unassisted. In your home or current household, do you have grab bars, elevated toilet, non-slip surfaces etc. in your bathroom to prevent falling?

Due to my height I do not have a elevated toilet because it is too high for me. Although I do have grab bars in my bathroom, and an a stool in the shower.

5. Every 16 minutes, someone is fatally injured at home in the United States from falling. Since falls is such a huge problem when older adults are living at home alone, do you have phone accesses thought your home? Or, carry a life alert button when roaming your household? If not, would you take advantage of having a home care nurse set you up with Life Alert?

Currently I have Life Alert button but I do not like to wear it around my neck. I have a cordless phone that I carry throughout my house I case of a fall.

TEAM CORE QUESTIONS

Sarcopenia refers to the atrophy of muscles and can affect all muscle groups, weakening the upper body and arms. It can impair balance and cause difficulties in rising from a chair, bathtub, or toilet, and in maintaining elders’ functional independence. Men and Women are at increased risk for sarcopenia after the age of 75, especially if they do not exercise. As an older adult do you do you exercise on a regular basis to prevent the risk of getting sarcopenia?

I exercise every day, I ride my stationary bike for about 15 to 20 minutes everyday. Sometimes when I wash dishes I march in place, and do leg exercises on a regular basis. I am aware that I need to exercise to in order to keep strength and keep walking.

Elizabeth Grentzer (Older Adult)

82 Years old

Living in a 3 bedroom ranch, in North Ridgeville

Falls do not have to happen. They are predictable, and if you can predict a fall, you can prevent it. Have you had a home care nurse perform a Home Hazard Assessment to evaluate the safety of the household you are living in? If not, how would you feel about having a home care nurse help assess your household?

I have never had any major health problems, therefore I have not needed a home care nurse evaluate my home. I would find it very helpful for a home care nurse to suggest what changes in my home that would be helpful to me.

The first and easiest test a home care nurse can have the patient perform is the “Get up and Go Test.” This test requires the home care nurse to observe the patient as they stand up from a chair without using their arms, and walk several paces and return to their seat. As an older adult how would you feel about having a home care nurse helping you with this evaluation?

I would feel good about having a home care nurse perform this procedure on be, because sometimes I do feel dizzy or light headed when getting out of my chair.

A common cause for falls results from the type of medication older adults are taking. Side affects of certain medications can be dizziness, drowsiness, and confusion. Would you as an older adult find it helpful for a home care nurse to assess your medications and help you become aware of the side effects?

Maybe in the future, but right now I am only taking cholesterol medication.

One of the most common causes of falls is when an older adult uses the restroom unassisted. In your home or current household, do you have grab bars, elevated toilet, non-slip surfaces etc. in your bathroom to prevent falling?

Yes, I do have grab bars and a non slip mat in my shower. I am not in need of a stool in the shower yet, but I do have grab bars in my shower.

Every 16 minutes, someone is fatally injured at home in the United States from falling. Since falls is such a huge problem when older adults are living at home alone, do you have phone accesses throughout your home? Or, carry a life alert button when roaming your household? If not, would you take advantage of having a home care nurse set you up with Life Alert?

At this point in my life I do not need a life alert button; however I do have phone access throughout my home. When I walk around my yard I do carry my cordless phone with me in case of an emergency.

TEAM CORE QUESTIONS

Sarcopenia refers to the atrophy of muscles and can affect all muscle groups, weakening the upper body and arms. It can impair balance and cause difficulties in rising from a chair, bathtub, or toilet, and in maintaining elders’ functional independence. Men and Women are at increased risk for sarcopenia after the age of 75, especially if they do not exercise. As an older adult do you do you exercise on a regular basis to prevent the risk of getting sarcopenia?

I do exercise my arms by curling ten pound weights, because I do yard work and garden. I also walk around my block a few times a week.

Rosemary Pizzuli (Older Adult)

84 Years Old

One Bedroom Apartment, Emerald Village, North Olmsted

Falls do not have to happen. They are predictable, and if you can predict a fall, you can prevent it. Have you had a home care nurse perform a Home Hazard Assessment to evaluate the safety of the household you are living in? If not, how would you feel about having a home care nurse help assess your household?

Yes, because I was in the hospital and a home care nurse came out to check my apartment. She checked my family room, bathroom, shower, etc.

The first and easiest test a home care nurse can have the patient perform is the “Get up and Go Test.” This test requires the home care nurse to observe the patient as they stand up from a chair without using their arms, and walk several paces and return to their seat. As an older adult how would you feel about having a home care nurse helping you with this evaluation?

Yes, I have had a home care nurse help me with his evaluation. She taught me how to safely get up from a couch, you scoot forward to the edge of your couch and easily get up straight slowly.

A common cause for falls results from the type of medication older adults are taking. Side affects of certain medications can be dizziness, drowsiness, and confusion. Would you as an older adult find it helpful for a home care nurse to assess your medications and help you become aware of the side effects?

No, my doctor clearly explains my blood pressure and heart medication to me, and I understand my medication. I do not like to take many medications, my doctor wanted to put me on vicodin for arthritis but I did not