The older adults chosen for the fall assessment included a 67-year-old female and a 69-year-old male. The female, who will be referred to as NH, has a history of a fall in 2014 with surgery to correct excess bone and injury in August 2018. She also has a history of two more falls since the surgery. The 69-year-old male, who will be referred to as BH, has no significant fall history. They are a married couple living in the same household. The home was evaluated for hazards, correcting immediate threats. The Timed Up and Go test, 30-second Chair Stand test and a 4-stage Balance test was performed on each participant, allowing sufficient rest between tests and providing any stability support needed (as documented in findings). The results of these tests are attached as a separate images to this analysis. After the home assessment was completed, tests were performed, and adequate rest time was allowed, the “What You Can Do to Prevent Falls Brochure” was reviewed with each participant, concerns were addressed and questions were answered.

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Fall Assessment Summary

There is a clear difference in the gait of the two subjects. NH has an obvious shuffle and unsteady gait. BH has no apparent difficult walking, moving, or changing positions. NH also exhibits difficulty changing positions. She requires armrest or assistance to go from standing to sitting and vice versa. When pivoting as she walks, she takes several small steps, often tripping over her other foot. She appears to have difficulty lifting her feet completely off of the ground. When asked about physical therapy since her initial fall and surgery, NH stated “I’ve been cleared by the one doctor, but I have to get another doctor to see if I need to learn to walk again. If he says yes, he will have to order it. It is just so expensive I haven’t gone in yet.”

Intrinsic Fall Risk Factors

Several intrinsic fall risk factors were identified during this assessment as identified by Touhy (Touhy, 2016, p. 248). NH is currently taking more than 4 medications, including several antihypertensives. As previously mentioned, she has a history of falls, two within the last six months. She has unsteady gait and balance due to surgery. She is unable to rise from a chair without the use of arms and has a slow walking speed. She also has a history of diabetes. NH expresses a fear of additional falls, stating “I just get so careful making sure I don’t hurt my bad foot that I baby it so much I fall.” BH takes antihypertensives, but does not have any other intrinsic fall risk factors.

Extrinsic Fall Risk Factors

Several extrinsic fall risk factors were identified during this assessment as identified by Touhy (Touhy, 2016, p. 248). There are two dogs living in the household that can get in the path of walking. There are no safety rails in the downstairs bathrooms. However, rails have been installed in the master bathroom to assist in ambulation, toileting, and showering. There are multiple changes in surface material (carpet to tile to wood, etc.) and two doorways have uneven thresholds, changing levels from one side of the doorway to the other. General clutter is visible throughout the house. BH was seen moving it out of NH’s path on multiple occurrences. 

Most Hazardous Factor Among Community-dwelling Older Adults

Many falls are multifactorial in origin and are not the result of one intrinsic or extrinsic cause. However, in community-dwelling older adults, the risk for falls is high due mainly to environmental factors and the ability to access the outdoors, which “brings with it a higher risk for falls based on current health conditions and a greater potential for accidental falls” (Kruschke & Butcher, 2017, p. 16). In a review of falls and risk factors, Soriano, DeCherrie, & Thomas found that “[g]reater than 70% of falls in the community occur in the home. Approximately 10% of falls occur on the stairs” (Soriano et al., 2008, p. 547). Knowing the high risk of falls due to environmental factors, a sufficient assessment of a client’s surroundings needs to be performed and avoidable risks need to be removed. This was discussed with the subjects and environmental factors were identified in the home.

Teaching Summary

The pamphlet “What YOU Can Do to Prevent Falls” was reviewed with both subjects. Both NH and BH had a good understanding of each medication they were taking and its purpose. They didn’t have a readily-accessible list of medications, so one was created for each to keep at home and placed on the refrigerator, available for first responders in the event of an emergency, and another copy was placed in each subject’s wallet. NH was encouraged to continue her current plan of treatment created by the provider treating her ankle. Both were encouraged to continue physical activity under the guidance of their physician. BH is very active in skiing, bicycle rides, and assisting family members when needed. NH has stated she has noticed she “doesn’t feel as strong as she used to before her fall”. She was encouraged to review her physical therapy exercises and discuss her concerns with her physician. BH stated he would help her remember to bring that up at the next appointment. Both NH and BH have had recent eye and feet exams. Both use glasses when reading, but do not need visual assistance when walking or performing other tasks. NH wears her shoes at all times with prescribed orthotic inserts. A throw rug kept in a threshold was removed after discussing its increased risk for falls. It was also discussed to take care when the weather is wet to ensure floors stay dry to avoid slipping. All bathtubs have non-slip mats and/or surfaces. The shower that NH and BH use has a handle and there is a shower chair available. The stairs of the house also have lighting at the base and it was encouraged to keep those lights on at all times when the house is not otherwise lit by sun or other sources.

Plan of Care

Kruschke & Butcher stated, “The focus for older adults living in the community… [should] include the goals of reducing polypharmacy, improving physical mobility, ensure appropriate care for health issues, and modifying environmental factors to increase safety” (Kruschke & Butcher, 2008, p. 20). Both NH and BH were encouraged to continue to go over medications with physicians at every visit, regardless of reason for visit. They will continue to use same pharmacy to fill all medications and keep an up-to-date list of medications, including supplements and over-the-counter medications. If a new medication is started, both BH and NH stated they will ensure they know its purpose and risks prior to leaving the doctor’s office and/or pharmacy.

When asked about physical therapy since her initial fall and surgery, NH stated “I’ve been cleared by the one doctor, but I have to get another doctor to see if I need to learn to walk again. If he says yes, he will have to order it. It is just so expensive I haven’t gone in yet.” She was encouraged to make an appointment with her physician to discuss concerns and possible options. Church resources were also discussed with both NH and BH regarding financial concerns. BH and NH will both continue to be physically active to the best of their abilities, according to recommendations from their physicians.

NH has an appointment with her physician in two weeks to discuss concerns regarding her walking and mobility. BH will attend with her. NH is encouraged to notify her provider of any fall or near-fall she experiences, including details of when it happened, where she was, how it happened, what she was doing, how she was feeling and environmental conditions at the time. An easy to read form was made for her to fill out with this information at her request. NH will continue wearing her shoes as prescribed, the stairs will remain lit, there are plans to install support rails in every bathroom (they are currently only in the master bathroom upstairs). NH was also encouraged to obtain a device such as Life Alert or other medical alert system to assist in the case of a fall with no one around. They will discuss this at her next appointment with her physician.

Conclusion

Overall, BH and NH were very receptive to the teaching and plan of care created. Several risk factors were identified and plans were made to minimize future falls. The cost of falls compared to the cost of fall prevention was discussed and well-received by both NH and BH. The continuous need to reassess the environment and fall risks was emphasized. These subjects, specifically NH would benefit from a complete 10-step fall assessment and prevention plan as recommended in Kruschke and Butcher’s “Fall Prevention for Older Adults”.

References

Kruschke, C., & Butcher, H. K. (2017). Evidence-Based Practice Guideline: Fall Prevention for Older Adults. Journal of Gerontological Nursing, 43(11), 15-21. doi:10.3928/00989134-20171016-01

Materials for Your Older Patients | STEADI – Older Adult Fall Prevention | CDC Injury Center. (2019, February 1). Retrieved from https://www.cdc.gov/steadi/patient.html

Soriano, T. (2008). Falls in the community-dwelling older adult: A review for primary-care providers. Clinical Interventions in Aging, Volume 2, 545-553. doi:10.2147/cia.s1080

Touhy, T. A., & Jett, K. F. (2016). Ebersole & Hess toward healthy aging: Human needs & nursing response (9th ed.). St. Louis, MO: Elsevier.