Journal of Gerontological Nursing

EDITORIAL 

Ounces and ounces of prevention . . .

Irene M Burnside, MS, RN

Abstract

On 3 recent flight, 1 watched a very old man using a cane make his way to the lavatory. Although he did not have far to go, it was not easy for him. By the time he was ready to return to his seat, we had hit turbulence. And as he made his way out of the lavatory door, there was nothing to grab onto in the galley except a vodka tonic and a cold can of coke sitting on the small shelf.

I began thinking about falls. I had an octogenarian friend who fell on a train en route to California. The train came to a sudden stop and she was in the aisle. She sustained a broken hip and was in the care of her 80year-old sister for weeks.

Recently, I listed a number of frail elderly fallers - all are in their 80s and 90s. While none were injured, of the five who had fallen, three of the caregivers who attempted to lift them sustained injuries! My mentor fell three times in five years and had three broken hips . . . after she retired. I still get upset thinking about that. I keep wondering where the ounce of prevention was for her so that pounds and pounds of cure/care did not have to be her fate.

Overstall1 reminds us that falls are so very common in older individuals that "they almost appear to be inevitable." Nickens2 states that "the relationships between falling in the elderly, and subsequent mortality and morbidity is generally underappreciated." Lindsay3 provides a bar graph to show the estimated cost of acute health care for fracture of the femur neck for the whole of the United States. In 1990 he projects it will cost S3 billion for that care. Only about half of the elderly hospitalized for a fall will be alive one year later.4

Among elders who have been institutionalized, 10% to 15% each year suffer a serious complication related to falls.5 The fifth leading cause of death in those over 65 is due to accidents, and falls account for two thirds of those accidental deaths.

Regarding falls among elderly living at home, Nickens' survey of the literature revealed that:

* Falling is common among the elderly, and especially among women.

* The incidence of falling increases with age for both sexes.

* Falling is more common in those judged to have poor health status.

* Environmental [extrinsic) contributors to falling appear to decrease with age.

With those grim statistics facing us, what are gerontological nurses going to do? I have been stymied often by the problems, and often felt unsuccessful. For example, throw rugs were the bane of home nursing for me. Older people I worked with just would not give up their throw rugs (scatter rugs as some called them) and placed them everywhere. The older people tolerated uneven stairs, wobbly or no handrails, poor lighting, and a host of other dangerous conditions.

Stall and Katz have observed another environmental hazard which occurs in hospitalized elderly - ill-fitting clothing.6 This includes, for example, oversized pants. But ill-fitting footwear, nightgowns, robes also create problems. Falls down stairs may be caused by tripping on untied bathrobe belts, stepping on the back of the robe of the nightgown and falling. Jogging suits seem to be gaining in popularity; perhaps the elastic in the ankle area of the pants is a blessing in disguise for older persons. Those are some of the visible extrinsic factors, but what of the intrinsic factors?

It will take much thought and many interventions by nurses to make inroads…

On 3 recent flight, 1 watched a very old man using a cane make his way to the lavatory. Although he did not have far to go, it was not easy for him. By the time he was ready to return to his seat, we had hit turbulence. And as he made his way out of the lavatory door, there was nothing to grab onto in the galley except a vodka tonic and a cold can of coke sitting on the small shelf.

I began thinking about falls. I had an octogenarian friend who fell on a train en route to California. The train came to a sudden stop and she was in the aisle. She sustained a broken hip and was in the care of her 80year-old sister for weeks.

Recently, I listed a number of frail elderly fallers - all are in their 80s and 90s. While none were injured, of the five who had fallen, three of the caregivers who attempted to lift them sustained injuries! My mentor fell three times in five years and had three broken hips . . . after she retired. I still get upset thinking about that. I keep wondering where the ounce of prevention was for her so that pounds and pounds of cure/care did not have to be her fate.

Overstall1 reminds us that falls are so very common in older individuals that "they almost appear to be inevitable." Nickens2 states that "the relationships between falling in the elderly, and subsequent mortality and morbidity is generally underappreciated." Lindsay3 provides a bar graph to show the estimated cost of acute health care for fracture of the femur neck for the whole of the United States. In 1990 he projects it will cost S3 billion for that care. Only about half of the elderly hospitalized for a fall will be alive one year later.4

Among elders who have been institutionalized, 10% to 15% each year suffer a serious complication related to falls.5 The fifth leading cause of death in those over 65 is due to accidents, and falls account for two thirds of those accidental deaths.

Regarding falls among elderly living at home, Nickens' survey of the literature revealed that:

* Falling is common among the elderly, and especially among women.

* The incidence of falling increases with age for both sexes.

* Falling is more common in those judged to have poor health status.

* Environmental [extrinsic) contributors to falling appear to decrease with age.

With those grim statistics facing us, what are gerontological nurses going to do? I have been stymied often by the problems, and often felt unsuccessful. For example, throw rugs were the bane of home nursing for me. Older people I worked with just would not give up their throw rugs (scatter rugs as some called them) and placed them everywhere. The older people tolerated uneven stairs, wobbly or no handrails, poor lighting, and a host of other dangerous conditions.

Stall and Katz have observed another environmental hazard which occurs in hospitalized elderly - ill-fitting clothing.6 This includes, for example, oversized pants. But ill-fitting footwear, nightgowns, robes also create problems. Falls down stairs may be caused by tripping on untied bathrobe belts, stepping on the back of the robe of the nightgown and falling. Jogging suits seem to be gaining in popularity; perhaps the elastic in the ankle area of the pants is a blessing in disguise for older persons. Those are some of the visible extrinsic factors, but what of the intrinsic factors?

It will take much thought and many interventions by nurses to make inroads into the prevention of falls. Where do we begin? Nearly all of the articles I studied about falls were not written by nurses, and yet nurses are "out there" where the fallers are (or "in there" where elders fall in institutions). We need more data on who falls, where they fall, circumstances involving the fall, and the prevention strategies which have been successful. One article pointed out that nursing home residents are apt to fall at predictable peak periods, and that one peak period is "during nursing staff activities such as shift change or breaks."7 What implications that finding has for preventionl

An excellent recent article by Spellbring et al includes both an assessment for high risks to falls and assessment and interventions for patients at risk for falls. They also designed a fall precautions check list for prevention and intervention. The reader is advised to study the "safely alert sticker."8

I sit here wondering what information you have that you could share with fellow readers of the Journal of Gerontological Nursing. If you sent in an overview of the research on falls, your studies, or methods of prevention in your work place, we could well have enough articles for a special theme issue on falls.

So, it is up to you . . .

Do you include content about falls in your classes - wherever you teach?

Do you work assiduously on prevention of falls in your work place?

Do you share your research, your knowledge of effective methods of prevention for reducing the number of the injuries) of falls?

Do you teach the caregiver how to handle the one who has fallen so there are no injuries in those important persons?

I hope this editorial will be the catalyst to help motivate you to write, or to change the conditions that you see as blatantly hazardous for elders in your care, or case load. Gerontological nursing can assume a major role in providing ounces and ounces and ounces of prevention.

References

  • 1. Overstall P: Determining the cause of falls in the elderly. Geriatric Medicine Today 1983; 2(8):63-66.
  • 2. Nickens H: Intrinsic factors in felling among the elderly. Arch Intern Med 1985; 145:1089-1093.
  • 3. Lindsay R: The aging skeleton, in Haug M, Ford A, Sheafor M (eds): The Physical and Mental Health of Aged Women, New York. Springer, 1984, p 71.
  • 4. Kane R, Ouslander J, Abrass I: Essentials of Clinical Geriatrics, New York, McGraw-Hill, 1984, p 137.
  • 5. Hogue C: Injury in late life. I. Epidemiology II. Prevention. J Am GeriatrSoc 1982; 30:183-190, 276, 280.
  • 6. Stall R, Katz P: RdIs and ill-fitting clothing. Journal American Geriatrics Society 1987; 3510):959.
  • 7. Kalchthaler T, Bascon R, Quintos V: Falls in the institutionalized elderly. J Am Geriatr Soc 1978; 26:424-428.
  • 8. Spellbring A, Gannon M, Kleckner T, et al: Improving safety for hospitalized elderly. J Gerontol Nurs 1988; 14(2):31-37.

10.3928/0098-9134-19880601-04

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