Keeping older adults safe at home

ABOUT 20% of the population in the United States will be age 65 or older by 2030.¹ We can expect health problems to increase as our society ages. This article focuses on assessing older adults and intervening to improve safety in the home. It addresses fall prevention and medication safety.

Fall risks add up

About one of every three older adults who lives in the community falls once every year.² Falls are the primary cause of injury-related deaths in this population, and many of these deaths occur after months of medical care and treatment.³

Many older adults have sensory impairments, including impaired hearing and vision, that contribute to fall risk. Their ability to adjust to night vision is decreased, and they need up to three times the amount of light that younger adults need to see well.

Older adults may experience altered depth perception that can put them at risk for falls. Functional limitations that impede their mobility and ability to engage in activities of daily living also increase the risk of falls and may ultimately contribute to placement in a long-term-care facility.³

Assessing older adults

Optimal nursing care can help keep older adults on their feet and in their own homes. A comprehensive nursing assessment can minimize their risks for injury, hospitalization, or long-term-care placement. (See Assessing older adults for fall risk.)

Conducting a focused geriatric assessment as part of the standard assessment can also improve older adults' quality of life and keep them as independent as possible for as long as possible.⁴

Best practices for fall risk assessment include the Hendrich II fall risk model (which includes the “get up and go” test), the Katz Index of Independence in Activities of Daily Living, and the Housing Enabler (in home settings). These assessment tools involve obtaining a thorough health history (including chronic diseases, elimination patterns, and medications) and physical assessment, including mental status and gait.⁵ The Hendrich II fall risk model considers being male an independent risk factor for falls.^5,6

Falls may be related to conditions in the home that can be classified as unsafe.⁷ Identify actual and potential safety risks both inside and outside the home for patients living independently in the community, such as scatter rugs that don't have slip-resistant backing and garden hoses that stretch over walkways. The Housing Enabler Rating forms consist of three parts: a descriptive part (for example, mobility aids and diagnoses); an assessment form for functional limitations (such as severe loss of sight or hearing, incoordination) and dependence on mobility aids such as wheelchairs; and an assessment form for environmental barriers such as narrow paths (less than 1.3 m wide), and irregular or unstable walking surfaces.⁸

Intervene effectively

After completing the home safety evaluation, follow up with patient-specific interventions to help older adults address modifiable risk factors and stay safe. For instance, all rooms should be clutter-free and brightly lit. Teach patients to wear shoes with nonskid soles.

To help keep older adults independent and relieve some stress on caregivers and family, consider recommending a medical alert system. These systems immediately notify caregivers or family members of a fall. Some medical alert systems have features such as an “auto-alert” that automatically notifies emergency services if a fall is detected.²

Educate patients about their medications and make sure they understand the importance of telling all healthcare personnel, including pharmacists, all of their prescribed medications. See Taking medications safely.

For patients with dementia, see www.nia.nih.gov/alzheimers/publications/homesafety.htm for safety tips.

Other concerns

A supportive environment encourages physical and mental activity and social interaction. These activities may help slow cognitive, physical, social, affective, and functional decline.

Physical activities such as walking, aquatic exercise, or tai chi reduce the risk of falls by improving strength, balance, coordination, and flexibility. If the patient can't or won't perform these exercises independently, the healthcare provider may refer him or her to a physical therapist.

Whether the patient's living situation is safe depends on many factors, including the ability to use the telephone, travel safely outside the home, and safely take medication. The availability of family or neighbors to provide social or financial support is also a consideration.⁹

As always, individualize decisions about how to balance safety and independence based on each patient's unique situation. Planning ahead is the key to helping older adults live their lives to the fullest.

Assessing older adults for fall risk

Assess your older adult patients for fall risk factors that are intrinsic, such as:

• advanced age, especially age greater than 75
• a fall in the recent past
• coexisting conditions that are associated with falls, including dementia, depression, hip fracture, arthritis, type 2 diabetes, Parkinson disease, and osteoporosis
• a functional disability or impaired gait, balance, or vision
• use of an assistive device or a physical restraint
• altered level of consciousness or impaired cognition
• use of medications associated with a high risk of falls, such as alprazolam and amitriptyline
• use of medications associated with a high risk of injury from a fall, including anticoagulants such as aspirin, warfarin, or clopidogrel
• urge incontinence
• use of inappropriate footwear or lack of footwear.

Routinely assess and document the patient's environment for fall risk factors that are extrinsic, then take corrective actions. Make sure that:

• floors are dry and level
• lights, including night lights, are bright enough and functional
• furniture, such as tables and beds, are sturdy and in good repair
• grab rails and grab bars are placed appropriately in the bathroom
• adaptive aids work properly and are in good repair
• bed rails used for transitioning or support are sturdy
• patients' clothing doesn't cause them to trip
• I.V. poles used for support while ambulating are sturdy
• I.V. tubing doesn't cause the patient to trip.

Source: Gray-Micelli D. Nursing standard of practice protocol: fall prevention. Hartford Institute for Geriatric Nursing. 2008. http://consultgerirn.org/topics/falls/want_to_know_more.

Taking medications safely

Give your patients these tips to help them stay safe:

• Make a list of all the medicines you take, including over-the-counter products and dietary supplements. Show it to all of your healthcare providers. Keep one copy in your medicine cabinet and one in your wallet or pocketbook. The list should include the name of each medicine, healthcare provider who prescribed it, reason it was prescribed, amount you take, and time(s) you take it.
• Read and save in one place all written information that comes with the medicine.
• Take your medicine in the exact amount and at the time prescribed.
• Call your healthcare provider right away if you have any problems with your medicine or if you're worried that it might be doing more harm than good.
• Use a memory aid to take your medicines on time. Some people use meals or bedtime as reminders to take their medicine. Other people use charts, calendars, and weekly pillboxes. Find a system that works for you.
• Don't skip doses of medication or take half doses to save money. Talk with your healthcare provider or pharmacist if you can't afford the prescribed medicine. There may be less costly choices or special programs to help with the cost of certain drugs.
• Avoid mixing alcohol and medicine.
• Take your medicine until it's finished or until your healthcare provider says it's okay to stop.
• Don't take medicines prescribed for another person or give yours to someone else.
• Don't take medicine in the dark.
• Check the expiration dates on your medicine bottles. Your pharmacist can probably tell you how to safely get rid of medicine you no longer need or that's out of date. The pharmacist might be able to dispose of it for you.
• Make sure you store all medicines and supplements out of sight and out of reach of children. Don't take your medicines in front of young children.

Source: U.S. National Institutes of Health. National Institute on Aging. AgePage. Medicines: use them safely. http://www.nia.nih.gov/healthinformation/publications/medicines.htm.