Effectiveness of Falls Prevention and Rehabilitation Strategies - Case Study Example

Effectiveness of Falls Prevention and Rehabilitation Strategies Introduction Prevention of falls is the problem that requires multifaceted approaches. For years, the risks of falls in older people represented one of the basic medical problems. Dozens of prevention strategies were developed to minimize the risks of falls in older patients. A variety of intrinsic and extrinsic factors were explored, to identify the reasons behind increase falls risks in older people. Today, with the development of the multiple assessment, screening, and prevention techniques, the problem of falls is still far from resolved. Although older patients have better chances to preserve their health and to avoid unnecessary falls and their complications, the risks of falls in older people are as acute as always and require developing through assessment and prevention techniques, which will let older people face falls challenges, make the risks of falls minimum, and improve the quality of their lives. Case study Mr. E. is a 82-year-old patient of the hospital, with the history of stroke and falls. Mr. E. has problems with his vision, experiences lower limb difficulties, and often feels a sense of confusion with regard to the surrounding reality. The patient lives alone; his wife died 3 years ago and his children moved to a bigger city. Mr. E. recognizes that he had major walking difficulties after the stroke, and although the stroke did not result in any serious movement complications, the patient believes that due to the stroke he can no longer control his movements and lives with the constant fear of falls. He recognizes that social workers and community care specialists visited his house, to make adjustments and changes necessary to reduce the risks of falls. Medical professionals developed a comprehensive falls prevention plan for Mr. E., to ensure that the risks of further falls are minimized. The current paper aims to evaluate the assessment, screening, and prevention procedures which medical professionals performed, and to compare them with the basic policy guidelines. The risks of falls: extrinsic and intrinsic factors That falls are caused by a variety of factors is difficult to deny. “Falls are a complex interaction between intrinsic and extrinsic risk factors. Over 400 risk factors for falling have been reported” (CSP 2001). More often than not, the risks of falls in older patients are the result of the complex factors and reasons: rarely or never can one single reason be responsible for the risks of falls in older people. Sometimes, researchers classify falls as “accidental, unanticipated physiologic, and anticipated physiologic” (Morse, 2002). Accidental falls are those that happen when people fall unintentionally and unexpectedly; these are the falls that occur as a result of slip, trips, or even the failure of the equipment and environment (e.g., spilled water on the floor). In their turn, unanticipated physiologic falls happen when the physical risk of the fall is not reflected in the list of the patient’s risk factors; as a result, medical professionals fail to predict this factor as the potential source of falls risks in older individuals. Finally, anticipated physiologic falls happen to patients who, according to the results of the risk assessment, are at risk of falls (Morse, 2002). Only 14 percent of falls are accidental, while 78 percent happen due to anticipated reasons. “Healthy older people may not perceive themselves at risk of falling…. more recent evidence concerning risk of falling in healthy older people suggests excessive physical activity, insomnia, visual impairments, social isolation and use of xanithines (e.g. theophylline) are more relevant to this group than mobility impairment, strength deficits and environmental hazards” (CSP 2001). Intrinsic factors are those that are integrated with the patient’s system and organism and result of the inner processes and age-related changes: these include previous falls, impaired vision, unsteady gait, problems with the musculoskeletal system, mental status, acute illnesses, and chronic illnesses. Acute illnesses may include seizure or strokes, while chronic illnesses may cover cataracts, arthritis, dementia, and diabetes (Curtin 2005). It should be noted, that abnormalities of gait and balance are the most predictive of falls because they are associated with pain, muscle weakness and joint stiffness, rigidity, spasticity, and impaired central processing (Curtin, 2005). These symptoms may be the results of both chronic and acute diseases which, consequentially, produce negative influence on the musculoskeletal and neurological functioning (Curtin, 2005). This information proves falls risks to be the result of the complex intrinsic factors which constantly interact and produce complex impact on the older person’s functioning and the quality of life. Extrinsic risk factors include medications, toilets and bathtubs, furnishings design, and the condition of ground surfaces. Poor illumination, types and condition of footwear, inappropriate use of devices like bedside rails and inadequate assistive devices may result in the increased risks of falls in older people. Curtin (2005) writes that extrinsic conditions of the older patient’s performance may include loose carpets, the lack of safety equipment, and even high steps. Finally, there are also activity-based factors that are situational and are difficult to predict: climbing ladders, walking uneven surfaces, reaching up, standing or rising from a chair, and even turning around quickly (Curtin, 2005). All these factors are necessary to take into account, in order to prevent and minimize the risks of falls in older patients. Mr. E. complained that he faces difficulties trying to go up the stairs in his house. He is not confident whether he can reach up his kitchen when he is walking from his bedroom down the stairs. He does not have conditions necessary to support him as he comes up and down the stairs. He is alone and does not have anyone to support him in his daily activities. It should be noted, however, that extrinsic factors were not the only reasons behind Mr. E.’s increased risks of falls. The history of falls, the history of strokes, and his problems with vision altogether make it difficult to maintain an appropriate balance. Mr. E. tries to avoid uneven surfaces and does not engage in activities that could result in a fall (e.g., running). He does not lift heavy weights but has to deal with his household chores. He complains having stiff muscles and muscle weakness after the stroke. Mr. E. cannot maintain good coordination of movements and confesses that he is constantly in the fear of a fall. His muscles no longer react to his activities and decisions as fast as they used to several years ago before the stroke. Other chronic illnesses, including arthritis and hypertension add their share of complexity to the current state of health in Mr. E. Assessment and screening Assessment and screening are the two essential elements of falls prevention in older patients. Medical professionals apply to various types of assessment and screening techniques which differ in validity, reliability, and practical convenience. In the NICE Falls Guidelines (2004) it is stated that tests must be simple enough to control and supply information that can help get more knowledge about an older person’s balance and gait. Risk assessments do not eradicate falls but they let reduce their risks. Assessments make the medical staff more aware of the risks falls and result in the development of more appropriate falls prevention strategies. It should be noted, that the current state of research provides a wide array of risk assessment solutions, and medical professionals can choose between several most popular assessment techniques. Despite the relevance of risk assessments in older people, not all risk assessment strategies and techniques are valid and have high accuracy of the results. The differences in the reliability of the risk assessment data may vary based on the individual patient differences, the factors responsible for the risks of falls, as well as the structure of the test itself. In case of Mr. E., the STRATIFY risk evaluation instrument was applied, to evaluate the risks of falls in the old people. The STRATIFY risk evaluation instrument consists of the five essential aspects, with each separately connected with falling (Vassalo et al, 2005). They include “presenting with a fall or having a fall on the ward, visual impairment, presence of agitation, the need for frequent toileting, and impaired ability to walk” (Vassalo et al., 2005). It should be noted, that the use of the STRATIFY evaluation instrument among the medical professionals are a common procedure in the hospital, for which they work. Mr. E. was just one of many other older patient who had been tested with the assistance of the STRATIFY instrument. The choice of the tool is not accidental: the current state of research confirms the validity and reliability of the test results. Compared with other, similar assessment tools, STRATIFY displays the best results and can be successfully used in a variety of clinical contexts (see Appendix 1). Prevention Given that the risks of falls are the results of complex factors, so should be the strategies governing the reduction of falls risks. “Fall prevention is a recent development in medical, rehabilitation and public health. Suggestions that falls could be prevented first appeared in the literature consistently around the 1980’s, and since then there has been considerable investment of time and money to gather evidence to support this hypothesis. Overall, the evidence suggests it is possible to prevent falls in some populations. Whether it is possible to prevent injurious falls is unproven” (CSP 2001). In case of Mr. E., a whole strategy was developed to address the risks of falls in the older patient. Actually, Mr. E. became the participant of the major falls prevention programs which was developed at the hospital level and had to reduce the incidence. Its many-sided method of making alterations and introducing innovations included the following: The use of trustworthy and suitable instruments to forecast and recognize patients with risk to fall. The hospital created a risk evaluation instrument, that is applied to evaluate individuals when they came to hospital and at each treatment stage. The evaluation is founded on the STRATIFY scale, “recorded in an electronic log, along with the appropriate risk-reduction strategies and interventions associated with each patient’s risk level” (Curtin,2005). Nurses now get daily reports of individuals who are at risk of falls and transfer them to the divisions so that high-risk people can be easily identified. Creating safe environment in the establishment. The team did their best to provide safe beds with alarms to help patients at risk avoid falls. Special bells were established also in bathrooms and other areas which are visited by the individuals with the risk of falls. In the development of its program, the hospital sought to follow the basic standards of the NICE Falls instruction/ guidelines and, more importantly, to ensure that the program worked for the patient’s benefit and worked to improve and maintain high quality of life. Rehabilitation therapy for the patient included medication management, health education, home visits, and hospital in-patient interventions. The combination of these methods exemplified a multifactorial approach to fall avoidance and had to provide the patient with the better chances for recovery. Based on the risk assessment of the patient, he was recommended to avoid heavy exercises but had to move regularly, to address the problems of weak musculoskeletal system and stiff joints. It should be noted, that the exercise is an effective way of decreasing the risks of falls when combined with other methods of cure and medication review. Researchers report significant improvements in patients who participate in exercise programs (CSP 2001). Exercise alone is an efficient means of reducing the risks of falls in older people, including those with severe impairments of balance and strength. Yet, because the comparative benefits of different kinds of exercise remain unknown, and because the possible complications and side effects of exercises on the musculoskeletal system of the older patient is difficult to predict, the discussed patient was not recommended to participate in any exercises. Medical professionals justified their rejection of physical activity by the need to protect the patient from additional risks of falls. Medication management became the key element of the multifactorial program developed for the patient. The system of medication for the patient was reviewed. Obviously, due to the wide range and complexity of chronic and acute health states in the older patient, he was bound to take a variety of medical preparations. As a result, the combination of preparations as well as their amount and number produced negative effects on the state of balance and gait in the old patient. The decision was taken to withdraw few medications to improve the state of the individual’s physical health and to reduce the risks of falls. Medication withdrawal proved to be an effective solution to the patient’s falls problems and risks. Health education became another approach to falls prevention. Health education programs are an effective means of reducing the risks of falls in older patients who live alone and have no one to control their movements and to support them in difficult situations. Health education does not simply aim to teach older people how to act in the case of a fall, but helps them prevent these falls by following a simple sequence of steps and precautionary measures. Health education programs have proved to be an efficient way of reducing the risks of falls (CSP 2001). Nevertheless, health education alone cannot suffice to decrease effectively the risks of falls in older patients. The discussed steps and approaches must be further supplemented with regular home visits, environmental modifications, and in-hospital interventions. Although the role of environmental changes in fall prevention is unclear, the latter are extremely useful for the success of any falls prevention programs. Whether the environmental changes made to the patient’s house were effective was not clear, but the falls prevention program also implied that the patient would have high quality of life. To make it happen, environmental changes were crucial and even vital. Environmental changes were supplemented with in-patient hospital interventions. To ensure that the hospital developed an effective prevention program, it is important to compare its basic provisions and approaches to the standards of falls risk assessment, care, and rehabilitation provided by the NICE. These standards will lay the foundation for developing more effective programs of care for older people, which are at risk of falls, and will also create a better picture of what resources, strategies, approaches, and solutions are needed to enhance the quality of falls prevention in the hospital. NICE standards of falls prevention and care To begin with, the patient claimed experiencing the fear of falls. As it was mentioned above, the falls are caused by a variety of factors. More often than not, the risks of falls in older people are the result of the complex factors and reasons: rarely or never can one single reason be responsible for the risks of falls in older populations. As it was already stated, researchers classify falls as “accidental, unanticipated physiologic, and anticipated physiologic” (Morse, 2002). Unfortunately, the hospital did not take into consideration the fear as a potential risk factor for falls. In distinction from the strategy which was developed in the hospital, the NICE guidelines treat the fear of falls as an important risk factor and requires that medical professionals measure patient’s risk of falling (NICE, 2004). According to the NICE (2004), “the fear related to falling is an important consideration when assessing older people and planning interventions”. As a result, effective measurement of fear is one of the basic predictors of any falls reduction program’s success. Even the simplest questions like “are you afraid of falling?” could add their benefits to the current state of falls prevention policies in the hospital. The questions could become a part of the prevention risk assessment policy used in the hospital. The proposed falls reduction strategy was beneficial in the sense that it followed the basic requirements toward falls interventions with the older patients. NICE recommends: “Older people in contact with health care professionals should be asked routinely whether they have fallen in the past year and asked about the frequency, context and characteristics of the fall/s” (Recommendation 1.1.1); “Older people reporting a fall or considered at risk of falling should be observed for balance and gait deficits and considered for their ability to benefit from interventions to improve strength and balance. (Tests of balance and gait commonly used in the UK are detailed” (Recommendation 1.1.2); “Older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment. This assessment should be performed by a health care professional with appropriate skills and experience, normally in the setting of a specialist falls service. This assessment should be part of an individualised, multifactorial intervention” (Recommendation 1.2.1). That the falls prevention program involved multifactorial analysis of risks and multifactorial interventions, including medications and environmental changes, became one of its benefits and the basic element of NICE standard compliance. Of course, no effective program is possible without interprofessional collaboration, rehabilitation and treatment. Because falls are caused by a variety of factors, problems, chronic and acute health states and their complications, managing falls in older patients without the support of other professionals is virtually impossible. Medical professionals are expected to work collaboratively, in order to efficiently control the state of the older people’s health and to improve the effectiveness of medical and non-medical falls prevention interventions (Hawley 2007). Because medical professionals must timely report any changes in the health state of the patient they monitor and take collective decisions regarding potential medications and interventions that may influence the risks of falls in older patients, researchers are confident that communication and collaboration are the basic factors of interprofessional support in reduction of falls. “Interprofessional collaboration has been purported to be the key to an effective and efficient health care delivery system. The goals of this approach related to client care have been described as; enhanced quality of care, system efficiency, client satisfaction, increased functional health, and adherence” (Baxter & Markle-Reid 2009). More advantages were showed for those that take part in interprofessional cooperation. These imply at least better communication among professionals, right division of professional responsibilities and duties, common goals, efficient collaboration. Baxter and Markle-Reid (2009) are correct in that “Much of what is written in the literature regarding interprofessional collaboration in the community setting describes how this model of care should be implemented. However, less is known about how teams actually engage with one another when planning and implementing a coordinated, interprofessional approach to complex patient care when practicing in the community (outside of long-term care settings). Even less is known about the barriers and facilitators faced by these providers and the perceived outcomes of engaging in a team approach”. Nevertheless, interprofessional approach remains one of the basic standards of effective care in falls prevention in older patients. Conclusion Prevention of falls is the issue that needs multifaceted methods. For years, the risk of falls in older people was one of the basic medical problems. Dozens of prevention strategies were developed to minimize the risks of falls in older patients. A lot of intrinsic and extrinsic factors were explored, to identify the reasons behind increase falls risks in older people. The current paper discussed the case of an old patient at risk of falls. An individual had a history of falls and a variety of chronic and acute health conditions, including the constant fear of falls. The most serious problems in the given case study is that the patient believed that due to the stroke he could no longer control his movements and lived with the constant fear of falls. He recognized that social workers and community care specialists visited his house, to make alterations, which were necessary to reduce the risks of falls. Medical specialists created a comprehensive falls prevention plan for Mr. E., to ensure that the risks of further falls are minimized. The current paper aimed to evaluate the assessment, screening, and prevention procedures which medical professionals performed, and to compare them with the basic policy guidelines. The assessment tool used in the evaluation of the falls risks in the patient was STRATIFY, which included 5 different factors/ measurements and is considered by researchers as the assessment tool with the highest reliability of the examination results. The prevention strategy included: The use of valid instruments to predict falls; The development of the system to trace incidence of falls; Maintaining a safe environment; Developing interventions for those individuals who can fall; Reducing the risks of falls; and Constantly monitoring patients at risk of falls. The proposed policy did not follow all NICE requirements. The standards of risk assessment and multifactorial analysis were followed. However, medical professionals did not take into account the fear of falls as the basic risk factor for falls in older patients. “Further work needs to be undertaken to ascertain better methods of preventing falls in healthy populations. Lifetime engagement in physical activity is likely to be protective against falls and fractures, but demonstrating this through randomised controlled trials is, at present, unrealistic” (CSP 2001). Health education is becoming another approach to falls in older people prevention. Health education programs represents efficient methods of decreasing the risks of falls in older patients who live alone and have no one to control their movements and to support them in difficult situations. The goal of health education is not simply to teach older people how to act in the case of a fall, but to help them prevent these falls by following a simple sequence of steps and precautionary measures. Interprofessional collaboration and support was used to help the patient recover after the stroke and to improve the quality of his life. References Baxter, P & Markle-Reid, M 2009, ‘An interprofessional team approach to fall prevention for older home care clients ‘at risk’ of falling: Health care providers share their experiences’, International Journal of Integrated Care, vol. 9, pp. 1-12. CSP 2001, ‘Effectiveness of falls prevention and rehabilitation strategies in older people: Implications for physiotherapy’, The Chartered Society of Physiotherapy, accessed online, http://www.csp.org.uk/uploads/documents/evidencebrief_falls_EB01.pdf Curtin, AJ 2005, ‘Prevention of falls in older adults’, Medicine and Health/ Rhode Island, vol. 88, no. 1, pp. 22-26. Hawley, H 2007, ‘Older adults’ perspectives on home exercise after falls rehabilitation: Understanding the importance of promoting healthy, active ageing’, Health Education Journal, vol. 68, no. 3, pp. 207-218. NICE 2004, ‘CG21 Falls: Full guideline’, National Institute for Health and Clinical Excellence, accessed online, http://guidance.nice.org.uk/CG21/Guidance/pdf/English Vassallo, M, Stockdale, R, Sharma, JC & Briggs, R 2005, ‘A comparative study of the use of four fall risk assessment tools on acute medical wards’, JAGS, vol. 53, no. 6, pp. 1034-1038. Appendix 1 Falls Risk Assessment Tool Resident’s Name Date of Birth Date of Assessment Assessor’s Signature Choose one of the following options which best describes the resident’s level of capability when transferring from a bed to chair Choose one of the following options which best describes the resident’s level of mobility Total the transfer and mobility score and answer the next question 1. Is the combined transfer and mobility score 3 or 4? 2. Has the resident had any falls in the last 3 months? 3. Is the resident visually impaired to the extent that everyday function is affected? 4. Is the resident agitated? 5. Do you think the resident is in need of especially frequent toileting? Total of questions 1 – 5 0 = low risk 1 = moderate risk 2 or above = high risk Read More