postural correction, fear of falling, poor balance strategies, dizziness, or avoidance behaviors. This may require physical and/ or occupational therapy in addition to the fall prevention classes that may be available. Clinicians should progress therapeutic goals as well as the types of exercise performed in the fall prevention exercise classes. This may require collaboration with the instructor of the fall prevention program in order to identify the most appropriate level of exercise difficulty and intensity. Long-term care setting Older adults who reside in long-term care facilities, who are at high risk for falls, or who have already fallen do not have as many evidence-based options for fall prevention as community- dwelling adults. This is unfortunate, as approximately half of ambulatory long-term care residents fall at least once a year (AGS/BGS, 2010). Although several studies have investigated single interventions, such as hip protectors, fall alarm devices, medication review, removal of physical restraints, fall prevention education, and vitamin supplementation, there is insufficient evidence to support any single intervention. Multifactorial interventions in long-term care, including structured exercise, also have been explored, but there is insufficient evidence for or against any of these singular interventions. Clearly defined results are difficult to achieve in this setting due to the wide variety of functional levels and the presence of compounding factors such as dementia and frailty. The AGS/BGS guideline does consider (with caution) the use of exercise programs for long-term care residents, although there is no proof that they decrease falls (AGS/BGS, 2010). Vitamin D supplementation for this population has been useful in fall prevention for older adults with vitamin D insufficiency. Vitamin D insufficiency can result from inadequate nutritional intake of vitamin D, inadequate sunlight exposure, disorders limiting vitamin D absorption, and conditions impairing vitamin D conversion into active metabolites. This is a simple, low-cost intervention (Annweiler et al., 2010). Vitamin D insufficiency has been associated with muscle weakness in proximal muscle groups, such as leg extensors, which are crucial for sit to stand. Supplementation of this vitamin can decrease falls and increase bone density (Janssen, Samson, & Verhaar, 2002). Therapists should be aware of patient complaints that may signal presence of this problem. Patients may describe a feeling of heaviness in the legs, tiring easily, and difficulty in mounting stairs and rising from a chair (Janssen et al., 2002). Changing the environment in a long-term care facility has shown promise in reducing injuries from falls and incidence of falls (Quigley, 2015). Suggested environmental changes that can decrease extrinsic fall risk factors include the following: ● Eliminate slipping and tripping hazards. ● Keep the bed at the proper height during transfer and when the patient rises to a standing position. ● Don’t keep the bed in a low position at all times. ● Check chairs, toilets, and safety grab bars for potential safety problems. ● Use proper room lighting. ● Make sure the patient wears proper footwear (not just nonskid socks). (Quigley, 2015) Decreasing severity of injury secondary to a fall can be accomplished by using protective equipment (such as floor mats and hip protectors), video surveillance, chair alarms, and eliminating sharp edges (Quigley, 2015). Although there is little evidence to support fall prevention interventions for older adults with dementia, there is growing interest in attempting to decrease fall risk with cognitive therapy (Smith-Ray et al, 2013). In a 2013 study with 51 participants living in independent living communities, cognitive training provided over a 10-week period had a significant effect on gait and balance as measured by the TUG test, gait speed, and gait speed with a cognitive distraction (Smith-Ray et al, 2013). The training was comprised of a computer-based cognitive
training programs instructed by gerontology researchers. The programs challenged visuospatial working memory, processing speed, and visual attention through the use of games. Although these participants were residents in independent living, this intervention may show promise in the long-term care population as well. A small number of studies have explored dual-tasking during activities such as treadmill walking and playing a gaming system programs. One study of 518 adults in a psychogeriatric ward did find promising findings on number of falls as a result of a multifactorial intervention with individually tailored therapy (Neyens et al., 2009). The study did not describe the details of the therapeutic interventions. More research is needed to determine which interventions can decrease fall risk in older adults with dementia in a variety of living environments. Frailty is another common geriatric syndrome that can potentially influence the effectiveness of interventions designed to decrease fall incidence in a long-term care setting. In a 20- week multicenter study involving 15 homes for the elderly, a moderate-intensity group exercise class was able to decrease falling and increase physical performance in pre-frail older adults, but not in the frail cohort (Faber, Bosscher, Chin A Paw, & van Wieringen, 2006). The risk for falls increased as the degree of frailty increased. If older adults are considered frail, then clinicians who intend to implement a fall risk program should adjust exercise interventions to match the level of physical performance for these frail adults, but can expect better results in a pre-frail versus frail population. They may need closer supervision during balance and gait activities. Hospital-based setting For older adults in a hospital setting, there are no adequate randomized controlled trials of multifactorial interventions proven to decrease falls. For older adults who are hospital inpatients, a multifactorial approach, although unproven, is typically a clinically appropriate approach for physical or occupational therapists who may be treating this adult for an unrelated diagnosis. Any inpatient over 65 years of age should be asked about fall history, gait, and balance, as previously described, especially those who may have been admitted as a result of a fall. Most hospitals remove trip hazards from patient rooms and maintain dry surfaces. At a minimum, clinicians should ask every older adult about falls in the past 12 months, circumstances surrounding the falls, and if the older adult has difficulty with gait or balance. More research is needed for fall prevention in this setting. A common fall risk assessment form used by nursing in the hospital setting is the Schmid Fall Assessment Tool (Lee, Lee, & Khang, 2013). This tool includes evaluation of the patient’s mobility, mentation, toileting, fall history, and use of psychoactive medications. A score of 3 or more is considered as an increase in fall risk, triggering the use of the following interventions: ● Appropriate orientation strategies. ● Access to patient’s hearing aids or glasses. ● Call bell. ● Access to patient’s personal items. ● Use of patient’s walking aids. ● Frequent comfort rounds. ● Patient and family education about fall risk. ● Early and frequent mobilization. ● Nonslip footwear. ● Elimination of barriers to transfer or ambulation. In a systematic literature review by Cameron and colleagues (2012), the authors found evidence of reduced fall rates with multifactorial interventions, but only inconclusive evidence for decreasing risk for falls in the hospital setting. More evidence is needed. Homebound setting Older adults who are homebound, at risk for falls, or have fallen have fewer evidence-based options for fall prevention ● Minimization of use of restraints. ● Use of bed alarm when necessary.
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Book Code: PTCA2622B
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