Ways to prevent falls in older patients
Ways to prevent falls in older patients
When her adult children brought a woman to the ED, they reported she was becoming unsteady on her feet. "The nurse noted the patient was taking lorazepam for anxiety," says Lowell W. Gerson, PhD, professor of epidemiology at Northeastern Ohio Universities College of Medicine in Rootstown. "She also found the family had been increasing her dose, as she was still anxious," Gerson adds. The nurse realized that this increased dose increased the patient’s risk of falling and made the children aware of the danger.
It is important to consider risk factors for falls in all elderly patients in the ED because of the high risk of falls and the burden of suffering they produce, urges Gerson. "Falls can be prevented, or at least have the risk reduced," he says.
Ninety percent of hip fractures are caused directly by falls, and two-thirds of elders never regain their previous level of function, says Barbara A. Foley, RN, executive director of Emergency Nurses CARE, the Alexandria, VA-based injury prevention arm of the Emergency Nurses Association. "You need to consider this with every older patient," Foley emphasizes. "It’s the same idea as making sure that all kids are buckled properly, even if they come in for an earache."
There is good evidence that detecting a history of falls, doing a fall-risk assessment, and linking the ED patient to an intervention is likely to reduce the chances of a fall in an elderly patient, says Gerson.1
Here are ways to prevent recurrent falls:
• Consider what caused a fall. Of the 4,500 older patients who come to the ED after a fall each day, 30 will die of that injury, says Gerson. "Chances are that one of the injured will visit your ED. Most likely, this person will be a woman older than 75 years who comes to you after a fall in her home," he says. Gerson advises you to think carefully about what actually caused the fall. "Was it a slip, a trip, or was it the result of an underlying medical condition like sepsis or medication toxicity?" he asks. "A fall is a complex chief complaint that may involve physiological, psychological, social, and environmental issues."
• Consider post-discharge issues. Gerson notes the importance of determining what accommodations will be needed after the patient leaves the ED. "Will he or she be able to transfer [out of bed or chair], walk, wash, go to the toilet, and feed him or herself? Will he or she be able to shop, pay bills, and make a telephone call?" he asks. Planning for the future is extremely important, says Gerson. "More than a quarter of elderly patients presenting with minor trauma suffer a post-discharge decline in their ability to do the activities of daily living," he says.
• Assess patient for risk factors. Multidimensional fall prevention programs are effective, especially if they include medical evaluation and modification of medications and exercise, says Gerson. "Your patient, who has had a fall, now has a major risk factor for having another," he warns. Other risk factors include postural hypotension, use of sedative-hypnotic agents, polypharmacy, muscle weakness, and impairment in gait, balance, or transfer skill, says Gerson. "Patients with these risks, regardless if they have fallen, are good candidates for fall prevention programs," he adds. Asking about these risk factors, observing the patient, or doing an "up-and-go test" are good ways to identify patients who may benefit from referral to a community fall prevention program, says Gerson.
• Encourage patients to be truthful about alcohol intake. Elderly patients may perceive a negative connotation to questions about alcohol consumption, notes Foley. "They may feel that if they answer yes’ when asked if they drink alcohol, it means they are an alcoholic," she says. Foley encourages you to speak frankly to patients when assessing alcohol intake. "Explain to them that if they normally have a glass of wine before go to bed, they should be truthful about this," she says. "Otherwise, the physician could order a sleeping pill and the patient could wake up disoriented and fall because of the interaction between the alcohol and medication."
• Warn patients about home hazards. Slippers and slide-on shoes could cause a problem if the patients’ walking isn’t steady, says Foley. "Encourage the patients to wear shoes that tie so they will be snug," she says. "Also, if they have scatter rugs in home, that could cause a problem." (To see recommendations to reduce hazards, click here.)
• Recommend that patients carry a list of medications. Taking too many medications can cause drowsiness, so it’s important that the physician know exactly what the patient is taking, says Foley. "Encourage the patient to carry a list of medications and dosages with him or her, including over-the-counter drugs," she suggests.
Reference
1. Weigand JV, Gerson LW. Preventive care in the emergency department: Should emergency departments institute a falls prevention program for elder patients? A systematic review. Acad Emerg Med 2001; 8:823-826.
Sources
For more information about prevention of falls in elderly patients, contact:
• Barbara A. Foley, RN, Emergency Nurses CARE, 205 S. Whiting St., Suite 403, Alexandria, VA 22304. Telephone: (703) 370-4050. Fax: (703) 370-4005. E-mail: [email protected].
• Lowell W. Gerson, PhD, Division of Community Health Sciences, Northeastern Ohio Universities College of Medicine, P.O. Box 95, Rootstown, OH 44272-0095. Telephone: (330) 325-6159. Fax: (330) 325-5907. E-mail: [email protected].
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