Falls and Stroke

1. Falls and Stroke Central South Regional Stroke Program September 2007 Funded by the Ministry of Health and Long-Term Care So let�s start with the presentation. Best practice priorities in long term care were identified for the Central South region. These priorities included acute changes and palliation, dementia and aggression, pain management, falls and restraints and incontinence. The Central South Regional Stroke program has created stroke specific education to support these best practice priorities in the long-term care environment. This presentation is one of 5 modules that have been created to be presented to PSWs to speak to stroke specific issues that your residents may be experiencing. So let�s start with the presentation. Best practice priorities in long term care were identified for the Central South region. These priorities included acute changes and palliation, dementia and aggression, pain management, falls and restraints and incontinence. The Central South Regional Stroke program has created stroke specific education to support these best practice priorities in the long-term care environment. This presentation is one of 5 modules that have been created to be presented to PSWs to speak to stroke specific issues that your residents may be experiencing.

2. Session Overview The types of stroke. The common changes that result from stroke. The link between stroke and falls. What factors put a resident at risk of falling Strategies to prevent a resident from falling This session will discuss the two types of stroke, the common changes that happen as a result of a stroke, the link between stroke and falls, what factors put a resident at risk of falling, and the strategies to prevent a resident from falling. This session will discuss the two types of stroke, the common changes that happen as a result of a stroke, the link between stroke and falls, what factors put a resident at risk of falling, and the strategies to prevent a resident from falling.

3. What is a Stroke An interruption of the supply of blood and oxygen to an area of the brain. This causes the brain cells in an area to die, and reduces the brain function in that area. The area of the body controlled by the damaged area in unable to function properly. There are two types of stroke. Let�s start off with talking about what a stroke is. A stroke is an interruption in the supply of blood and oxygen to an area of the brain. When this happens the brain cells that rely on that blood and oxygen may die and the functions in the body that those brain cells were responsible for are not able to work. There are two types of strokes; an ischemic stroke and a hemmohagic stroke. Let�s start off with talking about what a stroke is. A stroke is an interruption in the supply of blood and oxygen to an area of the brain. When this happens the brain cells that rely on that blood and oxygen may die and the functions in the body that those brain cells were responsible for are not able to work. There are two types of strokes; an ischemic stroke and a hemmohagic stroke.

4. What is a Stroke? This is an example of a stroke that results from a blood clot which has travelled to the brain and is now blocking one of the arteries �pipes� in the brain. This is called an ischemic stroke. If you look at the picture you can see where the blood clot has lodged and is preventing the blood to continue to other parts of the brain. It is the region of brain cells behind the blood clot that is at risk of changing or dying. Depending on how quickly the blood and oxygen can be re-established will determine if there will be changes to those brain cells and the functioning that those brain cells are responsible for. 80% of stroke are this type. This is an example of a stroke that results from a blood clot which has travelled to the brain and is now blocking one of the arteries �pipes� in the brain. This is called an ischemic stroke. If you look at the picture you can see where the blood clot has lodged and is preventing the blood to continue to other parts of the brain. It is the region of brain cells behind the blood clot that is at risk of changing or dying. Depending on how quickly the blood and oxygen can be re-established will determine if there will be changes to those brain cells and the functioning that those brain cells are responsible for. 80% of stroke are this type.

5. What is a Stroke? This is a hemmorhagic stroke. This happens when one of the blood vessels in the brain bursts and bleeds into area around it. 20% of strokes are this type. This is a hemmorhagic stroke. This happens when one of the blood vessels in the brain bursts and bleeds into area around it. 20% of strokes are this type.

6. Risk factors you can do something about� High blood pressure High blood cholesterol Heart disease Diabetes Being overweight Excessive alcohol use Physical inactivity Smoking Stress Let�s now talk about some of the factors that increase your risk of having a stroke. They include Having high blood pressure or poorly managed hypertension Having high cholesterol Heart disease which include having an irregular heartbeat Poorly managed diabetes Being overweight Drinking too much alcohol � limit of 2 drinks/day for men and 1 drink/day for women Physical inactivity � not getting your 30 minutes of exercise each day Smoking Stress Let�s now talk about some of the factors that increase your risk of having a stroke. They include Having high blood pressure or poorly managed hypertension Having high cholesterol Heart disease which include having an irregular heartbeat Poorly managed diabetes Being overweight Drinking too much alcohol � limit of 2 drinks/day for men and 1 drink/day for women Physical inactivity � not getting your 30 minutes of exercise each day Smoking Stress

7. I have had a chance to talk for a while. Let me now open up the discussion to include you. Can you give me some examples of what a resident who has had a stroke looks like? I have had a chance to talk for a while. Let me now open up the discussion to include you. Can you give me some examples of what a resident who has had a stroke looks like?

8. What are some of the losses due to stroke? paralysis or weakness on one side of the body; vision problems (double vision); trouble speaking or understanding language; Difficulty swallowing safely. (Often times the participants are able to name many of the characteristics of stroke losses listed here.) Paralysis is one example of a result that can happen when someone has had a stroke. This weakness can vary from mild to profound in which a resident may be dependent on you for all of their care. A resident may also have vision problems. Someone who has had a stroke may have a visual field cut which results in them only being able to see one half of the screen. Imagine your television at home and you are only able to see one side of it. These patients need to pay particular attention to their affected side so that they can scan that side and take in all of the information that is needed. The residents may also have double vision Some stroke survivors have trouble speaking or understanding language. Resident�s may have trouble receiving the information that is being given to them or they may have trouble expressing the thoughts and needs that they have. This is often referred to as aphasia. This can make it very difficult to understand a resident�s needs and meet those needs. There are strategies for helping residents with this challenge and it is called supportive conversation.(Often times the participants are able to name many of the characteristics of stroke losses listed here.) Paralysis is one example of a result that can happen when someone has had a stroke. This weakness can vary from mild to profound in which a resident may be dependent on you for all of their care. A resident may also have vision problems. Someone who has had a stroke may have a visual field cut which results in them only being able to see one half of the screen. Imagine your television at home and you are only able to see one side of it. These patients need to pay particular attention to their affected side so that they can scan that side and take in all of the information that is needed. The residents may also have double vision Some stroke survivors have trouble speaking or understanding language. Resident�s may have trouble receiving the information that is being given to them or they may have trouble expressing the thoughts and needs that they have. This is often referred to as aphasia. This can make it very difficult to understand a resident�s needs and meet those needs. There are strategies for helping residents with this challenge and it is called supportive conversation.

9. What are some of the losses due to stroke? inability to recognize or use familiar objects tiredness; depression; Sometimes a stroke will make it difficult for a resident to remember what they would do with a certain item. For example a resident may have a difficult time remembering that the deodorant is not for his toothbrush and that the razor is not used to brush their hair. Residents can also be more tired that usual after having a stroke�the body requires a lot of energy to do activities with weakened parts of the body. Depression is also another issue that can arise from stroke. There are many losses of function and independence that happens as a result of having a stroke. Just imagine how it would be to be fully functioning one day and then the next day be challenged to sit up and feed or toilet yourself by yourselfSometimes a stroke will make it difficult for a resident to remember what they would do with a certain item. For example a resident may have a difficult time remembering that the deodorant is not for his toothbrush and that the razor is not used to brush their hair. Residents can also be more tired that usual after having a stroke�the body requires a lot of energy to do activities with weakened parts of the body. Depression is also another issue that can arise from stroke. There are many losses of function and independence that happens as a result of having a stroke. Just imagine how it would be to be fully functioning one day and then the next day be challenged to sit up and feed or toilet yourself by yourself

10. What are some of the losses due to stroke? exaggerated or inappropriate emotional responses; difficulty learning and remembering new information; and changes in personality. Sometimes a stroke can happen in an area of the brain that controls emotion. This can result in a resident having increased emotional responses as well as uncontrollable emotional responses. I remember working with a patient in the hospital who would cry uncontrollably. When I asked him if there was anything wrong he told me that there wasn�t and that he could not understand why he would keep on crying. Some residents will have trouble learning new tasks as a result of a stroke. The short-term memory can be affected and this makes it very difficult for someone to learn something that is dependent on remembering previous learning or a previous step in the process. Some residents can have changes in their personalities. They can change from good to bad and bad to good as a result of the stroke.Sometimes a stroke can happen in an area of the brain that controls emotion. This can result in a resident having increased emotional responses as well as uncontrollable emotional responses. I remember working with a patient in the hospital who would cry uncontrollably. When I asked him if there was anything wrong he told me that there wasn�t and that he could not understand why he would keep on crying. Some residents will have trouble learning new tasks as a result of a stroke. The short-term memory can be affected and this makes it very difficult for someone to learn something that is dependent on remembering previous learning or a previous step in the process. Some residents can have changes in their personalities. They can change from good to bad and bad to good as a result of the stroke.

11. Stroke Statistics There are between 40,000 and 50,000 strokes survivors in Canada each year. 10% (4-5,000) of strokes survivors each year require long-term care. 40% (16-20,000) of strokes survivors each year are left with a moderate to severe impairment. http://ww2.heartandstroke.ca/Page.asp?PageID=33&ArticleID=1078&Src=news&From=SubCategory There are between 40-50,00 stroke survivors each year in Canada. Of this number, 10% or 4-5,000 individuals will need the type of care that you provide in a long term care home. As well, 40% or 16-20,000 stroke survivors each year are left with a moderate to severe impairment. This is important for people working in long-term care since you work everyday with people who have moderate to severe impairments. Each year there will be more and more people who will have impairments from stroke coming to live in long term care homes because they are not able to manage in the community with the level of support that they require. The more severe the changes from the stroke, the greater the demand for care of a PSW. There are between 40-50,00 stroke survivors each year in Canada. Of this number, 10% or 4-5,000 individuals will need the type of care that you provide in a long term care home. As well, 40% or 16-20,000 stroke survivors each year are left with a moderate to severe impairment. This is important for people working in long-term care since you work everyday with people who have moderate to severe impairments. Each year there will be more and more people who will have impairments from stroke coming to live in long term care homes because they are not able to manage in the community with the level of support that they require. The more severe the changes from the stroke, the greater the demand for care of a PSW.

12. So let�s talk about falls�So let�s talk about falls�

13. Falls in Canada In Canada, falls are the sixth leading cause of death among older adults (RNAO Best Practice Guidelines, Falls and Restraints, 2002) 33% of older adults fall each year (Campbell, Borrie & Spears, 1989). 36% of those who fall develop serious injuries (Koski, Luukinen, Laippala & Kiveal, 1998) 40% of admissions to nursing homes are the result of falls (Tinetti, Speechley & Ginter, 1998). Let�s go over some statistics about falls in Canada, Falls are the sixth leading cause of death among older adults 1 out of 3 or 33% of older adults fall each year 36% of those that fall develop serious injuries 40 % of admissions to nursing homes are the result of falls. Falls are a very important issue especially given the age of the people that live in nursing homes. Let�s go over some statistics about falls in Canada, Falls are the sixth leading cause of death among older adults 1 out of 3 or 33% of older adults fall each year 36% of those that fall develop serious injuries 40 % of admissions to nursing homes are the result of falls. Falls are a very important issue especially given the age of the people that live in nursing homes.

14. Falling can be a sign of other health problems. People in nursing homes are generally more frail than older adults living in the community. They tend to be older, have more chronic illnesses, and have difficulty walking. They also tend to have problems with thinking or memory, to have difficulty with activities of daily living, and to need help getting around or taking care of themselves (Bedsine et al. 1996). All of these factors are linked to falling (Ejaz et al. 1994).  Falling can be a sign of other health problems. People in nursing homes are generally more frail than older adults living in the community. They tend to be older, have more chronic illnesses, and have difficulty walking. They also tend to have problems with thinking or memory, to have difficulty with activities of daily living, and to need help getting around or taking care of themselves (Bedsine et al. 1996). All of these factors are linked to falling (Ejaz et al. 1994).

15. Falls related to stroke Poor balance Divided attention Impulsivity Slowed response times Inability to walk Weakness Gait problems ? spatial understanding of the world deficits ? ability to coordinate body movement Mental dysfunction Falls can also happen as a result of having a stroke. A stroke can impact of a resident�s balance, decrease or divide their attention, increase their impulsivity and decrease their response times. All of these factors will put a person at greater risk of falling. A resident who has had a stroke can also have difficulties walking due to weakness and gait problems. They may also have difficulties coordinating their body movement. A resident may also have thinking changes as a result of a stroke that decreases their ability to understand the world around them spatially. It may also decrease their planning, reasoning, problem solving and judgment.Falls can also happen as a result of having a stroke. A stroke can impact of a resident�s balance, decrease or divide their attention, increase their impulsivity and decrease their response times. All of these factors will put a person at greater risk of falling. A resident who has had a stroke can also have difficulties walking due to weakness and gait problems. They may also have difficulties coordinating their body movement. A resident may also have thinking changes as a result of a stroke that decreases their ability to understand the world around them spatially. It may also decrease their planning, reasoning, problem solving and judgment.

16. Other causes of falls Dizziness Accidents Environment factors Wet floors Poor lighting Bed rails and improper bed height ? blood pressure Sudden loss of consciousness Acute illness Medication side effects But it is important to remember that strokes are not the only causes of falls. Some of the other causes include, Dizziness Accidents Environment factors Wet floors Poor lighting Bed rails and improper bed height Decreased blood pressure Sudden loss of consciousness Acute illness Medication side effects.But it is important to remember that strokes are not the only causes of falls. Some of the other causes include, Dizziness Accidents Environment factors Wet floors Poor lighting Bed rails and improper bed height Decreased blood pressure Sudden loss of consciousness Acute illness Medication side effects.

17. What is balance? Balance is the ability of a person not to fall. In the literature, there is no universally agreed definition of the term balance (5,6). However, from an intuitive clinical viewpoint, human balance may be described as the ability of a person not to fall (6,7), In the literature, there is no universally agreed definition of the term balance (5,6). However, from an intuitive clinical viewpoint, human balance may be described as the ability of a person not to fall (6,7),

18. The ability of a person not to fall an ability which is required for a number of daily actions, like sitting, standing up and moving, about. As such, balance is an essential component of functioning. The ability of a person not to fall an ability which is required for a number of daily actions, like sitting, standing up and moving, about. As such, balance is an essential component of functioning.

19. Balance problems often improve naturally as the brain slowly repairs itself in the weeks after a stroke. Recovery is helped by trying to keep moving. Many people who have had a stroke regain their balance within three months. However, everyone is different and there is no fixed time that it will take to get better. The problems caused by the stroke may mean that a resident are not able to move around a lot and this can affect how long it takes for balance problems to improve. For some people, balance problems will never completely go away. Balance retraining exercises Balance retraining exercises may help people who have had a stroke improve their balance. Because there are several possible causes of balance problems after stroke, different types of exercises will be appropriate for different people. A physiotherapist can help you to work out which movements you need to practice and therefore which exercises are most suitable for you. The most common exercises will be simple tasks practicing everyday movements in an environment in which you feel safe. At first these will be practiced with the therapists and then either on your own or with a nurse or relative. � FACTSHEET 22 Balance problems after stroke The Stroke Association (October 2006) 2 Balance problems often improve naturally as the brain slowly repairs itself in the weeks after a stroke. Recovery is helped by trying to keep moving. Many people who have had a stroke regain their balance within three months. However, everyone is different and there is no fixed time that it will take to get better. The problems caused by the stroke may mean that a resident are not able to move around a lot and this can affect how long it takes for balance problems to improve. For some people, balance problems will never completely go away. Balance retraining exercises Balance retraining exercises may help people who have had a stroke improve their balance. Because there are several possible causes of balance problems after stroke, different types of exercises will be appropriate for different people. A physiotherapist can help you to work out which movements you need to practice and therefore which exercises are most suitable for you. The most common exercises will be simple tasks practicing everyday movements in an environment in which you feel safe. At first these will be practiced with the therapists and then either on your own or with a nurse or relative. � FACTSHEET 22 Balance problems after stroke The Stroke Association (October 2006) 2

20. Early signs of fatigue Foot dragging Increased leaning to one side Walking hunched over on the walker or leaning heavily on the walker Decreased balance � wobbly Since 75% of patients complaining of fatigue 6-26 months post-stroke (Leegaard (1983) Acta Neurol Scand 67: 348-55) it is important to be aware of the signs and symptoms of fatigue since fatigue can increase the risk of a resident falling. Some of the signs of fatigue can include: Foot dragging Increased leaning to one side Walking hunched over on the walker or leaning heavily on the walker�the walker is meant to assist the resident with their balance�not hold the resident up. Decreased balance �the resident looks wobblySince 75% of patients complaining of fatigue 6-26 months post-stroke (Leegaard (1983) Acta Neurol Scand 67: 348-55) it is important to be aware of the signs and symptoms of fatigue since fatigue can increase the risk of a resident falling. Some of the signs of fatigue can include: Foot dragging Increased leaning to one side Walking hunched over on the walker or leaning heavily on the walker�the walker is meant to assist the resident with their balance�not hold the resident up. Decreased balance �the resident looks wobbly

21. Strategies Note on medical chart or resident�s door that there is a high risk of falls Move high-risk residents to rooms close to the nursing station to increase observation Reassess after new episodes of illness or, change in meds. Lower side rails for those that climb out of bed. So let�s talk about some strategies that you might use with residents that are at risk of falling Make a note on the resident�s medical chart or door that they are at a high risk of falling Move high-risk residents to rooms closer to the nursing station to make it easier to watch them Reassess the resident after new episodes of illness or changes in their medication Lower the side rails for those that climb out of bedSo let�s talk about some strategies that you might use with residents that are at risk of falling Make a note on the resident�s medical chart or door that they are at a high risk of falling Move high-risk residents to rooms closer to the nursing station to make it easier to watch them Reassess the resident after new episodes of illness or changes in their medication Lower the side rails for those that climb out of bed

22. Strategies Increase staff to resident ratio. Attend falls prevention education. Use alarm systems when residents move unassisted Use protective hip pads Other strategies may include: Increasing the staff to resident ratio Having staff attend falls prevention education Using alarm systems when residents move unassisted Use protective hip padsOther strategies may include: Increasing the staff to resident ratio Having staff attend falls prevention education Using alarm systems when residents move unassisted Use protective hip pads

23. Another strategy is to make a referral to your in-house or CCAC occupational or physiotherapist to assess this resident for increased strategies with the resident.Another strategy is to make a referral to your in-house or CCAC occupational or physiotherapist to assess this resident for increased strategies with the resident.

24. It is important to encourage residents to ask for assistance. Many of the residents are aware of how busy everyone working in the LTC home is and they may try to do more on their own than what is safe for them to do. It is important that the resident�s know that it is best for everyone if they ask for help so that they don�t put themselves at added risk..It is important to encourage residents to ask for assistance. Many of the residents are aware of how busy everyone working in the LTC home is and they may try to do more on their own than what is safe for them to do. It is important that the resident�s know that it is best for everyone if they ask for help so that they don�t put themselves at added risk..

25. CASE STUDY So let�s look at a case study�So let�s look at a case study�

26. Sue Sue has just arrived to Cozy Acres long term care home from hospital. Sue was recently admitted for management of stroke. What are some of the concerns you might have regarding Sue�s ability to remain safe upon arrival at the long-term care home? mild dementia. Balance deficits Judgment Mobility aids Insight into deficits Previously falls Link to least restraint policymild dementia. Balance deficits Judgment Mobility aids Insight into deficits Previously falls Link to least restraint policy

27. Sue Later when you are able to review Sue�s transfer information, you are aware that Sue had fallen 3 times prior to her transfer to Cozy Acres. Sue walks with a four wheel walker and requires some hands on assistance to keep her balance. Sue is impulsive and is not aware that her lack of balance may cause her to fall and possibly hurt herself. Sue�s family is very concerned about her falls and the potential to hurt herself. What is your plan to maximize Sue�s safety? Chair alarms, bed alarms, hi/low beds Plan for prompt voiding Include in lots of activities � supervision/distraction OT � in facility for equipment to improve safety Education to family of safety vs. quality of life� PT � gait training and transfersChair alarms, bed alarms, hi/low beds Plan for prompt voiding Include in lots of activities � supervision/distraction OT � in facility for equipment to improve safety Education to family of safety vs. quality of life� PT � gait training and transfers

28. Next Steps� You are the eyes and ears of your facility Be aware of the diagnosis of your residents Take this information and use it with the residents that you work with. Share this information with other staff. You are the eyes and ears of your facility. It is important that you bring changes that you see with the residents to the registered staff to determine if there is a change occurring in their medical status. Remember, if a resident is having a stroke, there is medicine that may be appropriate for the resident to receive and that there is only 3 hours available for the resident to receive this treatment. It is important to know a resident�s diagnosis, so you are aware of the issues involved with that diagnosis. This way you know when there are changes that happen with the resident that needs to be shared with the registered staff. It is important that you are able to take this information and use it with the residents that you work with. Now that you have this information, share this information with other staff members so that you can help to improve the quality of life of the residents that you work with and care for.You are the eyes and ears of your facility. It is important that you bring changes that you see with the residents to the registered staff to determine if there is a change occurring in their medical status. Remember, if a resident is having a stroke, there is medicine that may be appropriate for the resident to receive and that there is only 3 hours available for the resident to receive this treatment. It is important to know a resident�s diagnosis, so you are aware of the issues involved with that diagnosis. This way you know when there are changes that happen with the resident that needs to be shared with the registered staff. It is important that you are able to take this information and use it with the residents that you work with. Now that you have this information, share this information with other staff members so that you can help to improve the quality of life of the residents that you work with and care for.

29. More Information Acute Changes and Stroke Continence and Stroke Dementia and Stroke Falls and Stroke Pain and Stroke This module is one of 5 stroke modules that were prepared for PSWs in the LTC homes. Please contact either Kim Young or Rebecca Fleck Carol if you have any questions or would like more modules presented in your home. This module is one of 5 stroke modules that were prepared for PSWs in the LTC homes. Please contact either Kim Young or Rebecca Fleck Carol if you have any questions or would like more modules presented in your home.

30. Acknowledgements Best Practices Long-term Care Advisory Group Best Practices Long-term Care Evaluation Group Best Practice Falls Working Group, Waterloo Mary-Lou van der Horst, Regional Best Practice Coordinator Long-Term Care Central South Region Wendy MacDougal, Regional Best Practice Coordinator Long-Term Care Central West. Beverley Morgan, Project Coordinator, RNAO Best Practice Guidelines, Hamilton Health Sciences Central South Regional Stroke Program Maryann Watts, Hamilton Health Sciences, Clinical Manager Neuro-ambulatory Centre Melanie Fall Stratton, Regional Stroke Program, Program Manager, Kim Young, Regional Stroke Program, Community and Long-term Care Specialist Lisa Colizza, Regional Stroke Program, Regional Stroke Development Specialist Nancy van Essen, Regional Stroke Program, Stroke Rehabilitation Coordinator Carol Pereira, Regional Stroke Program, LTC Project Coordinator There were many people who were involved in getting this education out to you. Here are a list of these people. There were many people who were involved in getting this education out to you. Here are a list of these people.

31. Thank you�Thank you�