Loss of control: Exploring the links between falls and incontinence can improve resident care, safety scores and provider risk ratings
Urgency and the need for frequent toileting raise the risk of falls in seniors 26% and bone fractures 34%, experts say. Residents often hesitate to ask for help when they need to go to the bathroom, i
It might seem odd to some that resident falls and incontinence would be mentioned in the same breath. It actually can be difficult to estimate the extent to which one causes the other.
Yet, as clinical detectives have discovered, both subjects have a way of winding up in the same discussions. It all relates to the dangers for those residents who have lost control of their bodies in one or more ways.
Emerging research and technology are growing closer to uncovering major underlying issues that could lead to reductions of incontinence and falls. As a result, they're instilling hope for a better quality of life for millions of seniors.
Researchers have long been pretty clear on what causes falls and what causes incontinence. Only recently have their discoveries led to compelling statistical relevance of one to the other.
“Existing research suggests that the causes and consequences of some falls, rather than the falls themselves, can lead to incontinence issues,” observes Karla Fettich, Ph.D, head of algorithm development at Mpower.me. The group boasts a predictive analytics solution that it says prevented falls by 54% and incontinence by 71% on its initial deployment. Mpower.me is part of Orchestrall.
“Among the causes of falls that can also influence the risk for incontinence are impairment of lower and upper extremities, vision and hearing loss, problems with emotion regulation, and aging-related changes in the brain,” Fettich says. “Once a fall occurs, it can sometimes lead to hospitalization, limited mobility and strength impairment, which in some cases can result in the onset or worsening of bladder incontinence for elderly patients.”
In a 2009 “position statement” about the nurse's role, the Wound, Ostomy and Continence Nurses Society revealed that in the elderly population, the need for frequent toileting and/or urgency to void increases the risk of falls by 26% and bone fractures by 34%.
Conversely, evidence clearly shows that the trauma of a serious fall can instill fear of repeat injury that is so paralyzing that skipping the trip to the bathroom itself leads to incontinence.
Either way, the end results are damaging, and often devastating. “Nobody dies from incontinence or having to go 10 times a night,” notes Medtronic Senior Living's Executive Director Britton Garrett. “But when you think of an 85-year-old man in the middle of the night trying to get up from his bed to go to the restroom, there are profiles associated with that action that unfortunately can put his life at risk.”
The company recently introduced Medtronic NUROTM, a system that stimulates the tibial nerve in the lower leg to restore bladder function.
“We can make the assumption that if a resident isn't getting up at night and walking to the bath- room, their fall risk decreases,” says Sue Nall, executive director of the Village of Marymount, a Gar eld Heights, OH, continuing care community. Nall said residents receiving the NURO treatment reported they had increased ability to wait for staff assistance, decreasing their need to go to the bathroom unassisted.
It was nighttime falls en route to the bathroom that led to an epiphany for caregivers at a Missouri memory care facility. Soon staff began using a new technology combining bed and room sensors, video, artificial intelligence and analytics to identify critical physiological changes and predict falls up to three weeks before they occur.
Foresite PatientcareTM, the technology, was developed over the past 10 years by STANLEY Healthcare in conjunction with University of Missouri researchers, among the pioneers in sensor technology applications in long-term care.
An elderly man's repeated falls, logged by in-room HIPAA compliant video over a seven-day period, led to a discovery, says Lauren Horn, RN, MSN. She's the national sales manager for fall management for STANLEY Healthcare and had been oversee- ing implementation of Foresite at the man's facility.
“Prior to implementing, the caregivers were finding him on the floor and didn't know why,” Horn says. Only after receiving the alerts for his falls and reviewing the Foresite data did a pattern emerge. “Every night between 1 a.m. and 5 a.m., he was getting out of bed trying to make it to the bathroom but instead would end up falling and losing control of his bladder.”
Horn showed the staff how to use the program's analytics to implement a care plan change. The new care plan established a schedule for staff to check on the man at set intervals and assist him on his way to the toilet.
“Since the care plan was put into place he has not fallen once,” she says. “Just that simple piece. Even someone sitting in his room wouldn't have picked up the trends. Using artificial intelligence through the advanced sensors and having the ability to review the data allowed them to quickly identify and help this guy. It was a big win for the caregivers and a huge one for the staff overall.”
Instead of scolding the night shift for missing the falls, the nursing director showed them the data and the video (which for privacy reasons is grainy, ghosted imagery).
“A lot of times it's the DON or director of wellness telling some- one they need to do this with a care plan and it's sometimes dif- cult for staff to understand why,” Horn says. “Being able to see the incident unfold and understand the data that's collected really put them in the driver's seat.”
According to Bryan Adams,
COO of GreatCall, passive monitoring technology benefits both providers and caregivers: enabling providers to achieve better health outcomes and reducing per capita costs of healthcare, and offering caregivers peace of mind that the care recipient is at lower odds of an adverse event.
For now, clinicians such as Horn more clearly understand the “revolving door” of incontinence and falls.
“Urinary tract infections can lead to so many other things like incontinence, which leads to falls, or delirium, which goes back to falls,” Horn says. “I've talked about this for years because some- times it's like the chicken and the egg. Often it's not one single cause or another. Incontinence and falls both go back and forth. One can precede the other. Without having data to identify the cause and effect, it's hard for caregivers to know what's really happening.”
Horn asserts there are three major root causes at work: Physiological — “a head injury, for example, that perhaps makes it difficult for the brain to signal the need to reach a bathroom to void.”
Physical — “A hip fracture, or decreased mobility just from the pain from the fall, can lead to you not being able to make it to the bathroom, which leads to incontinence.”
Psychological — “When someone falls, there is a true fear of fall- ing [again], whether they admit or not,” she says. “So they start to self-limit their activities and they don't get up, and that leads to further weakness, which can lead to further falls, but also to incontinence from the fear of falling.”
Mounting evidence also is beginning to reveal one culprit among the swirl of falls and incontinence. New overactive bladder treatments like anticholinergics, for example, provide cures that are arguably worse than the conditions they were developed to treat because they've been linked to blurred vision and dementia-like symptoms.
Researchers also are examining the increased use of insomnia medications that may be behind higher rates of urinary incontinence and falls. Insomnia itself also is a culprit.
“Short nighttime sleep duration and increased sleep fragmentation are associated with increased risk of falls in older women, independent of benzodiazepine use and other risk factors for falls,” says Tony Forsberg, national clinical director for Essity Health and Medical Solutions.
In other words, taking too many drugs leads to unpredictable outcomes.
“When you look at the top reasons for falls, I would say it goes beyond high-risk medications,” says Horn. “The real issue in our elderly right now is polypharmacy.”
In its white paper on nursing's role, WOCN asserts that while incontinence suffers from stigma and low reporting, approximately 80% of the people affected by urinary incontinence can be cured or improved. That's something many clinicians involved in its treatment can build upon every day.
Meanwhile, groups such as the Minnesota Hospital Association tout simple, yet proven “within-arm's-reach” methods for staff involvement in prevent- ing toileting-related falls, as well as sleep med management, and low beds and bedside floor mats.
Members of the vendor community continue reminding care- givers to toss out preconceived notions that incontinence is a lost cause. It is a battle that should be fought continually.
“While urinary incontinence is more prevalent with age, it is not a natural part of aging,” says Liz Jensen, RN, MSN, RN-BC, clinical director at Direct Supply. “Comprehensive, person-centric assessments and an interprofessional approach to care planning can help many residents who experience incontinence either reduce the number of episodes per day or restore continence altogether, while reducing risk of falls.”
That's a one-two combo every provider should be aiming for.