Addressing Falls Prevention Among Older Adults, Part II: Approaching Your Patients

A VOICES 60+ Senior Advocacy Program presentation

Nimali Jayasinghe, PhD
Assistant Professor of Psychology in Psychiatry
Weill Cornell Medical College


This is Part II of an earlier presentation on Falls Prevention in Older Adults, also by Dr. Jayasinghe, entitled Understanding Why Falls Happen.

Overview

In this second session of a two-part staff development training series offered by Hospital for Special Surgery VOICES 60+ Senior Advocacy Program, Dr. Jayasinghe presented an in-depth discussion of falls prevention strategies and interventions for older adults.

Dr. Jayasinghe outlined learning objectives for the presentation, including:

  • The importance of falls prevention
  • Initiating a dialogue about falls prevention with your patients
  • Asking the right questions and screening for risks
  • Choosing prevention strategies
  • Overcoming obstacles 
  • Addressing reactions a patient may have after having a fall

The Importance of Falls Prevention

Dr. Jayasinghe explained that for adults aged 65, 70, 80, and above, their fall risks increase significantly and they may be at a higher risk of suffering injuries due to osteoporosis or other illnesses. She also said that people who live alone may be at added risk for fall and greater injury because they are unable to get up and seek help. They could suffer from dehydration, develop sores, and may not be able to get medical care to quickly address any significant harm or health issue.

Initiating a Conversation

As stated by Dr. Jayasinghe in Part I of her presentation, it may be better to ask a patient about safety, rather than falling. It’s important to be able to assess his/her risk without making the patient feel uncomfortable. Simply ask questions such as, “Do you worry about your safety? Do you think about your safety?”

If the patient is receptive to these initial questions, followup questions regarding their concerns about their falls history could include the following:

  • Have you fallen in the last few days, months, or years?
  • What were the circumstances?
  • Did you get injured?
  • Did you get support?
  • Are you worried about falling again?

It’s always good to remind patients that falling is very common and that they need not be ashamed of it. Getting a snapshot of what's been happening over the last couple of days, months, and years that might have led to tripping and falling could be very useful in understanding the problem.

A lot of people attribute their falls to their environment. They will often say:

  • “It was the clutter”
  • “It was the dog”
  • “The uneven step”

The best option would be to sit down with your patients and chat with them about what they can do to protect themselves against falling. It’s important to talk to patients about their concerns and address their needs.

As an additional aid, Dr. Jayasinghe introduced a visual analog “Fall Efficacy” scale, on which patients are asked to mark down how worried they are about falling.

Patients are asked to rate on a scale from 1 to 10, with 1 being very confident and 10 being not at all confident, how they feel performing daily activities such as:

  • Taking a bath or shower
  • Reaching into cabinets or closets
  • Walking around the house
  • Preparing meals
  • Getting in or out of bed
  • Answering the door or telephone
  • Getting dressed/undressed
  • Personal grooming
  • Getting on and off the toilet

Risk Factors

Dr. Jayasinghe pointed out the top 10 questions regarding risk factors that should be addressed with patients:

  1. Do you exercise less than three times a week?
  2. Do you sometimes feel weak, dizzy, or unsteady on your feet?
  3. Have you experienced changes in your eyesight? (Have you had a vision exam in the last year? Spectacles, cataracts, glaucoma, macular degeneration?)
  4. Do you have foot problems or ill-fitting shoes? 
  5. Have you been diagnosed with a chronic medical condition, such as:
    • Arthritis
    • Diabetes
    • Osteoporosis
    • Parkinson’s Disease
    • Depression 
  6. Do you take four or more prescription or over-the-counter medications?
  7. Do you have tripping, slipping, or other hazards at home?
    • Floors, rugs, or clutter
    • Stairs and steps
    • Bathroom (toilet, bath, or shower)
    • Bedroom 
  8. Do you use an assistive device?
  9. Do you worry about falling? So much so that you avoid things you are capable of doing?
  10. Do you know how to:
    • reach safely overhead?
    • rise from a chair/sit down safely?
    • get up off the floor safely?

In reference to the 10 risk factors, Dr. Jayasinghe shared a few points to remember:

  • “Starting at the age of 40, all of us lose about 10% to 15% of muscle mass.”
  • “1 in 5 people will have an episode of dizziness over the course of their lives.”
  • “A cane holds 25% of your body weight while a walker can take 50%.”

Reactions a Patient May Have after Sustaining a Fall

Dr. Jayasinghe reported that patients often experience some levels of distress after a fall. Literature has shown that many patients will often have a low level of confidence about performing daily activities; they could be at risk of experiencing depression and also symptoms of post-traumatic stress disorder (PTSD).[1-4]

Low level of confidence can be present in all of the daily activities covered in the aforementioned Fall Efficacy scale.

Signs of depression after falling include:

  • Little interest or pleasure in doing things
  • Feeling down, depressed, or hopeless
  • Trouble falling asleep, staying asleep, or sleeping too much
  • Feeling tired or having little energy
  • Poor appetite or overeating
  • Trouble concentrating
  • Moving or speaking so slowly that other people notice
  • Thinking they would be better off dead

Signs of PTSD:

  • Re-Experiencing 
  • Avoidance/Numbing
  • Hyperarousal

Choosing Prevention Strategies and Overcoming Obstacles

It is important to discuss patients' falls risk or expressed concerns with their physician, who may refer them to an occupational or physical therapist who would be able to teach them how to move safely after they have experienced a fall. Upon further medical evaluation for risk factors, the physician may also want to further assess their patient’s medical status, daily medication regimen, etc.

Developing a strategic plan and motivating a patient to develop a plan taking into account his or her needs, as well as providing available informational resources, will help the patient to feel more involved and safe.

  1. Educate about options
  2. Correct myths and misconceptions
  3. Problem-solve logistical issues
  4. Make a plan
  5. FOLLOW-UP!

There are many specific things that can be done in terms of falls prevention, including:

  • Medication: there might be a need to change or reduce medication.
  • Physical problems such as balance, walking, or muscle strength: these can be countered by more physical exercise.
  • Home hazards: a home evaluation might be needed.
  • Fear of falling or depression: there are support groups that can help a patient feel more in power and less afraid of falling.

Motivation for falls prevention is critical for people who are at risk of falling. It helps empower them to be able to take the steps they need to take. And it’s more effective when motivation comes from multiple voices, including their friends, family, and health care providers.

About VOICES 60+

The mission of VOICES 60+ is to enhance the medical care experience of patients 60 and over by helping them to navigate and access the care, community resources, and education they need. These training sessions seek to address staff development needs which advance the Prevention Agenda for Public Health of our hospital’s Community Service Plan.

VOICES 60+ has expanded its existing program priorities to:

  • Goal 1: Educate and raise awareness of ethnically diverse older adults on issues related to communication with their health care providers about arthritis and related needs with a specific focus on falls prevention
  • Goal 2: Increase patient safety and support at home and in the social environment by linking older adults with community partners that provide language and culturally appropriate services

References

  1. “About 25% of people who have fallen experience a PTSD Symptom instead of Depression.” (Chung, M. C., K. J. McKee, et al. (2009). 
  2. Posttraumatic stress disorder in older people after a fall. International Journal of Geriatric Psychiatry 24(9): 955-64. 
  3. 9% to 15% of people experience depression after falling. Lenze, E.J., Munin, M.C., Skidmore, E.R., Dew, M.A., Rogers, J.C., Whyte, E.M., Quear, T., Begley, A., & Reynolds, C.F. (2007). 
  4. Onset of depression in elderly persons after hip fracture: implications for prevention and early intervention of late-life depression. Journal of the American Geriatrics Society, 55, 81-86.

Summary by Jacqueline Sandoval, Program Associate, VOICES 60+ and Juliette Kleinman, LCSW, ACSW, Manager, VOICES 60+

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