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Community health experts and health issues identified. • Dr. Zayas(Emergency room physician at The Kingston Hospital). • 1. Teenage birth control • 2. Teenage sexually transmitted diseases • 3. Elderly falls/injuries
Cont.…. • Dr. Costley (Family practice physician at Saugerties Family Practice). • 1. Mental health disorders/crisis • 2. Teenage prescription drug use • 3. Elderly safety
Cont.... • F. Connelly RN BSN (ICU/Emergency room nurse at Columbia Memorial Hospital). • 1. Elderly neglect • 2. Healthcare access • 3. Vaccination administration
Healthy people 2020 objectives in correlation to community health issues. • 1. Access to Health Services • 2. Immunization and Infectious diseases • 3. Substance Abuse • 4. Mental Health and Mental Disorders • 5. Older Adults • 6. Adolescent Health (Healthy people, 2012)
Older Adults According to healthy people 2020, older adults are one of the fastest growing population due to “ baby boomers.” “Approximately more than 37 million older adults will have at least 1 chronic condition to manage going into year 2030.” (Healthy People, 2012)
Older Adults.. The elderly population is at risk for low to poor quality of life. Chronic conditions like diabetes, dementia, arthritis, and heart disease coupled with sedentary lifestyle places older adults at greater risk than those without chronic condition (Healthy people, 2012).
Older Adults.. Healthy people 2020 looks to focus on quality of life, while helping elderly maintain optimal health and functioning. Healthy people 2020 position on this topic is to design objectives that meet the needs of this population by promoting healthy outcomes, and implementing preventative health services. (Healthy People, 2012)
Falls/ Injuries Quality of life in older adults can be affected by many risk factors. But, one of the most frequent issue that results in hospitalization, disability, fear, and death is falls. According to healthy people 2020, 1 out of 3 older adults experience severe disability related to falls (healthy people, 2012).
Falls/ Injuries Many older adults live alone, and experience a fall at sometime resulting in serious injuries, and even death. This is a growing concern in public health, and local communities due to musculoskeletal injuries, prolong hospitalization, and cost of acute and long-term care.
Falls/ Injuries “ Falls are the leading cause of death due to unintentional injury among older adults, deaths and injuries can be prevented by addressing risk factors.” (Healthy People, 2012)
Falls/ Injuries On the basis of the annual cost of hip fracture in 1984, an assumption that the average cost will remain constant, an inflation rate of 3% - 5%, and the increasing number of hip fractures, the estimated total annual cost of hip fracture in the United States could reach $82- $240 billion by the year 2040. (CDC, 2012)
Research Staying Steady: A community-based exercise initiative for falls prevention discusses a mixed method study in identifying risk factors for elderly falls, and implemented a program intervention to prevent falls. The study provided qualitative data, and quantitative data.
Risk factors identified in study • Fear of falling • Loss of confidence • Balance and gait abnormalities • Environmental hazards • Visual impairments • Multiple medications
Staying Steady: Community falls prevention program. This study used a mixed method approach in identifying risk factors of falls in elderly 65 years and older, implemented a evidence-based intervention program over 32 weeks, and compared physical activity before and after the intervention. Participants included 5 females with a mean age of 77, preexisting medical conditions, and had a history of falls (injurious or non-injurious).
Staying Steady program The program was run over 32 weeks. Participants attended four 8-week blocks, alternating once-weekly tailored group exercise and education sessions with an individualized home-based exercise program. Included exercise instructor to tailor individual needs. Also, Later Life Training Instructor (Postural Stability). (Hedley, Suckley, Robinson, Dawson, & Res, 2010)
Intervention: group exercise • Warm up- 15 to 20 minutes. • Cardiovascular exercises- 10 to 20 minutes. • Resistance training- 10 minutes. • Dynamic balance training- 10 to 15 minutes. • Cool down- 10 minutes. • Educational session post-workout.
Intervention: home exercise • Developed to meet each individual needs. • Included cardiovascular exercises, and resistance exercises- 30 to 40 minutes four times a week. • Consultation weekly with physical activity coordinator to discuss local low-cost activities.
Data Collection Qualitative Quantitative Gait and balance were assessed at baseline and week 32 using the Performance Oriented Assessment of Mobility tool. (reliable and valid measure for older people at risk for falling) Timed Sit-To-Stand chair stands in assessing lower limb strength. Grip strength in assessing muscle strength. • One to one interview with exercise instructors during week 8 and week 16. • Focus group session at week 32.
Findings: Participants substantially experienced improved balance and gait scores, had faster timed sit-to-stand chair raises, and increased hand grip scores. Participants also exhibited improvements in mood, increased alertness, better memory, and most important increase in confidence.
The purpose of this evaluation was to describe how an evidence-based intervention, targeting older people at risk of falls, could be implemented in clinical practice. “ Enhanced self-efficacy and self-confidence were considered key in promoting adherence to the Staying Steady program “ (Hedley et al, 2010, p. 434). (Hedley et al, 2010)
Recommendations for addressing the issue • Maintain a whole-community approach to falls prevention to ensure sustainability. • Understand the value of additional physical and psychological benefits of exercise and their impact of quality of life. • Implement strategies to enhance adherence to exercise. (Hedley et al, 2010)
Research Effect evaluation of a multifactor community intervention to reduce falls among older persons, is a study that involved 3 communities over a three year period assessing factors that contribute to falls in elderly, and evaluation of the effectiveness of interventions preventing falls in elderly.
Risk factors identified in study • Fear of falling. • Health (preexisting conditions). • Environment (inside or outside). • Behavior (physical activity). • Loss of control over his or her body posture.
Effect evaluation of a multifactor community intervention to reduce falls among older persons This study was carried out from November 1999 to November 2002 in the Province for Friesland. 1752 participants (1122 intervention; 630 controlled) ages 65 and older who lived independently, and experienced a fall (previous or recent). Study design was pre-test – post-test over 10 months. Interventional program over 14 months.
Interventions • Pre-test – post-test and self report intervention given to intervention and controlled communities for 10 months. Tests include how to answer a monthly phone call, health related questions, demographic information, medication use, frequency of falls, and fear of falls. • Interventional program included: Information and education; training and exercise, and environmental modifications experienced by intervention community over 14 months.
Findings: • People from the control communities had, relative to the intervention group, a higher level of educational attainment, lived more often in houses with two or more floors, experienced more difficulty with transfer from chair and less often reported dizziness with falls as a health problem in the past year. (Wijlhuizen, Bois, Dommelen & Hopman-Rock, 2007). • The intervention community appeared to be more physical active outside the home. However, this was true more for women than men.
Effectiveness of interventions • The interventions did not significantly reduce the period prevalence of fallers or the number of falls per 1000 persons per year relative to control. However, there was a significant relative reduction exceeding 20% in the period prevalence of fallers outside the home especially among women. (Wijlhuizen et al, 2007).
Wijlhuizen et al. (2007) states, “ Advice about falling was often depicted as common sense, only necessary for older or more disabled individuals and potentially patronizing and distressing “ (p. 30). • Suggestion on focusing more on the physical aspects of elderly person seems more promising, and effective in falls prevention.
Recommendations for addressing the issue • Wijlhuizen et al. (2007) discuss that future follow-up studies should assess to what extent people change their level of physical activity, both in and outside the home, as a result of prevention interventions. These data can provide insight into the way older people modulate the balance between task demands and performance capability in order to cope with their perceived risk of falling. (p. 33).
Steps to address issue at the community level The CDC has developed guidelines in designing an effective community-based fall prevention programs, which include: • Education- about falls and fall risk factors. • Exercises- that improve mobility, strength, and balance. • Medication review- to identify side effects or drug interactions that may contribute to falls. • Vision exams- by trained healthcare professionals (optometrist, ophthalmologist). • Home safety assessment and home modification- by occupational therapists or other healthcare professionals with specialized training, to identify and modify home hazards that can increase older adults’ risk of falling. (CDC, 2012)
Steps to address issue at the community level Washington State Department of Health has developed a community-based program called (SAIL) Stay Active and Independent for Life; a strength and balance fitness class for adults 65 and older. • The SAIL program helps older adults to stay active and independent. It helps to prevent falls, through group exercise classes that meet for 1 hour, three times a week. The classes are held at community sites, such as senior centers, parks and recreation facilities, and community fitness centers that often work in partnership with community healthcare and senior service organizations to offer the program. (CDC, 2012)
Steps to address issue at the community level Healthy People 2020 has developed objectives to prevent injury amongst older adults, and improve the quality of life in this target community. • Intervention: • Social Support Intervention in Community Settings: Healthy people (2012) states, “ These social support interventions focus on changing physical activity behavior through building, strengthening, and maintaining social networks that provide supportive relationships for behavior change (e.g., setting up a buddy system, making contracts with others to complete specified levels of physical activity, or setting up walking groups or other groups to provide friendship and support). (Health people, 2012)
Cont... Researchers do not know all the factors that contribute falls and fall related injuries in older adults, mainly, due to the person not remembering how the fall or injury occurred. However, fall prevention programs have effectively reduced falls in select populations by 30% - 50%, using multifaceted approaches that include various combinations of education, exercise, medication assessment, risk factor reduction, and environmental modifications. (CDC, 2012) (CDC, 2012)
Implications cont.… • According to CDC (2000), falls are the leading cause of injury and disabilities among person aged 65 or older. In the United States, one of every three older adults falls each year. (p. 2) • The cost of care attached to elderly with hip fracture can exceed $16,000-$19,000 during the first year following injury. (CDC, 2000) • “ In 1991, hip fracture accounted for an estimated $2.9 billion in Medicare costs.” (CDC, 2000) • “ An even more important factor than the monetary cost of hip fracture is the injury’s impact on a person’s life in the form of loss of independence and decreased quality of life.” (CDC, 2000)
Implications cont.… • In the article Falls in Nursing Homes (2012) discusses, “ About 1,800 older adults living in nursing homes die each year from fall-related injuries and those who survive falls frequently sustain hip fractures and head injuries that result in permanent disability and reduced quality of life.” (CDC, 2012)
Role of the advanced practice nurse: political • The role of the advanced practice nurse in dealing with elderly falls and serious injuries from a political perspective starts with policy design. The APN in combination with legislators, support persons, and special- interest groups must develop a policy back by research (data), that supports the findings and has favorable outcomes. • Milstead (2008) states, “ To improve the likelihood of policy success, APNs must be able to critically analyze policy content; that is, what the original intent of the policy is, and if the policy designed in such a way as to assure the intended outcome.” (p. 133).
Cont.. • The second phase of policy design, is policy implementation. As the APN, we have identified with a problem (elderly falls), problem solving techniques (fall prevention programs, community exercise programs for elderly), and policy goals (yearly decrease in elderly falls/ injuries). APNs must gain support from individuals, organizations, and other healthcare professional so that the implementation phase is a successful one.
Cont.… • Phase three involves program evaluation. As the APN, we have to continuously restructure policies due to public, environmental, governmental, and nongovernmental factors.(Milstead, 2008). • After the evaluation phase, the results of the evaluation should be communicated, so funding may be obtain from support persons, groups, and organizations for the legislative process.
Role of the advance practice nurse: community Advance practice nurses in the community should identify with risk factors in assessing target population. Provide education and promote community awareness in addressing the issue. APNs should carry out public policy guidelines within their scope of practice, while customizing care unique to the individual.
Cont.… • The most important aspect in dealing with community is screening the at risk population. • Development of measureable interventions that includes assessing medication usage, managing potential postural hypotension, and/or cardiac abnormalities in the elderly. Modification of home environment, assess and evaluate client footwear, educate and train family, or healthcare professional in identification of risk factors. (CDC, 2012)
Summary The elderly population is a vulnerable population. Many older adults live independently, and are at risk for serious injuries related to polypharmacy, preexisting medical conditions, fear, isolation, and falls. Although falls account for a large percentage of older adult hospitalization; serious injuries, and death; falls can be avoided with the appropriate interventions. The development of public policies and guidelines addressing the issue, the implementation of fall prevention programs within the community, and a multidisciplinary approach in prevention of falls are actions APNs can enact.
Reference: Hedley, L., Suckley, N., Robinson, L., & Dawson, P. (2010). Staying Steady: A community-based exercise initiative for falls prevention. Physiotherapy Theory and Practice, 26(7), pp. 425-438. doi: 10.3109/09593980903585059 Milstead, A. Jeri. (2008). Health Policy and Politics: A Nurse’s Guide (3rd ed.). Sudbury, MA: Jones and Bartlett Publishers, Inc. Wijlhuizen, J. G., Bois, D. P., Dommelen, V. P., & Hopman-Rock, M. (2007). Effect evaluation of a multifactor community intervention to reduce falls among older persons. International Journal of Injury Control and Safety Promotion, 14(1), pp. 25-33. doi: 10.1080/17457300600935189 U.S. Department of Health and Human Services. Office of Disease Prevention and Health Promotion. (2010). Healthy People 2020. Washington, DC. Retrieved from http://www.healthypeople.gov/2020/topicobjectives2020/overview.aspx?topicid=31 Center for Disease Control and Prevention. Reducing Falls and Resulting Hip Fractures Among Older Women. (2000). Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr4902a2htm Centers for Disease Control and Prevention. Falls in Nursing Homes. (2012). Retrieved from http://www.cdc.gov/HomeandRecreationalSafety/Falls/nursing.html