≥92% of participants will know how to assist patients with safely using assistive devices to decrease the risk of falls.
CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.
≥92% of participants will know how to assist patients with safely using assistive devices to decrease the risk of falls.
By the end of this course, the participant will be able to:
Patient safety refers to the process of keeping patients free from harm, and it is essential throughout all health care settings. It has become an important area of focus due to millions of patients sustaining injuries or death annually due to lack of safety or mediocre health care (WHO, 2019). In the United States, 700,000 to 1,000,000 patients fall in a hospital every year. Research has found that nearly one-third of those falls were preventable (AHRQ, 2021).
Falls are a regular occurrence in nursing facilities. It is estimated that half of the 1.6 million residents of nursing facilities in the United States fall every year. Falls typically have serious consequences, especially in the elderly population. Approximately 65,000 patients suffer a hip fracture annually. Falls with injuries can result in a decline in the resident's quality of life and functional performance. The most serious adverse effect of a fall is that it leads to an increased risk of death. Prevention of falls requires effective communication, strong leadership, and the involvement of the entire interdisciplinary team (AHRQ, 2017).
The Institute of Medicine developed one of the most influential guides for assessing quality in health care. It includes six domains vital to ensuring health care quality (AHRQ, 2018).
The six domains of health care quality include:
A fall refers to an event in which a person experiences an unintentional change in position from one plane to a lower one. Falls represent a major public health issue around the world. At around 684,000 fatalities a year falls represent the second leading cause of accidental injury death. Death rates are the highest in adults 60 years and older throughout all areas of the world. As for non-fatal falls, 37.3 million are severe enough to require medical care of some type (WHO, 2021).
Falls can significantly impact the overall quality of life, regardless of whether or not they result in injury. Older adults can become fearful of falling and may begin limiting their participation in activities and decrease their socialization with others. This physical limitation can lead to physical decline, depression, social isolation, and feeling helpless. In addition to the impact on the individual, there is also a large financial toll associated with falls in older adults. By 2030, the cost of falls in older adults may exceed $101 billion. The older adult population is anticipated to increase by 55% by 2060, resulting in increased fall rates and associated health care costs (NCOA, 2021).
The Centers for Medicare and Medicaid Services (CMS) identify falls that occur during hospitalization as preventable. This conclusion means that the additional cost of health care services or increase in the length of stay in the hospital due to injuries such as a fracture or brain injury is the hospital's responsibility. It has been found that multifactorial interventions are effective in extended-care and rehabilitation hospital settings. A systematic review suggests that these interventions may also reduce fall rates in acute care hospitals in the United States. However, the reduction was not statistically significant. Several individual trials in the review showed a fall risk reduction of up to 30%. It was found that utilizing standardized assessments to identify risk factors for which patient-centered care plans can be developed and implemented was effective. The care plans may include signs to prevent falling, patient and staff education, completion of toileting or safety rounds, medication reviews, and ensuring patients have the proper footwear on when they get out of bed. There is limited evidence to support the use of low beds and bed alarms for reducing fall risk. In nursing homes, it has been found that the use of multifactorial assessments and interventions by the interdisciplinary team can reduce falls by 33% and reduce the risk of recurrent fallers by 21% (Van Voast Moncada & Mire, 2017).
In general, there are many risk factors for falls. Some of the strongest modifiable risk factors include balance or gait impairments, generalized muscle weakness, and the use of certain medications. Many medications are associated with falls. These include anticonvulsants, antidepressants, antihypertensives, antiparkinsonians, antipsychotics, benzodiazepines, digoxin, diuretics, laxatives, opioids, nonbenzodiazepine, NSAIDs, and sedatives/hypnotics. About 60% of falls result from multiple fall risk factors (Van Voast Moncada & Mire, 2017).
Potentially modifiable risk factors:
Non-modifiable risk factors:
The purpose of a fall risk assessment is for the health care provider to determine how likely it is that a patient will fall. The CDC and the American Geriatric Society recommend yearly fall assessment screens for all adults aged 65 and older. The assessment typically includes an initial screening to determine overall health and previous issues with balance, walking, or previous falls. If the screening shows that a patient is at risk of falls, the health care provider will utilize fall assessment tools to test the patient's strength, balance, and gait. Many health care providers use the STEADI approach, which the CDC developed. STEADI stands for stopping elderly accidents, deaths, and injuries. It includes screening, assessing, and intervention. The screening questions will inquire about falls within the last year, whether or not the patient feels unsteady when standing or walking, and if the patient is fearful of falling. The fall assessment tools may include the Timed Up-and-Go (TUG), 30-Second Chair Stand Test, or 4 Stage Balance Test (Medline Plus, 2021). The Morse Fall Scale (MFS) is a commonly used fall assessment tool because it addresses all six common predictors of falls when it is used properly. These include the history of falls, secondary diagnoses, ambulatory aids, intravenous therapy, gait/transfers, and mental status. It was rigorously developed, accurate, and quickly completed with the patient present at the bedside. This scale is important as research has found that fall prevention practices are more successful when the patient is involved in the process (Dykes and Hurley, 2021).
Patients will be put into a category at the end of the assessment - low, moderate, or high risk of falls. The results may also show the areas which need to be addressed as part of the fall prevention intervention. The recommendations may include exercising, changing, or reducing the dose of certain medications, taking vitamin D to improve bone strength, having a vision assessment, changing footwear, visiting a podiatrist, and checking the home for potential hazards. These hazards can include insufficient lighting, rugs not adequately secured, or cords on the floor. It may be recommended that an occupational therapist or other health care provider assist with a thorough home assessment (Medline Plus, 2021).
As patients get older, factors such as chronic or complex illnesses, deconditioning, weakness, and impaired balance lead to increased risk of falls. For many patients, mobility assistive devices such as canes, crutches, walkers, and wheelchairs can help improve their safety and decrease their risk of falls. Canes can help improve standing tolerance and gait by off-loading a weak, injured, or painful limb. They are considered the least stable of assistive devices for mobility, and therefore patients who use them safely must have adequate balance, upper body strength, and dexterity (Sehgal et al., 2021). There are three types of canes - straight canes, quad canes, and tripod canes. Quad canes have a larger base of support than straight canes, therefore providing more stability. Tripod canes have a smaller base than the quad cane. However, they have a tip design that provides a larger support base and more stability than the straight cane (Bateni et al., 2018).
Older adults rarely use crutches because they require a tremendous amount of upper body strength. Walkers help provide a larger base of support for patients with impaired balance or lower body weakness. They are also helpful for patients who cannot weight-bear through one lower extremity, for example, following a hip or knee surgery. Two-wheeled rolling walkers are typically more functional and easier to maneuver than standard walkers without wheels. A four-wheeled rolling walker, commonly referred to as a rollator, is helpful for higher-functioning patients with good balance. They are useful because they provide a seat for resting for patients with impaired cardiopulmonary endurance (Sehgal et al., 2021).
For patients who lack sufficient lower body strength, balance, or endurance for ambulating, wheelchairs are a good mobility option. The wheelchair must be the appropriate size, especially width, to decrease the risk of skin breakdown. Manual wheelchairs typically require sufficient upper body strength and coordination. Many patients can use their lower body to assist with wheelchair propulsion as well. Power chairs are typically a good option for patients who require a wheelchair but lack sufficient strength, coordination, or endurance to propel the wheelchair for functional distances. One study found that 29.4% of adults 65 and older reported using an assistive device within the prior month when they were outside their home, and 26.2% used an assistive device inside the home. Assistive devices can improve the patient's overall safety and independence and decrease the risk of falls when used properly (Sehgal et al., 2021).
While the goal of an assistive device is to improve safety and decrease the risk of falls, research has found that in some situations, assistive devices can lead to an increased risk of falls. It is estimated that almost 50,000 adults 65 and over are treated in US hospitals every year due to falls associated with assistive devices. Some studies suggest that assistive devices may interfere with the legs' lateral movement, which impacts the user's ability to utilize compensatory stepping reactions in the case of a lateral loss of balance. Research suggests that walkers can limit the success of compensatory reactions more than canes. As a result, walkers can increase the risk of falls more than canes. One study found that 12% of falls associated with mobility assistive devices used canes while 87% used walkers. This study demonstrates the importance of proper training on the safe use of assistive devices (Bateni et al., 2018).
When choosing the proper mobility assistive device, several factors will need to be considered. The first factor is the main reason the patient needs the assistive device. A cane is a good option for patients with arthritis, pain, or injury on one lower extremity or only mildly impaired balance. Patients with arthritis or pain in both lower extremities or moderately or severely impaired balance and gait would benefit more from a walker. Another factor to consider is how much weight the patient needs the device to support. A cane can only support up to 25% of the patient's body weight, while a walker can support up to 50% (Health in Aging Foundation, 2019).
One of the most important aspects of using a cane or walker is to ensure a proper fit. This fit should be done in conjunction with a health care provider. The patient should wear their normal shoes and let their arm hang loosely by their side. The distance should be measured from their wrist to the floor. The walker or cane should be adjusted so that the top of the assistive device is the same distance as the measurement from the patient's wrist to the floor. When the length of the assistive device is correct, there should be a 20 to 30-degree bend in the patient's elbow (Health in Aging Foundation, 2019).
Patients must be cautious not only when walking with an assistive device but also when sitting down. They should back up until they feel the chair, bed, or another surface behind their legs. When using a walker or quad cane, it can be left in standing, and then the patient can place both hands on the arm of the chair, on the bed, etc., and ease down slowly to a sitting position. When using a standard cane, they should hold the cane in one hand and the armrest or sitting surface with the other hand and ease down slowly (Cleveland Clinic, 2019). Patients should push up from the surface they are sitting on using their arms when they transition to standing instead of pulling on the assistive device to ensure safety.
The stairs present another challenging area for patients using assistive devices. When going up the stairs with a cane, the patient should push down and step up with the stronger or uninjured leg. Then they step up with the weaker or injured leg and bring the cane up. When going down the stairs, the patient should put the cane down one step, step down with their weaker or injured leg, and then step down with the stronger or uninjured leg. The phrase "up with the good, down with the bad" is often used to remind patients. If a railing is present and within reach, it can be used for additional support with the hand not using the cane. Quad canes may have to be turned to the side to fit on the step (Cleveland Clinic, 2019).
Additional factors which can prevent falls when using assistive devices include:
In 2008, the World Health Organization (WHO) developed guidelines to standardize the process of wheelchair service delivery. The eight steps include referral and appointment, patient assessment, prescription for the wheelchair, funding and purchasing, device installation/preparation, device fitting, patient instruction/training, and follow-up maintenance and repairs. The main features of a wheelchair include a seat, wheels, tires, casters, leg rests, wheel locks, hand rims, armrests, and cushions. Additional items may include anti-tippers, lap trays, or seatbelts if needed (NCBI, 2021).
A comprehensive wheelchair evaluation includes a complete history and physical examination, cognitive and communication skills assessment, and consideration of premorbid functioning and co-morbidities. The patient's motor and sensory function, muscle strength and tone, vision, hearing, postural control, and range of motion will be assessed as significant deficits in any of those areas could make the operation of the assistive device unsafe. Consideration of functional impairments, ADLs, IADLs, occupational roles, social engagement, transportation needs, insurance funding, and the home or living environment must also be considered during the wheelchair assessment (NCBI, 2021).
A standard wheelchair is 24 inches in diameter with rear wheels, 8-inch front casters, weighs 40 to 65 pounds, and is designed to be operated using the hand rims on the wheels. There are many other types of wheelchairs available, including lightweight, ultra-lightweight, one-arm drive, standard heavy-duty, and motorized wheelchairs (NCBI, 2021).
The following measurements must be taken to ensure an appropriate fit for a wheelchair:
The wheelchair seating system should provide sufficient support when the patient is seated. It should allow for normal anatomical alignment while accommodating fixed postural asymmetries. There should be adequate stability when sitting in a neutral position with evenly distributed pressure. The wheelchair should promote function and the successful completion of ADLs and IADLs. The seating system will include a seat and back. It may also include lateral trunk supports, head supports, and pelvic belt supports. The seating system will either be placed on a manual or power wheelchair base. An efficient seating system should support the trunk and provide stability.
For this reason, the seat and back should be firm. The primary and secondary supports will minimize pressure at the bony prominences of the pelvis and sacrum. Various cushions are available, including foam, gel, contoured, saddle, wedge, antithrust, and pommel (NCBI, 2021).
Additional considerations for wheelchair fitting include:
There are inherent risks associated with the daily use of a wheelchair. These may include acute, estimated to include 5-21% per year, and chronic injuries. Pressure ulcers result from prolonged pressure to areas of the bony prominence, especially the ischial tuberosities. Pressure-relief seating systems and techniques such as wheelchair pushups and weight-shifting are important for preventing pressure ulcers. Patients may require assistance from staff with repositioning if they are unable to complete it on their own. If they are at home, family or caregivers should be trained in pressure-relieving techniques. Patients using manual wheelchairs are at risk of upper extremity injury related to self-propulsion. These injuries are common in the rotator cuff, medial epicondyles, and carpal tunnel. Patients must learn how to complete wheelchair propulsion by a physical or occupational therapist safely. The four common methods of self-propulsion include bilateral upper extremities, bilateral lower extremities, hemi-propulsion, or propulsion using all extremities. The most commonly recommended technique is using long forward strokes with both upper extremities. Even when appropriately trained in wheelchair propulsion and optimal seating systems, patients may still suffer from repetitive strain injuries due to the stress placed on the joints. Finally, tips and falls from a wheelchair are common issues. One data set showed that of the approximately 100,000 wheelchair-related injuries evaluated and treated in emergency departments in the US, 65-80% were related to tips or falls from wheelchairs. It is important that patients are monitored to ensure their safety in wheelchairs and reduce the risk of tips or falls whenever possible (NCBI, 2021).
Low vision refers to the loss of sight which cannot be corrected by prescription eyeglasses, contact lenses, or surgery. It involves various degrees of vision loss. The American Optometric Association divides low vision into two categories. Partially sighted refers to a person with visual acuity between 20/70 and 20/200 with conventional prescription lenses. Legally blind refers to a person with visual acuity no better than 20/200 with conventional corrective lenses or a restricted field of vision less than 20 degrees wide. Low vision can impact anyone as it can result from various conditions or injuries. However, age-related disorders such as glaucoma and macular degeneration are more common in older adults. One in six adults over age 45 has low vision, while one in four adults over age 75 has low vision. The most common types of low vision include loss of central vision, loss of peripheral vision, night blindness, hazy vision, and blurred vision. Low vision may result from age-related macular degeneration, glaucoma, eye cancer, brain injury, or diabetic retinopathy (Cleveland Clinic, 2020). In 2015, 1.02 million people were blind, and about 3.22 million people in the US had vision impairment. These numbers are expected to double to about 2.01 million people who are blind and 6.95 million people with vision impairment by 2050 (CDC, 2020).
Many types of supports are available to assist people with vision loss to move around safely and independently. Some supports have the purpose of assisting with mobility, while others notify other people of the vision impairment in the user. Guide dogs are an important mobility aid for people with vision loss. They also provide support and social benefits. Smartphones can assist with navigation for people with vision loss. BlindSquare is an app that is designed to work with screen readers (Fighting Blindness, 2021). Sunu Band is a smart mobility wristband that uses ultrasonic technology to detect and alert the user of obstacles up to 14 feet away. It can be used in conjunction with a white cane to improve spatial awareness for users with vision loss. The navigation sensors and haptic feedback inform the user how far away obstacles are to reduce accidents (APH, 2021).
There are different types of white canes that have different functions.
There are many other low vision devices to assist patients with low vision in completing daily activities to improve their overall quality of life. Optical aids use magnifying lenses to make objects larger and therefore easier to see. These include correctly refracted glasses, magnifying spectacles, stand magnifiers, handheld magnifiers, and telescopes. There are also non-optical assistive devices that can be helpful with daily tasks. These include watches, timers, and devices with audible features for tasks such as measuring blood pressure or blood glucose levels, large-print books, newspapers, magazines, checks, and large-sized numbers and high-contrast colors telephones, thermostats, watches, and remote controls. Several electronic devices can be helpful for patients with low vision. These include video magnifiers, audio and electronic books, smartphones and tablets with adjustable features, and computers with features such as reading aloud or magnifying the screen (AAO, 2021).
The number of visually impaired adults 70-79 years of age is predicted to increase by 211%, and those 80 and older are predicted to increase by 280% by 2050. Visual impairment can negatively impact older adults in many ways. However, the increased risk of falls can be one of the biggest threats. Some common causes of falls due to tripping include lack of attention to surroundings, encountering unexpected obstacles, and misjudging distances or angles. Visual impairment can contribute to those common causes of tripping falls. Research has found that older adults with visual impairment experience significant mobility deficits. One study found that 46% of people who experienced a fall-related hip fracture indicated that the cause of the fall was a poor vision (Nguyen et al., 2021).
Environmental modifications can be completed in the home in collaboration with home health therapists to decrease the risk of falls in patients with low vision. Modifications such as installing secure railings on both sides of stairs and hallways, ensuring adequate lighting and clear walkways in all rooms, removing or securing throw rugs, and installing grab bars near the toilets and inside bathtubs and showers are helpful for all patients, especially patients with low vision. Research has found that virtual home assistants such as Amazon Echo and Google Home can be connected to smart light bulbs for voice-activated lighting to decrease the risk of falls. Voice-activated lighting allows the user to turn on the light before getting out of bed and turn it off once they return to bed without needing ever to touch a light switch. This technology can be helpful for all patients, especially those with low vision. Home health providers must ensure that patients use the recommended assistive devices safely and consistently to decrease the risk of falls (Nguyen et al., 2021).
People with hearing loss have difficulty both hearing and understanding speech (HLAA, 2021). Disabling hearing loss affects nearly 25% of adults 65 to 74 and 50% of adults 75 years and older. Only 30% of adults 70 years and older who could benefit from hearing aids have ever used them. 736,900 cochlear implants have been implanted as of December 2019 worldwide. This count includes around 118,000 adults in the US (NIH, 2021). Despite the advances in hearing aids and cochlear implants, these devices are often insufficient to allow users to hear and understand communication in various settings. Hearing aids have limited range and make it difficult to separate background noises from the sounds the person is trying actually to hear. Hearing Assistive Technology (HAT) can improve the lives of people living with hearing loss. Assistive listening systems and devices can bridge the gap between the user and the source of sound by eliminating the effects of distance, background noise, and reverberation. Telecoils, or t-coils, expand the usefulness of hearing aids and cochlear implants, especially in loud environments. T-coils are built into many hearing aids, all cochlear implants, and some streamers. They are an essential component for users who want to access an assistive listening system easily and directly. People who use hearing aids or do not have a t-coil in their hearing aids can use a hearing loop, FM, or infrared system with a receiver and headphones, a telecoil-equipped personal amplifier, or special telecoil-equipped earbuds with a smartphone (HLAA, 2021).
Hearing loops consist of a copper wire in a room, theater, or counter connected to a special loop "driver" to a public address or sound system. An electromagnetic field is created, which connects to a telecoil in hearing aids, cochlear implants, or receivers. Loops are the most user-friendly assistive listening devices as they are simple, effective, and discreet. Infrared systems (IR) work like a television remote control. A transmitter sends sound from a public address or sound system to an IR receiver using infrared light waves. This technology cannot be used outside during the daytime as the light will affect the system. The signals are sent and received in a straight line, so the user should sit in a central location. FM systems transmit wireless, low-power FM frequency radio transmission from a sound system to FM receivers. The advantage over IR systems is that the FM is not affected by direct sunlight to be used outside. The user needs a receiver and either a headphone or neck loop for both IR and FM systems. Neck loops eliminate the need for headphones in users with telecoil-equipped hearing aids or cochlear implants (HLAA, 2021).
Assistive listening devices (ALDs) are handheld amplifiers with microphones that allow users to communicate more effectively in one-on-one conversations. They capture the sound the user wants to hear while filtering out some background noise. The Pocketalker is an affordable ALD. Bluetooth is a short-range wireless technology frequently used to connect cell phones, televisions, computers, tablets, hearing aids, and cochlear implants. Captioning refers to the text of the audio portion of a video or film, which is displayed directly on the screen. Communication Access Realtime Translation (CART) is the verbatim text of spoken presentations at live events. Sometimes people with hearing loss need CART in addition to an assistive listening system (HLAA, 2021).
Cindy is a home health nurse who was called to a home where the patient, Mrs. Graham, had experienced several falls over the last week. Her family was worried that Mrs. Graham would end up in the hospital as she is 89 years old. They report severe arthritis, has difficulty standing up and walking, and often shuffle her feet. During the admission assessment, Cindy noticed that Mrs. Graham became very agitated when she attempted to stand up and kept falling back into the chair. Cindy helped Mrs. Graham to stand up and asked her to walk with her for a short distance. She was very unsteady and needed assistance from Cindy to prevent falling backward. Cindy noticed unsecured throw rugs throughout the home. When she checked the bathroom, there were no grab bars in place. During a medication review, Cindy noted that Mrs. Graham was on an antidepressant and an antihypertensive, both associated with increased risk of falls. Cindy educated the family on the importance of either removing or securing the throw rugs and recommended installing grab bars near the toilet and in the shower. She informed Mrs. Graham and her family that she referred the patient for physical and occupational therapy services. They will collaborate as a team to work with the patient and her family on safety issues. Finally, Cindy informed Mrs. Graham's primary care physician of the referrals for therapy and the medications that could lead to falls. Cindy was able to take the necessary steps to keep the patient safe in the home setting.
Patient safety is the responsibility of the interdisciplinary team in any health care setting. Falls can be debilitating and even fatal. Health care providers must take all necessary measures to ensure the safety of their patients and decrease the risk of falls whenever possible. Falls can have a significant financial impact and impact the person's overall quality of life. Fear of falling can lead to social isolation and overall debility, increasing the risk of future falls. The goal of assistive devices is to improve the patient's safety and decrease the risk of falls. The patient must learn to use the devices properly as the assistive devices can pose a safety risk when used incorrectly. Assistive devices are also available for patients with low vision and hearing loss to improve their overall quality of life.
CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.