Older people´s safety and security in community care for the elderly : Focusing on fall risk and fall

Sammanfattning: Background: In Sweden the majority of very old people are healthy, and able to live in their own homes and manage without any assistance from their local authorities. However, many of them suffer from impaired cognitive and physical function, a decline in activity and poorer health, leading to a dependency on others in daily life. There are clear directions for the way in which municipalities should provide care for these elderly people, based on respect for their integrity, autonomy, safety and options for fulfilling their lives. Elderly people are often not aware either of the risk of falling, or what has caused a fall, and there are often several reasons underlying why a person falls. The primary reason for older adults falls is the surrounding physical environment, and sometimes it is difficult for elderly people who have a limited range of movement to move around. The effects of medication constitute a further cause of falls. Many older adults living at nursing homes often suffer from chronic diseases and use more medication than other groups of elderly people. Registered nurses (RN) and enrolled nurses (EN) use different types of physical restraints to protect these patients from falls and injuries. Aim: The overall aim of the thesis is to describe overall aspects of elderly people s safety and security. The thesis is divided into four parts, each with its own aim. In study I the aim was to describe perceptions underlying elderly people s decisions to move into a retirement home, as well as their concerns while living in their own homes, by focusing on feelings of safety and security. The aim of study II was to identify risk factors for falls in elderly people living in nursing homes. In study III the aim was to investigate the association between falls and fall risks, fractures, the use of physical restraints and the use of certain medications in somatic and dementia wards, respectively. The aim of study IV was to describe the views and reasoning of registered nurses (RN) and enrolled nurses (EN) on falls, fall risk, use of physical restraints, and patients safety and security in nursing homes. Methods: This thesis contains two qualitative studies and two with a quantitative design. Studies I and IV are based on a qualitative approach, using semi-structured interviews. A total of 12 residents, two males and ten females, aged between 69 and 99 years (M = 84), volunteered to participate in study I. In study IV, interviews were conducted with 15 registered nurses (RN), one male and 14 females, aged between 34 and 60 years (M = 47), and 10 female enrolled nurses (EN), aged between 40 and 63 years (M = 51.5). Data were analysed using a thematic content analysis method. Studies II and III, where the design is ecological with aggregated data, were carried out over a period of four years (2000-2003), and 21 nursing-home units in five municipal homes in Stockholm participated. Results: Elderly people with limited functional ability felt vulnerable in their own homes and this is why they made the decision to move into a retirement home. Home help services, which are crucial for elderly people s feeling of safety and security, were available (Study I). Study II covered 2343 reported incidents. There was a significant correlation between falls and fractures, fall risk and use of wheelchairs, safety belts, and bed rails; and between the occurrence of fractures and the use of sleeping pills with benzodiazepines. Association was also found between fall risk and the use of antidepressants. In study III, the total number of reported fall incidents was 2651; of these, 737 incidents were registered in dementia wards and 1914 in somatic wards. Dementia wards and somatic wards differed regarding falls and fractures, as it was only in dementia wards that falls were associated with fractures. There was also significant correlation between falls and assessed risk of falling, the use of certain kinds of medication, and physical restraints such as wheelchairs and bed rails in dementia wards. At somatic wards, an association was found between falls and the use of sleeping pills with benzodiazepines. The results of study IV indicated that RNs and ENs considered that elderly peoples impaired physical ability and poor balance constituted the main underlying risk of falling. The common argument for using restraints was that of protecting the patients. Physical restraints are used in clinical practice, but RNs and ENs emphasized that there are other good methods for protecting patients from falls and fall-related injuries. Conclusions: The results of this study indicate that municipalities today are not able to offer sufficient safety and security to elderly people who live in their own homes and suffer from impaired cognitive and physical ability. Preventive measures should focus on risk factor assessments. There are also indications that physical restraints do not always protect patients from falls and fall risk, and the use of precautionary measures is necessary in every situation. Finally, further education of staff and reduction of medication, especially benzodiazepines, should be implemented.