Integrating care team strategies to prevent falls related to behavioural factors

Posted February 1, 2016

Shaila Aranha RN, M.Sc.N, RNAO Long-Term Care Best Practice Coordinator for Waterloo Wellington LHIN and the team of Psychogeriatric Resource Consultants of Waterloo Wellington LHIN: Betty Perrin RN, BA (HS); Heidi Wagler RN; Terri L. Adlam B.A., M.Sc ; Sharon Stap RN, BScN, GNC(c)


The care teams in long term care homes are applying the education and training they have received related to Gentle Persuasive Approach (GPA), PIECES and U First, Validation and Montessori. Elements from each of these approaches form the foundation of the many best practices in long term care. Fall prevention is linked to each of these educational initiatives with subsequent awareness and behaviour support interventions.


Resident care teams in long term care homes in the Waterloo Wellington LHIN have an understanding of the meaning behind resident behaviour, as taught in GPA, and have demonstrated use of this learning to identify risk factors for residents with predictable responsive behaviours, including those that pose as a fall risk or may result in a fall. They have developed interventions and strategies to accommodate these behaviours and prevent falls.


Long term care home teams within the LHIN have shared strategies that they used by recognizing the early cues of a resident's behaviour. These strategies specifically resulted in reducing the risk of falls or preventing falls and related injuries by taking into consideration the intrinsic, extrinsic, environmental and pharmacological factors.


When they observed that residents were restless while sitting in their chairs, long term care teams recognized this as an indication that the resident was seeking a change in their position. The resident was more settled when they were escorted for a short walk down the hallway or repositioned in the chair. Caregivers offered rest periods in bed in a timely way, which may also have contributed to prevent a fall out of the chair.


Offering toileting assistance as needed and during regular scheduled rounds has reduced occasions when residents attempted to toilet themselves. This has decreased the number of falls and injuries occurring in the bathrooms. Care teams have found that providing assistance with turning on the lights for residents with dementia who have an altered perception of their environment, has reduced falls related to environmental risk factors.


During activities, LTC staff have encouraged guided exercise and rehabilitation for residents with dementia to support them with their loss of coordination and forgetfulness in performing complex motor tasks, such as walking. This has helped maintain their existing abilities. Care teams have recognized times of the day when residents may get bored, such as in the afternoon and often in the evening when there is diminished lighting. Introducing group activity periods during these times to engage the residents has minimized pacing behaviours and resulting falls.


Some residents, however, feel over stimulated participating in recreational activities, if the activities surpass their attention span. Care teams have observed such residents leaving the activity setting, thus predisposing them to falls when they leave the group. Activity programs of shorter duration have reduced prolonged stimulation, increased resident participation and provided increased opportunity for monitoring of residents while in the group setting.


The "Activity Apron" has been introduced for residents who have been identified as kinesthetic. Observations of residents' behaviours such as reaching down and out of their chairs to repetitively untie and tie their shoelaces or velcro straps was identified as an unmet need for "busy hands". When the resident wears the activity apron over their clothing, they are satisfied with working on the pockets, straps, ties, buttons, zippers and textured materials, which are within a reachable distance, so as to prevent sliding out of the chair.


Dining rooms within the homes were becoming an area of high stimulation and high traffic with a single seating dining arrangement. Residents were becoming more agitated and often removed themselves from this high stimulation zone. The limited space and high number of residents and caregivers assisting at a single seating created an environmental challenge for residents walking about, including those with walking aids. Moving to a two seating dining schedule has transformed the dining experience to one where residents are not only engaged in a more social setting, but where there are less environmental risks, which has prevented falls.


Non-pharmacological approaches and strategies used by care teams may sometimes be supplemented with medication to treat the behavioural and psychological symptoms of dementia. Care teams work together to monitor how the resident is responding to medications, noting side effects that may include an unsteady gait or dizziness. They carefully consider the benefits and risks associated with these medications, along with closely monitoring for side effects, which is essential to the prevention of falls.


Care strategies which were used as part of the Behaviour Support Ontario program to care for residents with responsive behaviours have demonstrated many successes when integrated into the fall prevention programs in long term care. Resident care teams have used their learning to guide their work related to behavioural factors, and have been creative in implementing ways to prevent risks, falls and injuries related to falls.