Falls by Residents of Alzheimer's Facilities
- Published on Wednesday, 02 September 2009 22:14
- Written by Stanton O. Berg
Overview: The risk or concern for falls of residents appear to have the attention of most Alzheimer's facilities. This is a very real concern and happens with almost clockwork regularity. Falls may be by a resident who is ambulatory and walking or from a wheel chair of a resident that is not ambulatory. While warning devices have been designed for and are routinely in use for wheel chairs, they do little to prevent a fall. Such devices serve to connect (cord) the residents to a warning device/buzzer (fixed to the chair back) that goes off if the resident pulls a loose a connection with the device. Unfortunately by the time the resident has pulled the connection loose, they are well on their way to a fall. It serves more to alert help to a resident that has fallen than prevent the fall. Many times a residents normal movements may set off the alarm so many are false alarms. On the other hand if they are set so loosely as to avoid being tripped by normal resident's chair movements, they do little to prevent a fall.
My general perception is that many of the Alzheimer's facility staff people are very unobservant. It is not that they do not care, they seem focused on their immediate task and appear to be largely unaware of what is going on around them. In the Alzheimer's facilities, the staff people need to be trained to be observant and aware of what is happening around them. I recall many times and usually daily, calling a staff members attention to a resident's problem that needed attention. I would always wonder why I noted this but they did not. Being a Sherlock Holmes fan, I can not help but be reminded of the Holmes's admonition "You see but you do not observe." Being more observant and having an awareness of what is going on around them would do much to prevent such falls.
Some Alzheimer's facilities have set up a committee to review falls on the premises and look for ways to prevent such falls. This of course helps to bring attention to the problem. My view however is that while it is important to be sure that this problem is "getting attention", it is far more important for the staff to simply "pay attention" to the residents who have the greatest risk of falling.
Editorial Note: A friend of mine who is on the staff of a nursing home and on their "Fall" committee, advised me that after seeing my comments on paying attention and being more observant; suggested perhaps they need signs similar to the road signs that say "See Motorcycles" but instead that reads: "See Residents.".
According to the CDC (Centers for Disease Control and Prevention) of the U.S. Department of Health and Human services:
"In 2003, 1.5 million people 65 and older lived in nursing homes. If current rates continue, by 2030 this number will rise to about 3 million. (Editorial Note: 50% of the residents of nursing homes have Alzheimer's or some form of dementia. 70% have some cognitive impairment. AA data.)
- About 5% of adults 65 and older live in nursing homes, but nursing home residents account for about 20% of deaths from falls in this age group.
- Each year, a typical nursing home with 100 beds reports 100 to 200 falls. Many falls go unreported.
- As many as 3 out of 4 nursing home residents fall each year. That’s twice the rate of falls for older adults living in the community.
- Patients often fall more than once. The average is 2.6 falls per person per year.
- About 35% of fall injuries occur among residents who cannot walk."
Note: Approx. 1800 nursing home residents die from falls each year. 10-20% of falls result in serious injury.
The Journal of the American Academy of Orthopedic Surgeons, 2011; 19: 402-9 reports that Falls are the leading cause of fatal and nonfatal injuries to older people in the United States. Approximately one-third of people aged 65 Years or older and half of those aged 80 years or older fall at least once annually, and 3-20% of hospital inpatients fall at least once during thier stay according to a comprehensive literature review by Terry A. Clyburn, MD, and John A. Heydemann, MD, of the University of Texas, Houston...reported in the AMDA Journal "Caring for the Ages, November 2011. (Hospitals, patients homes and long term care settings.)
The CDC also suggests the possible causes for such falls. (Editorial Note: for the environmental and medication causes, the solution is obvious.)
Muscle weakness and walking or gait problems are the most common causes of falls among nursing home residents. These problems account for about 24% of the falls in nursing homes.
- Environmental hazards in nursing homes cause 16% to 27% of falls among residents., Such hazards include wet floors, poor lighting, incorrect bed height, and improperly fitted or maintained wheelchairs.
- Medicationscan increase the risk of falls and fall-related injuries. Drugs that affect the central nervous system, such as sedatives and anti-anxiety drugs, are of particular concern. (Editorial Note: No antidepressants or antipsychotics are FDA approved for Alzheimer's and dementia patents and such use is warned against. Unfortunately their use has been very common.)
- Other causes of falls include difficulty in moving from one place to another (Transfer falls - for example, from the bed to a chair), poor foot care, poorly fitting shoes, and improper or incorrect use of walking aids.
The American Psychological Association through the publication ECPN (Early Career Psychologist Network) produced an excellent in depth article that studied falls related to nursing homes and Alzheimer's. A two part article authored by Rein Tideiksaar, PhD appeared the June/ 2007 and the July 2007 issues of the ECPN under the title of "Fall Risk and Alzheimer's". This discussed medications, mobility, assistive devices, protective equipment, circulation paths, lighting, floor surfaces, beds, chairs, and bathrooms. Their conclusions were:
"Falls are common in residents with AD. For the most part, they have been attributed solely to cognitive deficits. However. experience in caring for residents with AD indicates otherwise. Falls in AD may be regarded as a sentinel event indicating the presence of chronic conditions, adverse medication affects, and hazardous environmental conditions affecting mobility. By addressing these risk factors, long-term care facilities can greatly reduce falls in residents with AD."
Note: Tideiksaar is the president of "Fall Prevent" and has been active in the area of fall prevention for more that 20 years.
June's History of Falls at an Alzheimer's Facility
During June's first year in an Alzheimer's facility (The Wellstead of Rogers) she fell a total of eight (8) times that are recorded. During that first year in a facility, I was spending 7+ hours a day, 4 days a week on Mondays, Wednesdays, Fridays and Sundays. (This later went to 8 hour days.) My children visited June on the other three days of the week for an hour or two at a time. None of the falls took place while I or another family member was present. This suggests that a family caregiver's presence will prevent most or all falls during their presence.
(Photo below right is June at the Wellstead of Rogers in November 2005 during the period of her many falls.)
I was able to prevent falls by other residents during my times at both of the facilities by simply being nearby the resident at the time and noting their danger and intervening.
My daily logs also recorded the falls of 12 other residents during the year at the Wellstead - falls that I was not in position to prevent.
I also noted at times in my daily log that falls of residents were preventable such as residents with known falling problems were not properly staff supervised.
June's eight (8) falls at Wellstead are recorded on the following dates:
8/11/2005 June fell and bruised her knees.
10/28/2005 June fell and bruised her wrist landing on her buttocks.
12/5/2005 June fell and bruised her head after losing balance. June was Dizzy after the fall for a short time.
1/7/2006 June missed her chair in seating and fell to floor - supposedly uninjured.
1/19/2006 Incredible history - June was found lying on her back in a hallway with bruised knees. June had walked barefoot and in a nightgown from one side of the facility to the other side of the facility, past two nurses stations, walking with an unsteady gait until she was exhausted and fell to the floor. At least 6 staff people would have been along this route.
2/10/2006 Bizarre history - June fell - bruised and abraded right elbow was initial diagnosis. (I also noted large blood stains on right elbow.) June had pain in groin area and Could not walk, could not weight bear...would cry if asked to walk. Obviously more involved than the right elbow ... X-rayed with a portable X-ray. X-ray process was painful...crying and sad...X-rayed wrong leg -Several hours later June was found to have bruised and swollen knees. X-raying repeated. Old partially healed pelvic fracture discovered.
2/20/2006 June tried to get up from her wheel chair, fell to knees, complained of her right knee.
2/24/2006 June found with a bruised and swollen right hip.
Antipsychotic and antidepressant medications
None of these drugs are approved by the FDA for use on Alzheimer's or other dementia residents. They should not be used but unfortunately the usage is very common. The effect of such medications on resident falls can not be over estimated.
June's Drug's Experience
June was placed on Zoloft an antidepressant on the recommendation of an RN at the Wellstead in May 2005 and remained on it until early December 2005. (Drug was supposed to cure June's sadness and daily periods of crying. (It did not do so.) For a short time June was on the antidepressant drug Mirtazapine (Remeron). (8 December 2005 until 12 December 2005. June was switched to Paxil in late December 2005 at the recommendation of her Evercare NP. She remained on that drug until April 2007. My research subsequently revealed that such medications were not approved by the FDA for Alzheimer's residents and further that their value to the elderly and Alzheimer's victims is close to nil. My daily logs during the periods of June's falls suggest that such drugs may well have been a causative factor in such falls. In November 2005 I called attention to the development of tremors in June's hands so that she could hardly raise a spoon to her mouth after Zoloft dosage had been increased to 75mgs on 28 October 2005 at the Wellstead RNs recommendation. This continued into early December 2005 when it was gradually discontinued. June was placed on the third anti-depressant drug for a short time period in between Zoloft and Paxil. On 8 December 2005, June was started on 15 mgs of Mirtazapine (Remeron). My daily log for 11 December 2005 noted that June "seemed to have difficulty walking and her balance was not good." In an email to our children on 12 December 2005 I wrote: "Yesterday I noted that her walking had become more difficult (from my previous observations) Today it was so difficult that simply walking her from the dining area to the T Hall (room) seemed to exhaust her and she went for the closest chair. Wally mentioned (another husband caregiver) noting the same last night. I talked with the NP. The doctor and the NP will see Mom on Wednesday. However for the time being they are backing off the use of the new drug Mirtazapine (Remeron)."
After Junes last two falls in late February 2006, she became so frightened and demoralized that she would never again try to walk and remained in wheel chairs for the balance of her life in the facilities.
Note: The Alzheimer's resident normally would begin to experience progressive difficulty with walking in the middle to late stages of the disease. Eventually in the late stages, most would lose their ability to walk and would be wheel chair bound for their final days.
X-rays of June taken on 2/10/2006 revealed an old partially and almost healed fracture of the pelvic area. This means that in a previous recorded fall or an unknown and unreported fall, June fractured her pelvic area and that this fracture was not discovered until it was almost healed. That also means that June suffered the effects of the pain and healing of the fracture without any treatment.
Drug's Research Results
In addition to June's experience with drugs, all the studies appear to clearly indict antidepressant and antipsychotic drugs as a prime cause of falls.
The Medical Directors Association publication: "Caring for the Ages" in the June 2009 issue has an article in point - "Antipsychotic Reduction Efforts Pay Off". The sub title reads: "Study presented at Annual Symposium showed fewer falls once drugs were stopped." "Residents of 670 nursing facilities in New York state were studied. All had a ...diagnosis of dementia or Alzheimer's disease...residents taking antipsychotics were 24% more likely to fall and more likely to experience functional decline over time than those not taking antipsychotics.
Researchers at the University of North Carolina at Chapel Hill (10 July 2008) have created a list of prescription drugs that increase the risk of falling for patients aged 65 and older who take four or more medications on a regular basis"....perhaps two to three times greater," said Susan Blalock, Ph.D., an associate professor at the UNC Eshelman School of Pharmacy. Blalock is the principal investigator of an ongoing study of a falls-prevention program Both the list of prescription drugs and some of the study's finding were published in the June issue of the American Journal of Geriatric Pharmacotherapy." our study is to identify specific prescription drugs that are most likely to contribute to the falls," she said. The medications on the list cover a wide range of common prescription antidepressants, seizure medications, painkillers and more. The common denominator among them is that they all work to depress the central nervous system, which can make patients less alert and slower to react." (Editorial Note: June was also on a seizure medication - Depakote.)
See the article on this website on anti-depression drugs. Click this link:
Physical Therapy and Walking
It is common for nursing homes to prescribe physical therapy when ever there is an injury to or there appears to be a problem with the function of the legs or feet. Such therapy appears to be an automatic reflex action with little regard to other factors that may suggest such action is not in the best interests of the individual. The inability to walk is one of the normal progressions of Alzheimer's disease in the late stages. This factor should always have consideration in such judgment determinations. We should consider whether we are improving the quality of life for such residents or are simply adding misery to a life of little quality. Certainly PT is appropriate in early to middle stages of Alzheimer's but may not be appropriate in late stages.
After June's injury of 12 February 2006, she was placed in a wheel chair. When June was taken to the bathroom, she would not want to stand or take any steps. On 17 February 2006 June was started on physical therapy. The physical therapist was having June walk with a walker. Reading from my daily log I note: "She did not seem to have any pain but was very afraid and upset. She did walk with support of the therapist and an NA. It seemed to be exhausting. The PT seemed pleased and said she would be there three times a week to have June walk and try some leg strengthening exercises. They also had June fitted with a new wheel chair. On the 20th of February my log has the note: "In two sessions (PT) June walked the length of the hall. One session was with the walker and support by the PT and an NA. The other session was without the walker but with support by the PT and NA." June seemed exhausted and sad and was happy to get back down in the wheel chair." That evening the duty nurse called to say that June had tried to get up out of the wheel chair and fell on both knees. She complained of her knees and was given a pain medication. New X-rays on the 23rd of February revealed a partially healed fracture of the pelvic area. Her x-rays of the 10th were then again reviewed and revealed the same partially healed fracture. It had been overlooked on the 10th. Obviously it related to an earlier fall. (The healing period for such a fracture was said to be about 6 weeks.) In my log of March 3rd 2006 I have noted: "June was trying to walk with a walker and being assisted by the PT lady and one of the NAs following close behind with the wheel chair. This was very tiring for her" I recall as I watched them approach June appeared to be very upset and afraid. She was looking at me with eyes of sadness and anguish. It is one of the snapshots in my memory bank that still haunts me.
On the same day I talked with the PT lady and asked her if she thought June would ever be able to walk again by herself. She said "NO" but June could walk with a walker and while having assistance of a NA. I had felt in my heart for some time, that June would never walk alone again. While this is a normal progression of late stages of Alzheimer's, the falls had hastened that day. I talked with June's .primary care doctor on March 10th 2006 and asked him about June being able to walk. He advised that "it appeared that June would never walk again." My question than was: "Why then are we putting her through the physical Therapy walking sessions when it is so frightening upsetting to her - and we already know she will not walk." The PT sessions were then discontinued.
I recently visited with a friend whose wife has Alzheimer's and is in an Alzheimer's facility. I asked about her transition from walking to a wheel chair.. She did not have a fall that precipitated the non-walking..(She is in late stages) He advised me that the time came that she did not appear to want to walk. Physical therapy was of course automatically started by the facility.. Although she appeared to cooperate, the PT was not successful. The PT people would walk with her in a hallway (one on each side) holding on to her transfer belt .The PT did not produce any positive results. Near the end of the sessions the PT people were mostly supporting her weight as they moved down the hall. It was eventually discontinued as a failure. He noted that he would have given it up as a failure before they did.
I have myself observed a number such attempts to improve or promote walking of an Alzheimer's victim (in late stages) by use of physical therapy. My opinion has always been that very little if any improvement is noted by such attempts or is short lived and it is not long before the Alzheimer's resident is in a wheel chair permanently.
Minnesota's Nursing Home's Experience with Falls
Shortly after I published this article on June's web site, the Minneapolis Star - Tribune on November 15th, 16th and 17th, 2009, ran their own three (3) part article entitled "Deadly Falls". Quotes from the Star - Tribune aricle are noted below.
"More than 100 Minnesotans die each year after suffering falls in nursing homes. Few deaths are fully investigated by the state, and serious penalties for violations are rare." The article reports on a number of case histories in Minnesota and the Twin Cities areas...."more than 1,000 Minnesotans whose deaths were related to falls in nursing homes from 2002 through 2008...On average, one nursing home resident in the state dies every two days in circumstances stemming from a fall. The nursing home industry has tried to remedy the problem, but so far there are no signs that it's efforts or any state actions are significantly reducing the number of deaths. Less than 10 percent of fall related deaths in nursing homes ae fully investigated by the Minnesota Department of Health, which is charged with monitoring nursing home care. Usually nursing homes themselves are left to privately probe the cause of fatal falls on their premises. State regulators review those finding, but sometimes don't do more. Even when regulators discover that a mistake led to a residents death, they often do not cite nursing homes for violations of state and federal regulations."
"Minnesotans in nursing homes fell after aides left them alone on toilets, and went to tend to other residents. They fell while being transferred - such as from a bed to a wheelchair - by one aide when two were needed. They fell when aids misused equipment for moving them and dropped them in the process."
"Some died quickly, their fragil neck bones snapped or their aging bodies overwhelmed by internal bleeding caused by the fall and compounded by blood thinning drugs. Others - often still enjoying some quality of life - were sudenly bed ridden in excruciating pain from broken bones."
The article also points out that: "Minnesota's nursing home investigators issue far fewer citations in complaint investigations of all types compared to five other Midwestern states. Wisconsin, Illinois, Michigan, Indiana and Ohio cite nursing homes at a rate three times higher." This statistic is not surprising to me as that has been my own experience with filing a complaint (August 2006) against the Wellstead in regard to June's 8 falls listed above. The history of one of the falls (1/192006) almost bogles the mind. Although I felt the evidence was clear and compelling as to neglect in June's care, the state investigation however came up with an "Inconclusive finding." Much of my life has been spent in investigations both accidents and forensic investigations. The state investigation of June's case was inept, and incomplete in my opinion.
AMDA Thoughts on Nursing Home Falls
The AMDA publication "Caring for the Ages" February 2010 issue contains suggestions for nursing homes in an article entitled "Lessons From Nursing Facility Accidents."
"Federal regulations require only that nursing facilities be as free from accident hazards as possible and that each resident received "adequate supervision" and assistive devices that will prevent accidents"
Two cases of litigation are discussed. In 2006, a Georgia jury awarded $1.6 million to the estate of a deceased nursing home resident after it brought a wrongful death action against a nursing home. The estate alleged that during the 1 year that the resident lived at the facility he fell nine times. One, a fall from his wheelchair, resulted in a hip fracture. However, staff didn't identify the injury for a week. The resident then underwent hip replacement surgery and shortly afterward, fell from his bed when the side rails were not raised...complications of this fall eventually led to his death. In 2007, a Michigan jury awarded a nursing home resident $210,000 for the facility's negligence leading to a fall and amputation of the resident's right leg. She was a 90 year old woman who suffered from a previous stroke, osteoarthritis and Alzheimer's disease. When a nurses aid was transferring a resident from her bed to a chair, she ended up on the floor with her right leg bent under her left. She suffered an oblique fracture of the femur in her right leg. Amputation was done because "the residents dementia would prevent her from participating in required postsurgical therapy."
"Lessons Learned: "These are just two examples of poor outcome when nursing facilities allegedly fail to establish or follow accident prevention policies and procedures. In order to avoid similar situations, nursing home administrators and directors of nursing should ensure that all members of their staff are trained to identify and prevent potential accidents and to respond safely and effectively when one occurs. Some practical tips:
1. Develop a comprehensive accident prevention program...
2. Identify residents at increased risk of falls at admission and later in their stays.
3. Develop individualized interventions based upon each residents fall risk.
4. Conduct ongoing and consistent implementation and monitoring of resident interventions.
5. Teach and regularly reinforce the accident prevention program.
6. Conduct a thorough investigation after each accident."
Developing a culture of safety for all employees will reduce a facility's risk of falls and other accidents as well as its risk of litigation and citations.
The AMDA Publication "Caring for the Ages" , January 2012 has an article, "Falls in Older Adults in Acute Care Found Common but Also Preventable."
Dr. Edgar Pierluissi, Medical Director for Acute Care for Elders Unit at San Francisco General Hospital recently looked at falls in elders by the numbers. They are the number one cause of hip fractures.
1. For an elder 75 or older "a fall in the previous year increases the risk for a future fall 3-4 fold."
2, 50% of adults over age 80 years will fall in the next year.
3, Falls in adults aged 65 years or older cause injury in approximately 31% of cases.
4, Muscle weakness quadruples the risk for a fall.
5, (a.) Gait deficit, (b.) Balance deficit, or use of an (c.) Assistive device nearly triples the risk for falling.
6. (a.) Visual deficit, (b.) Arthritis, (c.) Depression, or (d.) Impaired activities of daily living more than double the risk for a fall. (e.) Cognitive impairment, use of some types of (f.) Medications, or (g.) Age older than 80 years each nearly doubles the risk for falling.
7. A number of forms of exercise reduced falls. Group tai chi exercise or multiple component group exercise was effective if it targeted at least two of the following: (1.) Strength, (2.) Balance, (3.) Flexibility and (4.) Endurance.
8. Withdrawing psychotropic medications and educating primary care physcians about the risk of falls association with drug therapy, reduced the number of falls...
The use of padded hip protectors did not reduce the number of hip fractures in a 20 month study...
Dana Greco - (25 January 2012): "Thanks...for all the information on the care for Alzheimer's patients, as my Mom just had two falls in the facility she is at in a one week period. This infomation is so vital for all to know. I admire the way you all took care of June, and she seemd like such a sweet person, and I am sorry for your loss. God Speed to you all, and thanks once again for your efforts of taking care of June, and this most valuable article."
June's obituary as printed in the Minneapolis Star Tribune following her death in October 2008 can be found on the top blue navigation strip under the label "In Memoriam" and on the drop down menu as item:
Last updated: 29 January 2012