Introduction (300 words)
Older people make up a significant portion of population in the UK. As these people grow older, they increasingly experience age-related changes, diseases and disorders. Such conditions have profound impact on older people’s ability to balance. They become more prone and at risk of falling. The rate of falling in UK had an immense growth over the years. There is a drive to review and evaluate status of fall among the elderly and prevailing falls prevention practices. My area of practice had been with an acute medical elderly acre ward. I worked as a staff nurse. My role is to communicate with the patients about safety, activity limitations and orienting them to bed area and other ward facilities and teach them how they can get assistance in particular.
In my area of practice I have learned that there is a prevalence of falls among older people community-dwellers. Falls among the community-dweller elderly represent a major care concern both for government and social institutions. Given the prevalence of falls in this group, the long-term consequences and the costs of fall-related injuries had become a burden to them and their immediate families. I have also observed that mostly falls occurred in their homes. The causes of falls are practically home-bound. Current literatures often discussed that falls are generally result from interactions among various risk factors. From a personal standpoint, I perceived that many of these factors could be corrected.
This paper will discuss how to minimise the risks for the aging population especially for community-dwelling older people. This paper will focus on the situation regarding falls and falls prevention in United Kingdom in light of my practice. The main objective of this paper is to minimise the risks for older people by means of critical analysis of falls prevention programs as far as existing literature allows. A number of methods and strategies regarding falls data collection will be employed. This will include a search and review of existing literature, patient observation and in-depth analysis of the literatures. The inclusion criteria for literatures are: topic – related to falls or falls prevention; age group – seniors; language – English; setting – communities (UK).
Opening Paragraph (100-200 words)
A comprehensive review of the contributing literatures was done. Articles from medical institutions publication were scrutinized as well. This was undertaken to ensure the inclusion of several relevant published material and information. Various electronic databases were also visited including Chartered Society of Physiotherapy and World Health Organization. Different nursing books were also reviewed so that the researcher could acquire insights. The materials that have been used are comprised of published informations in the last ten years. The key terms used are: falls, falls prevention, community-dwelling, older people, risks factors, reducing risks, staff nurses and falls prevention education. Falls prevention education was used to identify distinction between education in general and education that purports falls prevention for the patients.
Representing your subject (100-200 words)
Falls are common events in the lives of older people. Falls can result in different unfavorable outcomes such as minor bruises, fractures, disability, dependence and even death. The Kellogg International Working Group defined falls as the unintentional event that result in a person coming to a rest on the ground or another lower level. According to National Service Framework (NSF) for Older People standard six is devoted to the prevention and management of falls. Standard Six sates that:
The NHS, working in partnership with councils, takes action to prevent falls and reduce resultant fractures or other injuries in their populations of older people. Older people who have fallen receive effective treatment and rehabilitation, and, with their carers, receive
advice on prevention through a specialised falls service.
NSF has a well-developed localised service plan for falls prevention that puts emphasis on multidisciplinary working, reflecting the multi-factorial and complex nature of falls (The Chartered Society of Physiotherapy, 2001, p. 4). A report submitted by Health Evidence Network (HEN) discerns that a fall may be a first indication of an undetected illness. The report also claims that the prevention of falls is of major priority as they stimulate mortality, morbidity and suffering especially for older people and their families.
Across Europe, there is a geographic variation in fall injury rates but there is nominal generalisable information on the extent of the problem and potential risk factors. For community-dwelling older people, 30% of people over 65 and 50% of those who are over 80 fall each year; older adults who fall once are two to three times likely to fall again within a year; approximately 10% of UK ambulance service calls are to people over 65 who have fallen but only 60% of this cases are actually taken to the hospital; and 20 to 30% of those who fall suffer injuries that reduce mobility and independence and increase the risk of premature death (Windsor, 2007). Further, the main reason why older adults are hospitalized is due to fall-related injuries, five times more often compared to other causes for hospitalization. Falls had been the leading cause of injury deaths among people of 65 and over years of age and half occur in their own home. In their lifetime, more than one-third of women sustain one or more osteoporotic fractures and the majority of this is caused by a fall. For men, the lifetime risk of fracture is approximately half of what was observed among women (Todd and Skelton, 2004, p. 6). Based on these statistical evidences, the causative mechanism of falls among community-dwellers is perceived to be the prime reason of morbidity, mortality, suffering and death.
It is necessary then to reduce older people’s risk of falling and the consequent injuries of such fall occurrences for community-dwelling older people. The complex interaction between intrinsic and extrinsic risk factors led to the occurrence of most falls, as suggested by different literatures. The dynamics of falling have been postulated to occur in three stages (refer to Figure 1). These are the postural perturbation, the inability to right the perturbation and regain stability and the contact with the environment. Such perturbation was brought about by different risk factors. There are over 400 risk factors for falling that have been reported (The Chartered Society of Physiotherapy, 2001, p. 6). The intrinsic risks factors that are identified by HEN include history of falls, age, gender, ethnicity, medicines, medical conditions, impaired mobility and gait, sedentary behaviour, psychological status, nutritional deficiencies, impaired cognition, visual impairments and foot problems. The extrinsic risk factors are the environmental hazards like poor lighting, slippery floors and uneven surfaces among several others; footwear and clothing and inappropriate walking aids or assistive devices. HEN maintained the third risk factor which is exposure to the elements of risk (Todd and Skelton, 2004).
Some of these factors are surrounded by uncertainties. One explanation is that risk of falls and injurious falls varies with functional status. For example, frail older people are at high risk of falling and injuring themselves. On the contrary, healthy old people whom are engaged in diverse, challenging physical activities also have disproportionately high risk of falling (as cited in The Chartered Society of Physiotherapy, 2001, p. 6). This was described by the U-shaped association where the most active and inactive people are placed at the highest risk of falls. This factor reveals the complexity of the connection of risk, falls and activity (as shown in Fig. 3). In addition, understanding how these risk factors interact with each other to cause falls is tricky since the reasons for falling vary considerably from one person to another. Another example that shows this is evident in postural perturbation. The stress of the situation is manifested by the sufficient magnitude in taking a person out of their base of support and the need for an individual to maintain postural control and the speed of perturbation (p. 9). In both of these examples, the impact generated by the fall necessitates a comprehensive fall prevention interventions.
Suggestions for falls preventions first appeared in remedial literatures in 1980s. Since then there had been numerous effort to gather evidences to support falls prevention initiatives in medical, rehabilitation and public health. The evidences purport a possible prevention of fall in some populations but for injurious falls, it is yet to be proven. The general effectiveness of fall prevention strategies is connected to the functional status of older people. The first identified group is the healthy older people, though researches showed that reducing falls in healthy older people are ineffective (Gillespie, et al, 2001). The NSF identified frail older people as the high risk groups. Such groups include the significantly disabled and patients with acute and neurological illness. It is noteworthy to say that reducing risks factors does not necessarily mean reduction in falls and falls-related injuries. Though it is logical to assume this way, most intervention programmes regarding falls prevention provide only but limited success. The most practical fall prevention programmes for these identified risk groups include multi-factorial fall prevention programmes and exercise only (The Chartered Society of Physiotherapy, p. 11).
The multi-factorial fall prevention programme (MFPP) is based on a risk modification model. The approach is multidisciplinary for the reason that the older community is evaluated for potentially modifiable risk factors for falling. Subsequently, treatments will and are targeted to each of the risks factors. The disadvantage of this approach is express on high false positive results as suggested by the risk assessments. Another concern is the clarification of which of the elements of the treatment truly works. The evidence of the causality between the risk factors and the falls is feeble. Some medical practitioners even noted that there is an existence of redundant components in the programme (p. 11). The exercise only approach works for both at risk individuals and healthy older people through the effectivity of exercise is recommended to be even more effective if combined with other treatments. The practical implementation of the plan is efficient for men and women aged 80 years and above as the targets through individualised exercise prescription. Though the benefits of different types of exercise are unclear, an overview of successful programmes point that it improves muscle strength and postural stability. Exercises are done by trained personnel and should be graded in terms of difficulty (p. 12).
More than the structured interventions, which have inherent disadvantages, there are also practical yet of immense benefits of minimising the risks of falls for community-dweller older people. In order for all of us to identify which falls prevention programmes are the most viable and effective, I take that it is more necessary to identify the root causes of falls initially, from the most specific to complicated, and work from there. Minimising the risks for community-dwelling older people involve vertical and horizontal interventions. Falls prevention could start at home since homes are the most common setting of falls occurrences I identified in my practice. Preventing falls of the elderly in our own homes incepts with checking the conditions of the different parts of the house (Lord, Sherrington and Menz, 2007, p. 153). Preventing falls inside the confines of our homes necessitates these particular actions: remove scatter/throw rugs on the floor, place non-skid treads or double-sided tapes under area rugs, keep floors free from clutter, wipe up spills immediately and make sure floors are not slippery. Likewise, we should remove clutters on hallways and stairs and place non-skid treads or bright reflective tape to mark the edges of the stairs. Or better yet, we could build handrails so that the elderly will have something to hold on to in climbing or going down the stairs. Lighting must be also checked. Flashlights and night lights must be always available (Schulz, 2006, p. 528).
After making the house an elderly-friendly place, preventing the falls among them must be also applied in educating all the family members regarding the consequences of falls aside from the elderly residing in that house. I noticed in my practice that in most incidents of falls, fallers are always given information after the fall had occurred. There are no clear information dissemination processes regarding the matter. I supposed, if only they had given adequate information there would be a possibility of low- to non-occurrence of falls. Education combats a lot of ignorance. The role of education in falls prevention must not be undermined. Not only it will serve adjunct for systematized intervention programmes but would also include family members, caregivers, professionals and the entire community (Miller, 2006, p. 641). This can be carried-out through pamphlets and other printed materials, public talks, discussion and forums and the media. As such educating the people before and after the occurrence of falls are two separate constructs. As a staff nurse, I noticed that there are different categories for which education must purport to. These are the patients and non-patients in general: the actual patients of falls and the potential patients of falls. Under the potential patients of falls, the sub-categories include the pre-admitted and acute wards, the people that are already admitted in rehabilitation units, the actual people whom are involve in rehabilitation programmes and the residents of aged care facilities including the dementia-specific.
In lieu with this, there are considerations to take prior to educating actual and potential falls clients. The diversity in older people involves distinctions in the level and nature of ageing, their attitude and behavior concerning aging, their willingness and struggle to adapt to the process of aging and their outlook about care are some of this. This condition points to another premise which is there are specific needs for specific sets of people. This also implicates the role played by the care givers and staff nurses and the role of education as a two-way process in essence. Educating the patients include right timing, constant reminding, knowing, consulting and allowing control (Heath, 1995, p. 85). Since treatments and processes are highly-individualistic, carers must posses an array of educational and behavioural interferences. It is necessary then to educate them fully so that they can educate their patients. All staff must be involved in the process; hence, working as a health care team. Educating them must not focus on providing them awareness of who are at risk at falling or the very nature of falling but instead on how they can build personal knowledge based on what they observe in their practice. These could be an effective way to put ‘effective’ in different falls prevention educations.
In particular, this could be carried-out through cultivating to all staff on how they can act and serve as instruments to minimise risks among community-dwelling older people. The staff nurses have got to initiate best practices. Staff nurses, interns and other medical practitioners should be given basic skills on how to monitor, review, implement, document, report and discuss falls incidents aside from checking the patient, taking his vital signs and assisting the patients to get up on the floor (Pyrek, 2006, p. 276). This is more important on acquiring the whys and the hows of a specific incident or to always consider “Why did this happen?” Through this, they may possibly serve as emblem of a structured evaluation and subsequent implementation of falls strategies. Also, they could address the limitations of different strategies and probably address the aftermath solutions to falls. In this manner, they could do something to address the situation and give attention to several recommendations about falls prevention. The role of nurses is extended to collaborating with the families and promoting health, nutrition management, establishing supportive environments, collaborate with peers and provide opportunities for interdisciplinary collaborations on falls prevention. But the greater emphasis on the role of nurses and other medical associates are placed on improving processes. Put simply, staff nurses are effective sources of informations on identifying and acting on modifiable risk factors, improving care of vulnerable patients, providing synopsis of research evidence, detect and treat eyesight and hearing problems, suggesting ways to improve medication associated with falls and many others (Windsor, 2007).
Since they are the ones whom are most in contact with the community, community health workers must be given the opportunity to do first level assessments, implement ‘customised’ risk screen and intervention tool in addition. In this way, their local initiative could be carried through a broader scope, perhaps in the national level. This process could hone and enhance the research and development regarding falls prevention in older people. Prior to pursuing this initiative towards a more effective falls prevention program, there are issues to address. One is the availability of environmental audit tools. As already mentioned, there are ongoing debates on the subject of risk assessment tools. Literatures reveal that practitioners are more focused on this issue making them to overlook the necessity for environmental audit tools. To wit, risk assessment and environmental audit tools are both needed in falls prevention as primary measures. Environmental audit tools are comprehensive checklist of environmental risks factors. It could be applied to basically every place where the concentration of older people and risks are apparent. Results could be documented and may serve as points of follow-ups for staff nurses and carers. The attempt to document and report points to the second issue. There are no specific and accepted documentation and reporting processes. Documentations and reporting are very crucial as it can address the root causes and later avoidance of recurrence of falls. HEN claimed that “there is a complex causal interaction between risks factors and falls occurrence” (Todd and Skelton, 2004). Indeed, but there is also a complex causality between risks factors, falls occurrence and, I maintain, falls reoccurrence.
To further minimise the risks, it is also important to consider the risk assessment tools to be used. However, there are no screening tools that had been used or validated in a Europe-wide practice to assess risk of falling among the elderly either in community or in residential care facilities. The available risk assessment tools that have been used in a number of trials and clinical settings are as follows: stratify risk assessment tool, FRAT, fall-risk screening test, Tinetti balance and gait scale, Physiological Profile Assessment (PPA), “Get Up and Go Test”, Mobility Interaction Fall Chart and classification tree of prediction (Todd and Skelton, 2004, p. 10). More than devoting the effort to design a Europe-wide accepted risks assessment tool, I suppose attention must be given to addressing the independent risks factors independently. Should the fall evaluation (in Fig. 2) suggest that assessment is inherent to the risks factors, then, I argue that there are no reasons to use a country-wide accepted assessment tool. Rather, medical practitioners should focus on a more ‘customised’ risk assessment devices, more especially in terms of appropriateness/specificity, applicability and sensitivity.
Besides educating the patients/residents in general regarding the nature and consequences of the falls, falls prevention education must also take into account identifying the factors that influences client compliance and non-compliance in falls prevention programmes. Fallers are always tended to defy the seriousness of a fall and/or dispose blame to others. These are implications of a later resistance to participate in falls prevention programmes Lord, Sherrington and Menz, 2007, p. 209). Refusals are also considered opting to a level of acceptable level of risk factors. Though this can be tolerated at a certain degree, it is very dangerous to rely on circumstances. For people who have fallen, there is an evident overall lack of concern. Some perceived a fall to be natural part of aging process and others view different incidences as an opportunity to learn. These are all wrong. These may all lead to serious consequences in the long run. Taking this into consideration, preventing further falls and minimising risks for these individuals are a challenge especially for interventionists. There is a need to determine the patient’s interpretation of risks and interpretation of the incident as this critically affect the readiness to comply and participate with prevention programs. As a way to prevent falls, there is a need to communicate with first-time fallers the concept of prevention that should stem from individual willingness.
References
American Geriatrics Society (AGS) 2001, Guideline for the Prevention of Falls in Older Persons – American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention, Journal of American Geriatrics Society (JAGS), no. 49, pp. 664-672.
Chartered Society of Physiotherapy, The, 2001, Effectiveness of fall prevention and rehabilitation strategies in older people: implication for physiotherapy, Bedford Row, London, retrieved on 23 January 2008 from www.csp.org.uk.
Gillespie L D et al, 2003, Interventions to reduce the incidence of falling in the elderly. Musculoskeletal injuries module of the Cochrane Database of Systematic Reviews, no. 3.
Heath, H B M 1995, Potter and Perry’s Foundations in Nursing Theory and Practice, Elsevier Health Sciences.
James, K, Gouldbourne, J, Morris, C & Eldemire-Shearer, D n.d., Falls and Fall Prevention in the Elderly: Insights from Jamaica, Mona, Jamaica: Department of Community Health and Psychiatry, Mona Ageing and Wellness Centre.
Lord, S R, Sherrington, C & Menz, H B 2007, Falls in Older People: Risk Factors and Strategies for Prevention, 2nd edn, Cambridge University Press.
Miller, C A 2006, Nursing for Wellness in Older Adults: Theory and Practices, Lippincott Williams & Wilkins.
Pyrek, K 2006, Forensic Nursing, CRC Press.
Schulz, R 2006, Encyclopedia of Ageing, Springer Publishing Company.
Todd, C & Skelton, D 2004, What are the main risk factors for falls among older people and what are the most effective interventions to prevent these falls? Copenhagen, WHO Regional Office for Europe (Health Evidence Network (HEN) report), retrieved on 23 January 2008 from http://www.euro.who.int/document/E82552.pdf.
Windsor, J 2007, Bite Size Best Practice: Falls Awareness, Portsmouth Hospitals (PHT), NHS Library Service: NHS Trust, no. 10.
Reflective Summary
Introduction
The consequences of falls for community-dwelling older people are inevitable. Falls can be corrected. The implication of falls prevention and interventions could be enhanced further through the following recommendations and suggestions.
Main Text
The study identified different levels of improvement for each of these specific areas.
For the community:
· a community-wide effort for home modifications (Lord, Sherrington and Menz, 2007)
· continued community-participation of the community-dwelling older people in specific activities that show their functionality
· demand for appropriate services (environmental indicators as shown in Fig. 2) within the community that decrease the risk of injury of community-dwelling older people
For the academia:
· participate in educating the students in all levels regarding the benefits of converging into falls preventions for the elderly and the long-term consequences of falls
· educate them on their role of how can they make their homes and the streets convivial for the community-dwelling older people
· for nursing students, educate them on how they can fully utilise their knowledge into practice
· educate them on how they can completely understand the nature of falls and falls prevention that leads to honing skills and expertise
For the medical practitioners:
· interdependence among multi-disciplinary teams of interventionists
· set guidelines for proper risk assessments and proper implementation of falls prevention strategies
· outline guidelines that discuss how to deal with actual and patients resistance regarding health care interventions among community-dwelling older people
· cultivate an environment that respects protocols and adherence to SOPs
· instill to all staff the importance of accurate documentation and reporting
· emphasis on nutrition management and health promotion
· emphasis on best practices in falls prevention and falls evaluation (Journal of American Geriatrics Society (JAGS), 2001)
For the social institutions:
· advocacy on how people can save for health care services
· advocacy on integrating safety and quality issues on delivery of health care services
· further partnerships with other organisation involve in falls prevention among community-dwelling older people
For the researchers and developers:
· developing a separate falls assessment checklist for actual patients and potential patients
· studies on physiological and pathological changes that accompanies age, gender, psychological status and other intrinsic risks
· develop processes consistent data collection and dissemination
· develop processes of effective environmental assessment tools
· hone opportunities to transfer researches into practice
For the policy-makers:
· provision for hotline number for falls calls (e.g. FALLS = 32557)
· provision for recreations and other leisure activities for community-dwelling older people
· provision for effective cost reductions of falls prevention programs, assistance devices, hospital admissions or
· provision for financial assistance and low-rate out-of-pocket health insurances for community-dwelling older people
· provision for a nationwide falls and falls prevention information dissemination processes that includes informations about practical know-hows on before and after the occurrence of a fall incident
Conclusion\
Falls could affect us directly or indirectly. Therefore, we must all do our part to prevent falls among elderly residing in our communities. Notably, falls prevention is not a single effort, it is a proactive, responsive and closed-loop initiative between the community, the academia, the medical practitioners, the social institutions, the researchers and developers and the policy-makers. Providing them a quality of life can be achieved through systematic enhancements outlined above. Minimising the risks for the community-dwelling older people purports a close collaboration between these areas.
References
American Geriatrics Society (AGS) 2001, Guideline for the Prevention of Falls in Older Persons – American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention, Journal of American Geriatrics Society (JAGS), no. 49, pp. 664-672.
James, K, Gouldbourne, J, Morris, C & Eldemire-Shearer, D n.d., Falls and Fall Prevention in the Elderly: Insights from Jamaica, Mona, Jamaica: Department of Community Health and Psychiatry, Mona Ageing and Wellness Centre.
Lord, S R, Sherrington, C & Menz, H B 2007, Falls in Older People: Risk Factors and Strategies for Prevention, 2nd edn, Cambridge University Press.
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