Managing falls risk for mobile but cognitively impaired patients - PowerPoint Presentation

Slide1

Managing falls risk for mobile but cognitively impaired patients

Carrie Tyler

Falls Improvement Specialist Practitioner

Broomfield Hospital Site

MSE Hospitals

Slide2

Follow the evidence?

There is not published evidence to reduce falls within the acute setting for patients with altered cognition.

The MCA 2005 says use the least restrictive practice

The expectation is that we can prevent falls in hospital, so what can we do?

Slide3

Time to change our behaviour

Previously, patients who were thought to be at risk of falling secondary to altered cognition were placed by a nurses station and a one to one booked, with no thought to individualise the approach, or how appropriate the carer may be.

It was all about reducing “risk”

This may not prevent falls, it may increase falls and worsen delirium

Slide4

One to One Shifts

Through observation and conversation that , one to one shifts were often seen as quite stressful by the staff.

A qualitative survey was taken, staff reported that they felt anxiety when their patient tried to walk, alone during the shift, forgotten and stressed when asked to be the one to one nurse.

Slide5

The Burden of Expectation

Staff caring for patients who are risk of falling have a burden of expectation placed upon them, when caring for patients who are at risk of falling by:

Themselves

Relatives

Colleagues

But not the patient

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Understanding What Custodial care Is

Custody has 2 meanings:

To be entrusted with care

To imprison or restrict

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Unwittingly at times, we restrict our patients from standing by verbally advising to sit down

The larger impact of this is that the patient becomes :

Deconditioned & depressed

S

tarts to believe they are not safe to walk

Lead other patients to believe the patient can’t walk

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Avoiding custodial care

By changing our beliefs about falls and that “good practice” is to avoid all falls

Introduce “walking with risk” as a concept

Engage staff, patients and relatives actively in how to avoid deconditioning

Be realistic

Use national campaigns #

situpgetdressedkeepmoving

, #

endpjparalysis

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Understanding Human Factors

The work force needs to be aware of human factors and the influence this will have on behaviour and delivery of care

Is the staff delivering one to one care part of the ward team?

Have the stress factors regarding one to one been explored?

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Psychological Security

Behaviours can be influenced by either the staff or the patient attempting to give themselves psychological security in an uncertain environment

This is how the custodial care delivery can be perceived as safe, rather than restrictive, over bearing and harsher than being in prison

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Understanding Impulsivity

Impulsivity needs more understanding from how this will affect the management of the falls risks in some of our older population

For example:

Level 1 – Full insight, but took a “chance”

Level 2 – Full insight, likes the thrill of the risk

Level 3- No insight, has no idea of the dangers, but is impelled by the impulse to mobilise

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Delirium

Delirium is an acute confusional state that causes patients to have delusions, hallucinate and have hyper anxiety & hypervigilance, causing

ill-being

As well as illness, lighting, noise and lots of people can cause delirium to increase

Ill being is stressful to patients leading to reduced food and fluid intake, poor healing, disrupted sleep and causes stress to the patient

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Cortisol

Eustress creates a "seize-the-day" heightened state of arousal, which is invigorating and often linked with a tangible goal. Cortisol levels return to normal upon completion of the task.

Distress

, or free-floating anxiety, doesn't provide an outlet for the cortisol and causes the fight-or-flight mechanism to backfire

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Anyone can develop delirium, but the following factors put people at a higher risk:

Dementia

Over 65

Being frail or having multiple medical conditions

Poor vision or hearing

Being on multiple medications

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Treatment

It is important to find the underlying cause and treat it,

e.g

: antibiotics for infection.

Review the patient’s medication and stop any drugs linked with delirium.

Accurate pain scale assessment – using correct pain tool for individual patient, with consistent and continuous documentation.

Slide16

P

ain

I

nfection

N

utrition

C

onstipation/Communication

H

ydration/? Head injury

M

edication

E

lectrolytes/Environment

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A supportive and calm environment can also help someone to recover from delirium.

This includes:

24 hour clock with visible calendar

Ensuring any hearing aids or glasses are being worn properly and working

Avoiding any unnecessary noise at night

Not moving the person within and between wards unnecessarily

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We are aiming for patients living with dementia to be in an emotional state of well-being whilst in the

hospital

The Serene side room has some carefully chosen items, approved by the Dementia & the Falls Steering

Groups

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Why a side room? And when? 

Patients

experiencing altered cognition

cannot filter out all of the ward noises, and the side room provides a quieter environment to be able to heal and

recuperate

The

continual noise and activity can make some patient hyper vigilant and hyper anxious

Falls risks are not greater in the

sideroom

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Side Room Advantages

A side room can create a space of serenity on an acute ward

The noise, hustle and bustle can literally be shut out

It is myth that falls are stopped by nurses sitting at the nurses station, the nurses are not there, and ad hoc observation is not an evidenced falls reduction method

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SAD lamps & Sleep patterns

The light

projected at 5,000 or 10,000 lux . The light is used with

patients living with dementia,

whose serotonin producing pathways are gradually being

reduced.

We need serotonin to produce our "awake hormones" and in turn this produces melatonin. This is to reduce the effect of "

sundowning

" and nocturnal confusion.

Slide22

Slide23

Task Lighting & Concentration

LED clip on lamps-

Patients living with dementia are

loosing the pathways that link the eye and the brain. The images are harder to see and understand. Dementia

require

40% more light to assist clearer vision

and

aid concentration. "Task" lighting, is where the

plate

of food or activity is lit up and this aids the patient to accomplish more.

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Toilet Runway Lights & Orientation

Rope

lights

are used around the toilet door at night. This enables the eye to be drawn to the room, but does not create a black hole effect, which is frightening for patients

living with dementia

. The research carried out in Denmark found it reduced wandering , as patients were able to walk with purpose and find the toilet easily.

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Lighting

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Flooring

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Aromatherapy

Aromatherapy is used

in

the afternoon. A blend of oils are used to assist the patient to feel calmer, at a time of the day that patients

living with

dementia

can"sundown

".

Sundowning

can lead

to higher anxiety, wandering &

falls

Sonic diffusers are used, with no heat or mesh interior. They are dried and put away after use.

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Confusing Signage

Estates have assisted to update the signage

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Meaningful Activities

Staff requested to deliver one to one care to a patient living with dementia, with a known falls risk, with an illness in a new environment need as much support and equipment as possible

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Conversation starters

Not everyone can small talk, staff or patient

Use the patients information to choose what to talk about

Create or buy “chatting packs”, with background information and suggested questions

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Example -Britain in the 1950’s

The 1950s began with austerity and ended with affluence. Teenagers listened to American

Rock'n'Roll

, but Teddy Boys were a British cult

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Most

people can remember Green Shield Stamps, but there were other schemes. Does anyone remember Blue Star, Gift Coupon, Happy Clubs, Thrift Stamp,

Uneedus

Bonus, Universal Sales Promotions or Yellow Stamps?

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Reminiscence

Scentscapes

Activities trolley

Music

Dementia Garden Spaces

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Illusions

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Thank you

c

arrie.tyler@meht.nhs.uk