Need advice: Frequent falls of non compliant homebound pt with dementia

[autumnlea]

I'm RN supervisor for home health agency.

We have an at home 87 yr old frail, non compliant female pt with frequent falls and dementia.

Family wants to know from us how they and/or we, can keep her from falling out of wheelchair 4-6 x daily without using restraints (which we never use.)

I have spoken with the daughter several times re. state law prohibiting use of restraints.

She has a room to room monitor so she can hear her Mother.

Our 2 CNA's live on with the patient in her home. CNA's each have 12 hr shift.

Client will try to stand up or ambulate without giving any indication of her desires to get up and she has frequent daily falls up tp 6 x a day resulting in bruises and discomfort.

Any suggestions as to how without restraints this situation can be better managed?

Thanks for ANY suggestions or examples of what you have seen or done in similar situation.

[SamL]

Are you able to get her to sit in another chair than the wheelchair, which she is always slipping down and falling out of? Perhaps one that is deeper and she can't get out as easily. But maybe this would be seen as a restraint...

Otherwise, maybe a chair or floor sensor, so once she goes to move off the wheelchair, or slips down, an alert is raised.

[chrisrn24]

Another thought: any other major medical dx other than dementia??

Eta - a chair alarm too!

[autumnlea]

Good ideas.

Thank you.

[ClearBlueOctoberSky]

It is inappropriate to use Ativan, Seroquel or any other drug to keep this LOL from getting out of her chair. They MIGHT be appropriate for aggressive behavior, and WILL increase her falling.

You need to do root cause analysis to see WHY she is getting up. It is NOT just her dementia, there is a reason. There is an unmet need to cause her falling that you need to address. Alarms will increase your falls as well, and do nothing but tell you that they are up. Do a search on alarms and falling in the elderly.

Is there a reason the aides can't put a gait belt on and walk with her? Is she in pain, need to reposition herself, or potty? Is she bored and need something to do?

You really need to do the root cause to find an appropriate intervention. Medicating someone just to keep them sitting down? That IS a restraint, and frankly just tilts me and makes me angry. There is only a few appropriate diagnosis for antipsychotics in the elderly. Schizophrenia, Psychosis, Huntington's send Tourette's. Dementia is not one of them.

Find the cause, put the APPROPRIATE intervention in place, decrease the falls.

[malestunurse]

Is she in pain, need to reposition herself, or potty? Is she bored and need something to do?

OP said she gets up to try and get home. However, I agree benzos are chemical restraint. Are chemical restraints allowed but physical restraints not allowed?

[canigraduate]

Hmmm... I agree with the posters that mention something is causing this lady to get up. In my experience, dementia patients get up for four main reasons: their backs hurt from sitting down, they're bored, they have to potty, they're hungry/thirsty.

So, the first interventions I would try are help this lady reposition a lot or maybe ambulate with her if she is able, find some little activity to keep her occupied, toilet her frequently, and offer her snacks and drinks throughout the day.

If she is still falling frequently after all this, the next best thing to do is make the floor nearby soft enough that she doesn't hurt herself when she hits it. Place cushions, piled up blankets, pillows, or whatever you have on hand on the floor in front of the chair.

Oh, one more thing. Sometimes dementia patients are trying to "escape" from caregivers who they perceive as threatening. Make sure the CNA and whoever else is dealing with her are not approaching her from a place of frustration, because they can be exacerbating the problem.

[mercurysmom]

If she's sliding out of a wheelchair or chair, how about putting a piece of Dycem (a non-slip rubbery mat used to keep plates sliding off the tray) so she's less likely to slide around? I also agree that pain, hunger, boredom, fatigue, need to urinate/defecate need to be checked frequently.

[nurseprnRN, BSN, RN]

I agree with the snacks-at-hand and frequent toileting thing. I see that in brain injured folks all the time, and it just frosts me to see them diapered because nobody has the time or inclination to put them on bowel plans or do two-hourly toileting.

Maybe giving her something to do to occupy her for a bit? A pile of napkins to fold, a baby doll to rock, some mail (junk mail is fine) to open and read and sort, cards for solitaire...? Push her chair up to the table and attach a string to it so if she pushes away a bell rings. You could even jury-rig a battery-operated door-opening alarm for that.

[VivaLasViejas, ASN, RN]

I agree that antipsychotics are totally inappropriate in this situation, especially as they tend to INCREASE falls because of the sedative effect. A seat belt is no solution either.....what if she slides down and gets hung up in it? I like the idea of the non-skid pad in the W/C, plus there are special seat cushions that are made in such a way that it's more difficult to get up unassisted.

However, if she's going to continue being cared for at home, the house needs to be made safe enough for her to fall, because she's going to. If there are throw rugs, they need to go away. Her bed should be put on the floor and against a wall, with a crash pad on the open side.....far safer to fall from the floor to the floor. Hip and elbow protectors are a good idea also. Corners of furniture should be padded, and furniture itself should be minimal so there are fewer obstructions in her path. And she does need to have something to keep her busy, as well as FREQUENT toileting, snacks, ambulation, and interaction with other people.

Frankly, I think this lady ought to be in memory care where there are many activities geared to people with dementia, and where the physical layout of their surroundings are safer. But she can fall there just as often as she does at home, and if she and/or her family have the $$ to pay for 24-hour 1:1 care, she's obviously going to have better supervision.

Bottom line, she still has rights, and one of those is the right to fall. We may not like it, but we can't tie her into a wheelchair or drug her into submission. Both are restraints!

[autumnlea]

Dx is: Dementia, Alzheimer's,Depression, HTN and high cholesterol

[autumnlea]

Many thanks for taking an interest and offering these excellent ideas.

[autumnlea]

Thanks will look further into it.