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CHCAC417A Implement interventions with people at risk of falls

Reading 3: Implement fall minimisation strategies

1 © NSW DET 2008

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Contents

Introduction 4 Identify and explain options to minimise the risk of falls 4 Work with the older person and their carers to identify strategies that are consistent with their safety needs, priorities and specific requirements 10 Implement strategies in a safe and effective manner 13 Implement strategies in a manner that minimises the older person’s discomfort 14 Where appropriate, provide support to the carer to contribute to the strategy 17

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Introduction Planning and actually doing a falls assessment is one thing, however, all the planning in the world is not going to improve the health outcome of the client if no falls minimisation strategies are implemented.

Identify and explain options to minimise the risk of falls As mentioned in the previous reading falling is not a normal part of ageing and many falls can be prevented. As a carer you will be expected to be able to explain this to your client as part of your role. You will also need to be able to identify risk factors, implement strategies to assist clients so that their chances of falling are reduced.

Falls prevention and strategies have been studied for many years and throughout the world and yet falls still occur. There are a number of interventions that can be implemented to reduce the risk of an elderly person falling. These include gait and balance programs, drug review, review and modifications of the home environment, exercise and medication changes for example.

It is generally accepted that one falls prevention strategy is to keep active. Supporting your body weight if you are standing requires strength. So too does keeping your balance when you walk or undertake activities of daily living. You need to encourage your clients to stay as fit and healthy as possible. Participating in regular gentle or enjoyable physical activity is one strategy which will provide strength and muscle tone. Joint mobility will improve, the joint will be more stable and there will be less stiffness in the joints from regular, gentle exercise. Additionally, bone strength will be maintained and the effects of osteoporosis may also be reduced. Often a healthy weight will be maintained as well. All of these benefits will assist your client to remain independent.

Some examples of activities for elderly clients are:  individual exercise/gym programs  hydrotherapy– water based exercise  community based exercise programs  community day centre programs  day and hospital outpatient programs  other recreational activities such as gardening  tai chai

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 indoor/outdoor bowls  golf  walking  swimming  dancing.

Using the stairs and walking around the house is also good activity to be encouraged as they are part of the daily routine and can be undertaken in small amounts over the course of the day.

Reflection: Are high heeled stilettos the only shoes that could result in falls?

Feedback

High heeled stilettos are not the only shoes that can cause clients to fall. There are multiple indicators for unsafe shoes and there are very few people who will choose footwear based on comfort and safety. Shoes are more likely to be chosen because of the way they look.

Footwear

Many older persons are of the opinion that they are not able to move around as well as they used to because of their foot problems. Foot and leg problems can influence and reduce and restrict function. They may even result in admission to hospital and possibly into residential aged care facilities. Research undertake in 2005 at Latrobe University by Dr Hilton Menz identified that older women are more likely to wear shoes that do not fit and more than 70% of older people wear shoes that are too small. Others wear loose, poorly fitting slippers for example.

Unsafe shoes generally have:  soft or stretched uppers (feet can slide out of the shoe)  no laces (feet can slide out of the shoe)  high heels (change stability)  altering or cutting their shoe due to overgrown or ingrown toenails, painful corns and calluses  narrow heels (reduce stability)  slippery or worn soles (affect balance, particularly if it is wet or in wet areas such as the bathroom). Note: If high heeled shoes have been worn for many years caution is required prior to stopping an individual wearing high heel shoes).

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Safe shoes generally have:  a firm heel collar (increases the stability)  laces or Velcro fastenings (the shoe holds onto the feet whilst walking)  broad flared heel (increase ground contact)  textured soles (grip and prevent slipping)  a rounded or bevelled edge (prevent slipping).

An example of a safe shoe is illustrated below:

Illustration of a safe shoe

Figure: Features of safe shoe

Some tips for safe footwear include:  Have your feet measured at the end of the day. Your feet may swell and increase in size during the course of the day.  As you age, your feet change so always have your feet measured before buying shoes.  One foot is usually larger than the other. Always fit your shoe to your larger foot.  Choose your shoes by how they fit your feet, not just by their shoe size.  Select a shoe that is shaped like your foot.  During the fitting process, make sure there is enough space (3/8’ to 1/2’) for your longest toe at the end of each shoe when you are standing up.  Make sure the ball of your foot fits comfortably into the widest part of the shoe.  If the shoes feel too tight don’t buy them.  Your heel should not slip up and down in the shoe when you walk.  Walk in the shoes to make sure they fit and feel right. Walk them in at home before going out in them.

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 Buy shoes with soft, flexible uppers which match the shape of your foot. Shoes made of leather can reduce the possibility of skin irritations.  Soles should provide solid footing and not be slippery.  Thick soles cushion your feet when walking on hard surfaces.  Low-heeled shoes are more comfortable, safer, and less damaging than high-heeled shoes.  Walking shoes are best suited for daily activities.  Avoid scuffs, thongs and slippers.  Do not wear your socks without your shoes.  Keep the soles of your shoes clean as they can become very slippery from dirt, grease and dust.

Clothing

Older persons often lose height because of spinal changes and degeneration from their illnesses or ageing. Long dressing gowns, dresses, skirts and pants can trail on the floor. This can become a trip hazard. Sometimes they may trail, not because they are too long, but because the clothes have become loose. This may be because the elastic has gone, or because the client has lost weight. It is your responsibility to identify the cause and arrange for the clothes to be altered so that they are no longer a hazard. If the client has lost weight then nutritional factors would need to be considered.

Vision

Vision problems create an increased risk of falls because:  they affect how clearly people see objects  they can impact on how far people can see  affect how much they can see  the individual may not be able to differentiate between objects and/or backgrounds.

If your client suffers low vision, advice is available through Vision Australia Information Line 1800 331 000.

Balance

Balance is affected by a number of physical changes such as:  reduced muscle strength

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 walking more slowly  taking shorter steps  swaying more from side to side  slower reaction times and reflexes  reduced awareness of body position  decreased sensation particularly in the extremities from numbness in the feet for example.

Older persons have an increased risk of falling if they have problems with their balance. This can also impact on their ability to walk safely. Dizziness can also impact on balance and walking and therefore increase the risk of falling. Good balance ensures a person will stay upright. If a person is unsteady because of their balance problems or dizziness they are less likely to recover their balance if they trip or stumble. This also increases their risk of falling.

Medications

An increased risk of falls in the elderly can result from the side effects from medications or mixing multiple medications.

Research suggests that clients taking three or more medications are at higher risk of falling. It has also been found that as the number and type of medications increases, so too does this risk of falling. If there are side effects from the medications such as dizziness, drowsiness or confusion, there is an even greater risk of the person falling.

Health factors

There are a number of health factors which can result in a higher risk of falling for elderly clients. This includes memory loss, arthritis, incontinence, Parkinson’s disease, poor nutrition and lack of confidence (fear of falling) and alcohol abuse for example.

Generally, active healthy older people will have less falls than people who have chronic illnesses and/or who may be on multiple medications. Older people should be encouraged to partake in healthy diets with good fluid intake. This helps to maintain energy levels and reduces the risk of illnesses such as diabetes and osteoporosis.

The daily calcium intake should be approximately 1000mg-1200mg which is approximately four serves of dairy food per day. This equates to one glass of milk or a small tub of yoghurt or a slice of cheese. Other sources of calcium come from canned fish with bones such as tuna or salmon.’

Some examples of ways to encourage your clients to stay healthy:

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 have a wide variety of nutritious foods  keep active  eat at least 3 meals per day  care for their food: prepare and store the food correctly  eat plenty of vegetables (including legumes) and fruit  eat plenty of cereals, breads and pastas  eat a diet low in saturated fat  drink an adequate amount of water and/or other fluid (unless they have been placed on a fluid restriction by the General Practitioner)  limit alcohol intake  include foods high in calcium  choose foods low in salt and use salt sparingly  use added sugars in moderation.

Environment

Falls can occur in a variety of settings including either inside the home, outside the home, in residential aged care facilities, in hospitals or in any setting such as a shopping centre or on a foot path.

Identifying hazards is important because they can be removed or reduced once they are known about. Remember however that falls are often a combination of a number of factors including loss of balance therefore removing a hazard or reducing one risk factor, may not be sufficient to reduce the risk of falling for every client.

Whilst there is little that an individual can do in terms of a safe environment when they are out and about in a public place, there are some practical tips for making the home safe.

Some environmental factors to consider:  lighting – poor lighting reduces visibility  loose rugs or carpets can become a trip hazard  electrical cords across walkways are a trip hazard  cluttered furniture make it difficult to move around particularly if the client is using a walking frame  slippery floor surfaces  steps with no rails  cracked or uneven pathways  lack of grab rails in bathroom areas

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 furniture heights such as chairs or beds that are too high or too low  leaf litter on garden paths – may cause the path to become slippery  pets – small pets can get underfoot and larger pets, particularly if they are not properly trained can accidentally push a frail elderly person over.

Work with the older person and their carers to identify strategies that are consistent with their safety needs, priorities and specific requirements Given everything that we have discussed about all the factors involved with an increased risk of falling, it makes sense that the more risk factors that can be eliminated or reduced for a client, the less likely they are to fall. Ultimately it will be the client and/or their representative who will decide which strategies that we implement and in what order. Sometimes it may seem too hard or there may be too many things to consider. If this is the case, starting with one easy activity is a good way of dealing with feeling overwhelmed. If this happens, keep the review time short and introduce another easy strategy within a relatively short time frame to keep the momentum going.

For example, if you are discussing activity and trying to get the client to be as active as possible, start with their everyday activities. Imagine that your client reads every morning between 10.00am and 11.30am. Prior to sitting down, they make themselves a cup of tea and then carry the tea and a couple of biscuits into the lounge room. Encourage your client to lift the jug a couple of times up into the air – it doesn’t have to be above their shoulder – prior to boiling the jug. If they do this every time they go to boil a jug they will be increasing the muscle tone of their arm. They could use both arms and improve the muscle tone of both arms.

Instead of just getting up after they have finished reading and doing their usual routine, get them to stand up then sit down again. They can do this a couple of times and gradually increase the number of times this is done. This will increase the muscle tone of the upper legs. These are easy exercises and associated with what the client usually does, therefore they are much easier to incorporate into their daily routine than something the client has never done before. If your client has low self confidence these types of exercises are important when helping to improve their confidence.

Encourage your client to have a medical check up prior to commencing any new activity or program.

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Preventing foot problems

We know that foot problems can increase the risk of falling. Therefore we need to be able to inform the client about how to prevent or reduce foot problems:  Ensure your client’s feet are checked regularly. If the client cannot do this they should get a member of their family to do it. Podiatrists and doctors may be an alternative. If specialist treatment is required the client’s General practitioner will arrange this.  Encourage the blood to circulate to your client’s feet as much as possible. This can be done by having feet raised whilst sitting or lying down, stretching after long periods of sitting, walking, having a gentle foot massage or having a warm foot bath.  Remind the client not to expose their feet to cold temperatures or to be too close to a heater during the winter. This is particularly important if the client has numbness of their feet.  Don’t sit for long periods of time (especially with legs crossed).  Stop smoking.

Eyesight

We know that poor eyesight and problems with vision especially at night can increase the risk of falling. Encourage clients to:  have their eyesight reviewed every 12 months by an optometrist  wear prescribed glasses (if applicable)  keep reading glasses clean (as a carer you should offer to do this)  wear a hat or sunglasses outside to reduce glare (and stop sunburn)  have good lighting in the home (use 75watt globes)  have contrast markings on the edges of stairs or steps  avoid wearing bifocals on steps or stairs, have 2 pairs instead of one  leave a night light on or have a torch available to move around the home more easily and safely  make relevant home modifications such as installing safety rails.

Balance

We know that poor balance and walking difficulties can increase the risk of falling. Some tips for assisting a client/resident overcome balance problems include:

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 When moving from a lying to sitting position or from a sitting to standing position, get the client to take their time to avoid dizziness.  If dizzy sit down straight away, or remain seated – seek medical advice if this is a new symptom.  When getting up, especially from bed, sit on the edge of the bed for a short while. Getting up too quickly can cause a drop in blood pressure, resulting in an increased risk of falling.  When turning, take several smaller steps, do not turn suddenly.

Encourage your client/resident to keep fit by participating in carefully selected exercise programs using specific equipment to improve balance, strength and walking. Physiotherapists can help with specific balance and walking difficulties.

Install hand rails on steps, stairs and bathroom areas. Ensure mobility aides are fitted by a qualified health professional such as an occupational therapist. Equipment may include walking frames, shower chairs or rails in bathroom areas or on stairs.

Medications

As n aged care or health support worker, your responsibility is to report any concerns you may have to your supervisor. You also have a responsibility to encourage your client to report any concerns they may have to their doctor. Medication management and control is not your responsibility. It is the role and responsibility of the doctor, nurse and pharmacist. You do need to be aware of the medications your client is on and the potential impact of these medications. You also need to be able to discuss this with your client and if there are any questions you are unable to answer you should refer these questions to your supervisor or suggest the client discuss them with their general practitioner.

Assisting with fear of falling:

Discuss the following with your client to assist them to deal with their fear of falling. It may be necessary to refer them for counselling if their fear of falling becomes disabling.  Encourage the client to become aware of how fear of falling is affecting their activities and mobility.  Discuss the option of a personal alarm or cordless telephone. This can provide increased confidence and result in the client moving in and around the house more. Personal alarms are usually worn as pendants around the neck or as bracelets however, there is usually a cost associated with them.

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 Telephones should be placed on tables or shelves rather than on the wall as they may be difficult, if not impossible to reach, following a fall.  Consider the use of hip protectors. These are protective shields that fit into side pockets of special underwear garments. They have been shown to be effective in reducing hip fractures. The use of hip protectors should be discussed with specialist health professionals such as the general practitioner, registered nurse or physiotherapist.  An occupational therapist or physiotherapist can assist the team with developing new strategies and returning to previous activities. Physiotherapists can help by providing exercises and strategies to increase confidence and mobility. Occupational therapists can discuss what can be done to make the environment safer. Always ensure you have discussed the option of assistance from other health professionals with the client prior to making the referral. Remember, the client has the choice and the right to make these decisions.

Implement strategies in a safe and effective manner Strategies are generally either to reduce the risk of falls or prevent injuries from falls. Some strategies however, such as increasing the amount of activity, may potentially increase the risk of falls in the first instance particularly if they are not implemented safely or under specialised supervision. These strategies also reduce the likelihood of injury or the severity of injury because they improve strength and balance.

We have discussed various ways of attending to foot problems, including review and treatment of foot problems by the client’s general practitioner or podiatrist; wearing good footwear and not having clothes that drag on the floor.

Some other things to ensure strategies are implemented safely include:  ensure walking aids are maintained properly  ensure walking are fitted by qualified people. a properly fitted walking frame for one person may sometimes be dangerous or cause more problems for another person  encourage clients to seek advice about modifications in and around the home  remove trip hazards such as loose mats, cords and clutter in walkways  use non-slip mats in the bathroom  install grab rails in the toilet, bath and/or shower areas.

 install hand rails next to stairs and steps  improve lighting inside and outside the home  ensure there is access to a night light or torch when getting out of bed  be aware of the heights of beds, chairs and toilets – if they are too high or too low they can increase the risk of falling  have pathways and walkways maintained and cleared regularly  remove overhanging branches or other objects that obstruct pathways such as pot plants or garden hoses  medical clearance to participate in exercise programs should be gained before commencing the program  programs should be run by suitably trained individuals.

Here is a simple checklist for ensuring bathrooms and toilets are safe:  Are slip resistant mats used in the bathroom?  Are the soap, shampoo and towel within easy reach?  Are taps and towel rails used to assist the person to get out of the shower or bath?  Are there handrails in the bath or shower?  Is it easy for the person to get on and off the toilet?  Is there a raised edge or hob on the shower?

Implement strategies in a manner that minimises the older person’s discomfort Exercise that focuses on developing strength and balance is one of the most important ways of reducing the risk of falling but there is a risk. The intention of the strategies should also be to do no harm and may also be to reduce the occurrence of injuries.

Encourage your client to:  keep as fit as possible  participate in everyday activities such as personal care, cooking, cleaning and leisure activities  have a medical check up prior to commencing any physical activity that they have not been used to doing’  identify the need for specialist referral to a podiatrist or orthotists (specialist fitter) if required to ensure the right type of shoe

 encourage the client to have their clothing altered to ensure the clothing does not drag on the ground.

The more risk factors that are reduced, the less likely the person is to fall again and injure themselves. As their carer you have a responsibility to ensure the client understands this. Just think about what happens when you start an exercise program for example. Think how much your muscles ache the next day when you work hard at the program. For older persons, there is a risk that they may injury themselves if they over do it and are not careful.

Reflection: Just how much right does a client have if they are in danger of injuring themselves?

Imagine you have problems with your balance. Every time you try to get up and walk you lose your balance and fall over. Sometimes you hurt yourself. Someone that you have never seen before, keeps stopping you from getting up by putting a table in front of your chair. You know you can walk if only they would let you. How frustrating do you think that would be for you?

Feedback

This is a common scenario in some aged care facilities. Sometimes the choice is taken away from a client because there is a fear that they will injury themselves when they fall. For some elderly people, not being able to get up and walk can cause increased frustration for example and may actually increase their risk of falling.

Dignity of risk is an important consideration with elderly clients. This means that the client has the right to make a decision about the strategies they implement and sometimes that will mean that they may be at risk of injuring themselves.

Some medical conditions cause a person to be very unstable when they first start to get up out of a chair but rather than being restrained in a chair, the person may choose to be able to get out of the chair when they want to despite the potential injury they may sustain. Being tied to a chair does not necessarily promote dignity and sometimes a person restrained in a chair will actually get up and walk with the chair and be more at risk. The client has the right to make a decision about being able to get up freely from a chair without being restrained despite the risk of injury provided they have had the risks fully explained to them. This is something that you and your supervisor can do together.

Other things clients can do include:  wear their prescribed glasses and hearing aids  use a walking aid if required – one that has been specifically fitted for them

 wear safe footwear  be aware of the location of public toilets so that there is no need to rush to get to them  be aware of public seating and rest areas.

Injury prevention strategies may include:  The use of hip protectors. Hip protectors are generally used for clients who have osteoporosis, a history of falls and limited mobility. They are thought to assist the client by preventing fractures of the neck of the femur as well as reducing their fear of falling. They do not stop falls and do not prevent injuries from occurring in other areas of the body. However, sometimes clients can become irritated with hip protectors and will do everything they can to remove them and may actually place themselves at harm trying to remove them. hip protectors need to be used with caution and are generally used in residential aged care facilities rather than in the home. Ulceration and skin problems may also develop in the area around the hip protector. The cost of the hip protectors may be a concern for the client. The Department of Veteran’s Affairs may cover this cost for some veterans or the client’s private health fund (if they are members) may also contribute. Generally it is considered that even a small contribution by the client will increase their compliance.  Vitamin D. There is some evidence that Vitamin D may assist with improved muscle strength. Older people are often at risk of having low levels of vitamin D because they tend not to spend long periods outside and often the medications they are on, specifically require that the individual not spend long periods of time in the sun. Spending too much time in the sun can also place the client at risk. Additionally the client may not be able to absorb the Vitamin D due to medical problems. Nutritional supplementation of Vitamin D may also lead to toxicity. There are currently no recommended daily dosage levels. It is considered advisable to spend between 5-15 minutes in the sunlight, 4-6 times per week but not during the hours of 10.00am and 3.00pm during the summer months.  Osteoporosis management. Low bone density and a multiple history of falls leads to a person being considered at high risk of falling. There are a number of medications that can be given to the client to assist with the management of osteoporosis. Ultimately the aim is to strengthen and protect bones and reduce the risk of falls.

Additionally, if you are working in a hospital or residential aged care facility and a client has a history of falling out of bed, sometimes the first reaction is to put up the bed rails. However, if your client falls from a bed with bed rails up, if they are climbing over the bed rails to get out of bed, they will actually fall from a greater height and potentially do much more damage to themselves. Often it is a much better solution to lower the bed as close to floor as you can so that the client will roll out of bed. A mattress on

the floor next to the bed will also assist in preventing injuries so that the client rolls out of bed onto the mattress.

Bed and floor sensors will also alert staff to a resident who has attempted to get out of bed or a chair on their own. These sensors will not necessarily stop a resident from falling but they do alert staff that the resident is on the move and therefore at higher risk of falling. Staff members can immediately assist the client when they know this. They can therefore be very useful strategies in a suite of strategies for falls prevention.

Helmets are also sometimes worn by clients to prevent them from sustaining a head injury if the person falls. They are generally not the most glamorous of outfits however they can protect the person from sustaining a serious head injury. These helmets come in many varieties and may be soft or hard. Permission is required prior to putting a helmet on your client.

Don’t forget the simple things when it comes to preventing injuries and discomfort with clients.

Remember to ensure clients/residents do not walk around in their socks for example. Ensure they have reminders to use their walking frames.

Where appropriate, provide support to the carer to contribute to the strategy Clients with medical conditions or a disability may require an individually tailored programme. They may also require specialist advice from their general practitioner or allied health personnel such as a physiotherapist to ensure the programme meets their specific needs.

We have discussed before that changes to routine can have a significant impact on the client. It is important therefore to discuss with the client how they have found any changes that have occurred and how they feel about these changes. If the client has increased feelings of distress and anxiety about the changes that may have occurred this will make it difficult for them to implement the agreed strategies. They will need your support to work through this or possibly require referral for specialist counselling services.

You have a responsibility to remind your client to check with their doctor before they start a new exercise program.

It is your responsibility to remind your client of the importance to be checked by their treating medical officer prior to commencing any new program or physical activity that they do not usually undertake.

You also have a responsibility to talk through possible options with the client, how they will be implemented, how they will be reviewed and who will do this. Having the client supporting the proposed strategies is a fundamental component of ensuring that the program will work.