Hi-R-Ed Online

Interventions

Now let’s look at the prevention of falls.

Giving consideration to avoiding falls in the first place should be an integral part of any falls assessment. Preventing falls may be more effective than treating the injured patient after a fall, but this requires the clinical team to be pro-active. And while the statistics related to falls are daunting, falls prevention appears to be the best way to cope with the odds—and help lower the incidence (and costs) associated with them.

Role of nurses and physical or occupational therapists

–Nursing: medication, transfers, environmental hazards, incontinence

–Physical/occupational therapy: gait and balance training, strengthening, assistive devices

A combination of environmental assessment and necessary changes, medical treatment and rehabilitation may be necessary in preventing falls. The following factors should be considered with any at-risk patient, or with any patient that has a history of falling.

After a fall, any associated risk factors should be identified and any underlying medical conditions that that may have contributed to the fall should be treated.

-Assess the patient’s home environment and make any changes that make it easier for them to move about safely.

-Review their medications (singularly and in combination) and note any potential problems. Make necessary changes that avoid or control these problems, and help minimize problems.

-If necessary, provide patients with hip pads that can help prevent most hip fractures in the event of a fall.

-Implement exercise programs that can help build bone strength, muscle strength and improve balance.

Communication

In a long-term care setting it may seem obvious that all healthcare professionals should communicate with one another regarding patients who are at risk for falls. However, budget constraints and other factors have meant that some facilities may not have routine interdisciplinary meetings, which may lead to reactive rather than proactive interventions. In 1994, a group of researchers suggested tasks associated with assessing the risk of falls for nurses and therapists.

Interdisciplinary communication

Dividing responsibilities

Integrating other disciplines as necessary

Dividing responsibilities between disciplines, including nursing and rehabilitation therapists, helps to ensure that at-risk patients are evaluated and cared for appropriately based on their individualized needs. It also allows the different disciplines to work together when helping these at-risk patients, and makes it easier to integrate other disciplines into the care plan.

A systematic review of randomized clinical trials suggested that the successful programs most strongly related to the prevention of falls were multifactorial in nature, both in assessment and management aspects. Studies have looked at programs that fit into one of four categories: multifactorial, exercise, environmental modification, and education. Multifactorial programs included a systematic risk screening or a focused post-fall assessment, which was tied to intervention recommendations and action toward follow-up on any risk factors identified. Effective prevention of falls through multifactorial programs and exercise were seen for both initial falls and monthly fall events.

Prevention – multifactorial is best

–Physical exercise, training

–Patient education

–Devices

Assistive poles, grab bars

Walkers, canes, wheelchairs, scooters

Lifting/seating systems, ramps

Footwear, hip protectors/other devices

Exercise programs included general physical activity and targeted balance, gait, and strength training. Environmental modification included assessment and recommendations for poor lighting, sliding carpets, and other hazards. Not all of these programs assisted in the implementation of the recommendations.

Education programs included community, group, and individual education through posters, pamphlets, and/or counseling.[11]

Devices such as poles, grab bars, assistive devices such as walkers and canes and others should be properly matched and fitted to patient needs. Patient training on the proper use of these devices can help keep the patient safer when on their own. Footwear may include insoles for shoes that have a raised ridge around the perimeter to improve balance control. Hip protectors have been suggested for patients with a history of falls to prevent hip fractures. Hip pads can include padded areas and some high-tech devices, such as portable pre-impact fall detectors, are currently under investigation that will incorporate inflatable hip pads!

Treatments for specific injuries are important to restore functional capacity as much as possible and to build patient confidence in order to reduce having to minimize normal activities due to the fears of falls. Treatments should be tailored to minimize further compromise in function. It has been suggested that patients who experience depression or other repressive coping mechanisms after falls may underreport problems and risk inadequate medical treatment.[12]

An evaluation of the causes of a fall or falls can provide a checklist of issues to address. Education and training, including information on environmental hazards, careful matching and training on assistive devices, corrective gait or balance training, and even basic counseling on exercise or a tailored exercise program may help to prevent future falls. The health care team can also review and revise medications, especially psychoactive and pain medications, as appropriate to improve patient function. Any new factors that may be related to a fall or a risk for a future fall should also be addressed.

Strategies to improve overall health may help to both improve the patient’s risk profile and their quality of life.

[10] Chang JT, Morton SC, Rubenstein LZ, Mojica WA, Maglione M, Suttorp MJ, Roth EA, Shekelle PG. Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials. Br Med J. 2004;328:680-686.

[11] Wu G, Xue S. Portable preimpact fall detectro with inertial sensors. IEEE Trans Neural Syst Rehabil Eng. 2008;16(2):178-183.]

[12] Hauer K, Tremmel AD, Ramroth H, Pfisterer M, Todd C, Oster P, Schuler M. Represive coping in geriatric patients’ reports – impact on fear of falling. Z Geronol Geriatr. 2008 (June).