The use of modern technology in falls risk assessment, falls prevention and management
I INFORMATION ABOUT THE TRAINING PROGRAMMEThe use of modern technology in falls risk assessment, falls prevention and management
Falls represent an important source of morbidity among older adults 65 and older all over the world. It has been estimated that in the United States alone more than one out of four older people falls each year, but less than half of older adults falling see a medical professional about it. Falling once doubles an older adult’s chances of falling again1,2,3.
Identification of risk of falling, the assessment of the level or risk, measures for falls prevention and the management of falls, and falls rehabilitation methods/programs have to be delivered to / assimilated by health & care workers from outpatient and impatient older adults facilities such as community day centres, retirement facilities etc.
The current module will present:
- The problematic of falls in older adults
- Risk of falling: identification and assessment of level or risk
- Falls prevention
- Falls management
- Rehabilitation from falls
- The use of modern technology in falls risk identification and risk level assessment, falls prevention, management and rehabilitation
Objectives of the training:
- Raise awareness of health & care workers regarding the importance of falls in older adults
- Increase the knowledge level of health & care workers regarding methods for falls risk identification, falls prevention, management and rehabilitation
- Increase skills level of health & care workers regarding methods (including modern technology instruments such as mobile apps) for falls risk identification, falls prevention, management and rehabilitation
By the end of the module, the participants will be able to:
- Appreciate the negative impact falls have on the older adults population
- Understand the importance of fall risk identification and measurement of risk level
- Understand the importance of conducting falls prevention, management and rehabilitation programs
- Be able to conduct (with or without assistance/collaboration) falls risk identification / risk level measurement
- Be able to support / contribute to falls management and rehabilitation programs (conducted by professionals, inpatient or outpatient)
- Be aware about and have knowledgeable in using modern technology applications (such as mobile apps) for falls risk assessment, falls prevention, management and rehabilitation.
The main barriers to get connected and effectively use internet services are lack of knowledge & skills, affordability, accessibility and lack of awareness.
The main target group for this module comprises health & care workers from inpatient and outpatient older adults care settings such as community day centres, retirement facilities etc.
A second target group is individual care takers, either family members or employed personnel, involved in home nursing or home care services.
A third target group is older adults that should be aware about the falls risk and the negative health impact of falls, falls risk assessment and home based falls prevention strategies.
Duration - 6 hours
Format - online training
Learning methods - Asynchronous online learning – based on lectures prepared and uploaded on the platform in advance, reading materials, quizzes and other support materials
Module structure
The module will comprise 3 sub-modules lessons, as follows:
- Lesson 1: The problematic of falls in older adults, fall risk identification & risk level assessment
- Lesson 2: Falls prevention in older adults
- Lesson 3: Falls management and rehabilitation from falls
II CONTENTS OF THE TRAINING PROGRAMME
Lesson 1: The problematic of falls in older adults, fall risk identification & risk level assessment
Falls represent an important source of morbidity among older adults 65 and older all over the world. In the EU, an average of 35,848 older adults (65 and above) are reported to have died from falls on an annual basis (data 2010-2012). Falls are also the predominant cause (58%) of injury related emergency department (ED) attendances for older people within the EU Also, The costs of falls are high, both to the individual, carers and society. The health care expenditure for treating fall-related injuries in the EU is estimated to be 25 billion Euros each year4.
Figure 1. Injuries related fatalities, hospitalizations and ED visits in the EU
Source: https://eupha.org/repository/sections/ipsp/Factsheet_falls_in_older_adults_in_EU.pdf
Source: https://eupha.org/repository/sections/ipsp/Factsheet_falls_in_older_adults_in_EU.pdf
1.1 Falls risk factors5
Many falls result from interactions among multiple risk factors, individual and/or environmental. The risk of falling increases linearly with the number of risk factors accumulated. However, even among community-dwelling people aged 75 years old and older, without risk factors, approximately 10% fall during any given year. Therefore, all older adults should be recognized as being at some increased risk for falling.
Figure 2. Individual and environmental risks factors for falls
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4707663/
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4707663/
1.2 Fall risk identification
Figure 3. Checklist for identification of risk of falling
Figure 3 above presents a checklist that can be used by health & care personnel in order to identify older adults at risk of falling. The checklist works in the format of a YES/NO, threshold instrument, where scoring 4 points or more includes a patient in the fall risk category, whereas scoring less than 4 points has the interpretation of the individual not having a risk of falling. However, the results should be interpreted in the context, given that it is a known fact that, for example, a fall in the recent past doubles the risk of falling. Therefore, if the answer to statement 1 is “Yes”, the older adult (65+) might be at risk of falling, and the following statement could be revisited if, e.g. the answer to all of them was “No”.
1.3 Assessment of level of risk of falling
In previous years, the CDC used to classify risk of falling in 3 categories: low, moderate and high risk, based on the algorithm presented below, extracted from Phelan et al6. However, currently this direct algorithm is not used, a ”Screened – Not at risk” / “Screened – At risk” assessment method being preferred, as it will be detailed in Lesson 2.
However, there are tools available that can be used as proxy instruments for the assessment of levels or degrees of risk for factors that influence the risk of falling. One of these tools is the Berg Balance Scale. This scale measures balance in older adults. It comprises 14 five-point scale questions and if provides 3 risk categories (low, moderate or high fall risk), depending on the score obtained by the person the test is being administered to7.
Berg Balance Scale can be administered by health & care providers by using a mobile app with the same name, developed and offered free of charge by Doctot. The app can be downloaded from the App Store or Google Play. Please see section 1.4 below for details about the mobile app use.
Figure 4. Former CDC algorithm for classification of risk of falling in low, moderate and high risk
1.4 Doctot Berg Balance Scale App Graphic Tutorial
The figures and explanations below are a guideline to use the BBS mobile app developed and offered free of charge by Doctot, available in Apple Store and Google Play.
Figure 5. Registration and introductory panels in BBS mobile app
Figure 6. BBS mobile app information panels
Figure 7. BBS mobile app test panels
Advantages of using the BBS mobile app (instead of paper and pencil):
- Possibility to save and share the results (to the patient or caretakers – via e-mail) and access them at any point in time (without having to open e.g. a patient’s physical medical record)
- Features such as timing of the timed tests included in the app (no need for second device)
- Time saving through: automated progress through test and automated score calculation
- Accessible to use, at any time, by multiple target groups, from health & care providers to home caregivers (family or nurses)
- More user-friendly and handy than paper and pencil.
Lesson 2: Falls prevention in older adults
As illustrated in Figure 8 below, the first step in the process of falls prevention is actually timely identification of the risk of falling. The CDC STEADI algorithm presents the steps that need to be followed in order to: 1) screen for fall risk and divide individuals/patients into at risk and not at risk; 2) assess at risk patients modifiable risk factors and fall history and 3) intervene to prevent falls by trying to reduce the modifiable risk factors for falls.
Figure 8. CDC’s algorithm for fall risk identification, assessement and intervention
For each of the 3 steps presented above, an elaborated training must be performed for health & care workers, to: provide knowledge and skills for:
1) Conducting the anamnesis
2) Administering the gait, strength and balance tests (i.e. Timed up & Go, 30-Second Chair Stand and 4-Stage Balance Test)
3) Provide recommendations / refer patient to specialists.
The current module does not aim to cover this detailed information, but rather raise awareness of the health & care personnel regarding the necessary knowledge and skills to conduct a complete fall risk intervention, from screening, to in-depth evaluation and follow-up treatment/recommendations.
Falls prevention in older adults can include a variety of methods, targets and activities, looking to address the personal and environmental risk factors increasing the risk of falling. The CDC guide titled: “PREVENTING FALLS: A Guide to Implementing Effective Community-Based Fall Prevention Programs” presents in detail the steps that should be undertaken by community or health care institutions managers in order to implement a successful falls prevention program at community level. However, in this section, for the purposes of this training program, focused on the use of modern technology for fall risk assessment, falls prevention, management and rehabilitation, we will briefly present two falls prevention mobile apps.
These apps, titled “React to Falls” and “Stop Falls” can represent useful tools for falls prevention in older adults for health & care workers, family care takers or older adults themselves. They can support or even lead the effort of identifying and mitigating the individual and environmental risk factors exposing older adults to an increase risk of falling.
“React to Falls” mobile app
Figure 9. “React to Falls” mobile app panels
“React to Falls” is a mobile app developed and offered free-of-charge by the University of Nottingham. The app provides information regarding falls prevention, covering 4 major themes, respectively: activity, communication and understanding, environment and equipment and personal hygiene. Each of these 4 themes comprises a various number of specific topics, and for each topic the information is presented in the format of Q&A or checklists. There is also an “Extra Resources” section, from where training videos can be accessed. The app does not require a registration, and can be used by anyone who wants to prevent someone they know (or themselves) to suffer a fall.
“Stop Falls” mobile app
Figure 10. “Stop Falls” mobile app panels
“Stop Falls” is a mobile app developed by Hertfordshire Care Providers Association (HCPA), aiming to reduce falls with the use of exercises, assessments and prevention techniques. It comprises 4 sections, of which three of them address falls risk identification and prevention: risk factors, assessments, exercises, and the 4th address falls management and will be present in sub-module / lesson 3 of this module.
Depending on each section, the information is presented either in the format of cause -> reason -> reaction (e.g. for risk factors) or PDF or video files for e.g. exercises. The app is free-of-charge and does not require registration and, depending on the sections of the app accessed, can be used by various beneficiaries.
Lesson 3: Falls management and rehabilitation from falls
Immediate falls management and rehabilitation from falls are integral and essential parts of falls prevention programs, as it is proved that a fall doubles the risk of falling for an older adult. While acute, emergency response have to be performed by any adult individual (that benefited from a basic training), a multi-disciplinary team has to be in charge or the rehabilitation process.
A mobile app that can assist the emergency response/management of falls is described below.
“Stop Falls” mobile app – Module 4: Intervention
Figure 11. “Stop Falls” mobile app panels - Module 4: Intervention
The Intervention module of mobile app “Stop Falls” comprises 4 sections, respectively:
- Urgent Falls Checklist: first actions to uptake when you see a person on the floor
- How to help a person who has fallen on their front
- How to help a person who has fallen on their back
- SBAR communication tool (Situation-Background-Assessment-Recommendation)
In what regards the rehabilitation process, it involves a multi-disciplinary approach, including physical therapy to ensure that the senior is increasing flexibility, strength, balance and coordination. The physical therapist will provide muscle re-education as well as balance training and strengthening exercises, as well as gait training so the senior can learn how to walk with a cane or walker. The physical therapist can also recommend some exercises to continue doing at home once the senior is discharged. An assessment of why the fall happened in the first place will need to be done for proper senior fall recovery. For instance, did something in the environment cause the fall, like furniture or a rug being in the way, or was it because the senior was in poor overall physical health? Does the senior have good vision and hearing? The physical therapist will prescribe the correct physical therapy for seniors of all abilities depending on their needs, including training for walking correctly with a mobility aid like a walker or cane.
Also, during the stay in the rehabilitation or skilled nursing facility, an occupational therapist will help ensure the senior is comfortable maintaining activities of daily living, like dressing, eating, bathing, grooming, etc. The occupational therapist will also perform a home safety test, in which they evaluate the senior’s living space and make suggestions for making the areas safe for daily living. This may include recommending the removal of throw rugs and some furniture which can be tripping hazards, as well as installing better lighting, grab bars and railings through the home8.
QUIZ - Progress tracking / achievements
References:
1. Bergen G, Stevens MR, Burns ER. Falls and Fall Injuries Among Adults Aged ≥65 Years — United States, 2014. MMWR Morb Mortal Wkly Rep 2016;65:993–998. DOI: http://dx.doi.org/10.15585/mmwr.mm6537a2
2. Stevens JA, Ballesteros MF, Mack KA, Rudd RA, DeCaro E, Adler G. Gender differences in seeking care for falls in the aged Medicare Population. Am J Prev Med 2012;43:59–62
3. O’Loughlin J et al. Incidence of and risk factors for falls and injurious falls among the community-dwelling elderly. American journal of epidemiology, 1993, 137:342-54.
4. https://eupha.org/repository/sections/ipsp/Factsheet_falls_in_older_adults_in_EU.pdf
5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4707663/
6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4707663/
7. https://www.brandeis.edu/roybal/docs/Berg-Balance-Scale_Website.pdf
8. https://www.asccare.com/senior-rehabilitation-after-a-fall/