Dr Ludomyr Mykyta Consultant Geriatrician March 2018 The Giants of Geriatrics Bernard Isaacs 1975 Immobility Instability Incontinence Intellectual Impairment Common Features Multiple Causation ID: 706331
Download Presentation The PPT/PDF document "Falls in Residential Care" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Falls in Residential Care
Dr Ludomyr Mykyta
Consultant Geriatrician
March 2018Slide2
The Giants of Geriatrics
Bernard Isaacs, 1975
Immobility
Instability
Incontinence
Intellectual Impairment
Common Features
Multiple Causation
Chronic Course
Deprivation of Independence
No simple cureSlide3
Falls are Common & Serious
Of an aged population (65 & over)…
1 in 3 will fall within 1 year, and…
1 in 40 will be
hospitalised
as a result of a fall
Of those hospitalised…about 50% will be dead within one year.For every fall resulting in death, there are 20 resulting in a hip fracture.
Falls in in Nursing Homes
More than 50% will have at least one fall per year (1.5 falls/bed/year)
More than 40% more than one fall
10-20% serious injury
2-6% fractureSlide4
Causes of falls
Known for many years
Intrinsic Risk Factors
Attributes of the person that predispose, increase vulnerability
Affecting the capacity to maintain a stable upright position both standing & moving
Extrinsic
Environmental factors that increase the risk of falling and the resultant injuryMixedSlide5Slide6
HLC Residents
A very special group
The sickest & most disabled people in our community
Very old
Multiple co-morbidities
Multiple disabilities
DementiaSlide7
Risk Factors for Falls 1
Postural Hypotension
Visual Impairment
Somato
-sensory Impairment
Vestibular ImpairmentSlide8
Risk Factors for Falls 2
Restricted Range of Movement
Reduced Muscle Strength
Balance Impairment
Gait Impairment
Deconditioning
Body Mass Index
Foot ProblemsSlide9
ADRs
Many drugs,
particularly Psychotropic Drugs & Opiates can impair perception, consciousness & alertness, and cognitive function & exacerbate postural hypotension.
Antipsychotic drugs can cause extrapyramidal signs and symptoms and affect movement and balance.Slide10
Dementia
The most disabling condition
Loss &/or impairment of Procedural Memory
Executive Dysfunction
Changes in Personality & Behaviour Slide11
Intellectual & Dysexecutive Changes
Loss of insight & Perception
Results from inability to make new memories
Inability to recognise that there is a problem
Misperceptions: Delusions & Hallucinations
Inability to reason
Impaired judgement & Inability to take probable consequences of an action into account
Inability to plan, sequence, and follow through a course of action, and/or Failure to complete assignments
Impaired problem solving skills
Inability to learn from errorsSlide12
Changes in Personality and Behaviour
Loss of concentration & attention
Lack of inhibition,
Impulsivity, loss of impulse control,
risk-taking
Irascibility, verbal aggression
Loss of empathy
Apathy, lack of initiative and spontaneitySlide13
Risk Factors for Falls
External/Extrinsic Hazards
Access
Barriers, Clutter
Surfaces
Pets
Furniture
Domestic work setting
Illumination
Safety EquipmentSlide14
Home-like environment
A HLC Facility is primarily a place of care.
The architecture should facilitate delivery of care in a safe & effective manner, & the highest achievable level of independent function.
“Home is where the heart is” a place shared with people we love & who love us. It is not a fairy-tale cottage.
Relationships are more important than places.Slide15
People with dementia need surveillance & supervision
Adequate staffing levels in all categories
Technology
The architecture should enable rapid responses for those at highest risk
Privacy vs Safety Slide16
High risk fallers
Common Problems
Deconditioning
Muscle weakness
Poor balance
Gait
MedicationResponses
Increase fitness, strength and balanceModify all risk factors presentModify behaviourCorrect use of aids to mobility & ADLSlide17
Learning, Prevention, & Rehabilitation in Dementia
The brain runs on information, which is held in the memory stores. Memories are lost & decay & must be continually up-dated to be relevant.
The ability to learn, to make new memories is severely impaired in advanced dementia.
Procedural memories (doing complex things) are the most robust. They form “routines” that are accessed sub-consciously. These routines are acquired through constant reinforcement.
All activities, individual & group, should be deliberately designed as part of the responses listed previously.
Physiotherapists & physical trainers are experts in these activities.Slide18
RGH(Daw Park) Rehabilitation Unit
In the 1970s every patient was provided with a “geriatric chair” adjusted to the individual, a personal walking aid, and had to wear correct footwear when up and about.
All were taught how to rise from the chair, use the walking aid, & move off; & how to approach the chair and sit down.
Every member of the staff who had contact with patients (including orderlies & cleaners: that is what team care is all about) was taught the same techniques, and deputised to make the patient repeat the actions if they were not done correctly at any time, day or night. Our outcomes & length of stay was commended by a formal rehabilitation unit review. Slide19
Caring in Residential Facilities
No matter who you are in the hierarchy, to be effective you must become a trusted friend of the resident, dedicated to the resident’s well-being.
You must be able to engage in all situations.
You may become the one that the resident looks to for advice and reassurance, & the conduit for communication with other elements of the team, which is always headed by the resident’s partner or relative.Slide20
Use of medication in dementia
Alter the course of the dementia: stop or slow progression
Treat and prevent the psychiatric disorders: Psychosis, Anxiety & PTSD, Depression.
Promote engagement & Manage behavioural problems in conjunction with non-pharmacological methods
Slide21
Prescribing Rules – A Reminder
Diagnosis
Clear Indications/Treatment Goals
Do a “risk-benefit” analysis
Pharmacology
Understand the pharmacology and ADR profile
Anticipate ADRs
Don’t panic, the S/E may be transient
Dose
“Start low, go slow”,
but get to a therapeutic level!
Regimen
The simpler, the better
Minimise PRN (Pro Re
Nata
– as needed)Slide22
What and when is Palliative Care?
The Context
“Palliative care is the
active total care
of patients whose disease is not responsive to curative treatment…the goal of palliative care is the achievement of the best possible quality of life for patients and their families”.
WHOPalliative does not mean nihilistic: “For those near the end of life, physicians have a moral & ethical obligation to provide comfort and dignity”.
Slide23
Goals of Palliative Care
Attending to
suffering
and
distress
in all domains:
Biological and PhysicalPsychological and Emotional
Social and InterpersonalSpiritual and Religious
Intellectual and Professional
Safety & Security
The best Quality of Life attainable in the circumstances
When all else is gone the most precious thing we have is relationshipsSlide24
Prescription in the Palliative Phase
Management of distress takes precedence over all other indications
Discontinue medications that are not essential for life or the prevention & treatment of distress
A Risk/Benefit approach must be taken to Adverse Effects must be made in awareness of the context
What could be worse than the present situation?
Immediate risk outweighs statistical risk (Hypotension vs hypertension)
That this is the Palliative Phase must be understood and accepted by the resident’s partner/relatives & everyone involved the resident’s care after a comprehensive assessment, education, and counselling.