Residents of nursing homes are almost 3 times more likely to fall than seniors living in the general community, and nearly 10 times more likely to incur catastrophic injury from a fall. This is why fall prevention is extremely important in long-term care. In this week’s episode, nursing home abuse lawyers Rob Schenk and Will Smith welcome guest Dr. Ngaire Kerse of the University of Auckland to discuss fall risk assessments in nursing homes and keeping residents safe from falls.
Schenk: Hello out there and welcome back. My name is Rob Schenk.
Smith: And I’m Will Smith.
Schenk: And we are your hosts for this episode. This episode we’re talking about one of the more common injuries, one of the more common problems that we see as nursing home abuse and neglect lawyers in long-term care facilities, and that is injuries from falls. And one of the more – I don’t know how you would say it – one of the principal, one of the main ways in which nursing homes can prevent injuries from falls and prevent falls themselves is through efficient, accurate assessments upon admission and thereafter. And so we’re going to dedicate the bulk of this episode to talking about fall risk assessments. We’re not going to do that alone. We have a special guest. Will, tell us who we have today all the way from the other side of the globe in New Zealand?
Smith: Well we actually have Professor Ngaire Kerse who’s currently the Joyce Cook Chair in Ageing Well, head of the School of Population Health, faculty at Medical and Health Sciences University of Auckland New Zealand with a part-time general practice clinical commitment and a full-time academic work. Her research interests include gerontology research focusing on maintaining function and quality of life, preventing falls and ensuring evidence-based delivery of primary medical care. She has been a leader in fall prevention having conducted eight clinical trials in the area and it part of the Cochrane Review Group for fall prevention in residential care. She leads the Lilacs New Zealand Cohorts Studies of Maori and Non-Maori Octogenarians – that’s a lot of syllables – and ongoing advisory roles with the Ministry of Health in New Zealand. That’s a lot to say – Octogenarian, Maori…
Schenk: I’m actually quite proud that you made it through. That was a difficult introduction. But at any rate, Dr. Kerse, welcome to the show.
Smith: Kia Ora.
Ngaire: Thank you very much, Rob, happy to be here.
Schenk: Excellent. So Will and I just a second ago were talking about how falls and injuries from falls can result in some pretty serious injuries for nursing home residents, and that one of the main ways that nursing homes can prevent falls is by accurately assessing each individual resident for their – what’s the word I’m looking for – for their…
Schenk: Yeah, their risk of falling, the likelihood that they will fall. So if you could, Ngaire, could you just walk us through what makes fall risk assessment so important and what role do they have at the admission of a nursing home resident?
Ngaire: Okay, so there’s some important things to realize about risk assessment. So risk assessment may be a process with the admitting nurse or admitting doctor with the factors or characteristics of the person that make them more likely to fall. For instance [03:55] more likely to fall than the others at a particular risk of falling such as sleeping habits increase the risk of falling. So for the clinician who’s admitting the person, it’s understanding those risks so that the care plan or the way that the person is supported in the nursing home can be adapted.
Now it’s not so much the risk assessment as what happens as a result of the risk assessment that’s important. You can imagine you have a nice checklist in front of you and you’ve got the risks related to mobility, people who have had strokes and have had difficulties walking, people who have lower leg weakness or significant arthritis are much more likely to fall. You can check that box, but unless you actually organize care to take that risk into account, you’re not going to change the situation for that person. Does that make sense to you?
Smith: No, it does. I mean it would be pointless if you have a great assessment but you’re not actually…
Schenk: You don’t go anywhere with it.
Smith: You don’t go anywhere with it.
Ngaire: Exactly. That’s exactly right. And there’s been quite a lot of work done about risk assessments. Now risk assessments can be really long and there are 25 things on them or they can be quite short and focused. And also who does the risk assessment is important. If it’s a well-trained nurse or health professional, then you’re already thinking when you’re doing the risk assessment of what’s available to meet those risks, if you’d like. So the better qualified clinician you can get to do the risk assessment, the better outcome in the long term.
Smith: Yeah, I’ve noticed in – and I’m not trying to be disparaging because I worked in the healthcare field, my dad’s a nurse, my brother’s a nurse, but I have found that in my experience, a lot of nurses, it’s just a rote thing that they do where they go through the motions and they’re like, “Okay, do you have a history of falls? Do you have this?” And there’s really no attempt to really analyze this person’s risk assessment. It’s a check mark that they have to do, like, “Okay, did you check this off? Check this off?”
Schenk: Right, before going to the next task.
Smith: And so now I’ve got to go to the… And a lot of times, it’s here in America, these people are really understaffed, so that’s a problem.
Ngaire: Yes, I totally agree. Understaffed and under pressure, and the risk assessment is part of the KPI or the performance appraisal. So the more risk assessments they do, they think they’re doing a good job and they are doing a good job. I think we have to realize that most people who work with age residential care really want to do the right thing and really want to be resident-centered and really want to do the best thing, but they’re under so much pressure.
So the risk assessment is very useful, but you have to get the organization to deliver the real resource changes that are needed from the risk assessment. So the person with mobility risks who is at risk of falling because they’ve got severe arthritis in the knee, that has balance problems because they’ve had a stroke, they need physical therapy and they need an individualized physical therapy program that they have been assisted to whatever it takes – that means sit-to-stand, lower leg stretching, balance retraining, and that of course is expensive. And so we have to, as families and other people supporting older people in residential care or nursing homes, push the organizations to turn on the tap so that they can get that physical therapy. So the risk assessment is good to identify what is needed, but then they have to actually get it before the risk is reduced.
Schenk: That makes sense. Ngaire, you mentioned just a few minutes ago some assessments that might be five questions and some that might be 25 questions. What are, in your opinion, what are the characteristics of the risk assessment that would set one apart from the other to make one better or worse than another one? What characteristics of a risk assessment make one good or bad or differentiate from one another?
Ngaire: Well I think it’s about the person who does it as much as it is the risk assessment itself.
Schenk: I see.
Ngaire: So the person who does it has knowledge and understands the risks and the therapies that might be available to meet the risks. And the risk assessment that points you straight to the response is the best. So I have one seen the called the “Break Up” or the “Flex,” which is so you’ve got one of the areas is mobility, and so it’s simply the clinician thinking about that person’s mobility, realizing that his balance and gait, and therefore going to physiotherapy. The next area might be health conditions. So we know that people have Parkinson’s disease are six time the risk of falling than people who don’t have Parkinson’s disease. And so it’s the ability of the person to understand Parkinson’s disease, extra risk, let’s get those doctors to review those medications. Let’s get the neurologist to review the management of the Parkinson’s disease. So it’s the ones where the most utility in accessing the resources can be operationalized. So I don’t want to recommend any particular risk assessment over any other risk assessment, because each facility, each home, has a pretty good idea about what they have available and what they want their staff to do.
Schenk: So I guess the analogy would be then, Ngaire, the risk assessment is a tool, and a tool is only as good as the person who is using that tool.
Ngaire: Exactly. Yeah.
Schenk: That’s kind of how to look at it.
Ngaire: So you need a very good carpenter, and very good carpenters can do stuff without tools, but if you give them good tools, they’ll do an extra exemplary job.
Smith: Yeah, it’s a poor workman who blames his tools.
Ngaire: Yeah. Exactly right. Yeah.
Schenk: And then you mentioned kind of varying categories, different categories that would have their own subset of questions on an assessment. So for example, you mentioned does the individual have any disease diagnosis like arthritis, or does the individual have medication? Can you kind of elaborate on that? What are the different categories and why are those categories important?
Ngaire: Yeah. So in the health condition area, you have the specific health conditions that make them very likely to fall – Parkinson’s disease, specific neurological disorders, PSP is one that some people might know about, having had a stroke, it affects your mobility, having a specific balance disorder or movement disorder – those are the categories of conditions that make you at very high risk. And then there’s the general comorbidities category. So people who have a lot of health conditions that might interact with each other are at higher risk.
Then there’s psychological issues or psychiatric disorders, so having dementia puts you at higher risk of falls, and there’s quite a few reasons for that. People with dementia become disoriented in their place and forget where the bathroom is, for instance. So increased confusion. People with dementia also – some of them are very active and walk a lot, but many of them have that secondary symptom of apathy and sit a lot, so low activity is another risk and that’s related to dementia.
Depression is a very interesting medical condition that puts you at increased risk of falls. People who have depression are between two or five times increased risk of falls in the next year. And depression is very common, so up to 50 percent of people in nursing homes have been thought to have some depressive symptoms. Now the reason for that is two-fold, two ways to think about those symptoms. People who are depressed just don’t want to do as much so they sit more, so less activity increases your risk of falls. And then people with depression may also get a central process going on in their brain where the brain neurotransmitters are lower, and that also affects coordination and balance. So there are two strikes against them for those who have depression.
So in general, you’ve got in summary the specific balance and gait issues and health conditions. Then you’ve got the multiple comorbidities where people are just quite sick. And then you’ve got psychological depression and dementia under the health conditions banner.
Now medications – we can talk about medications for a long time, and medications are a double-edged sword. All the people in nursing homes need medications to control their diseases and to control their symptoms, but the combination of those medications causes other side effects. And so for instance, when you give somebody good treatment for heart failure, it might include a diuretic, which makes you pass more urine. Having passed more urine, sometimes that makes you dizzy when you stand up so you can be more likely to fall because you’re dizzy when you stand up, which is because of the medication but you need the medication for the heart failure. So you have to be very clever and look at the medication list and try to decide, “Okay, everybody wants us to stop medications, but which ones should we stop and which one does this particular patient or resident really need?” And that’s a really complicated question.
The medications we know put people at a high risk at falls include the psychotropic medications, so these are the medications which are for anxiety, which are for agitation. It’s actually an antidepressant medication that also puts you at a higher risk for falls. So medications – yes, try to stop some of them but be aware that if people are on medications, they might need a bit more time when they stand up to let their blood pressure catch up with them as they stand up. Or they might be additional balance training if you know their psychotropic medication is necessary, then think about the falls prevention activity program as well as the medication. So there’s quite a lot to think about in these risk areas of health conditions and medications.
Schenk: Wow, there’s a lot to that. It seems to me, Ngaire, and I might be wrong, but is it fair to say you could do an accurate fall risk assessment without ever laying eyes on the person just using the medical records? Or what is it to say that we should actually be looking at somebody as we do this?
Ngaire: Okay, so that’s a really good question too. You can do parts of your risk assessment by just looking at their medical records because there will be information about health conditions and medications. It is very difficult to do a proper mobility assessment by looking at the record. Now some records have it, so for instance, in nursing homes in New Zealand, there is a standardized comprehensive assessment done on everybody as they come in and that’s called an enterprise assessment, and it just runs through all whole different areas of function and health. And the functional status is recorded. Now the functional status can determine a lot, but it basically means is the person able to mobilize themselves? Are they able to transfer themselves from a chair to a bed or the chair to standing? Are they able to mobilize independently? Can they put their own clothes on independently? Can they get to the toilet? So their functional status gives you very good information about mobility. So if you have that information in the medical record, you can use the medical record. And in fact, that standardized residential care enterprise assessment does give you information about falls risk because it uses some algorithms to look at those areas in the assessment that are there to give you a falls risk. So you can do some things just with looking at the record but not everything.
Schenk: Right, that makes sense.
Ngaire: Does that make sense?
Schenk: That makes perfect sense. So you hinted at this a few times, but let’s transition to this. You have a great assessment. You’ve factored in the medication. You’ve factored in physical issues, the diseases and disorders, you’ve done all that, you’ve come down with the rating. You’ve come down with the probability that the individual would fall, and now it’s time to execute. So can you just walk us through some of the techniques and interventions that nursing homes can use to prevent the falls based on the information they have from that assessment?
Ngaire: Yeah. Yep. Okay, so when you look at the literature about interventions in nursing homes, there’s a very mixed picture that you get and I don’t know whether people have heard of something called a Cochrane review – that is a systematic review where people sit down and they systematically search all the literature that’s been published in the area. Then they quality assess the articles and they put them together into groups.
So the Cochrane review about care homes and nursing homes really has inconsistent messages on what it should be gathering. So we know that the risk associated with the falls, but sometimes interventions specifically for those residents have not been consistently successful.
One thing that’s very simple that is successful is to supplement all residents with Vitamin D. Vitamin D in people in nursing homes, Vitamin D, you can eat Vitamin D, but we get most of our Vitamin D from contact with the sun with their skin. And anybody who’s been into nursing homes know how hard it is to get people outside, especially in the winter in North America and other places. So Vitamin D is usually a deficient vitamin in people with nursing homes and easy to supplement. Many nursing homes are already doing this. There are only a couple of issues where people should not get Vitamin D and they’re well-known to doctors and nurses. So in New Zealand, we try to do an audit so it’s recommended that everybody has a supplement of Vitamin D. And we know that reduces falls in nursing homes where people add Vitamin D to a person. So that’s a very simple thing and it’s actually not related to the risk assessment. So that’s the first thing.
So let’s talk about the mobility risks. There have been a lot of strategies tried to reduce risks and injuries from falls in nursing homes. Now one that is commonly used that actually hasn’t been supported by randomized trial is alarms. So some homes will have an alarm attached to the shoulder of an older person, so when they get up, the alarm goes off and somebody comes to assist. Now that doesn’t seem to prevent that person from falling and I think there’s a few reasons for it. Firstly, it inhibits the person from actually being active because the alarm goes off and they get scared and they sit down again, so they don’t actually get their usual amount of activity to keep their lower legs stronger or not.
The issue that it’s trying to combat is having a large amount of staff to be able to provide surveillance and to provide assistance when people want to mobilize. So while it’s there to try to protect the person, somehow it doesn’t seem to work, and other strategies such as changes in staffing have been shown to make some differences.
There are times during the day when the staff are not as available or not as accessible to all the residents, and those are times of change of shifts and mealtimes, and that is because they’re busy doing other things. Usually in the mornings, all the showering and the all the moving people around, there are more staff. So all homes should think on an individual basis how they can make sure there’s enough staff available in the common areas so when the residents who are quite frail want to get up and go to the toilet or want to get up and transfer, they can be there to give them some assistance without needing to hit an alarm. So we know that staffing patterns make a difference, so that’s an important thing.
Smith: The other thing I don’t like about alarms is you quickly – and we use a lot of pressure alarms too, so they get out of bed, the alarm goes off – you quickly become very numb to hearing alarms.
Ngaire: They all cry wolf.
Smith: Oh yeah, they’re going off all the time, and so it’s not – you just – you zone them out. I mean you tune them out.
Ngaire: Yes. So I think that’s partly why they’re not effective either because at the end of the day, the alarm goes off, there’s got to be a response, and if the response doesn’t happen, then the person who’s on… So it’s important to realize there are limitations. The pressure alarms are interesting too. I know they’re very, very prevalent, but the evidence base for them is not as consistent. Can I ask you guys about those pressure alarms? Would you say that most nursing homes are using them?
Smith: In my experience, most nursing homes are using pressure alarms versus the alarms that attach. So they’ll go in the wheelchair. They’ll go in the bed. They’ll go in the Geri chair.
Ngaire: Yeah. Yeah, yeah, and if everybody’s got one and they go off all the time…
Smith: Oh, they’re constantly going off. Yeah, if you’re going to have an alarm, it needs to be a rare event so that when it happens – so for example, they’ll have sometimes the RFID bracelets that go wanderers so that they don’t leave certain areas, or if they do, we know about it and we can respond quickly. But if you’ve got a pressure alarm, you’re going to have one going off constantly, and staff just, as humans, tune them out.
Ngaire: Yeah, that’s a good point. I think this new technology coming in this area that might be quite helpful for older people, because if you have an RFID bracelet on a wanderer, that in a way keeps things safer because the staff can see where they are at a particular time, and it enables them to be more liberally – it allows them to be active because they can go into the gardens or around into an outside area and still people know where they are.
And the other thing about – yeah, sorry, go ahead.
Smith: I said and get that Vitamin D that they so desperately need, yeah.
Ngaire: Yeah, exactly. Get that Vitamin D. So let’s talk about exercise. Now exercises are really, really successful in people in the community for falls prevention, and the exercise pattern is for low leg strengthening and balance retraining. So the lower leg strengthening is simple things like sit-to-stands, like hanging a small weight on the ankle and bringing your leg out to the side as you’re standing behind a chair, simple lower-leg strengthening. The balance retraining as well – you challenge your balance. So you might be leaning forward through the point to where you might fall over, but you don’t actually fall over because you may be supported by a chair or something.
Now tai chi is a very interesting activity program. Tai chi has been shown to be very successful in the community and has been used in specific parts in nursing homes with good success. If you think about what tai chi is, it’s very challenging to your balance and it’s also very good for your concentration. So there’s a cognitive component here as well, and I think emerging in the literature is this idea that if you have good cognitive stimulation as well as some balance and lower leg strengthening, that might be even more successful.
Schenk: Yeah, it’s interesting because if people are wanting some type of, not necessarily quick fix, but secret fix or whatever with the two principal things that you’ve mentioned, number one, Vitamin D, a vitamin, and two, exercise to prevent falls.
Ngaire: Yeah, but the exercise has to be real exercise, because I think to many facilities, they say, “Yeah, we have exercise,” and you go on in and you see people are seated and they’re batting balloons around or they’re doing simply stretches. That doesn’t actually work.
Schenk: Yeah, that’s more for the mind, I would say, the cognitive.
Ngaire: Yeah, it’s good entertainment and it’s good – it’s a good, purposeful thing to do, but it doesn’t change the way, your ability to get up and mobilize, which is what prevents you from falling. So in any fall prevention exercise program, I think we should think about it in that specific category of fall prevention exercises, and it needs to be challenging. It needs to have the person huff and puff – nobody likes to do that to their grandma, and it needs to be progressive on the muscles. So when you to five sit-to-stands, that get too easy, then you do 10 sit-to-stands, so progressing the amount of activity. And if we can manage to do the high, more individualized, more high-intensity exercises, then there is evidence that falls can be prevented in residential care. The difficulty is it’s expensive because you need physical therapists and people who are trained to be able to do it. You need to do it for at least an hour, maybe twice a week. Once a week may not be enough. And so that’s quite expensive.
Schenk: I can imagine. Well Ngaire, we talked about the importance of risk assessment, what goes into them. We talked about the interventions and the execution of what you’ve learned from the assessment. Let’s talk about nursing home staff and what they should do, unfortunately, after a fall has occurred. Exactly, what are some of the standard operating procedures that a nursing home should undertake after a fall?
Ngaire: Okay, so I think everyone would recommend help assist after a fall. I mean each fall is different. Most falls in nursing homes, when you look at the records, records say found on the floor. So it’s quite unusual for somebody to see the fall happen. Important to realize after the fall that significant injury could have happened. And to do an injury screen if you’d like, so to talk to the person, are they awake, to find out if there’s any areas of bleeding or obvious areas of injury. Think about hip fractures. Hip fractures are really quite common, 10 times the rate in nursing homes compared to the community. Are you still with me?
Smith: Yes, ma’am. Go ahead.
Ngaire: Okay, good. And so that technique of recognizing a hip fracture is relatively straightforward, and all nurses and most care assistants should be able to check for that. And then there’s the sort of heart assessment, if you’d like, if there’s been a significant injury. And also at the time, try to work out what actually happened, how did they come to fall? Sometimes it’s obvious – there’s some kind of environmental hazard – and I guess that’s the other thing haven’t talked about in the area of interventions that might work. Environmental hazards – things that people could trip over, things for them to run into, lighting levels in nursing homes, all those things are really important to think about. Is there a reason for this fall? The second most common reason – has there been a major medical event with this person? So are they acutely unwell and has that caused the fall? Have they had a heart attack? Do they have the flu? Do they have a yeast or a urine infection? So what’s the acute urgent – okay, there’s not really a significant injury. The next stage is thinking about have they had a cause for this fall or what is the cause that we can address? Make sure that they have a good health assessment, and that may include a urine test, a blood test and a physician to look a person over and listen to their chest. So those two stages…
And then the third – the last and third stage is, okay, now we know this person is at a high risk of fall because they’ve had a fall – how can we institute some fall prevention strategies that will prevent them from falling over again.
Smith: So what are some of the things that families can do to get more involved in fall risk prevention?
Ngaire: That’s a really good question. I’m really passionate about getting families into nursing homes and getting them involved in the processes and the activities and homes. I think falls prevention, the more people who are around all the people, the more preventive activities that the older resident can do, the less likely they are too far. So what families can do is I think that families know their older person the best. So they can think about activities and things, more purposeful activities the older person can do and go in and engage with the person. That’s a strong activity within itself. Take the person for a walk. Do the physical exercises with them. Understand where they’re at with any therapies that they need and participate. So that’s my call to families is to participate with your older relatives in their nursing homes.
Schenk: Well that’s a lot of fantastic advice. This 30 minutes has gone by very quickly.
Ngaire: I do understand the limitations that families have because there’s just no time, but if the one thing you can do is free up some time for your older resident and go in and find out more, where they’re at, and do stuff with them, you will reap the benefits and so will they.
Smith: Yeah, absolutely. Well Ngaire, we really appreciate you coming on. Your expertise in this is extremely impressive. And just for anybody out there listening to this, this is barely the tip of the iceberg.
Ngaire: It’s the tip of the iceberg, I agree.
Smith: Yeah. I mean it really is. But we thank you for taking your time and meeting with us early in the morning on the other side of the world.
Schenk: On the other side of the world.
Ngaire: That’s right, yeah. It’s not too early. I’m okay.
Schenk: Very good. Well Ngaire, thank you so much.
Ngaire: Okay, and I want to say thank you to you guys too. I know you guys do a good job in getting messages out there to people who are really keen to hear them. So thank you for the opportunity.
Schenk: Don’t touch that dial. While we concluded our conversation with Dr. Kerse, we unfortunately lost the rest of the episode. There wasn’t that much left to it. We were just going to say you can catch new episodes of the Nursing Home Abuse Podcast every other week on Monday mornings wherever you get your podcasts or you can always check us out on our YouTube channel or on NursingHomeAbusePodcast.com. And with that, we will see you next time.