Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J

Professor Keith Hill,

Head, School of Physiotherapy and Exercise Science,

Curtin University – Keith.Hill@urtin.edu.au

Falls prevention for people living with dementia:

Education session for home care workers

Gippsland (Victoria): September 2014

Overview How common are falls among older people

What are the effects of falls on an older person

Why do older people fall

What effect does dementia have on falls

What should an older person do if they have a fall

How can a home care worker help clients to avoid falls

Case studies

Resources to help older people who fall

Falls in older people – Is it a problem???

One third of people over 65 years of age fall each year

10% cause a serious injury such as a fractured bone

Even falls that don’t cause an injury can cause loss of confidence in walking

Other factors

implicated in up to 40% of admissions to residential care

quality of life issues◦ independence◦ community living◦ active life-style◦ other

There are many possible causes of falls

Intrinsic factors

Extrinsic factors

Medications

Healthproblems

Ageing

Environment

Activityrelatedrisks

Health problems contributing to risk of falling

Poor eyesight

Arthritis in the legs

Dementia

Incontinence

Dizziness

Also includes:- other medical conditions such as stroke, Parkinson’s disease- pain (low back and legs)- low blood pressure

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Number of risk factors

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lNumber of risk factors

Modifiable and non-modifiable risk factors

There are many possible causes of falls

Intrinsic factors

Extrinsic factors

Medications

Healthproblems

Ageing

Environment

Activityrelatedrisks

Environmental problems contributing to risk of falling

Poor lighting

Loose mat or slippery / uneven surface

Poor footwear

….. having had a recent fall

The biggest risk for having a future fall is …….

Why is this important?◦ The Doctor can

assess the cause of the falls provide treatment to reduce

risk of a further fall◦ But if the Doctor is not

aware of the fall there will be no actions put

in place to reduce ongoing risk of falls

another fall is likely to occur

However many older people who fall do not tell a Doctor or other health professional

Reduced awareness of environment and safety

Agitation

Wandering

Increased unsteadiness

What effect does dementia have on a person’s risk of falling?

Even greater risk of falling

But the person with dementia may also have other falls risk factors…

Poor eyesight

Arthritis in the legs

Incontinence

Dizziness

• Poor eyesight• Dizziness• Incontinence• Arthritis • etc

OFTEN THESE CAN BE TREATED• Poor eyesight• Dizziness• Incontinence• Arthritis • etc

Case: Mary

85 yo lady Lives at home alone, has a home care worker visit twice weekly Has a personal alarm Has been falling for more than 10 years Multiple fractures from falls Medical past history includes osteoporosis, diabetes, depression,

osteoarthritis, cataracts Medications include sleeping tablets, antidepressants, and

several others Increasing unsteadiness in past few months Had a recent fall, has not seen Doctor about falls Environmental hazards

Early identification of risk: Mary

Case: Mary – what might the home care worker observe?

85 yo lady Lives at home alone, has a home care worker visit twice weekly Has a personal alarm Has been falling for more than 10 years Multiple fractures from falls Medical past history includes osteoporosis, diabetes, depression,

osteoarthritis, cataracts Medications include sleeping tablets, antidepressants, and

several others Increasing unsteadiness Had a recent fall, has not seen Doctor about falls Environmental hazards

Can the risk of falls among older people be

reduced?

YES!

What can help to reduce an older person’s risk of falls: 1. See the doctor or other health professional

If a person has a fall - even if they think it was just an accident

If a person is feeling more unsteady when walking / turning

Commences using a different walking aid

If a person is reducing their activities

What can help an older person to reduce their risk of falls: 2. Exercise

Evidence of what works in exercise in falls prevention

Group exercise programs

Home exercise programs (often prescribed by a physiotherapist)

Tai Chi- (note: different types of Tai Chi may have different effects)

Foot and ankle exercise as part of podiatric multi-faceted program (Spink et al, 2011)

Usually under intermittent supervision of physiotherapist or accredited exercise physiologist

Often need for encouragement to maintain participation

Many older people have an exercise program to do at home

What can an older person do to reduce their risk of falls: 3.

Medication review Keep medications to the

minimum needed

Take medications as prescribed

Have medications reviewed by the doctor regularly

Try to avoid / minimise use of sleeping tablets, anti anxiety tablets etc

Largest effect of any falls prevention study involved weaning people off

sleeping / anxiety medications

What can an older person do to reduce their risk of falls: 4. Vision

check

Regular vision review

Cataract surgery

◦ First eye effective

Bifocals and multi-focal glasses– can be a problem

What can an older person do to reduce their risk of falls: 5. Home

safety

Removing environmental hazards will reduce risk of falls

If having falls should have an occupational therapy home assessment

What can an older person do to reduce their risk of falls and fall injuries: Vitamin D and calcium

Many older people have low levels of vitamin D

Main sources of vitamin D are:◦ Sunlight (approx 20 min/day)◦ Some foods (eg sardines)◦ Supplements

Vitamin D and calcium together have been shown to reduce fractures and falls (in high risk samples)

What can an older person do to reduce their risk of falls injuries: Hip protectors

Useful if falling frequently, and / or if bones are weak

Will reduce risk of hip fracture substantially, if worn...

Several different types◦ Hard shields◦ Foam

Other interventions from best practice guidelines

Safe footwear

Treat posturalhypotension

Education

Treat incontinence

Change walking aid

Case: Mary – how can her falls risk be reduced?

85 yo lady Lives at home alone, has a home care

worker visit twice weekly Has a personal alarm

Has been falling for more than 10 years Multiple fractures from falls

Medical past history includes osteoporosis, diabetes, depression, osteoarthritis, cataracts

Medications include sleeping tablets, antidepressants, and several others

Increasing unsteadiness in past few months

Had a recent fall, has not seen Doctor about falls

Environmental hazards

Use her personal alarm if a fall occurs and cannot get up

Discuss hip protectors / vitamin D / possibly bone-strengthening medications

Review re cataracts-?surgery Review medications, in particular

sleeping tablets Physiotherapy assessment of balance

and mobility - ?exercise program Have a medical review AND report the

fall Home safety assessment by

occupational therapist

Case: if Mary also had dementia…

85 yo lady Lives at home alone, has a home care

worker visit twice weekly Has a personal alarm Has been falling for more than 10 years Multiple fractures from falls Medical past history includes osteoporosis,

diabetes, depression, osteoarthritis, cataracts Medications include sleeping tablets,

antidepressants, and several others Increasing unsteadiness in past few months Had a recent fall, has not seen Doctor about

falls Environmental hazards

POSSIBLE OPTIONS TO REDUCE RISK OF FALLS Use her personal alarm if a fall occurs and

cannot get up Discuss hip protectors / medications to

strengthen bones Review re cataracts-?surgery Review medications, in particular sleeping

tablets Physiotherapy assessment of balance and

mobility, and to provide an exercise program Have a review by a Doctor AND report the

fall Home safety assessment by occupational

therapist

• Dementia friendly environment• Ensure consideration of causes and management of agitation• Other …..

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Home exercise programs for people with dementia, supported by a carer, have been shown to reduce falls

Need for assessment by physiotherapist and provision of exercise program

Followup home visits, support from others (eg home care workers) to encourage ongoing participation

Exercise to reduce falls in people with dementia

David:◦ 70 year old◦ Inoperable

hydrocephalus◦ Frequent falls◦ Unable to get up after

a fall – needed ambulance call out

Successful case studies from Gippsland region (1)

Treatments◦ Home based

physiotherapy commenced (low compliance so physio home visits, as wife and carers were unable to persuade participation)

OUTCOMES• Maintained mobility • No falls• Able to remain at home for extended period

before further decline and need for Nursing Home

James:◦ 70 years old◦ Alzhiemer’s disease◦ Lived on hobby farm◦ Previously active and

enjoyed daily walks◦ As dementia progressed,

activity reduced and needed prompting / supervision

Successful case studies from Gippsland region (2)

Treatments◦ Not suitable for community

Rehab because of high level of prompting and supervision needed

◦ Home based physio exercise program introduced

◦ Wife and home care worker monitored and supported exercisesOUTCOMES

• 1.5 years later, balance had been maintained, continuing with supervised walking but small decline in endurance

Look for indicators of increased risk:◦ Signs of a fall (eg bruises)◦ Increased unsteadiness (furniture walking)◦ Change in type of walking aid used◦ Increased difficulty getting out of a chair◦ Increased environmental hazards in the home

increasing risk of trips

Ways a home care worker can assist in reducing client’s risk of falling

Report to your manager

If the client has a home exercise program:◦ ask the client about the program◦ encourage regular completion of the exercise

program

Ways a home care worker can assist in reducing client’s risk of falling

Report to your Manager or the physiotherapist

Falls are common among older people, especially in people with dementia, and can cause serious injuries and loss of confidence

All falls should be reported to a doctor

There are a number of ways that falls risk can be reduced

Home care workers can play an important role in identifying potential risks for falling among their client, and supporting participation in recommended fall prevention activities

Summary