Certain classes of medication are more likely to increase the risk of falls. Taking more medications is associated with an increased risk of falls. ABPG p78 ABPG p78 -New or old medication that may affect their blood pressure? Does the patient take greater than 5 medications of any sort? Does the patient report dizziness or presented following a fall/collapse? Dizziness in the hospital setting remains a difficult diagnostic problem because it has many potential causes and may result from disease in multiple systems. Patients who report unexplained falls or episodes of collapse should be assessed for the underlying cause. ABPG p72 ABPG p67 Interventions 10.7.1 Liaise with Medical Officer (MO) or Pharmacist for review of medication associated with falls Review medication, particularly high risk medications such as sedatives, antidepressants, antipsychotics and centrally acting pain relief. Older people admitted to hospital should have their medications (prescribed and non-prescribed) reviewed and modified appropriately (and particularly in cases of multiple drug use). Patients on psychoactive medication should have their medication reviewed and, where possible, discontinued gradually to minimise side effects and reduce their risk of falling. SQIG p21. ABPG p77 ABPG p77 Also: see note under “Other Individualised Interventions” p22.
If reporting dizziness, check lying/standing blood pressure. If a drop >20mmHg systolic or 10mmHg diastolic is present, discuss plan of care with MO Monitor and record postural blood pressure. Assessment and management of postural hypotension and review of medications, including medications associated with pre-syncope and syncope should form part of a multifactorial assessment and management plan. ABPG p69 ABPG p67 Educate patient to stand up slowly and wait until dizziness resolves before mobilising. If dizziness persists, discuss plan of care with MO Encourage patient to sit up slowly from lying, stand up slowly from sitting and wait a short time before walking. When patients describe being “dizzy”, “giddy” or “faint”, this may mean anything from anxiety or fear of falling, to postural disequilibrium, vertigo or presyncope. An important step in minimising the risk from falls associated with dizziness is to assess vestibular function. ABPG p69 ABPG p72 ABPG p73 Cognitive State Risks 10.6.1 Previous delirium or known diagnosis of dementia? Dementia has been associated with falls in hospital Patients with dementia are more susceptible to delirium. Older people with cognitive impairment have an increased risk of falls. ABPG p50 ABPG p51 ABPG p50 New or worsening memory impairment, confusion or disorientation? Repeatedly and regularly check for the presence of delirium. Rapid diagnosis and treatment of a delirium and its underlying cause (e.g. infection, dehydration, constipation, pain) are crucial. The presence of confusion or disorientation has been independently associated with falls and fracture in ABPG p51 ABPG p50
hospital patients. Any changes in the environment such as room change or ward change can increase confusion. ABPG p50 Drowsiness, is easily distracted, withdrawn or depressed? Cognitive impairment, delirium and disturbed behaviour are risk factors for falling in hospitals. The key signs to look for are that the patient: cannot answer your questions is inattentive or easily distracted has disorganised thinking has an altered level of consciousness is agitated is overly sleepy – this may be hypoactive delirium. Hypoactive delirium is subtype of delirium characterised by people who become withdrawn, quiet and sleepy. Hypoactive (or mixed) delirium can be more difficult to recognise. Depressive symptoms were found to be consistently associated with falls in older people, despite the use of different measures of depressive symptoms and falls and varying length of follow-up and statistical methods. ABPG p15 ABWTC (6) (clinicians) p4 NICE 103 (7) Kvelde et al. 2013 (8) (ABWTC) are a series of resources developed by the ACSQHC to guide services in improving care of people with cognitive impairment within the context of the NSQHS Standards. There are separate resources for clinicians, health service managers and patients /carers. Settings were community and rehabilitation. There was no difference between community samples and those with identified healthcare needs with respect to depressive symptoms being a risk factor for falls. Interventions 10.7.1 Establish a baseline cognitive screen e.g. Abbreviated Mental Test (AMT) or as per local Identifying the presence of cognitive impairment should form part of the falls risk assessment process. Think of cognition as another vital sign that needs to be ABPG p37 ABWTC
Re-orientate patient and ask family to assist in orientating and settling patient Establish orientation programmes using environmental cues. Repeat orientation and safety instructions regularly. Encourage family members or carers to spend time sitting with the patient. ABPG p53 ABPG p97 Increase frequency of patient checks to proactively attend to patient needs Place high-risk patients within view of, and close to, the nursing station. Falls commonly occur at times when observational capacity is low. Provide more frequent observation, supervision and assistance to ensure that older patients with delirium or dementia who are not capable of standing and walking safely receive help with all transfers. SQIG p21 ABPG p15 ABPG p52 Continence / Elimination Risks 10.6.1 Require assistance with toileting? Assess and address functional considerations, such as reduced dexterity or mobility, which can affect toileting. Numerous falls in hospital occur when people go to or return from the toilet. ABPG p58 ABPG p57 Have constipation, urinary or faecal frequency/urgency or nocturia? Obtain a continence history from the patient. Incontinence, urinary frequency and assisted toileting have been identified as risk factors for falls in the hospital. People will often make extraordinary efforts to avoid an incontinent episode, including placing themselves at increased risk of falling. Transient incontinence is present in 50% of older hospital patients. ABPG p58 ABPG p56 ABPG p56
Interventions 10.7.1 Monitor/record toileting needs to check frequency, retention or constipation. Use site specific documentation. Obtain a continence history from the patient, which may include a bladder chart. Check post void residuals in incontinent older patients. Consider risk factors for falling related to incontinence, along with the symptoms and signs of bladder and bowel dysfunction. ABPG p58 ABPG p58 ABPG p58 Review toileting needs with patient daily including frequency, patient’s requirement for continence/ toileting aids and assistance required to access toilet facilities Establish a plan of care for bowel and bladder function. Assess functional considerations such as mobility and accessibility of the toilet. As part of multifactorial intervention, toileting protocols and practices should be in place for patients at risk of falling. Managing problems with urinary tract function is effective as part of a multifactorial approach to care. SQIG p21 ABPG p58 ABPG p55 ABPG p55 Complete urinalysis. If abnormal, discuss with MO if MSU indicated Organise routine screening urinalysis to identify urinary tract infections. Ward urinalysis should form part of routine assessment for older people with a risk of falling. SQIG p21 ABPG p55 Minimum Interventions 10.4 Environmental modifications should be included as part of a multifactorial intervention. ABPG p91 Provide ongoing orientation for patient to bed area, toilet facilities and ward Orient the patient to the bed area, room, ward or unit facilities. Some patients might need repeated orientation because of cognitive impairment. ABPG p24
fold increased risk of falling and athletic shoes are associated with the lowest risk. Discourage people from walking in socks, because this is associated with a 10 fold increased risk of falling. Patients should not walk in anti-embolism stockings without appropriate footwear on their feet. Bare feet provide better slip resistance than non-slip socks and therefore might represent a safer foot condition. Walking with socks, compared with walking barefoot, might present a greater balance threat for older adults. Clinically, safety precautions about walking in socks should be considered to be given to older adults, especially those with balance deficits. Barefoot or nonslip socks may be a safer footwear option than standard cotton socks for older people walking indoors on potentially slippery surfaces. Compared with wearing standard socks, wearing nonslip socks improves gait performance and may be beneficial in reducing the risk of slipping in older people. No significant differences were observed between the barefoot and non-slip socks conditions. Non-slip socks improved slip-resistance during gait when compared to conventional socks and [backless] slippers. Patients with a high risk foot should not walk bare foot. Peripheral neuropathy is implicated in the development of a foot ulcer where chronic trauma (e.g. ill-fitting footwear) or acute injury goes unrecognised in the ABPG p64 Chari et al. 2009 (11) Yi-Ju Tsai, Sang-I Lin. 2013 (12) Hatton et al. 2013 (13) Hubscher et al. 2011 (14) High risk foot MOC (15) p16 compression stockings. For the purposes of this model the High Risk Foot is defined as a foot with progressive deformity, ulceration,
dizziness and vertigo medication vision environmental considerations individual surveillance and observation restraint requirement for minimising injury protective equipment adequacy of calcium and vitamin D management of falls National 10.1.2 The use of policies, procedures and / or protocols is regularly monitored. You should audit the patient clinical record to confirm policies procedure and protocols are in use. Reference SQIG p11 via: The FRAMP both facilitates the operationalisation and documentation of many of the NSQHS standard 10 policy requirements and is an easily audited clinical record providing the most efficient means for each clinical area/ ward/ unit to provide evidence to meet these standards. National 1.9.2 The design of the patient clinical record allows for systematic audit of the contents against the requirements of these Standards. Reference SQIG Standard 1 p30 via: Design elements of the FRAMP prompt for and record standard 10 requirements as much as possible. National 10.4.1 Identify and facilitate access to the equipment and devices required for the patient population being served. You should adjust the environment for the patient risk profile and equipment should be available for the patient to mitigate the risk of falling. Ensuring a call bell is within reach of patients at risk, as well as personal items including mobility equipment, is important. Reference Nil via: The FRAMP contains information of minimum interventions which should implemented for all patients as appropriate, including call bell and personal items including mobility aid within reach. Shift by shift sign prompts and records review of both minimum and individual interventions. National Reference via: