1. No category

REACHING for your goal
Taking a STAND on FALLS
What can PT, OT, Activities and Nursing Staff
do to Reduce Falls?
Melinda Jaeger, PT
[email protected]
Objectives
1. Explain how the Empira Falls Prevention program
reduced the prevalence of resident falls between
20% and 30% in 16 long term care facilities.
2. Identify successful strategies of promoting
movement and offering opportunities to reach and
stand.
3. Share the journey of the Empira Falls Prevention
program- specifically the collaboration of PT and
OT and Therapeutic Rec (Activities Department)
4. Review approaches that can be incorporated in
your facility to reduce falls.
Agenda
• Provide an overview of the Empira Falls Program
• Share PT/OT fall assessment tools
• Review the important role of Therapeutic
Recreation /Activity Staff in the prevention of falls
• Demonstrate how all staff can incorporate
reaching and standing in daily cares to reduce
falls
Background & Process

Empira awarded 3-year MN DHS PIPP grant, began 10/1/08
~ A project implementing best practices from evidence based studies
~ Goal: Reduce CMS QI/QMs; Falls, Depression & Anxiety,
Decline in LL ADL, Decline in movement
~ Reduction Goal: 5% first year, 15% second year, 20% third year

16 SNFs, 4 companies participate in PIPP Fall Prevent project

Facility–wide Program: All departments, residents, family, MD

Investigation and Interventions based on Root Cause Analysis


Fall Risk Coordinator in each SNF reports to administrator
who oversees the program – it’s not a nursing program!
Project completion date: 10/1/11
Results after 2½ years
• Prevalence of Falls (number of residents who have
fallen) – decreased by 31%
(QI 1.2)
• Incidence of Depression – decreased 20%
(QI 2.1)
• Incidence Worsened ADLs – decreased 17%
(QI 9.1)
• Incidence Worsened Room Move – decreased 12%
(QI 9.3)
• Falls per 1000 resident days (number of falls that
occurred) – decreased by 14%
• Recurrent Falls – double digits to single digit
* Compared to a baseline from July 1, 2006 to June 30, 2007
Key Components To The Empira Falls Program
•All staff are responsible to reduce falls. This is
NOT just a nursing program
•Promote movement and increase functional
mobility offering opportunities for residents to
reach and stand throughout their day
•Don’t do more…..do things different
Physical Changes As We Age…
Posture
ROM
Strength
Reaction Time Slows
Visual Changes With Aging
• Acuity
•Depth Perception
•Contrast Sensitivity
•P
eripheral Visio
n
Somatosensory Changes
• Proprioception (position sense)
Ability to walk in the dark
• Sensation
Diabetic changes, numbness, tingling
• Vestibular
Works with vision to determine whether the world or
we are moving. Activated in the inner ear when we
move our head. Dizzy with position change.
• Pain
Affects all movement
BALANCE
•Combination of posture,
ROM, strength, reaction
time, visual perception
somatosensory and pain
“Balance Exercise Reduces Risk of Falling”
Journal of the American Geriatrics Society,
December 2008
Strength training alone may not effectively reduce
falls since impaired balance is a stronger risk factor
for falls than poor muscle strength.
Walking programs did not appear to have much
effect in preventing falls.
The greatest effect in preventing falls were seen
with exercises that challenged balance.
How can YOU encourage Standing
•Stand at the sink
•Pause during the transfer
•Allow standing for a moment
Little time but BIG rewards
TRANSFER POLE
ENCOURAGE
STANDING
Fitting Balance During ADLs and Cares
• Wheel chair locked
Adapt if necessary with extenders, tennis balls,
or auto lock if they forget to use brakes
Encourage to self propel
• Feet flat on floor
Bed at proper height
Encourage ankle strengthening by tapping feet
• Change position Slowly
Count to 4 stay off the floor
• Encourage reaching, turning and weight shifting
during cares
Improves balance and flexibility
Reaching and Turning in ADL’s
• Turn to get toilet paper and do self hygiene
• Reach for towel at sink
• Turn and reach for clothing items once set up
• Lift arms and lift head to assist with dressing
• When offering something to resident have them
reach- kleenex, snack, toothbrush, ?????
• Encourage self propel wheelchair (works lots of
muscles, posture, balance and independence)
Ambulation Programs
TALL
• Stand
• Keep walker close
• Good shoes
• Stepping: Length and height of step
• Use distraction
• Parkinson’s walk past destination to decrease
freezing in place
• Stand in place and shift weight from leg to leg
•FOCUS ON STANDING AND BALANCE
EVERYONE IS RESPONSIBLE TO REDUCE FALLS
•ACTIVITY STAFF WERE KEY TO OFFER
OPPORTUNITY TO REACH AND STAND TO
REDUCE FALLS…..
•Here’s how we implemented this strategy.
Independent Risk Factors for Falling Among Community-Living Older Adultsa,b
Tinetti, M. E. et al. JAMA 2010;303:258-266.
Copyright restrictions may apply.
Name ____________________________________________ Med Record# ____________
Room________________
Recommendation for Ther Rec Program
*Static balance
*Dynamic balance
AD
indoors_________
⃞ hands free
AD
outdoors________
*Static Balance: front reach while upright ⃞ 1 hand support
⃞ 1 hand support
I A gait
*Dynamic Balance : kick, bend,
⃞ 2 hand support
⃞ 2 hand support
I A curb
reach overhead, retro gait
⃞ Assist by staff
⃞ Assist by staff
I A stair with rail
⃞ hands free
I A van/bus step
⃞ seated programming only
W/C only for outing
Precautions:
Therapist initial ________________________________ Date______________________
The A, B, C’s
AMBULATE
BALANCE
CHAIR
Offering Opportunities to REACH
Wheel chair bound can improve balance
•Promote core strengthing
•Improves balance
•Practical in everyday activities- reach
for items
•Let’s try it….sit ups and balance seated
Balance Challenges
Easy……………..Difficult
Head straight
Reach
Wide stance
Head turned
Push
Pull
Feet together
Head lift
Eyes closed
Overhead
Turn
Tandem
One leg
Reaching and Turning in ADL’s
• Turn to get toilet paper and do self hygiene
• Reach for towel at sink
• Turn and reach for clothing items once set up
• Lift arms and lift head to assist with dressing
• When offering something to resident have them
reach- kleenex, snack, toothbrush, ?????
• Encourage self propel wheelchair (works lots of
muscles, posture, balance and independence)
SAFETY
 Wheelchair
brakes lock
 Chair sturdy with arms
 Table secure
 Using Assistive device as appropriate
 Wearing glasses, hearing aide
 Proper footwear
 STOP if pale, shaky, dizzy,
 Report any change in demeanor
 If in room, make sure bed is correct height
Your Activity Calendar
Do the Activities
Promote
Standing and
Balance?
STAND UP↑
Charades Noodlin’ (Exercising the brain and body)
Have the resident stand in front of a table with a chair behind, leg rests removed. Pass out noodles, alternate
colors. Say the action and have the residents act out the action with the noodles.
• Hammer
• Wave flag
• Rolling pin
• Hold the pole on the bus-
• Make an X in the air
• Sword fight across the table
• Statue of Liberty
• Shakers
stand on toes, rock back on heels
• One side of table put down their
• Cast the fishing pole
noodles, do tug of war across
• Catch the fish
• Steering wheel **free hand balance
• Paddle the canoe
• Open drawer ** free hand balance
• Lawrence Welk band conductor• Close drawer ** free hand balance
• Iron the clothes
• Marching band director and march
• Stir the soup
• Twirl the baton
• Helicopter
Song: New York… New York
Slide to middle of chair so 4” is between chair and resident, feet flat on floor. Sit TALL. Have resident pass
noodle to neighbor high or low. Switch it up.
Hold noodle at arm’s length. Tap feet through out: Start the music and have fun!
1. Push and Pull
2. Push Left – Center – Right while kicking alternate legs
3. Twist right hand on top – Twist left hand on top (Steering
wheel)
4. Turn head and swing left – center – Turn head and swing right
5. Lift alternate knee to noodle
6. Paddle left – Paddle right
7. Kick noodle with alternate feet while switching noodle in hands
8. Tap noodle in front to left –to right while tapping feet
9. Sway noodle overhead while looking upward
10. Touch head- shoulder- knee- shin-knee-shoulder -head
11. Draw circle in air several times then draw big X several times
12. Sway side to side ……end with holding noodle out and shaking
it!!
When turning in the noodles have those with red noodles stand and pass theirs in. Then yellow stand and pass....
Exercise With Complex Activity
•Increases neurotransmitters
•Stimulates neuron growth
•Strengthens and expands brain network
Challenging Leisure Activities
•Dancing, of all kinds, is the most
effective activity as far as decreasing
risk of dementia and cognitive decline.
•Playing board games and musical
instruments, doing word puzzles and
reading also decrease your risk.
(Cohen, 2005)
Meaningful Activities
Personally Relevant/Important, Contribute to Wellbeing
• Brings back good memories
• Relaxing
• Enjoyable
• Makes you laugh
• Makes you feel healthy
• Makes you feel good about yourself
• Let you try something new or get better at something
• Helps you express your feelings,
• Validates life experiences
Diagnosis Specific Strategies
 Parkinson’s - direct past destination, count or
encourage long steps to ↓ shuffle, work on
posture
 MS - don’t overtire, heat intolerant
 Arthritis - encourage ROM, awareness of flare
ups, avoid heavy weights
 Osteoporosis – avoid flexion and weights
 Macular Degeneration – avoid bright light, poor
central vision, poor contrast, ↓ face recognition
 Dementia – ↓ distractions, use calm, reassuring
manner, familiar activities
•A personal invitation and the support of
family and friends will encourage older
adults to take part in fall prevention
programs.
Stepping It Up
• Golf Putting
• Bean Bag Toss
• Bowling
• Wii
• Ball Toss
• Dance to Music
• Cooking
• Art
• Walk Through Europe
or Walk to Hutchinson
• Massage
• Tai Chi
Community Involvement
• Quilting
• Card Club
• Book Club
• Gardeners Club
• Art Class
• Tai Chi – Chair Yoga
• Support Group: Grief/Loss, Parkinson’s
Stroke, Diabetes, MS
Bright Light promotes the
secretion of Serotonin
• Serotonin is the “happy, feel good” biochemical.
• It regulates mood and provides a sense of well-being and
happiness.
• It also helps to regulate appetite, wakefulness, sleep, and
the cognitive functions of memory and learning.
• Serotonin is also a growth factor for some cells, which
gives it a role in healing, especially wound and skin healing.
• Serotonin is triggered by the presence of bright light.
More light = more serotonin produced
Less light = less serotonin produced.
LIGHT METER TO MEASURE LIGHT
$33 on Amazon
500- 1000 lux for 120 min (Indoors)
10000 lux for 30 minutes (Out Doors)
Happy Light …It outputs up to 2500 lux (150
watts) of Natural Spectrum® daylight from a
cool burning 26 watt bulb.
Measures 9" H x 4 3/4" W x 2 1/4" D. UL
listed. $39.00
OR..
Open the blinds and let the sun in!!
NO BENDING
•Use reacher
•Use long handle shoe horn
•Use elastic shoe laces or easy
shoes to put on
•Keep room accessible so resident
does not bend
•Keep items out of low drawers
•Keep floor clean
Incorrect FootwearSlippers…
Gripper socks a real
hazard on carpet!
Lets try it out
Shoe Brochure
On Admission
Falls Trending Report
• What is it
• What does it mean to TR
5-5:59
4-4:59
3-3:59
2-2:59
1-1:59
12-12:59AM
11-11:59
10-10:59
9-9:59
8-8:59
7-7:59
6-6:59
5-5:59
4-4:59
3-3:59
2-2:59
1-1:59
12-12:59PM
11-11:59
10-10:59
9-9:59
8-8:59
7-7:59
# of
6-6:59AM
August 2012 Falls In One of Our NH
6
5
falls 4
3
2
1
0
Time of day
R- August 2012 Fall Summary
Critical times to provide activities
1-3 p.m.
• Routine time for naps- Naps rob the sleep bank
Nap
NIGHT SLEEP
How long does it take to put a resident down for a
nap?..The NAR can use this time instead to engage
the resident. Activity staff can focus on activities
during traditional nap times to reduce boredom.
Purpose:
To provide active, purposeful
engagement for residents to reduce
boredom(apathy), napping and
pharmacological treatment for
behaviors which disrupts sleep.
Focus on the Dementia resident who is unable to initiate self
driven activities.
CMS NATIONAL GOAL
REDUCE ANTIPSYCHOTICS BY 15%
• Nursing Homes antipsychotic drug use is available on
Nursing Home Compare
• Antipsychotics increase fall risk in elders
• CMS is emphasizing non-pharmacological alternatives for
nursing home residents including: consistent staff
assignments, increased exercise of time outdoors,
monitoring and managing pain and planning
individualized activities.
Activity Improves Sleep and Decreases
Agitation
• 1 nursing home 29 residents over 14 weeks
• Sleep efficiency improved from baseline of 51.7% to
62.5% (17% improvement)
• Control group Sleep efficiency was 66.3 at baseline,
after 14 weeks 67% (no change)
• 7 of 15 residents who had activities during 14 weeks
had decrease in observed agitation
• Control group only 1 of 14 had decrease in observed
agitation.
Alessi CA, Yoon EJ, Schnell J et al. A randomized trail of a combined physical
activity and environment al intervention in nursing home residents: do sleep and
agitation improve” J am Geriatr Soc 1999 47:784-91
ACTIVE ENGAGEMENT
• Pulls participants out of a passive state, expending energy, providing
pleasure and movement opportunities, and reducing other
neuropsychiatric symptoms”
(Buettner, Fitzsimmons & Dudley, 2010)
Need to reduce apathy to reduce agitation
INTEREST BOX IDEAS
• Fishing Box
• Jewelry Box
• Recipe Card/Spices
• Sales Receipt Box
• Envelope and Stamp
• Scratch and Sniff Sticker
• Playing Card Box, dominoes
• Sports/Gardening
• Key and Lock
• PVC pipe fitting
•Your Ideas
Share Activity Ideas – What can I
implement tomorrow????
•What should go in the activity bin for NARs
to engage the resident during traditional
nap hours? Simple, easy set up, cross
cultural and gender
•What will TR Dept provide during nap
hours?
Engaged (busy) Residents
•Sleep better
•Have less falls
•Have less depression
•Have less behaviors
August 2012 Falls In One of Our NH
6
5
# of falls
4
3
2
1
0
Time of day
R- August 2012 Fall Summary
Critical times to provide activities
6- 8 p.m.
• Delay the bed time for residents so they do not
awaken at 2-3 a.m.- promotes restorative sleep
• Utilize managerial staff talents to “entertain” engage
the residents. Great opportunity for management
and non clinical staff. Wonderful modeling for NARs.
How can we all participate in engaging the
residents?
• Nonclinical staff- housekeeping , maintenance,
business office,
• Managers
• SW, Chaplains
• TR
• NAR
• Nurses, LPN, TMA
• Families
• Volunteers
volunteermatch.org
• Other Residents
What did you see?
Resident is leading this activity
SHARING & CARING
PIPP RSVP Project
Facility Managers Share their Talents to
Improve Care of our Dementia Residents
Providing Meaningful Engagement
WIFM- What’s in it for me?
• One flex day per month to come in later and work through 7 p.m.
Morning free to schedule appointments.
• The rewards of sharing your talents, skills with the residents of your
facility. An opportunity to build relationships.
• Budget neutral- doesn’t cost the facility $ but provides programming
for the resident.
• Gives management an opportunity to review evening shift practices
and systems.
• Great visibility to the NAR and front line staff. They feel supported in
their role of caring for the resident.
• Meets CMS directive to provide non-pharmacological alternatives for
dementia Nursing Home residents.
WHAT WILL I DO?
• 6-7 pm will fill the void after dinner and before bed. The residents need an
activity
• Share your talent
• Musical- piano, harmonica, sing, guitar
• Read poems, discuss POSITIVE events in the newspaper, use the
resource bin with books on elder nostalgia, trivia
• Talk about a recent trip, your garden, your recent smart phone apps,
bring in props for residents to see and touch
• Use magazines to create collage, draw together
• Play dominoes, shake dice, shuffle and sort cards
• Use the resource bin on the unit which has hand lotion for hand
massages, horseshoes and bean bag toss for physical games, lots of
activities provided for you
• Also have the 101 activities resource for ideas in this folder
101 Things to do with a
person with Alzheimer's
.
and Dementia Disease
Provide existence with
meaning. Make each activity
success oriented, failure free,
purposeful and meaningful
1. Make collage from magazine
2. Put together nuts and bolts
3. Bake cookies
4. Read paper
5. Invite children to visit
6. Read a letter out loud
7. Listen to music
8. Parachute game
9. Color/Paint
10. Make lemonade
11. Wipe off table
12. Talk about gardening
13. Make Pigs-in-a-Blanket
14. Spelling bee
15. Readers Digest
16. Fold clothes, sort socks
17. Pet visit
18. Cut out cards
19. Wash silverware
20. Bake bread
21. Sort objects
22. Sing Christmas songs
23. Life Review
24. Put silver away
25. Make a Valentine's collage
26. Sing songs
27. Look out window, what do you see?
28. Make a pie
29. Read a poem
30. Dye Easter eggs
31. Sort socks
32. Take a walk
33. String fruit loops
34. String cranberries
35. SNOEZELEN ®
36. Look at photos
37. Reminisce
38. Clip coupons
39. Sort poker chips
40. Count things
41. Fold towels
42. Afternoon Tea
43. Reminisce/Inventions
44. Play a game
45. Paint
46. Cut out paper dolls
47. Identify states and capitols
48. Make a family tree
49. Color American Flag
50. Cook hot dogs
51. Grow magic rocks
52. Water house plants
53. Reminisce - first kiss
54. Play horseshoes
55. Dance
56. Sing a hymn
57. Make ice cream
58. Plant bulbs
59. Make cards
60. Sort cards by suit
61. Write a letter
62. Dress in team colors-talk sports
63. Pop popcorn
64. Name the U.S. Presidents
65. Give a manicure, hand massage with scented lotion
66. Music, Movement & Props
67. Plant or weed
68. Make a may basket
70. Finish a famous saying
71. Feed the ducks
72. Mold dough
73. Picture books
74. Put a simple puzzle together
75. Sand wood
76. Rub on hand lotion
77. Decorate place mats
78. Arrange fresh flowers in a vase
79. Remember famous people
80. Rake leaves
81. Make a fruit salad
82. Sweep the patio or room
83. Talk about famous events
84. Nursery Rhymes. You start
85. Make sandwiches
86. Dust furniture
87. Cut up paper/ Tear paper
88. Take care of bird cage/fish tank.
89. Trace/cut leaves
90. Simple trivia questions
91. Finish Bible quotes
92. Paint with string
93. Cut out pictures
94. Read/listen to a short story
95. Put coins in a jar
96. Sew sewing cards
97. Put seed in bird feeder
98. Clean out pumpkin
99. Roll yarn
100. Reminisce about vacation
101. Make a cake
Exercise and Brain Health
• Inactivity kills our brains-physically shrinking
them.
• If your brain isn’t actively growing, then it is dying.
• Toxic levels of stress and chronic depression erode the connections
between billions of nerve cells and shrinks certain areas of the brain.
• Exercise has a profound impact on cognitive abilities and mental
health.
• Because the aging brain is more vulnerable to
damage, anything you do to strengthen it has a more pronounced
effect than it would on a young adult.
• Exercise is preventive medicine as well as an antidote.
Good Strategies to Reduce Falls
• Keep awake with bright light, in front of windows or
outdoors. Residents are bored….not sleepy!
• Keep it simple, no distractions (clutter free, quiet)
• Make eye contact and use body language that is
positive (I want to be here, I have time, you are
important)
•Follow Human Biological Clock
• Stimulate the senses- Smell, Visual, Touch,
Proprioceptive, Vestibular, Auditory (sound) and Taste
Human Biological Clock: Ideal 24 Hours
(3:30 PM)
Serotonin secretion starts
(6:00 PM)
20:00 Serotonin
(8:00PM)
Lowest blood pressure
Greatest healing and growth occurs
secretion stops
Aromatherapy
• Aroma targets different neuro-chemicals in
the brain
Aromatherapy
• Certain studies involving brain wave frequency
indicated that smelling lavender increases alpha
waves in the back of the head which calm and
reduce falls
J Am Geriatr Soc. 2012 Jun;60(6):1005-11. doi: 10.1111/j.1532-5415.2012.03977.x. Epub 2012 May 30.
Fall prevention using olfactory stimulation with lavender odor in
elderly nursing home residents: a randomized controlled trial.
Sakamoto Y1, Ebihara S, Ebihara T, Tomita N, Toba K, Freeman S, Arai H, Kohzuki M
• The fragrance of jasmine and citrus increases
beta waves in the front of the head, which are
associated with a more alert state.
• Peppermint applied topically causes nerves to be
less stimulated and pain relieved
PUTTING IT ALL TOGETHER
EVIDENCE BASED PROGRAM
• “Balance Training Program is Highly Effective in
Improving Functional Status and Reducing the Risk of
Falls in Elderly Women with Osteoporosis.” MM.
Madureira, PhD., et al., Osteoporosis International, Vol. 18, pp. 419 –
425, 2007.
• “Effective Exercise for the Prevention of Falls in Older
People: A Systematic Review and Meta-Analysis.”
Catherine Sherrington, PhD., et al., Journal of American Geriatric
Society, Vol. 56, pp. 2234 – 2243, 2008.
• “Not Preventing Falls – Promoting Function,” Elizabeth
Capezuti, RN, PhD, et al., Geriatric Nursing, Vol. 32, No. 1, p. 55 - 57.
January/February 2011.
We all have a role in managing falls
•No alarms,
•Standing, Reaching, Balance!
•Bright light during the day to promote
wakefulness.
•NO naps. Provide engagement at key times
•What will you do to prevent falls when you
get back to your facility?
Workshop Wrap Up
1.
2.
3.
4.
5.
6.
214 Bed Home Average Quarterly Falls
per 1000 Resident Days
8
7.5
7.9
7
6.5
7
7
6.8
6 6.6
6.2
5.5
6.1
5.9
5.9 6 6
5.7
5
5.6
5.5
5.4
5.2
4.5
5.1 4.9 5.1 5.1 5
4
Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
'08 '09 '09 '09 '09 '10 '10 '10 '10 '11 '11 '11 '11 '12 '12 '12 '12 '13 '13 '13 '13