Silverado Fall & Injury Prevention Programs for Seniors

Injuries in the Frail Elderly - Incidence and Prevention

Silverado recognizes that elderly persons are at greatly increased risk of injuries from falls, or soft tissue injuries such as bruising and skin tears. Increasing age and frailty compounds the risk of these injuries.

Fall Incidence and Risk of Injury

Falls are very common in older adults, even those adults who are still living independently in their own homes. Thirty-three percent of adults aged 65 years and older fall each year and falls are the leading cause of accidental deaths in persons over the age of 65 years old (CDC). The mortality rate for falls increases dramatically with age, with falls accounting for 70% of accidental deaths in persons 75 years of age and older. (1) Injury rate for falls increases with advanced age and is highest among persons 85 years of age and older. (2)

One-fourth of elderly persons who sustain a hip fracture die within six months of the injury. Hip fracture survivors experience a 10-15% decrease in life expectancy and a meaningful decline in their overall quality of life.

Intrinsic risk factors for falls and fractures, in addition to advanced age, are cognitive decline, polypharmacy, sensory decline, acute illnesses, and chronic diseases of the cardiac and central nervous systems as well as osteoporosis. Extrinsic factors in the environment include poor lighting, obstacles, unsafe stairways, etc.

Figure 1 shows how intrinsic and extrinsic factors can combine to change the likelihood of falling in the elderly patient. (3)

Injury Statistic
Key:
A = Pt. with an accidental fall and no intrinsic or extrinsic risk factors
B = Patient with acute illness
C = Patient with moderate illness, loss of mobility and some prescription medications who falls because of an extrinsic factor
D = Severely ill patient with many medications who falls even without extrinsic factors
E = Elderly patient with numerous age-related changes who falls because of an extrinsic factor.

Compared to children, elderly persons who fall are 10 times more likely to be hospitalized and 8 times more likely to die as the result of a fall. Major injuries, including head trauma, soft tissue injuries, fractures and dislocations, occur in 5 to 15 % of falls in any given year. More than 90% of hip fractures are associated with falls, and most of these fractures occur in persons more than 70 years of age. Fractures account for 75 % of serious injuries, with hip fractures occurring in 1-2% of falls.

Our Residents

Silverado Senior Living's business is to care for a unique segment of the elderly population, the most frail of the aged. 100% of the residents living at Silverado have some form of cognitive impairment, most commonly dementia from Alzheimer's, Parkinsons, vascular etiology or history of head trauma. Compared to the rapidly growing assisted living industry, only 6% of all assisted livings are free-standing dementia care facilities. (5) The average age of residents at Silverado is 83 years old and over 70% of residents at Silverado need assistance with all of their ADL's (activities of daily living).

In the traditional model of assisted living (AL), residents will transition out to higher levels of care as they age and gain increasing frailty. Over 33% of residents in traditional assisted living will be discharged out to a nursing facility and only 30% will remain at the assisted living through the end of their lives. (5)

At Silverado Senior Living, the residents and their families view this placement as their last "home". Silverado Senior Living's goal is to avoid the "transfer trauma" when dementia residents are transferred out to local emergency departments and acute care hospitals. This acute care system is poorly equipped to manage the behaviors of dementia patients and often these patients will be physically or chemically restrained to keep them quietly in bed. This can result in rapidly developing debilitation and pressure ulcers. At Silverado, licensed and registered nurses are available 24/7 and less than 2% of residents will be transferred out to a nursing facility, and over 92% will remain at Silverado throughout the end of life.

Due to their advanced age, dementia and the many complex health conditions of the residents at Silverado, there is always a risk of residents experiencing falls and injuries. As mentioned previously, in elderly populations, falls are a frequent and serious event. Studies show that 33% of adults aged 65 years and older fall each year (6) and of those who fall, 20-30% suffer moderate to severe injuries (7). Three out of four people in nursing homes fall each year (8). In CCRC's (Continuing Care Retirement Communities), 56% of residents will fall each year (9).

Leading the way in fall and injury reduction

While Silverado's residents have advanced age, with dementia and other multiple serious risk factors for falls and injuries, Silverado has been able to be a leader in fall and injury reduction for elderly with dementia. Silverado's proactive approach to preventing resident falls and injuries includes gait and strength assessment, the use of physical therapy and restorative care as appropriate, review of medications to decrease risk of sedation and other adverse effects, maintaining good nutrition and hydration, activity programs to maintain muscle and bone strength, and use of hip protector garments. Silverado's residents remain active throughout their lives in our communities avoiding unnecessary debilitation which increases their risk of fall and injuries.

Incidence of Soft Tissue Injuries and Associated Risk

Other common injuries in the frail elderly include trauma to the skin and soft tissue areas, such as skin tears and bruising. Some of the major risk factors for these injuries include advanced age, lack of independence, polypharmacy, anticoagulant usage, chronic diseases, normal skin changes of advanced aging, gait abnormalities, and visual decline.

With aging, dermal tissue loses 20% of its thickness. The loss of the natural padding that the thicker skin would provide, allows for easier tearing and bruising of the skin. Skin tears and bruising can result from minor environmental insults. Skin tears most commonly occur in the upper extremities, with 80% of them on arms and hands. Skin tears of unknown origin make up one half of the total skin tear population. Of skin tears whose causes are known, 25% result from wheelchair injuries. Another 25% occur from accidents involving bumping into objects and 28-24% occur due to transfers and falls (11). Patients and residents who are totally dependent on others for ADL's, are at the highest risk for sustaining skin tears (12).

Skin tears occur in institutionalized elderly each year, with prevalence rates between 14-24% (13). Silverado's residents are active and engaged in activities. Good nutrition, hydration and protective clothing help prevent many skin tears. If a resident does sustain a skin tear, our nurses are available to assess and begin treatments.

Another type of common skin injury in the frail elderly is the development of pressure ulcers. For many of the same reasons that skin tears and bruising can easily develop, such as the loss of dermal thickness, as well as the decrease in muscle mass and the loss of the ability to easily reposition oneself, pressure ulcers deep into the subdermal supporting layers can develop within hours on frail elderly patients. At nursing homes, 23% of patients have pressure wounds (14).

The residents at Silverado have many of the same risk factors for the development of pressure wounds, yet because our residents are active and do not spend extensive time in bed, as well as they are well nourished, pressure ulcers are rare. If any redness or skin irritation develops, a plan of care is established to prevent additional skin breakdown.

Quality Assurance Program

Caring for the frail elderly with dementia is a challenge for all aspects of the health care industry, as well as the senior housing industry. Their needs are complex and not easily met. Silverado Senior Living has a comprehensive on-going quality assurance program to monitor all aspects of clinical care, as well as quality of life experience for their dementia residents. Silverado's focus is to return quality of life experience and independence, as appropriate, to their residents. Figure 3 shows the numbers of residents who have regained some important quality of independence for their ability to re-ambulate, self feed and self toilet.

(Figure 3)

Silverado Resident Improvement Graph

References:

1. Fuller GF. Falls in the Elderly. Am. Fam. Phys 2000;Vol 61/No 7, :2173-2189
2. Runge JW. The cost of injury. Emerg. Med. Clin. North Am 1993;11:241-53
3. Steinweg KK. The changing approach to falls in the elderly. Am Fam. Physician 1997;45:735-8
4. Sattin RW. Falls among older persons: a public health perspective. Annual Rev. Public Health 1992;13:489-508
5. 2006 Overview of Assisted Living-aahsa, ASHA, ALFA, ncal, nic.
6. CDC Fact Sheets/Falls
7. Alexander BH, Rivara FP, Wolf ME. The cost and frequency of hospitalization for fall-related injuries in older adults. Am. J. of Public Health 1992;82(7);1020-3
8. Rubenstein LZ, Josephson KR, Robbins AS. Falls in the nursing home. Annals of Internal Medicine 1994;121:442-51
9. Resnick B, Junlapeeya P. Falls in a Community of Older Adults. Applied Nursing Research 2004; 17:81-91 and Kerse N, Butler M, Robinson E, Todd M. Fall Prevention in Residential Care. J. of the American Geriatrics Society 2004; 52:524-531
10. Rubenstein LZ, Robbins AS, Schulman BL, et al. Falls and instability in the elderly. J. of the American Geriatrics Society 1988;36:266-78
11. McGough-Csarny J, Kopac CA, Skin tears in the institutionalized elderly; an epidemiological study. Ostomy Wound Manage. 1998;44 (3A Suppl): 14-24
12. White M, Karam S, Cowell B. Skin tears in frail elders: a practical approach to prevention. Geriatr. Nurs. 1994;15 (2):95-99
13. Bank D, Nix D. Preventing skin tears in nursing and rehabilitation center: an interdisciplinary effort. Ostomy Wound Manage. 2006;52 (9):38-46
14. Pressure Ulcer Treatment, Clinical Practice Guideline #15, Dec. 1994, U.S. Dept. of HHS