 Good afternoon everybody and welcome to our broadcast. I'm Stan Stovall your host for today's broadcast and our topic today will be Fall prevention and we're fortunate to be joined by renowned lecturer and researcher Dr. Courtney Lider. Dr. Lider Thanks for joining us. Thank you Stan. It's great to be here Okay, and Dr. Lider will be sharing some of his insights on falls and fall prevention with us this afternoon But before we get started Dr. Lider We just want to open up the phone lines and the fax lines right now at the beginning of this program and Take some calls as they come in throughout the course of the program So if you have a question for Dr. Lider There's no need to wait for that official Q&A session Go ahead and pick up the phone and call in right now and we'll get right to your question And we also have a live studio audience with us tonight an audience You want you to feel free as well to ask any questions that you may have during the course of this program good enough Okay, they say good enough now. Dr. Lider will we get to a call or one of the audience questions We're gonna break in your presentation and we'll go ahead and take that question as it's appropriate in the program Sound good to you sounds great to me Stan. Okay. All right. Keep in mind the lines are now open If you'd like to call in your question, then you should dial 1-800-953-2233 if you'd prefer to fact your question then you should dial 1-410-786-0123 Let me give you those phone numbers again for the phone questions 1-800-953-2233 for the facts questions 1-410-786-0123 All right now dr. Lider, what do we need to know about falls and fall prevention? Well, Stan the incidence of falling among the elderly is quite large in fact 30 to 50 percent of community dwelling elders fall on an annual basis in Hospitals about 4 to 12 falls occur per 1,000 patient days 50% of elders in long-term care will fall annually and in fact 70% of all emergency room visits by elders are directly related to falls. Okay, this may sound like a I'm gonna say dumb question But I think it's safe to say that we all probably assume we know what a fall is But from your particular field give me the technical term of what is considered a fall Quite often people think of falling as this dramatic thing that they'll see on on a soap opera or whatever a fall in its most simple terms is Whenever you inadvertently are on the floor it could be a slip It could be a slide you could be not even falling on the ground by falling from one level to the other Anything that is inadvertently and they find themselves on a floor or the next level That is what we operate you define as a fall and you gave us some statistics early on in your presentation I had no idea the problem with falls was so vast absolutely in fact It falls are the sixth leading cause of death in among elders in the United States three to five percent of elders fall will lead to some sort of fracture and 1% will lead to a hip fracture Is these hip fractures are of particular concern because research has shown that hip fractures significantly increase the risk of death? 30% of elders who fall will fall again and 50% of elders who sustained falls will die within one year of falling Women are twice as likely to sustain serious injuries But men and in particular Caucasian men are 22% more likely to suffer a fatal fall ending in death These are some pretty alarming statistics. You just gave us for example I had no idea that simply from a fall or perhaps a hip fracture that it could lead to death Why specifically is that we're thinking a broken bone heals there should be no other problem, right? Well, and that's a great great question I'm quite often what will happen is that the fall may not in and of itself cause the death Although there are times when we see hip fractures where the person may become get Infected and from the infection and or sepsis they may actually die quite often why falls are so serious Is because they render the patient or the elder in mobile and it is that immobility where you may set up conditions such as pneumonia As one that will eventually cause the death So the fall is the precursor But it is the sacroili of all these other conditions that may occur and that therefore the elder will succumb to death With so many people falling and so many problems coming from falls I would imagine that the care required to support these people. It's got to be very expensive Oh, the cost of falling is staggering when you think about the cost of hospital bills and the cost of Interventions that are in place the number is immense Although we don't have an exact figure are known right now But we estimate that it costs between 200 million and 300 million annually to manage falls in hospitals Yeah, I would imagine no one here can certainly argue that falls can be a huge problem Especially among the elderly and that quite frankly everyone it really is at risk But it does seem to me though that some would be at greater risk than others Are there some identifiable factors when it comes to falling? There are Stan In fact, we've identified quite a number of factors that increase the risk of fall There are numerous risk factors for identifying those residents that are risk for falls in nursing homes There is a direct correlation between the number of risk factors and the potential for falls Thus when you have more risk factors in a case or in an elder you tend to have a higher potential for falls It certainly makes sense to me We can divide our risk factors into two basic types One type being those intrinsic risk factors. That is those biological or physiological factors And then we have extrinsic risk factors, which are things we can perhaps control in the environment Whether it be nursing homes the home or a community setting Now what I want to do is talk about these two types of risk factors more closely When we look at intrinsic risk factors, we see there are many of them that are really age-related As we get older many physiological and anatomic changes occur that may place an elder at risk for falling For example Decreased muscle mass may lead to poor back flexibility and stability Decrease lower extremities decrease knee strength and flexibility as well as poor endurance These may all place the elder adult at risk for falling Also in pure blood pressure control, which could be postural or orthocytic hypertension is a major issue The the resident or the elder will stand up. They become hypertensive Which leads them to becoming lightheaded and then they may actually fall as a result Some additional issues include foot problems such as ingrown toenails or bunions Or poor fitting shoes Acute and recent illnesses such as depression and anxiety are all risk factors for falls Now I understand that that that all of these things certainly are part of the natural aging process So is there anything that we can actually do about these type of problems that seem to be just sort of a natural progression of getting old? Absolutely, I think we can be very acutely aware of them Stan That's the main thing if we are aware of the possibility or the probability of a problem Then we can watch for it and do whatever possible to mitigate the problems. It may cause Another problem along those same lines are sensory changes that normally occur with age including such things as poor vision Poor hearing as well as poor proprioception systems. So for example Elders may find it very difficult to delineate between different surfaces when walking or placing their hands along handrails These sensory changes are quite often normal in the aging process, but they do place the elder at risk for falls Cognition and altered cognitive status may have the potential to increase the risk for falls certain cognitive conditions such as Alzheimer's disease multi-infarct dementia Picks dementia or Parkinson's may have cognitive components that can cause the elder to become confused Which will increase their risk of falling certainly make sense Now I can see where you know mental status and the clearness of thought would certainly figure into the problem It's gonna be significant or not. All right. Do we have a we have a call we have a question from the audience? Yes, ma'am Is it possible to prevent falls in every person? That is an excellent question In fact, it is almost impossible to prevent falls in every single person because we are not with our elders 24 hours a day seven days a week 365 days out of the year But what we can do is try to identify those factors that may place that specific older adult at risk And so I was about to say that I can see where mental status Clearness of thought would certainly figure into whether you have a significant falling problem or not Absolutely speaking of thought stand interestingly enough a major risk factor for falls Then most people don't realize is the actual thought or fear of falling Because when someone is afraid of falling their level of anxiety may increase and they may actually take more hesitant steps They may even shuffle rather than lifting their feet up in a more normal position So it's this shuffling gate that definitely increases their risk of falling. That's a real catch 22 Almost a self-fulfilling prophecy that I fear heights. So therefore I'm going to fall so to speak How do you deal with that situation? Absolutely? You must be a doctor Stan it's rather like being on a high ladder and Constantly telling yourself don't look down. Don't look down. And of course sooner or later. You look down One major intrinsic factor that is only indirectly related to the aging process is medication Studies have shown that people 65 years of age and older take on average nine to 13 medications per day in addition 70% of elders may self-medicate with over-the-counter medications We know so little about various drug-to-drug interactions that a high amount of medications being taken may Significantly increase the risk of confusion as a side effect or the interaction of those medications This increases the elders risk for falls. I would imagine that that unexpected Interaction of drugs certainly aren't the only possible problems. What about medications that we know will increase the risk of falling? Oh, there are medications that have been shown through research and in the literature to Individually increase the risk of falling Such classifications as the anti-hypertensives for example can be quite problematic in our older adults Because they tend to cause the blood vessels the arteries to to dilate or to open up when this happens They don't constrict as well. And so when the elder adult stands up, they may become hypertensive and fall Very interesting. I mean at least for me because you know blood pressure medication would be one of those things I would not think of considering when it comes to increasing my risk or my elderly grandparents risk for falling Absolutely another category of medications that actually will place the older adult at risk for falling are those Classifications that we know as the sedatives and the hypnotics They have a huge potential for increasing the risk of falling because they actually can confuse your resident or the resident If in the case of a sedative may actually become Sleepy or drowsy some of the other things that you want to think about Are the anti-hypertensives as I said as well? Another similar medication group is the diuretics drug such as lasix Diuretics may keep the elder up at night going to the bathroom multiple times and Increased frequency of the trips to the bathroom Particularly at night time in the dark will certainly increase the risk of falls So the use of diuretics should be closely monitored especially at night time It's just a matter of Oz the more you the more you do it sooner or later You're gonna trip and fall and it certainly makes perfect sense, but I don't know that that I would have thought about that There are other drugs that wouldn't seem to pose a problem, but often they do Particularly in the over-the-counter medications. I'm not picking on the one any one specific drug, but just to give you an example Fixed 44 is a basic harmless Decongestant, but it can cause confusion which makes it a risk factor for falls Further some over-the-counter medications may contain alcohol, which the older adult may not be aware of So they may take this medication have mental status changes due to the alcohol It seems that while these are certainly intrinsic factors that when it comes to fall These are certainly not beyond our control These are things we can take charge of and make sure that we are alert to the possibilities of a fall I agree completely and these are not all of us are out of our control and at least in many cases We can control them and the extrinsic factors are even more under our control Okay, give me an example of that when we look at well There are a number of extrinsic risk factors that can place the elder at risk for falling one is poor lighting in Poor lighting elders may stumble or bang their feet or their arms on their way from point a to point b for example from the bed to the bathroom and This can increase their risk for falls another risk factor is sleep-free floors Any sort of liquid on the floor whether it be soda or juice or even water Can change the properties of the floor surface and increase the risk for falls. Okay, all right I that makes common sense. I would have guessed that both of those things would be a problem Also improper assistive devices can be a significant risk factor as well It is important that an elder receive a careful and proper Evaluation when they are being provided with an assistive device to ensure that the height of the cane or walker is Correctly proportional to the height of the elders body I'm aware of older adults in the community who share assistive devices with one another So it's so important for elders to avoid this practice Because the bottom line is one size walker does not fit all people You know, I thought a cane was a cane was a cane, you know But obviously not and certainly with walkers I can see that the the height of the patient would certainly have an impact as to whether or not That's really going to be a help or it's gonna hurt you as you try to make your way and by the same token doctor I would imagine residents should not be permitted to use other people's assistive devices That's absolutely correct a walker may be helpful in maintaining the balance But only if it's the right size for the user. Okay, anything else on that subject? Absolutely inadequate bathroom fixtures are another major problem It is critical that elders have proper fixtures such as bars on the commode so that they are able to raise themselves up bars or Hand holes on the tub and or shower are also a necessity So that the elder can support him or herself when performing those activities of daily living One major culprit in many falls is a cluttered room Nursing home rooms as well as individuals rooms at once personal residents are quite often small and Tend to have wheelchairs or walkers or knickknacks or and other cluttered items into the small space So staff and family members and caregivers need to stop look and think and Ask the question What in this room or this house would increase my loved ones or my own self chance of falling? you know when I was a nurse practitioner in a Housing and urban development senior housing complex in New Haven, Connecticut I also made a practice of not just seeing my elder dealt patients in the medical office But I would also do an impartment inspection and remove anything that I thought Impeded a smooth path from one room to the next. Yeah, we're talking about things in general I've got another one for you. How about pets dogs cats I know I have a puppy at home right now and every time you try to climb up the stairs or down the stairs He's right by your feet that could lead to a nasty fall Absolutely, I think and you know there are many nursing homes that actually in particular that will have pet days where you may have a Dog or you may have a cat visitation visit hating and the reality is those animals should always be on a leash and be Supervised because as we get older sometimes with poor vision We may not see the dog running past Past you or the cat and you trip and you fall so we must be very concerned to make sure that when we do have Pet days or or or in a facility or at a home that the animal is actually supervised Yeah, you're talking about room clutter and you know there never seems to be enough room to store all the things that you have We can't exactly make the room any larger So you have to go the other course and remove the clutter Absolutely, and I mean I'm not geriatric yet, but I will tell you I suffer with clutter as well What I recommend is that people Yes, then is That people as much as possible try to remove the items that may impede the walkway Between the bed and the bathroom, especially at night I see most often falls occurring when the elder is attempting to go From the bedroom or from the bed to make it to the bathroom is a very problematic area Yeah, and that's an easy fix that is something that is very doable for everyone clear out the clutter Absolutely another thing is the use of throw rugs and loose carpets that should really be avoided Because elders can easily slip or trip on the carpeting uneven flooring Surfaces should be avoided wherever possible As I mentioned earlier elders commonly suffer from appropriate receptive changes That may impede their ability to differentiate between flooring areas of different height or pitch So having to negotiate these sorts of areas can be most problematic Also, I suggest removing cords and wires Anything that may increase the incidence of them tripping and then subsequently falling should be also done I also believe that wax floor should be avoided since that floor surface may be more slippery when wet They look nice, but they could be dangerous for you. Absolutely Stan. Okay. That's a lighter We have another question from the audience. Yes, ma'am. Hi, Dr. Lider I was wondering if you could do some discussion for us of devices that could help align our elders when they're in chairs or wheelchairs Absolutely, there are many older adults that sit a lot all day in wheelchairs or chairs And when you have assessed that that elder perhaps has an alignment problem things such as Wedges can be used to give them proper alignment Alignment pommel cushions can be used to keep them aligned So any time I look at an older adult and I see they're not sitting straight up like I should be And they're sliding to one side or the sliding under On their chair putting wedges pommel cushions will help to keep them aligned making sure that their feet are from a Planet firmly on the ground so that the risk of sliding out of the chair is is is reduced Okay, you know Dr. Lider you mentioned earlier that For example, it always helps to have For example in the bathroom setting if you have something that you can grip on to as you're perhaps using the commode or getting out The bathtub some some handles you can grab on to to help you get out so you can avoid it fall that way Moving to the bed. How about, you know on the sides of bed bed rails? Would that be a good idea to keep people from rolling out of bed because I've heard of that happening before Which can lead to a broken hip or even worse, you know Well Stan that's actually not the case. No No, okay. I see them in every hospital. I've been in I'm thinking it's got to be good. They're in the hospitals, right? Absolutely, there have been studies that have shown that the use of restraints and including bed rails and bed rails are a form of restraints can actually increase the risk of falling When a facility reduces its use of restraints the residence risk of falling have been shown to actually Decrease you're kidding me. Absolutely What happens is that patients who are restrained by bed rails? Especially may want to get out of the bed. Okay, so they try to climb over the railing They are much more likely to fall doing this process that if they were simply had the side rails down So they could get out of the bed For some patients that are prone and I have patients like that when I was a nurse practitioner in The nursing homes in Connecticut who were prone to climbing over rails You may wish to place their beds on the floor to help to mitigate that climbing over and then sustaining a Permanent damage. Okay, certainly good to know that But again, what about the problem of if you've got no bed rails the rolling problem possibly rolling out of bed Is there an alternative to bed rails? Absolutely, one of the things that that we were implementing in one of the my nursing homes was the idea of Having actual electronic monitors that you can actually watch the patients more more more closely You can actually also in beds use pillows that may actually be used to to wedge the the elder in there But I actually like the use of bed monitoring and censoring so that we can tell when an elder may be You know trying to get out of the bed You can there's their sensors you can place on the actual person their sensors You can place on the bed so that the staff can be alerted that there is more gross motor movement going on where you may need to Assist the resident. I'm very absolutely Before we continue I'd like to give everyone Those facts and phone numbers again so you can call or fax in your numbers if you have a question for dr. Lider to call in your question You should dial 1-800-953-2233 if you have a question you want to fax it in Then you should dial 1-410-786-0123 again by phone. It's 1-800-953-2233 For fax it's 1-410-786-0123 the lines are open right now They will remain open throughout the remainder of this broadcast So go ahead and get on the phone or fax and send us your question. We'd love to answer it All right now dr. Lider since you've identified many of the contributing factors for falling I'm assuming that there are also some sort of risk assessment tools that can be used to help to sort of Quantify these risk in any given situation Absolutely Stan Concerning the potential for falls a clinician should think about the activities of daily living cognition and emotional states health problems incontinence medications Sensory deficits neurological deficits and social history especially for the use and or misuse of drugs and alcohol We can cover all of these areas by thinking of two basic components to a fall risk assessment The first is a basic physical examination The second we want to assess their balance and gait When we first look at physical examination, we want to think about what cognitive issues may be present So the use of a mini mental status exam questionnaire to see if the elder has a cognitive Pyramid is the first step that any clinician would want to do within a nursing home the home or a doctor's office, etc Second because hypertension and postural hypertension may be a major risk factor for falling We also want to check for the occurrence of both of these conditions Third the use of a cell and chart to assess visual acuity is important Because impaired vision can be a major contributing factor to falls Certainly makes sense. I've got a question for you right now when it comes to assessing a patient based on a questionnaire format Being honest and forthright on that questionnaire about the patients part. That's critical, isn't it? Absolutely, and you would hopefully not only perhaps elicit the the answers from The patient or the resident, but hopefully you can elicit information as well from the caregivers from the staff So that you get a real comprehensive Well-rounded approach of what is actually occurring for this particular patient or elder I'm thinking in terms of you know when you have a toothache It's hurt you for like a week or so as soon as you walk in the dentist office It doesn't hurt anymore whether that's fear management or whatever when it comes to assessing a patient's gait You need a fair and accurate assessment of what their real gait is like not what they think the doctor wants to see or what you'd like to hear correct That is absolutely correct And that's why it is essential that when you're looking at doing an assessment It is a multi-dimensional assessment So you're hopefully not just ascertaining information from the actual Resident or the elder but from all and many sources from the physical therapists from the nurses from from the caregivers from the family From the spouse whom ever you can get to give you an accurate and comprehensive View of that elder okay now since you've already identified intrinsic risk factors It seems very logical that the first step in that making that a fall risk Assessment would be to first look to them and make sure you're getting some other feedback as well correct absolutely It's done however probably the best indicator of a risk for falling is when your balance and gait assessment There are several tools that we can use to assess this One is the fall efficacy scale which measures how confident the individual is when performing their activities of daily living a Major risk factor for falling is the fear of falling as I mentioned before So by utilizing this instrument we can get a sense of how fearful or not fearful that elder may in fact be The specific balance confidence scale is another tool that can be used to assess how fearful that elder may be a falling Finally the Tannetti mobility assessment scale allows us to assess both gait and Balance when we talk about the fear of falling being a potentially a contributing factor For our people who are listening and watching right now put in perspective what exactly that means what happens when you have that basic fear Let's say if you're coming to a set of steps or some some areas that you're not familiar with walking How does the fear take over in effect your your physical motor skills? I think what tends to happen Stan is that it's you get almost a buildup of anxiety and when The elder is anxious where they would normally have perhaps a normal even gait pattern What you begin to see is more hesitant steps more small steps and it's the small Almost like childlike steps that actually may increase the risk for the elder to actually fall because it's unnatural for them To take those kind of steps. I absolutely correct Stan Okay, now you mentioned several different ways of measuring some of these. How are these scales actually used sure? Let's start with the first one, which is the fall efficacy scale As I said this scale assesses the resident's confidence in avoiding a fall This is important since we know that the fear of falling is a major risk factor for falls If this instrument is completed correctly It should take about no more than three to five minutes as long as the elder is cognitively intact There are ten variables that you would want to assess and Using a Likert scale from zero through ten with zero being not at all confident and ten being Completely confident we can get a sense of where the elder is These are the variables that will be reassessed with regard to the elder's level of fear Involving in each of these activities. So one of those activities you ask well, I'll tell you Stan How well are they cleaning their home? Are they fearful of that or not and he would grade it Can they get dressed or undressed? Can they take a bath or shower without the fear of falling or what level of fear of falling they may have? Can they go shopping and complete simple shopping tasks without the fear of falling? Can they get in and out of a chair? Can they go up and down the stairs? Can they walk around their neighborhood or nursing home facility without the fear of falling or at what level of fear of falling that they may have? Can they reach into cabinets where they have to lift up on their feet? Can they answer the phone? Based on how the elder answers these questions You can get a sense of how much fear they are feeling If the average score is five or less You should be concerned that they are afraid and therefore at a higher risk for falling The second scale that can be used is the specific confidence balance scale Which is like the efficacy scale in that it tries to assess the confidence that the individual feels When doing basic daily living activities This scale is used just like the self-efficacy scale But this time the individual's level of confidence is rated on a 100 point scale on a number of variables such as Walking around their house the neighborhood or nursing home facility walking up and down the stairs bending over and picking up their slippers from the floor Reaching for a small shelf item or putting something away on a shelf Standing on their on their toes and reaching for something sweeping or vacuuming the floor Walking outside on an icy or slippery surface Again Based on the individual's responses to these questions You can get a good sense of how confident the person is With regard to the fear of falling. Okay, Dr. Leiter. We have another question from the audience So let's go ahead and take that right now. Yes, ma'am. Hello, Dr. Leiter My question is when is a fall assessment? It's supposed to be completed and should it be completed. That's an excellent excellent question And the answer is I believe a fall assessment should be completed on going If you have a resident who is being admitted to the nursing home They need to have a fall assessment done within the first the time of admission. I Also think it should be done on a quarterly basis as their conditions may actually change depending on certain comorbid conditions acute illnesses that may occur Also, when that patient or resident actually has a fall you want to have the team come together to decide What were the factors that that contributed to this person's fall? What can we do to make sure that that hopefully that doesn't happen again? I always train my staff that the minute I see a patient walking into the nursing home or see a patient in our patient clinic I am assessing their risk for falling. It should be an ongoing Process throughout the elders stay in a nursing home if they're in a community setting I'm always looking at my reasons for the for the potential of fall if they come to an office for a visit I'm assessing their gate their balance. I'm looking at everything to make sure what is their risk So the easy answer is from a mission Every three months if there's a change in status and condition But also every time they are in the dining room. You should be thinking about what is the risk of my patient for falling? Are they sitting up firmly in their chair? Are they slouching? What's going on? It should be almost continuous in the back of your your mind. Thank you. Thank you for your question You know, we've been talking about tools that you can use to do risk assessment as for falls And they all seem to be Very effective But aren't they really based on on the elders own perceptions of what their abilities are And are there any assessment instruments out there that are based on the clinician's objective or point of view? absolutely and probably The most important scale Is the tinnetti mobility assessment scale Because it is the only tool By assessing both mobility and a gate that you can truly get a sense of the level of risk That this elder adult faces with regard to falling The tinnetti mobility assessment scale has two basic components. One is gate And the other is balance. Now, let's take a look at balance In balance, you are assessing six different variables sitting balance arising standing My favorite one stand is the nudge test The 360 degree turn and how the patient goes from the standing to the sitting sitting down in a chair position With the sitting test look at how the individual sits Is he or she leaning sliding in the chair? How is their posture? Is it perfectly aligned? In this case the person would be rated as either a zero which means they are leaning or sliding Or a one which means that they are quite steady and safe while seated For a rising See how comfortable the individual is when rising from a sitting to a standing position You can rate this on the scale of zero through two at zero The person is unable to rise from the chair without help While at a two the person can stand up without even using their arms for support to stand up I'm going to ask you about the nudge one and we're talking about literally just sort of nudging you to see what your balance is like Whether you'll stand your feet or not Absolutely stand and of course when you're doing the nudge test You always want to make sure that you have you you have your hand behind them So when you're nudge in the front, you don't create a fall yourself. So absolutely Okay, so when you're doing the assessment The scales are not the same for each variable in this particular assessment, is it that is correct So for some of the scales you would use a zero to two while in other scales You would score a zero to one and I will say in the tennetti scale It clearly helps you to figure out when the elder or the adult Is a zero a one or two depending on the specific subscale Very interesting this I know that sounds somewhat complicated, but it really is not complicated once you get the hang of it That is the advantage of the tennetti balance Gave evolution instrument. It's very simple to use When you have a clinician that's trained you can probably complete the assessment in about 10 to 15 minutes Hardly any time at all Absolutely Now for the standing test you want to see how steady they are within the first five seconds after arising Are they leaning? Are they standing subtly in place? Is the feet planted firmly on the ground? Now remember I tell you about the nudge just I want to repeat it one more time because it's my favorite favorite of the of the subscales Literally what you want to do is when I use the palms of your hand And you gently nudge the elder in the sternum to see how well they can able to hold their balance Remember being very safe so that you put your hand behind so in case you nudge and they fall back You're not you're not the problem So gently nudge making sure you you provide safety After the nudge test the clinician should have the person turn 360 degrees When they are doing this watch closely to see how well they are able to keep their balance during the rotation And finally check to see how well the patient goes from the standing to sitting down Look at both and overall How well did they do this and also check for any sort of aberrant movements that may occur on the way down Are their arms flailing around? What's going on? Is it a smooth transition sitting down? Okay, so we've done the test How do you determine what a score and how do you interpret that? Absolutely on the scale what it will say is from from dr. Tinedi a score of less than 10 would indicate that the resident is at high risk for false And this is all assessing balance That's correct. That's correct. But the second part of the tinedi mobility assessment tool looks at gait In this case, we are assessing the actual plan tar movement of the feet So one variable that we would examine is the actual length and height of their steps Looking at how long and how high the right swing foot is versus the left swing foot To do this you would have them actually walk One maybe two feet and look at how they're swinging out their right and their left feet Another thing that you would examine is their step symmetry As well as their step continuity. Is it symmetrical? Is it in is it flowing or is it rather Whatever we'll say staccato, but is it is a choppy You want to be sure to watch to see if one leg is higher than the other For example, all of these things could indicate an individual is at increased risk for gait immobility or instability For that resident, okay Let me just remind our viewers that our phone lines are open dr. Liner if you'd like to call in your question the number you should dial is 1-800-953-2233 If you prefer to faction your question that number is 410-786-0123 All right as we can continue here any other factors that would be taken into consideration on this absolutely Well beyond the actual step you want to take a look at the elder's trunk How stable is their trunk when they are walking? Their gait stance can also provide an important indicator Is their walking stance quite wide which indicates an increased risk for fall? Or is your stance more normal indicating good stance abilities? Again the score here will give you an idea of the individual's capabilities A score of less than nine in this section would indicate that the person or the elder is at a higher risk for falls It would sound like you can get a pretty solid assessment of a person's Not only their abilities, but also their risk without having to spend a great deal of time Or putting a lot of stress on the individual as you do the assessment Exactly with these assessments being so quick and easy to use There's no reason why they shouldn't be utilized as much as possible The biggest risk is an individual who isn't known to be at risk Okay, so we have all of these risk factors in mind And these are things that you know very common sense oftentimes and we're having our assessments of our patients done What should those who work with the elderly do to try to prevent falls based on all this information They've gathered on all of these tests now. It's time to put it into action Absolutely When we look at a fall prevention and fall prevention programs, it has to be a multidisciplinary approach Fall prevention is just not in the domain of nursing or medicine But it really is a problem that belongs to all of us. We have to all own it So when you're thinking about implementing a fall prevention program It needs to involve all of the necessary disciplines nursing medicine physical therapy occupational therapy It could be podiatry as well as perhaps orthotics and the general staff We need to be sure that our programs and care plans do as much as possible to prevent falls While realizing that we cannot prevent every single fall within an individual resident Or a nursing home The way that we do this in my opinion is to ensure that all health care professionals are involved and working together To create a successful program a fall prevention program is simply not on a mission Every six months every two weeks. It's a constant thing that staff Interacting with residents should be constantly thinking about what is the level of risk? What are those factors that may place that individual at risk? And you've mentioned practically every health care professional who would deal with the elderly and try and do what says say A risk of falls and injury from that One you left out. I noticed families got to play a part in there, too. Don't they absolutely families and caregivers are Are essential. It's everyone's problem and everyone's challenge. We need it all It all really basically requires more than just a basic resident level program And certainly a lot more than just a slogan be careful. Don't fall down, right? Absolutely The first thing that we have to remember is that falls are a system issue and are not the fault of the resident The caregiver the nurse So in order to implement a successful fall prevention program We need to make sure that it is implemented at the system level Most of what we will discuss applies to both elders in nursing homes as well as those elders that live in the community Okay, well, give me some specific things uh that that that could be done to prevent or would be included in a fall prevention type program Absolutely one of the things that we've learned comes from the FICIT project Which is frailties and injuries cooperative studies for intervention techniques This was a group of seven control studies looking at what were the best interventions to prevent falls from occurring among our elders Interestingly what they found in those seven studies looking At these studies and they actually did a meta analysis Was that exercise and balanced training when put together With health education did decrease the incidence of falls So exercise should be a key component of any fall prevention program The exercise should focus on balance strengthening training Strength training because when muscles are strengthened In the gait and the trunk will help to decrease the risk of falling Okay, you mentioned the word exercise and a lot of people sort of panic They envision does that mean I've got to do power squats or big bench presses What kind of exercise are we talking here? Good point when we think about what specific exercises, I'll tell you within the The rcts that were actually done to are looking at What what exercise and there were several different types of exercise in there To see what decreased the incidence of falls What they found and what they concluded was No one specific exercise was the key So generally any basic exercise program Combined with balanced training can be effective in reducing the incidence of falls Things that will increase endurance should also be encouraged like walking I actually promote and and there's some literature out there that the supports this The use of tai chi is very popular some senior centers gyms and even Some nursing homes actually offer courses in tai chi Alternatively the availability of something like an aqua aerobics Where you're getting the swimming etc Step aerobics or anything that can be used to increase the resident strength Balance and endurance should be encouraged along with of course the education That it's okay. It's absolutely okay to help them get over the fear of falling all working together Okay, we shouldn't be caught up in the misconception that if we're talking about falls it deals with the lower extremities Therefore the exercise should be limited just to the legs the hips area, right? Absolutely, and that's why I absolutely promote swimming because swimming is one of the best exercises that actually works out The entire body and most of the muscle groups obviously when we're looking at At exercise programs, this should be obviously in consultation with the physician or nurse practitioner And as well as bringing in physical therapists in there as well to plan a program that is specifically Tailored for that particular resin because once again, no one exercise works in every single elder adult Okay, sounds good. What else could we include in a fall prevention program? And I you know, I made a little crack about a slogan slogans do help if they're effective They'll get you thinking about the things you should do, right? But what are some of the other things we should include in that prevention program? Absolutely. Another area of which a fall prevention team has to be very cognizant is medications and their effects As I've said before medications can be a major risk factor in falls Most elder adults take a large number of daily medications and research has shown That there are groups of medications that clearly place an elder at higher risk for falls Feeds include the analgesics, which should be given for pain The anti-hypertensives the sedatives the end hypnotics as well as many others So anything that can be done to decrease the potential Of polypharmacy will therefore decrease the likelihood of confusion or sedation And therefore decrease the likelihood of a fall So a fall prevention program should also take great care to correct any sort of visual Or auditory problems that may exist This can include ensuring that individuals have annual audiology consults and evaluations And that they can see an optometrist or an or an ophthalmologist on a regular basis So that they make sure that they have glasses that are for their for their specific eyes I think it goes without saying that ensuring that the elderly can see As they are walking will greatly reduce their likelihood of suffering a fall We have another question in the audience. So we'll go right to it. Yes, ma'am Yes, dr. Lighty talked a lot about educating health care providers Does educating the patient about fall prevention help decrease the incidence of falls? Absolutely. I think it goes without saying the more that we can educate our patients about what are the right things to do in the area of falling i.e Clearing a path making sure that if for example, you have Furniture and you may have sharp sharp edges on the furniture that that area is padded Anything that we can do putting on light lights at night so that once again the path from the bed To the bathroom is clear is lighted. They can see putting on their glasses before they they they walk about Anything that we can do to educate them to look for those Factors that may increase their risk is greatly important The same thing I will add is that also educating their spouses Their family members so always remember look Listen see what's out there. What may be a risk factor for me that may fall. So education along With exercise and endurance training is the best Prevention absolutely. Yeah, thank you. Thank you for your question You know we talk about prevention a lot of the things that you have listed so far that they are so Common sense, but oftentimes they are so overlooked Exactly exactly Another issue that I think needs to be addressed by a fall prevention program Is here we go again the fear of falling I can't stress that enough as I stated before This is a major risk factor for falling So we need to look at perhaps behavioral therapy and see how we can get our elder adults to move beyond the fear of Falling and work with them on a cognitive level as well to reduce this fear It may be an intrinsic risk factor, but you know what it can be worked on Yeah, oftentimes that that fear has been developed because they took a nasty fall. Isn't it and they don't want to do it again That's absolutely that's absolutely right and we know for example The fact that one has fallen increases their risk of falling again Okay, what about some physical issues within a healthcare facility? Are there program factors that should be considered there? I know There are many things that we should actually think about From an extrinsic factor Physical adjustments are a major component of any sort of successful fall reduction program For example lighting is an issue that a facility must address if it is to prevent falls Areas of poor lighting need to be avoided and bright lights should be provided in common areas Particular in hallways and stairwells at night time a nightlight is crucial So that residents have a clear visible path from the bed to the bathroom Floor maintenance is key as well Slippery floors must be avoided for example by placing rubber mats by the sinks So that splash water does not create a hazard I will also say for if the resident has slippers for example That they have non skid slippers so that they when they're walking they're not slipping and sliding So anything that we can do to to to create a less slick surface Whether what is on their feet or on the floor is to be promoted Incontinence or other open room spills and liquids must be paid careful attention to In order to ensure that the floor is kept as dry as possible By the same token you should make sure there are few uneven walking surfaces With visual changes in the elderly they may have difficulty recognizing a change in height or level Therefore reducing the steps and keeping things as much as possible to one level Will help to reduce the incidence of falling and you mentioned this before no loose carpeting No throw rugs because that's a quick way to fall isn't it you'll learning quickly Stan That is absolutely true Clutter is not your friend you want to minimize it especially at night Well travel pathways clear them away Such as I keep going back to the bed to the bathroom because I have seen in my practice Many falls occurring from that path bathroom to the bed bed to the bathroom I would also say be sure that the nurses and clinicians clinicians work side by side with physical therapy To ensure that any assistive device That are used are correctly sized and are appropriate for that elder for whom they are in fact intended to okay we can't stress the importance enough of handrails making handrails available absolutely Handrails are are well appropriate and ample bathroom assisting fixtures are a absolute must Handrails and side rails for the commode and for the bathtub shower are very important To ensure that the elder does not slip and fall while trying to use these fixtures A commode that is too low should have a handrail on the commode itself because residents may slip and fall As they're trying to sit down While we're we're in the area fixtures furniture is another concern It is important to assure that furniture is of the right height and construction for that particular individual If a chair requires a drop of three inches to sit down Elders may have problems with slipping and falling Therefore, it is important to either allow them to feel the back of the chair And then lower themselves or have a jumper seat so that they may sit without falling These all sound pretty universal. Is is there anything else? I'm telling you pretty much have covered the gamut there Well, there's some other things, um, you know, they should limit their alcohol intake When when out when outdoors they should avoid slippery surfaces Use extra care when getting perhaps out of vehicles that may be transporting them from from one place to another And for whatever ask for assistance when needed to help them get out of a car To help decrease their risk for falling Also, some nursing homes and community dwelling elders have pets as we mentioned before They should make sure that the dogs are on leashes and are always accompanied because as we mentioned before Elders may miss them while walking and trip and fall over them, which injuring themselves as well as the the the pet They should not be left to just wander around in in a facility or in a home. Trust me. I've done that myself I've been stripped up by my pup. Listen at least back back east. We've been dealing with some very cold weather Wet snowy weather icy conditions on the sidewalks and driveways. What have you? You know people do have to go out But at the same time if you are prone to falls, perhaps you should always have some assistance when you go out Absolutely. I I think it's it's always important, especially in the northeast To to be sensitive to to slippery surfaces and not be too proud To say I don't need assistance in getting in getting out and walking up walking about because it may save their life I've heard real horror stories about people taking nasty falls and they end up breaking their hip I hear it's one of the most painful things you can you can possibly go through There's a recent invention on the market correct me if i'm wrong something called a hip protector that That people can can wear to protect from broken hip. Absolutely. There are Hip protectors have been around for a couple years now But for those elderly adults who we who have a history of falling or and I use them or recommend them for elders Who may have brittle bones or from from osteoporosis to protect the the to protect the hips and literally If you think of almost like an an nfl player That's wearing padding you literally put it around the hip area put on their their their Normal garments so their their hips may be a little bit more wider But at least if there is a potential for fall it acts as a great cushion also for people who you may be concerned about For for head trauma who may fall a lot putting on helmets to once again protect the head From trauma is also very important Some of the research in the hip fractures have shown that actually by using these hip fracture protectors have actually Decreased the rates of hip fractures in about 30 percent so they should be used For people who have a history Falling And we should go back we mentioned this earlier about about these hip fractures They can actually become a fatal situation not necessarily because of the broken hip But because of some problems that can exist after you've broken your hip correct? Absolutely I mean hip fractures is probably the most serious serious concern for any clinician because When you have an elder who has a broken hip The the the potential for complications Or the sacralase from that hip fracture could be fatal And I often think of patients who you know slipped fell down Broke Had a major fracture and then two weeks later died because they got pneumonia or or they became septic or whatever So even if the hip fracture in and of itself doesn't A cause the mortality the sacralase from that is can well off not well often, but can Kill them so it's important. Yeah, and something I have to admit my own ignorance And we go back to this whole thing about the bed rail thing Maybe I'm old school, but I've seen a lot of bed rails and in hospital settings When we've had when I've had convalescing elderly relatives at home We got beds and head side rails on them, but you're telling us that's not the way to go I get asked quite often whether or not the use of side rails on a bed actually reduces the incidence of falls As I mentioned before the research on this topic is relatively inconclusive But it does appear that the use of side rails may in fact not Reduce the incidence of falls in fact side rails can actually increase the risk of falls as elders try to climb over The side rails to get out of bed and that's because they can't lower the side rails from in the bed You have to reach over and okay, that is correct because side rails is a form of restraint Now there are patients who perhaps are or elders who are cognitively intact and therefore They may want a reminder to call the nurse or to call their caregiver But when you're seeing especially patients who may have a little cognitive impairment Side rails actually may increase their their risk for for falls Okay, I I found that awfully surprising the first time you mentioned it and I still find it amazing, but it makes perfect sense And you know this whole fall prevention process provides a tremendous amount of Opportunity for things for facility staff to consider also family members as you mentioned Is there some kind of a uh, how shall I say maybe a cheat sheet a way to have a quick Refrigerator reminder on some of the things that we need to keep in mind Oh, there's a wonderful acronym that I came across a couple years ago By uh, by Campbell and and and colleagues and the acronym is I hate falling Now what this acronym does it focuses the direct care staff on what are some of the key issues in falling and fall prevention Let me run through that acronym now I I stands for inflammation of joints or joint deformity Is important to remember that as joints become deformed and rigid Elders may have problems with gait and movement H stands for hypertension This means that we need to be aware of the possibility that hypertension Particularly postural hypertension can cause falls When patients are in blood pressure medications the anti-hypertensives We need to monitor them so that we can ensure that they are not bottoming out When they stand up a Stands for auditory and visual abnormalities once again Make sure that appropriate hearing aids and glasses are available to rectify any sort of auditory and visual irregularities T means tremor Residents who have neuromuscular issues may have difficulties Particularly those with Parkinson's Because the typical shuffling gait that they use will increase their risk of tripping and falling E stands for equilibrium problems Again, make sure that there are no throw rugs or other impediments to balance F indicates foot problems If there are issues because of bunions or other foot ailments Then the risk of falling may increase Thus the services of a podiatrist or the use of orthotic shoes may be helpful Anything that will improve the movement of the foot is a plus. It's a must A Is to remind us of effects of arrhythmias and heart blocks Many of the medications commonly used to treat these sorts of source of medical conditions Can contribute to falls by lowering pressure