Geriatric rehabilitation has as its goal maximizing the functional independence of elderly patients within the constraints imposed by disease, illness, and injury (Weber, Fleming, & Evans, 1995). To strive toward this goal, patients participate in an interdisciplinary treatment program designed to increase their mobility and their ability to safely and effectively complete activities of daily living (ADLs). Geriatric rehabilitation also includes, when applicable, treatment components designed to help patients learn how to manage their own medication, enhance their nutritional status, cope with cognitive or emotional difficulties, better their communications skills, and optimize family relationships and living arrangements on discharge.
Because the goal of rehabilitation is to facilitate patient autonomy and independence, patients on a geriatric rehabilitation program are encouraged to actively participate in all aspects of their care and scheduled activities while on the unit. For example, patients are encouraged to complete their self-care, grooming, and toileting with increasing independence, in keeping with their progress in rehabilitation. For many patients, doing this involves a relearning process, as recent changes in cognition or physical abilities can make completing such everyday tasks difficult. Therefore, rehabilitation team members must balance fostering patient functional independence and increasing activity levels, while at the same time ensuring patient safety. One such safety issue on the rehabilitation unit is the prevention of falls.
Fall-related injuries are a serious health problem among elderly patients because they are associated with considerable impairment or morbidity. Non-fatal injuries often result in marked functional deterioration or institutionalization (Tinetti et al., 1994). According to Sattin (1992), fall-related injuries are the sixth-leading cause of death in individuals older than age 65. Estimated prevalence rates of falls on inpatient geriatric rehabilitation units have been reported to be as high as 39% (Nyberg & Gustafson, 1996). Together, these data support the importance of implementing standardized interventions to reduce the risk for falls among hospitalized geriatric patients.
Patients on a geriatric rehabilitation unit typically are frail and suffer from a variety of conditions associated with increased risk for falls. The most frequent primary diagnoses on the Geriatric Rehabilitation Program of the Sisters of Charity Hospital of Ottawa (SCO) are orthopedic injuries and cerebrovascular accidents (CVAs). However, secondary and tertiary diagnoses also are frequent. Examples include osteoarthritis, osteoporosis, diabetes, renal failure, pulmonary disease, other neurological disorders, and hypotension (Harris, O'Hara, & Harper, 1995). These conditions often are associated with symptomatology which can result in significant risk factors for falls. For example, right-hemisphere CVAs often yield visual-spatial deficits which create difficulties in orienting oneself through space when walking or reaching for objects. These difficulties can be further exacerbated by damage to the motor or sensory cortex, resulting in balance or mobility problems associated with sensory or motor deficits (Patrick, 1996).
Although there is a growing body of literature addressing assessment of fall risks, considerably less information is available regarding standardized nursing interventions designed to prevent falls in rehabilitation patients who have been assessed as being at risk. Such interventions are particularly crucial on geriatric rehabilitation units where staff must prevent falls while concurrently encouraging high rates of patient physical activity and mobility. Thus, the purpose of this article is to describe the interdisciplinary intervention protocol established on the Geriatric Rehabilitation Program of the SCO.
Figure: Relationships among fall risk, level of independence, and interventions.
The following is an outline of the decisional criteria used in determining patients' level of independence on the unit for different categories of risk for falls (i.e., high, moderate, low risk). Also outlined is the related intervention protocol for each combination of fall risk and level of independence. This article concludes with a description of behavioral strategies developed by the interdisciplinary team, which nursing staff teach to patients. Patients learn to compensate for cognitive or physical deficits - factors which can otherwise put them at increased risk for fall-related injuries. See the Figure for a pictorial representation of the relationships among fall risk, level of independence on the unit, and intervention protocols outlined in this article.
Fall Risk Factors and Level of Independence
The evaluation of patients' risk for falls in this program currently is based on an aggregate of clinical judgment and the score from the Falls Risk Assessment (Heslin et al., 1992). This scale classifies patients' overall risk on a three-category system (i.e., Level I, II, III). It has been used in acute care, long-term care, and residential care settings, but its use with geriatric rehabilitation populations has not been studied. To the knowledge of these authors, a fall-risk scale designed and validated specifically for geriatric rehabilitation patients is not yet available. As such, the authors also currently are piloting the use of a riskfor-falls scale developed specifically for geriatric rehabilitation patients, based on criteria which have prospectively been identified empirically as risk factors in related populations (Maki, 1996; Morse, Morse, & Tylko, 1989; McCollam, 1995; Sensening, Donaher, & Rubinsky, 1990; Tinetti, Williams, & Mayewski, 1986).
Seven risk factors are included in the new scale being piloted (Table 1). Each risk factor is evaluated by the member of the interdisciplinary team who has the most expertise in assessing that factor using the standardized assessment tools and methodology of that individual's profession. For example, balance and mobility deficits (Risk Factors 5 and 6) are assessed by a physiotherapist, using the Physiotherapy Functional Mobility Profile (PFMP) (Piatt, Bell, & Kozak, 1998). This instrument was designed particularly for use with a geriatric or chronic care population and is sensitive to aspects of mobility relevant in this clientele, such as sit-to-stand transfers and standing balance. The PFMP is composed of nine subscales, each scored on a 7-point range (balance subtests scores below 7 reflect severe impairment, scores of 7 to 1 1 reflect moderate impairment, and scores of 12 or above reflect low impairment).
FACTORS FOR EACH CATEGORY OF FALL RISK AMONG GERIATRIC REHABILITATION PATIENTS
Visual impairment (Risk Factor 2) is assessed by a physician using the Snellen test (Brajkovich, 1980). The physician also evaluates secondary medical diagnoses (Risk Factor 3). Rehabilitation team members involved in the fall-risk assessment process also include a nurse who evaluates functional status and fall history (Risk Factor 1 ), a psychologist who evaluates mental status (Risk Factor 4), a pharmacist who conducts a high-risk medication assessment (Risk Factor 7), and an occupational therapist (OT) who evaluates sensory deficits (Risk Factor 2). The scale yields a total score ranging from 0 to 39. The risk factors have been weighted for scoring purposes using previously established reports of their relative strength in predicting falls in related populations (Heslin et al., 1992; Tinetti et al., 1986). Thus, Risk Factors 1, 3, and 4 are weighted more heavily. Total scores of 0 to 13 represent low risk for falls; scores of 14 to 26 indicate moderate risk; and scores of 27 to 39 represent high risk. These assessments are completed within 24 to 48 hours of admission. Based on these aggregated interdisciplinary assessments, the rehabilitation staff makes an initial clinical determination of patients' risk-for-falls category (i.e., high, moderate, or low). Overall, a conservative approach to fall-risk assessment is taken. If rehabilitation staff estimate that a given patient's risk still is unclear (e.g., initial behavioral observations seem inconsistent with the metric assessment score), the patient is supervised and assessed further. It is noteworthy that the evaluation of patients' risks for falls are revisited as they progress through their rehabilitation programs. Thus, a patient may progress from a higher fall-risk category to a lower fall-risk category as gains in functional mobility and balance are made and as other riskfor-falls factors are reduced with rehabilitation treatment. The risk-for-falls assessment and intervention protocols are continuous and dynamic processes.
DECISIONAL CRITERIA FOR DETERMINING PATIENT LEVEL OF INDEPENDENCE ON UNIT
Having determined patients' initial fall-risk category on admission, a decision then is made regarding patients' level of independence, incorporating behavioral observations and clinical judgment using criteria outlined in Table 2. The decisional outcome of the application of these criteria is that patients are either considered dependent or independent. In deciding whether or not to allow independent mobility on the unit, one must consider several factors such as the extent of the patients' ability and willingness to use strategies to compensate for their functional deficits, the probability of injury if a fall occurs (e.g., presence of osteoporosis), and the specific pattern of cognitive dysfunction if present (e.g., impulsivity versus initiation deficits). For example, patients who have no cognitive problems and, thus, are more likely to appreciate the need to compensate for their physical impairments are considered more suitable for independence on the unit. Patients with cognitive difficulties which prevent them from learning and initiating the use of safer, alternative methods of performing their ADLs are considered at greater risk if they are independent on the unit. Similarly, patients with plans for a discharge home following rehabilitation may at times be given independent status on the unit, despite being at some risk for falls, to allow for a more comprehensive assessment of their suitability for independent living.
Six intervention protocols have been developed to help prevent falls in patients with different levels of fall risk and independence on the unit. Therefore, each level of independence within each risk category has an associated intervention protocol. The protocols address factors such as patient supervision, identification of patients at risk and visual alerts, mobility and transfers, toileting schedules, education with patient and family members, and medication management. A detailed description of each intervention protocol is presented in Table 3. The intervention protocols were derived from a synthesis of published recommendations, inferences extrapolated from risk assessment studies, and the authors* clinical experiences (Maki, 1996; Morse et al., 1989; Tideiksaar, 1996; Tinetti et al., 1994). It is noteworthy that the rehabilitation unit is a restraint-free unit. Intervention Protocols A and C include the use of bed rails which are employed as a reminder to patients to call for assistance when transferring out of bed. After it has been established that patients have learned safe transferring techniques and remember to initiate them, bed rails are no longer used. According to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), bed rails are not considered restraint interventions and do not fall under their policy and procedures on restraints (JCAHO, 1997). Nevertheless, considerable evidence recently has emerged in the literature of the need to judiciously employ bed rails to prevent accidents or injuries (Barazovski & Rosin, 1997; O'Keefe, Jack, & Lye, 1996). Thus, the safe use of bed rails is ensured by following the recommendations of Miles (1996) and Parker and Miles (1997) that state beds should be kept in the lowest position, only electric beds with permanently attached full-covered side rails (i.e., non-split type) should be used, and a safe spacing between the mattress and rails must be verified.
An important aspect of this intervention approach to preventing falls - an aspect which is consistent across all protocols - is the teaching of behavioral compensatory strategies for physical or cognitive impairments. The goal of this teaching is to reduce the handicap that patients with disabilities experience, and, thus, reduce the fall risks.
Teaching of Behavioral Strategies
Rehabilitation staff teach patients and their families methods of safely managing (i.e., without falling) dizziness, vision impairment, balance problems, transfers, completion of ADLs, indoor ambulation, and toileting. Involving family members in the learning of these strategies increases the likelihood that patients will continue to employ them after discharge because family members can foster a learning environment at home.
All rehabilitation team members are involved in the fall prevention protocols. Following assessments, the physiotherapist designs a specific treatment program tailored to the individual patient to reduce the risk of a fall. For example, the program can include exercises to stimulate balance and strength, which promote postural stability, and gait training to improve stability in stance on different types of surfaces and around obstacles. Patients typically progress with a grathent of difficulty. As such, the physiotherapist regularly communicates to rehabilitation team members the baseline instructions for completing transfers and ambulation with each patient, according to the individual's current abilities. Compensatory strategies are incorporated into the sequence of instructions, taking into account the patient's cognitive profile as assessed by the psychologist. This way, staff work at both the impairment and handicap levels to reduce fall risk.
Nursing staff foster the use of these tailored instructions and strategies with patients when completing toileting and self-care routines, activities which are frequently associated with falls in the frail elderly individual. The OT works with patients to foster the use of the instructions and strategies when helping patients relearn the management of their ADLs, such as preparing meals in the OT kitchen. This interdisciplinary safety teaching is an ongoing activity throughout the duration of rehabilitation treatment.
Strategies for Completing Safe Transfers. Patients are taught the relationship among postural hypotension and dizziness and risk for falls when changing positions. For managing dizziness, the technique is to move one's limbs in bed before sitting up, to change positions gradually when progressing from lying to sitting, and to sit up for a period of time after rising and before getting out of bed, thus managing blood pressure and allowing dizziness to subside.
The characteristics of safe and appropriate shoes suitable for different types of surfaces and the definition of a good fit are outlined. Instructions to put shoes on before getting out of bed or attempting transfers are provided. Each patient is shown how to use a walker safely, including the proper distance to hold it from the body, how and when to use the brakes, how to complete a turn and avoid pivoting, and how to back up or walk sideways. The safe use of the walker to transfer to a chair or commode is also taught, ensuring that the back of the individual's legs touch the chair before attempting to sit and that hands are placed on the arms of the chair when sitting down or getting up. Staff also encourage patients to proceed slowly when transferring and cue them to recall the specific sequence of learned steps.
Strategies for Completion of ADLs. The relationships among balance, stability, surface types, and the dangers of obstacles is explained to patients. Instructions include how to use a walker when ambulating instead of using furniture as support for moving around. Patients further are encouraged to use the tray on their walker to carry objects and not to attempt carrying objects in their hands while using the walker. Encouragement to sit in a chair instead of on the edge of the bed to accomplish functional activities is provided. Teaching patients to use reaching devices (provided by the OTs) to retrieve items from cupboards or off the floor helps patients manage daily activities when faced with balance problems. Making use of such devices safeguards patients against reaching out beyond their base of stability. Reminders to sit down before using the devices are frequent. Instructions also include teaching patients to place belongings within easy reach as much as possible. Avoiding walking on wet floors (e.g., spills in bathroom) and keeping rooms uncluttered as much as possible is recommended. Another behavioral suggestion is to check the location of the telephone cord to prevent tripping. Patients also are taught to use the bathroom on a regular schedule to avoid urgent need and rushing, which can lead to falling.
Strategies for Perceptual or Sensory Impairment. Visually impaired patients are taught to recall the layout of their bedroom on the unit, to move slowly around obstacles, and to keep the room uncluttered to reduce maneuvering. Scanning techniques to enhance visual field coverage are used, for example, for those with left visual neglect following a right hemisphere CVA. This facilitates patients' ability to walk around without hitting objects and possibly losing their balance. It also ensures that when trying to sit down, they are positioned on the entire seat of chair, preventing sliding off and falling. Individuals who have suffered a CVA frequently also have hemiparesis, or sensory neglect. They need to learn to position their affected arm in a safe position for transfers to prevent balance problems or injury to the arm. Further instruction to turn on the light at the bedside before getting up during the night is given.
It is noteworthy that not all patients retain such new information and adopt new behavioral routines through the same venue. Those with declarative versus procedural memory deficits or patients with apraxia, for example, require distinct instructive paradigms tailored to their cognitive profiles. Members of the interdisciplinary team are able to adjust their teaching methods to compensate for cognitive deficits. By way of example, the relearning of movement sequences in physiotherapy can be based primarily on procedural paradigms, reducing the reliance on observation and verbal instruction for those with declarative memory problems. Team members working on ADL performance use sequencing cues to help remedy identified deficits in executive functioning. Patients with cognitive impairments undergo a neuropsychological evaluation to assist in determining their intellectual strengths and weaknesses, identifying their optimal learning paradigm, and maximizing rehabilitation potential. For an outline of learning paradigms in geriatric rehabilitation, readers are referred to Patrick (1996).
Many factors contribute to falls in elderly individuals. Geriatric patients undergoing rehabilitation treatment often are faced with a multifactorial fall-risk profile because of their frail health and a complex pattern of physical or cognitive deficits imposed by disease, illness, and injury. The nursing and allied health staff on a rehabilitation unit can play a significant role in helping patients cope effectively with these deficits and reduce their fall risk. Through in vivo education and training within the context of ADLs (e.g., grooming, toileting, mobility), interdisciplinary team members can help patients minimize the handicaps which frequently accompany disabling conditions. The implementation of empirically based and standardized nursing intervention protocols for fall prevention is an important aspect of supporting patients in reaching their goals of autonomy and independence.
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FACTORS FOR EACH CATEGORY OF FALL RISK AMONG GERIATRIC REHABILITATION PATIENTS
DECISIONAL CRITERIA FOR DETERMINING PATIENT LEVEL OF INDEPENDENCE ON UNIT