Cogentin

"HELP, I'VE FALLEN..." LESSEN THE CHANCES OF HEARING THOSE DREADED WORDS WITH THESE TECHNIQUES.

As a home health care nurse, you're in the position to protect your fragile elderly clients from debilitating and possibly life-threatening falls. To develop effective fallprevention strategies, start by assessing intrinsic (clientrelated) and extrinsic (environmental) risk factors.

ASSESSING INTRINSIC RISK FACTORS

Intrinsic factors that may increase a client's risk of falling involve deficiencies in physical and mental functions. These include medical conditions and agerelated changes that affect vision, hearing, balance, righting reflexes, gait, muscle strength, mental acuity, and cardiovascular function.

To assess an elderly client's abilities, visit him at a time when you can watch him do some activities: walking from room to room over different floor surfaces; going up and down stairs (if present); transferring from beds, chairs, and toilets; getting in and out of the bathtub or shower; and reaching up or bending down to get things from shelves. Don't rely on his word that he can do these things; he may overstate his abilities to appear more independent than he really is.

If you notice any problems with gait, balance, or strength, refer him to the physical therapist for further evaluation. She can recommend exercises, assistive devices, and environmental adaptations.

Besides watching your client move around, take a thorough history to identify medical risks and learn about any past falls. Assess for diseases and disorders that increase risks, especially stroke, dementia, vascular disease, cardiac disorders, dehydration, occult bleeding, foot problems, postural hypotension, syncope, Parkinson's disease, incontinence, osteoporosis, and certain medications.

Of these, medication use may be the easiest to modify. Specific medications, recent changes in dosages, and total number of prescriptions (more than three) have all been associated with an increased risk of falling.

Take note if your client has prescriptions for common drugs that may increase the risk of falling, including many antianxiety drugs, antipsychotics, antidepressants, sedatives, antihypertensives, diuretics, and antiparkinson drugs, such as benztropine (Cogentin).

When you assess your client's medication use, ask to see all medications kept in the home, both prescription and over-the-counter drugs. Like many older people, your client may be treated by several providers, who may unknowingly prescribe medications that interact with other drugs he takes. Contact all his providers to verify that his prescriptions are appropriate and current.

ASSESSING EXTRINSIC RISK FACTORS

Environmental variables that may contribute to falling are called extrinsic factors. To identify them, thoroughly assess your client's home environment, keeping his functional level in mind. Look for safety features in the bathroom, such as assisting bars, a nonslip tub or shower mat, a stable toilet seat, and working fixtures. In the kitchen, look for such potential hazards as high cabinets your client needs a step stool to reach or towels hung above a stove. Also, advise him and his family to avoid using throw rugs (which can slip or wrinkle) and to keep cords and other obstacles out of walkways.

Check out your client's stairs. They should be in good condition, have sturdy railings, and be kept clear of items "to go up."

If you can, take a moment outside your client's home to evaluate for good lighting and slipproof surfaces; if you notice any leaking water (for example, from broken gutters or downspouts), cracked or broken pavement, or other hazards, advise your client to have the problems fixed or to avoid the area.

CASE IN POINT

An 89-year-old woman is referred to your home health care agency after discharge from the hospital, where she'd been treated for a sprained ankle sustained in a fall. Her discharge papers indicate multiple health problems: acute ambulatory dysfunction, hypertension, Type 2 diabetes, coronary artery disease, hyperthyroidism, bilateral cataracts, and a urinary tract infection. She'd fallen three other times in past months.

As you examine her, you note that she has a bruised left ankle wrapped in an elastic bandage.

She's alert and oriented and afraid of falling again. Because of pain, she walks on the ball of her foot, hobbling around her apartment by holding on to furniture. She was given a walker at the hospital but says she doesn't know how to use it. She tells you she used a cane before her fall. Her BP is 130/70 both sitting and standing, and her eyesight is poor. She doesn't understand her medication schedule or the purpose and possible adverse effects of her drugs.

You ask about her past falls to learn more about her abilities and judgment, which will help you develop a treatment plan. She says her first fall occurred when she fell forward after rising from her sofa, which is low and soft. She fell the second time after tripping over her cane when she stepped off an elevator and couldn't see where she was going. The third fall resulted when she bent over to pick something up from the floor and lost her balance. The fall that caused her ankle injury occurred when she slid off of a chair as she pulled herself closer to the television.

In your notes, you document the following findings: The client has difficulty getting up from the sofa, has difficulty balancing herself, walks on the ball of her foot, has weakness of the left leg, and uses a cane inappropriately. The only adaptive equipment in her home is a tub bench and grab bars in the bathroom. She scored 1 out of 16 on balance and 1 out of 12 on gait on the Tenetti Balance and Gait Evaluation.

An occupational therapist's assessment of the client's activities of daily living reveals that her functional activity tolerance is 8 minutes with moderate exertion. She can't get in and out of the shower or wash her own hair. She can't prepare her meals; however, she lives in a senior building with a meal delivery service.

ASSESSING THE RISKS

A complete assessment of your client reveals the following intrinsic risks: left footdrop secondary to Type 2 diabetes neuropathy, fair to poor dynamic mobility balance, impaired endurance, decreased strength, intermittent dizziness, and decreased coordination and perception. She also has bilateral cataracts that significantly impair her vision, uses multiple medications, and has impaired judgment. You find the following extrinsic risks: poorly supportive furniture and no assistive transfer equipment.

You schedule a team meeting involving all disciplines and develop the following plan:

Monitor response to medications, including cardiac status and adverse reactions, such as orthostatic hypotension and dizziness.

Ask her primary care provider to review her medication regimen to simplify it and discuss the feasibility of cataract surgery.

Teach her to take her medications correctly and tell her about expected benefits and possible adverse reactions.

Evaluate and address her level of pain. If it interferes with her daily activities, identify how it does and what you can do to help.

Assess how her sprain is healing. Note whether swelling and pain are decreasing, check pedal pulses, see if her range of motion has increased, and so on.

Evaluate her diet and nutritional status. Arrange for meals to be brought to her room until her ankle heals.

Monitor her blood glucose levels.

Develop a plan of care for the Medicare-covered home health care assistant to help with personal care and an exercise program.

Develop a plan of care for social services so your client can get a home health care assistant after Medicare services end.

Encourage her to ask her provider about cataract surgery and to get assistive devices for her home. Recommend things like an elevated toilet seat or "reaching" tools-whatever might help.

ADDITIONAL THERAPIES

After evaluating your client, the physical and occupational therapists develop the following plan to help reduce risks and improve her functional level:

Evaluate her need for a walker and teach her how to use it, if appropriate. Consider whether she might use her cane instead-making sure she uses it correctly-or whether a quad cane appeals to her more than the walker.

Teach her exercises for balance and lower-extremity strengthening.

Show her how to use cushions with boards under them to raise the sofa height and make it more firm. Also, tell her to use sturdy chairs with arms.

Practice safe transfers.

Practice activity tolerance and energy conservation skills when dressing.

Show her how to use a reacher.

Evaluate bathroom equipment and suggest improvements.

Instruct her on safe transfers in the bathroom.

SIGNS OF IMPROVEMENT

After 5 weeks of home health care, your client can ambulate safely to the dining room for meals and to the physician's office in her building for medical follow-up; she's working on getting in and out of a car. At the occupational therapist's recommendation, your client got a raised toilet seat with arms. She refuses to get a new tub bench, however, because she's afraid to get in and out of the tub and prefers to sponge bathe. She refuses to practice tub transfers or use a reacher.

Her energy conservation skills when dressing have improved from 8 minutes to 20 minutes. Her balance has improved from 1 to 12 (out of 16) and gait from 1 to 9 (out of 12) on the Tenetti Balance and Gait Evaluation. You've arranged for a home health care assistant to visit twice a week to sponge bathe and shampoo her and to help her with laundry.

IMPLICATIONS FOR PRACTICE

This case study emphasizes the need for home health care services to take an in-depth look at client falls and standards of care. You may find fall risk assessment tools helpful in assessing your clients' risk factors. Then you can use a team approach to address the risks.

After you assess a client's risks, develop management approaches for each identified risk factor. Your goals are to help clients do activities of daily living safely and address all potential fall risks.

Ann Walker is the administrator for home care services, Care Masters of the Philadelphia (Pa.) Protestant Home.

Copyright Springhouse Corporation Apr 1999
Provided by ProQuest Information and Learning Company. All rights Reserved