Health Issues in Gerontological Nursing

Question: Discuss about the Health Issues in Gerontological Nursing. Answer: Overall decline in function, cognitive impairment, aging-associated chronic diseases and poor balance are the major reasons of falls in the elderly. The road to recovery due to falls among the elderly ?65 years of age is difficult and ridden with problems is a significant burden on the health and social care facilities. The economic and man power costs are huge and avoidable to some extent. Therefore special focus is required on the prevention of falls. Identification of the factors that make the elderly vulnerable to falls and the treatment of co-morbidities that heighten the risk of falls can reduce the incidence of falls among the elderly. From minor injuries to major injuries, such as, fractures that require surgeries and physical rehabilitation or traumatic brain injury that can be fatal, falls my require intensive medical treatment for several weeks or months. Some patients may remain disabled and become dependent on care givers. The psychological impact of falls can also make the elderly hesitant in moving out and this can lower their quality of life. Fall prevention programs focus on minimising injury and improving balance. Improvement in balance is usually brought about by exercise programs. Nursing staff has to be more cautious in dealing with patients in the geriatric ward. They can play an important role in counselling patients and their care givers on ways to prevent further falls t the time of discharge. Precaution is usually the key factor. The economic burden of treating fall related injuries among the elderly is considerable. Longer hospital stays strain the health and social care resources, so prevention of falls is key to their management. As people age beyond 65, the propensity to fall may increase due to lack of balance when performing everyday tasks, due to frailty or some other health concern that has occurred as a result of aging. A fall can result in injury and fractures that can lead to orthopaedic surgeries and require hospital stays and physiotherapy. According to available statistics about 30% of people aged over 65 years of age have experienced a fall. One in 10 falls results in a fracture and one in 5 falls requires some medical intervention(Gillespie, et al., 2012). In hospitals 1.3 to 8.9 falls are reported for 1000 bed days. This amounts to about 1000 falls a year in a large hospital. Wards that specialize in geriatrics, neurology and rehabilitation are more likely to report falls. Although, on the whole, the several incidents of fall go unnoticed, many due to poor recall by elderly patients(Miake-Lye, Hempel, Ganz, Shekelle, 2013). A study reports that 60.2% of reported falls among the elderly occur at home while 21.7% falls are reported from residential institutions (Faul, et al., 2016). Not only do falls prolong the stay of elderly patients in hospitals, costs incurred from falls increase the health care expenditure by 0.85% to 1.5% according to estimates in the United States, the European Union, Australia and United Kingdom (Cangany, Back, Hamilton-Kelly, Altman, Lacey, 2015). It is estimated that exercise-based fall prevention exercise programs in the elderly who have experienced a fall can reduce the incidence of falls by about 42% (Gawler, et al., 2016). The impact of falls on the elderly can vary from minor injuries that cause pain, require an ice pack, wound dressing, limb elevation, pain medication and other medications to more severe injuries. Moderate impact of a fall could require suturing or splintering. Major injuries following a fall may include surgery, traction or casting. Some injuries may need a neurologic exam due to altered level of consciousness. Physical restraint may also result following a fall incident. The most severe impact of fall is that it might cause a fatality (Shorr, et al., 2012). The severity of the injury affects the quality of life of the patient. The ability to self-care declines among the elderly on experiencing fall. Their ability to participate in social and physical activities is compromised. About 20% to 39% people may develop a fear of falling which further reduces their quality of life and they begin to exercise restraint on movement (Phelan, Mahoney, Voit, Stevens, 2015). Rate of injury is hi gher for people who are more aged. The impact of falls is not confined to physical suffering but results in considerable mental agony. Due to the fear of fall the elderly restrict their ambulatory movements and this causes them distress. Many of them feel depressed. They begin to lose social contacts and tend to remain isolated which adds to their sense of misery. The loss of confidence makes them dependent on family members or the nursing staff for even small movements, from the bed to chair, or from one room to another. Traumatic brain injury among the elderly is caused due to falls in 51% of the cases among the elderly and can even be fatal in several cases. Hailing from an ethnic minority and being male heightens risk of traumatic brain injury. Age- related co-morbidities often play a role in increasing the risk of falls and subsequent brain injury in the elderly (Thompson, McCormick, Kagan, 2006). The impact of falls and injuries on the health care system is considerable. The cost of treatment of injuries is high and it prolongs the hospital stay of the patient. According to one study an average expenditure of $13,316 is incurred on treatment of the severe injuries and the patients who suffered from a fall injury were likely to stay in the hospital for a duration of 6.3 days more than the control group(Wong, et al., 2011). Operational costs incurred are higher for hospitals due to incidents of fall. An Australian study points out that the injuries incurred as a result of falls during the hospital stay caused the length of hospital stay to increase by 8 days and the hospital costs were an additional $6669. Additional costs incurred by the hospital were mean of $4727 per case of fall injury (Morello, et al., 2015). This necessitates the prevention of fall prevention program and minimising injury during a fall. The burden of the fall related injuries on the health and social care systems is immense due to the increase in the demand for the man hours of work required by the care giving and nursing staff. Several factors contribute to the falls in the elderly. The elderly who live alone are more likely to experience fall than those who live with other family members or are living in a community for the elderly or residential care facility. Some of the elderly who are using a lower limb prosthesis or other assistive devices are also more likely to fall. Environmental factors that can contribute to a fall include a cluttered living space, weather conditions that cause wet floors or deposition of ice on the walking surface. Dim lighting of the residential spaces can cause falls. If the flooring material in the bath or the shower is not the anti-skid variety, falls due to slipping can occur. If the living space is new and the environment is unfamiliar the elderly are likely to falter while moving or collide with unfamiliar objects when moving. If the space is dimly lit, the likelihood of falls is increased because obstructions cannot be seen by the elderly whose vision may be failing and weak eye sight is a common problem with the elderly. Feet, footwear and walking sticks may get entangled in throw rugs in the living area increasing the risk of falls. Use of alcohol or drugs can increase the risk of falls among the elderly. Physiological factors that increase the propensity to fall include acute illness, drastic alterations in blood sugar levels, weakness due to anaemia, arthritis, less strength in the lower limbs, problems with foot health can cause reduced grip and a difficult gait. An episode of diarrhoea can render the elderly weak and prone to falls. Many elderly feel faint when trying to extend or turn the neck. They have difficulties with hearing, poor balance, general physical mobility is compromised and they may be suffering from incontinence. Urinary urgency may cause them to rush with movement causing a fall. Insomnia may compromise their level of alertness when walking, neuropathy, postoperative recuperation and orthostatic hypotension, visual difficulties and change in cognitive functions are factors that heighten the risk of falls. Obesity, elevated abdominal perimeter, chronic obstructive pulmonary disease and dizziness when walking add to the risk of falling. Vitamin D deficiency, frailt y, and metabolic syndrome are also contributing factors (Sousa, et al., 2016). Psychological factors, such as, fear of falling, depression and anxiety play a role in making the elderly prone to falls. Socio-economic factors, such as, lack of education, low economic status and belonging to a black or an ethnic minority can contribute to the chances of a fall. At times the elderly have difficulty using public transport systems and this can put them at a high risk (Kumar A, 2014). Difficulty in rising from a chair without support makes the elderly falter. A general decline in mobility is often observed. The elderly with fear of falling and sensory decline are reported to be 5 times more likely to fall (Viljanen, et al., 2012). Fear of falls leads to self imposed restriction of physical activity among the elderly and decreases their quality of life considerably (Allison, Painter, Emory, Whitehurst, Raby, 2013). Low confidence due to lack of balance and improper pain rehabilitation cont ribute to increased fear of fall in the elderly. Alleviation of pain therapy may help them to reduce the fear of falls (Stubbs, West, Patchay, Schofield, 2014). Prevention strategies aimed at reducing falls include exercises that improve balance and allow the elderly to move within their surroundings. But more research is required to determine the kind of exercise, the duration of workout and the type of exercise that will suit the individual needs of a patient. Tai Chi is known to improve balance among the elderly (El-Khoury, Cassou, Charles, Dargent-Molina, 2013). A fall prevention program aims to reduce the environmental hazards and provision of training paths. Use of walking stick, support rails wherever possible can help them to remain mobile and reduce the risk of falls. Use of bedrails, alarm devices that track movement, increased assistance, low beds, provision of hip protectors, calcium and vitamin D supplements and fall assessment are strategies that help in prevention of falls. Depending on the needs of the patient group or solitary exercises are planned. In a South Korean study a comparison was made between functional walking ex ercise and exercises that focus on in-balance based on Tai Chi, it was found that fewer falls were reported by the group that performed Ti Chi based exercises. But frailty accounted for increase in the possibility of a fall (Faber, Bosscher, Chin A Paw, van Wieringen, 2006). Fall prevention programs have been designed to include advice for individuals, information leaflets, regular home visits and an exercise program. Compared to the control group, the group that received a multifactorial fall prevention intervention reported a significant reduction in the number of falls (Prula LA, et al., 2012). The importance of exercise alone has been found to be more effective than a multifactorial intervention by two studies that involved the elderly living in community dwellings (Petridou, et al., 2009; Kuptniratsaikul, et al., 2011). Inclusion of balancing exercises in the fall prevention program has been found to lower the incidence of falls in persons who have experienced falls earlier an d has improved the overall quality of life in the elderly (Kuptniratsaikul, et al., 2011). In the light of the above studies, a nurse should ensure that the patient enrols in an exercise program after discharge from the hospital. Weekly follow-ups will ensure that the patient adheres to the prescribed program. The use of walking sticks and holding rails will help the patient to remain mobile and improve self-efficacy. The treatment of pain can increase the confidence of the elderly and their fear of fall can be managed to some extent and help them to engage in physical activity with greater confidence and improve their overall quality of life. Pain rehabilitation forms an important aspect of fall prevention in the elderly. In conclusion, falls among the elderly are a preventable malady. The physical, psychological and financial burden of falls on the patients and their families is immense. Falls can result in minor injuries, moderate injuries and result in fractures. Hip fractures are a common outcome of falls and require surgery and a long stay in the hospital. Cluttered living environments with poor light can increase the risk of falls. The general physical and psychological health of the patient are important contributors to the possibility of fall related injuries among the aged. Poor balance can be improved with exercise, the efficacy of Tai Ichi is proven in improving balance. Socio-economic factors and the quality of dwelling can affect the chances of fall. Most of the elderly who have experienced fall suffer from the falling and restrict physical mobility and compromise their quality of life. Many among the elderly remain depressed due to the fear of falling. It is the responsibility of a nurse to counsel patients at the time of discharge and educate them about fall prevention. References Allison, L., Painter, J., Emory, A., Whitehurst, P., Raby, A. (2013). Participation restriction, not fear of falling, predicts actual balance and mobility abilities in rural community-dwelling older adults. Journal of Geriatric Physical Therapy, 36(1):13-23. Cangany, M., Back, D., Hamilton-Kelly, T., Altman, M., Lacey, S. (2015). Bedside nurses leading the way for falls prevention: an evidence-based approach. Critical Care Nurse, 35(2):82-4. El-Khoury, F., Cassou, B., Charles, M., Dargent-Molina, P. (2013). The effect of fall prevention exercise programmes on fall induced injuries in community dwelling older adults: systematic review and meta-analysis of randomised controlled trials. BMJ, 347, f6234. Faber, M., Bosscher, R., Chin A Paw, M., van Wieringen, P. (2006). Effects of exercise programs on falls and mobility in frail and pre-frail older adults: A multicenter randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 87(7), 885-96. Faul, M., Stevens, J., Sasser, S., Alee, L., Deokar, A., Kuhls, D., Burke, P. (2016). Older Adult Falls Seen by Emergency Medical Service Providers: A Prevention Opportunity. American Journal of Preventive Medicine, 50(6):719-26. Gawler, S., Skelton, D., Dinan-Young, S., Masud, T., Morris, R., Griffin, M., . . . team., P. (2016). Reducing falls among older people in general practice: The ProAct65+ exercise intervention trial. Archives of Gerontology and Geriatrics, 67:46-54. Gillespie, L., Robertson, M., Gillespie, W., Sherrington, C., Gates, S., Clemson, L., Lamb, S. (2012). Interventions for preventing falls in older people living in the community. The Cochrane database of Systematic Reviews, 12(9), 12;(9):CD007146. Kumar A, C. H. (2014). Which factors are associated with fear of falling in community-dwelling older people? Age Ageing, 43(1):76-84. Kuptniratsaikul, V., Praditsuwan, R., Assantachai, P., Ploypetch, T., Udompunturak, S., Pooliam, J. (2011). Effectiveness of simple balancing training program in elderly patients with history of frequent falls. Clinical Interventions in Aging, 6, 111-117. Miake-Lye, I., Hempel, S., Ganz, D., Shekelle, P. (2013). Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Morello, R., Barker, A., Watts, J., Haines, T., Zavarsek, S., Hill, K., . . . Stoelwinder, J. (2015). The extra resource burden of in-hospital falls: a cost of falls study. The Medical Journal of Australia, 203(9):367. Prula LA, V.-F. F., Rodrguez, V., Ruiz-Moral, R., Fernndez, J., Gonzlez, J., Prula, C., . . . Group., E. S. (2012). Effectiveness of a multifactorial intervention program to reduce falls incidence among community-living older adults: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 93(10), 1677-84. Petridou, E., Manti, E., Ntinapogias, A., Negri, E., Szczerbinska, K. (2009). What works better for community-dwelling older people at risk to fall?: a meta-analysis of multifactorial versus physical exercise-alone interventions. Journal of Aging and Health, 21(5), 713-29. Phelan, E., Mahoney, J., Voit, J., Stevens, J. (2015). Assessment and Management of Fall Risk in Primary Care Settings. Medical Clinics of North America, 99(2): 281293. Shorr, R., Chandler, A., Mion, L., Waters, T., Liu, M., Daniels, M., . . . Miller, S. (2012). Effects of an Intervention to Increase Bed Alarm Use to Prevent Falls in Hospitalized Patients. Annals of Internal Medicine, 157(10): 692699. Sousa, M.-V. L., Caldevilla, C., Henriques, M., Severino, C., Pedro, S., Alves, S. (2016). Risk for falls among community-dwelling older people: systematic literature review . Revista Gacha de Enfermagem, 37(4), e55030. Stubbs, B., West, E., Patchay, S., Schofield, P. (2014). Is there a relationship between pain and psychological concerns related to falling in community dwelling older adults? A systematic review. Disability and rehabilitation, 36(23):1931-42. Thompson, H., McCormick, W., Kagan, S. (2006). Traumatic Brain Injury in Older Adults: Epidemiology, Outcomes, and Future Implications. Journal of the American Geriatric Society, 54(10): 15901595. Viljanen, A., Kulmala, J., Rantakokko, M., Koskenvuo, M., Kaprio, J., Rantanen, T. (2012). Fear of falling and coexisting sensory difficulties as predictors of mobility decline in older women. Journal of Gerontology, 67(11):1230-7. Wong, C., Recktenwald, A., Jones, M., Waterman, B., Bollini, M., Dunagan, W. (2011). The cost of serious fall-related injuries at three Midwestern hospitals. Joint Commission Journal on Quality and Patient Safety, 37(2):81-7.