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.

[chrisrn24]

Playing devils advocate...so Ativan, Seroquel and Haldol have NO uses? I know they are "chemical restraints" but if you try all these non-medication interventions and they don't work, why not try a small dose? The person is clearly agitated if they keep trying to stand and if a walking program, scheduled tolieting program and nothing is working, is that it??

I agree not to jump to antipsychotics and antianxiety meds but for many, many people they are effective!

[ClearBlueOctoberSky]

Just because she is trying to get out of the chair, it doesn't mean she is agitated. Again, what is making her want to get up? Alzheimer's patients wander. It can be comforting to them of it could be she is looking for something. It is not something that can or should be "fixed" with antipsychotics.

Antipsychotics were never meant for this. They increase falls, confusion, can cause paradoxical agitation, and increase the risk of death. Is her getting up and wanting to wander really that bothersome that you need to chemically restrain her? If it was my mother, I would be livid.

Find out what she is wanting, and then make her environment safer for her. One intervention would be hipsters. There are some that have been proven to prevent or reduce the risk of hip fractures with falls when used properly.

[morte, LPN, LVN]

does she have RLS? is she anemic?

[autumnlea]

What are hipsters?

Her dx is: Alzheimer's, Dementia, Depression, HTN and high cholest.

[morte, LPN, LVN]

garmnts that look like shorts with foam rubber over the lateral hip area.

What are hipsters?

Her dx is: Alzheimer's, Dementia, Depression, HTN and high cholest.

[ClearBlueOctoberSky]

Google safehip hip protectors.

Another question would be is if she is falling within 5 feet of her wheelchair, or whichever transfer surface she is getting up from, have you checked orthostatic vital signs? Have done a review to see if she actually still needs her HTN meds?

[kbrn2002, ADN, RN]

Can you consider a mobility alarm? There are several on the market that sound when pressure is lifted off the alarm alerting staff that she is standing up. Also there are seat cushions that make it more difficult, but not impossible to stand. The pommel cushions are nice, but really need to be properly fit to the person or they are uncomfortable and thus defeat their purpose totally. The wedge shape cushions usually require a little shorter chair to ensure the pt can easily reach the floor with their feet, otherwise it limits mobility and this can in some circumstances be considered a restraint. Depending on state laws/guidelines a seat belt may be appropriate, but I personally would look into it very carefully before considering one. I am guessing the family is determined to keep her at home as long as possible, unfortunately she may be reaching the point where that is no longer safe. Good luck finding something that works.

[cancermom]

If it is determined that she is getting up because she is bored there are several things you can do. Google activity aprons or pillows and you will see a variety available. Folding and refolding a stack of washcloths, or separating a can of nuts and bolts may help to keep her occupied. I remember one patient who was confused in the acute care setting and was always trying to get out of bed...after we assured all basic needs were met I asked the family what the gentlemans work was before he retired. Turns out he was a math teacher. I spent 5-10 minutes jotting down some math problems and it kept him occupied for a while. The next day the family brought in a math activity book that you buy for kids and that kept him busy also. He was s/p cardiac bypass and often those patients had what we lovingly referred to as "pump head". Some would clear the minute they walked out of the hospital. I know this may not seem appropriate for the home, but sometimes you need to try anything.

[BrnEyedGirl, BSN, MSN, RN, APRN]

I don't understand why it is illegal to use a seatbelt, posey vest etc on an elderly person, who isn't strong enough to stand/walk/transfer on her own, who isn't mentally capable of understanding the consequences of attempting to walk/stand etc and might hurt themselves by trying. However I am encouraged to strap my 18 month old into her car seat highchair, stroller, baby carrier, etc because she isn't strong enough to walk/stand etc............. makes no sense at all!

[chrisrn24]

I don't understand why it is illegal to use a seatbelt posey vest etc on an elderly person, who isn't strong enough to stand/walk/transfer on her own, who isn't mentally capable of understanding the consequences of attempting to walk/stand etc and might hurt themselves by trying. However I am encouraged to strap my 18 month old into her car seat highchair, stroller, baby carrier, etc because she isn't strong enough to walk/stand etc............. makes no sense at all![/quote']

I know!

[VivaLasViejas, ASN, RN]

Elderly people are not children. It is a dignity issue. Remember, people with dementia weren't always this way---even though they may behave like children, they are adults who have lived their lives, raised their families, worked and paid taxes, and done interesting things.

Think for a minute about what you yourself would want if you were to become frail, sick, demented. Imagine yourself being belted or tied into a chair. Do you think you might feel a little bit agitated, not knowing whether anyone will take you to the toilet, fix you something to eat, bring you some cool water to drink? I know I would.

Some of you probably don't remember the horror stories from the "old days" when elders were routinely strapped into wheelchairs or beds and left alone, sometimes to marinate in their own wastes, for hours on end. Some even became entangled in their restraints and were injured, or worse. I've only been a nurse for 16 years, but that's long enough to have seen too many lonely, frightened, confused human beings fastened to beds and geri-chairs for much of their hospital stays. The aim was a noble one---we didn't want them falling out and breaking a hip---but no one will ever know what the damage to their psyches might have been.

[kbrn2002, ADN, RN]

Totally agree with Viva's above post. I have been in elder care for long enough to remember the days of posey belts, bed restraints, geri chairs, merry walkers and full side rails. I don't miss them at all. Not only is it a dignity issue [would you want your mother to be tied down with something that closely resembles a straight jacket? or you when you can no longer care for yourself?] but I really don't think they prevented injury and in several cases caused physical harm. We had many more pressure ulcers in those days because people couldn't move, and sad as it may be since they were tied down and couldn't move anyway their toileting needs were often neglected for long periods of time so they were also sitting/laying immobile and soiled. In cases where an inevitable fall still happened the risk of severe injury was much higher since it wasn't just the person that fell but also the chair they were strapped to. Even the full bed rails just contributed to injury when residents crawled over them and fell from an even greater height and in a very awkward position. As difficult as preventing falls may be, there are definitely better options than those.