Journal of Community Health Nursing
ISSN: 0737-0016 (Print) 1532-7655 (Online) Journal homepage: http://www.tandfonline.com/loi/hchn20
Are the Elderly Safe at Home? Anne B. Moss To cite this article: Anne B. Moss (1992) Are the Elderly Safe at Home?, Journal of Community Health Nursing, 9:1, 13-19, DOI: 10.1207/s15327655jchn0901_2 To link to this article: http://dx.doi.org/10.1207/s15327655jchn0901_2
Published online: 07 Jun 2010.
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Article views: 8
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Citing articles: 6 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=hchn20 Download by: [York University Libraries]
Date: 07 November 2015, At: 07:48
JOURNAL OF COMMUNITY HEALTH NURSING, 1992,9(1), 13-19 Copyright O 1992, Lawrence Erlbaum Associates, Inc.
Are the Elderly Safe at Home? Anne B. Moss, RN,MSN, CEN
Downloaded by [York University Libraries] at 07:48 07 November 2015
St. Elizabeth Hospital Medical Center
Injury is the fourth leading cause of death for all age groups surpassed only by heart disease, cancer, and strokes. The direct and indirect costs of caring for injured patients in the United States is between 75 to 100 billion dollars each year (Committee on Trauma, American College of Surgeons, 1989). Accidents were once regarded as a rqsult of random chance. Lately, injury has been viewed as an event that is caused by the interaction of specific factors which are amenable to preventive interventiovs (Thompson, 1986). If nurses are aware of specific risk factors, they can perhaps make an impact on these statistics. The purpose of this article is to examine the nursing diagnosis, potential for injury, as it applies to the geriatric patient and to propose possible interventions for use in the home setting. Potential for injury is defined as "a state in which the individual is at ri& of injury as a result of environmental conditions interacting with the individual's adaptive and dekknsi've resources" (McLane, 1987, p. 487). This diagnosis consists of three parts: (a) poisoning, (b) suffocation, and (c) trauma. Potential for injurytrauma is defined as the accentuated risk of accidental tissue injury and is the focus of this article. The statistics for geriatric injuries support the use of the diagnosis, potential for injury, for the elderly population. Accidental injury accounts for 23,000 deaths each year in persons 65 years old and older, with 40% of these occurring in the home. Another 750,000 elderly incur disabling injuries from accidents which result in an average hospital stay of 11.7 days. Only patients with malignancies have longer hospitalizations. The most frequent cause of these injuries is falls ("Accident facts," cited in Persons & Levy, 1987).
REVIEW OF THE LITERATURE ON RISK FACTORS Several risk factors for injury of geriatric patients have been identified in the literature. Qordon (1989) identified numerous risk factors such as disorientation, impaired judgment, muscle weakness, paralysis, incoordination, balancing difficulties, mobility impairment, sensory-perceptual deterioration, history of previous trauma, lack of safety precautions and safety education, and excess alcohol ingestion. A Requelsts for reprints should be sent to Anne B. Moss, RN, MSN, CEN, St. Elizabeth Hospital Medical Center, 1044 Belrnont Avenue, Youngstown, OH 44501.
Downloaded by [York University Libraries] at 07:48 07 November 2015
14
Moss
number of external or environmental factors are also listed including slippery, littered, or obstructed floors; bathtubs without hand grips; entering unlighted rooms; unanchored electrical wires; high beds; struggling within bed restraints; and inappropriate call-for-aid mechanisms for bed-resting clients. Several studies identified other risk factors related to falls such as incontinence, sleeplessness, depression, use of certain medications that can impair the elderly person's performance, cardiovascular disorders, and improper fitting footwear (Barbieri, 1983; Janken & Reynolds, 1987; Spellbring, Gannon, Kleckner, & Conway, 1988). In the following review of literature, the risk factors are classified into several categories: cardiovascular, neurologic, musculoskeletal, urologic, sleep disorders, medications, history of falls, psychological, and environmental. Cardiovascular
Several cardiovascular changes occur in the elderly as a result of normal aging that can make them more susceptible to falling. there may be a decreased number of pacemaker cells in the sinoatrial node making the elderly more prone to dysrhythmias. Also, the baroreceptors which regulate the blood pressure are less sensitive in the aged and can be associated with orthostatic hypotension (Matteson & McConnell, 1988). Robbins and Rubenstein (1984) suggested that 30% to 50% of the elderly population have orthostatic hypotension. A number of studies have identified cardiovascular problems as a significant risk factor for falling. Rodstein and Camus (1973) reported that acute changes in cardiac status add to the frequency and severity of accidents. During a study of elderly people's methods of fall prevention, Johnston (1988) found cardiovascular disease to be a significant risk factor for falls in the elderly. Barbieri (1983) performeda retrospective study of patients who fell in a hospital and discovered that 48% had a primary or secondary cardiovascular diagnosis. Neurologic
Several studies identified neurological changes as being present in elderly patients who fell (Barbieri, 1983; Berryman, Gaskin, Jones, Tolley, & MacMullen, 1989; Janken & Reynolds, 1987; Lund & Sheafor, 1985; Spellbring et al., 1988). The elderly may experience a number of neurological changes as a result of the normal aging process. Vision changes include a decrease in visual acuity and fields, decreased adaptation to darkness, and decreased color vision (Lamb, Miller, & Hernandez, 1987). The elderly may also have an increased sensitivity to visual glare and a loss of depth perception (Matteson & McConnell, 1988). Bright, sunny rooms with high gloss floors can be hazardous in such situations. Advanced age is associated with decreased hearing, especially of high-pitched sounds (Matteson & McConnell, 1988). This may interfere with the elderly's ability to hear environmental warning signals, such as the sound of a car. Other normal neurologic changes associated with aging include decreased proprioception, de-
Are the Elderly Safe at Home?
15
creased reaction time, and decreased vestibular function resulting in dizziness (Lamb et al., 1987). There are also a number of pathologic neurologic changes seen more frequently in the elderly that may result in falls. These include Parkinson's disease, transient ischemic attacks, cerebrovascular accidents, seizures, peripheral neuropathies, and dementia.
Downloaded by [York University Libraries] at 07:48 07 November 2015
Musauloskeletal A number of studies found musculoskeletal problems associated with falls in the elderly (Barbieri, 1983; Berryman et al., 1989; Janken & Reynolds, 1987). A decrease in muscle mass and tone may occur with aging resulting in decreased strength and coordination. Posture and gait changes also occur with aging (Lamb et al., 1987). These changes, together with an increased loss in bone mass with aging, make the elderly more at risk for fractures (Matteson & McConnell, 1988). At least a portion of these changes are attributed to sedentary life styles and inadequate protein intake in the elderly (Milde, 1988; Smith & Gilligan, 1983).
Urologic The elderly may have a variety of alterations in urinary elimination that may put them at risk for falls. Patients with urgency may rush to the bathroom or may slip on urine if they are incontinent. Urinary retention may result in micturition hypotension after voiding large amounts (Lamb et al., 1987). Kustaborder and Rigney (1983) noted in their study that 25% of the hospital falls involved patients who were walking to or from the bathroom or getting on or off the tailet. Barbieri (1983) found that 52% of the falls had something to do with patientshttempts to urinate. Incontinence was also found to be significantly related to fall status in hospitalized patients (Janken & Reynolds, 1987). Sleep Disorders The elderly often require more time to fall asleep, sleep lighter than younger people, and may wake up several times during the night (Yurik, Robb, Spier, & Ebert, 1984). All of these factors can contribute to daytime sleepiness. Sleeplessness as a risk factor for falls was addressed in only one of the studies of those reviewed, Janken and Reynolds (1987) however, found sleeplessness significantly related to fall status in hospitalized patients. They also noted that the falls of patients with sleeplessness were evenly distributed throughout the 24-hr period. Medications The elderly often take multiple medications for a variety of physical problems. As people age, however, their ability to absorb and excrete medications is affected, making them more susceptible to drug toxicity which may lead to symptoms such as dizziness, confusion, and cardiac dysrhythmias. Medications that may contribute to
16
Moss
falls include psychotropics, antihypertensives, diuretics, cardiotonics, hypoglycemics, and sedatives including alcohol and narcotic analgesics (Lamb et al., 1987). Several studies found use of certain medications significantly related to falls (Barbieri, 1983; Janken & Reynolds, 1987; Johnston, 1988; Louis, 1983; Lund & Sheafor, 1985; Spellbring et al., 1988). In these studies the most significant medications were diuretics and antihypertensives.
Downloaded by [York University Libraries] at 07:48 07 November 2015
History of Falls
Although some may argue that a history of previous trauma does not predict future injury, Elliott (1979) found that over half of the patients who fell were involved in multiple falls and that these falls occurred in a series over a short period of time. This was supported by Spellbring et al. (1988). Psychological A variety of psychological factors have been associated with falls. Recent life stresses, such as the death of a spouse, can result in depression, anxiety, and grief. These responses can affect the person's ability to concentrate on their personal care and safety. Depression can also lead to confusion and disorientation, which can contribute to the risk of falling (Tideiksaar, 1986). Barbieri (1983) found these risk factors to be possible contributing factors in several patients who fell. In comparison, Johnston (1988) identified recent pleasant life events to be a significant risk factor for falls. The fear of falling or falling again can also cause a fall. Patients may become rigid when walking or transferring from a bed to a chair which can contribute to decreased independence and mobility (Lamb et al., 1987). Other patients who fall do not seek help when needed because of their determination for independence (Barbieri, 1983). Examples of this motive may be fear of slowing down or desire not to bother others.
Environmental
Most people do not live in a risk-free environment. Many environmental factors can contribute to injuries in any age group. These factors just add to the already high risk of falls in the elderly. Tideiksaar (1986) identified certain areas of the home that deserve special attention. Areas include the kitchen, the bathroom, the bedroom, the indoor stairways, and the sidewalk and stairs outside the home. The kitchen should not have slippery or highly glossed floors, chairs with wheels, or have difficult to reach cabinets. Bathrooms should have nonskid bathmats, tub and toilet grab bars, and elevated toilet seats as necessary. The bedroom should have accessible light switches near the door, night lights, and nothing on the floor by the bed such as throw rugs which may contribute to a fall. Outside the home, potholes, cracked sidewalk pavement, and steps in ill repair or without handrail support may be hazardous. The staircase is the most common site of home falls in the geriatric population
Are the Elderly Safe at Home?
17
(Caird & Judge, 1973). The elderly may inadvertently miss a step or become dizzy when looking down a staircase. Tideiksaar (1986) recommended that stairways be adequately illuminated, have handrails on both sides, and have the top and bottom steps marked with bright contrasting tape. Other environmental factors that have been associated with falls include ill-fitting shoes, slippers, or clothing (Barbieri, 1983; Stall & Katz, 1987).
Downloaded by [York University Libraries] at 07:48 07 November 2015
IMPLICATIONS FOR NURSING
The ilsue of falls in the elderly population is one that deserves special consideration by cotnmunity health nurses (CHNs). The first step involves performing a detailed assesslment of the risk factors associated with falls in the geriatric population. An example of a data collection form is shown in Table 1. Nurses can use this form TABLE 1 Data Collection Form for Risk Factors for Home Injuries
SECTION I: GENERAL INFORMATION Sex Age Medical diaanosis SECTION 11: RISK FACTORS 1. History of Previous Fall 2. Mebtal Status Disbriented Confused Forketful Impaired Judgement 3. obi lit^ Deficits Balancing Difficulties Generalized Weakness Paralysis Deureased Muscle Coordination Use of Walker/Crutches/Braces/Cane 4. Semory Deficits Blind Blurred Vision Cataracts Usd of Glasses Use of Hearing Aid Deif Limited Hearing 5. Medications Diqretics Antihypertensives Hypoglycemics Nan'cotics Barbituates Tranquilizers S@tives/Hypnotics Alcohol Antihistamines Anqiepileptics Cardiotonics 6. Uribary Alterations Ugency - Frequency Incbntinence - Use of Bathroom at Night 7. SleQp Disturbances 8. Caadiovascular/Neurovascular Alterations Orthostatic Hypotension Dizziness Blackouts 9. Psykhological Factors Emptional Upset Recent Loss of Significant Person/Object 10. Environmental Factors 111-$itting Shoes, Slippers, Clothing Un#ven Sidewalks Inadequate Lighting Abience of Handrails on Stairways Slippery, Littered, Obstructed Floors/Stairs Unqnchored Rugs/Carpets Ablence of lbb/Toilet Grab Bars Abience of Mat or Skidproof Strips in l b b Absence of Night Lights in Bedroom/Bathroom -
-
Downloaded by [York University Libraries] at 07:48 07 November 2015
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Moss
during initial contact with patients. The form can also be utilized during subsequent visits because patients' conditions may change. Once nurses are aware of significant risk factors for geriatric falls in the home, appropriate interventions can be planned to minimize the number of injuries. A number of environmental adaptations have already been mentioned. Other interventions may include educating patients about the presence of identified risk factors and working with them to minimize these risks. An exercise program may be utilized to increase muscle strength and flexibility. Certain medications may need to be reevaluated with the physician. In other situations, psychological support may be necessary to help patients cope with recent emotional upsets. The interventions can be as numerous as the risk factors for falls. By helping identify and minimize the risk factors associated with falls in the elderly, CHNs can help reduce the number of injuries in this rapidly increasing segment of our population.
REFERENCES Barbieri, E. (1983). Patient falls are not patient accidents. Journal of Gerontological Nursing, 9(3), 165-173.
Berryman, E., Gaskin, D., Jones, A., Tolley, E., & MacMullen, J. (1989). Point by point: Predicting elders' falls. Geriatric Nursing, 10(4), 199-201 . Caird, E, & Judge, T. (1973). Assessment of the elderlypatient. London: Pitman. Committee on 'lt-auma, American College of Surgeons. (1989). Advanced trauma life support course. Chicago: Author. Elliott, D. (1979). Accidents in nursing homes: Implications for patients and administrators. In M. Miller (Ed.), Current issues in clinical geriatrics (pp. 97-137). New York: Tiresias. Gordon, M. (1989). Manual of nursing diagnosis (4th ed.). New York: McGraw-Hill. Janken, J., & Reynolds, R (1987). Identifying patients with the potential for falling. In A. McLane (Ed.), Classification of nursing diagnosis (pp. 136-143). St. Louis: Mosby. Johnston, J. (1988). The elderly and fall prevention. Applied Nursing Research, 1(3), 140-145. Kustaborder, M., & Rigney, M. (1983). Interventions for safety. Journal of Gerontological Nursing, 9(3), 159-173.
Lamb, K., Miller, J., & Hernandez, M. (1987). Falls in the elderly: Causes and prevention. Orthopaedic Nursing, 6(2), 45-49. Louis, M. (1983). Falls and their causes. Journal of Gerontological Nursing, 9(3), 142-156. Lund, C., & Sheafor, M. (1985). Is your patient about to fall. Journal of Gerontological Nursing, 11(4), 37-41.
Matteson, M., & McConnell, E. (1988). Gerontological nursing: Concepts andpractice. Philadelphia: Saunders. McLane, A. (Ed.). (1987). Classification of nursing diagnoses. St. Louis: Mosby. Milde, E. (1988). Impaired physical mobility. Journal of Gerontological Nursing, 14(3), 20-24. Parsons, M., & Levy, J. (1987). Nursing process in injury prevention. Journal of GerontologicalNursing, 13(7), 36-40. Robbins, A., & Rubenstein, L. (1984). Postural hypotension in the elderly. Journal of the American Geriatric Society, 32(10), 769-774. Rodstein, M., & Carnus, A. (1973). Interrelation of heart disease and accidents. Geriatrics, 28, 87-96.
Smith, E., & Gilligan, C. (1983). Physical activity prescription for the older adult. The Physician and Sports Medicine, 8, 9 1 - 101. Spellbring, A., Gannon, M., Kleckner, T., & Conway, K. (1988). Improving safety for hospitalized elderly. Journal of Gerontological Nursing, 14(2), 31-37.
Are the Elderly Safe at Home?
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Downloaded by [York University Libraries] at 07:48 07 November 2015
Stall, R., & Katz, P. (1987). Falls and ill-fitting clothing. Journal of the American Geriatric Society, 35(10), 959. Thompson, J. (1986). Clinical nursing. St. Louis: Mosby. Tideiksaar, R. (1986). Geriatric falls in the home. Home Health Care Nurse, 4(2), 14-23. Yurick, A., Robb, S. A., Spier, B., & Ebert, N. (1984). The aged person and the nursing process (2nd ed.). Norwalk, Cl? Appleton-Century-Crofts.
ISSN: 0737-0016 (Print) 1532-7655 (Online) Journal homepage: http://www.tandfonline.com/loi/hchn20
Are the Elderly Safe at Home? Anne B. Moss To cite this article: Anne B. Moss (1992) Are the Elderly Safe at Home?, Journal of Community Health Nursing, 9:1, 13-19, DOI: 10.1207/s15327655jchn0901_2 To link to this article: http://dx.doi.org/10.1207/s15327655jchn0901_2
Published online: 07 Jun 2010.
Submit your article to this journal
Article views: 8
View related articles
Citing articles: 6 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=hchn20 Download by: [York University Libraries]
Date: 07 November 2015, At: 07:48
JOURNAL OF COMMUNITY HEALTH NURSING, 1992,9(1), 13-19 Copyright O 1992, Lawrence Erlbaum Associates, Inc.
Are the Elderly Safe at Home? Anne B. Moss, RN,MSN, CEN
Downloaded by [York University Libraries] at 07:48 07 November 2015
St. Elizabeth Hospital Medical Center
Injury is the fourth leading cause of death for all age groups surpassed only by heart disease, cancer, and strokes. The direct and indirect costs of caring for injured patients in the United States is between 75 to 100 billion dollars each year (Committee on Trauma, American College of Surgeons, 1989). Accidents were once regarded as a rqsult of random chance. Lately, injury has been viewed as an event that is caused by the interaction of specific factors which are amenable to preventive interventiovs (Thompson, 1986). If nurses are aware of specific risk factors, they can perhaps make an impact on these statistics. The purpose of this article is to examine the nursing diagnosis, potential for injury, as it applies to the geriatric patient and to propose possible interventions for use in the home setting. Potential for injury is defined as "a state in which the individual is at ri& of injury as a result of environmental conditions interacting with the individual's adaptive and dekknsi've resources" (McLane, 1987, p. 487). This diagnosis consists of three parts: (a) poisoning, (b) suffocation, and (c) trauma. Potential for injurytrauma is defined as the accentuated risk of accidental tissue injury and is the focus of this article. The statistics for geriatric injuries support the use of the diagnosis, potential for injury, for the elderly population. Accidental injury accounts for 23,000 deaths each year in persons 65 years old and older, with 40% of these occurring in the home. Another 750,000 elderly incur disabling injuries from accidents which result in an average hospital stay of 11.7 days. Only patients with malignancies have longer hospitalizations. The most frequent cause of these injuries is falls ("Accident facts," cited in Persons & Levy, 1987).
REVIEW OF THE LITERATURE ON RISK FACTORS Several risk factors for injury of geriatric patients have been identified in the literature. Qordon (1989) identified numerous risk factors such as disorientation, impaired judgment, muscle weakness, paralysis, incoordination, balancing difficulties, mobility impairment, sensory-perceptual deterioration, history of previous trauma, lack of safety precautions and safety education, and excess alcohol ingestion. A Requelsts for reprints should be sent to Anne B. Moss, RN, MSN, CEN, St. Elizabeth Hospital Medical Center, 1044 Belrnont Avenue, Youngstown, OH 44501.
Downloaded by [York University Libraries] at 07:48 07 November 2015
14
Moss
number of external or environmental factors are also listed including slippery, littered, or obstructed floors; bathtubs without hand grips; entering unlighted rooms; unanchored electrical wires; high beds; struggling within bed restraints; and inappropriate call-for-aid mechanisms for bed-resting clients. Several studies identified other risk factors related to falls such as incontinence, sleeplessness, depression, use of certain medications that can impair the elderly person's performance, cardiovascular disorders, and improper fitting footwear (Barbieri, 1983; Janken & Reynolds, 1987; Spellbring, Gannon, Kleckner, & Conway, 1988). In the following review of literature, the risk factors are classified into several categories: cardiovascular, neurologic, musculoskeletal, urologic, sleep disorders, medications, history of falls, psychological, and environmental. Cardiovascular
Several cardiovascular changes occur in the elderly as a result of normal aging that can make them more susceptible to falling. there may be a decreased number of pacemaker cells in the sinoatrial node making the elderly more prone to dysrhythmias. Also, the baroreceptors which regulate the blood pressure are less sensitive in the aged and can be associated with orthostatic hypotension (Matteson & McConnell, 1988). Robbins and Rubenstein (1984) suggested that 30% to 50% of the elderly population have orthostatic hypotension. A number of studies have identified cardiovascular problems as a significant risk factor for falling. Rodstein and Camus (1973) reported that acute changes in cardiac status add to the frequency and severity of accidents. During a study of elderly people's methods of fall prevention, Johnston (1988) found cardiovascular disease to be a significant risk factor for falls in the elderly. Barbieri (1983) performeda retrospective study of patients who fell in a hospital and discovered that 48% had a primary or secondary cardiovascular diagnosis. Neurologic
Several studies identified neurological changes as being present in elderly patients who fell (Barbieri, 1983; Berryman, Gaskin, Jones, Tolley, & MacMullen, 1989; Janken & Reynolds, 1987; Lund & Sheafor, 1985; Spellbring et al., 1988). The elderly may experience a number of neurological changes as a result of the normal aging process. Vision changes include a decrease in visual acuity and fields, decreased adaptation to darkness, and decreased color vision (Lamb, Miller, & Hernandez, 1987). The elderly may also have an increased sensitivity to visual glare and a loss of depth perception (Matteson & McConnell, 1988). Bright, sunny rooms with high gloss floors can be hazardous in such situations. Advanced age is associated with decreased hearing, especially of high-pitched sounds (Matteson & McConnell, 1988). This may interfere with the elderly's ability to hear environmental warning signals, such as the sound of a car. Other normal neurologic changes associated with aging include decreased proprioception, de-
Are the Elderly Safe at Home?
15
creased reaction time, and decreased vestibular function resulting in dizziness (Lamb et al., 1987). There are also a number of pathologic neurologic changes seen more frequently in the elderly that may result in falls. These include Parkinson's disease, transient ischemic attacks, cerebrovascular accidents, seizures, peripheral neuropathies, and dementia.
Downloaded by [York University Libraries] at 07:48 07 November 2015
Musauloskeletal A number of studies found musculoskeletal problems associated with falls in the elderly (Barbieri, 1983; Berryman et al., 1989; Janken & Reynolds, 1987). A decrease in muscle mass and tone may occur with aging resulting in decreased strength and coordination. Posture and gait changes also occur with aging (Lamb et al., 1987). These changes, together with an increased loss in bone mass with aging, make the elderly more at risk for fractures (Matteson & McConnell, 1988). At least a portion of these changes are attributed to sedentary life styles and inadequate protein intake in the elderly (Milde, 1988; Smith & Gilligan, 1983).
Urologic The elderly may have a variety of alterations in urinary elimination that may put them at risk for falls. Patients with urgency may rush to the bathroom or may slip on urine if they are incontinent. Urinary retention may result in micturition hypotension after voiding large amounts (Lamb et al., 1987). Kustaborder and Rigney (1983) noted in their study that 25% of the hospital falls involved patients who were walking to or from the bathroom or getting on or off the tailet. Barbieri (1983) found that 52% of the falls had something to do with patientshttempts to urinate. Incontinence was also found to be significantly related to fall status in hospitalized patients (Janken & Reynolds, 1987). Sleep Disorders The elderly often require more time to fall asleep, sleep lighter than younger people, and may wake up several times during the night (Yurik, Robb, Spier, & Ebert, 1984). All of these factors can contribute to daytime sleepiness. Sleeplessness as a risk factor for falls was addressed in only one of the studies of those reviewed, Janken and Reynolds (1987) however, found sleeplessness significantly related to fall status in hospitalized patients. They also noted that the falls of patients with sleeplessness were evenly distributed throughout the 24-hr period. Medications The elderly often take multiple medications for a variety of physical problems. As people age, however, their ability to absorb and excrete medications is affected, making them more susceptible to drug toxicity which may lead to symptoms such as dizziness, confusion, and cardiac dysrhythmias. Medications that may contribute to
16
Moss
falls include psychotropics, antihypertensives, diuretics, cardiotonics, hypoglycemics, and sedatives including alcohol and narcotic analgesics (Lamb et al., 1987). Several studies found use of certain medications significantly related to falls (Barbieri, 1983; Janken & Reynolds, 1987; Johnston, 1988; Louis, 1983; Lund & Sheafor, 1985; Spellbring et al., 1988). In these studies the most significant medications were diuretics and antihypertensives.
Downloaded by [York University Libraries] at 07:48 07 November 2015
History of Falls
Although some may argue that a history of previous trauma does not predict future injury, Elliott (1979) found that over half of the patients who fell were involved in multiple falls and that these falls occurred in a series over a short period of time. This was supported by Spellbring et al. (1988). Psychological A variety of psychological factors have been associated with falls. Recent life stresses, such as the death of a spouse, can result in depression, anxiety, and grief. These responses can affect the person's ability to concentrate on their personal care and safety. Depression can also lead to confusion and disorientation, which can contribute to the risk of falling (Tideiksaar, 1986). Barbieri (1983) found these risk factors to be possible contributing factors in several patients who fell. In comparison, Johnston (1988) identified recent pleasant life events to be a significant risk factor for falls. The fear of falling or falling again can also cause a fall. Patients may become rigid when walking or transferring from a bed to a chair which can contribute to decreased independence and mobility (Lamb et al., 1987). Other patients who fall do not seek help when needed because of their determination for independence (Barbieri, 1983). Examples of this motive may be fear of slowing down or desire not to bother others.
Environmental
Most people do not live in a risk-free environment. Many environmental factors can contribute to injuries in any age group. These factors just add to the already high risk of falls in the elderly. Tideiksaar (1986) identified certain areas of the home that deserve special attention. Areas include the kitchen, the bathroom, the bedroom, the indoor stairways, and the sidewalk and stairs outside the home. The kitchen should not have slippery or highly glossed floors, chairs with wheels, or have difficult to reach cabinets. Bathrooms should have nonskid bathmats, tub and toilet grab bars, and elevated toilet seats as necessary. The bedroom should have accessible light switches near the door, night lights, and nothing on the floor by the bed such as throw rugs which may contribute to a fall. Outside the home, potholes, cracked sidewalk pavement, and steps in ill repair or without handrail support may be hazardous. The staircase is the most common site of home falls in the geriatric population
Are the Elderly Safe at Home?
17
(Caird & Judge, 1973). The elderly may inadvertently miss a step or become dizzy when looking down a staircase. Tideiksaar (1986) recommended that stairways be adequately illuminated, have handrails on both sides, and have the top and bottom steps marked with bright contrasting tape. Other environmental factors that have been associated with falls include ill-fitting shoes, slippers, or clothing (Barbieri, 1983; Stall & Katz, 1987).
Downloaded by [York University Libraries] at 07:48 07 November 2015
IMPLICATIONS FOR NURSING
The ilsue of falls in the elderly population is one that deserves special consideration by cotnmunity health nurses (CHNs). The first step involves performing a detailed assesslment of the risk factors associated with falls in the geriatric population. An example of a data collection form is shown in Table 1. Nurses can use this form TABLE 1 Data Collection Form for Risk Factors for Home Injuries
SECTION I: GENERAL INFORMATION Sex Age Medical diaanosis SECTION 11: RISK FACTORS 1. History of Previous Fall 2. Mebtal Status Disbriented Confused Forketful Impaired Judgement 3. obi lit^ Deficits Balancing Difficulties Generalized Weakness Paralysis Deureased Muscle Coordination Use of Walker/Crutches/Braces/Cane 4. Semory Deficits Blind Blurred Vision Cataracts Usd of Glasses Use of Hearing Aid Deif Limited Hearing 5. Medications Diqretics Antihypertensives Hypoglycemics Nan'cotics Barbituates Tranquilizers S@tives/Hypnotics Alcohol Antihistamines Anqiepileptics Cardiotonics 6. Uribary Alterations Ugency - Frequency Incbntinence - Use of Bathroom at Night 7. SleQp Disturbances 8. Caadiovascular/Neurovascular Alterations Orthostatic Hypotension Dizziness Blackouts 9. Psykhological Factors Emptional Upset Recent Loss of Significant Person/Object 10. Environmental Factors 111-$itting Shoes, Slippers, Clothing Un#ven Sidewalks Inadequate Lighting Abience of Handrails on Stairways Slippery, Littered, Obstructed Floors/Stairs Unqnchored Rugs/Carpets Ablence of lbb/Toilet Grab Bars Abience of Mat or Skidproof Strips in l b b Absence of Night Lights in Bedroom/Bathroom -
-
Downloaded by [York University Libraries] at 07:48 07 November 2015
18
Moss
during initial contact with patients. The form can also be utilized during subsequent visits because patients' conditions may change. Once nurses are aware of significant risk factors for geriatric falls in the home, appropriate interventions can be planned to minimize the number of injuries. A number of environmental adaptations have already been mentioned. Other interventions may include educating patients about the presence of identified risk factors and working with them to minimize these risks. An exercise program may be utilized to increase muscle strength and flexibility. Certain medications may need to be reevaluated with the physician. In other situations, psychological support may be necessary to help patients cope with recent emotional upsets. The interventions can be as numerous as the risk factors for falls. By helping identify and minimize the risk factors associated with falls in the elderly, CHNs can help reduce the number of injuries in this rapidly increasing segment of our population.
REFERENCES Barbieri, E. (1983). Patient falls are not patient accidents. Journal of Gerontological Nursing, 9(3), 165-173.
Berryman, E., Gaskin, D., Jones, A., Tolley, E., & MacMullen, J. (1989). Point by point: Predicting elders' falls. Geriatric Nursing, 10(4), 199-201 . Caird, E, & Judge, T. (1973). Assessment of the elderlypatient. London: Pitman. Committee on 'lt-auma, American College of Surgeons. (1989). Advanced trauma life support course. Chicago: Author. Elliott, D. (1979). Accidents in nursing homes: Implications for patients and administrators. In M. Miller (Ed.), Current issues in clinical geriatrics (pp. 97-137). New York: Tiresias. Gordon, M. (1989). Manual of nursing diagnosis (4th ed.). New York: McGraw-Hill. Janken, J., & Reynolds, R (1987). Identifying patients with the potential for falling. In A. McLane (Ed.), Classification of nursing diagnosis (pp. 136-143). St. Louis: Mosby. Johnston, J. (1988). The elderly and fall prevention. Applied Nursing Research, 1(3), 140-145. Kustaborder, M., & Rigney, M. (1983). Interventions for safety. Journal of Gerontological Nursing, 9(3), 159-173.
Lamb, K., Miller, J., & Hernandez, M. (1987). Falls in the elderly: Causes and prevention. Orthopaedic Nursing, 6(2), 45-49. Louis, M. (1983). Falls and their causes. Journal of Gerontological Nursing, 9(3), 142-156. Lund, C., & Sheafor, M. (1985). Is your patient about to fall. Journal of Gerontological Nursing, 11(4), 37-41.
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