Prevention of falls in older people

In recent years the evidence base for prevention of falls in older people has increased and associated with this has been an inevitable expansion in clinical services which attempt to localize and implement what is described in the literature. This article reviews the basic physiology implicit in maintenance of the upright posture; highlights the diversity of medical and non-medical risk factors associated with falls; describes the clinical assessment of an older person at risk of falls; reviews the evidence for intervention in the prevention of falls in older people; and acknowledges the need for a clear strategic direction to successfully prevent falls and the requirement for ongoing research as well as much needed service evaluation.     

Prevention of falls in older people

In recent years the evidence base for prevention of falls in older people has increased and associated with this has been an inevitable expansion in clinical services which attempt to localize and implement what is described in the literature. This article reviews the basic physiology implicit in maintenance of the upright posture; highlights the diversity of medical and non-medical risk factors associated with falls; describes the clinical assessment of an older person at risk of falls; reviews the evidence for intervention in the prevention of falls in older people; and acknowledges the need for a clear strategic direction to successfully prevent falls and the requirement for ongoing research as well as much needed service evaluation.     

Prevention of falls in older people

In recent years the evidence base for prevention of falls in older people has increased and associated with this has been an inevitable expansion in clinical services which attempt to localize and implement what is described in the literature. This article reviews the basic physiology implicit in maintenance of the upright posture; highlights the diversity of medical and non-medical risk factors associated with falls; describes the clinical assessment of an older person at risk of falls; reviews the evidence for intervention in the prevention of falls in older people; and acknowledges the need for a clear strategic direction to successfully prevent falls and the requirement for ongoing research as well as much needed service evaluation.     

Preventing falls in older people: risk factors and primary prevention through physical activity

Falls among older people represent a major public health issue, which can in part be tackled through an integrated falls service combining both primary and secondary prevention. Many falls can be prevented following comprehensive assessment to identify risk factors and to plan interventions to eliminate them or ameliorate their effect. Community nursing staff are well placed to undertake such risk assessments and can instigate programmes of primary prevention designed to reduce the likelihood of a person falling. Increased physical activity among older people represents one element of a prevention programme. While this is beneficial for the older person's general health and well-being, certain types of exercise can also be used to reduce falls in individuals with muscle weakness, reduced mobility and balance problems. With the exception of balance training the evidence base related to exercise and falls prevention is patchy; Carter et al (2001) suggest that as yet there is insufficient evidence to suggest an optimum exercise programme for falls prevention. Each person should therefore be individually assessed and the results used to identify what type of exercise they might benefit from in order to address a specific risk factor. Once an appropriate form of exercise has been identified, practitioners should put the older person in contact with a physical activity coordinator to assist them in accessing an exercise programme.     

Older people, continence care and catheters: dilemmas and resolutions

Urinary incontinence (UI) is a common problem and has a profound impact on quality of life among older people. There are various nursing interventions and treatments which can improve UI for the majority of people. Catheterization should be considered for specific clinical indications only when other options have been ruled out. Many complications are associated with catheterization, including catheter-associated urinary tract infections (CAUTIs), which are the most common cause of hospital-acquired infections. It is important for nurses and other healthcare professionals to appreciate how catheters produce infection so that appropriate catheter care is used. The best way to avoid CAUTI is to avoid catheterization, whenever possible, and to remove indwelling catheters when they are no longer required. There is a need to raise public awareness about UI and the interventions and treatments available so that more older people seek help. The challenge for nurses is to avoid using catheters and develop alternative approaches to the care of older people with incontinence.     

Do sleep problems or urinary incontinence predict falls in elderly women?

The objectives of this cross-sectional study were: (1) To determine if night-time sleep disturbance, daytime sleepiness, or urinary incontinence were associated with an increased risk of falling in older Australian women and (2) to explore the interrelationships between daytime sleepiness, night-time sleep problems, and urge incontinence. Participants were 782 ambulatory, community-dwelling women aged 75 to 86 recruited from within the existing Calcium Intake Fracture Outcome Study, in which women above 70 years were selected at random from the electoral roll. Daytime sleepiness, night-time sleep problems, urinary incontinence and falls data were collected via self-complete questionnaires. Thirty-five per cent of participants had fallen at least once in the past 12 months and 37.7% reported at least one night-time sleep problem. However, only 8.1% of the study sample experienced abnormal daytime sleepiness (Epworth Sleepiness Scale score > 10). Pure stress, pure urge, and mixed incontinence occurred in 36.8%, 3.7%, and 32.6% of participants respectively. In forward stepwise multiple logistic regression analysis, urge incontinence (OR 1.76; 95% CI 1.29 to 2.41) and abnormal daytime sleepiness (OR 2.05; 95% CI 1.21 to 3.49) were significant independent risk factors for falling after controlling for other falls risk factors (age, central nervous system drugs, cardiovascular drugs). As urge incontinence and abnormal daytime sleepiness were independently associated with an increased falls risk, effective management of these problems may reduce the risk of falling in older women.     

Urinary incontinence strategies for frail elderly women

Among the majority of frail older women, urinary incontinence has not been adequately assessed or treated, with resultant negative impact on quality of life. An assessment and intervention model based on type of incontinence, evidence-based interventions, and the influence of patient preference and capacity to carry out interventions are described.     

Primary prevention research on incontinence in older adults

Primary prevention research on urinary incontinence in older adults is in its nascent phase. Most clinical research has focused on secondary or tertiary prevention, that is, testing interventions to cure, improve, or manage incontinence. When urinary incontinence is recognized as a public health issue, resources become available to reduce the risk of incontinence and prevent its occurrence. Methodological issues that face nurse researchers desiring to conduct primary prevention research include inadequate theory and outcome development, need for gender and culturally sensitive measurement instruments, and sampling and design issues. Rather than viewing primary prevention as a futile endeavor, nurse researchers must combine the roles of researcher and advocate, articulating the vision for primary prevention, and developing sound clinical studies to prevent urinary incontinence in the older adult population.     

Promoting effective continence care for older people: a literature review

Recent United Kingdom guidelines have identified the need for integrated continence services within health regions. While there is evidence of improvements in community services there is little evidence that the quality of nursing care offered for older people with urinary incontinence in care settings has improved. This literature review identifies some of the underpinning issues that impact on continence promotion for older people. Despite evidence that older people suffer physical, social and psychological distress as a result of mismanaged urinary incontinence, costs of promoting continence are higher in financial terms than containing incontinence. The extent of the problem is difficult to identify in terms of how many older people are affected by different types of urinary incontinence. Nurses' attitudes are found to affect the quality of continence care delivered, and there continues to be a lack of evidence around sustainable strategies for continence promotion in care settings.     

Falls and their prevention in elderly people: what does the evidence show?

A large proportion of falls and fall injuries in older people is due to multiple risk factors, many of which probably can be modified or eliminated with targeted fall prevention interventions. These interventions must be feasible, sustainable, and cost effective to be practical for widespread use. The most promising prevention strategies involve multidimensional fall risk assessment and exercise interventions. Incorporating these intervention strategies whenever feasible into a fall prevention program seems to be the most effective means for fall prevention in older adults.     

Fall prevention in assisted living: assessment and strategies

Residents in assisted living residences have similar risk factors for falls as do community-residing older adults and, as such, can benefit from the research findings on falls prevention conducted with that population. Some risk factors can be managed, such as, medication side effects, and muscle weakness; others such as degenerative neurological changes, cannot. Knowing a resident's falls history and conducting a full risk assessment, in combination with appropriate interventions, can reduce the probability of a future fall. Exercise appears to be the most effective factor in reducing the risk of falls and injuries from falls. The fear of falling, whether or not associated with a previous fall, is more common among older women and can seriously restrict their quality of life. This article describes evidence-based falls risk assessment instruments and interventions to reduce falls risk. T'ai chi, for example, can reduce falls risk by improving balance. The article describes a standard fall prevention program for older adults that can be part of a resident's care or service plan, criteria for an occurrence report, quality improvement monitoring, and a formula to calculate the residence's monthly falls rate.     

Nurse care manager contribution to quality of care in a dual-eligible special needs plan

We evaluated the quality of care provided to older patients with complex needs in a dual-eligible, community-based Medicare Special Needs Plan that used a nurse care manager model. Care provided by physicians was substantially supplemented by nurse care managers, as measured by Assessing Care of Vulnerable Elders quality indicators. We describe selected nurse care manager activities for six geriatric conditions (falls, dementia, depression, nutrition, urinary incontinence, and end-of-life care) during provision of patient care coordination and management for patients in the highest decile of clinical complexity. We identify areas of high nurse performance (i.e., falls screening, functional assessment, behavioral interventions for dementia problems, advance care planning) and areas of potential missed opportunities (i.e., follow up for new memory problems, targeted dementia counseling, nutrition, and behavioral approaches to urinary incontinence). Increasing the collaborative interaction between nurses providing care in this model and physicians has the potential to enhance nurses' contributions to primary care for vulnerable older adults.     

Protection of continence in pregnancy,labor and postpartum periods

Urinary incontinence (UI) is a common problem among women. Pregnancy and labor are the major risk factors for UI among young and middle‐aged women. In some studies, the presence of incontinence before and during pregnancy has been shown to be an independent risk factor for urinary and anal incontinence after delivery and beyond. Recently, the need and consequences of many routine interventions applied during each delivery are questioned on an evidence‐based basis. Episiotomy and interventions (forceps, fundal pressure) at the second phase of delivery result in pelvic floor injury by perineal trauma. Similar interventions during delivery pose a risk for urinary and fecal incontinence. Therefore, episiotomy should be avoided as much as possible during delivery, and spontaneous and non‐interventional labor opportunities should be created. Pelvic floor muscle training (PFMT) is often advised as a conservative management method in UI during pregnancy. Investigations suggest that women with stress, urge or mixed UI should be advised to perform PFMT that is part of the conservative management program. There is some evidence in primiparous women that PFMT may prevent UI on the late weeks of pregnancy and the postpartum period. When postpartum pelvic floor exercises are applied along with feedback, they induce a decrease in postpartum incontinence. Furthermore, motivation and the initiative in reminding women regarding kegel exercises were not found to be effective in the postpartum prevention of UI. Postpartum pelvic floor exercises were not found to be consistent with decreased incidence of fecal incontinence. Multidisciplinary approaches are needed to inform women about the risk of postpartum UI.     

The influences of prompted voiding for urinary incontinence among older people in nursing homes

Research question: What are the influences of prompted voiding (PV) for urinary incontinence (UI) among older people in nursing homes? Research problem: This study aims to evaluate the effects of PV for UI of older people's subjects in nursing homes. Management of UI among older people is needed to overcome the possibility of new problem for older people. A randomized controlled study was performed of pre‐test post‐test design for 12 subjects (6 of control and 6 of intervention group). An intervention group followed PV instructions for 24 hours during 28 days, while the control group was instructed to urinate in toilet or to use diapers. Outcome variables were measured using incontinence severity index (ISI). There was statistically significant main effect across ISI among intervention group pre‐ (8.67 ± 1.97) and post‐ (6.67 ± 2.73) intervention of PV (P = .007). While there was statistically significant differenced ISI between control and intervention group (9.67 ± 1.86 vs 6.67 ± 2.73) post‐intervention of PV (P = .005). There was higher reduced ISI in the intervention group (?M ?2.00 ± 1.09) after 28 days of PV (P = .001). PV could be used to increase the older people's initiative to go to toilet and decrease incontinence episodes during a short time by their self in the nursing home.     

State of the art

Many falls and injuries related to falls can be prevented with existing knowledge and technology. But effective fall prevention will require the collaborative efforts of many organizations as well as changes in the behavior of older adults and providers, and systematic changes in organizations. Many effective interventions currently exist, but improved access, additional resources, and coordination and commitment across systems are needed. In summary, we know how to prevent falls and reduce injuries, using proven intervention strategies aimed at both low-risk and high-risk older adults. There is a wide spectrum of screening and assessment tools available and effective intervention practices. The challenge now is to put into practice throughout California the state-of-the art knowledge that has already been compiled through innovative programs and rigorous research.     

Transdermal and Oral Clonidine

The term geriatric syndrome is used to characterize multifactorial clinical conditions among older people which are not subsumed readily into disease entities, but which nevertheless predispose older people to disability and death. Commonly included are frailty, dementia, delirium, incontinence, falls, and dizziness. Geriatric syndromes are common among older people: in a recent survey, 50% of those aged more than 65 had one or more of these conditions. Better methods for prevention and treatment are needed, but current strategies have lacked a coherent conceptual and diagnostic framework. Prevention and interventions need to be targeted at earlier ages, with geriatrics expertise needed in the definition and operationalization of these complex entities. In this review we consolidate evidence that vascular disorders, including vascular ageing and vascular diseases, are key etiological factors of geriatric syndromes. Identifying this vascular dimension would offer opportunities for more efficient preventive strategies and mandates earlier intervention, especially for women, among whom vascular disease is often expressed more insidiously than among men. This would entail a sensitization of the health care system to the systematic detection of the syndromes, which are currently underdiagnosed. Further disentangling of the mechanisms of vascular ageing may offer therapies for vascular diseases and geriatric syndromes alike.     

A systematic review of topical skin care in aged care facilities

Aim. This systematic review aimed to evaluate the best available evidence regarding the effectiveness of topical skin care interventions for residents of aged care facilities. Introduction. Natural changes to skin, as well as increased predisposition to pressure sores and incontinence, means residents of aged care facilities readily require topical skin care. A range of interventions exist that aim to maintain or improve the integrity of skin of older adults. Methods. Pubmed, Embase, Current Contents, CINAHL and The Cochrane Library databases were searched, as well as Health Technology Assessment websites up to April 2003. Systematic reviews and randomized or non‐randomized controlled trials were evaluated for quality and data were independently extracted by two reviewers. Results. The effectiveness of topical skin interventions was variable and dependent on the skin condition being treated. Studies examined the effectiveness of washing products on incontinence irritated skin. Disposable bodyworns may prevent deterioration of skin condition better than non‐disposable underpads or bodyworns. Clinisan, a no‐rinse cleanser may reduce the incidence of incontinence associated pressure ulcers when compared with soap and water. Conclusion. In general the quality of evidence for interventions to improve or maintain the skin condition in the older person was poor and more research in this area is needed. Relevance to Clinical Practice. Skin care is a major issue for nurses working with older people. On the basis of this review no clear recommendations can be made. This lack of strong evidence for nurses to base effective practice decisions is problematic. However, the ‘best’ evidence suggests that disposable bodyworns are a good investment in the fight against skin deterioration. No rinse cleansers are to be preferred over soap and the use of the bag bath appears to be a useful practice to reduce the risk of dry skin (a risk factor for breaches in skin integrity).     

Factors associated with the risk for falls in PACE participants

ObjectiveThe purpose was to determine the relationship between frailty, fear of falling, and depression with falls risk in vulnerable community-dwelling older adults.MethodsA cross-sectional correlational design and chart review were completed. Nursing home eligible older adults ≥55 who live in the community were surveyed on frailty, fear of falling, depression, and the risk for falls. Pearson's correlation, multiple regression and hierarchical regression were used to analyze the data.ResultsIncreased frailty, fear of falling, and depression were significantly associated with an increased risk for falls. Frailty and fear of falling were significant predictors of the risk for falls while depression did not contribute to the regression model. When controlling for sociodemographics, frailty, fear of falling, and incontinence were significant predictors for the risk for falls.DiscussionThe results of this study will assist in assessment and interventions to decrease the risk for falls in high risk older adults.     

Individualized interventions to prevent bed-related falls and reduce siderail use

Five categories of problems that often result in siderail use: memory disorder, impaired mobility, injury risk, nocturia/incontinence, and sleep disturbance. As nursing homes work toward meeting the Health Care Financing Administration's mandate to examine siderail use, administrators and staff need to implement interventions that support safety and individualize care for residents. While no one intervention represents a singular solution to siderail use, a range of interventions, tailored to individual needs, exist. This article describes the process of selecting individualized interventions to reduce bed-related falls.