Fall Prevention and Home Safety:
The Role of the Home Health Professional
(Course: AB0059)
By Andrea Easton, MA, MBA, Deborah A. Shipkin, OTR and Ouida Hummell, RN
Learning Objectives:
After participating in this program, the learner will be able to:
1. develop a working knowledge of the demographic trends in the U.S. especially as they pertain to the growing elderly population and implications on healthcare
2. develop a working knowledge of neural and systemic physiologic changes related to the aging process and their functional implications
3. demonstrate an understanding of the medical and psychological impact of falls on the older adult
4. identify ways in which the home health professional can assess and intervene to prevent falls
American society is aging and the implications for the healthcare system are enormous. For every member of the healthcare team, it is crucial to understand the physiological changes that occur with the aging process and how those changes predispose the elderly population to falls. Home health professionals are in a unique position to understand how assessment and prevention are key to keeping the elderly safe in their own homes.
Key Demographic Trends
The baby boom generation, those Americans born between 1946 and 1964, begins to turn age 60 in 2006 and age 65 in 2011. The population of people 65 years of age and older will increase by 14 percent over the next 10 years and will more than double between now and 2050, bringing the total to 80 million. The growth in the oldest segment of the population, those who are age 85 and older, is explosive. Over the next 10 years, this segment will grow by 33 percent from 4 million to 5.6 million. Even more phenomenal, there will be a 328 percent growth in this group to 18 million between now and 2050, making it larger than the age 65 to 85 group. The growth rate of the elderly exceeds that of the general population under age 65, so the proportion of the elderly overall will increase sharply from just 13 percent today to 20 percent over the next 50 years.[1]
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Figure 1: Population Age 55+ By Age Group
Source: U.S. Bureau of the Census, (1996a), Projections of the Population, by Age and Set: 1995 to 2050.
In the future, the elderly in America will be predominantly female. Although life expectancy at birth for males is increasing from 73 in 1995 to a projected high of 86 in 2050, it is also increasing for women from 79 in 1995 to a projected high of 92 years in 2050.[2] (Table 1) The ratio of males to females (males per 100 females) is currently 70.4 and will increase to 75.0 in 2010 and 84.3 in 2050.[3] (Table 2)
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Table 1: Age Expectancy at Birth |
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|
Sex, All Races |
1995 |
2050 |
|
Male |
73 |
86.4 |
|
Female |
79.3 |
92.3 |
Source: U.S. Bureau of the Census (1996a), Life Expectancy at Birth. Based on high series of U.S. Bureau of the Census.
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Table 2: 65+ Age Group |
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|
Year |
No. Males |
No. Females |
Ratio (males per 100 females) |
|
1995 |
13,678 |
19,866 |
68.9 |
|
2000 |
14,346 |
20,364 |
70.4 |
|
2010 |
16,887 |
22,522 |
75.0 |
|
2030 |
31,718 |
37,661 |
84.2 |
|
2050 |
36,076 |
42,783 |
84.3 |
Source: U.S. Bureau of the Census (1996a), Projections of the Population, by Age and Sex: 1995 to 2050.
Economic and Social Implications
It is clear the senior population boom is straining the country’s healthcare resources. The demand for elder care already exceeds state and federal governments’ ability to pay. The federal government has responded to this crisis with its prospective payment system (PPS), a result of the Balanced Budget Act of 1997. The PPS reduces Medicare reimbursement for hospitals, nursing homes and home health agencies and has resulted in serious financial difficulties for these industries. Four of the eight largest long-term care chains have gone bankrupt during the last two years and 2,500 home health agencies in the U.S. have closed their doors. [4],[5]
The elderly population also reports a shortage of caregivers. Of the nine million Americans over age 65 who live alone, two million say they have no one to turn to if they need help. Lack of an available caregiver is a serious problem for older people who have chronic conditions and limited ability to care for themselves and their homes.[6]
Because of limited access to home care and long-term care placement and an increasing shortage of caregivers, the healthcare industry has the challenge of assisting older people in caring for themselves in their own homes. This can be accomplished as telemedicine continues to develop, existing technology such as personal emergency response services are integrated, and strategic partnerships with pharmaceutical, high technology, and utility industries have continue. By monitoring chronic care conditions, providing preventive health prompts and developing home safety adaptations, healthcare providers can enable older Americans to remain independent.[7] The first step in this process is to understand the physiological changes that occur with the aging process and their implications for safety, particularly fall prevention.
Physical Aspects of Aging
It is important for healthcare providers to understand how the aging process affects individual body systems and to be able to differentiate between changes that are related to disease or aging. Many normal age-related changes that occur independent of pathological processes have functional consequences.
Cardiovascular System
The physiological changes of the cardiovascular system affect and alter the function of the whole body.
When a person ages, the heart’s elasticity and cardiac output decreases. Its intrinsic contractile function decreases and there is a loss of conduction system components. Blood vessels produce an increased peripheral resistance and systolic blood pressure increases with a lessened rate of increase in diastolic pressure. Myocardial ischemia and infarction, orthostatic hypotension, and arrhythmia can occur and may predispose the elderly to falls.
Pulmonary System
The respiratory system is affected both structurally and functionally as a person ages, producing more shallow and rapid respirations. Respiratory muscle strength decreases, the chest wall becomes less compliant and pulmonary elastic recoil decreases. Other pulmonary changes involve a decrease in respiratory muscle strength, arterial PO2 and pulmonary circulation. Increases in residual volume and functional residual capacity with air trapping as well as vital capacity and expiratory flow rates are a result of the aging process and can affect the elderly in varying degrees. Changes in lung volumes can also occur and include an increase in residual volume and functional residual capacity and a decrease in vital capacity and expiratory flow rates. Gas exchange can also be affected by a decrease in arterial PO2.
Changes in respiratory function can increase the risk of falling for the elderly. A decrease in PaO2 levels may cause shortness of breath that produces exertion, fatigue and confusion. Less efficient ventilation is also a consequence of the aging process and requires more energy for inspiration and expiration.
Genitourinary (GU) System
As people age, there is a substantial reduction in renal function.[8] Bladder capacity, the ability to postpone voiding and urinary flow rate appear to decline in both sexes. Uninhibited contractions become more prevalent and muscle tone and bladder capacity decrease. Additional pathologic, physiologic or pharmacologic injuries further increase the risk of incontinence. Many elderly people, even those without peripheral edema, renal disease or heart failure, excrete most of their daily-ingested fluid during the night. Because of this and an increased prevalence of sleep disorders, most healthy seniors have one or two episodes of nocturia every night, which lead to an increased risk of nighttime falls. Other physical changes that affect the GU system can contribute to the risk of falling. Confusion, lethargy and immobility have been associated with urinary tract infections and fainting while emptying the bladder is also a risk.
Musculoskeletal System
The musculoskeletal system is greatly impacted by the aging process. The structural integrity of the skeleton depends on the metabolic processes of its bony tissue, which varies depending on the person’s age. Between the end of puberty and age 25 or 30, bone density increases and bone resorption and formation continues. However, after age 30, the rate of resorption gradually exceeds that of formation, resulting in a net loss of bone density with age.[9]
Aging causes an atrophy of all muscles, causing a decline in muscle strength, tone, mass, endurance, agility and efficiency. A decrease in elasticity of tendons and ligaments results in a generalized stiffening of the joints, particularly the knees, hips and spine. Even with these changes, most older adults remain mobile and independent unless they develop an underlying disease process.
Following is a list of some of the more common musculoskeletal changes that occur with the aging process:
1. osteoarthritis
a degenerative disorder of the movable, weight bearing joints that is non-inflammatory and progressive
2.
osteoporosis
a metabolic bone disorder resulting in an
uncoupling of the relationship between osteoclastic bone resorption and
osteoblastic (new bone) formation which ultimately leads to skeleton failure
resulting in fractures
3.
rheumatoid
arthritis
chronic, non-specific, symmetric
inflammation of the peripheral joints resulting in progressive destruction of
articular and periarticular structures
4.
gout
recurrent acute arthritis of peripheral
joints in which crystals of monsodium urate from supersaturated hyperuricemic
body fluids are deposited in and about the joints and tendons
Changes in the musculoskeletal system are directly related to the incidence of falls in the elderly. Decreased muscle weight, strength and endurance put the elderly at risk along with the hardening of ligaments, joints and tendons. Another concern is intervertebral space narrowing. This results in the shortening of trunk and causes gait changes. Pain and weakness caused by bone loss and a decrease in the water content of the hyaline cartilage may also occur and become a contributor to the issue of safety.
Neurological System
The functioning of the neurological system is dependent on the other body systems, making it difficult to identify how greatly the aging process affects it.[10] This relationship and complexity of function of the nervous system also make it difficult to differentiate changes that are caused by aging or disease. Alterations of the nervous system can impact an individual’s activities of daily living, contribute to impaired functional status and modify the quality of life of an individual. Physical changes that occur include neuronal losses, a decrease in dendrite spines, and decreased neuronal glucose and protein synthesis. There is also decreased vascularity and fibrotic changes that occur throughout the central and peripheral nervous system as the body ages.
For the elderly, these physical changes may slow their voluntary or automatic reflexes and affect their ability to respond to multiple stimuli. A slowed reaction time may also occur. With age, peripheral nerve fibers decrease in number and size and decrease motor and sensory nerve conduction, causing possible diminished position sense. Other consequences of neurological changes that predispose this population to falls are lowered nerve conduction velocity and a reduced kinesthetic sense.
Sensory Systems
Vision, hearing and smelling and proper functioning of the skin are all impacted with aging. Decreased visual accommodation, contrast sensitivity and capacity are common changes that enhance the risk of falling. A decrease in visual acuity and visual fields may also occur, leaving the elderly vulnerable. Hearing loss of some sort affects about one-third of all adults between 65 and 74 years of age and about half of those between 75 and 79. In the U.S., over 10 million elderly people have a hearing impairment, resulting in impaired speech discrimination and tone thresholds.[11] Hearing loss is a concern for the elderly who live alone and may not be able to hear warning sounds in cases of emergency. Additionally, vertigo, caused by wax accumulation in the ears, causes a safety concern and may lead to falls.
The smelling and tasting sense should not be ignored when treating the elderly. Poor nutrition and lack of interest in food may be caused by the loss of fine taste and smelling and can result in weakness, increasing the person’s susceptibility to falling. Likewise, skin problems such as corns and calluses may also lead to an impaired gait. A walking aid is a recommended precautionary tool for those at risk of falling. However, healthcare providers should be aware that loss of skin nerves may reduce the user’s ability to use the walking aid properly.
Physiological changes in the elderly should be evaluated and addressed by treating healthcare providers. Advances in pharmaceuticals and medical equipment technology have created optimism and enhanced the quality of life for many older Americans who wish to remain independent in their own homes. Providers should inform patients of available options and resources. However, even with recent technological advances, the incidence of falls among the elderly is increasing.
Fall Statistics
Falls and injuries caused by falls are a common occurrence among the elderly. Studies show that 30 percent of people over the age of 65 who live in the community fall each year and the incidence increases to 50 percent for those over the age of 80.[12],[13],[14],[15] The majority of falls – 60 percent – occur in the home, 30 percent occur in public places and 10 percent occur in healthcare institutions.[16]
The data reported in the literature on falls among older persons may be conservative. Most falls among the elderly are unreported by patients or unrecognized by family members or caregivers.[17] Older people may forget a fall or forget to inform their physician or other healthcare professional when they have experienced one. They may assume that falling is a natural part of the aging process and not worth reporting; they may deny a fall out of embarrassment; or they may fear that revealing a fall will lead to restricted activities or loss of independent living.[18]
Each year at least 10 percent of older people have a serious injury caused by a fall, such as a fracture, joint dislocation or severe head injury.[19],[20],[21],[22] In fact, falls are the second leading cause of spinal cord and brain injury among older adults, and the leading cause of injury deaths among people 65 years and older. [23],[24] Among people over age 65, falls cause more deaths than pneumonia or diabetes and all other types of accidents combined.[25]
For the elderly who fall and are unable to get up on their own, the period of time spent immobile often affects their health outcome. Breakdown of muscle cells can begin after only 30 to 60 minutes of continual muscle compression.[26] Dehydration, pressure sores, hypothermia and pneumonia are other complications that may occur.[27]Among the elderly, a fall that results in a serious injury often represents the beginning of an irreversible decline in both health and lifestyle, especially if the patient lies on the floor for a prolonged period.
The following statistics reinforce the seriousness of falling among the elderly:
1. for the 9.5 million Americans 65 or older who live alone, the risk of being found helpless or dead in the home is 3.2 percent per year, which is about the same as the combined risks of myocardial infarction and stroke[28]
2. in a study of 367 patients found in their homes either helpless or dead, 67 percent of patients who were estimated to have been helpless for more than 72 hours died, compared to only 12 percent of those who had been helpless for less than one hour[29]
3. falls have been found to be a strong predictor of placement in a skilled-nursing facility[30]
Even the 90 percent of falls that do not result in injury may have a detrimental impact on health and well-being. The fear of another fall can cause many older adults to lose confidence and restrict their activities. The most successful strategy for decreasing these statistics is prevention. Clinicians who provide or manage the care of the elderly are in a unique position to identify those who are at risk for health-related safety concerns, particularly those who are in the home.
Risk Assessment
The Outcome and Assessment Information Set (OASIS) contains several sections that identify patients who are at risk for falls or who have a history of falls. Although it is the primary clinician who is responsible for completing the OASIS tool, the observations and suggestions of the entire home health team are valuable. Often the home health aide interacts most with the client and can therefore make valuable contributions to his or her functional assessment. In some situations, the patient may not be the best historian. It may be necessary to question friends, relatives or caregivers about falls.
Table 3: OASIS Assessment Regarding Risk of Falls
OASIS Section |
Functional Implications for Falls |
Living Arrangements |
The presence of structural barriers or safety hazards places the patient at high risk for falls. In the event of a fall, if the patient lives alone or spends considerable amount of time alone during the day, patients are at higher risk for mortality and increased morbidity due to possible extended length of time being “found down.” [31] |
Sensory Status |
Vision problems make it difficult to see potential hazards. Inner ear problems can affect balance. Hearing deficits can also make it difficult for patients to follow directions properly. |
Neuro/Emotional/Behavioral Status |
Careful observation of the client’s level of alertness, attention, memory, problem solving and judgment are very important in determining his or her safety in the home. Patients who are confused or unaware of their limitations may attempt high-risk activities, such as showering alone, climbing stairs, and not using appropriate assistive devices. |
ADL/IADL |
Observe if patients are able to maintain balance as they reach for items during dressing or meal preparation and if they demonstrate good judgment and awareness of their limitations during bathroom transfers (showering, toileting). Also, note any difficulties with gait, balance and coordination, which are all important risk indicators. |
Medications |
Consider medications that may cause dizziness or blurred vision, upsetting balance. |
A referral to an occupational or physical therapist is indicated for patients who demonstrate mobility or activities of daily living (ADL) deficits. If there are no obvious mobility, balance or ADL problems, then a fall safety assessment should be performed.
Fall Prevention Checklist
To ensure the safety of the elderly who choose to live independently, members of the healthcare team should work with family caregivers to assess the home environment. The following checklist can be used as a guide when conducting a home safety assessment.
General Household
1. Install adequate lighting, especially around stairwells, kitchen and bathrooms.
2. Are there handrails that are sturdy and can be easily grasped on both sides of the staircases? Apply non-skid treads securely to each step.
3. Is furniture arranged to allow free and safe movement in heavily traveled areas? Keep electrical cords and other low-lying objects out of walkways.
4. Area rugs should be firmly fixed to the floor with rubber backing or tape.
5. Is furniture sturdy enough to give support and allow for safe transfer on and off? The best chair is one with arms, a supportive back and a high seat. A seat that is 18 inches from the floor is ideal.
6. A phone in every room can prevent falls. Cordless phones kept in a pocket or walker basket are useful.
7. A personal emergency response system (PERS) may be necessary to provide immediate assistance in the event of an emergency. With some PERS systems, the telephone can be answered by pressing the personal help button worn as a pendant or wristwatch.
Kitchen
1. Avoid highly polished floors such as linoleum tiles.
2. Shelves should be at eye level with frequently used items within reach.
Bathroom
1. Grab bars placed in the bath, shower and toilet area improve safety. Non-skid rubber mats should be placed in areas likely to get wet. Switching to shower curtains instead of glass doors is a significant safety measure.
2. Assistive devices such as a shower seat, bath bench, shower hose or raised toilet seat may improve safety.
3. Some PERS systems use waterproof personal help buttons that should be worn in the shower in the event a fall occurs.
Bedroom
1. Is the bed at an appropriate height for easy transfers on and off?
2. Check for proper footwear and clothing; scuff-type slippers and long nightgowns can cause tripping.
Healthcare providers should work with elderly patients to make their home environment as safe as possible. Fall prevention is critical for the elderly to remain healthy and independent. It is also a financial concern for the healthcare system.
Cost of Falls
The cost associated with fall-related injuries among the elderly is sizable and growing. The total direct cost of all fall injuries in 1994 for people age 65 and over was $20.2 billion.[32] By 2020, the cost of fall injuries is expected to reach $32.4 billion.[33]
The personal cost of falls – the effect on the person’s dignity, self-reliance and self-confidence – cannot be measured financially. Fall prevention is critical to maintaining the good health of older people and extending their ability to remain functional and independent in their homes. In the event that a fall does occur, the best defense against the known medical and psychological outcomes is to assure that a personal emergency response system is in place so the patient can receive immediate assistance.
Falls are a common problem for the elderly with serious health, social and psychological consequences. Correcting potential hazards, adapting the home and employing the use of assistive devices are all part of the management of patients at high-risk for falls. A healthcare professional that is attentive to the issue of falls can make a significant difference in the long-term safety and well-being of patients who wish to live independently in their own homes.
Bibliography
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19. The Rehabilitation Engineering Center on Aging at the State University of New York at Buffalo, Workshop: Using Technology to Promote Independence for Older Adults, Fall, 1999.
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23. U.S. Bureau of the Census (1996a). Projections of the Percentage Increase in Population, by age: 1995 to 2010, 1995 to 2030, 1995 to 2050.
24. U.S. Bureau of the Census, Life Expectancy at Birth, Age 65, and Age 85, by Sex and Race/Hispanic Origin: 1995 and 2050.
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