An Occupational Therapy Study on a Falls Prevention and Management Training Programme

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1 Introduction An Occupational Therapy Study on a Falls Prevention and Management Training Programme We are independent Occupational Therapists who have recently carried out a number of one-day training programmes in the Prevention and Management of Falls for a chain of care homes that specialise in dementia; these have been initially in residential care homes in the South East of England. Falls in care homes are a major problem and account for approximately 90% of reportable injuries and are the leading cause of mortality due to injury ( Falls prevention is a priority for the UK and the Government s aim is to reduce the number of falls which result in serious injury and to ensure effective treatment and rehabilitation for those who have fallen (NSF Standard 6 DOH 2005). The NICE Clinical Guidelines Standard 21: Falls (DOH 2004) - is based on the assessment and the prevention of falls in older people and multi-factorial falls risk assessment. consequence of falling in terms of cost to the NHS and Social Services is estimated to be 1.7 billion each year (HOP 2011). The cost to people in terms of loss of independence, reduced quality of life and well-being is immeasurable. The Falls Training Programme We wrote and delivered the Prevention and Management of Falls training programme from up-to-date falls research and the latest Falls Tool Kit developed by the Social Care and Social Work Improvement Scotland ( published in June 2011 for use in Care Homes in Scotland. As practising Occupational Therapists working with older people in the community and in care homes we are able to apply this knowledge in the most effective way in terms of enabling carers, senior staff and managers to apply falls prevention strategies into their everyday work. The whole approach to our training programme is to adopt a preventative approach with strategies care staff and managers can implement. Not all falls can be avoided, but the majority of falls can be prevented or significantly reduced as we have seen from our latest study following a review of our post falls training.

2 Our training covered an in-depth multi-factorial risk assessment approach, focusing on intrinsic and extrinsic factors. As a guide, we used the concept of the Multi-factorial Falls Risk Assessment and Management Tool (includes Osteoporosis screen) within our training programme (Tool 5 We also covered some common disorders that increase the risk of falls and serious injury such as Osteoporosis, Parkinson s Disease, Dementia, Stroke and Diabetes. The training had a number of practical activities for carers to participate in during the day which enhanced their learning. For example, an observational walk-about activity looking at different areas within the home as well as observing residents to find any intrinsic and extrinsic factors and reporting back to the group how many could be found. We highlighted that reducing falls needs to be multi-faceted both in risk assessment and intervention and that addressing one factor would not achieve the results, and further, that successful falls prevention needs to be a team effort rather than just left to the manager or to certain staff. We used the Scottish tools which had recently and very timely for us been published and are freely available to download ( Outcome Following our training we returned to one of the dementia residential care homes, whose 42 residents have, moderate to severe dementia, five months later to see if there had been any reduction in falls. The manager of this home had been recording falls monthly. The numbers of falls recorded were a combination of individual residents falling multiple times during the month and other residents who had fallen on a single occasion and were due to numerous factors. They also had recently had an unannounced visit from the Care Quality Commission and a Safeguarding Vulnerable Adults Alert Section 2 had been placed on the home because they had one particular resident who was falling repeatedly. In hindsight, following our training, the manager found that the home had many post-falls management guidelines in place but no falls prevention strategies and the belief had been generally that falling is a normal part of the ageing process. The Manager was very determined to implement the multi-factorial risk assessment and strategies that were recommended by a combination of our knowledge as experienced

3 Occupational Therapists and in the multi-factorial risk assessment tools used in conjunction with our training. Care staff and managers who attend our training programme are able to practically use the falls prevention strategies and tools during the day to enable them to put theory into practice and to make it meaningful for them, so they can apply it to their everyday work. They have since implemented these tools within their own falls prevention policies and recording/documentation procedures to help them to prevent, reduce and manage falls more effectively. Results Since carrying out our falls training in June 2011 and providing a more proactive approach to preventing falls - the number of falls in this home fell dramatically and this also led to a significant reduction in hospital admissions by up to 50%. The home now record about 5-6 falls monthly and with only 2 falls recorded in November see table below. It also appears from the table that falls in regular fallers have been reduced. Falls from April to November 2011 Month of fall No. Of falls No. of people who fell reasons if known/likely April mixture of reasons May mixture of UTIs, infections, poorly June mixture of infections, UTIs/poorly, July UTI, 1 in garden, 1 poorly, 1 new resident Aug UTI, 2 very poorly, 3 infections Sept chest infections, 1 UTI, 1 slip, 1 trip Oct UTIs, 1 trip, 1 poorly Nov trip, 1 not witnessed The factors below represent the actions taken by the care home, following our training, which significantly reduced the amount of falls occurring: Medication Reviews The Manager requested their GP carry out a medication review of every resident who was taking more than 4 different medications, particularly those who were taking sleep medication. The GP was compliant with this request. The Manager has also been vigilant in becoming familiar with the side

4 effects of certain drugs that are known to increase the risk of falls. The majority of residents were taken off their sleep medication by the GP. This did not affect the residents sleep patterns or cause any behavioural issues. Only 3 residents had to start re-taking their sleep medication. One resident who had been falling regularly whilst taking sleeping medication has not had any falls since stopping the medication. Paracetamol is now given to residents regularly rather than as required to keep a steady amount in the blood stream (according to GP advice) as it is difficult to tell if residents are in pain as many cannot express themselves due to the dementia. The manager has also typed up a list of side effects of the common medications to enable staff to be more aware of these so they can alert management if they suspect these effects in a resident. Note that we in no way recommended staff should stop or change medications, but that they should speak to the GP if they were concerned about side effects. Osteoporosis Sensory Fluid Intake Osteoporosis checks are only carried out if the resident is at risk as these are too expensive to carry out on all residents. However, carers are now more aware of the signs of this disease. All residents had eye and ear tests and many were found to have wax in their ears, highlighting that many residents with dementia have sensory problems which are not picked up as residents are unable to express themselves. Fluid intake has been increased in all residents, resulting in less Urinary Tract Infections and therefore less falls staff now do not walk past a resident who has a full glass of fluid, instead they prompt the resident to drink. The Manager has noticed a significant reduction in the number of urine infections and resultant falls following an increase in fluid in-take and care staff are now more knowledgeable in the importance of encouraging fluids for residents.

5 Environmental Risk Assessments and Care Plans The manager reported carers are more aware of falls risk factors in general and are more vigilant around the home during their day time routines, so for example, if they notice clutter, walking aids not in reach, trousers that are too long, more confusion than normal in a resident, etc, they now either take action themselves or report the problem to the manager or senior staff. The Manager has invested in night lights and sensor pads under carpets for residents who fall regularly so as to alert staff as soon as they get up. Changing and/or adapting the environment have played a significant part in reducing the amount of falls. They are using the measles chart ( to plot patterns of falls; while this had not yet shown any particular patterns of falling at the present time, it is an ongoing document within the home. Toileting routines are better managed care staff prompt toileting more regularly to avoid residents having to rush to the toilet and thereby increasing their risk of falls. The manager and senior staff had rewritten or reviewed all care plans using Tool 5 Multi-factorial risk assessment and Management Tool ( and included a simple clear risk assessment for each resident highlighting the main risk factors for each resident. The risk assessment was easy to access and read for all care staff. Headings on the Risk Assessment Form included: Areas of Need/Problems; Action to Take; Goal/Outcome; Target Date. Attitudes to Falling The manager also reported that the whole mindset of both herself and her staff had changed and rather than accepting falls as a part of aging they now actively and determinedly worked to prevent them. The manager has the drive to reduce falls and the enthusiasm and energy to encourage and motivate staff to do the same. The carers have greater knowledge of falls risk factors and the manager reports she now tries to involve them in problem solving by asking them how certain problems might be solved and taking their views into account. Care staff are more empowered and motivated as they now have more responsibility.

6 The manager also reports she takes time to think and reason about what might cause a fall and uses her growing knowledge about the falls risk factors to improve her problem solving skills. For instance she has looked at times medications are given and times of falls to see if there is a link and has sometimes found these were related; therefore by changing the times or the activities following medication, falls can be prevented. Or she may advise staff to push a wheelchair behind a mobilising resident who has a higher risk of falling - for instance, residents who are beginning to have reduced weight bearing ability, but are still mobile. Case study Mrs E is a 91 yr old lady with dementia, osteoporosis, falls, poor eyesight, previous fractured collar bone. She lived with her husband who died recently, following which she moved into the care home in June Since moving in she has had 9 falls and is particularly prone to UTIs. After taking time to clinically reason what could be done to reduce the falls, many of which had occurred between 1am and 3am at night, her bedroom furniture was moved around so that she did not have to walk around the bed to get to the toilet room. A night light and pressure mat have been provided. Her toileting regime has been changed - she is now toileted at 11pm even if she is asleep as on balance it seems better to wake her than wait until she gets up and is at risk of falling. She now does not get up at 3am and her falls have decreased. Now care staff are particularly vigilant about ensuring she drinks regularly and is toileted regularly during the daytime as well. Her care plan has been rewritten clearly with a multi-factorial risk assessment included. In August she had 4 falls while on antibiotics for a UTI, one fall in September, but since then no further UTIs and no further falls. This shows the multi-factorial approach needed to reduce falls. Summary The feedback from this home highlighted the importance of an enthusiastic and proactive manager who was committed to reducing falls and prepared to put in the effort to implement falls prevention measures and to persist in the face of resistance, which often initially occurs when changes to working practices are made. It emphasised the importance of team work among all staff and the need for constant vigilance for possible risk factors. In particular, it highlighted the importance of the need for a multi-factorial approach to

7 prevention strategies. 2BE INDEPENDENT LLP The manager reported that the whole experience had been a massive learning curve for herself as well as her staff, which had greatly widened her outlook and improved her awareness and problem solving skills. The care home has since asked us to return to assess a complex case, as we are also working together with the chain of care homes to support and provide OT intervention when required as access to health and social services OTs are difficult due to long waiting lists. From these results and the feedback we are constantly adjusting our falls training prevention programme accordingly, with more of an emphasis on management initiative, commitment and positive leadership with a firm but fair style, and an open minded approach and willingness to trial various interventions. We are also including more on team work among all staff, greater involvement and responsibility for staff, and the importance that staff feel that they can make a difference. We want to highlight the vital need for a change of attitude with the mindset that falls can be reduced rather than just believing falling is inevitable in older people. We hope to run this programme in other care homes as we too are dedicated to reducing falls in older people. We are more aware than ever that training needs to be targeted at both management and staff if it is to be truly effective. References Bexley Primary Care Trust, Managing Falls in Care Homes, Department of Health (2004) NICE GUIDELINES Clinical Practice and Guidelines for: The Assessment and prevention of falls in older people (Clinical Guideline 21) ( of Health (2005) National Service Framework: Falls Standard 6 ( J (Ed) (2011) The Guide to The Handling of People a systems approach (hop6), 6 th edition, Middlesex, UK: Backcare.Social Care and Social Work Improvement Scotland (28/6/11) A best practice toolkit resource guide, Authors: Angela Schoonewagen BScHons Occupational Therapy Jo Doubleday BScHons Occupational Therapy Date: 2 nd January 2012 Contact Details: 2Be Independent LLP - jodoubleday@live.co.uk Mobile: Be Independent LLP is registered with Companies House Reg. No: OC Our Registered Office is: - McCabe, Ford, Williams, Bank Chambers, High Street, Cranbrook, Kent TN17 3EG)