Mobility, falls prevention and living better with dementia in residential care settings

In the UK, long-term continuing care for older people is principally provided by independently owned (small, medium or large businesses and charities) care homes. The typical resident is statistically female, aged 85 years or older, and in the last years of their life. The majority of care home residents have dementia and take seven or more medications. Many, it turns out, live with depression, mobility problems and pain. But it is noteworthy he mobility of older adults with dementia often declines following admission to a residential care setting.

Maintenance of mobility is an important component of quality of life for all individuals, including those in long-term care facilities; in fact, long-term care residents and staff identify mobility as pivotal to residents’ quality of life. Mobility limitation leads to increased health care utilisation, pressure sores, muscle atrophy, bone loss, pneumonia, incontinence, constipation, and general functional decline. Sedentary behaviour and limited mobility, common among older adults in nursing homes, can contribute to disability in activities of daily living and increased need for personal care.

Almost 90 percent of nursing home residents have some type of mobility limitation which can negatively affect their health and general well-being. When residents’ mobility is compromised, not only do they experience difficulties performing daily activities such as walking, toileting, and socialising, but they are also prone to falls, pressure ulcers, incontinence, and pneumonia – all of which can lead to complications and hospitalisation. Those with reduced mobility are more likely to experience adverse events such as falls, incontinence, pressure ulcers, and pneumonia, all of which reduce quality of life and exponentially increase the cost of resident care. Therefore, interventions directed at improving mobility and activities of daily living are an important research focus. Some individuals in long-term care may have their needs overlooked for a variety of reasons (e.g. complexity of behaviour). However, residents rely on primary health care services, for medical and nursing support, and access to specialist services. Despite evidence that low-intensity exercise can improve physical performance and activities of daily living among frail older adults in long-term care facilities, residents still spend the majority of their waking hours lying in bed or sitting.

Nursing home residents with cognitive impairment represent a large portion of the nursing home population and are at an increased risk of falling. Falls in all residential care are hugely important, of course. Some have challenged the American Geriatrics Society and British Geriatrics Society guideline which states that there is insufficient evidence to support any recommendation to reduce fall risk for older people with cognitive impairment.

“Falls and fall-related injuries are a major public health issue among older adults worldwide. Approximately one-third of people aged 65 years and older fall at least once each year, and one sixth fall recurrently. Many factors have been associated with an increased risk of falls, such as medication, co-morbidity, decreased mobility, female gender, and age.” (Oliver et al., 2007)

Oliver D, Connelly JB, Victor CR, Shaw FE, Whitehead A, Genc Y, Vanoli A, Martin FC, Gosney MA. Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analyses. BMJ. 2007 Jan 13;334(7584):82. Epub 2006 Dec 8.

If injuries and falls can be prevented, the long-term survival and quality of life of institutionalised older adults can be extended. Emerging evidence exists that even mild injury has devastating outcomes for older adults. There are multiple known risk factors for falls. Research findings have shown that factors contributing to falls are multifactorial, complex, and interrelated, and can be fixed or transient. Fixed intrinsic factors (e.g. visual changes, comorbidities, muscle weakness, and impaired balance) by definition do not change rapidly over time and are therefore poor indicators for change in risk status. The risk of falling and sustaining an injury as the result of a fall increases with age. Falls often indicate underlying frailty or illness and thus require a broad approach to assessment and management. Transient factors that change over time (e.g. elevated temperature, dehydration, room change, or a medication change) may be more sensitive to changes in fall risk for nursing home residents and indicators for the need for additional interventions.

Due to the large burden of injurious falls, fall incidents put a high and increasing demand on healthcare resources. Up to 20% of admissions to general hospitals for hip fracture are from care homes. Nursing home residents with dementia have substantial care needs. The complexity of falls is reflected by the high prevalence of pre-morbid functional loss and limited mobility, coupled with multiple medical comorbidities, high rates of polypharmacy and a high prevalence of dementia. Older persons are at an increased risk for serious injuries even after a minimal trauma, such as a fall, due to underlying medical conditions like osteoporosis. Approximately a third of older fallers sustain fall-related injuries, which require medical treatment. Most evidence about successful prevention strategies, however, is derived from less frail and more clinically stable people living in their own homes.

There is considerable debate as to whether “multi-faceted interventions” (which included factors such as removal of physical restraint, falls alarm devices, exercise, calcium and vitamin D treatment and changes in the physical environment) are to be statistically significant in reducing falls. A Cochrane review has shown, though, that multi-faceted interventions to reduce falls in care homes were effective if they were coordinated via multi-disciplinary teams. The strategies usually promoted are: falls risk assessment; mobility assessment; use of hip protectors; calcium and vitamin D supplementation; continence management; exercise programs; appropriate footwear; medication Falls may also lead to loss of function, anxiety, depression, impaired rehabilitation, increased length of hospital stay, and inability to return to previous residence, thus contributing to additional health and social care costs. Falls and fall-related injuries among nursing home residents are serious concerns for health care providers, administrators, nursing home residents, and families.

Falls in institutions may even result in complaints or litigation from families. All of this leads to anxiety for staff and proprietors, who require guidance on best practice in preventing falls and injuries. The use of chair restraints has even been associated with higher risks of falls among residents without dementia. Fall risk may be increased by the use of psychotropic medications, particularly sedative hypnotics, antipsychotics, and antidepressants, which are more commonly prescribed to people with dementia. Clearly any attempts by the medical profession to reduce wellbeing amongst people living with dementia, whatever the well meant intended consequence, need to be carefully analysed.

Factors associated with fall prevention may be amenable to intervention (balance, anxiety, and medication use) or need to be considered when designing any approach to intervention (attention and orientation). Potential interventions include exercise comprising balance training, medication review, and strategies to understand and manage poor attention, and agitation. Falls affect rehabilitation, physical and mental function, can increase length of stay in hospital settings and the likelihood of discharge to long-term care settings. Fear of falling due to falls can further lead to loss of function, depression, feelings of helplessness, and social isolation; research into this is to be welcomed, as is confidence of people in not falling.

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