Tuesday, November 18, 2014

Falls, Part One: How OT's Can Better Identify Factors that Contribute to Falls in SNF

Back to my blog home page: http://travelingotr.blogspot.com

I received an email from Jessi, with whom I have communicated about a lovely dementia patient of hers in the past. She writes:

“You were so helpful before, I wanted to ask you for more advice. If you get the chance, would you consider doing a post on reducing fall risks? It's really been on my heart lately to seek more solutions to preventing them at the SNF I work at. Searching online has only revealed the basics we were taught in school (reducing restraints, increasing balance, ADL mobility training, Cane vs walkers, nonskid socks/shoes, education on using caregivers, etc.) but I'm really hoping for more outside of the box ideas. I recently realized that fall mats can sometimes increase fall risks instead of helping if a person is stable on a level surface but has poor balance and is getting out of bed without caregivers present, for example.  If you feel like sharing your own thoughts or others' reading materials too, I am all ears! “

Head injuries, broken skin, broken bones, pain, and fear…
I want share with you how to assess falls, how to write goals related to reducing falls and how to lower your patients' fall risk. It's such a complex subject that it's going to take a couple posts to get through it.
....let's talk first about the factors that contribute to falls (in no particular order):
HINT HINT: you need to identify and assess these factors on your evaluations!!
cause dizziness, altered visual input, reduced alertness and multiple secondary symptoms that can increase fall risk, especially at night. Go to the chart, people.

You may find an answer it the meds.

Vision deficits
include double vision, macular degeneration, a person not wearing his/her glasses, diabetic retinopathy, glaucoma, and cataracts. Visual deficits impair a person's ability to correctly perceive the visual field and depth perception in the environment when walking and transferring between surfaces. The chart may yield info if a person is diagnosed with one of the above conditions; however, don't forget to check vision when you're doing your evaluation.
Postural deficits
include forward neck flexion, kyphosis, and a flexed trunk over hips. Postural deficits contribute to reduced visual field access, a change in center of gravity and loss of control when attempting to change positions or walk.  For example, try to walk with your chin on your chest and look straight ahead. It's impossible to maintain an adequate visual field. I'll write more about posture in the article about treatment; in the meantime, check out a blog I wrote earlier on posture: http://travelingotr.blogspot.com/2012/01/for-snf-pt-and-ots-78192.html
Muscle weakness
say no more. Muscle weakness is usually a symptom of another issue such as pain, depression or immobility following surgery/trauma or steep cognitive decline. People stop moving when they experience pain or fear of falling. Get your people moving - and not just while sitting leaning against the back of the wheelchair. Get them on the mat so they have to engage proximal and distal!! Stabilize the trunk, work on the head and neck. (My pet peeve is "lazy therapy."..)
Environmental obstacles
 are a frequent reason for falls, much of which can be prevented. We'll list and address these on the next article.
can contribute to our clients' fall risk when they forget they are unable to stand or walk without losing their balance or when they forget to use their assistive devices. For example: I read this information in a research article referencing the use of the Allen Cognitive during a trial to reduce falls in the elder with mild dementia:
At the 4.4 level of function behaviour is goal directed but people do not visually scan their environment, do not anticipate hazards and cannot solve problems independently, so it is not recommended that they live alone.
Orthostatic Hypotension
can cause a person to begin to feel dizzy, weak, fuzzy, nauseous or faint due to low blood pressure with postural changes. Are you taking sitting and standing vitals at initiation of and during treatment?
can cause a person to drop, literally. Let's help them manage their pain!
Inability to maintain balance while using hands
can cause loss of balance and falls, most notably in the bathroom, in SNF speak. More on this later! Anytime I see a fall in the bathroom, the first thing I want to know is if the person was alone and if they were attempting to pull the pants or skirt up or down. Don't be timid to ask about the details of the fall. It will lead to revelations!
Poor positioning
can cause a person to slide, roll or topple off a bed or wheelchair.
- or should I say - Incontinence - plays a huge role in falls in SNFs! Find out which patients or residents are mildly incontinent. They are the ones with whom you want to start a UI (urinary incontinence) program, including Accelerated Care Plus' protocol using one month of exercises (which are good for all of us!) and moving on to the use of e-stim following one month of exercise.
Reduced supervision of high risk fallers
...some people just need to be checked on frequently. People who are high risk should not be left alone in their rooms! Falling star, falling leaf...any of these people should be engaged with activities, in a public room, such as the tv room or library, and should have frequent contact with staff.
-some people have conditions that prevent them from feeling safe during positional changes of the head, such as Benign Paroxysmal Positional vertigo, when the crystals in the structures of the inner ear that make you sensitive to gravity become dislodged and move into the semicircular canals. For more on BPPV, see: http://www.mayoclinic.org/diseases-conditions/vertigo/basics/definition/con-20028216.
Treat the BPPV; resolve the dizziness!
Progressive Neuromuscular Diseases,
such as Parkinson's Disease, Multiple Sclerosis, Huntington's, ALS, Myasthenia Gravis and the Muscular Distrophies, cause deficits in muscle strength, coordination and sensation that increase fall risk as a person's medical status begins to decline. We'll talk more about Parkinson's on a future blog!

One of the first things we therapists can do
with someone who is high risk for falling or who is a chronic faller
is to
identify which factors
are influencing the falls.

Did you know there is a Home Fall Prevention Checklist?
Click to access -
it's a great tool to share with family members
or people you are rehabbing back home
even if you are planning a home evaluation!

If you're interested in presenting to the community about Falls Prevention,
don't reinvent the wheel.
which includes a Power Point presentation that you can use
and handouts to print.
Dandy, right?
Jessi, I know I haven't quite gotten to the info you wanted, but I needed to lay a foundation! If there is any factor you think I have missed, please add a comment below. Your comments assist everyone reading in learning more...