Course Instructor: Dr. Jose R. Rafols

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

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:

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.

The leading causes of falls among Aged Adults
Prevention of Home & Work Related fall-Injuries: A Transdisciplinary Approach The leading causes of falls among Aged Adults

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

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 devises and generalized weakness in LE’s.

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

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.

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).

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.

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.

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.

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 .

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

(Pham and Dickman, American Family Physician, 2007)
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)

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

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).

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).

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.

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.

Home Assessment: A Walk Through the Interior & Exterior
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

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 to grey in place, thus, older adults want to return to their home after D/C.

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 performed prior 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)

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

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

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.

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.

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.

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 OK

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!)

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 fall a 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

23. Rocking chairs (or) chairs w/casters
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.): Light switches (automatic: motion sensors). Keep the patient’s “hands on the wheel” when using assistive ambulation devices. Rocking chairs (or) chairs w/casters Chairs/sofas/benches should always be stationary. Piles newspapers & magazines pack-rat mentality-can’t bear to throw anything away. These are important decisions-enlist the assistance of family members. Rocking chair photo should be under lite switch photo (*Pictures were switched)

Home Assessments (special considerations)
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” for patients with questionable mobility and balance.

Home Assessments (special considerations)
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 . Impairs the patient’s ability to ambulate with canes, walkers and wheelchairs. OK

Floor plans-of- single wide
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

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 retrofits to mobile homes, as any structural change to the home have dangerous consequences to the structural integrity.

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

Retrofits, Modification and Functional Improvements
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. OK

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.

Functional Improvements
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.

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 OK

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 Ok [B] Lathem Keyless Entry Door Lock Model#LX100R

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

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. Ok

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.

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 support and overhead lighting Mouse placement and wrist guard Computer chair with 5-casters vs. 4 casters. OK

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 OK

Prevention of Home & Work Related fall-Injuries: Abatement Considerations Campbell, 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).

Prevention of Home & Work Related fall-Injuries: Abatement Considerations Adler, 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. OK

Telehealth Program LDLP at FL International University
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

Telehealth Program LDLP at FL International University
Prevention of Home & Work Related fall-Injuries: Abatement Considerations Home Ergonomics … (Medical Surveillance) Telehealth and Seniors … allow PCMs and specialists to reach-out to home-bound patients: Frequent check-ups (Face to Face and Video-Teleconference) keep high-risk patients out of hospitals. Telehealth allows for what is referred to as “Telemonitoring”… vital signs, drug compliance, wound-care check-ups, proper use of O2, etc. Allows the PCM/Specialist to answer questions. Allows for the three “R’s” (reassure, review and redirect) in a timely manner. OK Telehealth Program LDLP at FL International University

(Retrofits, Modifications, and Functional Improvements)
Prevention of Home & Work Related fall-Injuries: Abatement Considerations RMFs (Retrofits, Modifications, and Functional Improvements) THINK FUNCTION

Prevention of Home & Work Related fall-Injuries: Abatement Considerations Retrofits, Modification and Functional Improvements Approach homes and surrounding areas as potential hazards. Look at toilet heights. Look at floor surfaces, such as, unrecognizable steps (or) step-offs. Non-tempered glass in shower-stalls. The entry-portal of the house and the height of the threshold. OK

Prevention of Home & Work Related fall-Injuries: Abatement Considerations Retrofits, Modification and Functional Improvements Shower glass panes: recommend use of another shower or remove glass doors and hang shower curtains. Concrete stairs: build an appropriate ramp; however, with this abatement a ramp could not be placed; grab bars were installed in the door-way & double sided bright tape placed at edge of each concrete step. OK

Prevention of Home & Work Related fall-Injuries: Abatement Considerations Retrofits, Modification and Functional Improvements Low lying toilet seat: use three-in-one toilet chair or the elevated toilet (plastic toilet seat insert) to promote ease of use. Raised entryway: change out for the kind that connects to the bottom of door, thus, allowing for smooth transition from out-side-to-inside and vise-versa. Ask the patient, spouse, family members or friends if they feel comfortable doing the retrofits or modifications or if they prefer to hire a certified and licensed ADA contractor. Seek-Help! Ok

Prevention of Home & Work Related fall-Injuries: Abatement Considerations Retrofits, Modification and Functional Improvements Home safety should never be taken for granted. Never assume the patient’s home is safe, just because they have never fallen or incurred injury. The patient’s or caretaker’s recollection may be clouded (*poor judgment or poor cognition). As you begin to conduct home or environmental assessments, think … how would I abate these obstacles or safety concerns and how much will they cost? OK

Prevention of Home & Work Related fall-Injuries: Abatement Considerations Retrofits, Modification and Functional Improvements Camouflaged Cats: the area rug in the living room had to be removed-as the cats blended into the “background”. Outdoor Terrace: there was a dangerous step-off from the terrace to the backyard; a gentle concrete incline was used to abate the situation; grass was also planted-to even out the holes & rough terrain. OK

Prevention of Home & Work Related fall-Injuries: Abatement Considerations Retrofits, Modification and Functional Improvements Suspicious Shoe-boxes: the walk-in closet was cleaned up and the empty shoe boxes were discarded. Computer-Clutter: the work station was reorganized, plastic tie-ons were used to secure loose cabling; everything on the floor was removed. [Note]: Walk-in closets are cramped and do not have much room to maneuver, thus, anything on the floor needs to be picked up or removed. OK

Prevention of Home & Work Related fall-Injuries: Abatement Considerations Retrofits, Modification and Functional Improvements Concrete barriers & safety hazards-lead to falls Home decorations-obstruct home mobility Doorway obstacles & narrow doorways-limit entry/exit with assistive ambulation devices Awkward stair height-pose trip hazards OK

Prevention of Home & Work Related fall-Injuries: Abatement Considerations Retrofits, Modification and Functional Improvements Retaining wall: this safety and trip hazard caused the patient to incur poly-trauma, hospitalization and incapacitation due shoddy construction & poor decision making skills. I. a pneumatic chisel was rented & the 4 inch retaining wall was removed. also a proper drain-field w/drain was installed by a licensed plumber. grab bars were mounted on each side of the door-frame for transfer safety. OK

Prevention of Home & Work Related fall-Injuries: Abatement Considerations Retrofits, Modification and Functional Improvements Christmas Tree Crowding: the tree was crowding into the kitchen entryway; abatement consisted of moving the tree back 24 inches. Bathroom door will not open-fully: the entertainment cabinet (console) was moved 20 inches to the “right” to allow the patient with a quad-cane to access the bathroom. OK

Prevention of Home & Work Related fall-Injuries: Abatement Considerations Retrofits, Modification and Functional Improvements Narrow bathroom Doorway: Some bathroom doors can be as narrow as 24” inches; this obstacle impairs pt’s with walkers from entry/exit safely. Shallow Tiled Stairs: the depth of these tiled stairs are shallow & make it awkward to negotiate; visually impaired pts. may have difficulty seeing the demarcation of each stair. OK

Prevention of Home & Work Related fall-Injuries: Abatement Considerations Retrofits, Modification and Functional Improvements Welcome mats & loose floor mats-pose a trip hazards Entryway of homes/apartments Bathrooms Optical Illusion- many tiled surfaces will appear the same; these surfaces pose several trip hazards in home OK

Prevention of Home & Work Related fall-Injuries: Abatement Considerations Retrofits, Modification and Functional Improvements Unwelcomed-Welcome: the welcome mat was removed and a lower-profile mat with rubber backing was used in its place. Slick Carpeting in Bathroom: slick area carpet was removed and a porous/absorbent mat was used; also grab bars were installed in the shower-stall. * The patient was also cautioned against using the aluminum towel-rack for weight bearing purposes. OK

Prevention of Home & Work Related fall-Injuries: Abatement Considerations Retrofits, Modification and Functional Improvements Optical Illusion: sunken living rooms or awkward steps in patient’s homes cause visitors to trip & fall: *this situation was remedied by changing out the corner-tile to a dark- brown tile and a laminated sign placed on the column stating there is a “step- down”. OK

Prevention of Home & Work Related fall-Injuries: Abatement Considerations Retrofits, Modification and Functional Improvements Shoring up the hand-railing of stairs-to support more weight-bearing. Use of house-hold appliances (e.g. washing machine) Misguided Steps throughout transitional spaces Round doorknobs; level type are better suited for patients with RA, OA and CVA. OK

Prevention of Home & Work Related fall-Injuries: Abatement Considerations Retrofits, Modification and Functional Improvements Stair-rails: stair-well was fitted with rails on both sides to allow better support; the wall-mounted rail (banister) was reinforced with additional support cleats to allow for robust weight bearing by the patient. Top loading washing machine: is very difficult to use if you are W/C bound or have poor standing balance; abatement consisted of having a church-group adopt pt., and every 7-10 days assisted with the chore (*church groups are referred to as FBOs: faith-based-organizations). OK

Prevention of Home & Work Related fall-Injuries: Abatement Considerations Retrofits, Modification and Functional Improvements Misguided step … the shallow stairs into the family-room look very similar causing the pt. with impaired vision to miss one & fall; * stairs were outlined with double-sided strips of green & orange tape to identify the edges of the stairs. Round Door-knobs … these door knobs cause difficulty when opening doors; however, they may be swapped out for lever-type door knobs-to facilitate opening. OK

Fall Prevention is a Transdisciplinary Effort
Prevention of Home & Work Related fall-Injuries: Abatement Considerations Fall Prevention is a Transdisciplinary Effort Prevention of falls is not some initiative that depends solely on home-assessments, it must be multi-focal (*multidisciplinary) in nature: I. Home-site assessment by a qualified OTR/PT II. Pharmacological reconciliation (PCP/PCM) III. Adaptive Equipment needs from an OT or PT IV. Gait analysis and mobility from a PT V. Neurological assessment by a neurologist VI. Follow-up assessment by nurse case manager or MSW; ensure pt has access to community- resources. VII. The family members or care-givers (*very important). OK

Home Ergonomics & Safety (Resources)
Prevention of Home & Work Related fall-Injuries: Abatement Considerations Home Ergonomics & Safety (Resources) NIH Senior Health (Fall Proofing Your Home); nihseniorhealth.gov/falls/homesafety/01.html GO4Life (Prevention of Falls-Tip Sheet); National Institute on Aging, U.S. Department of Health & Human Services: PreventingFalls.pdf NCOA (National Council on Aging); (pdf) fact- sheet on seniors & falls at home; also, “Debunking the myths of older adults and falls” OK

Home Ergonomics & Safety (Cont. Resources)
Prevention of Home & Work Related fall-Injuries: Ergonomic Considerations Home Ergonomics & Safety (Cont. Resources) National Institute on Aging (Prevention of Falls and Fractures among the elderly); Center for Disease Control & Prevention CDC-P) and National Center for Injury Prevention & Control (NCIPC) Fall Prevention Check-List in English, Spanish, & Chinese National Resource Center for patient safety-falls tool kit: OK

Prevention of Home & Work Related fall-Injuries:
“What is functional mobility?” OK

Prevention of Home & Work Related fall-Injuries: “What to look for”
Functional Mobility …is impaired when medical conditions, such as, CVA/stroke, LE-amputation, osteoarthritis (DJD), disuse atrophy, spinal cord injuries, COPD and cardio-vascular complications impact the patient's ability to safely navigate through their homes: Kitchen mobility tasks Bathroom mobility tasks Bedroom mobility tasks Gaining entry/exit into the home Pools, Patios, & Pastures (P3) Home management Tasks Leisure Pursuits & Hobby tasks OK

Functional Mobility OK Each room has a different set of criteria to assess, and each space within the home is uniquely different.

Concerns regarding wet-areas and back splash on kitchen counters and floors. Most kitchens require repeated movement to various stations (e.g. stove top, oven, sink, food prep-area, food pantry, refrigerator, etc.). Counter top surfaces are high for the W/C-bound Electrical hazards pose safety concerns-multiple electrical appliances located near water-source (*GFI-Outlets “ground fault interrupter”… these outlets are used in bathrooms, kitchens, near pools, & outdoor areas). Kitchens OK

Bathroom Mobility: Standard bathtubs are difficult to get into/out of with impaired mobility. Bathrooms have tiled surfaces-which cause slips & falls. Standard bathrooms are small, cramped and do not allow for mobility with wheelchair (*ADA requirement is 5 X 5 ft turning radius). OK

Bathroom Mobility: Most residential bathrooms have a TTS configuration (e.g. tub, toilet, sink) and getting to them can be tricky, if not, down-right dangerous. Doorway entry is difficult due to narrow door width (*pt’s with walkers, wheelchairs, and canes modify how they enter/exit the bathroom). Double hinges for narrow doorways allow the door to open up wider and allow patients better access. OK ***** Picture of double hinge

Bathroom Mobility Bathrooms: glass-tile-water do not mix well; thus, when possible eliminate one of these variables from the equation (*the sliding glass panels were taken off as an abatement recommendation). However, there still remains a step-down shower stall to assess and abate…? OK

Bedroom Mobility: Bed-rest or convalescing patients spend a considerable amount of time in this room: The Bedroom is turned into a multi-purpose room (e.g. patients entertain, eat, perform hygiene and toileting ADL’s, as well as, watch TV and sleep). OK

Bedroom Mobility: Transferring into/out of the bed can become a chore when ambulation and balance are impaired (e.g. bed height): Use plastic risers to bring the bed up to a height where the patient can safely transfer in/out of. If plastic risers are not available you may substitute PVC tubing (polyvinyl chloride) to raise or lower the patient’s bed to the appropriate height (*PVC tubing is strong, lightweight and inexpensive).

Bedroom Mobility: (Continued) Weight-bearing over flimsy furniture leads to falls. Patients who have poor balance will weight-bear on furniture Recommend that night-tables be sturdy in the event the patient weight-bears over it (*they often do!) Bed-rails must be bolted onto the bed-frame; the kind that slides between the box-springs & mattress is unacceptable & unsafe.

Bedroom Mobility: Bedrooms, Clutter, and Oversized Bedspreads

Bedroom Mobility: (Continued) Patients get tangled in their bed-sheets, comforters, or bedside furniture. Patients using walkers, quad-canes or crutches are particularly vulnerable to entanglement.

Entry Portal: The Entry-Portal can be any of the following: the homes’ main entrance, the carport entrance, a utility room, the garage entrance…etc.

Gaining Entry/Exit from Home/Apartment: The Entry Portal for a pt’s [home] is a safety concern because of the many obstacles found in this area; obstacles such as: stairs, weather-stripping, insufficient railing-support, poor-lighting, cracked-cement, narrow entry-ways, and the need for proper ramp-abatement.

Gaining Entry/Exit from Home/Apartment: Weather … impacts the patient’s ability to enter/exit the home safely. Poor lighting … also impacts safety; particularly with patients that have decreased visual acuity. Ramps must have a 1:12 ratio, with regards to incline (*min) and must be installed by certified/licensed & bonded contractor.

Pools, Patios & Pastures: (P3) Pools and Patios are areas of concern, due to water and slick surfaces. Pools and patios areas are becoming popular areas for family gatherings Pools and patios: are used for entertainment and relaxation Pools and patios: are elaborate, made of varying materials (e.g. pavers, stamped concrete, loose polished rocks, etc.). Pools and patios: often require stepping outside the house (*transitional space). Take out P3 (P3 removed)

Pools, Patios & Pastures (P3): Lawns, gardens, and pastures are relaxing, therapeutic, and offer patients a chance to be out-doors; however, unsupervised use can lead to falls and injuries among patients with decrease ambulation/balance: Exposed tree-roots or loose gravel beds Uneven concrete disks or blocks Tall grass (uncut or unkempt lawns) Mulch beds around trees and bushes Extension cords for water fountains and decorative lights OK

The current trend is to maximize the outdoor living experience, and therefore, these outdoor spaces will continue to be very elaborate and popular.

Home Management Tasks: Patients who wish to age in place … are still required to manage the home & its surroundings. Who will do the following? a. Painting & weather proofing the home b. Cutting the grass & trimming bushes/hedges c. Retrieving the mail (Postal Service Variances) d. Curb side trash pick-up (Large Trash-bins) e. Compliance with home-owner’s association f. Paying the electrical & gas bills

Home Management Chores: Who will assist your patients in doing these important chores?

Leisure Pursuits & Hobby Tasks: Patients who return to their HOR (home of residence/record) wish to return to the things that they enjoy. When conducting a home evaluation also ask if the patient engages in a particular hobby or leisure pursuit: If [Yes] … the evaluator needs to look at modifying the task to fit the patient’s physical and/or cognitive abilities. Biomechanical & Safety may have to be woven into the activity (e.g. no prolonged standing, joint protection, use of splints, built-up handles, improved lighting, etc.).

Prevention of Home & Work Related fall-Injuries: Ramps: “What to look for”
Information on ADA guidelines for wheelchair ramps. ADA Homepage for Accessibility Guidelines for Buildings and Facilities

Functional Mobility Ramps: “What to look for”
Heads-up (more information on Ramps): OK ADA: Accessibility for Building and an Facilities, (Guidelines for ADA rated wheelchair ramps): Standard Chapter IV, Section 206 : Updated:

Information Regarding Ramps: ADA guidelines call for 1:12 inclination; however, 1:16 or 1:20 is recommended for those with limited ambulatory skills. Handrails must be placed on both sides of the ramp (*rails must be smooth & free of splinters). Min. ramp width is 36 inches; however, 42 inches is better Ramps must have a landing that is 60 inches the bottom and top; the landing must be as wide as the ramp. Pressure treated lumber and galvanized nails/screws are mandated. Post supports are 4 X 4 posts and are inserted 18 inches into ground with concrete.

Information Regarding Ramps (More ADA Standards): W/C ramps can be permanent or portable structures Handrails on ramps are required if the ramp is more than 6” high or longer than 72” long. The ramp should not exceed 36” in height without some sort of directional change (e.g. switch-back). Ramp landings must be 60” square at the bottom, the top and along any directional change. Ramps may be built out of a variety of materials, such as, aluminum, treated lumber, concrete, etc., as long as they meet ADA’s building criteria.

Where do falls occur around the home? Bathrooms Stairs Kitchen Entrance or Entryway Patio or grassy areas Doorways and halls Center for Disease Control and Prevention (2010e); And Carter, SE, et al. (1997): Environmental Hazards in the Homes of Older People

Prevention of Home & Work Related fall-Injuries: “What to look for” Rubenstein, L., and Josephson, K. (2006). What leads to falls at home? Lack of physical exercise … caused from poor muscle tone and decreased balance. Impaired vision … age related visual impairments and poor lighting are generally regarded as two main factors for home. Poly-medication … taking several meds at the same time cause, lethargy, vertigo, syncope, etc. (meds such as, sedatives, anti-depressants, and anti-psychotics) (*NIH Senior Health 2013). Several co-morbidities … cause fatigue, need for supplemental O2, several medicines, decreased mobility, and dependence on health care provider. Surgery …post operatively patients are weak and debilitated. Environmental hazards … one-third of all falls among the elderly population are caused from hazards originating in the home (*NIH Senior Health 2013). OK

Prevention of Home & Work Related fall-Injuries: A Transdisciplinary Approach CDC: What you can do to Prevent Falls, e-brochure, 2012 Exercises to Improve Balance: Tight-rope walk: walk a straight line 10, 20, 30 feet with hands out to the side for balance (*place a strip of masking tape on floor).

Prevention of Home & Work Related fall-Injuries: A Transdisciplinary Approach CDC: What you can do to Prevent Falls, e-brochure, 2012 Exercises to Improve Balance: II. Rock-the-boat: with hips shoulder-width apart, weight shift Rt-to-Lt- to-Rt; while wt. shifting to one side, lift the opposite foot off the ground (*hold X 5, 7, 10 sec’s).

Prevention of Home & Work Related fall-Injuries: A Transdisciplinary Approach CDC: What you can do to Prevent Falls, e-brochure, 2012 Exercises to Improve Balance: III. Heal-to-toe: walk placing the toe of one foot immediately behind the heal of the opposite foot (*do this X steps).

Prevention of Home & Work Related fall-Injuries: A Transdisciplinary Approach CDC: What you can do to Prevent Falls, e-brochure, 2012 Exercises to Improve Balance: IV. Flamingo Stand: while stabilizing (holding) on to the back of chair, stand on one foot (*hold for 10 sec, then change to other foot).

Impaired Mobility Advisory:
Prevention of Home & Work Related fall-Injuries: A Transdisciplinary Approach Impaired Mobility Advisory: In 2009 more than 14,400 people over age 65 died and 1.7 million were treated and hospitalized because of falls (CDC-Foundation, 2009). Among adults 70 years old, 3 in 10 will fall each year; 1 in 10 will suffer a serious fall injury, such as, a broken bone or head injury ( ,2010). About 53% of the elderly population who are D/C’ed from the Hospital for fall related injuries will experience another fall w/in 6 months. (CDC 2007). OK

Prevention of Home & Work Related fall-Injuries: A Transdisciplinary Approach
Impaired Mobility Advisory: Falls are the leading cause of death among the elderly due to injury…[87%]... of all fractures among the elderly are due to falls (CDC-Foundation, 2010). The financial toll for older adults who sustain falls is expected to increase as the population ages and may reach $54.9 billion by 2020 (CDC-Foundation and CDCP, 2013). 66% of persons who fall will experience another fall within six months; 50-66% of all falls occur in or around the home (NCIP Estimates, 2012). Hip Fx’s are the most frequent type of fall-related fracture. The average hospitalization cost was $18,000; this was 44% of the direct medical-cost for hip Fx’s (NCIP and Pain, Wipf & Ericson, 2011). OK

Functional Mobility A Transdisciplinary Approach
Falls at home (What we know): We know where our patients/clients fall most often. We know what the leading causes of falls and injuries are at home. We know which patients are most vulnerable to falls and injuries. We are well-prepared and well-equipped to rehab patients once they do incur injury from falls. And yet, we will freely return (e.g. after D/C) the patient back to the same environment that caused their injury and hospitalization in the first place. OK American Academy of Orthopedic Surgeons, 2010 (AAOS)

Navigating through, around and over obstacles in the home is most challenging when the patient presents with neuro-musculo-skeletal injuries (NMSIs). OK

Functional Mobility…(*Recap and Review) Occupational Therapist (Role) …receives the recommendations on functional-gait and assistive devices offered by the physical therapist and dovetails these recommendations into the patient's functional activities (e.g. bathing, dressing, cooking, bed-mobility, toileting, dressing etc.). OK

Functional Mobility…(*Recap and Review) Physical Therapist (Role) …performs gait analysis and training while using assistive ambulation devices (canes, walkers & crutches, wheelchairs, etc.) to ensure the patient can ambulate safely when working with the occupational therapist or engaged in functional tasks. OK

Equipment Index: Automatic (motion sensor) light switch: Home Depot and Busy Mart stores Bathroom Grab bars: Cambridge Moms Site Handheld Shower Head: Model Number 75527SN; Lowes hardware Plastic Furniture Riser (Set of Four): Online Product Number ; Target Stores Lever Handle for Doors: Model Number 720 CHL; Handle Sets web site Keyless (Smart Key) System for Doors: Lathem Keyless Entry Door Locks Model#LX100R and Keyless Entry System Model Number 2835-SN; Home Security Stores (Manufacturer: Digital Systems). Easy Ergonomics for Desktop Computer Users (PDF Handout/workbook, 2005): Plastic (Cable tie-ons) Nelco Products: Nelco-Products GFI (Ground Fault Interrupter) Outlets: Grainger Company PVC (Polyvinyl Chloride) Tubing/Pipes: US-Plastics Bedside Rails to enhance transfer independence: SKU No vSTD5800; Parent giving

Questions? OK

Course Instructor: Dr. Jose R. Rafols

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