The following was posted by Tony Northcote, a member of the Aged Care Matters Facebook Group. I am not sure of why Facebook disabled the comments – perhaps due to its length. I have reproduced the post here until Facebook replies to our messages. I have not included the links that Tony supplied.
************
“A recent post concerning falls quickly generated over 130 comments. While I have no doubt the members of this group only have the best intentions, there are obviously some misconceptions about falls and how to deal with them.
Advances in clinical management come from evidence-based information. We wouldn’t expect any less than a thorough examination of any new drug, procedure or practice. Please be careful with anecdotal advice, do your own research and leave emotion at the door.
Apologies in advance for the length of this post…but this is such a big subject and I’ve only scratched the surface
(A special mention to Eddie Uzsakt for collating some of the recent discussion points)
As a clinician and manager for thirty years, here’s what I know to be true: I invite you to consider the following:
Falls
There is only one way to prevent old people falling…invent an anti-gravity device. Until then, gravity will ALWAYS win.
According to the AIHW, falls are Australia’s leading cause of injury hospitalisation and death, representing 43% of injury hospitalisations and 42% of injury deaths. It’s no surprise that the highest risk group is females over the age of 65…and the risk increases exponentially as we get older.
In 2021-22, fall injuries in people 65 and over accounted for 60% of hospitalisations and 94% of deaths. The full data set can be found on AIHW website.
It makes for sobering reading. It shows that falls are an extensive and common problem for the entire population and almost an inevitable consequence of getting old and frail.
Despite the thousands of researchers writing thousands of research papers and developing lots of great preventative strategies, we’re still falling…a lot. When you throw some cognitive impairment, frailty, poor vision, decreased strength and chronic diseases like Parkinson’s or diabetes into the mix, we’re almost guaranteed to hit the deck at some stage.
My point here is that while there are certain interventions that can and should be implemented in residential aged care, none of them are 100% effective….it’s just not possible to prevent every fall.
If your expectations don’t align with this reality, you’re setting yourself up for a fall (Sorry).
Bed Rails
This is not the 1950s…DO NOT use them. Although some people consider they’ve had a win by getting them installed, the numbers don’t lie…they are dangerous. There is a plethora of information available on the dangers of bed rails.
It’s important to note that even when all the known risks have been managed, no institution can guarantee that mattresses won’t be swapped and beds relocated in the normal course of daily operations, so a mattress or bed that may have initially had the correct clearance measurements can easily become a potential injury risk.
Padded or covered bed rails are still dangerous. They isolate the person and will fall from a greater height when they climb over them. And it’s not just the bed rail structure that needs to be considered: is the mattress correctly matched to the bed base? Is there a gap of more than 10cm between the mattress edge and the rails? Have the rails been fitted correctly (you wouldn’t believe how many get installed reversed).
Hospital bed side rails are different. They’re segmented: typically two – three separate sections on each side and they are only a few hundred mm high. You’ll also note they swing out and under the bed, not along the length of the bed.
For the most part, hospitals aren’t very good at caring for people with dementia…they’re ill-equipped in both design and skill when it comes to severe cognitive impairment. Even with nurse /patient ratios as high a 3: 1 in some areas, aged care residents regularly hit the deck during a hospital admission. (Hospitals are also very quick to reach for the Benzos and anti-psychotics when someone doesn’t ‘behave’)
While you might think you’re acting in the person’s best interest when you demand that bed rails are fitted… you really aren’t. I lay the blame squarely on the facility manager and other key staff. They obviously haven’t sat down with you to have a candid discussion or provided the evidence that would at least give you some confidence when deciding not to use bed rails.
Solutions?
Despite the utopian assertion that falls are preventable, they’re not. The current data suggests that only about one third of all falls are linked to potentially preventable factors.
For the cohort we’re all concerned about, falls prevention is a nightmare. Consider just a few of the increased risk factors Mum or Nana are dealing with:
Decreased mobility, balance and dexterity
Failing eyesight and hearing
General physical decline
Cognitive impairment
Arthritis: there goes your flexibility and here comes the pain
Diabetes: complications include blindness and peripheral neuropathy (the inability sense the position of your extremities plays havoc with your proprioception)
Parkinson’s, Stroke and a myriad of other neurological conditions that can impact balance, strength and spatial awareness
Continence issues: when you gotta go…
Polypharmacy: Probably one of the biggest offenders…hands up everyone taking 5 or more regular medications?
The list of potential risk factors is extensive…you can appreciate the challenges.
Here are a few things that can actually make a dent in fall rates.
Strength and balance training: If your facility physio isn’t running daily exercise classes that specifically target these areas, ask them why not….and then lobby the service to implement a suitable program. A month of sit to stand exercises and balance work can yield extraordinary results for almost everyone. (Just being able to get on and off the toilet safely can significantly impact fall rates)
The Environment:
De-clutter the room,
If they use a walking aid, make sure it’s easily accessible,
Good lighting is essential… and always have a night light on
The best room designs will ensure the bathroom is clearly visible from the resident bed.
Make sure the call bell is in reach
Make sure the things they need are close at hand (TV Remote, glasses, water, tissues, etc.)
For the ambulant resident, get rid of the ill-fitting sandals and fluffy slippers and buy some comfortable joggers with non-slip soles
Ensure the bed is always set at the appropriate height when they’re in it.
No floor coverings with swirling or geometric patterns. These affect orientation and spatial awareness in older persons and even more so in those with cognitive impairment.
Regular and individualised toileting schedules
Medication reviews: This is a big one. GPs are good at prescribing but not so hot with de-prescribing. Is the person still on the same dose of blood pressure medication they were taking when they were more active and living at home? I’d wager the answer is yes. This is something that frequently gets missed…a person enters residential care, becomes more sedentary and starts falling down whenever they stand up because their blood pressure is too low. A pharmacist review is a good place to start…then get a geriatrician to look at their entire medication regimen. They should be the one who has the helicopter view of the entire person. Endless trips to specialists and the cumulative tinkering with medications are a recipe for disaster. Frustratingly, the medical profession continues to operate with a silo mentality, so you need someone who knows what they’re doing to take a holistic view. (You can also help by not pressuring the GP to prescribe additional medications for every minor or temporary ailment. You don’t need to treat everything, every time)
.Ditch the sleeping tablets. Mum might be used to taking them every night for past twenty years, but they stopped being effective about two weeks after she started. After a very short period, benzos are essentially useless as sleeping meds but they remain very effective at screwing with alertness and motor coordination.
Try to reduce the need to pee overnight: less chance of falling as they groggily stumble to the loo and a better chance of getting a good night’s sleep.
Ease up on the coffee and tea after 6pm.
If they’re taking diuretic tablets, these should be administered in the morning. If they’re prone to oedema and their legs swell up over the course of the day, make sure they reduce the fluid intake from the late afternoon and put their feet up regularly. (When they finally get into bed at night, reabsorbing all that retained fluid can be the equivalent of downing a few schooners)
Consider the facility’s daily routine. Do the afternoon staff come on duty at 3pm and start putting people to bed? This is an appallingly common practice and effectively sentences some residents to being in bed for 18+ hours every day (No wonder they become restless and try to get up). The very frail should have an afternoon rest and be up for the evening meal…and nobody should be in bed before 7pm unless they specifically request it (and you can’t talk them out of it!) And you can’t just leave someone in a tub chair all day either.
But…
Some people with cognitive impairment will be more challenging. After all, they’ve been used to getting around independently for the past eight or nine decades.
Even the very few useful interventions available are still just reactive. Bed sensors only alarm after someone gets out of bed (Although, they are very effective at generating ‘alarm fatigue’; endless false alarms induce staff complacency “…don’t worry, it’ll just be another false alarm…’’) and most of the sensors on the market are ordinary, at best.
Infrared bed exit sensors can be useful, but you won’t find many places that use them…or if they do, have them set up correctly.
Placing someone in a lo-bed attempts to reverse the circumstances…now gravity is working against the person as they try to stand up and not with them as they fall down. There is some interesting research on the physics of falling and the height /speed /force, etc. that causes injury; ideally, we should aim for a total bed height under 30cm. (including the mattress). Good lo-beds will easily go lower than that.
Use proper crash mats: not the spongy foam units you see in most facilities. The high density foam mats are only a few centimeters thick and you can stand on a chair and drop onto your knees without sustaining any injury (try doing that with your current crash mat…actually, don’t)
The person will probably still roll onto the floor but the chances of serious injury are greatly reduced (but NOT eliminated entirely).
Note: When used for a person who has been assessed as requiring assistance with mobility, has been reviewed by the physio, GP, clinical manager, etc. and discussions held with their representative, Lo-Beds are NOT a form of restraint. Although the commission identified them as a form of restraint in a 2020 regulatory bulletin, this does not accord with the legislated definition: (They do not impede or restrict the free movement of the resident.) A few years back the commission would crucify you for not using low beds…now, their reactive and ham-fisted interpretation of the legislation has them more interested in regulation than preventing head injuries. If your facility manager can coherently present this rationale they’ll easily counter any allegations of noncompliance.
Furphies
‘Dignity of risk’ is getting a quite a flogging of late…it’s almost as popular as ‘open disclosure’. People seem to like using these terms; it gives the impression you know what you’re talking about
With regards to falls, restraint and consent, one can’t just say “dignity of risk” and call it done. It’s way more nuanced because the ethos rarely matches the reality. This topic warrants its own separate discussion, but suffice to say it does not mean we allow people to exercise choice in ALL circumstances. Nor does it give the right to place your relative in jeopardy just because you can. When a service asks you to sign a waiver (most of these are less useful than toilet paper) they’ve already calculated the implications of risk and their obligations as a healthcare provider and concluded it’s easier to transfer the responsibility to someone else….you!
Please be very careful with this stuff. Also, recognise that when we act as someone’s representative, we’re often basing our decisions on their historical preferences; in many instances, those preferences are no longer appropriate.
A Falls Management Plan sounds like a useful document. But in practice 99’9% of them are essentially useless pieces of paper, produced for the sole purpose of appeasing the commission at audit time. Line up all the plans at any facility and you’ll see the same generic ‘intervention strategies’, the same aspirational toileting schedules and the same set of mobility and activity directives that the staff aren’t following. How could they when nobody actually reads these things?
(It never ceases to amaze me that people continue to believe these documents inform the delivery of care. Does anyone seriously believe that all care personnel read the entire thirty+ pages of care plans for every resident at the beginning of every shift?)
Many of the ‘standard’ protocols in aged care serve no valid purpose. The Falls Risk Assessment Tool (FRAT) is a good example: Like most predictive tools, they just give the impression that something is being done. Ask anyone about the care strategy differences for a medium falls risk and a high falls risk: they won’t be able to tell you because there aren’t any. Even more curious is the number of providers who insist that a FRAT is done after every fall. Even for people who are already rated as high risk. This is absurd…there’s no point doing the same risk assessment after the event… And there’s no such thing as an ‘extra-high’ risk category.
Sight charts and monitoring charts: Hourly, half-hourly, 15 minutes…There’s no point. Check them every 5 minutes? They can still fall over right after you’ve checked them. We used to call these “lie to me” charts. Staff will typically batch complete them at the end of the shift. (Having to battle with a dozen or more of these ludicrous documents every shift, I would too).
Anyone trying to sell you this as an effective strategy is either incompetent or trying to hoodwink you.
Finally
While there are some acute medical situations where restraint is a valid intervention, it’s rarely the case in residential care. Keeping a person restrained “for their own good” is problematic. Tying them up or caging them in is a clumsy and primitive approach to a complex problem.
Ultimately, this is an ethical and moral dilemma: do you keep someone ‘safe’ by restraining them and turning their every waking moment into a torment of frustration, confusion and distress…or do you implement the things you can and accept the consequences? Do you want them to live or just exist? Are you looking for quality or quantity? What would your mum have wanted for her final months… drug- addled imprisonment or freedom (and all its associated risks?) I know what my choice would be. I think we sometimes forget that our folks have been through wars, depressions and much greater risks than we’ll ever experience. We can certainly improve on the current standard of care but there is no perfect solution…so please don’t beat yourself up because you’re unable to fix everything.
Falls, Bed Rails & Reality
A recent post concerning falls quickly generated over 130 comments. While I have no doubt the members of this group only have the best intentions, there are obviously some misconceptions about falls and how to deal with them.
Advances in clinical management come from evidence-based information. We wouldn’t expect any less than a thorough examination of any new drug, procedure or practice. Please be careful with anecdotal advice, do your own research and leave emotion at the door.
Apologies in advance for the length of this post…but this is such a big subject and I’ve only scratched the surface
(A special mention to Eddie Uzsakt for collating some of the recent discussion points)
As a clinician and manager for thirty years, here’s what I know to be true: I invite you to consider the following:
Falls
There is only one way to prevent old people falling…invent an anti-gravity device. Until then, gravity will ALWAYS win.
According to the AIHW, falls are Australia’s leading cause of injury hospitalisation and death, representing 43% of injury hospitalisations and 42% of injury deaths. It’s no surprise that the highest risk group is females over the age of 65…and the risk increases exponentially as we get older.
In 2021-22, fall injuries in people 65 and over accounted for 60% of hospitalisations and 94% of deaths. The full data set can be found on AIHW website.
It makes for sobering reading. It shows that falls are an extensive and common problem for the entire population and almost an inevitable consequence of getting old and frail.
Despite the thousands of researchers writing thousands of research papers and developing lots of great preventative strategies, we’re still falling…a lot. When you throw some cognitive impairment, frailty, poor vision, decreased strength and chronic diseases like Parkinson’s or diabetes into the mix, we’re almost guaranteed to hit the deck at some stage.
My point here is that while there are certain interventions that can and should be implemented in residential aged care, none of them are 100% effective….it’s just not possible to prevent every fall.
If your expectations don’t align with this reality, you’re setting yourself up for a fall (Sorry).
Bed Rails
This is not the 1950s…DO NOT use them. Although some people consider they’ve had a win by getting them installed, the numbers don’t lie…they are dangerous. There is a plethora of information available on the dangers of bed rails.
It’s important to note that even when all the known risks have been managed, no institution can guarantee that mattresses won’t be swapped and beds relocated in the normal course of daily operations, so a mattress or bed that may have initially had the correct clearance measurements can easily become a potential injury risk.
Padded or covered bed rails are still dangerous. They isolate the person and will fall from a greater height when they climb over them. And it’s not just the bed rail structure that needs to be considered: is the mattress correctly matched to the bed base? Is there a gap of more than 10cm between the mattress edge and the rails? Have the rails been fitted correctly (you wouldn’t believe how many get installed reversed).
Hospital bed side rails are different. They’re segmented: typically two – three separate sections on each side and they are only a few hundred mm high. You’ll also note they swing out and under the bed, not along the length of the bed.
For the most part, hospitals aren’t very good at caring for people with dementia…they’re ill-equipped in both design and skill when it comes to severe cognitive impairment. Even with nurse /patient ratios as high a 3: 1 in some areas, aged care residents regularly hit the deck during a hospital admission. (Hospitals are also very quick to reach for the Benzos and anti-psychotics when someone doesn’t ‘behave’)
While you might think you’re acting in the person’s best interest when you demand that bed rails are fitted… you really aren’t. I lay the blame squarely on the facility manager and other key staff. They obviously haven’t sat down with you to have a candid discussion or provided the evidence that would at least give you some confidence when deciding not to use bed rails.
Solutions?
Despite the utopian assertion that falls are preventable, they’re not. The current data suggests that only about one third of all falls are linked to potentially preventable factors.
For the cohort we’re all concerned about, falls prevention is a nightmare. Consider just a few of the increased risk factors Mum or Nana are dealing with:
Decreased mobility, balance and dexterity
Failing eyesight and hearing
General physical decline
Cognitive impairment
Arthritis: there goes your flexibility and here comes the pain
Diabetes: complications include blindness and peripheral neuropathy (the inability sense the position of your extremities plays havoc with your proprioception)
Parkinson’s, Stroke and a myriad of other neurological conditions that can impact balance, strength and spatial awareness
Continence issues: when you gotta go…
Polypharmacy: Probably one of the biggest offenders…hands up everyone taking 5 or more regular medications?
The list of potential risk factors is extensive…you can appreciate the challenges.
Here are a few things that can actually make a dent in fall rates.
Strength and balance training: If your facility physio isn’t running daily exercise classes that specifically target these areas, ask them why not….and then lobby the service to implement a suitable program. A month of sit to stand exercises and balance work can yield extraordinary results for almost everyone. (Just being able to get on and off the toilet safely can significantly impact fall rates)
The Environment:
De-clutter the room,
If they use a walking aid, make sure it’s easily accessible,
Good lighting is essential… and always have a night light on
The best room designs will ensure the bathroom is clearly visible from the resident bed.
Make sure the call bell is in reach
Make sure the things they need are close at hand (TV Remote, glasses, water, tissues, etc.)
For the ambulant resident, get rid of the ill-fitting sandals and fluffy slippers and buy some comfortable joggers with non-slip soles
Ensure the bed is always set at the appropriate height when they’re in it.
No floor coverings with swirling or geometric patterns. These affect orientation and spatial awareness in older persons and even more so in those with cognitive impairment.
Regular and individualised toileting schedules
Medication reviews: This is a big one. GPs are good at prescribing but not so hot with de-prescribing. Is the person still on the same dose of blood pressure medication they were taking when they were more active and living at home? I’d wager the answer is yes. This is something that frequently gets missed…a person enters residential care, becomes more sedentary and starts falling down whenever they stand up because their blood pressure is too low. A pharmacist review is a good place to start…then get a geriatrician to look at their entire medication regimen. They should be the one who has the helicopter view of the entire person. Endless trips to specialists and the cumulative tinkering with medications are a recipe for disaster. Frustratingly, the medical profession continues to operate with a silo mentality, so you need someone who knows what they’re doing to take a holistic view. (You can also help by not pressuring the GP to prescribe additional medications for every minor or temporary ailment. You don’t need to treat everything, every time)
.Ditch the sleeping tablets. Mum might be used to taking them every night for past twenty years, but they stopped being effective about two weeks after she started. After a very short period, benzos are essentially useless as sleeping meds but they remain very effective at screwing with alertness and motor coordination.
Try to reduce the need to pee overnight: less chance of falling as they groggily stumble to the loo and a better chance of getting a good night’s sleep.
Ease up on the coffee and tea after 6pm.
If they’re taking diuretic tablets, these should be administered in the morning. If they’re prone to oedema and their legs swell up over the course of the day, make sure they reduce the fluid intake from the late afternoon and put their feet up regularly. (When they finally get into bed at night, reabsorbing all that retained fluid can be the equivalent of downing a few schooners)
Consider the facility’s daily routine. Do the afternoon staff come on duty at 3pm and start putting people to bed? This is an appallingly common practice and effectively sentences some residents to being in bed for 18+ hours every day (No wonder they become restless and try to get up). The very frail should have an afternoon rest and be up for the evening meal…and nobody should be in bed before 7pm unless they specifically request it (and you can’t talk them out of it!) And you can’t just leave someone in a tub chair all day either.
But…
Some people with cognitive impairment will be more challenging. After all, they’ve been used to getting around independently for the past eight or nine decades.
Even the very few useful interventions available are still just reactive. Bed sensors only alarm after someone gets out of bed (Although, they are very effective at generating ‘alarm fatigue’; endless false alarms induce staff complacency “…don’t worry, it’ll just be another false alarm…’’) and most of the sensors on the market are ordinary, at best.
Infrared bed exit sensors can be useful, but you won’t find many places that use them…or if they do, have them set up correctly.
Placing someone in a lo-bed attempts to reverse the circumstances…now gravity is working against the person as they try to stand up and not with them as they fall down. There is some interesting research on the physics of falling and the height /speed /force, etc. that causes injury; ideally, we should aim for a total bed height under 30cm. (including the mattress). Good lo-beds will easily go lower than that.
Use proper crash mats: not the spongy foam units you see in most facilities. The high density foam mats are only a few centimeters thick and you can stand on a chair and drop onto your knees without sustaining any injury (try doing that with your current crash mat…actually, don’t)
The person will probably still roll onto the floor but the chances of serious injury are greatly reduced (but NOT eliminated entirely).
Note: When used for a person who has been assessed as requiring assistance with mobility, has been reviewed by the physio, GP, clinical manager, etc. and discussions held with their representative, Lo-Beds are NOT a form of restraint. Although the commission identified them as a form of restraint in a 2020 regulatory bulletin, this does not accord with the legislated definition: (They do not impede or restrict the free movement of the resident.) A few years back the commission would crucify you for not using low beds…now, their reactive and ham-fisted interpretation of the legislation has them more interested in regulation than preventing head injuries. If your facility manager can coherently present this rationale they’ll easily counter any allegations of noncompliance.
Furphies
‘Dignity of risk’ is getting a quite a flogging of late…it’s almost as popular as ‘open disclosure’. People seem to like using these terms; it gives the impression you know what you’re talking about
With regards to falls, restraint and consent, one can’t just say “dignity of risk” and call it done. It’s way more nuanced because the ethos rarely matches the reality. This topic warrants its own separate discussion, but suffice to say it does not mean we allow people to exercise choice in ALL circumstances. Nor does it give the right to place your relative in jeopardy just because you can. When a service asks you to sign a waiver (most of these are less useful than toilet paper) they’ve already calculated the implications of risk and their obligations as a healthcare provider and concluded it’s easier to transfer the responsibility to someone else….you!
Please be very careful with this stuff. Also, recognise that when we act as someone’s representative, we’re often basing our decisions on their historical preferences; in many instances, those preferences are no longer appropriate.
A Falls Management Plan sounds like a useful document. But in practice 99’9% of them are essentially useless pieces of paper, produced for the sole purpose of appeasing the commission at audit time. Line up all the plans at any facility and you’ll see the same generic ‘intervention strategies’, the same aspirational toileting schedules and the same set of mobility and activity directives that the staff aren’t following. How could they when nobody actually reads these things?
(It never ceases to amaze me that people continue to believe these documents inform the delivery of care. Does anyone seriously believe that all care personnel read the entire thirty+ pages of care plans for every resident at the beginning of every shift?)
Many of the ‘standard’ protocols in aged care serve no valid purpose. The Falls Risk Assessment Tool (FRAT) is a good example: Like most predictive tools, they just give the impression that something is being done. Ask anyone about the care strategy differences for a medium falls risk and a high falls risk: they won’t be able to tell you because there aren’t any. Even more curious is the number of providers who insist that a FRAT is done after every fall. Even for people who are already rated as high risk. This is absurd…there’s no point doing the same risk assessment after the event… And there’s no such thing as an ‘extra-high’ risk category.
Sight charts and monitoring charts: Hourly, half-hourly, 15 minutes…There’s no point. Check them every 5 minutes? They can still fall over right after you’ve checked them. We used to call these “lie to me” charts. Staff will typically batch complete them at the end of the shift. (Having to battle with a dozen or more of these ludicrous documents every shift, I would too).
Anyone trying to sell you this as an effective strategy is either incompetent or trying to hoodwink you.
Finally
While there are some acute medical situations where restraint is a valid intervention, it’s rarely the case in residential care. Keeping a person restrained “for their own good” is problematic. Tying them up or caging them in is a clumsy and primitive approach to a complex problem.
Ultimately, this is an ethical and moral dilemma: do you keep someone ‘safe’ by restraining them and turning their every waking moment into a torment of frustration, confusion and distress…or do you implement the things you can and accept the consequences? Do you want them to live or just exist? Are you looking for quality or quantity? What would your mum have wanted for her final months… drug- addled imprisonment or freedom (and all its associated risks?) I know what my choice would be. I think we sometimes forget that our folks have been through wars, depressions and much greater risks than we’ll ever experience. We can certainly improve on the current standard of care but there is no perfect solution…so please don’t beat yourself up because you’re unable to fix everything.”
