January 2009
by Neil B. Alexander, MD
http://www.blogtalkradio.com/smithbits
At the heart of any nursing or assisted living home is the activity program it has for residents. It is an integral part of the cultural change movement and central to person-centered care. It is essential for resident quality of life. Nursing Home activities are governed by federal regulations called F-Tags. While Assisted Living activities are not as highly regulated, many facilities emulate the standards set for nursing homes.
F-Tag and Implication
F-Tag 248 states that ”the facility must provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident.”
Beyond Bingo
The stereotype of activities in elder care homes is playing bingo and watching television. Of course some progress has been made in the PR front as Wii games in nursing homes have become big media stories. F-Tag 248 stipulates that activities should be relevant to the specific needs, interests, culture, background, etc. of the individual for whom they are developed.
At the heart of any nursing or assisted living home is the activity program it has for residents. It is an integral part of the cultural change movement and central to person-centered care. It is essential for resident quality of life. Nursing Home activities are governed by federal regulations called F-Tags. While Assisted Living activities are not as highly regulated, many facilities emulate the standards set for nursing homes.
F-Tag and Implication
F-Tag 248 states that ”the facility must provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident.”
Beyond Bingo
The stereotype of activities in elder care homes is playing bingo and watching television. Of course some progress has been made in the PR front as Wii games in nursing homes have become big media stories. F-Tag 248 stipulates that activities should be relevant to the specific needs, interests, culture, background, etc. of the individual for whom they are developed.
Most falls occur when people with a physical condition that impairs mobility or balance encounter an environmental hazard. Although many people have no symptoms before a fall, some experience dizziness or other symptoms. After a fall, people may have broken bones or bruises.
Doctors often do tests to evaluate whether an underlying condition contributed to the fall. Falls may be prevented by taking precautions around the home. After injuries are treated, people work with physical therapists to help reduce the risk of subsequent falls.
Many older people fear falling. And they have good reason to do so. Falls are common among older people. About one third of older people who live at home fall at least once a year, and people who live in a nursing home fall even more often.
Falls often cause injuries. Some of the injuries, such as a broken hip, can be serious. Older people are more likely to break bones in falls because many older people have porous, fragile bones (osteoporosis).
Fear of falling can lead to problems. People may worry about doing their usual activities and thus lose their self-confidence and even their independence. Older people can do many things to help overcome their fears and to reduce their risk of falling. Knowing what causes falls can help.
Did You Know...
Although many older people fall, falls are not a normal part of growing older.
Causes
Falls can be caused by physical conditions that impair mobility or balance, hazards in the environment, or potentially hazardous situations. Most falls occur when several causes interact. For example, people with Parkinson's disease and impaired vision (a physical condition) may trip on an extension cord (an environmental hazard) while rushing to answer the telephone (a potentially hazardous situation).
People's physical condition is affected by changes due to aging itself, physical fitness, disorders present, and drugs used. The physical condition probably has a greater effect on the risk of falling than do environmental hazards and hazardous situations. Not only does a poor or impaired physical condition increase the risk of falls, but it also affects how people respond to hazards and hazardous situations.
Physical impairments that increase the risk of falling include those involving
Balance or walking
Vision
Sensation in the foot
Muscle strength
Cognition
Use of drugs that affect attention or lower blood pressure can also increase the risk of falling.
Hazards in the environment are involved in many falls. Falls may occur when people do not notice a hazard or do not respond quickly enough after a hazard is noticed.
Environmental hazards that increase the risk of falling include
Inadequate lighting
Throw rugs
Slippery floors
Electrical or extension cords or objects that are in the way of walking
Uneven sidewalks and broken curbs
Most falls occur indoors. Some happen while people are standing still. But most occur while people are moving—getting in and out of bed or a chair, getting on or off a toilet seat, walking, or going up or down stairs. While moving, people may stumble or trip, or balance may be lost. Any movement can be hazardous. But if people are rushing or if their attention is divided, movement becomes even more hazardous. For example, rushing to the bathroom or to answer the telephone or talking on a cordless phone can make walking more hazardous.
Symptoms
Often before falling, people have no symptoms. When an environmental hazard or a hazardous situation results in a fall, there is little or no warning. However, if a fall is partly or completely due to a person's physical condition, symptoms may be noticed before falling. Symptoms may include dizziness, light-headedness, or irregular or rapid, pounding heartbeats (palpitations).
After a fall, injuries are common and tend to be more severe as people age. Over half of all falls result in at least a slight injury, such as a bruise, sprained ligament, or strained muscle. More serious injuries include broken bones, torn ligaments, deep cuts, and damage to organs such as a kidney or the liver. About 2% of falls result in a broken hip. Other bones (in the upper arm, wrist, back, and pelvis) are broken in about 5% of falls. Some falls result in loss of consciousness or a head injury.
Falls can cause even more problems if people cannot get up right away or summon help. Such a situation may be frightening and may make people feel helpless. Remaining on the floor, even for a few hours, can lead to problems such as dehydration, low body temperature (hypothermia), and skin sores due to pressure (pressure sores).
The effects of a fall may last a long time. About half of people who could walk before they fell and broke a hip cannot walk as well afterward, even after treatment and rehabilitation. People who have fallen may develop a fear of falling that robs them of their self-confidence. As a result, they may stay at home and give up activities, such as shopping, visiting friends, and cleaning. When people become less active, joints can become stiff and muscles can become weak. Stiff joints and weak muscles can further increase the risk of falling and make remaining active and independent more difficult. For all these reasons, falls can greatly reduce quality of life. Falls seem to be an important consideration in the decision of many people to move to a nursing home or an assisted living facility.
Rarely, falls result in death. Death may occur immediately—for example, when the head hits a hard surface and causes uncontrolled bleeding in the head. Much more commonly, death occurs later, resulting from complications of serious injuries caused by the fall.
Diagnosis
People who have fallen may be reluctant to discuss the problem with anyone, including a doctor, especially if they have not been injured. But even people who have been seriously injured during a fall and have been treated in an emergency department may be reluctant to admit they have fallen. People may be reluctant because they think falling is just part of getting older. And they do not want others to think they are helpless and now must move from their home into a more supervised environment such as a nursing home. Because of this reluctance, doctors should routinely ask all of their older patients whether they have fallen in the recent past.
If a person has fallen, doctors try to identify the cause of the fall. To do so, they ask about the circumstances of the fall, including any symptoms experienced just before the fall and any activities that may have contributed to the fall. Doctors also ask about the use of drugs—prescription and nonprescription—that may have contributed to the fall.
Doctors do a physical examination first to check for injuries and to obtain information about possible causes of the fall. Parts of the examination include the following:
Blood pressure measurement: If blood pressure decreases when people stand up, the fall may be caused by orthostatic hypotension (see Symptoms of Heart and Blood Vessel Disorders: Dizziness or Light-Headedness When Standing Up).
Heart sounds: With a stethoscope, doctors listen to the heart for evidence of a very slow heart rate, abnormal rhythms, and heart failure.
Muscle strength and range of motion assessment: Doctors assess the back and legs and check for problems in the feet.
Vision and nervous system assessment, including sense of position and balance.
Doctors sometimes ask people to do some usual activities, such as sitting in a chair and then standing up or stepping up on a step. Observing these activities may help doctors identify conditions that contributed to the fall.
If the fall resulted from an environmental hazard and no major injury occurred, no tests may be done. However, when people's physical condition could have contributed to the fall, tests may be needed. For example, when the physical examination detects evidence of a heart problem, heart rate and rhythm may be recorded using electrocardiography (ECG). This test may take a few minutes and be done in the doctor's office.
Or people may be asked to wear a portable ECG device (Holter monitor) for 1 or 2 days. Blood tests, such as a complete blood count and measurements of electrolyte levels, may be helpful in people who have been experiencing dizziness or light-headedness. If the nervous system appears to be malfunctioning, computed tomography (CT) or magnetic resonance imaging (MRI) of the head may be helpful.
Prevention
Older people can do many simple, practical things to help reduce the risk of falling.
Exercising regularly: Weight training or resistance training may help strengthen weak legs and thus may improve steadiness during walking. Tai Chi and balancing exercises such as standing on one leg can help improve balance.
Wearing appropriate shoes: Shoes that have firm, nonslip soles and low heels are best.
Standing up slowly after sitting or lying down and taking a moment before starting to move: This strategy can help prevent dizziness because it gives the body time to adjust to the change in position.
Learning a simple head maneuver: A simple head maneuver called the Epley maneuver may help some older people who feel dizzy when they move. It involves turning the head in specific ways. Doctors usually do the maneuver the first time, but people can learn how to do it themselves if it needs to be repeated.
Reviewing drugs being taken: People can ask a doctor or another health care practitioner to review all prescription and nonprescription drugs being taken to see if any of the drugs could increase the risk of falling. If such drugs are being used, doctors may be able to lower the dose or people may be able to stop taking the drug.
Having vision checked regularly: Getting the correct glasses and wearing them can help prevent falls. Treatment of glaucoma or cataracts, which limit vision, can also help.
Consulting with a physical therapist about ways to reduce the risk of falling: Some older people need a physical therapist to train them to walk, particularly if they need to use a walker or cane.
Hazards in the environment can sometimes be removed or corrected.
Lighting can be improved by increasing the number of lights or changing the types of lights.
Light switches can be positioned so that they are easily reached. Or, lights that turn on when they are touched or when they detect nearby motion can be used.
Adequate lighting for steps (inside and outside) and for outdoor areas used at night is particularly important. Steps should have sturdy, secure handrails.
Electrical or extension cords that are in the way of walking can be eliminated by adding more electrical outlets, or the cords may be tacked over doorways.
Items that clutter floors and stairways can be stored out of the way of walking.
Grab bars can be installed next to toilets, tubs, and other places for people who need something to hold onto when they stand up. Grab bars must be installed correctly, so that they do not pull out of the wall.
Raised toilet seats can help.
Loose throw rugs can be removed or taped or tacked down.
Nonslip mats should be used in the bathroom and kitchen.
Frequently used household items can be stored in cabinets, cupboards, or other spaces between waist and eye level, so that they can be reached without stretching or bending.
Learning how to safely handle potentially hazardous situations may be more important than removing an environmental hazard. Sometimes people need to pay more attention to potential hazards and think about ways to accomplish daily tasks more safely. For example, they can place cordless phones around the home so that they do not have to rush to answer phone calls.
Falls cannot always be prevented. So, people who are likely to fracture a hip—such as people who have osteoporosis—should maximize the strength of their bones by taking adequate calcium and vitamin D
and taking additional prescription drugs to slow their bone loss. Some people may consider wearing a hip protector, an undergarment with a plastic and foam pad placed over the hip, which may prevent hip fractures if worn regularly.
Knowing what to do if a fall occurs can help older people be less afraid of falling. If they fall and cannot get up, they can turn onto their stomach, crawl to a piece of furniture (or other structure that can support their weight), and pull themselves up.
Older people should also have a good way to call for help. People who have fallen several times may keep a telephone in a place that can be reached from the floor. Another option is installing a personal emergency response system (a medical alert device) that signals someone to check in on them. Most of these systems include an alert button worn on a necklace. Pressing the button calls for help.
Treatment
The first priority is treatment of injuries, such as fractures, sprained ligaments, and strained muscles. The next priority is to prevent subsequent falls and injury due to falls.
Disorders that may have contributed to the fall are treated. For example, in people who have a very slow heart rate accompanied by light-headedness, a pacemaker for the heart may be implanted. If possible, potentially harmful drugs are stopped, the dose is reduced, or another drug is substituted.
Physical and occupational therapists can help improve people's walking and balance as well as their self-confidence after a fall. They can provide tips on how to avoid falling. Therapists can also encourage people to remain active. Physical therapy and supervised balance training and stretching can help reduce the risk of falling.
