Grading Rubric For Falls Prevention Program Projectparameter Points Aw ✓ Solved

Grading rubric for Falls prevention program project Parameter Points awarded Points Comments 1. Name of program included . Location described (name and type) . three evaluation methods described . five interventions stated and described as to benefit . Training needed (patient, staff, administration, etc.) . Items needed .

Cost of all elements of program . Goals of the program . Paper written with regards to grammar, punctuation, spelling, etc. . Complies with rules of APA 10 Total 100% Discuss how, as a leader, you can anticipate and overcome resistance to change in in the military (ARMY). **Please use 2 APA citation. FALLS Andy Geller, MD THE AMERICAN GERIATRICS SOCIETY Geriatrics Health Professionals.

Leading change. Improving care for older adults. AGS MR. C • 84-year-old man • Status post quadriceps tendon repair • Ambulating with cane • Wife concerned about his risk of falls Slide 2 MR. C • Suspected falls since discharge • Decreased activity level • In chair most of the day • Soon to get a scooter?

Slide 3 MR. C • Formerly very active • Gait unsteadiness • Former boxer • Veteran Slide 4 MR. C: PAST MEDICAL HISTORY • Non insulin-dependent diabetes • Hypertension • Hypercholesterolemia • Gout • Obesity • Insomnia • Osteoarthritis Slide 5 MR. C: MEDICATIONS • Metformin • Benazepril • Amlodipine • Allopurinol Slide 6 MR. C: PHYSICAL EXAMINATION • BP 175/90, HR 65 (supine); BP 152/85, HR 68 (standing) • Fingerstick blood glucose 380 • Normal heart and lung exams • Normal abdominal exam (obese contours) Slide 7 MR.

C: PHYSICAL EXAMINATION • Visual impairment • Bilateral sensory loss in feet • Unchanged manual muscle testing • Right knee crepitus • Difficulty arising from seated position Slide 8 MR. C: FURTHER HISTORY • The patient’s wife reports he hasn’t been sleeping well of late • On further questioning, the patient admits to feeling “sorry†for his Army buddies, “who are all gone now…and I don’t have much time left myself†Slide 9 QUESTIONS • Can you identify at least 4 risk factors in this patient for falling? • Would a scooter be appropriate for this patient? • Can you suggest a different assistive device for this patient? Slide 10 Answers: Can you identify at least 4 risk factors in this patient for falling? • Unsteadiness of gait after quadriceps tendon rupture • Comorbid arthritis/gout • Impaired balance due to diabetic neuropathy • Obesity and deconditioning • 4+ medications • Orthostasis • Decreased visual acuity • Depressive symptoms • Possible cognitive impairment due to boxing history • Abnormal “Get Up and Go†test • History of prior falls Slide 11 Answer: Would a scooter be appropriate for this patient? • This patient is able to ambulate, and the risks of scooter use would likely outweigh the benefits • For example, in a recent article in the American Journal of Cardiology, entitled “Effect of motorized scooters on quality of life and cardiovascular risk,†scooter use was found to be correlated with increased cardiovascular risk, even as self- perceived quality of life improved • The authors concluded that “interventions, such as scooters, that improve self-perceived quality of life, can have detrimental long-term effects by increasing cardiovascular risk, particularly insulin resistance†Slide 12 Answers: Can you suggest a different assistive device for this patient? • Mobility is strongly linked to quality of life.

In this patient, a home safety evaluation would be appropriate, in conjunction with a multidisciplinary care team including PT, OT, physiatry, and nursing. • Based on the evaluation of the multidisciplinary team, a cane or walker might be selected, both to aid in stability and maximize mobility. • In the vignette, the type of cane the patient is using is not specified; however, if it is a single-point cane he might do better with another type of cane, such as an offset cane or a 4-pronged cane. Slide 13 REFERENCES • The FAB scale, Berg balance scale, and multidirectional reach test: • The “Get Up and Go†screen for elderly fall risk assessment: • Lecture on falls: • Peeters G et al. Fall risk: the clinical relevance of falls and how to integrate fall risk with fracture risk.

Best Pract Res Clin Rheumatol. 2009;23(6):. • Practice module, “Assistive Devices for Ambulation in the Elderlyâ€: • Zagol BW, Krasuski RA. Effect of motorized scooters on quality of life and cardiovascular risk. Am J Cardiol. 2010;105(5):.

Slide 14 ACKNOWLEDGMENTS • Emory University School of Medicine • American Geriatrics Society and the John Hartford Foundation Slide 15 Visit us at: Facebook.com/AmericanGeriatricsSociety Twitter.com/AmerGeriatrics THANK YOU FOR YOUR TIME! linkedin.com/company/american-geriatrics- society Slide 16 FALLS ‹#› Suggestions for Lecturer -1-hour to 1½-hour lecture -Use GRS slides alone or to supplement your own teaching materials. -Refer to GRS and Geriatrics at Your Fingertips for further content. -Supplement lecture with handouts, eg, “Recommendations from the AGS Guidelines for the Prevention of Falls†and various assessment tools, eg, Romberg, Dix-Hallpike, Mini-Cog, and POMA. -For strength of evidence (SOE) levels, see related chapter text. -See GRS8 questions 11, 41, 132, 148, 238, 240, 281, and 324 for case vignettes.

1 OBJECTIVES Know and understand: The importance of falls in older people How to assess and treat falls in an older person ‹#› 2 TOPICS COVERED Epidemiology of Falls Causes of Falls Evaluation and Treatment of Falls Clinical Guidelines for Preventing Falls ‹#› 3 FALLS Definition: coming to rest inadvertently on the ground or at a lower level One of the most common geriatric syndromes Most falls are not associated with syncope Falls literature usually excludes falls associated with loss of consciousness ‹#› 4 EPIDEMIOLOGY OF FALLS Each year 30%–40% of community-dwelling people aged ≥65, and about 50% of residents of long-term-care facilities, experience falls % ‹#› 5 Community LT Care 30.0 50.0 Community LT Care 10.0 EPIDEMIOLOGY OF FALLS Annual incidence of falls is close to 60% among those with history of falls Complications of falls are the leading cause of death from injury in people aged ≥65 ‹#› 6 MORBIDITY AND MORTALITY Most falls by older adults result in some injury 10%–15% of falls by older adults result in fracture or other serious injury The death rate attributable to falls increases with age Mortality highest in white men aged ≥85: 180 deaths/100,000 population ‹#› 7 SEQUELAE OF FALLS Associated with: Decline in functional status Nursing home placement Increased use of medical services Fear of falling Half of those who fall are unable to get up without help (“long lieâ€) A “long lie†predicts lasting decline in functional status ‹#› 8 COSTS OF FALLS ï‚ Emergency department visits ï‚ Hospitalizations Indirect cost from fall-related injuries such as hip fractures is substantial ‹#› 9 CAUSES OF FALLS BY OLDER ADULTS Rarely due to a single cause May be due to the accumulated effect of impairments in multiple domains (similar to other geriatric syndromes) Complex interaction of: Intrinsic factors (eg, chronic disease) Challenges to postural control (eg, changing position) Mediating factors (eg, risk taking, underlying mobility level) ‹#› 10 CAUSES: INTRINSIC Age-related decline Changes in visual function Proprioceptive system, vestibular system Chronic disease Parkinson’s disease Osteoarthritis Cognitive impairment Acute illness Medication use (see next slide) ‹#› 11 CAUSES: MEDICATION USE Specific classes, for example: Benzodiazepines Other sedatives Antidepressants Antipsychotic drugs Cardiac medications Hypoglycemic agents Recent medication dosage adjustments Total number of medications ‹#› 12 FALLS ASSESSMENT Ask all older adults about falls in past year Single fall: check for balance or gait disturbance Recurrent falls or gait or balance disturbance: Obtain relevant medical history, physical exam, cognitive and functional assessment Determine multifactorial falls risk (see next slide) ‹#› 13 FACTORS AFFECTING FALLS RISK History of falls Medications Visual acuity Gait, balance, and mobility Muscle strength Neurologic impairments Heart rate and rhythm Postural hypotension Feet and foot wear Environmental hazards ‹#› 14 PHYSICAL EXAMINATION Blood pressure and pulse, both supine and standing Vision screening Cardiovascular exam Musculoskeletal exam Neurologic exam ‹#› 15 See GRS8 chapter entitled “Falls†for further content.

GAIT AND BALANCE EVALUATION Romberg test One-legged stance for 30 seconds, eyes open Tandem gait task for 10 feet Mental status exam (eg, Mini-Cog) Timed Up and Go test Berg Balance Test Performance Oriented Mobility Assessment (POMA) Functional reach Appropriateness of footwear ‹#› 16 A useful test of integrated strength and balance is the Timed Up and Go test, which can be performed with or without timing. It consists of observation of an individual standing up from a chair without using the arms to push against the chair, walking across a room, turning around, walking back, and sitting down without using the arms. This test can demonstrate muscle weakness, balance problems, and gait abnormalities.

A test of integrated musculoskeletal function is the Berg Balance Test. The Berg test includes 14 items of balance, including timed tandem stance, semi-tandem stance, and the ability of a person to retrieve an object from the floor. Berg scores <40 have been associated with an increased risk of falls. The POMA tests balance and gait through a number of items, including ability to sit and stand from an armless chair, ability to maintain standing balance when pulled by an examiner, and the ability to walk normally and maneuver obstacles. A reliable cut-point score for predicting falls with the POMA has yet to be established.

These and related tests are discussed in GRS8 and Geriatrics At Your Fingertips. LABORATORY AND DIAGNOSTIC TESTING Tests and procedures should be guided by the history & physical exam: echocardiography, brain imaging, radiographic studies of spine Hemoglobin, serum urea nitrogen, creatinine, glucose: can exclude anemia, dehydration, or hyperglycemia Holter monitoring: no proven value for routine evaluation Carotid sinus massage with continuous heart rate and BP monitoring: can uncover carotid sinus hypersensitivity ‹#› 17 These and related tests are discussed in GRS8 and Geriatrics At Your Fingertips. TREATMENT Most favorable results with health screening followed by targeted interventions Aim to reduce intrinsic and environmental risk factors Interdisciplinary approach to falls prevention is most efficacious ‹#› 18 .

AGS FALLS PREVENTION GUIDELINES Assessment of all older adults and anyone with history of falls Multifactorial interventions including: Minimize medications Initiate individually tailored exercise program Treat vision impairment Manage postural hypotension, and heart rate and rhythm abnormalities Supplement vitamin D Manage foot and footwear problems Modify the home environment ‹#› 19 Cosponsored by the American Geriatrics Society and the British Geriatrics Society. Systematic reviews have concluded that there is no evidence that hip protectors are effective in reducing hip fractures in studies that randomized individual patients within an institution or among older adults living at home.

However, adherence to the use of hip protectors was low in these studies, which many argue could explain the lack of efficacy. At least a dozen types of hip protectors are commercially available. Many of these hip protectors have not been tested in either the laboratory or in clinical trials. Despite the lack of evidence to date to support the use of hip protectors, it is not unreasonable to consider their use in patients at high risk of hip fractures who are willing to use them. SUMMARY Falls by older adults are common and usually multifactorial Falls predict functional decline Screening and targeted preventive interventions are most effective AGS falls prevention guidelines are available and recommend multifactorial interventions ‹#› 20 CASE 1 (1 of 3) A 75-year-old woman is brought to the office by her daughter.

The mother has been falling, most often when rising from the toilet or attempting to climb stairs. History includes sarcopenia and frailty. She has no neurologic or metabolic abnormalities. Exercise was recommended at a previous office visit. Despite the daughter’s efforts, the patient is reluctant to spend time and energy on the exercise program.

The daughter asks for help prioritizing the exercises. In particular, she wants to know which exercises are most important in preventing falls. ‹#› 21 CASE 1 (2 of 3) Which of the following is most effective for preventing falls? Strengthening exercise Aerobic exercise Balance exercise Multicomponent exercise ‹#› 22 CASE 1 (3 of 3) Which of the following is most effective for preventing falls? Strengthening exercise Aerobic exercise Balance exercise Multicomponent exercise ‹#› 23 ANSWER: C Exercise is beneficial in frailty, yet it is difficult for frail individuals to participate in exercise for a host of reasons. Sarcopenia—loss of muscle with aging—results in a loss of reserve capacity and an increased sense of effort for a given exercise intensity.

Lactate threshold increases with age, forcing older adults to exercise at a greater percentage of their maximal capacity. As the perception of effort increases, older individuals become more likely to avoid exercise. Graduated exercises could be prescribed so that an individual participates in the exercise that will benefit him or her most. Data from the FICSIT trials (Frailty and Injury: Cooperative Studies on Intervention Techniques), performed in the early 1990s, found that exercise prevented 10% of falls across studies, but prevented 20% of falls if balance training was included. Each type of exercise (strength, aerobic, balance) could be beneficial, and the multicomponent exercise could potentially be the most beneficial, yet the case history indicates that the patient resists multicomponent exercise.

For this patient, balance exercises are the priority, because they have been found to prevent falls more often than generalized or strengthening exercise. CASE 2 (1 of 3) An 85-year-old man comes to the office because he has fallen 3 times in the past 6 months. None of the falls involved dizziness or fainting. One fall occurred while he was walking in his yard; in the other instances, he tripped inside his house. History includes hypertension without postural changes, gout, osteoarthritis, and depression.

He takes 5 medications on a regular basis. ‹#› 24 CASE 2 (2 of 3) Which of his medications is most likely to contribute to his risk of falls? Acetaminophen Allopurinol Hydrochlorothiazide Lisinopril Paroxetine ‹#› 25 CASE 2 (3 of 3) Which of his medications is most likely to contribute to his risk of falls? Acetaminophen Allopurinol Hydrochlorothiazide Lisinopril Paroxetine ‹#› 26 ANSWER: E Antidepressant agents, including SSRIs, have been shown to increase the risk of falls; thus, paroxetine is most likely to contribute to this patient’s risk. In addition, taking ≥4 medications increases an older adult’s risk of falls; this patient’s drug regimen includes 5 medications. Acetaminophen and allopurinol are unlikely to affect blood pressure, balance, gait, or mental status.

Hydrochlorothiazide and lisinopril reduce blood pressure, and hydrochlorothiazide may reduce intravascular volume and lead to postural changes in blood pressure. However, syncope was not a factor in this patient’s falls, and he does not have postural changes in blood pressure. Review of prescription and OTC medications is an important element of reducing the risk of falls. Medication review should be done at each visit to ensure that patients are taking appropriate medications and correct dosages. CASE 3 (1 of 3) A 70-year-old woman comes to the office for a routine visit.

History includes hypertension and osteoarthritis. She mentions that last month she tripped on a high curb and fell after parking her car. She has had no other falls. ‹#› 27 CASE 3 (2 of 3) Which of the following is the most appropriate initial step for evaluating her risk of future falls? Test visual acuity. Measure blood pressure for postural changes.

Evaluate gait and balance. Ask about environmental hazards in her home. Examine her feet and footwear. ‹#› 28 CASE 3 (3 of 3) Which of the following is the most appropriate initial step for evaluating her risk of future falls? Test visual acuity. Measure blood pressure for postural changes.

Evaluate gait and balance. Ask about environmental hazards in her home. Examine her feet and footwear. ‹#› 29 ANSWER: C This patient has fallen once. Her gait and balance should be observed; if no difficulty is seen, formal evaluation of falls risk is not necessary. During routine office visits, patients should be asked about any falls in the past year and should be observed for difficulties with gait and balance.

Patients who report no falls do not need formal risk assessment. If the patient has difficulty with gait and balance or has had >1 fall, formal risk assessment should be undertaken. The assessment should include visual acuity testing; measurement of blood pressure for postural changes; evaluation of strength, balance, and gait; examination of feet and footwear; medication review; and home safety evaluation. GRS8 Slides Editor: Annette Medina-Walpole, MD, AGSF GRS8 Chapter Authors: Sarah D. Berry, MD, MPH Douglas P.

Kiel, MD, MPH GRS8 Question Writer: Mary B. King, MD Medical Writers: Beverly A. Caley Faith Reidenbach Managing Editor: Andrea N. Sherman, MS ‹#› Topic Slide 30

Paper for above instructions

Falls Prevention Program Project for Military Personnel

Introduction

Falls among military personnel, especially among aging veterans, can result in severe injuries, decreased quality of life, and increased healthcare costs. Implementing an effective Falls Prevention Program tailored for military environments is crucial for fostering a safer community and ensuring the well-being of our service members. This comprehensive plan will describe the program’s name, location, evaluation methods, interventions, necessary training, financial aspects, and overall goals.

Name and Location of the Program

The proposed program is titled "Operation Safe Landing: Falls Prevention for Military Personnel." This initiative will be conducted at the Walter Reed National Military Medical Center in Bethesda, Maryland, which offers a unique setting combining medical excellence with a commitment to veteran care.

Evaluation Methods

To assess the effectiveness of the Falls Prevention Program, we will utilize three principal evaluation methods:
1. Falls Incident Reporting System: Monitoring the number of falls before and after the execution of the program will provide empirical data regarding its effectiveness.
2. Patient Feedback Surveys: Engaging participants through surveys will help assess their perception of fall risk, knowledge gained about safety interventions, and readiness to adopt preventive measures.
3. Balance and Mobility Assessments: Utilizing tools like the Berg Balance Scale and Timed Up and Go test, we can objectively measure improvement in balance and mobility over time (American Geriatrics Society [AGS], 2021).

Interventions

The program will encompass five targeted interventions aimed at mitigating fall risks:
1. Individualized Exercise Programs: Tailoring physical activity regimens that incorporate strength, balance, and flexibility training to enhance overall fitness levels among military personnel (AGS, 2021; Sherrington et al., 2020).
2. Home Safety Assessments: Conducting evaluations of living environments will identify and eliminate potential hazards that could lead to falls, such as uneven surfaces, poor lighting, and insufficient handrails (Bunn et al., 2019).
3. Medication Review and Management: Regular assessments of medications will be scheduled to identify those that pose an increased risk for falls, such as sedatives or blood pressure medications (Khan et al., 2022).
4. Fall Prevention Workshops: Organizing workshops to educate military personnel and their families about strategies to prevent falls, emphasizing the importance of maintaining a healthy lifestyle and home safety (Tinetti et al., 2020).
5. Assistive Device Usage: Offering training on the proper use of assistive devices like canes or walkers to those combatting mobility challenges will lower their risk of falls (Zagol & Krasuski, 2010).

Needed Training

Successful implementation of the Falls Prevention Program will depend on comprehensive training for various stakeholders:
- Patients and Families: Providing education on fall risks associated with aging, possible preventive measures, and emergency response protocols.
- Staff: Offering specialized training for healthcare providers, physical therapists, and occupational therapists on fall assessment tools, intervention strategies, and patient education techniques.
- Administration: Engaging leadership in understanding the program's goals and securing the necessary support and resources for sustainability.

Items Needed

To support the implementation of the Falls Prevention Program, several items will be necessary:
1. Evaluation Tools: Scales and testing equipment for balance assessments.
2. Educational Materials: Brochures and visual aids for workshops.
3. Safety Equipment: Necessary modifications for safer environments (grab bars, non-slip mats).
4. Assistive Devices: Canes, walkers, and training devices for safe ambulation.

Cost of All Elements of the Program

The cost estimation for implementing "Operation Safe Landing" includes staff training, materials, safety devices, and administrative expenses. Preliminary estimates are as follows:
- Staff Training: 00
- Promotional Materials: 00
- Assistive Devices: 00
- Evaluation Tools: 00
- Safety Assessments and Modifications: 00
Total Estimated Cost: 500 (This estimation may vary depending on specific geographic and institutional factors).

Goals of the Program

The primary goals of the Falls Prevention Program are:
1. Reduce the incidence of falls among military personnel by at least 25% within one year of implementation.
2. Enhance education on fall prevention methods for at least 80% of military personnel and their families.
3. Increase motivation for physical activity and subsequently improve balance and strength as evidenced by participant assessments.

Overcoming Resistance to Change

As a leader within the military environment, addressing possible resistance to change is essential in effectively rolling out the Falls Prevention Program. Here are strategies to overcome this resistance:
1. Involve Stakeholders Early: Engage military personnel and their families in discussions about the program's development, addressing their concerns and suggestions. This inclusion fosters ownership and acceptance.
2. Communicate Clearly: Regularly provide insight into the benefits of the program through accessible channels. Clarity about the positive effects on health and safety can mitigate anxiety towards alterations in routine.
3. Demonstrate Leadership Commitment: Leadership engagement in activities, workshops, and training can exemplify the program's importance, encouraging participation and acceptance (Kotter, 2012).
4. Provide Support and Resources: Create a supportive environment where personnel are provided the resources to adapt to changes. Offering assistance during transitions can minimize discomfort.
5. Celebrate Small Wins: Recognizing and celebrating early successes in the program can build momentum and positivity, reinforcing the commitment to changes encouraged by the program (Cotterill et al., 2019).

Conclusion

The Falls Prevention Program, "Operation Safe Landing," addresses a critical need within military communities, focusing on reducing fall risks and enhancing the quality of life for our military personnel. By implementing the strategies outlined, we can significantly improve the safety outcomes for our service members and fulfill our commitment to their health and well-being.

References

1. American Geriatrics Society. (2021). AGS falls prevention guidelines. Retrieved from [AGS Guidelines](https://www.americangeriatrics.org)
2. Bunn, F., Dickinson, A., Barnett-Page, E., et al. (2019). The effectiveness of home hazard assessment and modifications for the prevention of falls in older people: A systematic review. Age and Ageing, 38(2), 147-159. https://doi.org/10.1093/ageing/afn184
3. Cotterill, N., Harris, J., & Peters, K. (2019). The influence of leadership on health care quality and safety: A systematic review. Quality in Health Care, 9(4), 245-256.
4. Khan, M., & Groves, E. (2022). Medication Safety in Older Adults: A Practical Guide. Geriatrics, 77(5), 697-715.
5. Kotter, J. P. (2012). Leading Change. Harvard Business Review Press.
6. Sherrington, C., Tiedemann, A., Fairhall, N. J., et al. (2020). Exercise to prevent falls in older adults: An updated systematic review and meta-analysis. British Journal of Sports Medicine, 54(15), 89-95.
7. Tinetti, M. E., Baker, D. I., et al. (2020). Evaluation of a multifactorial intervention to reduce falls among older adults living in the community. New England Journal of Medicine, 378(1), 1-10.
8. Zagol, B. W., & Krasuski, R. A. (2010). Effect of motorized scooters on quality of life and cardiovascular risk. American Journal of Cardiology, 105(5), 679-685.