Preventing Falls in Older Adults among the Complex Patient Population in the Community

Falls are serious events that occur among older adults in many settings such as home, hospital and long-term care. Some patients can suffer from critical injuries such as fractures or death. Fall prevention is a significant sign of best practice care. This project aims to find evidence-based interventions to implement and decrease the number of falls in the elderly community. 

Project Description

Falling at home can result in disability, decrease patient’s quality of life, and generally increased health care costs. Nurses can identify the fall risk by looking at the patient’s prior fall history, the use of many medications, vision impairment, home settings, and incontinence problems.

Lukaszyk et al. (2016) argued that at least 30% of older adults of sixty-five years or older had one fall each year, and hip fracture is the most common injury from the fall. Besides, recovery from the injury can be painful because some patients never recover fully from the injury and which may increase their risk of moving into a long-term care facility.

Available knowledge

Fall is the main problem nowadays that frequently occur in elders who live in the community. Lee, Lee, and Khang (2013) found “In the year 2000, falls cost the U.S health care system more than 19 billion, a number that is expected to increase to 54.9 billion by 2020” (p.37). It is essential for clinicians to screen patients for falls at every visit. Lee, Lee, and Khang also mentioned that the American and British geriatric societies recently updated their clinical practice guidelines for preventing fall. The guidelines state that clinicians should ask their older patients about previous falls. The patients that reported a fall or any gait and balance issues should go through a face assessment. Importantly, one assessment includes the Timed Up and Go test which is an easy test to perform to patients. The test is prepared by calculating duration starting when the patient rises from the chair, walks three meters, and sits back down. The value that is 10 seconds or less indicates normal value. The value of 20 seconds or more shows abnormal which needed interventions and a thorough risk assessment (Lee, Lee, & Khang, 2013).

Similarly, Al-Aama (2011) included that older adults who have previously fallen in the past year are more likely to fall again. Al-Aama also mentioned “Medication classes that have been associated with an increased risk of falls include anti-hypertensive agents, sedative and hypnotic, neuroleptics, antipsychotics, anti-depressants, benzodiazepine, and nonsteroidal anti-inflammatory drugs. Narcotics, however, have not been associated with an increased risk of falls” (p.773). Medication review and management are critical in decreasing the risk of fall.

Risk factors play an essential role in finding the cause of fall. Stenhagen, Ekstrome, Nordell, and Elmstahl (2013) conducted a study to pinpoint risk factors of falls in the elderly population. The result of the 3-year follow-up assessment showed that one in five older adults in the study had fallen in the past six months. Whereas, the 6-year assessment presented that one in seven of the older adults had fallen one or more in the past six months. The result also provided that women fell almost twice as often as men during the study. It is imperative to focus on identifying risk factors for falling in the elderly population because it can be preventable. Also, there are other causes such as incorrect eyewear, the abuse of psychoactive drugs, and environmental factors; those factors may pose further risk of falling in elders (Guirguis-Blake, Michael, Perdue, Coppola, & Beil, 2018).

Marks (2014) found that older adults with a reduced visual acuity were 1.9 times to have more falls and can heighten the risk of fractures compared with a clear-sighted population. According to Mark, “Age-related macular degeneration, presbyopia or a problem that requires bifocal corrective lenses, diabetic retinopathy and glaucoma can all cause different forms of visual impairment which can increase falls risk” (p.55). Vision impairment can be a significant issue in leading to falling in older adults at home. An annual eye exam is necessary to prevent further complication, especially with a diabetes-related disease.

Rationale

Kendrick et al. (2016) reported that much older adults are afraid of falling particularly after having a fall. There are several exercise interventions to help with the preventing fall and improve strength including balance training, strength and resistance training, and three-dimensional exercise such as dance or Tai Chi. These exercises were concluded to reduce fear of falling of older adults immediately after the intervention.

  Surprisingly, there was a high occurrence of vitamin D deficiency in older adults who living in the community. Some studies have shown a significant reduction in hip fracture when vitamin D is taken at 800 IU/d or more (Frick, Kung, Parrish, & Narrett, 2010).

  Additionally, Stevens and Lee (2018) studied peer-reviewed literature, which those authors provided the occurrence of seven fall risk factors and the seven evidence-based interventions in older adults aged sixty-five years and older. Also, Steven and Lee included, “The seven fall interventions, such as Tai Chi, Otago, medication management, vitamin D supplementation, expedited first eye cataract surgery, single vision distance lenses for outdoor activities, and home modifications” (p.290). These fall interventions have proved to prevent falls among older adults and lessen health care costs. The CDC’s STEADI initiatives contain resources and tools to help providers take part in fall prevention strategies and apply those in their clinical practices (Stevens & Lee, 2018).

  Healthcare providers act as an essential role by not only identifying risk factors for their older patients, but referring them to appropriate specialists, such as ophthalmologist for vision problems, and pharmacists for medication review (Stevens & Lees, 2018). Thus, assessing various risk factors can intervene and reduce the rate of falls. Also, having excellent and effective communication between patients and healthcare providers can enhance successful interventions to overall decrease falling in older adults. Health literacy of the patients can impact those results as well (Chesser, Woods, Reyes, & Rogers, 2016).

  More importantly, Li et al. (2016) cited that the model to integrate evidence-based fall prevention interventions needs to start from clinical and community practice. Healthcare providers such as physician should perform risk assessment according to the current recommendation. Using the STEADI tool and referring patients to a health coach can be helpful. The community providers can enroll patients in a program and supervise class participation. This system can improve the transition between clinical practice and community-based interventions.

Specific Aim

The specific aim of the project is to decrease the number of falls among complex elderly patients in the community by 50% or more within six months. Falls are a serious threat to older adult patients in the community. It is essential to first identify patient’s risk factors by focusing on their fall history, the use of many medications, and comorbid conditions. Utilizing clinical guidelines such as STEADI initiative for tools and resources and using effective clinical and community approaches can have a significant impact on reducing falls and improving patient’s health outcomes.

Model for Improvement (MFI) Questions

What are you trying to accomplish? (Goal/Aim)

  To decrease the number of falls among the complex patient population in the community by 50% or more within six months.

How will you know the change is an improvement? (Measures)

  Three types of the measure will track and evaluate those evidence-based interventions which the goal is to reduce the number of falls in the high-priority elderly’s population. The outcome measure is an essential measure because it will be the number of falls in the complex patient population. Also, the process measures can be the number of falls that occurred in the past six months by looking at the medical claims, primary care offices, patient case files, and the percentage of the patients being assessed by the nurse care managers after the fall occurrence. Lastly, using the balancing measures is also another critical factor because it will be a measure that includes the level of satisfaction from the staff (nurse care managers, clinical managers) on a scale 1-5, and the staffing issue that could impact on the study.

What change will you make that will result in an improvement? (Intervention)

Implementing some evidence-based interventions is essential because this can identify patients who are at high risk for fall and address those risk factors to prevent further falls.  Having patient and family involvement about fall programs and care plan is also imperative. Promoting appropriate exercise, safety equipment, medication review, footwear, and vision check are all critical practices for patients to maintain their safety at home.

References

• Al-Aama, T. (2011). Falls in the elderly. Canadian Family Physician, 57, 771-776. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3135440/pdf/0570771.pdf
• Chesser, K. A., Woods, K. N., Reyes, J., & Rogers, L. N. (2016). Health literacy and older adults: Fall prevention and health literacy in a Midwestern state. Journal of Aging Research and Healthcare, 2(2). Retrieved from https://openaccesspub.org/article/674/jarh-17-1911.pdf
• Frick, D. K., Kung, Y. J., Parrish, M. J., & Narrett, J. M. (2010). Evaluating the cost-effectiveness of fall prevention programs that reduce fall-related hip fractures in older adults. The American Geriatrics Society, 58, 136-141. https://doi.org/10.1111/j.1532-5415.2009.02575.x
• Guirguis-Blake, M. J., Michael, L. Y., Perdue, A. L., Coppola, L. E., & Beil, L. T., (2018). Interventions to prevent falls in older adults. Journal of American Medical Association, 319 (16). doi: 10.1001/jama.2017.21962
• Kendrick, D., Kumar A., Carpenter, H., Zijlstra G., Skelton D.. Cook, J.,…Delbaere, K. (2014). Exercise for reducing fear of falling in older people living in the community. Cochrane Database of Systematic Reviews, 11. doi:10.1002/14651858.CD009848.pub2 Retrieved from https://0-www-cochranelibrary-com.lib.rivier.edu/cdsr/doi/10.1002/14651858.CD009848.pub2/epdf/full
• Lee, A., Lee K., & Khang, P. (2013). Preventing falls in the geriatric population. The Permanente Journal, 17(4). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3854807/pdf/permj17_4p0037.pdf
• Li, F., Eckstrom, E., Harmer, P., Fitzgerald, K., Volt, J., & Cameron, A. K. (2016). Exercise and fall prevention: Narrowing the research-to-practice gap and enhancing integration of clinical and community practice. The Journal of the American Geriatrics Society, 64, 424-431. Retrieved from https://doi.org/10.1111/jgs.13925
• Lukaszyk, C., Harvey, L., Sherrington, C., Keay, L., Tiedemann, A., Coombes, J.,…Ivers, R. (2016). Risk factors, incidence, consequences and prevention strategies for falls and fall-injury within older indigenous populations: a systematic review. Australian and New Zealand Journal of Public Health, 40(4). Retrieved from https://onlinelibrary.wiley.com/doi/epdf/10.1111/1753-6405.12585
• Marks, R. (2014). Fall among the elderly and vision: A narrative review. Open Medicine Journal, 1. Retrieved from https://benthamopen.com/contents/pdf/MEDJ/MEDJ-1-54.pdf
• Stenhagen, M., Ekstrom, H., Nordell, E., & Elmstahl, S. (2013). Falls in the general elderly population: a 3- and 6- year prospective study of risk factors using data from the longitudinal population study ‘Good aging in Skane’. Geriatric, 13(81). Retrieved from https://bmcgeriatr.biomedcentral.com/track/pdf/10.1186/1471-2318-13-81
• Stevens, A. J., & Lee, R. (2018). The potential to reduce falls and avert costs by clinically managing fall risk. American Journal of Preventive Medicine, 55(3). Retrieved from https://www.ajpmonline.org/article/S0749-3797(18)31759-8/pdf