The older population is highly heterogeneous. Although the general development of diseases and disabilities is similar as they age, the trajectory and rate of change in health and functional ability is widely varied in each individual and those with the same chronological age can have extremely different biological ages. Thus, it is difficult to measure the heterogeneity of the aging process in older people.
According to the New York Times, the federal government will be implementing significant changes to the rating system of nursing homes in the United States. Currently, the ratings are based on a five star system that is scrutinized by the public. This five star rating system “has been criticized for its reliance on self-reported, unverified data.” The current system was implemented five years ago and evaluates staffing levels and quality of care, which is reported by the nursing homes and not audited by the federal government. This flawed rating system “relied heavily on unverified and incomplete information that even homes with a documented history of quality problems were earning top ratings.” In 2009 37% of nursing homes had ratings of four or five stars and by 2013 over 50% had exceedingly high ratings. With more than 15,000 nursing homes in the United States, it is crucial that the optimal quality of care is guaranteed by skilled nursing facilities. Continue Reading
A study published in the Journal of the American Medical Association found a correlation between an increased risk of hip fractures and injuries from falls and the use of nonbenzodiazepine hypnotic drugs. Such drugs are a class of sleep medication prescribed prevalently by health care providers in nursing home settings to help elderly residents cope with insomnia and other sleeping issues. Nursing homes are environments that generally do not prioritize residents’ quality of sleep. Therefore, nursing home residents often experience poor sleep and insomnia because they frequently take daytime naps, are subject to nighttime awakenings, or may be suffering from sleep disorders such as sleep apnea.
Many elderly nursing home residents suffer from falls in nursing homes, and these falls can lead to fractures, complications, and even death. Many of these injurious falls may take place at night due to risk factors such as toileting, urinary continence or incontinence. Initially, nonbenzodiazepine sleep medications were thought to be safer than benzodiazepines, in relation to fall risks. As such, the study found there was an increase in the use of nonbenzodiazepine hypnotic drugs in nursing homes. However, the results of the study showed that there was actually a two-fold increased risk for hip fractures when nonbenzodiazepine hypnotic drugs were used. The study was conducted using a sample of 15,528 long-stay nursing home residents who were 50 years or older. This population exhibited a 66% increase in their risk for hip fracture after 30 days of using such sleep medication.
Elderly residents of nursing homes and hospitals are often victims of falls and related injuries. As such, one bad fall can significantly lengthen a patient’s hospital stay, which can increase the risk of further complications, as falls can lead to broken bones and even death. However, these occurrences are highly preventable with adequate staffing and fall prevention procedures. Safety experts even state bad falls are events which should never take place inside protective settings such as hospitals.
Currently, 39 states do not require hospitals to report instances of falls that occur within their facilities. However, many states, such as California, require hospitals to report incidences of falls that occur within the hospital to the state health department. Some hospitals have begun moving toward the implementation of more fall prevention methods, and they have proven to be very successful. For example, an increased movement towards patient safety and fall prevention occurred in Washington, when around 90 people fell victim to injuries and death due to falls last year.
Many elderly individuals have a higher risk of falling, and usually sustain greater injuries from such falls due to their frail nature. Additionally, because those residing in long term care facilities are generally frailer than their peers living in the community, they are more prone to falling and are likely to suffer greater consequences as a result. While it is commonly known that elderly individuals residing in such facilities are considered to be poor candidates in performing physical exercise due to their functional, cognitive and physical conditions, a study has demonstrated that exercise programs within this population are still effective in reducing the number of falls in this environment.
Physical exercise has been shown to have beneficial effects on cardiovascular and metabolic diseases. However, this study has aimed to demonstrate how physical exercise would also help to reduce an elderly individual’s susceptibility to falls, despite their particularly frail nature. For example, exercise has been shown to promote an increase in strength, muscle flexibility, balance, and endurance. Additionally, exercise has also contributed to reducing physical disability, as well as decreasing functional limitations and restrictions by increasing an elderly individual’s mobility. Combined, these effects from physical exercise were generally shown to promote fall prevention within the elderly population, even in those shown to be frailer and residing in nursing homes.
The Centers for Disease Control and Prevention (CDC) reported that about one out of three people who are 65 years and older fall each year. Moreover, one-half to three-fourths of nursing home residents suffer from falls every year. These falls, while preventable, are dangerous and may have lasting, serious repercussions for this vulnerable population. For example, these falls may not only result in permanent disability and a diminished quality of life, but the CDC reported that within nursing homes, there are about 1,800 elderly residents who die from falls each year. However, while serious, such falls are very preventable.
The injuries resulting from these falls may range from head trauma, to a variety of fractures including hip and leg fractures. In addition, many traumatic brain injuries are caused by falls. Not only do these falls lead to physical injury, but many elderly residents who do fall also begin to develop a fear of falling which may further limit their willingness to engage in physical activity. If elderly residents begin to reduce their mobility, it will heighten their actual risk of falling. Additionally, their fear of falling may also lead to feelings of helplessness and depression.
Unfortunately, statistics demonstrate that falls occur more frequently among nursing home residents. It is true that nursing home residents are generally in poorer health and frailer than their peers, as they are generally older and suffer from other chronic problems. In addition, they may need more aid in going about their daily activities. However, despite these factors, falls and resulting injuries are very preventable if caretakers remain proactive in fall prevention. Thus, it is important and necessary for caretakers to assess patients to identify their fall risk and implement prevention strategies.
A new study that was published in the May 2012 edition of the Journal of the American Geriatrics Society was the first national study to assess fall rates among newly-admitted nursing home residents. Researchers for the study, which was spearheaded by University of Southern California gerontology and occupational science researcher Natalie Leland, evaluated data from over 230,000 first time nursing home residents in the year 2006. This data was obtained when patients who had stayed at the nursing home facility for at least thirty days completed a minimum data set (MDS). A MDS is a federal prescribed clinical evaluation of all residents in a certified nursing home that serves to assess each patient’s health needs and functionalities.
The data shows that approximately 21% of the patients studied (over 47,000 patients) experienced one or more falls within the first thirty days after admission to a nursing home. The study also identified characteristics of nursing homes that reported fewer incidents of falls suffered by newly-admitted residents. Most important to a lower fall incidence was a higher ratio of certified nursing assistants to residents. Most first-time nursing home residents are faced with unfamiliar surroundings and people. The constant presence of attentive staff is vital to residents adjusting to their new life and ensuring their safety. Qualified staff are needed to accompany new residents around the facility, orient residents with important procedures (such as use of call buttons), and to take notice of the residents’ former and current health issues.
Even with this study confirming the obvious – that higher staff-to-patient ratios reduce the incidence of falls – it is an unfortunate fact that many nursing homes continue to operate chronically understaffed to the detriment of the welfare of its residents. A properly staffed nursing facility is not just essential for the transitioning of newly admitted residents. Existing long-term residents also need the staff’s attention in monitoring changes in their conditions and assisting with basic activities of life.
To have an understaffed facility is to have distracted and overwhelmed workers which could lead to careless acts or omissions. Staff will most likely struggle to attend to the unique needs of all its residents, and therefore puts them all at risk of suffering not only preventable injuries like falls, but also preventable ailments such as pressure ulcers and infections. Furthermore, understaffing creates potential situations where staff may choose convenience over what is right for the resident.
Adequate staffing levels are so important to the well-being of elderly residents in nursing homes that specific ratios are codified into the California Health and Safety Code as a resident’s enforceable right. The California Health and Safety Code section 1430(b) provides strong statutory authorization for a plaintiff to seek civil relief from nursing home facilities if this or any other rights within its provisions are violated.
Falls occur very frequently within nursing homes and usually result in bone fractures, broken hips, or head injuries. These injuries often require hospitalization and can be prevented with proper attention and supervision, along with a decrease of environmental hazards within nursing homes that contribute to the problem. The Centers for Disease Control and Prevention (CDC) documented that a typical nursing home with 100 beds would report as many as 100 to 200 falls in a year, and many falls still go unreported. Falls can greatly affect a nursing home resident’s happiness and self-assurance, as the resulting disability, functional decline and reduced quality of life can cause depression, social isolation, and feelings of helplessness.
A risk factor study on falls among older residents in nursing homes was recently conducted by the Journal of the American Medical Directors Association (JAMDA). It differed from most risk factor studies, which usually focus on a smaller scope of cognitive or physical performance, in that the study was a more comprehensive examination of the various medical, psychological, and physiological factors that could affect the fall risk for older patients who suffer from cognitive impairments while residing in residential care. The main objective of the study attempted to better understand potential fall risk factors and their causes while providing possible methods that could help lower the chances of a falling accident. Data was collected in three to four interview sessions with participants from seven different South London care homes, and any additional information was obtained from care staff interviews and medical records.
The study results showed that there was a definite correlation between the patients who fell more often and the amounts of medication administered. The researchers were concerned with the possibility that medications affecting the central nervous system had a large impact on fall risk through a direct affect on balance control. Fallers were more likely to be taking psychotropic medications, which are often used to treat mental disorder symptoms such as depression, dementia, bipolar disorder, and other anxiety disorders. These medications include sedative hypnotics, antipsychotics, and antidepressants, which are commonly overused by understaffed nursing homes as a tool to subdue the more difficult patients that require larger amounts of attention. The medication essentially becomes what is known as a chemical restraint, the negative aspects of which greatly outweigh any positive aspect that could be determined. The simultaneous usage of too many drugs on a patient, known as polypharmacy, can actually aggravate dementia further, and even double the risk of death in dementia patients. Despite this evidence, some nursing homes still persist in using antipsychotics as a chemical restraint on their patients.
The study also found that older people diagnosed with dementia and cognitive impairment often have either double or triple the annual fall incidence in comparison with their peers who were considered to be cognitively-intact. Because patients with dementia often require more care and supervision, understaffed facilities are usually unable to monitor these residents closely enough to prevent falls from occurring. Instead, they are often chemically restrained, by psychotropic medications, which increases the risk of falls, as discussed above.
Based on these findings, the researchers were able to identify four significant, independent predictors of falls: poor attention and orientation, anxiety, antidepressant use, and increased postural sway with eyes closed. The fact that researchers were able to identify four predictors of a falling scenario shows that nursing homes are more than capable of reducing the amount of falls that happen every year. Because falls can usually be avoided provided that proper care and supervision is given by the caretakers of the nursing homes, understaffing plays a large role within a facility’s means to prevent a fall from occurring. A nursing facility is required under California law to provide a minimum of 3.2 nursing hours per patient per day, but older patients often need more time and care than the bare minimum requires. For this reason, the law also requires that nursing homes provide sufficient staff to fully tend to the needs of its patients, even if this requires a staffing level higher than 3.2 nursing hours per patient per day.
The study highlighted potential interventions that nursing homes should put into practice in order to lower fall risks for residents, such as medication review, exercises that improve balance ability, and the employment of better strategies in order to understand and manage wandering behaviors, agitation, and poor attention. Researchers also emphasized that, more than anything else, the reduction and minimization of psychotropic medication usage plays an important role in reducing fall risk among nursing home residents.
Depressive symptoms are common in patients suffering from dementia. Because of this, many patients are given anti-depressants, or selective serotonin uptake inhibitors (SSRIs). Research has shown that increased use of SSRIs is associated with an increased amount of falls in the elderly population, however details are still lacking on the exact relationship in the specific population of nursing home residents. A recent study published by the British Journal of Clinical Pharmacology shed light on the issue by looking specifically at the details of the relationship between SSRIs and injurious falls in the nursing home population. The study found that higher doses of SSRIs increase the risk of falls by three-fold. As falls are becoming increasingly common in nursing homes, it is important to understand all the risk factors that contribute to falls.
The study analyzed daily drug use and monitored falls over a two year period for residents who were able to walk independently (with or without a walking aid). All 248 patients studied met the criteria for dementia. To emphasize the huge effect drugs had on the rate of falls, the study cited one example from one of the patients they studied. An 85 year old female resident, who was on no SSRIs, hypnotics, or sedatives, had a risk of an injurious fall (per day) of 0.12%. After placing her on a dosage of SSRIs, her risk of an injurious fall (per day) jumped up to 31%. What is even more shocking is that her dosage was only 0.25DDD (Defined Daily Dose), whereas the average dosage given to nursing home residents is 1.00DDD. This means that the risk of an injurious fall increases by 198% when you place a patient on SSRIs or other various forms of drugs.
The study also points out the dangerous cycle of drugs and falls. Many nursing homes argue that drugs not only alleviate symptoms but also prevent falls when in fact the opposite is true. Behavioral disturbances like agitation and aggressive behavior (for which SSRIs are often recommended) often lead to an increased fall risk, which in turn lead to a higher drug dosage. Also, increased dosage of SSRIs has not even been shown to be more effective on depressive symptoms. In fact, there is very weak support for the idea that SSRIs are an effective treatment for patients with depression and dementia. Due to these reasons, the study urges clinicians and nursing home staff to prescribe SSRIs to their patients with due caution as to not increase the risk factor for falling.
Despite the consequences of SSRIs, the use of SSRIs and other drugs is quite common in nursing homes. In fact, a huge problem nursing homes often have is that many residents are on too many drugs at once. In previous studies, polypharmacy has already proven to be extremely detrimental to patients, but as this study has shown, the use of drugs can also greatly increase the incidence rate of falls. Many studies have offered more effective alternative treatments for dementia symptoms, but these alternative treatments require an adequate amount of staff to carry out the treatment. Unfortunately, many nursing homes are understaffed which is ultimately the reason why polypharmacy and easily avoidable falls occur.
According to the American Geriatrics Society Foundation for Health in Aging, approximately half of nursing home residents experience falls each year. Because falls are such a common accident, it is important that nursing homes understand how to handle the situation immediately after a fall, and the best ways to prevent falls. An article by the Assisted Living Column emphasizes that falls not only cause physical injury, but also psychological damage that may lead to more falls in the future. The article also stresses the importance of caregivers at nursing homes to be educated about the nature and impact of falls.
The psychological impact of falls is important as it almost always leads to more falls. After falling once, older adults become fearful of falling again, and so engage in less physical activity. This reduction of physical activity results in reduced mobility, which is a risk factor for a second fall. In a long-term residential facility such as a nursing home where residents are unfortunately at a risk of experiencing falls, staff should be trained on preventative measures.
The article emphasizes the importance of proper prevention methods. The staff at the nursing home should be aware of all the risk factors and work to eliminate as many of these risk factors as possible. Many of the risk factors for falls are environmental factors; the floor may be too smooth or slippery, rooms and hallways may have inadequate lighting, or furniture placement might be dangerous. All of these factors are things that can be easily fixed with an observant and knowledgeable staff. Unfortunately, a problem in many nursing homes is that the nurses often give a lack of direct care. Direct care involves physical and psychological treatment of the patients, while indirect care mostly involves administrative tasks. If there is a lack of direct care for the residents, it becomes increasingly difficult for staff to take notice of the environmental hazards that the nursing home may have.
Another major risk factor is the type and amount of medication that the patient is on. A study done by the Yale FICSIT (Frailty and Injuries: Cooperative Studies of Intervention Techniques) found that those who were on psychoactive medications were more likely to experience a fall due to the medication’s side effects. Unfortunately, psychoactive drugs are one of the most frequently used drugs in nursing homes. Nursing homes often find it more convenient to use psychoactive drugs to prevent episodes of agitation. However, rather than using psychoactive drugs, nursing homes should provide more direct care and should not be using chemical restraints to subdue their residents as this is a direct violation of the Patients’ Bill of Rights.