AMDA: Publications - Caring for the Ages

Traditionally, hip fractures in the frail elderly have been viewed by clinicians and the public as portents of inevitable decline. Studies estimate that 30% to 50% of hip fracture patients don't regain prefracture functional status and that the one-year post-fracture mortality rate may be as high as 25% in older populations.

But sources interviewed for this article say the time has come to see hip fractures as opportunities for improving residents' status and quality of life--not portents of inevitable decline. Through careful attention to interdisciplinary care processes and by instituting preventive and rehabilitative strategies, long-term care providers can make a difference in residents' outcomes after fracture and injury.

First Assessment Steps

Every resident fall that occurs in a facility requires immediate, as well as follow-up, evaluation. Standard procedure for aides and nursing staff at the Bethany Homes skilled nursing facility, Fargo, N.D., where CNA Kim Chase works, entails keeping the resident on the floor until their vital signs have been assessed. Though this may frustrate the residents who fall, it's necessary to rule out serious injury.

"We want them to squeeze our hand and make sure they can move their toes," she explained. After the resident is examined for possible fracture or neurologic injuries, they are helped up.

In the days and weeks following a fall, caregivers carefully monitor residents because delayed appearance of fracture or injury is common.

"We watch for any bruises or anything [else] that might occur," said Chase, recalling that CNAs noticed one resident who, after a seemingly straightforward fall incident, cried out each time she was turned in bed. Knowing that this was not typical behavior for that resident, they asked that an x-ray be obtained. In fact, the x-ray revealed a fracture that had been missed initially.

Another common scenario in long-term care is that the patient/resident may fall during the night, said Hosam K. Kamel, MD, CMD, director of Geriatrics and Extended Care at St. Joseph's Mercy Health Center, medical director, Post Acute Care Service for Mission Clinical Services, Hot Springs, Ark., and recent chair of the committee responsible for updating AMDA's Clinical Practice Guideline: Falls and Fall Risk. Unless the fall results in serious injury requiring urgent care, the physician is usually notified the next morning.

"Even if there are no reported injuries, this patient has to be examined by a clinician provider--within 24 hours," emphasized Dr. Kamel. This examination should entail "a complete examination of the patient, review of his medications, and obtaining a consensus from nursing staff of what happened. (Was the patient dizzy? Was there poor lighting or a tripping hazard present?)"

Any number of complications can result from a fall, such as internal or external bleeding, sprains, concussions, or reduced loss of confidence and independence. Most important, said Dr. Kamel, the clinician must determine whether there were impacts to the head or hip because even minimal trauma to the head can result in a subdural hematoma. Likewise, as in the example above, a hip fracture can also be missed at the outset. Dr. Kamel immediately orders x-rays in cases of either head or hip impact from a fall. This is for the patient's well-being, as well as for medical-legal purposes.

Interdisciplinary Evaluation Improves Outcomes

After a resident has been stabilized and/or treated for fall injury, it's incumbent upon the facility to thoroughly evaluate the causes leading to the fall. AMDA's Clinical Practice Guideline: Falls and Fall Risk recommends initiation of an investigation of the cause within 24 hours of a fall and provides an algorithm for conducting this evaluation.

Falls among facility residents are often due to multiple factors, and so must involve the entire interdisciplinary team, from the physicians to the physical therapists--and even housekeeping staff, advised Elaine Townsley, RNC, MSN, nurse consultant for Convacare Management, Inc., Hot Springs, Ark., and owner of Nurse Consultants of Arkansas, LLC, Searcy, Ark. Townsley was a member of the Arkansas Process Indicator Team, which developed the Arkansas Process Indicator for Falls and Fall Risk for use by state-wide facilities. (See worksheet at this link) Steven Levenson, MD, CMD, multi-facility medical director, Baltimore, Md., and Caring editorial board chair, guided the generation of the falls process indicator, which included participation of the University of Arkansas, the Arkansas Office of Long Term Care, the Arkansas Health Care Association, and the Arkansas Foundation for Medical Care.

Dr. Kamel said that evidence demonstrates that performing a falls assessment after a fall decreases both the morbidity due to the fall, as well as the recurrence of falls. "This has to be an interdisciplinary assessment," he said, concurring with Townsley. "The physician will look at the patient to see if he has an injury and what contributed to the fall, as well as review the medications. Nursing also has a part, especially in determining environmental hazards that may have contributed. The physical therapist is also important, because balance training after a fall is one of the best ways to decrease the risk of another fall."

Detective Work

Townsley likened a thorough falls assessment to detective work. "I've noticed that with falls, many times we do not get a good assessment of what that resident's usual lifestyle was. Some may have worked on a farm their entire life and were used to getting up at 3 in the morning, fixing coffee, and going outside to feed the chickens," she explained. "So they get up at 3 a.m., and climb over the side rails or over the end of the bed, and maybe they don't realize that they can no longer walk or that they are recuperating from a fractured hip or pelvis.

"We need to go back as far as we can, sometimes by asking the family, to try and find that person's patterns. And if we can intervene with that--say, go in the room at 3 a.m. and help that resident get up to their wheelchair, let them get a cup of coffee and go out to the lobby or whatever--then we will be putting that resident back into the life that they remember and were comfortable with," she continued. "That, in turn, may decrease their falls, and probably restraint usage and weight loss as well. It's a domino effect."

When determining causes of recurrent falls, it may be reasonable to involve the consultant pharmacist more than once a month, suggested Diane Crutchfield, PharmD, CGP, FASCP, Knoxville, Tenn. Many medications, including antiarrhythmics, anticholinergics, antidepressants, antihypertensives, anti-Parkinsonian agents, vasodilators, and benzodiazepines, can increase fall risk.

Dr. Crutchfield, president of Pharmacy Consulting Care and current president-elect of the American Society of Consultant Pharmacists, said that medication changes could help prevent falls. For instance, determine whether taking psychoactive medications might have contributed to the resident's fall. Then, the patient's physician could either withdraw the medication or change the dosage. Conversely, under-treating a condition may affect fall risk. If a resident has knee pain due to arthritis, instituting a stronger anti-inflammatory medication may prevent the pain when they rise from the bed or wheelchair.

A fall risk evaluation also offers the care team a good opportunity for assessing whether the resident has osteoporosis, noted Naushira Pandya, MD, CMD, medical director of the State Veterans' Administration Nursing Home, Pembroke Pines, Fla., associate professor and chair of geriatrics at Nova Southeastern University College of Osteopathic Medicine, Fort Lauderdale, Fla., and principal author of AMDA's recently revised Clinical Practice Guideline: Osteoporosis. Not every resident will benefit from aggressive diagnostic efforts, and the clinical practice guidelines addresses the degree of evaluation to be used in a variety of patients.

For instance, a severely debilitated patient may not benefit from a DEXA study because it may induce more confusion or increase discomfort--especially if an osteoporosis diagnosis can be made on clinical and historic data, said Dr. Pandya. An example might be a resident over age 50 with a history of known fractures who has obvious kyphosis.

However, patients who have the potential to return to the community or who have a good prognosis and life expectancy, might benefit from a DEXA scan that would help the clinician assess whether the disease process is in the mild, moderate or severe range. DEXA scans also help practitioners tailor treatments.

Prevention: A 3-Pronged Approach

To prevent or reduce falls, facilities may employ a full range of medical, environmental, and psychosocial strategies. Often, adjusting medications to counter orthostatic hypotension addresses dizziness and prevents fall recurrence. Nursing staff and social workers may check to see if residents have proper eyeglass prescriptions and to ensure that shoes fit properly.

To prevent residents from falling out of bed, the Bethany Homes facility inserts Styrofoam "fun noodles" (sold as swim toys) underneath fitted sheets to form a slight rise at the edge of the mattress, said Chase.

Even with a range of techniques and care plans to prevent falls, facilities may be unable to keep all residents from falling, said Dr. Kamel. Those with Parkinson's disease or extreme agitation with dementia can't be guarded at all times.

In light of this reality, the focus has shifted to include fall prevention as one of three interdependent goals--the other two are strengthening bone by diagnosing and treating osteoporosis, and reducing the severity of injury as a result of falls. The latter entails such techniques as lowering the bed to within inches of the floor and using rubber floor mats. That way, if residents roll out of bed, the potential for injury is greatly reduced.

Even so, noted Chase, such interventions require full discussion with residents and caregivers. A bed that sits only three inches off the floor may prevent a resident from getting up and end up being more frustrating than the possibility of falls.

The Healing Process: New Directions

Researchers who work with hip fracture patients are demonstrating promising new rehabilitation strategies. Barbara Resnick, PhD, CRNP, associate professor, University of Maryland School of Nursing in Baltimore and a member of Caring's editorial board, believes it's time to dispel the myths surrounding hip fractures.

"There has been this belief that a hip fracture is the beginning of the end," she said recently, referring to statistics that 25% of the elderly who suffer a hip fracture die within a year of related complications. "This does not need to be. In many ways, I look at a hip fracture as an opportunity to turn one's life around--as we do with heart attacks. How many men--and women--have a heart attack and [see it] as a kind of warning: Change your behavior, quit smoking, start exercising, [and] eat better? I think a hip fracture can be seen in the same way. It's an acute event that can be used not to be 'the end,' but to change some of your behaviors."

Dr. Resnick is the principal investigator of a National Institute of Aging study testing the effectiveness of a home-based exercise program, the Exercise Plus Program. This study, which is part of the Baltimore Hip Studies directed by Jay Magaziner, MD, exposes older women post-hip fracture to a home-based exercise program that combines aerobic and resistance exercise with motivational interventions. Fear of falling has been shown to be a major factor in the deconditioning that often follows a hip fracture. This, in turn, puts the resident at greater risk of falling again.

Final analyses aren't yet complete, but Dr. Resnick said that many have reported positive benefits related to recovery through their participation in her intervention study. While there are many challenges to getting women who've had hip fractures to initiate and adhere to regular exercise, Dr. Resnick believed that this research would continue to support the important benefit of exercise for these individuals and provide new information about how to effectively motivate these women to exercise post-fracture.

Dr. Kamel would like to see hip fractures receive the same targeted, interdisciplinary focus as that now directed toward rehabilitating stroke patients. In the VA system, frail stroke patients with increased needs are admitted to Geriatric Evaluation and Management Units where they are managed by interdisciplinary teams of providers. Stroke units have now become the standard of care, he noted, and have had a positive effect on patient outcomes.

"We cannot afford to keep continuing like this [with poor outcomes for hip fracture]," he asserted. "We have been aware of the high morbidity and mortality for the last decade." He believes it would be possible to institute "hip fracture units" by reorganizing currently available resources and providers.

Keep Families in the Loop

When facilities generate new care plans to manage residents' falls, they must keep families apprised of these changes. "In my experience families feel very reassured if you explain what your efforts are [to prevent falls] and what you can achieve," explained Dr. Pandya. "You have to be diligent in your efforts to try to detect all risk factors. But even with the best care, and the best of therapies, such as attention to lighting and footwear, trying to improve leg strength and gait, and addressing medications, patients will still fall."

In that case, medical directors and other members of the health-care team may engage in negotiations with the family regarding possible restraints. "Some families cannot tolerate the risk of their loved one falling at all, and they will actually ask for [the use of] restraints," she said. "Other families don't want that, but they have to [be made to] understand the trade-off [of more risk of falling]."

Keeping communication lines open with families offers other benefits as well: Often the practitioner gleans valuable information about the patient's history from such conversations.

"You might learn that the resident has had a bone density scan or another fracture that you didn't know she had," said Dr. Pandya. In addition to improving relations between the providers and families, good communication may lower the risk of unwarranted litigation, "because sometimes bad outcomes cannot be prevented, but it's the reaction and the involvement of the family that determines their subsequent action."

Conclusion

In the frail elderly, falls can be a major cause of disability, utilization of health-care resources, and even mortality. To prevent further falls and reduce the seriousness of injury during unpreventable falls, a facility-wide interdisciplinary approach is imperative, said the sources interviewed for this report. Many facilities have elected to use falls as a key indicator in their quality improvement efforts. In this sense, falls may in fact come to be seen as opportunities for improvement--for both the resident and the facility.

LTC Team in Action

As a long-term care professional, what is the biggest challenge you face in working with hip fracture and fall injury patients?

Medical Director
When patients come to the nursing home after hospitalization for a fracture, they have not been mobilized quickly enough. According to a study I recently published (Time to ambulation after hip fracture surgery: relation to hospitalization outcomes. J Gerontol A Biol Sci Med Sci. 2003;58 [11]:1042-1045), complications increase dramatically with every day of delay in mobilization.
Surgeons may be concerned that early mobilization can cause delayed fracture union or malfunction of the prosthesis, but if the patient stays in bed too long, it may be too late to rehabilitate them fully. In addition, patients' pain is often not managed properly. Providers tend to overlook the amount of pain that patients have. Pain management is very important for their quality of life, and also for their ability to participate in exercise.
--Hosam K. Kamel, MD, CMD

Medical Director
The problem is that not all falls can be prevented and that prevention requires an intensive evaluation and looking out for falls all the time. Physicians or other health professionals, such as nurse practitioners, may approach writing the regulatory progress note as a cursory requirement. But this is an ideal opportunity to address fall risk, to scan the patient's record to see how many incidents the patient may have had since the last note and whether there is a pattern in the circumstances or medical issues at the times of the falls.
Have there been changes in the patient's medical condition and, especially, function? If the patient was walking and is now in a wheelchair, what caused this? Can we get them back to walking and being more independent?
Also, facilities must be diligent at quality improvement meetings and may choose falls as an indicator to be evaluated on a monthly basis. At my last facility in Michigan, that monthly meeting occurred at the same time as consideration of restraints in the facility. All key people in charge of patient care--nurse managers, heads of restorative care and physical therapy--were all in the same room. So that was a great opportunity to brainstorm and see if further falls could be prevented.
--Naushira Pandya, MD, CMD

CRNP
One of our challenges [in the hip fracture exercise intervention study] is that after hip fracture, and after getting back to their baseline [levels of activity], patients want to stop there.
We need to change the mindset that says, "I'm back to what I was doing; I don't want to do any more." We need to change behaviors and improve their lives. In many ways, I think we have done this better with cardiac disease.
--Barbara Resnick, PhD, CRNP

PharmD
The most important thing is to assess these residents using a team approach. The consultant pharmacist certainly plays a significant role in terms of a focused review of medications to screen for any that could cause hypotension, sedation, dizziness, or gait disturbance. We also need to be aware of the other questions to ask in addition to looking at the medications.
For example, nursing staff may indicate the cause of the fall is related to environmental factors, such as the resident tripping on the foot pedal of the wheelchair, or slipping on a wet floor. The social worker may have additional information, such as the resident losing his or her glasses and being unable to see well enough to ambulate alone. You have to really look at the whole individual [and situation].
--Diane Crutchfield, PharmD, CGP, FASCP

CNA
We try to keep the residents at risk [of falls] closer to the nurses' station, and we do have bed alarms. But sometimes a bed alarm goes off and by the time you get to a room that may be farther away [from the nurses' station], they may be already on the floor.
We also have some families who do not want their loved one to have these alarms. One family, when we told them we wanted to use a chair alarm for their family member, decided against it--they wanted their family member to be as independent as possible. They were willing to accept that risk of falling, and said, "If they're going to fall, they're going to fall." So we have to include these decisions in the care plan.
--Kim Chase, CNA

RN
Once a resident has one fall, many times this escalates into more falls. Repeat falls may be due to the fact that the resident's dementia progresses, since they are moved from environment to environment, and their confusion increases.
In addition, older people think they should be able to get up and do everything immediately. They have always done everything for themselves, and didn't have the niceties [and conveniences] that we have nowadays. I find that lots of people want to get up and do more before it's time for them to do so (especially after a fall and/or a fall related injury). They don't allow their bodies to heal.
--Elaine Townsley, RNC, MSN

After the Fall

LTC experts say hip fracture & other injuries best managed using interdisciplinary approach