Sharing Your Knowledge With Patients & Caregivers Can Ensure Fall Prevention
By Donna Cifuni, PT, DPT
Physical Therapist
One of the most common sources of a FOX PT or OT referral is a patient’s fall. How many times have you gotten a referral for a “frequent flyer” (or a “frequent faller”) patient who has once again fallen in their home? A majority of the time, when we did discharge that patient, they were using both hands to stand, they were walking with improved stride, and their posture had dramatically improved during walking. So why did they fall again?
Most of the time, the answer is that the patient has not adhered to what has been taught to them or the caregiver may not have been properly cueing the patient after discharge. This is why patient and caregiver education through demonstration and handouts is so important!
EDUCATION ON HOME SAFETY ASSESSMENT RESULTS
It is important to educate caregivers from the get-go. One good way to do this is to perform a home safety assessment during your first visit with the patient. Usually, you are going to want to see all the rooms of the patient’s home anyway, in order to observe grab bars, equipment used/needed, the distance between rooms, etc. Since you are already doing that, a home safety assessment is easy to perform (and can be found as a quick-access button on your evaluations through FOX’s digital portal).
A wonderful benefit to the home safety assessment is that you can review your findings with the patient/caregiver. I recently performed an evaluation including a Home Safety Assessment asking the patient to show me a tour of his home. I noticed that the patient had area rugs in every single room and hallway, including overlapping area rugs in the hallway that I myself almost tripped over. The PT in me was cringing. When the patient and I sat down for a break I said to his wife, “I noticed that you have a lot of area rugs in the hallway and around the home. Area rugs are a big tripping hazard, so my suggestion would be to remove them in order to reduce the chance of you or your husband falling.”
Another one of the many items included in the Home Safety Assessment is proper lighting, which may not be something you think about naturally because we are usually at patients’ houses when the sun is out. Night lights around the home and in hallways are integral if the patient has to walk into the hallway at night to get to the bathroom. Nightlights are an easy fix and can be purchased at the local dollar store, pharmacy, or even grocery store for a low price, so it shouldn’t take too much convincing once you educate on their importance.
Furthermore, you can always suggest the addition of grab bars where you see fit, or other equipment you think the patient would benefit from in the home. I suggest calling the primary contact or power of attorney to explain your recommendation for the patient’s home and why this would benefit the patient and reduce the effort required of the caregiver or why this would provide a safer alternative. Usually, your team will have a list of companies that can help install grab bars in the home that you can refer the patient/caregiver too. Some patients/families may have never thought they needed certain equipment until a skilled professional suggests it, and this is why continuous education and communication are key to our patients’ success.
EXPLAINING OUTCOME MEASURES TO CAREGIVERS
As the thorough PTs and OTs that we are, we also perform a variety of outcome measures during our evaluations and throughout our plan of care. It is natural for us to analyze gait and detect that a patient is at high risk for falls, but most caregivers are not trained to perform gait analysis and may not recognize factors that could contribute to falling. If you perform a Tinetti Balance and Gait Assessment, you can educate the patient/caregiver on the difference between step-through and step-to, and the difference between the wide and narrow base of support. With the Tinetti, you can also demonstrate a patient’s balance deficits with their eyes closed, which can actually tie into the low-lighting scenario mentioned earlier in our home safety assessment.
Some other outcome measures that may be easier to explain to caregivers can include the 5x Sit to Stand, the 30-Second Chair Stand Test, and the ABC Scale. These are easy outcome measures that we can not only explain, but we can also teach the caregiver to perform periodically after discharge to monitor for a decline. A great way to do this is to formulate a handout with the normal values and instructions on how to perform the tests (as a Fox clinician, all of this information can be found by clicking on these tests in your Raintree notes under FOMs). If a drastic change is noted by the caregiver in the amount of time taken to stand five times, or if the patient shows increased difficulty performing multiple stands in 30 seconds, it may be time for a PT followup. While we normally will put in for a followup, we should also educate patients/caregivers that they can reach out at any time if they notice a decline.
Leave your business card with the patient so that they are able to contact you or your home office when they feel they may need PT or OT services again.
EDUCATING ON BASIC TRANSFER AND GAIT SAFETY
As mentioned earlier, caregivers are not necessarily trained to “analyze gait” but that doesn’t mean we can’t educate them on what to look out for. We can teach caregivers how to provide verbal cues for increasing step height, increasing stride length, and straightening posture with walking.
Another very common verbal cue needed from caregivers is for hand placement. How many times does a patient stand and try to grab the walker? Or how many times has a patient plopped straight down into the chair taking their walker with them? Providing verbal cues for hand placement is a very simple task that caregivers can perform when assisting patients with transfers. You can write these cueing suggestions into the Home Exercise Program (HEP). It is also strongly encouraged that the caregivers are present as often as possible during treatment sessions, allowing caregivers to learn the frequent verbal cues given by the PT or OT during transfers and gait activities.
The use of an assistive device is also something that should be strongly encouraged when deemed necessary. A lot of patients are resistant to using a walker instead of a cane or even a cane instead of nothing at all. As a PT you may feel like you are constantly educating patients and caregivers to use the recommended device. And OTs, how many times do you try and suggest a transfer tub bench, and the patient says “I’m fine, I don’t need that.” There are many reasons a PT or OT will suggest using an assistive device for a task, and the only way a patient or caregiver will follow through with our recommendation is if they truly understand the purpose and reasoning. Sometimes it even requires demonstrating how hard the task looks without the recommended assistive device to truly understand why they need it.
Another key to safe transfers is education on when to lock/unlock wheelchair and rollator brakes. It is good to practice transfers from a wheelchair using verbal sequencing. “Okay, first we are going to lock the brakes on both sides of the wheelchair and on the rollator, then we are going to push off using both our arms on the armrests, then we are going to place both hands on the rollator handles, then we are going to unlock the brakes to begin walking…” Continuous practice of sequencing will allow patients to more easily carry over the task. Informing the patient of the risk that the wheelchair may wheel away from them if they stand without locking the brakes and educating on how the patient should always sit into a stable, non-moving surface should allow for an understanding of the purpose.
ENCOURAGING CAREGIVER ADHERENCE TO THE HOME EXERCISE PROGRAM
A home exercise program is one of the patients of the main intervention neglect to perform after discharge. You may often spend upward of 90 days with these patients, performing all their lower extremity and upper extremity exercises, and most patients become very good at remembering what their exercises are and how many to perform. On discharge, the patient (or their caregiver) is marked as “independent,” and we give them a handout we printed at a local copy center (and sometimes we even enlarge the photos to one per page).
“Have you been doing your exercises” – PT on evaluation day of case number 4
“No … ” – patient who fell 3x since discharge
Muscles can experience muscle atrophy in as little as 72 hours. Many patients are not spending their days exercising but rather sitting in their wheelchairs and recliners watching TV. Many times, the only time a patient will get up is to go to the bathroom or when they are getting in/out of bed. In my experience, I have found writing down a walking schedule holds the caregivers and patients accountable for performing their walking daily. This also works with regular HEP. The schedule can include checkboxes for “After Breakfast,” “After Lunch,” and “After Dinner” to ensure the patient performs them at least 3x a day.
EDUCATING CAREGIVERS ON THE IMPORTANCE OF MONITORING VITALS
As we all know, low blood pressure can contribute to a patient feeling dizzy when standing in addition to a low O2 level. It is our role as healthcare providers to encourage caregivers and patients to purchase items that will allow the caregivers to monitor their vitals on days where OT and PT are not present, as well as upon discharge. A pulse oximeter (Zacurate Pulse Oximeter) can be purchased for as little as $12-$20 and an electronic blood pressure reader (Greater Good Blood Pressure Monitor Kit) can be purchased for $30-$40. A handout can be provided with a chart of normal values. We can also provide education on where that patient’s personal vitals usually fall during sessions. On this handout, we should also write the physician’s phone number in case the patient’s values fall out of the normal range.
Of course, education on drinking water and sticking to a regulated medication schedule (especially when BP medications are involved) are key to maintaining BP in the normal range.
CLOTHING CHOICE FOR PATIENTS CAN IMPACT FALL RISK
Proper footwear. How many patients do you have walking around on hardwood floors with socks (and not the non-skid kind.) Or sometimes worse … backless slippers? Caregivers who assist patients with getting ready in the morning should be educated to have the patient wear socks with grips, sneakers, or closed-toe and closed-back shoes. These types of footwear prevent the likelihood that the patient will go sliding across hard floors like they are the new star of Risky Business. They also reduce the chance of the patient losing their shoes while walking and prevent tripping over the toe of the slipper when it starts sliding off.
Avoiding long nightgowns or pants. A patient should never wear clothing that is too long because they could potentially trip over their clothing. Again, educate caregivers if you notice the patient’s pants, dress, skirt, etc. are going past the bottom of their feet.
THE IMPORTANCE OF EDUCATION IN PLANS OF CARE
With all of the above suggestions, education is something that should be performed continuously throughout a plan of care. While it may seem like there are a lot of topics to educate caregivers on in order to reduce fall risk, most tasks listed above take a very small period of time to actually perform but can make a huge impact on carryover when these patients are discharged from our services. With the implementation of handouts, visual demonstration, and verbal education, hopefully, we can all prolong the time between admissions to our services and, most importantly, reduce the number of falls in our patients.
If you see anything not listed above, please comment below with added ideas on how to educate caregivers in order to reduce post-discharge falls.