Homecare Assessment: Patient Falls And Functional Ability

The Acting Director of the CDC, Dr. Fleming, gave testimony to the Subcommittee on Aging 6/11/02 on the topic of falls. The following is an excerpt from his testimony (CDC, 2003).

Falls represent a serious public health problem in the United States. One out of every three older Americans, about 12 million seniors, falls each year. Data shows that falls are the leading cause of injury death among people 65 years and older. In 1999, more than 10,000 older adults died from fall-related injuries. This number will increase as the number of people over the age of 65 continues to grow. Nonfatal falls are also significant. Falls are the most common cause of hospital admissions for traumatic injuries. In 2000 alone, 1.6 million seniors were seen in emergency departments for fall injuries. Every year, falls among older people cost the nation more than $20.2 billion in direct medical costs. By 2020, the total annual cost of these injuries is expected to reach $32.4 billion. Annual Medicare costs for hip fractures are almost $3 billion. These economic costs are significant. Of all fall-related injuries, hip fractures not only cause the greatest number of injury deaths, but they also lead to the most severe health problems and reduced quality of life. Women sustain 75-80% of all hip fractures and the rate increases sharply from age 65 to 85. One out of three women will have a hip fracture by age 90. In 1999, there were over 300,000 hospital admissions for hip fractures, 77% were women. The impact of hip fractures is significant, both in terms of quality of life and economically. Only half of community- dwelling older adults who sustain a hip fracture can live independently one year later. This contributes to the fear of falling and loss of independence, which are a great concern of older adults. In a recently published study, 80% of the older adults in the study said, they would rather be dead than experience the loss of independence and quality of life from a bad hip fracture and admission to a nursing home.

More than one-third of adults ages 65 years and older fall each year. Among older adults, falls are the leading cause of injury deaths and the most common cause of nonfatal injuries and hospital admissions for trauma. In 2000, 1.6 million seniors were treated in emergency departments for fall-related injuries and 353,000 were hospitalized. The chance that a fall will cause a severe injury requiring hospitalization greatly increases with age. White men have the highest fall-related death rates, followed by white women, black men and black women. Women sustain about 80% of all hip fractures. Among both sexes, hip fracture rates increase exponentially with age. People ages 85 years and older are 10 to15 times more likely to sustain hip fractures than are people ages 60 to 65 (CDC, 2003).

Research has identified the following seven risk factors as the most probable root causes of falls in the elderly (CDC, 2003):

1. abnormalities of gait and/or balance,
2. muscle weakness,
3. taking four or more medications (and taking certain types of medications),
4. vision deficits,
5. certain chronic diseases such as Parkinson’s Disease, arthritis, stroke, and cognitive impairment, and
6. previous falls,
7. having multiple risk factors.

Falls are not always innocuous and should not be taken lightly. In 1999, about 10,000 people ages 65 and older died from fall-related injuries and more than 60% of people who die from falls are 75 and older. Of those who fall, 20% to 30% suffer moderate to severe injuries such as hip fractures or head traumas that reduce mobility and independence. The most common fractures are of the vertebrae, hip, forearm, leg, ankle, pelvis, upper arm, and hand and falls are a leading cause of TBI (traumatic brain injury). The latest statistics on outcomes of falls provided by the CDC (2003) include the following 3 factors:

1. Among people ages 75 years and older, those who fall are four to five times more likely to be admitted to a long-term care facility for a year or longer;
2. Among older adults, the majority of fractures are caused by falls; and
3. Approximately 3% to 5% of fractures experienced by older adults are caused by falls. Based on the 2000 census, this translates to 360,000 to 480,000 fall-related fractures each year.

Many home care patients admitted for services are at risk for falling. Use this information to begin identifying at-risk patients. Muscle weakness and abnormalities of gait, and/or balance is common among patients admitted with diseases of the musculoskeletal system, or connective tissue and/or some type of arthritis. 18.9% of home care patients are admitted with a primary diagnosis of heart disease.

Table nine represents utilization of home healthcare by Medicare beneficiaries. When you view the data in table ten, patients discharged from facilities to home health services were recipients of rehabilitation, a trend that for the most part has continued since 1997. The majority of admissions are seldom single-diagnoses patients; therefore the potential for multiple risk factors is likely.

Standard assessment forms are a vehicle for communicating and sharing patient information. Their value is in the clinician’s ability to form an opinion about the appropriateness for admission to the agency, develop the patient’s care plan, provide care, and prepare the patient for discharge. The clinician must apply his/her knowledge and judgment when applying principles and specific recommendations to the assessment and management of individual patients. Decisions to adopt any particular recommendation(s) must be made by the clinician, taking into consideration available evidence, resources, and the patient’s functional ability.

Functional ability in the elderly is often limited. Eight million of the nation's elderly population has some form of disability for which they require assistance with activities of daily living and by 2020. That number will rise to an estimated 15 million. Studies of multifactorial interventions that included assistive devices have demonstrated benefit but no direct evidence that the use of assistive devices alone prevents falls. Assistive devices are effective elements in multifactorial intervention but clinicians and patients should not rely on them solely to prevent falls. Patients 85 years and older have more difficulty performing ADLs and require more assistance compared to those between the ages of 70 –74 years.

Given the prevalence of functional disability in the elderly population, a falls assessment is warranted. The Guideline for the “Prevention of Falls in Older Persons” defines a fall evaluation as an assessment that includes the following four situations (AGS, 2001):

1. A history of fall circumstances, medications, acute or chronic medical problems, and mobility levels,
2. An examination of vision, gait and balance, and lower extremity joint function,
3. An examination of basic neurological function, including mental status, muscle strength, lower extremity peripheral nerves, proprioception, reflexes, tests of cortical, extrapyramidal, and cerebellar function, and
4. Assessment of basic cardiovascular status including heart rate and rhythm, postural pulse and blood pressure and, if appropriate, heart rate and blood pressure responses to carotid sinus stimulation.

The percentage of geriatric persons falling increased from 27% for those with no or one risk factor to 78% for those with four or more risk factors. The percent of persons with recurrent falls increased from 10% to 69% as the number of risk factors increased from one to four or more (AGS, 2001). The prevalence of cardiovascular causes of falls in the general population is unknown, but there is emerging evidence of an overlap between the symptoms of falls and syncope in some older adults. To date, the overlap has been reported in selected populations with bradycardiac disorders such as carotid sinus syndrome.

There are pre-existing conditions or events that have been identified that predispose the elderly to fall. This information can be found in the patient’s medical record or obtained during interview and lays the foundation for developing effective interventions and prevention plans. Once the patient is found to be at risk for falls, the care plan must be developed to reduce the risk of falls. This plan needs to be shared with and followed by the professionals and the paraprofessionals involved in the patient care.

Very little information on the prevention of falls is in the Home Health Aide (HHA) curriculum. It is the responsibility of the clinician creating the HHA’s care plan and supervising the HHA to further develop the knowledge of paraprofessionals. HHA‘s can often spend more time in the home with the patient that any other clinician and they can significantly impact the independence of the patient.

When creating paraprofessional care plans, consider the goals of the patient and how best the HHA can assist in meeting those goals. When the focus is on the provision of personal care, which is usually the primary reason for the HHA being assigned; the clinician loses valuable insight into the patient’s functional ability and independence.

Case Example: Mrs. Ex was s/p CVA and had right upper and lower extremity weakness. She required assistance with showering and a HHA was assigned. The RN interviewed the HHA and the patient to determine how the patient was progressing and to begin development of discharge plans. They both explained that Mrs. Ex was not able to shower without assistance and the RN was granted approval to observe the HHA while providing personal care services. The RN questioned them regarding the use of a hand-held shower and the patient was amenable to the suggestion. The follow-up visit revealed that Mrs. Ex was able to adequately shower with the use of a simple assistive device, a hand-held shower.

There is no blame in the above case scenario. Neither the paraprofessional nor primary clinician was able to focus on facilitating independence because the focus was on how the HHA was performing the required task as assigned. The better approach to HHA assignments is one that incorporates the paraprofessional’s observations and feedback. Give HHA’s the active role of promoting independence while providing care.

The patient’s care plan to reduce the risk of falls should follow standard guidelines that are evidence based.

The American Geriatrics Society, the American Academy of Orthopaedic Surgeons and the British Geriatrics Society formed a Panel on fall prevention. The goal was the development of guidelines to assist healthcare professionals in the assessment and management of patients at risk of falling and those who had fallen. Their document, “Guideline for the Prevention of Falls in Older Persons”, was published in 2001.

The Panel’s Guideline for the Prevention of Falls in Older Persons is consistent with other guidelines. It was also more evidenced based. There are two specific recommendations detailed below that are from the Guideline for the Prevention of Falls in Older Persons. Barts London Queen Mary School of Medicine in October of 2000 published a Guideline For The Prevention of Falls In People Over 65 (Feder, Cryer, Donovan, & Carter, 2000). Because their recommendations expand on the Panel’s findings, both recommendations are presented graphically.

The Panel’s specific recommendation on multifactorial Interventions for individuals living in their own homes), should include the following six factors (CDC, 2003):

1. exercise programs, with balance training as one of the components;
2. gait training and advice on the appropriate use of assistive devices;
3. review and modification of medication, especially psychotropic medication;
4. treatment of postural hypotension;
5. modification of environmental hazards; and
6. treatment of cardiovascular disorders, including cardiac arrhythmias.

There is a consistent association between the uses of psychotropic medication and falls in the home, long-term care facilities, hospitals and rehabilitations centers. Psychotropic medications include neuroleptics, benzodiazepines, and antidepressants. There are no randomized controlled studies of manipulation of medication as a sole intervention but reduction of medications is an important component of effective fall-reducing interventions in community-based and long-term care multifactorial studies. Trial studies suggest that a reduction in the number of medications in patients who are taking more than four preparations is beneficial. Compliance with intervention needs to be continuous to be effective. Case series report an overlap of symptoms of falls and syncope and a causal association between some cardiovascular disorders and falls, particularly orthostatic hypotension (CDC, 2003).

Patients who have fallen need to have their medications reviewed and altered or stopped as appropriate. Particular attention to medication reduction should be given to older persons taking four or more medications and to those taking psychotropic medications (CDC, 2003). The home environment is particularly vulnerable to accidental poly-pharmacy, as many home care clinicians know. It is warranted to ask a patient to see all of her/her medications as patients may continue to take similar or even the same medications because of variations in drug names. Medications used to prevent or treat osteoporosis reduce fracture rates, but do not reduce the rates of falls.

The management of postural hypotension was part of the effective intervention. Self-management programs were not beneficial in the five studies in which they were reported. Advice alone about fall risk factor modification (with-out measures to implement recommended changes) was of equivocal benefit in three and of no benefit in two studies (CDC, 2003) (AGS, 2001).

When a patient is admitted to a facility or hospital they are the “guests”. When a clinician sees a patient in their home, the clinician is the guest. Home is one of the few environments that allow the occupants to be in control and unfortunately, the CDC reported that 60 percent of older adults fall in their home. Most fall injuries are caused by falls from a standing height by tripping while walking and occur on a level floor, rather than falling down stairs. Therefore, the CDC feels it makes sense to reduce home hazards and make living areas safer even though researchers have found that simply modifying the home does not reduce falls. Clinicians cannot predict patient behavior but they can advocate for safety measures. Include even the obvious when teaching patients and their significant others. Common environmental fall hazards include tripping hazards, lack of stair railings or grab bars, slippery surfaces, unstable furniture, and poor lighting (CDC, 2003).

Case Example: Patient A was admitted for home care services after she sustained a fracture to her right hip. She was residing in her son’s home and where a walk-in shower, safety grab bars and skid prevention appliqués were installed prior to her relocating to his home. The patient fell after walking back into the shower area to wipe down the windowsill. Wet tiles are extremely slippery, his mother’s behavior was not predictable and appliqués are not as effective as mats, which tend to cover more surface area.

The Panel on falls found that supportive evidence of the benefit from modification of home environmental hazards was equivocal in one study and of no benefit in a second study. In a subgroup of older patients, a facilitated home modification program after hospital discharge was effective in reducing falls. Otherwise, modification of home environment without other components of multi-factorial intervention was not beneficial. In addition, they found no evidence to support restraint use for falls prevention. Their recommendation is that when older patients at increased risk of falls are discharged from the hospital, a facilitated environmental home assessment should be considered. (AGS, 2001).

There are no randomized controlled studies of interventions for visual problems despite a significant relationship between falls, fractures, and visual acuity. Fall-related hip fractures were higher in patients with visual impairment. Visual factors associated with two or more falls included poor visual acuity, reduced contrast sensitivity, decreased visual field, posterior subcapsular cataract, and nonmiotic glaucoma medication. Patients should be asked about their vision and if they report problems, their vision should be professionally assessed and corrected when possible (AGS, 2001).

No experimental studies of footwear examining falls as an outcome but there are some trials that report improvement in intermediate outcomes, such as balance and sway from specific footwear intervention. In women, results of functional reach and timed mobility tests were better when subjects wore walking shoes than when they were barefoot. Static and dynamic balance was better in low-heeled rather than high-heeled shoes or the patient’s own footwear. In men, foot position awareness and stability were best with high mid-sole hardness and low mid-sole thickness. Static balance was best in hard-soled (low resistance) shoes (CDC, 2003).

There is emerging evidence that some falls have a cardiovascular cause that may be amenable to intervention strategies often directed to syncope, such as medication change syndrome present with falls and have amnesia for loss of consciousness when bradyarrhythmia is induced experimentally. Preliminary studies suggest those patients with recurrent unexplained falls and a bradycardiac response to carotid sinus stimulation experience fewer falls after implantation of a permanent cardiac pacemaker. The Panel does not recommend pacemaker therapy for the treatment of recurrent at this time (AGS, 2001).

Adaptive equipment can promote safety and functional independence in mobility, eating, writing, dressing, grooming, cooking, and other daily activities. Adaptive equipment is used only if other methods of performing the task are not possible or cannot be learned. The equipment must have proven reliability and safety. Engage the services of an occupational therapist if the equipment is associated with ADLs requiring upper extremity function. Make sure that proper instruction to the patient and caregiver on the correct and safe use of the equipment has been completed. Do not assume a vendor has done so.

Today’s healthcare environment changes rapidly and it can be challenging enough just to keep up the latest in wound care, medications, and other treatments, let alone what adaptive equipment is available and how to best utilize such equipment. There are vendors willing to provide hands-on inservices to clinicians and paraprofessionals. An annual update on adaptive equipment and the indications for the equipment is recommended. If possible, provide a rehabilitation-training program (at least 20 hours) to paraprofessionals as well. Clinicians should also check the FDA‘s website on medical equipment alerts and recalls if you are not on the FDA’s mailing list.

Mobility equipment is aimed at achieving stability and freedom in ambulation/locomotion so the patient/client is not homebound. Common mobility equipment includes:

• Wheelchairs, walkers and/or canes
• Braces
• Prostheses

The Panel of Falls does not have supporting evidence that hip protectors do affect the risk of falling. However, there are a number of studies, including three randomized trials that strongly support the use of hip protectors for prevention of hip fractures in high-risk individuals (AGS, 2001).

Bathroom aids are aimed at promoting independence in grooming, bathing, and toileting.

• Grab bars (essential for safety) professionally installed in tub and/or shower enclosures
• Concave magnifying mirror
• Hand-held shower head
• Shower chair
• A tub seat minimizes risk of falls in the tub when balance is compromised
• Soap on a rope or kept in a hand mitt
• Wash mitt that fastens with Velcro around the wrist
• Shower caddy for easy access to hygiene/bathing products
• Raised toilet seat
• Brush holder, using only one hand, a scrub brush with suction cups can be attached to the sink surface to clean fingernails or to clean dentures

The aids are especially useful for patients with significantly compromised sitting balance, those with back pain, or any other condition in which excessive bending is unsafe or aggravates pain.

• Promote easy wear garments with minimal buttons, zippers, Velcro and front-closure bras
• Long-handled shoe horn
• Sock aid (many sock aids work best if talcum or baby powder is sprinkled on the inside of the device to assist with a smooth slide)
• Zipper pull and/or button hook

•  Arrow cut-outs to use in cues for directions
• Label relevant cues such as the start button on the microwave
• Amplifier on phone system
• Light to replace doorbell or phone sound

These aids are aimed at promoting independence in meal preparation. Common aids used in the home are:

• Rolling cart
• Tabletop electric broiler and/or microwave
• Microwave-safe dishware
• Light-weight pots and pans
• Plastic dishware and glassware
• Tools with long handles, such as a dustpan and duster
• Electric can opener
• Jar opener installed on the wall
• Rubber gripper to open jars or placed over door knobs to provide a better grip
• Reacher/grabber

The Association of Rehabilitation Nurses, Standards of Care calls for rehabilitation nurses to assist in the education of the patient/client and significant others in regards to functional and self-care skills and safety. Home care clinicians are prudent to follow those standards. Accreditation bodies such as the Joint Commission on Accreditation of HealthCare Organizations (JCAHO) have set forth the same standards. Education of the patient and or significant other is a responsibility of clinicians and effective education requires a thorough assessment, identification of knowledge deficits, and a patient focused learning approach. With that said, the Panel of Falls found that the elderly living in their own homes found that the educational staff education programs alone were not effective in reducing falls. At best, the Panel’s study on a structured group educational program did not reduce the number of falls, but did achieve short-term benefits in attitudes and self-efficacy (AGS, 2001).

Behavioral and Educational Programs must exist as part of a multifactor intervention plan. If an agency’s safety program is not multifaceted for both the patient and multi-discipline clinicians, a reassessment of its structure is advised. That structure should include the following eight factors:

1. abnormalities of gait and/or balance,
2. muscle weakness,
3. taking four or more medications including psychotropic drugs,
4. vision deficits,
5. certain chronic diseases such as Parkinson’s Disease, arthritis, stroke and cognitive impairment,
6. previous falls,
7. assessment of multiple risk factors, and
8. the Panel’s specific recommendation on multifactorial Interventions for individuals living in their own homes.

The Panel on Falls identified several high priority issues related to falls prevention in regards to future research and analysis (AGS, 2001). Many of the issues also apply to an agency’s safety program such as the following eight questions.

1. What is the cost effectiveness of recommended strategies for the agency as well as the patient?
2. Can fall-prone individuals be risk identified in terms of whom would most benefit from assessment and interventions?
3. How can falls best be prevented in patients with cognitive impairment and dementia?
4. What are the effective elements of exercise programs?
5. What are the effective elements of cardiovascular programs for fall prevention?
6. For whom and when is home assessment by an occupational therapist or other home care specialist effective?
7. What is the effectiveness of assistive devices used alone as a strategy for preventing falls?
8. Does treatment of visual problems prevent falls?
9. What is the safest footwear for people who have fallen or are at risk of falling?
10. What is the role of hip protectors in persons who have fallen or are at risk of falling and what are the most effective designs?

It is the professional nurse’s responsibility to assess for falls risk and to implement a care plan that will minimize the risk of falls. The professional nurse must be knowledgeable of the multiple guidelines and adaptive devices available for the patient’s use.

Home Care Clinicians are in an ideal environment to develop and test new interventions that might include behavior change and environmental modification. New interventions are needed to decrease the risk of falling and decrease the risk of injury when older people fall. Consider developing a task force composed of clinicians from other agencies as a part of the Agency’s safety plan.

1. Information on falls and other injuries is available from the CDC-funded National Resource Center on Aging and Injury established by the San Diego State University Center on Aging, in conjunction with the American Society on Aging. The resource center has an interactive website (www.olderadultinjury.org) that includes links to newspaper and journal articles, and other websites. The center hosts online seminars on falls prevention and related issues.
2. The CDC collects data on the number of people who die, are hospitalized or visit emergency departments from falls. National and state-level data about deaths and emergency department visits are available to researchers and the public through CDC’s interactive, web-based system called WISQARS (Web-based Injury Statistics Query and Reporting System) at www.cdc.gov/ncipc/wisqars. Clinicians can use WISQARS to create reports and maps specific to problem in their communities.
3. In an effort to spread the word about the risk of falls and to promote physical activity among older adults, CDC has Internet resources available for the public and practitioners. Such as the National Blueprint on Physical Activity Among Adults Age 50 and Older to promote physical activity among older adults.
4. A Tool Kit to Prevent Senior Falls, developed by the CDC is a collection of research findings and educational and assessment materials for use by professional service providers. Available in English and Spanish.

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