Quality and Safety Practice: Prevention of Patient Falls - Literature Review
Introduction
Whether an elderly person is living alone, with others, within a nursing home, or under care in a medical facility, falling is a major threat. For seniors older than 65 years of age living in a community situation, one in three will suffer a fall every year; for individuals over 85 years of age, the rate climbs to half of all residents (Cameron et al., 2010; CBO, 2004; Neyens, 2007; Tinetti, 2003). If an elderly adult is institutionalized, the possibility of falling in a year rises to 1.5 to 2 times (Dijcks et al., 2005) and a serious injury results from one out of every ten incidences (CBO, 2004; Dijcks et al., 2005; Neyens, 2007; Rubenstein et al., 1994). The psychological, economical, and physical consequences of an elderly person falling have significant impact on patients, staff, facility, and the costs of health care. It is for this reason that extensive research and strategies have developed to address the issue.
The primary influences in causing falls are degenerating muscle strength, side effects of medications, poor vision, inadequate balance, foot pain, vitamin D deficiencies, and problems with walking (CDC, 2016; Tinetti, 2003). Impaired balance, gait, and strength increase the possibility of falling by three or four times ("Summary of the Updated American Geriatrics Society/British Geriatrics Society Clinical Practice Guideline for Prevention of Falls in Older Persons", 2011). The articles included in this literature review address some of these negative forces.
For the purpose of this paper, a fall is defined as “an event which causes the patient to come unintentionally to the ground or some lower level, regardless of the cause” (Kellogg International Work Group, 1987, p 2). Unger et al. (2013) state the etiology of falls is usually due to multiple physiologic reasons related to age or the environment. In order to identify risk factors to enable preventative planning, it is necessary to evaluate individual influences.
Physiologic Changes
El-Khoury, Cassou, Charles, and Dargent-Molina (2015) noted in their study that as the human body ages, alterations in performance in terms of function, neurological transmission, musculature, and bones results in problems such as loss of the ability to balance, decreased strength, muscle atrophy (particularly type-II muscle fibers, less neurons for the senses, and osteoporosis. A longitudinal study by Rubenstein (2006) of individuals over the age of 65 showed that 10 percent required help in walking across a room, 40 percent could not walk more than 150 feet, and 20 percent had problems climbing stairs. Muscle weakness is primarily in the lower legs in 48 percent of patients living at home (Campbell, Borrie, and Spears, 1989; Damián, Pastor-Barriuso, Valderrama-Gama & de Pedro-Cuesta, 2013) and in 80 percent of elderly people living in nursing home (Robbins, 1989).
Unger et al. (2013) identifies syncope as one of the major reasons an elderly person falls. Reports of cardiovascular syncope related to a fall are given by 20 percent of patients over the age of 70 and by more than 20 percent of seniors with Carotid Sinus Syndrome. These numbers encourage assessments of individual elderly of neuroautomatic and cardiovascular function.
Pain creates a number of balance issues as seniors alter body alignment to accommodate for back discomfort, uncomfortable ambulation, aches in the joints, and others. Although analgesics assist in some relief, habits of poor body movements place some elderly individuals at higher risks of falls.
Nutrition
Neyens et al. (2013) conducted a study concerning the relationship between malnutrition and falls. There are a number of reasons the elderly suffer from malnutrition: lack of access to nutritious foods (living alone) or the inability to prepare it, decrease in taste sensations, problems with chewing and swallowing, depression, lower appetite due to less activity, and others. For these reasons and more, seniors may suffer from malnutrition that impacts muscular strength and balance. Neyens et al. (2013) analyzed the statistics from over 400 Dutch health care facilities during 2008 including home health organizations, nursing homes, hospitals, and senior living communities. In addition, questionnaires were used with 6701 residents of long-term care facilities to gather documented information and answers to scales on activity and care. Using standards blood work, intake, and other criteria, between 31.2 percent and 22.8 percent were categorized as malnourished. A univariate analysis of the information gathered showed that malnourished long-term care residents fell significantly more often that the patient not categorized as being malnourished.
Medications
The specific medications routinely prescribed to older patients have potential for influencing balance, particularly antirrhythmics, benzodiazepines, digoxin, diuretics, antipsychotic, antihypertensive, and antidepressant drugs (Hartikainen, Lonnroos, and Louhivuori, 2007). Meta-analysis of statistics showed that taking more than four types of drubs increase the risk of an elderly person falling significantly (Damián, Pastor-Barriuso, Valderrama-Gama & de Pedro-Cuesta, 2013).
Dangers in the Environment
Threats to balance are inherent in the area where the elderly attempt to ambulate. Unger, Brunetti, Tesi, and Marchionni (2013) propose that barriers in the environment account for 30 percent to 50 percent of falls. While attempting to maneuver outside or in unknown environments is difficult for the elderly, most falls take place at home; the reason may be that they are more confident in their usual physical surroundings and become careless. Threats that cause tripping include doorway thresholds, carpets that are worn or wrinkled, mats and rugs with edge, poor lighting, stairs, glaring light, and slippery surfaces such as kitchen or bathroom floors with spilled liquids.
The American Geriatrics Society has created guideline for addressing hazards within the environment for the elderly. Appropriate recommendations regarding canes and walkers, paths for training, and hip protectors may avoid falls in some patients. Gillespie et al. (2012) found that statistically, assessments for home safety were effective for decreasing the risk and the rate of falls. They were considered more effective when the individual is at higher risk secondary to issues such as severe visual impairment and when they are promoted by an occupational therapist.
Interventions against Elderly Falls
Physical training.
Loss of balance is a serious risk factor in falls in elderly individuals. Exercises for balance increase awareness of body positioning and stature. El-Khoury, Cassou, Charles, and Dargent-Molina (2015) promote education of seniors with well-designed programs for exercise that focus on remaining erect. Their six trial study determined that the risk of fractures is significantly lower when seniors participate in exercise programs designed to prevent falls. The most dramatic conclusions of the study were that approximately a 37 percent reduction for any fall causing an injury, a 43 percent reduction in falls resulting severe injuries, and 61 percent for falls that caused a bone fracture.
Resistance training promotes strength even in older exercise practitioners, but this does not directly improve balance and risk of falling (Orr, De Vos, and Singh et al., 2004). The concept of enhanced core strength improving overall physical performance has been a topic of research currently because it is the kinetic link between the upper and lower body. Van der Burg, van Wegen, Rietberg, Kwakkel, and van Dieën (2006) found in their study with Parkinson’s patients that during incidences of tripping, the participants displayed a high level of muscle use in the trunk; this leads to the idea that weak trunk muscles prevent effective restoration of balance in the course of falling. By increasing trunk strength through the use of specific exercises such as sit-ups and back flexion, the risk of falling for an elderly person is decreased (Granacher, Gollhofer, Hortobágyi, Kressig, and Muehlbauer, 2013).
Gillespie et al. (2012) updated a Cochran review updated in 2009 by conducting a review of 159 trials that included 79,193 participants comparing interventions against falls with no interventions. Exercise was used as the only intervention in 59 of the trials and in cooperation with other interventions in 40 trials. The most significant impact was seen when exercise was used with other interventions to reduce incidences of falls. Unfortunately, Merom et al. (2012) concluded from his study on elderly participation is low in exercise programs designed to prevent falls.
A gentle exercise performed standing, against a support, or even in a chair is Tai Chi. Research by Faber, Bosscher, Chin A Paw, and van Wieringen (2006) recommended Tai Chi for improving balance and reducing the risk of falls in the elderly. Participants in Tai Chi classes in the Gillespie et al. (2012) study showed borderline significance in reduction of falls. The researchers also found in a trial with 305 participants that the rate of falls was significantly reduced when patients with disabling foot pain were trained with ankle and foot exercises.
When exercise programs address multiple issues such as gait, function, strength, endurance, and flexibility, improvements are made in coordination and reaction time in additional to overall functioning; there is also evidence that executive function in cognition also benefits (Barnett, 2003; Fitzharris, Day, Lord, Gordon, and Fildes, 2010; Liu-Ambrose, 2010). Gains in balance assist in preventing falls, but better cognitive functioning, faster reflexes such as grabbing support, and lessening impact by enhancing the ability of soft tissues to absorb impact promote decreased injuries if falling or stumbling does occur.
Vitamin supplementation.
The study conducted by Gillespie et al. (2012) demonstrated that while supplementation with vitamin D neither decreased the rate of falls or risk of falls, there is a possibility it may have a more pronounced effect when administered to seniors with low vitamin D levels before they started treatment. A study by Cameron et al. (2010) concluded vitamin D supplementation effectively reduced the number of falls in nursing homes. Balzer, Bremer, Schramm, Lühmann, and Raspe (2012) state after a comparison of research results on the effects of vitamin D on rates of falls that the evidence is inconclusive.
Modification in medications.
Gillespie et al. (2012) found that when psychotropic medications were gradually reduced, the rate of falls decreased and therefore recommended physicians modifying prescription programs when possible.
Modifications in the environment.
One type of intervention concerning the environment was suggested by Gillespie et al. (2012); the researchers found that a shoe device that reduced slipping decreased the number of falls occurring when walking on ice. Assessments of the environments of elderly individuals, whether living in a nursing home, community, or in a private home warrants attention to barriers to ease of ambulation including mats, rugs, uneven surfaces, maneuvering around furniture, relatively long distances without options for hand holds, light impediments, and other risk factors. A report by Balzer, Bremer, Schramm, Lühmann, and Raspe (2012) states that when the environment is considered high risk, such as in some homes, modifications are probably effective in decreasing the possibility of falls for the elderly.
Conclusion
Falls are a serious health risk factor for the elderly influenced by medications, environmental hazards, and changes in physiology. As the number of older people in a general population increases, it is necessary for research to address sciences concerned with exercise, aging, and physical therapy.
Statistics indicate the rising numbers of falls reported by elderly people secondary to the increasing populations of seniors (Cameron et al., 2010; Campbell, Borrie, and Spears, 1989; CBO, 2004; Damián, Pastor-Barriuso, Valderrama-Gama & de Pedro-Cuesta, 2013; Dijcks et al., 2005; Neyens, 2007; Rubenstein et al., 1994;Tinetti, 2003). Causes included physiologic changes (CDC, 2016; El-Khoury, Cassou, Charles, and Dargent-Molina, 2015; Robbin, !989; Tinetti, 2003), syncope (Unger et al., 2013), malnutrition (Neyens et al., 2013), prescriptions of large numbers of medications (Hartikainen, Lonnroos, and Louhivuori, 2007), and environmental dangers (Gillespie et al. (2012; Unger, Brunetti, Tesi, and Marchionni, 2013). Interventions proposed to address the negative impact of these causes are physical training (El-Khoury, Cassou, Charles, and Dargent-Molina, 2015; Faber, Bosscher, Chin A Paw, and van Wieringen, 2006; Granacher, Gollhofer, Hortobágyi, Kressig, and Muehlbauer, 2013; Orr, De Vos, and Singh et al., 2004; Van der Burg, van Wegen, Rietberg, Kwakkel, and van Dieën, 2006), vitamin D supplementation (Balzer, Bremer, Schramm, Lühmann, and Raspe, 2012; Cameron et al., 2010; Gillespie et al., 2012), reduction in the number of prescription medications )Gillespie et al., 2012), and modifications in the home environment (Balzer, Bremer, Schramm, Lühmann, and Raspe, 2012; Gillespie et al., 2012). Exercise may also benefit cognitive function (Barnett, 2003; Fitzharris, Day, Lord, Gordon, and Fildes, 2010; Liu-Ambrose, 2010). All article recommend further research into these areas based on changing methods of statistical analysis, alterations in criteria, and other variables.
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