Preventing Falls in Acute Care   19  

Deanna Gray-Miceli and Patricia A. Quigley

OVERVIEW

Three specific aims of any effort in acute care institutions to reduce falls among older adults are (a) to reduce risk of injury from falls, including fatal falls; (b) reduction of injury; and (c) to champion an interprofessional fall-prevention program to prevent patient falls and fall-related injuries. These three aims seek to promote improvements in patient safety by reducing preventable falls through system-wide solutions whenever possible (The Joint Commission, 2006).

Overall, across all patient settings, evidence exists that fall-prevention programs are effective. The RAND report cites, from a meta-analysis of 20 randomized clinical trials (among all patient settings, but mostly long-term care), that fall-prevention programs reduced either the number of older adults who fell or the monthly rate of falling (U.S. Department of Health and Human Services, 2004). Hospital-based studies are emerging that provide solid scientific evidence of the effect of fall-prevention programs on fall rates and, more important, fall-related injuries.

Oliver et al. (2007; Oliver, Healy, & Haines, 2010) have produced a compilation of the best evidence of practice innovations used by hospitals across the United States and the United Kingdom, and their outcome effect on falls and injury reduction. After careful scrutiny (Oliver et al., 2007, 2010), they have identified the key components guiding multifactorial interventions used to prevent falls in hospitals (i.e., education, use of toileting schedules, and alarm devices). Oliver et al.’s (2007) approach has analyzed and weighed the individual intervention—within the multifactorial intervention—into its constituent parts, thereby minimizing any methodological design issues (Oliver et al., 2010). Many of these multifactorial interventions are targeted on education initiatives and environmental issues, or they seek to improve equipment implicated in falls. Recent evidence from systematic reviews consistently suggest that, in acute hospitals, no single interventions are fully supported, rather multifactorial interventions in facilities may reduce falls by 18% to 31% (Oliver et al., 2010). To be most effective, action needs to be taken by both leaders and by frontline staff, to be championed by all members of the interprofessional team, including support workers, and tailored to the preferences and needs of individual patients (Degelau et al., 2012; Ganz et al., 2013; Oliver et al., 2010; Shekelle et al., 2013; Spoelstra, Given, & Given, 2012).

Before beginning any discussion on specific individual fall and injury prevention interventions, the acute care nurse must realize her or his role in championing a team effort in fall and injury prevention. Professional nurses are uniquely poised because they know the biopsychosocial and functional needs of their patients and situational contexts of how patients respond to the acute care environment. Such individual knowledge of each patient the nurse cares for positions the professional nurse, along with leadership skill, in a unique position to champion teamwork on their acute care unit.

BACKGROUND AND STATEMENT OF PROBLEM

The Importance of Fall and Injury Prevention in Acute Care

Many of the adverse health care outcomes resulting from falls, such as injury and/or functional decline, typically strike those patients older than 85 years and can be prevented. The most serious outcome is a fatality. The National Center for Injury Prevention and Control (NCIPC) ranks fatal falls as the number one cause of unintentional injury–fatality among older adults aged 65 to 85+ years between 1999 and 2010 (Centers for Disease Control and Prevention [CDC], NCIPC, 2015b). The fatal fall incidence increases with age—those older than 85 years being the most vulnerable.

Falls with injury populate our health care delivery system at alarming rates, resulting in more than 2.4 million injuries treated in emergency departments (EDs) annually, 772,000 hospitalizations, and more than 21,700 deaths (National Council on Aging, 2012). The CDC reports that every 29 minutes an older adult dies from a fall-related injury. Reported hospital in-patient falls vary according to the type of study conducted, that is, multi-site or single-site study, the type of unit (medical–surgical, telemetry, rehabilitation, or other), skill mix, and total number of nursing hours per patient day. The rate of falls in acute care hospitals, drawn from single-site studies, is estimated to range from 1.3 to 8.9 per 1,000 bed days, which translates into well more than 1,000 falls per year in a large facility (Oliver et al., 2010). The rate of falls, drawn from multisite studies, however, increases to three to five falls per 1,000 bed days (Oliver et al., 2010). In terms of unit type, recent evidence from a longitudinal study using National Database of Nursing Quality Indicators (NDNQI) data found the mean fall rates for most unit types are stable or are decreasing, whereas those for surgical units increased over time (He, Dunton, & Staggs, 2012). Changes in practice are cited as potential key drivers behind the increased rate of falls postsurgery. As early ambulation is encouraged, more patients on these units are out of bed. Fall rates have also been associated with registered nurse skill mix and total nursing hours per patient day. In He et al.’s study, lower fall rates were significantly associated (p < .001) with higher registered nurse skill mix and total number of nursing hours per patient day.

Serious injuries resulting from falls range from minor to severe types of injuries, such as hip fractures and traumatic brain injury (TBI), among others. And although we would like to believe that seemingly “minor” strikes to the head, spine, or limbs produce minor injury, evidence shows this simply is not true. We now know ground-level falls from a standing position among older adults older than 70 years cause more severe injuries, and those afflicted are less likely to survive compared with adults younger than 70 years (Spoelstra, Given, & Given, 2012). In fact, those 70 years and older are three times as likely to die from these low-level, ground falls compared with adults younger than age 70 years. Evidence suggests that seemingly minor strikes to the head can result in tears in cranial blood vessels and subdural matter (Weisberg, Garcia, & Strub, 2002). Given these findings, significant changes in clinical practice approaches are urgently needed for early identification of serious complications related to head trauma in older adults who appear to have “minimal head trauma, no obvious signs of head injury or concussion.” New evidence supports a ramping up of the classic markers of head injury toward greater vigilance in recognition of other critical signs and symptoms of head trauma. Ergo, it is just not enough to assess older adults for risk of falls, but one must assess for risk for injury. Convential practice has always drilled into practitioners the need to assess for hip fracture injury or spinal fracture injury. Stepped up changes are warranted for heightened surveillance by health care professionals for all types of injury outcomes, most important, TBI as well as hip fracture. A brief overview of the evidence related to TBI and hip fracture incidence is presented.

Traumatic Brain Injury

About 1.7 million people sustain TBI annually (CDC, 2015a). Of all external causes implicated in TBI, such as assault, being struck, motor vehicle accident, falls account for 35%. The CDC reports falls as the leading cause of TBI for adults aged 75 years and older (CDC, 2015a). Of all the TBI-related ED visits in the United States during 2006 to 2010, the 65-years-and-older age group accounted for 81.8% of the TBI-related ED visits (CDC, 2015b). This age group also has the highest rates of TBI-related hospitalization and death. Because of limitations in study design, baseline health status, and inability to grade injury severity across studies, we have much less evidence of who, among the 75+-year-old cohort carries the greater risk for TBI. Is it the patient with type 2 diabetes, Parkinson’s disease, or those patients on anticoagulation medication? One study that relied on a 15-state CDC TBI surveillance system found an increased incidence of depression, dementia, and Parkinson’s disease in patients with fall-related TBI (Coronado, Thomas, Sattin, & Johnson, 2005).

The issue of increased comorbidity has been suggested as a likely contributing factor for the higher incidence of TBI in persons 65 years and older, owing to increased use of aspirin and anticoagulation in management of these chronic conditions (Thompson, McCormick, & Kagan, 2006).

Groups at risk for the development of TBI include men, who are twice as likely to sustain a TBI, adults aged 75 years or older, and African Americans who have the highest death rate from TBI (CDC, NCIPC, 2007). Older adult residents who experienced head injuries from a fall were more likely to live in assisted living (47.9%; p < .04) and to be walking at the time of their fall (69.0% versus 36.1%) compared with older adult fallers without a head injury (Gray-Miceli, Ratcliffe, & Thomasson, 2013). The link between ambulation and head injury when fall occurs from a standing position has clinical relevance across all settings of care.

Physiological changes in the brain matter itself, seen with aging, have also been suggested as contributing factors to the increased risk of TBI in older adults. It has been suggested that dura matter becomes more adherent to the skull with age (Thompson et al., 2006) giving way to the development of tears even with minor strikes or blows to the head. The field of cellular neuroscience has also isolated changes of the microglia, rendering them weaker against protection of the brain after an ischematic or traumatic insult (Lourbopoulos, Erturk, & Hellal, 2015). Although it is unknown, age-related changes among older adults’ brain tissue and supporting structures may underlie accumulating evidence, which has shown that elderly patients with TBI have worse mortality and functional outcome than nonelderly patients who presented with head injury despite lower injury severity (Susman et al., 2002). Noted neurosurgical experts report that when the head hits a stationary object, such as the patient hitting his or her head on the floor, “lesions are produced in the white matter of the brain from these shearing forces … resulting in strain and stretching of axons and vessels.” This damage is in addition to any bleeding or clot formation (Weisberg et al., 2002, p. 2).

Hip Fracture

The news headline, well known to older Americans, reads: “Death or Immobility Often Follows Hip Fractures in Nursing Homes.” This common adverse outcome of a fall is realized not just in nursing homes, but also among those living independently in the community. The CDC estimates that more than 95% of hip fractures are caused by falling, often sideways, on the hip (CDC, 2015c). Annually, at least 258,000 hospital admissions for hip fracture among those 65 years and older occur nationwide (CDC, 2015c).

Women, especially White women, carry the greatest risk for hip fracture compared with men (National Hospital Discharge Survey), African American, or Asian women (Ellis & Trent, 2001). An underlying diagnosis of osteoporosis increases risk for fall-related hip fracture (National Osteoporosis Foundation, 2013). There are 54 million people with osteoporosis and/or low bone mass (43.4 million with low bone mass and 10.2 million with osteoporosis; National Osteoporosis Foundation, 2013). Classic risk factors for osteoporosis, pertinent to hospitalized patients, include immobility, insufficient calcium or vitamin D supplementation, and lack of weight-bearing exercises owing to the acute treatment of other diseases.

The U.S. Preventive Health Task Force recommends screening for osteoporosis in women aged 65 years and older and in younger women with other circumstances (U.S. Preventive Services Task Force, 2013). Health-promotion activities, including regular screening for osteoporosis, begin with a complete health history. Once detected, osteoporosis is treatable by medications that build bone, supplementation of calcium and vitamin D, coupled with regular walking and exercise. Although it would seem advantageous to recommend the use of hip pads to protect the hip bone from injury during a sideways fall, there is insufficient evidence to recommend hip protectors routinely for all persons at risk of a fall.

Falls with injury remain a major prioritized patient safety focus when considering that, in 2010, older adults who were aged 65+ years accounted for approximately 45% of the inpatient population. The repeat-fall age group is 75 years and older and compromised 28% of the inpatient population (CDC, 2015c).

Older adults in acute care hospitals are a vulnerable population at risk of falls and falls with injury, be it from age-related factors, disease-related factors, medications, functional declines or disabilities, or for all of these reasons taken together. Therefore, the nurse’s antenna for suspicion for injury should be raised so that assessment for these serious types of injuries predominate our postfalls and fall risk analyses.

FALLS AND INJURY RISK ASSESSMENT

The older adult’s risk potential of incurring a fall and or fall-related injury is contingent on several “real-time” underlying factors: (a) baseline pathophysiological changes at the time of the fall, such as presence of osteoporosis/osteopenia, sensory neuropathy, or prior falls and prior fracture history; (b) use of high-risk medications; (c) presence of fall risk factors, such as cognitive impairment (i.e., delirium and dementia) with impaired safety judgment; (d) situational factors; and (e) behavioral factors, such as the presence of agitation or overestimation of ability to function. Some of the more common issues seen in clinical practice are described in the following; a more complete discussion can be found elsewhere (Gray-Miceli, 2014).

Baseline Pathophysiological Changes

Pathophysiological changes of the sensory system, from age or from disease, can potentiate not only a fall but a fall with injury. Some of the more common age-related changes of the sensory system related to vision that predispose to falls include the presence of cataract formation or macular degeneration. With cataracts, the crystalline lens becomes yellowed and cloudy, thus creating a visual alteration and potential for blindness depending on the severity of the cataract. Age-related macular degeneration, however, causes loss of central vision, which can obfuscate ability to see objects directly in front of the patient. Assessment is geared at identifying unilateral visual loss and monocular vision. Seeing at night can become troublesome, therefore, higher levels of illumination are required. Consultation with an ophthalmologist for treatment of these disorders can prevent falls and falls with injury.

The contribution of vision to risk for falling has been summarized by fall experts (Lord, Smith, & Menant, 2010) substantiated by numerous studies of older persons’ stance and balance. Evidence confirms significant increases in postural sway when loss of vision occurs, such as when older adults’ eyes are closed (Lord, Clark, & Webster, 1991; Paulus, Straube, & Brandt, 1984).

A common sensory disorder affecting the peripheral nerves among older adults is peripheral neuropathy. Common among persons with B₁₂ deficiency, disorder of the microvasculature, or type 2 diabetes, sensory neuropathy is a painful disorder that leads to loss of sensation typically affecting a stocking–glove distribution. Feeling one’s feet on the floor can be a lost sensation altogether. Changes in gait are also evident with ambulation, as the foot is slapped against the floor surface in an attempt to secure foot placement. Referral to physiatry can be of help to find appropriate footwear and to discuss treatment options.

Age-related changes in the neurological system can also predispose to falls and falls with injury. The reduction in the righting reflex and an overall decrease in reflexes accompanying age cause not only slow movement but also potential for balance impairment resulting in a fall and/or injury, especially if ambulating on an uneven surface. With a slowed reflex, the ability of the older adult to reach out and stop the fall may be lost all together. In this situation, the person can fall flat on the face, shoulder, or back, resulting in serious cranial or extremity fractures. Although not considered normal aging, “frailty” is associated with a higher case incidence of falls. Frailty is defined according to clinical markers and, as suggested by Linda Fried, includes: gait speed slowness and slowness in movement, evidenced by an increased time to perform standard tests such as the Timed Get Up and Go test. It is estimated that frailty increases with age, and is highest among older adults aged 85 years and older and is more common among women.

Age-related changes in the musculoskeletal system are commonly encountered among older adults who fall and incur fall-related fractures. Normal aging results in some dimunition of muscle mass and strength and osteopenia (thinning of the bones). Older adults with diseases affecting the musculoskeletal system, such as osteoporosis, are at high risk of bone fracture as a result of underlying loss of trabeculated bone. In essence, the bone becomes porous and fragile and breaks with any impact.

Past Medical History of a Fall or Fracture Injury

Many studies have shown a prior fall to be the most potent predictor of another fall among older adults (Degelau et al., 2012; Gates, Smith, Fisher, Lamb, & Phil, 2008; Oliver et al., 2004). Therefore, careful fall-history screening is vital as a health-promotion measure and quality-of-care check for all newly admitted patients to the hospital or seen in the ED.

The presence of a current fracture injury, such as a hip fracture, could reoccur if care is not taken to protect such vulnerable patients. Older adult patients with a current hip fracture, and/or surgical repair, have muscular weakness, incisional and referred limb pain with potential loss of sensation, all of which contribute to their inability to maintain balance and prevent a fall from occurring should they become off balance. During ambulation or transferring, the patient puts less weight on the surgical limb, shifting it toward the unaffected limb, which bears the brunt of the patient’s body weight. If osteoporosis exists and has been untreated, it is possible that the impact of walking can cause the “good” limb to fracture. In any event, the presence of pain or use of narcotic analgesia can also alter the patient’s response to “avoid slips, spills, or obstacles” in her or his path.

An additional account of more of the common medical events and diseases associated with falls in older adults is described elsewhere (Gray-Miceli, Johnson, & Strumpf, 2005; Table 19.1).

High-Risk Medications Contributing to Falls and Injury Risk in Older Adults

“Culprit” drugs or medications implicated in increasing fall risk are those causing potentially dangerous side effects, including drowsiness, mental confusion, problems with balance or loss of urinary control, and sudden drops in blood pressure with standing (postural hypotension; Ensrud et al., 2002; Neutel, Perry, & Maxwell, 2002; Smith, 2003). Classifications of medications implicated in falls for older adults include psychotropic agents (benzodiazepines, sedatives/hypnotics, antidepressants, and neuroleptics), antiarrhythmics, digoxin, and diuretics (Leipzig, Cumming, & Tinetti, 1999). The risk of falls alone should not automatically disqualify a person from being treated with warfarin (Garwood & Corbett, 2008).

A recent review of medications and fall risks, taking into account a series of studies, finds strong evidence for benzodiazepines, antidepressants, and antipsychotics to increase risk of falls (Boyle, Naganathan, & Cumming, 2010; Bulat, Castle, Rutledge, & Quigley, 2008a, 2008b). Their analysis confirms that there is no evidence that very short or short half-life benzodiazepines, selective serotonin reuptake inhibitor (SSRI) antidepressants, or atypical antipsychotics are safer in terms of fall risks than earlier generations of drugs in the defined drug category. Furthermore, they conclude that antihypertensives, in particular diuretics, are associated with a modestly increased risk of falling (Bulat, Castle, Rutledge, & Quigley, 2008c).

In short, the use of medications in older adults is not without risks of fall or risks to injury. Reduction in medication use, whenever and wherever feasible, is the guiding light for practical management of older adults’ health conditions. Constant attention to identifying risk versus benefits should be exercised by all practitioners caring for vulnerable populations of older adults at risk for falls and serious injuries.

TABLE 19.1

Medical Events and Diseases Associated With Falls in Older Adults

CHF, congestive heart failure; CVA, cerebrovascular accident; OH, orthostatic hypotension; MID, multi-infarct dementia; PVD, peripheral vascular disease; TIA, transient ischemic attack.

Sources: Gray-Miceli et al. (2005); Rubenstein and Josephson (2006).

Why Do Older Adult Patients in an Acute Care Setting Fall and Who Is at Greatest Risk?

Evidence from systematic reviews of fall risk factors in hospital inpatients supports the following risk factors to be linked to falls: a recent fall, muscle weakness, behavioral disturbance, agitation or confusion, urinary incontinence or frequency, use of “culprit” medications (especially sedative/hypnotics), postural hypotension, syncope, and age greater than 85 years (Oliver et al., 2010).

The nursing assessment of the older adult patient who falls does not stop with administration of these assessment tools or other types of assessment. Rather, the assessment is a dynamic and continuous process of quality improvement, which extends to formulate an analysis of the information and situational context of the patient so that corrective plans of action can unfold.

The Value of Identifying Fall Type

Different types of falls exist. The three most commonly used types of falls are accidental fall (related to an unsafe environment or environmental risk factor), anticipated physiological fall (related to known intrinsic and extrinsic risk factors of the individual), and unanticipated physiological fall (resulting from an unexpected medical event) (Morse, 2009). Risk factors vary by the type of fall, and the interventions to reduce an accidental fall are different from the interventions used to reduce risk factors associated with anticipated physiological falls.

Reasons for patient falls and injuries are tied directly to impairments in consciousness, cognition, behavior, and acute and chronic types of medical conditions, in addition to the situational context of the fall. Some of these risks are caused by intrinsic factors, whereas others are the result of extrinsic factors. The standard of care calls for assessment of fall risk factors and then to develop an intervention plan targeted toward each of these factors. Not all fall risk factors are modifiable; those that are should be treated.

Accidental or environmental falls are potentially preventable because they encompass foreseeable events, such as spills or improper footwear, which is correctable (Connell, 1996). Important intrinsic risks that comprise anticipated physiological falls among older adults are summarized in Table 19.2; common extrinsic or environmental factors, which represent preventable falls, are highlighted in Table 19.3.

Fall risk is formally assessed through administration of fall risk tools (Table 19.4). The National Center for Patient Safety recommends the Morse Fall Scale, but not for long-term use (www.brighamandwomens.org/Patients_Visitors/pcs/nursing/nursinged/Medical/FALLS/Fall_TIPS_Toolkit_MFS%20Training%20Module.pdf). The Morse Fall Scale is a screening tool and should only be completed using the FACT acronym: after a fall, on admission of the patient, on change in patient status, and on transfer or discharge (National Center for Patient Safety [NCPS] Falls Toolkit, 2014). The St. Thomas Risk Assessment Tool in Falling Elderly Inpatients (STRATIFY) tool has also been widely used, but overall, researchers report that the use of any of the tools offers no added benefit over nursing staff’s clinical judgment. Oliver et al. (2010) recommend the Morse Fall Scale and the STRATIFY tool as the two screening tools with best predictive properties, and the Morse Fall Scale was designed specifically to predict the probability of an anticipated physiological fall.

TABLE 19.2

Intrinsic Risks to Falls

^aIndicates independent predictor of falls with prolonged lengths of stay and increased nursing home placement (Corsinovi et al., 2009).

Sources: ECRI Institute (2006); Oliver et al. (2004); Papaioannou et al. (2004); Rubenstein and Josephson (2002).

TABLE 19.3

Extrinsic Risks to Falls

TABLE 19.4

Some Empirically Tested Fall-Assessment Tools

TABLE 19.5

Medical Factors Associated With Risk of Fall Caused by Impaired Safety Judgment

Some of the more commonly encountered risks of fall and injury observed in acute care are evident on many of the widely published and available risk-analysis tools. All of the tools include cognitive impairment (i.e., delirium and dementia).

It is very important to recognize cognitive impairment as studies have shown that early detection of acute mental status changes, that is, delirium, leads to early treatment and resolution. Moreover, early recognition of cognitive impairment caused by underlying chronic dementia is equally important. Acute care studies have shown that in patients with underlying dementia before hospitalization cognitive function typically worsens with hospitalization. Both acute delirum and chronic dementia are notorious conditions, potentiating impaired safety judgment. Impaired safety judgment is a nursing diagnosis that refers to the patients’ inavailability to recognize whether their actions are safe or not. Therefore, when safety impairment exists in the acute care setting, it is incumbent on the registered nurse to protect the patient from harm. Table 19.5 illustrates some of the common medical problems, acute or chronic, that can result in impaired safety judgment.

TABLE 19.6

Matrix of the Patient Situation by Risk for Falls That Result in Injury

TABLE 19.7

Medical Conditions That Raise the Risk of Serious Injury/Internal Bleeding

Table 19.6 lists some examples of age-related and associated conditions that cause falls. Positive predictive validity of falls has also been used as evidence by the patient’s underlying history of falls, visual impairment, requiring toileting assistance, dependency in transfer/mobility, balance disturbance, and cognitive impairment (Blahak et al., 2009; Papaioannou et al., 2004; Tinetti, Williams, & Mayewski, 1986).

In addition, many medical conditions raise the risk for serious injury, as outlined in Table 19.7. An integral component of the nursing assessment is to evaluate patients who may possess these risk factors. If present, strategies must be integrated into the patient’s individualized plan of care, which mitigate, reduce, or eliminate these risks altogether. Table 19.8 lists best practice interventions for patients suspected of injuries.

Diagnosis: Cognitive Dysfunction (Dementia/Delirium)

Important characteristics of level of alertness are the patients’ ability to sustain attention, and determining whether the patient is awake or not. If impairment exists in level of consciousness, an assessment should be made to differentiate delirium from dementia. Cognitive impairment is a known fall risk factor, requiring clinical assessment to differentiate.

Delirium. Delirium has many synonyms, including acute confusional state, altered mental status, reversible dementia, and organic brain syndrome.

On admission, all patients older than the 65 years regardless of admitting diagnosis, should be assessed for both dementia and delirium. Assessment is usually completed with the Confusion Assessment Method (CAM; Degelau et al., 2012).

Dementia. Patients with dementia include those with a diagnosis of Alzheimer’s disease, vascular dementia, Lewy-body dementia, frontotemporal lobe dementia, and those associated with other disorders. Such patients normally have slower reaction times and demonstrate impaired judgment. Individuals with dementia also possess varying degrees of alterations in visual–spatial orientation. Screening for dementia can be completed with the Mini-Cog, Mini-Mental State Exam (MMSE; Borson, Scanlan, Chen, & Ganguli, 2003; Folstein, Folstein, McHugh, 1975) and Kokmen Short Test of Mental Status Sources (Degelau et al., 2012; see Chapter 17). These patients are at risk of falls and injury, if injury-reduction practices are not implemented.

Additionally, any postoperative surgical patient is at great risk of injury from a fall owing to changes in the level of consciousness resulting from the sedative effects of medications. An important factor in determining a patient’s safety within his or her environment will be whether he or she can process information and execute simple one-, two-, and/or three-stage commands. The ability to execute a command is contingent on the level of consciousness, behavior, and cognition.

Traditionally, the level of consciousness is assessed and written as alert and oriented times three, referring to person, place, and time. The ability of the person to sustain attention can be gauged by observation of his or her ability (or not) to execute a command, for instance, following instructions. This type of assessment is typically routine when the nurse first greets the patient and is beyond a simple assessment of whether or not the patient is awake, “alert,” and oriented and can say, “Hello.” All of these determinations are critical factors in the nurse’s judgment of patient safety. After the first assessment, the nurse should reassess the older patient frequently because the level of consciousness can change quickly. Thus, at first glance it appears to the nurse that the patient is awake and alert, but later in the shift, the patient may typify “delirium” and appear hyper-or hypoalert. Thus, patients require frequent monitoring of the level of consciousness.

Observation of a patient’s behavior includes the patient’s affect, demeanor, and ability to process stimuli in the environment. Agitated older adults are at risk of falls and injury because attention to the normal environmental cues is blunted or lost altogether. Depressed older adults may be at risk of impaired safety awareness and management because of blunted responses or apathy as well as centrally acting medications used to treat the depressants.

For each of these four factors—consciousness, affect, behavior, and cognition—nurses work with physicians to evaluate the underlying causes and find treatable solutions wherever possible. Note that the roots of many of the disturbances of consciousness, behavior, and affect are some classic acute medical events such as hypotension, infection, dehydration, profound blood loss, or toxicity from medications (Tables 19.5 and 19.7). If no identifiable solution exists, prudent and standard care (i.e., best practice) requires nurses to ensure the safety of patients by instituting interventions related to improved monitoring and assistance with activities. In the order of least to most restrictive, nurses employ various solutions until the patient is no longer judged by the nurse to be at risk of a safety issue or in danger of a serious fall-related injury (Table 19.8). Note that research on these best practices for fall prevention is slowly emerging, and the absence of research in this area does not justify not using the intervention, because it may be a best practice intervention accepted as standard care.

TABLE 19.8

Best Practice Interventions for Patients Suspected of a Serious Injury

NPO, nothing per mouth; RICE, rest, ice, compression, elevation.

Critical-Thinking Points

How many times do nurses reassess their own judgment and make changes accordingly to their original impressions? Typically, in fall risk screening and clinical assessments, the reassessment is made during each shift and at the time of transition to another unit. Although a patient may “look to be safe” resting in bed, he or she may be totally unsafe if he or she sits up on the side of the bed or takes a step to walk. Therefore, it is very important to note the situational context.

Consider these points: while patients are safe in bed, are they also safe to be unsupervised alone? Are they safe to sit, transfer, or walk unassisted?

All of these nursing observations and ultimate clinical determination of patient safety hinge on the older patient’s level of consciousness, level of alertness, as well as behavior and current cognitive capabilities.

The level of consciousness is formally measured by the use of standardized assessment tools such as the CAM and other such tools (see consultgerirn.org/resources).

Situational Context and Fall

When assessing the patient’s risk of falls and risk of injury, it is imperative that the nurse consider the situational and environmental context as well as the medical stability of the patient (behavior, level of alertness, and cognition). So, although it may appear that the alert and oriented older patient with lower extremity weakness who is resting in a low-rise bed surrounded by floor mats is at a low risk of an injurious bed fall, his or her risk of injury increases as he or she walks, because of the lower extremity weakness. As the patient is out of bed and walking, with weakened limbs, risk of ambulatory falls occurs.

Thinking about the fall you are trying to prevent, whether it is a bed fall, an ambulatory fall, or a fall during transitioning from bed to chair, will further help in identifying risk fall and source of trauma for injury. With the older adult patient lying in bed or sitting on the chair, try to identify patient situations that place the older adult at a greater risk of falling or injury. Various circumstances of falls identified in the literature and commonly encountered in clinical practice include falls:

A risk-versus-benefit analysis should always be part of fall management decision making for patient safety and prevention of injury (Quigley & Goff, 2011), especially when patients move about on the hospital unit.

Given the patient’s intrinsic and extrinsic risks of falls and risk of serious injury (based on the most recent nursing assessment), it can be helpful to use the matrix in Table 19.6 to envision the various risks of fall or injury with the patient in various types of positions.

Behavioral Factors

Older adults in the acute care setting enter hospitals for management of their conditions. They may have never encountered an illness or event that resulted in sudden changes in their bodies. When medically unstable or cognitively impaired, these factors pose a safety risk as physical capacity and physical independence in functioning are suddenly altered. These patients often cannot do the things they once could with ease and are admitted to an unfamiliar environment. As physical independence decreases, their autonomy and desire to do what they are accustomed to doing may remain. This creates a conflict. They wish to get up, but may not fully recognize it is really not safe for them to do so. Gender, degree of fraility or injury, cultural background, baseline personality, and prior hospitalization experience are all likely to influence how the patient is coping with this sudden illness (Agency for Healthcare Research and Quality [AHRQ], 2013). Assessment should include whether older adults perceive these changes as stressors; and, if so, do they believe they do not require help? Nurses caring for elderly patients must remember that they have many years of experience in coping, or not, with their chronic condition. How they have coped and managed day to day is likely to influence current reaction to the hospital experience and current behavior. Reminding the patient that he or she is ill and needs temporary help is one remedy through the use of teach-backs, but it is likely to be ignored or short lived by persons who refuse help and want to remain independent despite medical advice. Those with cognitive impairment, depending on the severity of impairment, may not have the current cognitive ability to recognize that they are overestimating their actual ability to perform.

Assess and Diagnose the Older Adult Patient’s Risk of Serious Injury

Fractures

Nurses must ask a few commonsense questions when determining whether an elderly patient is at risk of serious injury (Tables 19.9 and 19.10). Serious injury is defined as injuries that result in loss of function and loss of life (Boushon et al., 2012). The National Quality Forum (NQF) defines moderate harm as the harm from falls resulting in suturing, Steri-Strips, fracture, or splinting; major harm as those falls that result in surgery, casting, or traction; then death (NQF, 2006). All of the items listed in Tables 19.1 to 19.3 are acute or chronic medical illnesses or conditions giving rise to the possibility that an acute injury could result. One of the most prevalent conditions increasing risk of serious injury in older patients, such as a fracture, is the presence of osteoporosis. For many reasons, the true incidence of osteoporosis is unknown in the older population, especially in men (Kaufman et al., 2000) who comprise a large percentage of the acute care hospital and long-term care beds. Therefore, it is entirely conceivable that the older adult will fracture an extremity or vertebrae with a fall, even though there is no documented diagnosis of osteopenia or osteoporosis. Depending on bone density and the severity of the trauma sustained during a fall, fracture risk must remain a consideration so that interventions to reduce harm can be implemented. Nurses must remember that osteopenia and osteoporosis can be present, even though they have not formally been diagnosed. Nurses must know risk factors for osteopenia and osteoporosis, as not all older adults have received a dual-energy x-ray absorptiometry (DEXA) or bone densitometry scan. Most older individuals with hip fractures have osteoporosis; yet, findings from a retrospective analysis of records of patients receiving hip-fracture surgery show that the frequency of treating these high-risk older patients for osteoporosis is less than optimal; women are offered treatment more than men (Kamel, 2004).

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