Prepared by Julia Poole CNC Aged Care RNSH September 2007

1. The Changing Paradigm in Falls Implications in Acute Care Prepared by Julia Poole CNC Aged CareRNSH September 2007

4. Cost of fall injury to older people • Total lifetime cost of falls $644 million ($333 million direct costs & $311 million mortality & morbidity costs) in NSW • If current admission rates continue, by 2050 NSW will need 800 new acute care beds and 1200 new aged care places to manage the impact of the demographic change. • A serious fall frequently becomes the precipitating event into permanent residential care for a frail older person.

5. Falls Facts for Acute/Sub-acute Care • In Australian Hospitals 1/3rd of all patient incidents involve a fall. • Most people who have a fall in hospital are over 65 years of age. • Falls in hospital are being given a high priority as they are considered to be generally predictable and often preventable within a scheme of falls prevention activities.

6. Risk Factors for Falls In Hospital • History of falls prior to coming in to hospital or has fallen in hospital • Patient is confused or agitated - can be long standing eg dementia or can be made worse on admission to unfamiliar environment, confusion post operatively or from acute infection (delirium). • Mobility and transfers are unsafe. May have a walking aid such as a frame.

7. Risk Factors for Falls In Hospital (cont’d) • Needs to go to the toilet frequently or is incontinent • Takes medications associated with increased risk of falls eg psychoactive, diuretics, antihypertensives • Has poor vision, such that everyday function in the ward is impaired

8. Consequences of Falls • Falls in hospital are associated with: • Increased mortality • Increased length of stay • Serious injury eg hip fractures, cerebral haemorrhage • Change in discharge living arrangements

9. Consequences of Falls • Other consequences of falls: • Fear of falling and loss of confidence, correlates with depression and social isolation. • Reduces older persons' confidence to return home and function independently.

10. 2001 - 2 # NOF, 1 # Ondontoid, 21 skin tears 2002 - 2 # NOF, 1 # Radius, 14 skin tears 2003 -1 # NOF, 1 # Humerus, 18 skin tears 2004 - 1 # humerus, 1 # scaphoid, 16 skin tears Volunteer Companions, IPS

11. Delirium, the major risk factor for fall in an acute aged care ward(unpublished) Poole J and Ogle S • n = 312 • File audit • ‘confusion’ documented in 96% of notes

12. DEMENTIA The word “Dementia” is used widely to describe a group of diseases which affects the brain and cause a progressive decline in a person’s abilities to remember, think and learn. The main abilities affected are: • Judgement • Orientation • Emotions • Memory • Thinking

13. WHAT CAUSES DEMENTIA? • There are different forms of dementia and each has its own causes. Some of the most common forms of dementia are: • Alzheimer’s Disease • Vascular dementia • Frontal Lobe dementia • Dementia with Lewy Bodies (see www.alzvic.asn.au)

16. What is Delirium? • an acute organic mental disorder characterised by confusion, restlessness, incoherence, anxiety or hallucinations which may be reversible with treatment Sometimes known as : • Acute Confusion • Acute confusional state • Acute brain disorder • Acute brain syndrome Gelder, Mayou & Geddes (1999); Moran & Dorevitch (2001); Inouye (2006);

17. DSM-IV 1994 • Delirium is characterised by a disturbance of consciousness and a change in cognition that develop over a short period of time • American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th Ed).Washington: American Psychiatric Association. • ICD-10-AM Diseases 2003 • F05 -Delirium, not induced by alcohol and other psychoactive substances • non specific organic cerebral syndrome • concurrent disturbances of consciousness and attention, perception, thinking, memory, psychomotor behaviour, emotion, and the sleep-wake schedule • F05.1 Delirium superimposed on dementia

18. Pathophysiology of Delirium • Multiple mechanisms Inouye 2006 The NEJ M 354:1157-65. • Neurotransmission, Inflammation, Chronic stress Moran 2001 The Australian Journal of Hospital Pharmacy. 31(1):35-40. • decreased cerebral oxidative metabolism causing altered neurotransmitter levels • stress-induced increased plasma cortisol levels causing altered neurotransmitter activity Yokata et al.2003 Psychiatry and Clinical Neurosciences.75(3):337-339. • cerebral hypo-perfusion in the frontal, temporal & occipital cortex

19. Predisposing Vision/hearing impairment Severe illness Cognitive deficit AMTS < 7/10 MMSE < 25/30 Dehydration Precipitating ‘Mechanical’ restraint Malnutrition/dehydration 3 new medications IDC Unpleasant event/s surgical procedure med. toxicity falls infections faecal impaction etc Delirium Risk AssessmentWeber et al. 2004 Internal Medicine Journal. 34:115-121.

20. Prevention of Delirium Inouye et al. 1999 NEJM 340(9):669-676.

21. DeliriumMaher & Almeida 2002 Current Therapeutics. March:39-43. • Is a medical emergency • Incidence of up to 56% in hospitalised elderly • Independent predictor of adverse outcomes • falls • incontinence • pressure sores • decreased functional levels • increased mortality • increased LOS in acute care • INCREASED COSTS

22. “Think about when you have looked after an agitated older patient - tell us about it?” Registered and enrolled nurses in a large teaching hospital were asked to discuss their feelings and actions in regard to caring for agitated older patients • six taped focus groups, n = 36 thematically coded and analysed. Poole, J. and Mott, S. (2003) Agitated Older Patients – nurse’s perceptions and reality. International Journal Of Nursing Practice, 9:306-312.

23. 1. See (to understand)cont’d • -ve - ‘you think you’ve calmed them down and they seem sweet or whatever, people can just change’ , ‘Doctor would chart a minuscule amount...didn’t touch her’, ‘won’t even numb a little finger’ • Particular concern- ‘sometimes it (restraint) makes them more agitated but you’d rather that so you can get out and get some of the other work done and come back to them later and calm them down’

24. 3. Span of time • The burden placed on staff by agitated patients was clear - ‘trying to work out how to get the rest of the jobs done’ and ‘nothing else gets done’. • ‘if I’ve been with one patient, I get complaints from other patients and relatives because I haven’t been with them and then it sort of snowballs and you get more agitated and frustrated ... because you can’t give everyone the same care’.

25. FALL RISK ASSESSMENT SCOREto be completed on admission or transfer in, DAILY and where so warranted by a change in the patient’s condition (Mercer 1997)

31. Take Home Messages • Increasing numbers of older sicker patients in hospitals • Older patients have • increased predisposition for delirium and/or dementia • increased predisposition for falls • increased predisposition for injury from falls • increased predisposition for death from falls • Falls are COSTLY for everyone • The best way to manage delirium and prevent falls is to increase patient support & surveillance (NOT RESTRAINT) • Hospitals must be designed to enable surveillance of patients eg windows, glass walls etc