Risk Factors Associated With In-Hospital Falls

• Previous falls and current in-hospital falls 
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• Gait or balance instability, muscle weakness
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• Medications: polypharmacy (multiple prescribed medications); changed medication regimen; or fall-risk-increasing drugs, which include psychotropic drugs, such as antipsychotics, antidepressants, benzodiazepines, sedatives, and cardiovascular drugs, such as diuretics, Type Ia antiarrhythmics, anticoagulants, and digoxin 
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• Impaired mental status: confusion, disorientation, decreased judgment 
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• Acute illness or trauma resulting in admission
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• Unfamiliar surroundings and environmental hazards
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• Dizziness, vertigo, or hypotensive episodes
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• Altered toileting (schedule, urinary incontinence, or nocturia)
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• Reluctance to ask for assistance, particularly with male gender
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• Female gender
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• Length of hospital stay

When older adults spend a significant portion of their day in bed or in a chair, they become increasingly limited in their mobility activities, such as walking.

Inactivity affects not only the muscles, but also other body systems such as the cardiovascular system. As a result, the older adult may begin to demonstrate decreased muscle strength and endurance and may become fearful of getting up or walking because of a fear of falling.


Occupational therapy approach to fall prevention-

Approach	Definition	Relevance for Inpatients
Create, promote (health promotion)	An intervention approach that does not assume a disability is present or that any factors would interfere with performance. This approach is designed to provide enriched contextual and activity experiences that will enhance performance for all persons in the natural contexts of life (adapted from Dunn, McClain, Brown, & Youngstrom, 1998, p. 534).	This approach is not applicable to hospital inpatients because it assumes the absence of disability or factors interfering with performance.
Establish, restore (remediation, restoration)	An intervention approach designed to change client variables to establish a skill or ability that has not yet developed or to restore a skill or ability that has been impaired (adapted from Dunn et al., 1998, p. 533).	Engage the patient who was admitted with pneumonia in morning ADL sessions that increase in length each day with the goal of building endurance. Collaborate with the patient and nursing staff to establish healthy sleep-wake patterns.
Modify (compensation, adaptation)	An intervention approach directed at �finding ways to revise the current context or activity demands to support performance in the natural setting, [including] compensatory techniques, [such as] enhancing some features to provide cues or reducing other features to reduce distractibility� (Dunn et al., 1998, p. 533).	Teach the patient who underwent a total hip replacement how to use a shower bench, grab bar, long-handled sponge, soap-on-a-rope, and hand-held shower head when showering. Provide a visual schedule to help an inpatient follow hospital routines over the course of a day.
Maintain	An intervention approach designed to provide the supports that will allow clients to preserve the performance capabilities they have regained, that continue to meet their occupational needs, or both. The assumption is that, without continued maintenance intervention, performance would decrease, occupational needs would not be met, or both, thereby affecting health and quality of life.	Provide multisensory activities to maintain alertness in the hospitalized patient who has a history of depression. Provide the patient with rheumatoid arthritis with an exercise program designed to maintain upper and lower extremity joint range of motion. Teach the patient how to complete the exercise program while she is in the hospital. Help the client develop a plan that will support her continued use of the program upon discharge. Maintain safe and independent access to the hospital room for the patient with low vision by recommending increased lighting in the room.
Prevent (disability prevention)	An intervention approach designed to address clients with or without a disability who are at risk for occupational performance problems. This approach is designed to prevent the occurrence or evolution of barriers to performance in context. Interventions may be directed at client, context, or activity variables (adapted from Dunn et al., 1998, p. 534).	Work with a patient who was hospitalized after having a stroke (and therefore at high risk for falls) to help him gain an appreciation of his physical capabilities and limits and teach him how to transfer and safely use an assistive device that is new to him. Collaboratively work with a patient who has Parkinson�s disease and who expresses a fear of falling and her caregiver to create a schedule and a plan that supports the patient in her goal of attending church at least twice a month.
Source. AOTA, 2008.

Shared Features of the Matter of Balance and Stepping On Programs - 

Shared features	Description
Emphasis on multifactorial approaches	Instead of focusing on one approach to reducing falls (e.g., increasing leg strength), several fall prevention strategies are used. For example, using an exercise program to build balance skills and/or strength and teach older adults skills needed to identify and manage fall hazards in the home.
Dedication to client-centered practice	Collaborative approaches that actively involve the older adult in the process of identifying and mitigating fall risk factors are used, and individualized fall prevention plans are developed.
Use of social cognitive theory	Both programs apply Bandura�s (1997) social cognitive theory, which emphasizes the importance of vicarious experiences (listening to and watching others); verbal persuasion, which can occur as peers relay their successful efforts to reduce fall risk; and enactive mastery experiences (learning by practicing new skills). Enactive mastery experiences include practicing assertive communication skills, refining exercise skills, and implementing action plans.
Use of groups	Both programs use the group process, which may be particularly beneficial to older adults learning to manage fall risk. By observing peers, older adults can preserve or enhance a sense of self-efficacy in the face of changing abilities (Frey & Ruble, 1990).

Recommended Fall Prevention Web Sites

Joint Commission Fall Reduction Program Resources for fall reduction programs and answers to frequently asked questions. American Pharmacists Association Patient education brochures intended for the general public, available in pdf format on topics ranging from how to ask a pharmacist about prescription and nonprescription medications to the benefits of having a medication checkup. Connecticut Collaboration for Fall Prevention www.fallprevention.org Guide for Clinicians that includes materials for clinicians and handouts for older adults. National Council on Aging, Center for Healthy Aging, Falls Free Coalition National Action Plan State Coalitions on Fall Prevention: A Compendium of Initiatives My Medicare Community (for updates on preventive benefits for 2011 and beyond) Center of Excellence for Fall Prevention www.stopfalls.org Resources and issue briefs National Center for Injury Prevention and Control (CDC) www.cdc.gov/injury/index.html Fact sheets Cost information Posters, publications, and brochures Traumatic brain injury awareness, Brain Injury Awareness Month Veterans Administration National Center for Patient Safety Falls Toolkit Hip Protector Toolkit Other fall prevention resources For information regarding local fall prevention activities and resources, contact your local Area Agency on Aging.

Dementia-tips for communication

Communication tips to use with a client that has dementia:

• Speak in a gentle, caring manner.

• Keep sentences short and simple, giving instructions one step at a time.

• Allow ample time for what you have said to be understood and for he/she to respond. Fill in words when needed.

• Try to avoid over-stimulation via the TV, computer, or radio.

• Maintain regular routines which help reduce agitation and confusion.

• Don’t argue or confront the person with dementia.

• Don’t tell the person with dementia what they can’t do. Re-frame in a positive light by emphasizing what they can do.

• Don’t be critical. A critical or judgmental tone of voice can be picked up (even when the words don’t make sense).

• Don’t mention if something was forgotten or repeated.

• Don’t talk in front of the person with dementia as if he/she is not present.

Balance and independence-TUG test

TUG test - the person is asked to stand up from a chair, walk 3m, turn back and return to the chair.  you can start with a demonstration by the therapist and a practice trial by the client. Timing begins when the first observable movement of the client occurs and ends when the client’s buttocks touch the seat of the chair. During the test it's beneficial to assess; sit to stand, walking and turning speed. 

Typical times range from under 10 sec to 15 sec. Generally, scores under 10 sec indicate an independent person. Scores under 20 sec indicate people with good mobility who are usually independent in daily activities, can climb stairs and can navigate alone outside of the home. Scores between 20 and 29 sec are considered a gray zone because of the variability in balance abilities and functional mobility; such clients may be independent or need some help with routine daily tasks. Scores above 30 sec are generally indicative of clients who need help with transfers (chair, toilet), bathing and climbing stairs. These clients may not navigate outside of their house alone (Bischoff-Ferrari et al., 2004; Bohannon, 2006; Isles, Low Choy, Steer, & Nitz, 2004; Lin et al., 2004; Podsiadlo & Richardson, 1991).

Occupational Therapy Intervention Approaches

health promotion An approach that does not assume  a disability is present. The goal is to provide enrichment and experiences that will enhance performance for all. remediation, restoration Designed to change and establish a new skill or ability or to restore a skill or ability that has been impaired. Maintain Provide the supports that will allow clients to preserve the performance capabilities they have regained.  Modify=compensation Finding ways to revise the current context or activity demands to support  performance in the natural setting. Prevent Designed to address clients with or without a disability who are at risk for occupational performance problems.

Falls Behavioural Scale

Older Persons’ Adaptations to Protect Themselves From Falling: Ten Dimensions

The Falls Behavioral Scale for Older People (FaB; Clemson, 2003; Clemson, Bundy, Cumming, Kay, & Luckett, 2008) is an assessment designed to evaluate behavioral factors that could potentially protect against falling.

FaB Behavioral Factor Examples Factor 1: Cognitive adaptations Use traffic lights whenever possible. When outdoors move around carefully, and look for potential               hazards. Hold onto a handrail when climbing stairs. When feeling ill take special care when moving around Factor 2: Protective mobility Use a walking stick or walking aid if need it. Moving at a slower pace. When standing up make a pause to get the balance. Bend over to reach only with a firm handhold. Avoid ramps and other slopes. Factor 3: Avoidance Ask for help when needed Use night light. Factor 4: Awareness Ask the physician questions about the side effects of medications. I notice spills on the floor. Factor 5: Pace Don't hurry when doing things. Don't turn around quickly. Factor 6: Practical strategies Avoid walking about in crowded places. Clean spills on the floor. Factor 7: Displacing activities don't go out on windy days. Factor 8: Being observant Check the soles of shoes to see if they are slippery. When walking outdoors look ahead for potential hazards. Factor 9: Changes in level When wearing bifocals I misjudge a step or do not see a                      change in floor level. When I am getting down from a ladder or step stool I think                              about the bottom rung or step. Factor 10: Getting to the phone I hurry to answer the phone.

"No hand walker"

Went today to the Maker Faire - that is, Part science fair, part county fair, and part something entirely new. All of these “makers” come to Maker Faire to show what they have made and to share what they have learned. 

In this very interesting faire I found "LifeGlider" - a walker designed to be used with minimal to no use of arms. The inventor is Rob Karlovich, that is currently still working on prototyps, but they are definitely looking very promising!

Use of Technology in Home Modification

On December, 2014, I traveled all the way from sunny CA to beautiful Charlotte, NC to participate in an AOTA conference on Home Modification and Fall Prevention. The conference exceeded my expectations. There was a lot of new and valuable information I would like to share.

I'm adding links to the items I found interesting, with examples on ways to use them-

http://wirelesstag.net/ - Motion sensor that can send notifications when items were moved. E.g. if you're worried about your parent that lives alone and is losing weight, place a sensor on the fridge door so you have an idea how many times the fridge was opened during the day.

http://www.mobilehelp.com/ - Medical alert that includes GPS and is based on the cellular system instead of the traditional land line, can be used in and outside of the house. Can be beneficial for older adults that are active and enjoy the outdoors. The regular home systems might not have good coverage of the backyard, leaving the older adult unprotected in an area that is not visible to people passing by.

http://www.homedepot.com/p/Chamberlain-MyQ-Garage-Universal-Smartphone-Controller-MYQ-G0201/204394627?N=5yc1vZc1jwZ1z0um34 - Garage door controller, operated by smart phone from anywhere. Wish we had one when we left our garage door open for a few hours. When we returned home and found our brand new bicycle intact, we were very thankful to all the law abiding people that passed by our wide open garage that day.

http://www.managemypills.com/content/ - Medication dispensing system. Can be beneficial for people who take multiple medications at different times, and have difficulty following correct dosage and timing.