1. Slide 1 Falls and Stroke Central South Regional Stroke Program September 2007 Funded by the Ministry of Health and Long-Term Care

2. Slide 2 Session Overview The types of stroke. The types of stroke. The common changes that result from stroke. The common changes that result from stroke. The link between stroke and falls. The link between stroke and falls. What factors put a resident at risk of falling What factors put a resident at risk of falling Strategies to prevent a resident from falling Strategies to prevent a resident from falling

3. Slide 3 What is a Stroke An interruption of the supply of blood and oxygen to an area of the brain. An interruption of the supply of blood and oxygen to an area of the brain. This causes the brain cells in an area to die, and reduces the brain function in that area. This causes the brain cells in an area to die, and reduces the brain function in that area. The area of the body controlled by the damaged area in unable to function properly. The area of the body controlled by the damaged area in unable to function properly. There are two types of stroke. There are two types of stroke. http://www.hc-sc.gc.ca/iyh-vsv/diseases-maladies/stroke-vasculaire_e.html#ef

4. Slide 4 What is a Stroke? A Guide to Understanding Stroke, Heart and Stroke Foundation of Canada, 1996 A stroke can happen when a blood clot blocks a blood vessel in the brain. 80% of strokes are this type.

5. Slide 5 What is a Stroke? A Guide to Understanding Stroke, Heart and Stroke Foundation of Canada, 1996 A stroke can also happen when a blood vessel breaks and results in bleeding in the brain. 20% of strokes are this type.

6. Slide 6 Risk factors you can do something about… High blood pressure High blood pressure High blood cholesterol High blood cholesterol Heart disease Heart disease Diabetes Diabetes Being overweight Being overweight Excessive alcohol use Excessive alcohol use Physical inactivity Physical inactivity Smoking Smoking Stress Stress Pearson et.al., (2002) AHA Guidelines for Primary Prevention of Cardiovascular Disease and Stroke: 2002 Update: Consensus Panel Guide to Comprehensive Risk Reduction for Adult Patients Without Coronary or Other Atherosclerotic Vascular Diseases Circulation, 106, 388-391.

7. Slide 7 What does a resident who has had a stroke look like in LTC?

8. Slide 8 What are some of the losses due to stroke? paralysis or weakness on one side of the body; paralysis or weakness on one side of the body; vision problems (double vision); vision problems (double vision); trouble speaking or understanding language; trouble speaking or understanding language; Difficulty swallowing safely. Difficulty swallowing safely. http://www.hc-sc.gc.ca/iyh-vsv/diseases-maladies/stroke-vasculaire_e.html#ef

9. Slide 9 What are some of the losses due to stroke? inability to recognize or use familiar objects inability to recognize or use familiar objects tiredness; tiredness; depression; depression; http://www.hc-sc.gc.ca/iyh-vsv/diseases-maladies/stroke-vasculaire_e.html#ef

10. Slide 10 What are some of the losses due to stroke? exaggerated or inappropriate emotional responses; exaggerated or inappropriate emotional responses; difficulty learning and remembering new information; and difficulty learning and remembering new information; and changes in personality. changes in personality. http://www.hc-sc.gc.ca/iyh-vsv/diseases-maladies/stroke-vasculaire_e.html#ef

11. Slide 11 Stroke Statistics There are between 40,000 and 50,000 strokes survivors in Canada each year. There are between 40,000 and 50,000 strokes survivors in Canada each year. 10% (4-5,000) of strokes survivors each year require long-term care. 10% (4-5,000) of strokes survivors each year require long-term care. 40% (16-20,000) of strokes survivors each year are left with a moderate to severe impairment. 40% (16-20,000) of strokes survivors each year are left with a moderate to severe impairment. http://ww2.heartandstroke.ca/Page.asp?PageID=33&ArticleID=1078&Src=news&From=SubCa tegory

12. Slide 12 Falls

13. Slide 13 Falls in Canada In Canada, falls are the sixth leading cause of death among older adults (RNAO Best Practice Guidelines, Falls and Restraints, 2002) In Canada, falls are the sixth leading cause of death among older adults (RNAO Best Practice Guidelines, Falls and Restraints, 2002) 33% of older adults fall each year (Campbell, Borrie & Spears, 1989). 33% of older adults fall each year (Campbell, Borrie & Spears, 1989). 36% of those who fall develop serious injuries (Koski, Luukinen, Laippala & Kiveal, 1998) 36% of those who fall develop serious injuries (Koski, Luukinen, Laippala & Kiveal, 1998) 40% of admissions to nursing homes are the result of falls (Tinetti, Speechley & Ginter, 1998). 40% of admissions to nursing homes are the result of falls (Tinetti, Speechley & Ginter, 1998).

14. Slide 14 frail and older  chronic illnesses  difficulty walking  thinking or memory,  independence with activities of daily living, Increased falls happen in LTCHs because: People tend to be more: (Bedsine et al. (1996) Medical care of the nursing home resident. Philadelphia (PA): American College of Physicians. (Ejaz et al. (1994) Falls among nursing home residents: an examination of incident reports before and after restraint reduction programs. Journal of the American Geriatrics Society, 42, 9:960-4.

15. Slide 15 Falls related to stroke Poor balance Poor balance –Divided attention –Impulsivity –Slowed response times Inability to walk Inability to walk –Weakness –Gait problems  spatial understanding of the world deficits  spatial understanding of the world deficits  ability to coordinate body movement  ability to coordinate body movement Mental dysfunction Mental dysfunction Hyndman et.al., (2004) Stops walking when talking as a predictor of falls in people with stroke living in the community Journal of Neurology Neurosurgery Psychiatry; 75:994-997 Ugar et.al., (2000) Characteristics of falling in patients with stroke. Journal of Neurology Neurosurgery Psychiatry. 69, 649-651

16. Slide 16 Other causes of falls Dizziness Dizziness Accidents Accidents Environment factors Environment factors –Wet floors –Poor lighting –Bed rails and improper bed height  blood pressure  blood pressure Sudden loss of consciousness Sudden loss of consciousness Acute illness Acute illness Medication side effects Medication side effects Rubenstein et.al., (1994) Falls in Nursing Homes Annals of Internal Medicine. 121, 6:442-451.

17. Slide 17 What is balance? Balance is the ability of a person not to fall. Balance is the ability of a person not to fall. Gustavsen, Marit, Aamodt, Geir and Mengshoel, Anne Marit (2006),'Measuring balance in sub-acute stroke rehabilitation', Advances in Physiotherapy, 8:1, 15 - 22

18. Slide 18 Balance is important because it is involved in day-to-day activities, such as getting up from a chair, walking and bending over to pick up something. Gustavsen, Marit, Aamodt, Geir and Mengshoel, Anne Marit (2006) 'Measuring balance in sub-acute stroke rehabilitation', Advances in Physiotherapy, 8:1, 15 - 22

19. Slide 19 Balance can be improved. S Significant improvement in balance, mobility, and gait can be made after a stroke. Garland SJ. Willems DA. Ivanova TD. Miller KJ. Recovery of standing balance and functional mobility after stroke. Archives of Physical Medicine and Rehabilitation. 2003 Dec; 84(12): 1753-9.

20. Slide 20 Early signs of fatigue Foot dragging Foot dragging Increased leaning to one side Increased leaning to one side Walking hunched over on the walker or leaning heavily on the walker Walking hunched over on the walker or leaning heavily on the walker Decreased balance – wobbly Decreased balance – wobbly Michael et.al., (2006) Fatigue After Stroke: Relationship to Mobility, Fitness, Ambulatory Activity,... Rehabilitation Nursing; Sep/Oct 2006; 31, 5; ProQuest Nursing & Allied Health Source pg. 210

21. Slide 21 Strategies Note on medical chart or resident’s door that there is a high risk of falls Note on medical chart or resident’s door that there is a high risk of falls Move high-risk residents to rooms close to the nursing station to increase observation Move high-risk residents to rooms close to the nursing station to increase observation Reassess after new episodes of illness or, change in meds. Reassess after new episodes of illness or, change in meds. Lower side rails for those that climb out of bed. Lower side rails for those that climb out of bed. Rubenstein et.al., (1994) Falls in Nursing Homes Annals of Internal Medicine. 121, 6:442-451.

22. Slide 22 Strategies Increase staff to resident ratio. Increase staff to resident ratio. Attend falls prevention education. Attend falls prevention education. Use alarm systems when residents move unassisted Use alarm systems when residents move unassisted Use protective hip pads Use protective hip pads Rubenstein et.al., (1994) Falls in Nursing Homes Annals of Internal Medicine. 121, 6:442-451.

23. Slide 23 Always remember that you can request an OT/PT referral from CCAC if you need assistance with finding the right strategy.

24. Slide 24 Remember to encourage the residents to ask for assistance.

25. Slide 25 CASE STUDY

26. Slide 26 Sue Sue has just arrived to Cozy Acres long term care home from hospital. Sue was recently admitted for management of stroke. What are some of the concerns you might have regarding Sue’s ability to remain safe upon arrival at the long-term care home?

27. Slide 27 Sue Later when you are able to review Sue’s transfer information, you are aware that Sue had fallen 3 times prior to her transfer to Cozy Acres. Sue walks with a four wheel walker and requires some hands on assistance to keep her balance. Sue is impulsive and is not aware that her lack of balance may cause her to fall and possibly hurt herself. Sue’s family is very concerned about her falls and the potential to hurt herself. What is your plan to maximize Sue’s safety?

28. Slide 28 Next Steps… You are the eyes and ears of your facility You are the eyes and ears of your facility Be aware of the diagnosis of your residents Be aware of the diagnosis of your residents Take this information and use it with the residents that you work with. Take this information and use it with the residents that you work with. Share this information with other staff. Share this information with other staff.

29. Slide 29 More Information Acute Changes and Stroke Acute Changes and Stroke Continence and Stroke Continence and Stroke Dementia and Stroke Dementia and Stroke Falls and Stroke Falls and Stroke Pain and Stroke Pain and Stroke Please contact: Rebecca Fleck or Kim Young Community and Long Term Care Specialist Central South Regional Stroke Program 905-521-2100 x 44127

30. Slide 30 Acknowledgements Best Practices Long-term Care Advisory Group Best Practices Long-term Care Advisory Group Best Practices Long-term Care Evaluation Group Best Practices Long-term Care Evaluation Group Best Practice Falls Working Group, Waterloo Best Practice Falls Working Group, Waterloo Mary-Lou van der Horst, Regional Best Practice Coordinator Long-Term Care Central South Region Mary-Lou van der Horst, Regional Best Practice Coordinator Long-Term Care Central South Region Wendy MacDougal, Regional Best Practice Coordinator Long-Term Care Central West. Wendy MacDougal, Regional Best Practice Coordinator Long-Term Care Central West. Beverley Morgan, Project Coordinator, RNAO Best Practice Guidelines, Hamilton Health Sciences Beverley Morgan, Project Coordinator, RNAO Best Practice Guidelines, Hamilton Health Sciences Central South Regional Stroke Program Central South Regional Stroke Program Maryann Watts, Hamilton Health Sciences, Clinical Manager Neuro- ambulatory Centre Maryann Watts, Hamilton Health Sciences, Clinical Manager Neuro- ambulatory Centre Melanie Fall Stratton, Regional Stroke Program, Program Manager, Melanie Fall Stratton, Regional Stroke Program, Program Manager, Kim Young, Regional Stroke Program, Community and Long-term Care Specialist Kim Young, Regional Stroke Program, Community and Long-term Care Specialist Lisa Colizza, Regional Stroke Program, Regional Stroke Development Specialist Lisa Colizza, Regional Stroke Program, Regional Stroke Development Specialist Nancy van Essen, Regional Stroke Program, Stroke Rehabilitation Coordinator Nancy van Essen, Regional Stroke Program, Stroke Rehabilitation Coordinator Carol Pereira, Regional Stroke Program, LTC Project Coordinator Carol Pereira, Regional Stroke Program, LTC Project Coordinator

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