Prevention of Home & Work Related fall-Injuries: Using a Transdisciplinary Approach

1. Prevention of Home & Work Related fall-Injuries:Using a Transdisciplinary Approach Instructor’s Home Office; Redlands, Miami, FL Dangerous septic tank retrofit, Augusta, GA Course Instructor: Dr. Jose R. Rafols OTD, MHSA, OTR/L, CEAS

2. Prevention of Home & Work Related fall-Injuries:Using a Transdisciplinary Approach Conflict of Interest In the effort to comply with appropriate state boards and professional associations, I declare that I do not have an affiliation with or financial interest in a commercial organization that could pose a conflict of interest with the following presentation:

3. Prevention of Home & Work Related fall-Injuries:Using a Transdisciplinary Approach Course Objectives • Will be able to identify 75% of the abatement recommendation discussed in the seminar, as well as, direct clients and family members to the risks factors that lead to falls at home, per recommendations from the National Center for Injury Prevention and Control, Atlanta, Georgia. • Will be able to offer six out of eight contemporary off-the-shelve products, such as, tub-benches, grab bars, motion sensor switches, etc., to minimize and/or prevent fall-related injuries in and around the client’s home. • Will be able to identify three emerging practice trends in Telehealth, Telemedicine, and medical surveillance to enhance the home-bound client’s ability to gain access to health care services. • Will understand five primary causes of falls and related injuries among the elderly which impact functional mobility and independence with ADL’s. • Will have a superior understanding of the use of readily available training materials, such as, handouts, brochures and governmental websites to use adjunctively to educate clients and care-givers on fall prevention.

4. Prevention of Home & Work Related fall-Injuries:ATransdisciplinary Approach The leading causes of falls among Aged Adults

5. Prevention of Home & Work Related fall-Injuries:The leading causes of fall among Aged Adults Causes of Falls: • Decreased Visual Acuity • Decreased Balance • Gate Disturbances • Decreased Strength • Decreased Cardiac Capacity • Decreased Bone Density & OA/DJD • Decreased Cognition • Complication from Co-morbidities • Adverse Drug Interactions • Fear of Falling • Environmental barriers/obstacles

6. Prevention of Home & Work Related fall-Injuries:The leading causes of falls among Aged Adults • Decreased Visual Acuity … as aged adults develop Cataracts, Glaucoma, and require corrective lenses to see, they may not see obstacles in darkened areas of their homes. • Decreased Balance … cause aged adults to loose their balance easily; they also loose their balance due to LE-weakness, and vestibular irregularities. • Gait Disturbances … are often caused by poor choice of shoes, use of slick-socks, improper use of assistive ambulation devisesand generalized weakness in LE’s.

7. Prevention of Home & Work Related fall-Injuries:The leading causes of falls among Aged Adults • Decreased Visual Acuity … visual impairments rises with age in older adults: • From 1.1% throughout ages 65-to-69 years and this rises to 16.7% at age 80 and above. • Nearly 22 Million Americans are diagnosed with Cataracts. • More than 150 million Americans use corrective eye-ware to compensate for refractive errors (e.g. poor eyesight). • Americans spend more than $15 Billion dollars each year on eye-ware. • Diagnosis- that impact the Visual System due to age related decline are: • Macular Degeneration • Glaucoma • Diabetic Retinopathy • Loss of peripheral vision • Visual acuity & contrast sensitivity • Dry Eyes • Reduced Pupil Size

8. Prevention of Home & Work Related fall-Injuries:The leading causes of falls among Aged Adults • Decreased Cardiac Capacity … due to inactivity the aged adult’s cardiac vital capacity is impacted; thus, they are unable to engage in moderate cardiopulmonary exercises. • The aged adult may have trouble performing cleaning chores in & around the house. • The aged adult will have trouble with moderate lifting, bending, squatting, pushing, pulling tasks at work. • The aged adult may have trouble taking care of a loved one, as a result decreased cardiac capacity.

9. Prevention of Home & Work Related fall-Injuries:The leading causes of falls among Aged Adults VI. (a) Decreased Bone Density … as aged adults enter their 5th, 6th, and 7th decade of life, they lose the rigid supportive framework within their bones; as the bones become more brittle and less supportive, they become more susceptible to fractures due to falls. VI. (b)Osteoarthritis … causes disuse, more so in the morning, and this leads to inactivity, joint-stiffness, and decreased functional range of motion and pain. (*OA-impacts the weight-bearing pillars of the body first; e.g. hips, knees, ankles, wrists, and shoulders).

10. Prevention of Home & Work Related fall-Injuries:The leading causes of falls among Aged Adults • Decreased Cognition … aged adults with cognitive impairments or “altered mentation” present difficulty in complying with home-programs. It is best to farm-out these responsibilities to health care surrogates (e.g. reliable care-givers) who will insure compliance with HEPs, home-safety, poly-pharmacy and medical surveillance. • Alzheimer's Disease • Dementia • Parkinson’s Disease • Aged Adults with mild cognitive impairment are two times more likely to fall as compared to normal older adults.

11. Prevention of Home & Work Related fall-Injuries:The leading causes of falls among Aged Adults • Complication from Co-morbidities (CMs) … aged adults presenting with several CMs, such as, CVA, CHF, DM-II, PVD, or HTN require “close medical surveillance”. • Doctors who manage these patients report that if their clients present with three (3) or more Co-morbidities a “red-flag” should be raised and Comprehensive Health Care Management should be instituted. • Health Care Providers (HPCs) … must coordinate care, poly-drug adherence is a must, a weekly exercise regime should be incorporated into the aged adult’s schedule, and finally, the aged adult must touch-base with a nurse, PCM or doctor at least once a week.

12. Prevention of Home & Work Related fall-Injuries:The leading causes of falls among Aged Adults IX. Adverse Drug Interaction … aged adults usually take more than one type of medicine. Key to this complex issue is that aged adults do not metabolize medication at the same rate as do younger adults. • Current poly-drug surveillance is hard to implement when patient/clients do not return to the attending physician’s office for routine check-ups. • Education on how to properly administer, safeguard, and store the medication is not always followed. • Mixing of prescription drugs, OTC meds and Herbs & Supplements without the attending physician’s knowledge can lead to unexpected drug interactions.

13. Prevention of Home & Work Related fall-Injuries:The leading causes of falls among Aged Adults X. Fear of Falling … the aged adult is typically cautious when walking in and around obstacles; they have good reason to: • One in three adults age 65 and older fall each year. • Over 95% of hip fractures are caused from falls; the fx rate for females are three times greater than they are for males (*Why?). • Every 15 seconds, an older adult is treated in the emergency room for falls & every 29 minutes an older adult dies from fall-related injuries. • In the United States, 16 percent of all Emergency Department visits and almost 7 percent of all hospitalizations are for fall-related injuries .

14. Prevention of Home & Work Related fall-Injuries:The leading causes of falls among Aged Adults XI. Environmental barriers … the aged adult is often immersed in a dangerous environment (e.g. home) that poses great hazards, such as: • Slick surfaces • Uneven surfaces or stairs • Darkened hallways, corridors, entryways, and rooms • Clutter filled rooms • Narrow doorways • Lack of hand-rails and grab-bars … for stability • Too much furniture which leads to trip hazards • P3 (pools, patios & pastures): the exterior of the house • Transitional Spaces

15. Prevention of Home & Work Related fall-Injuries:Adverse Drug Interactions In the United States $75 Billion Dollars are spent annually on Prescription Medicine (Pham and Dickman, American Family Physician, 2007)

16. Prevention of Home & Work Related fall-Injuries:Managing Adverse Drug Interactions Adverse Drug Interactions … the aged adult who is labeled as a polypharmacy candidate is one that has several co-morbidities and consumes four or more prescription medications daily. • Providers resort to polypharmacy for symptom management among patients with complex medical problems. • Avoid or use with extreme caution when administering … Digoxin (Lanoxin), Glyburide (Diabetic Medication), Robaxin(muscle relaxant), Benzodiazepine (Valium), Chlordiazepoxide (Librium),Meperidine(Demorol), OTC-drugs, such as, Tylenol PM and Benadryl. • Gigoxin • Glyburide • Robaxin • Benzodiazepine • Chlordiazepoxide • Meperidine • OTC-drugs • Herbs and Remedies

17. Prevention of Home & Work Related fall-Injuries:Managing Adverse Drug Interaction Why should we (e.g. providers) be concerned with Polypharmacy? • Because more than 40% of ambulatory adults older than 65 years of age use at least five (5) medications per week, and 12 % use at least ten (10) medications a week (Pham and Dickman, 2007). • Because about one in three older adults taking at least 5 medications will experience an adverse drug event each year (Pham and Dickman, 2007). • Patient non-adherence (non-compliance) occurs at 40-60% of those taking prescription medication. This issue is dual-hatted as it indicates that patients do not take their prescribed medications when told to and when told to stop taking them-patients continue to consume these medications-thinking they are beneficial (Pham and Dickman, 2007). . • Two-thirds of older adults do not tell their physician in advance that they plan to underuse a medication because of its cost, and in follow-up visits 35% never discuss that they have underused or misused the medication. (Pham and Dickman, 2007).

18. Prevention of Home & Work Related fall-Injuries:Managing Adverse Drug Interaction What are the six questions seniors should ask their provider (MD, PA, NP, PCM)? • What is the name of the medicine? • What is the medicine supposed to do? • How and when do I take it and for how long? • What foods drinks, and other medicines or activities should I avoid while taking this medicine? • What are the possible side effects and what do I do if they occur? • Is there any written information about the medicine? *By having the patient/client ask his/her provider these six questions they can prevent confusion and potentially avert adverse drug events (ADEs).

19. Prevention of Home & Work Related fall-Injuries:Managing Adverse Drug Interaction Tips on prevention adverse drug interactions: • OTC’s… even though OTC (over the counter) medications do not need a prescription they can lead to serious side effects among aged adults; thus, you should ask your provider prior to taking them. • Med-Log … make a list of all the medications you take, their doses, and how often you take them; remember to update any new drug(s) or doses to your list when a change is made. • Med-Reconciliation … make an appointment once or twice a year to review your medicines with your PCP/PCM; ask whether you need to continue taking each one at its current dose. • Med Instructions … take your medicines exactly as directed by your health care provider; try to have all your prescriptions filled/dispensed at the same pharmacy…most pharmacies have medical data-bases that alert the pharmacist of possible drug interactions.

20. Prevention of Home & Work Related fall-Injuries:Managing Adverse Drug Interaction Medication “Do’s and Don’ts” • Do … throw away medication if the medicine has expired • Do … make a list of your medications and understand what each one does • Do … ask questions (to MD, PA, NP, Pharmacist, etc.) • Do … use a pillbox (dispenser) to help you remember when to take your medication. • Don’t … take medication that has passed its expiration date. • Don’t … stop taking medication just because you feel better . • Don’t … ingest alcohol when you take your medication, unless you have spoken with your doctor first; drinking alcohol when taking sleep, anxiety or depression medicines is considered unsafe.

21. Prevention of Home & Work Related fall-Injuries:“Let’s take a close look at the many barriers & obstacles” Home Assessment: A Walk Through the Interior & Exterior

22. Prevention of Home & Work Related fall-Injuries:“Let’s take a close look at the many barriers & obstacles” Home Assessment & Safety: • Home assessments are performed to ensure patients can safely return and/or reintegrate into their home environment. • Home assessments… just follow the A, B, C’s: a. (Allow) … for safe and clutter-free mobility within the patient’s home. b. (Barriers) … identify potential barriers that could lead to falls & do so before the pt. returns to his/her home. c. (Convey) … the importance of fall-prevention and home-safety to family members and care-givers. • The general consensus is togrey in place, thus, older adults want to return to their home after D/C.

23. Prevention of Home & Work Related fall-Injuries:“Let’s take a close look at the many barriers & obstacles” Home Assessment & Safety: • Home assessments • Should be performedprior to the patient returning to their respective home. (*Gold-Standard) • Should be performed in a standardized fashion that includes the interior & exterior of the structure (e.g. home, mobile-home, apartment, townhouse, condo, etc.). • Should never be complex, lengthy or costly. • Should never cost the homeowner a lot of money to abate the safety hazard; 85% of all abatement recommendations for home modifications cost absolutely nothing (Stevens, J.A. 2005: NCOA National Center for Injury Prevention & Control, CDC)

24. Prevention of Home & Work Related fall-Injuries:“Let’s take a close look at the many barriers & obstacles” Home Assessments & Safety: • Home assessments evaluate the following barriers: 1. Throw-rugs, area rugs or afghan rugs 2. Extension cords or loose telephone- cords strewn over common areas 3. Floor-surface: a. Tiled surface b. Wood surface c. Carpeting d. Polished or stained concrete

25. Prevention of Home & Work Related fall-Injuries:“Let’s take a close look at the many barriers & obstacles” Home Assessments & Safety: • Home assessments evaluate the following barriers: 4. Entry threshold (e.g. weather seals) can become a trip hazard-when using a walker. 5. Long transparent O2-tubing 6. Stairs and flimsy hand-rails (banisters) a. cause bowing b. not made for weight-bearing c. can be pulled from the wall (*improperly anchored) d. require additional support

26. Prevention of Home & Work Related fall-Injuries:“Let’s take a close look at the many barriers & obstacles” Home Assessments evaluate the following barriers (Cont.) 7. Narrow doorways (*old homes) • old homes have very narrow doorways (>25 inches wide) 8. Dimly lit hallways/passage-ways 9. Bathtub height (*difficulty with transfers) 10. Bathtub & Shower water temperature 11. Steps/stairs leading to the entrance/exit of the home. The Laws of Unintended Consequences.

27. Prevention of Home & Work Related fall-Injuries:“Let’s take a close look at the many barriers & obstacles” Home Assessments evaluate the following barriers (Cont.) 12. High kitchen Counters/cabinetry • Difficult for wheelchair bound patients to access. • Expensive retrofits for kitchen cabinetry can be prohibitive in cost. 13. Central Island Designs • Force patients/clients with walkers, canes, and in wheelchairs to navigate around these Islands. 14. Crowded Kitchen floor-plans • Patients incur falls w/in kitchens because they must crisscross the area often (or) must navigate around the kitchen’s central island.

28. Prevention of Home & Work Related fall-Injuries:“Let’s take a close look at the many barriers & obstacles” Home Assessments evaluate the following barriers (Cont.) 15. Flimsy night tables at bedside • Patients tend to weight-bear over furniture-which lead to falls at night 16. Bed height-may be too low or too high 17. Cordless or Wall-mounted Telephones: cause unnecessary walking to answer the phone • Move phone to night table & avoid using long telephone extensions or use cell-phones.

29. Prevention of Home & Work Related fall-Injuries:“Let’s take a close look at the many barriers & obstacles” Home Assessments evaluate the following barriers (Cont.): • Floor vents for (AC/Heating) • trip hazards • Iron steam heaters (*radiator type). • May cause burns due to polyneuropathy and being insensate (* a hazard for both the elderly and the children). • Exposed pipes (*in the bathroom sink). • Ditto-as per above

30. Prevention of Home & Work Related fall-Injuries:“Let’s take a close look at the many barriers & obstacles” Home Assessments evaluate the following barriers (Cont.): • In-door Pets (*poor vision among the aged cause them to trip or fall over their pets). • Pets congregate around their owners when they stand up. • Pets enjoy lying next to their owner’s feet • Pets require care, maintenance, and supervision • Safety concern for recurring falls (get help!)

31. Prevention of Home & Work Related fall-Injuries:“Let’s take a close look at the many barriers & obstacles” “My pets! They are adorable and very loved, but they run around and get under your feet. My grandma has a hard time moving around the house in her walker sometimes when they are playing. So, they were responsible for causing her to falla few weeks back. My grandmother tripped on one of their play-toys.” Quotes from the granddaughter of an elderly patient who tripped and sustained a Fx’ed Hip (2009) Tannen Bailey

32. Prevention of Home & Work Related fall-Injuries:“Let’s take a close look at the many barriers & obstacles” Home Assessments evaluate the following barriers (Cont.): 22. Light switches (automatic: motion sensors). • Keep the patient’s “hands on the wheel” when using assistive ambulation devices. 23. Rocking chairs (or) chairs w/casters • Chairs/sofas/benches should always be stationary. 24. Piles newspapers & magazines • pack-rat mentality-can’t bear to throw anything away. • These are important decisions-enlist the assistance of family members.

33. Prevention of Home & Work Related fall-Injuries:“Let’s take a close look at the many barriers & obstacles” Home Assessments (special considerations) 25. Mobile Homes: • Gaining entry into a mobile home may prove difficult, as a result of the steps that lead into it. • Metal grating steps are narrow. • Metal grating steps are steep (steep-pitch). • Most steps do not have hand-rails. • This is a dangerous “transitional space” forpatients with questionable mobility and balance.

34. Prevention of Home & Work Related fall-Injuries:“Let’s take a close look at the many barriers & obstacles” Home Assessments (special considerations) 26. Mobile Homes: • Mobile homes do not allow for extensive modification due to their construction. • Narrow hallways and doorways. • Small bathrooms, bedrooms & closets. • Walls are thin and constructed out of aluminum, plastic, and/or fiberglass . • Impairsthe patient’s ability to ambulate with canes, walkers and wheelchairs.

35. Prevention of Home & Work Related fall-Injuries:“Let’s take a close look at the many barriers & obstacles” Mobile Homes: Floor plans-of- single wide mobile homes are less accommodating than are double wide homes

36. Prevention of Home & Work Related fall-Injuries:“What you should be looking for” Mobile Homes: • Keep in mind that patients that live • in mobile homes may be renting, thus, • any modifications that are recommended • must be cleared through the landlord • first. • You cannot advocate for extensive retro- • fits to mobile homes, as any structural • change to the home have dangerous • consequences to the structural integrity.

37. Prevention of Home & Work Related fall-Injuries:Abatement ConsiderationsCDC-Center for Disease Control & Minnesota Safety Council, 2004 RMFs Retrofits, Modifications and Functional Improvements

38. Prevention of Home & Work Related fall-Injuries:Abatement Considerations Retrofits, Modification and Functional Improvements • Bathtub grab-bars need to be mounted vertically, as well as, horizontally. • Grab-bars should have a non-slip rough finish. • Grab-bars must be secured with proper anchors to support wt. bearing. • [Do not] … use slick porcelain-finished grab bars . • [Do not] … use suction-cupped grab bars. • Shower-stalls are preferred over tub-showers: • Promotes energy conservation & safety. • Hand-Held Shower-head is preferred over a standard overhead shower.

39. Prevention of Home & Work Related fall-Injuries:Abatement Considerations Retrofits, Modification and Functional Improvements • Sliding glass doors mounted on bathtubs and showers (trip & fall hazard): • As a rule of thumb, glass, water and slick-tile should never mix. • Sliding glass shower doors are generally made of non-tempered glass, thus, it will shatter and form sharp edges. • Patients with poor balance or cannot transfer independently may weight-bear on the metal towel-rack and shatter the glass.

40. Prevention of Home & Work Related fall-Injuries:Abatement Considerations Retrofits, Modification and Functional Improvements • The bed-height should be raised or lowered for the elderly or disabled patient to use safely. • Be careful with bedside-rails … these ought to be installed properly to prevent falls. • Bedside rails also promote transfer independence into/out of the bed. • Night-lights are an invaluable tool for bedrooms, bathrooms and dimly lighted hallways.

41. Prevention of Home & Work Related fall-Injuries:Abatement Considerations Retrofits, Modification and Functional Improvements • The bed-height (plastic risers); these are commercially available and inexpensive; (A) Courtesy of North Coast Medical; Furniture Riser Set, 2013 • Bedding causing a trip-hazard (e.g. fluffy comforters): • Beds with draped sheets, comforters, or fancy ruffles that are used around patients with poor ambulation skills or balance… must be removed. A

42. Prevention of Home & Work Related fall-Injuries:Abatement Considerations Retrofits, Modification and Functional Improvements • Doors with keyless entry or “Smart-key Systems” can be retrofitted to the homes’ entrance to mitigate the need for keys • Great for Arthritic & Neuro-patients; and enhances the security of ones’ home. • Door handles should be lever-handles not of the door-knob type. B [B] Lathem Keyless Entry Door Lock Model#LX100R

43. Prevention of Home & Work Related fall-Injuries:Abatement Considerations Retrofits, Modification and Functional Improvements • Uneven driveways, entryways, decorative pavers, stamped-concrete need to be assessed. • Uneven surfaces can cause patients to lose their balance when ambulating over them. • Concrete sidewalks with cracks are very much a trip hazard; these need immediate attention. • ½ to ¾ inch plywood can be placed over these irregular surfaces until the patient’s balance or ambulation-skills improves. B

44. Prevention of Home & Work Related fall-Injuries:Abatement Considerations Retrofits, Modification and Functional Improvements • Self-dimming lights are used in frequently traveled areas of the house, such as, the hallways, bathroom, kitchen and entrance. • These lights are triggered by movement (e.g. motion sensor). • Patient or family member adjusts the “time-on” and “width” or sensitivity of the sensor (beam). • When sensor is triggered-the light is turned on for a preset period of time, then it turns off automatically.

45. Prevention of Home & Work Related fall-Injuries:Abatement Considerations Retrofits, Modification and Functional Improvements • Transitional Spaces: • Entry foyer (front-door) • Bath tub or shower • Stairs & Sunken-living-rooms • Pools, Patios & Pastures • Transitional Spaces & increased threat of falls: • Patients incur a greater risk of falling • Places that are regarded risky if the patient has low vision, poor balance, and less than ideal functional ambulation skills.

46. Prevention of Home & Work Related fall-Injuries:Abatement Considerations Retrofits, Modification and Functional Improvements • Poor Ergonomics and overuse syndromes: problems crop-up at home, as well as, the office-workplace (*Cumulative Trauma Disorders: CTDs). • Assess the person’s equipment & how they use it;such as: • Keyboard positioning • Monitor location • Monitor screen (Polarizing filters) • Lumbar supportand overhead lighting • Mouse placementand wrist guard • Computer chair with 5-casters vs. 4 casters.

47. Prevention of Home & Work Related fall-Injuries:Abatement Considerations Telecommuting Retrofits, Modification and Functional Improvements • Many workers are opting to work from their homes part-time or full-time. • Workers are more productive working from their homes than they are in traditional worksites. • It reduces the physical-space requirements of the “home-office” (e.g. headquarters). • It reduces the “down-time” incurred from non-productive vehicular commutes. • Young parents are better able to balance children, families, and work responsibilities. Raftey, I. (2013). Telecommuting, CNBC

48. Prevention of Home & Work Related fall-Injuries:Abatement ConsiderationsCampbell, R.J. (2008) (Computers & Seniors) • Seniors and computer-phobia (*A known myth): • Seniors are interfacing with the home PC with increasing frequency because they need goods and services. • Seniors have accepted this foreign method of communication because they are “home-bound”. • Seniors make up 28% of all online users w/in the U.S. (the 55+ y/o) • Seniors are the fastest growing segment of internet users in the U.S. • Seniors spend more time online than do teenagers (13-19 y/o).

49. Prevention of Home & Work Related fall-Injuries:Abatement ConsiderationsAdler, R. (2002) (Computers & Seniors) • Seniors and computer-phobia: • Seniors make up 60% of all healthcare spending in the U.S. ($2.28 Trillion dollars annually). • Seniors purchase 51% of all over the counter medicines. • Seniors spend over $7.5 billion dollars on online purchases annually. • Seniors are very comfortable in the use of Skype to connect with their children and grandchildren & will use this “media” to speak with their doctor/nurse.

50. Prevention of Home & Work Related fall-Injuries:Abatement Considerations Home Ergonomics … (Computers-&-Access) • Telehealth and Seniors … telehealth, telemedicine, and tele-consultation are becoming acceptable means of monitoring seniors: • Because they are unable to use public transportation and/or cannot drive to the PCM’s office. • Because technology (bandwidth, and internet speed) allows connectivity from virtually any remote location on earth. • Because elderly pts with more than three comorbities are considered “high-risk-patients” and are the most vulnerable to relapse & readmissions. Telehealth Program LDLP at FL International University