Elder Care In Hospital

Video Series

 Mobility in Elder Care

Nova Scotia Health Authority, 2017.

 Why is Mobility Important?

Nova Scotia Health Authority, 2017.

 Barriers to Mobility & Potential Solutions

Nova Scotia Health Authority, 2017.

Supporting Resources

Mobilization Tools

Introducing Mobility into Everyday Life

  • Educate the patient and their family about the value of the patient taking part in their own care
  • Mitigate environmental risks (e.g. good lighting, appropriate footwear, uncluttered area, etc.)
  • Optimize pain management
  • Facilitate participation of the patient in their own care, no matter how small the task (e.g. washing face)
  • Progress participation of the patient in their own care (e.g. bedpan -> commode -> toilet)
  • Ensure that the patient is using assistive devices (e.g. glasses, hearing aids, etc.) as needed
  • Mobilize often throughout the day

Levels of Assistance

  • 100% assistance from caregiver
  • Mechanical lift
  • Full assistance for activities of daily living (ADL)
  • 75% assistance from caregiver
  • Possible mechanical lift or assistance x 2 people
  • Minor participation for activities of daily living (ADL)
  • 50% assistance from caregiver
  • Assistance x 1-2 people for transfers
  • Can participate in bathing/dressing
  • 25% assistance from caregiver
  • Assistance x 1 person for transfers or standby assistance
  • Setup for activities of daily living (ADL) provided by caregiver
  • No assistance from caregiver
  • Independently mobile
  • Fully independent for activities of daily living (ADL)

Falls Management

Falls & the Importance of Mobility in Older Hospitalized Patients

According to Miake-Lye, Hempel, Ganz, and Shekelle, fall rates for acute care hospitals range from 1.3 to 9 per 1,000 bed days. Higher falls rates have been observed in specialty units such as geriatrics, neurology or rehabilitative services (2013). In-patient accidents, which include falls, account for 3% of all harmful events in Canadian hospitals. Electrolyte and fluid imbalance accounts for 15% and delirium accounts for 10% of all harmful events in the same Canadian hospitals (CIHI, 2016).

Evidence indicates that the more complex an individual patient’s needs are, the higher their risk of harm. Hospitalized older adults often have more complex needs due to co-morbidities which increase their risk of falls (Watson, Salmoni & Zecevic, 2015). While most falls do not result in serious injuries, a fall should alert the health care provider to investigate the cause.

Factors Associated with Increased Risk of Falls: 

Intrinsic (internal to the patient)

  • Previous history of falls
  • Acute illness 
  • Vertigo
  • Orthostatic hypotension
  • > 80 years of age
  • Cognitive impairment (lack of insight, impulsiveness, restlessness)
  • Balance/gait impairment
  • Depression, Arthritis, Parkinson’s Disease, Stroke, Diabetes, Dementia, Cardiac Arrhythmia
  • Musculoskeletal problems in lower limbs such as decreased muscle strength 
  • Deconditioning (including dehydration)
  • Needing help with transfers and mobility
  • Sensory impairment (decreased vision, decreased hearing, lower limb neuropathy)
  • Urinary urgency or urinary incontinence

Extrinsic (external to the patient)

  • Polypharmacy 
  • Certain medications (see below)
  • Environmental hazards such as poor lighting, clutter, loose carpets, slippery floors
  • Poor, unsupportive footwear like “mule slippers”
  • Physical restraints
  • Inadequate assistive devices (e.g. a walker that is not the correct height)

Medications

The relationship between falls and medications is well documented (Huang, Mallet, Rochefort, Eguale, Buckeridge, & Tamblyn, 2012; Leipzig, Cumming, & Tinetti,1999). Residents who take four or more prescription medications and/or have a higher medication related anticholinergic load have an increased risk of falls. Changes in medication type or dose may trigger a fall. Many medications increase the risk of falls for older patients. The most common medications that contribute to an increased fall risk are:

  • Antidepressants
  • Antipsychotics
  • Benzodiazepines
  • Anticonvulsants 
  • Antihypertensives

               (Tinetti, 2003)

Points to Consider

  • Health care providers must be aware of fall risk factors and medications for individual patients in order to implement appropriate interventions that can reduce the patient’s fall risk. 
  • Consider the risks and benefits for individual patients when implementing interventions to prevent falls and minimize injuries. Competent adults have the right to take risks that care providers may not agree with (i.e., make decisions with, or take actions that increase their risk for falls) (Registered Nurses’ Association of Ontario, 2017).
  • No one intervention will absolutely reduce an individual’s fall risk or a unit’s rate of falls. Often it may be a combination of multiple interventions (particularly in a geriatric or a rehabilitation setting) that seems to help (Cameron, Dyer, Panagoda, Murray, Hill, Cumming, & Kerse, 2018; Miake-Lye et al., 2013).  

Interventions to Reduce Fall Risk in Hospitalized Patients

  • Educate health care providers, patients, family members and patient attendants on interventions to prevent falls
  • Teach patients and their families about reducing fall risks through choice of appropriate footwear, asking for help if needed, knowing and understanding medications, reporting dizziness, etc.
  • Implement mobilization as part of the daily care plan soon after admission. Engage families with assisting in walking with their loved one if safe to do so
  • Consider implementing a volunteer walking program on your unit
  • Conduct a medication review to reduce doses or eliminate unnecessary medications, including highly anticholinergic medications if possible
  • Adjust the care plan to address cognitive impairment in older patients. For example, health care providers may need to post a sign to cue the patient’s memory to call the nurse before standing
  • Consider using bed/chair alarms (as appropriate) to alert staff when a patient with cognitive impairment is getting up and is at high risk of fall/injury
  • Consider using a beveled, rubberized bedside mat as a temporary safety option to prevent a restless and confused patient from serious injury due to an out-of-bed fall
  • Assess the patient’s ability to transfer safely on a daily basis
  • Investigate cause of expressed dizziness for out-of-bed transfers as soon as possible. Perform an orthostatic hypotension assessment on patients who are dizzy
  • Ensure patients wear supportive footwear and use necessary assistive devices, such as walkers, with ambulation
  • Eliminate clutter at the bedside
  • Use stable and adequate height chairs with strong armrests at the bedside
  • Always leave the call bell within reach
  • Ensure loose clothing is not dangling, such as the belt of a robe, while ambulating
  • Perform “purposeful rounding” to decrease impulsive patient behaviour for unmet needs
  • Identify patients at high risk for falls as per your facility’s policy (e.g., flagging their medical record, armband, bed sign, etc.).
    • Refer to least restraint and patient attendant guidelines/policies as required

Addressing Orthostatic (Postural) Hypotension

Orthostatic Hypotension occurs when an individual’s systolic blood pressure value has decreased by greater than or equal to 20 mmHg OR an individual’s diastolic blood pressure value has decreased by 10 mmHg within 3 minutes after rising from a lying position to either a sitting or standing position.

Kennedy, Davenport, Liu, & Arendts, 2018

If your patient expresses feeling dizzy or reaches for support when getting out of bed or a chair, it is very important to check them for orthostatic hypotension. Often overlooked in hospitalized older patients, orthostatic hypotension may be a cause of falls in older patients. It may affect patients in particular who have diabetes, hypertension or neurodegenerative disease (Ricci, De Caterina, & Fedorowski, 2015). Prevalence of orthostatic hypotension varies from 5–33% in the general older adult population to about 50% in frail older adults who reside in long-term care facilities (Grant, 2003).

What is Postprandial Hypotension?

Postprandial hypotension is a decline in arterial blood pressure that may occur after an older individual has eaten a meal. “Up to one third of institutionalized and non-institutionalized elderly persons have a postprandial blood pressure decline > 20 mmHg within 75 minutes of eating a meal. This decline can be even greater when hypotensive medications are taken before a meal.” (The Merck Manual of Geriatrics, 2nd edition, 1995, p. 473). It may be a common cause of syncope and falls in the elderly (~ 8%).

Interventions for Suspected Orthostatic Hypotension

  • Inform the physician caring for patient. Medication adjustment may be required.
  • Review the patient’s medications (including diuretics or antihypertensives) and hydration status
  • Ask the patient to sit on the side of the bed for a few minutes when first rising in the morning. Dangle the feet over the side of the bed.
  • Encourage the patient to perform ankle-pumping exercises or to cross/uncross their legs before standing
  • Remind the patient to rise from the sitting to standing position slowly
  • Use the chair armrests or edge of bed for support when rising
  • Advise the patient to sit down immediately if feeling dizzy. Call nurse for assistance if it does not pass.
  • Rest after meals if experiencing postprandial hypotension.
  • Patient may require elastic stockings or abdominal binding if symptoms are more advanced.
  • Avoid prolonged immobilization or prolonged standing
  • If compatible with physical status and medical advice, patient may require increased salt and water intake

For Healthcare Workers

For Patients


Fall and Injury Prevention Policy and Procedure

Articles

Abrams, W., Beers, M., & Berkow, R. (Eds.). (1995). The Merck Manual of Geriatrics (2nd ed.). Whitehouse Station, N.J.: Merck Research Laboratories.

Brady, R., Chester, F. R., Pierce, L. L., Salter, J. P., Schreck, S., & Radziewicz, R. (1993). Geriatric falls: Prevention strategies for the staff. Journal of Gerontological Nursing,19(9), 26-32.

Cameron, I. D., Dyer, S. M., Panagoda, C. E., Murray, G. R., Hill, K. D., Cumming, R. G., & Kerse, N. (2018). Interventions for preventing falls in older people in care facilities and hospitals. Cochrane Database of Systematic Reviews, (9).

Canadian Institute for Health Improvement, Canadian Patient Safety Institute. (2016). Measuring Patient Harm in Canadian Hospitals. Ottawa, ON: CIHI.

Creditor, M. C. (1993). Hazards of hospitalization of the elderly. Annals of Internal Medicine, 118(3), 219-223

Fuller, G. F. (2000). Falls in the elderly. American Family Physician, 61(7), 2159-68.

Gordon, J. (2000). Rational approach to prescribing for seniors. Drugs and Therapeutics for Maritime Practitioners, 23(1), 1-6.

Grant, M. (2003). Treatment of orthostatic hypotension: Preserving function and quality of life. Geriatrics and Aging, 6(7), 32-36.

Greysen, S. R., & Patel, M. S. (2018). Annals for Hospitalists Inpatient Notes - Bedrest Is Toxic—Why Mobility Matters in the Hospital. Annals of Internal Medicine, 169(2), HO2-HO3. doi: 10.7326/M18-1427.

Grymonpre, R. E., & Montgomery, P. R. (2000). 10 Drugs your elderly patients may not need: Inappropriate medication use in the elderly. Pharmacy Practice, 16(4): 38-44.

Huang, A. R., Mallet, L., Rochefort, C. M., Eguale, T., Buckeridge, D. L., & Tamblyn, R. (2012). Medication-related falls in the elderly. Drugs & Aging, 29(5), 359-376.

Kennedy, M., Davenport, K. T., Liu, S. W., & Arendts, G. (2018). Reconsidering orthostatic vital signs in older emergency department patients. Emergency Medicine Australasia, 30(5), 705-708.

Krueger, P. D., Brazil, K., & Lohfeld, L. H. (2001). Risk factors for falls and injuries in a long-term care facility in Ontario. Canadian Journal of Public Health, 92(2), 117-120.

Leipzig, R. M., Cumming, R. G., & Tinetti, M. E. (1999). Drugs and falls in older people: a systematic review and meta‐analysis: I. Psychotropic drugs. Journal of the American Geriatrics Society, 47(1), 30-39.

Miake-Lye, I. M., Hempel, S., Ganz, D. A., & Shekelle, P. G. (2013). Inpatient fall prevention programs as a patient safety strategy: a systematic review. Annals of Internal Medicine, 158(5-Part 2), 390-396.

Morse, J. M. (1997). Preventing Patient Falls. Thousand Oaks, California: Sage Publications.

Registered Nurses’ Association of Ontario. (2017). Preventing Falls and Reducing Injury from Falls (3rd ed.). Toronto, ON: Author.

Ricci, F., De Caterina, R., & Fedorowski, A. (2015). Orthostatic hypotension: Epidemiology, prognosis, and treatment. Journal of the American College of Cardiology, 66(7), 848-860.

Rubenstein, L. Z., Robbins, A. S., Josephson, K. R., Schulman, B. L., & Osterweil, D. (1990). The value of assessing falls in an elderly population: a randomized clinical trial. Annals of Internal Medicine, 113(4), 308-316.

Tinetti, M. E. (2003). Preventing falls in elderly persons. New England Journal of Medicine, 348(1), 42-49.

Watson, B. J., Salmoni, A. W., & Zecevic, A. A. (2015). Falls in an acute care hospital as reported in the adverse event management system. Journal of Hospital Administration, 4(4), 84-91.