Promotion Wellness in Physical Function of

Older People:
Mobility and Safety

SN 402 Gerontological Nursing

Prepared by Dr. Justina Liu, RN PhD

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 Intended Learning Outcomes
Upon the completion of this lecture, students should be able to:
– explain age-related changes in the musculoskeletal and CNS
system that may affect mobility and safety of older people
– identify risk factors that may increase the risk of developing
unsafe mobility and immobility
– discuss the negative functional consequences related mobility
and safety: increased susceptibility to falls, fractures, disability
– conduct a nursing assessment of musculoskeletal performance
and risks for falls
– Identify interventions directed toward safe mobility and the
elimination of risks for the negative functional consequences
related to unsafe mobility and immobility

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 Discussion Time
Please describe the fall prevention strategies you
have encountered during your clinical placement

Any comments in terms of the effectiveness of

preventing falls

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 Falls in older people
Prevalence and consequences of falls:
• Fall accident is a common cause of morbidity and mortality.
• Approximately 28% - 35% of community-dwelling elders aged > 65
falls every year (WHO,2007).
• 10% - 15% of fallers sustain serious injuries, e.g., traumatic head
injuries and fractures (WHO,2007)
• Fracture of the hip, e.g., can result in immobility and decline in
self-care ability and subsequent institutionalization among
community-dwelling elders (Gill, 2013).
• Falls can also have psychological and social impacts on older
people, including loss of confidence, diminished self-esteem, self-
imposed daily / social activities restriction due to fear of falling
(Howland, 1998, Jang, 2007, Ziilstra, 2007).
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 Falls in older people
Prevalence of falls in HK:
• Among community-dwelling Chinese older people,
local studies reported an annual incidence of falls
about 18% - 20%.
• Of 187 registered deaths due to falls among people
aged > 65 in 2012
• Males accounted for about two-thirds of all
registered deaths due to falls
• Over two-fifths of the fatal falls happened at home.

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 Falls in older people
Prevalence of falls :
•2/3 of seniors in LTCHs fall once per year
• Half of those who fall are likely to fall again
• 40% of seniors admitted to LTCHs are falls-
related
• 15% of these falls result in serious injuries
• 50% of those admitted to hospital due to falls
will die within 1 year

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Age-related changes of joint
The Effects of Wear & Tear

Degeneration of collagen & elastin cells

--Degenerative changes extensive

fraying, cracking &shedding
--Outgrowths of cartilaginous clusters

 Viscosity of synovial fluid

--Formation of scar tissue & areas of

calcification
--Fragmentation of fibrous structures in
connective tissues
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Consequences of age-related changes of joint
A loss of efficiency at the level of an organ (Impairment):
•Impaired flexion & extension
• flexibility of the fibrous structure
• protection from forces of movement
•Erosion of bones underlying the outgrowths of cartilage
• ability of the connective tissue transmit the tensile forces to
the affected joint
•Predispose older people to osteoarthritis

How would those changes affect

daily activities /
safe mobility?
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 Age-related changes of bone
Watch a video
(2:44)

Bone Remodeling
Osteoblastic (Bone forming cells ) & Osteoclastic (Bone destroying cells) activities

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 Age-related changes of bone
• Impaired regulation of osteoblast activity & reduced
osteoblastic production of bone matrix   bone formation
•  bone reabsorption
•  calcium absorption  serum parathyroid hormone
•  no. of functional marrow cells
•  estrogen in women and testosterone in men
 decreased bone mass density
 predispose older people to
osteopenia and osteoporosis
 increased risk of fractures
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Features of osteoporosis according to age & sex

Fig (a) The risk of hip fracture Fig (b) Schematic diagram showing
the decrease in bone density
with increasing age, along with
an increased fracture risk
This figure shows the spinal
changes caused by osteoporosis
 Locations where fractures are most likely to occur

Thoracic spine
• Thoracic vertebral # Distal radius
Lumbar spine • Colles’#
• Lumbar vertebral # • Cause: a fall on an
outstretched hand.
S/S of Spinal compress #
•Progressive kyphosis & loss of
height
•Acute pain (exacerbated by sitting Proximal Femur
or standing) •# Neck of femur
• Localized tenderness
• neurological deficits
 Age-related changes of muscle
Loss of muscle mass & decreased muscle fibers : between 40 &
75
Causes: - reduced levels of physical activities
Musculoskeletal Changes: Muscles
- reduced rate of skeletal muscle protein synthesis
Consequence: a loss of muscle strength & endurance
Observable Consequence: difficultly rising from a seating
position, fatigue easier, shuffling gait
Complete bed rest worsen the loss of muscle mass & strength in
elderly. The rate of muscles loss is about 1.5%/day
Healthy young persons: 30% of body weight is muscle
By age 75: only about 15% of body weight is muscle

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 Age-related changes of muscle

• size and number of muscle fibers

• Loss of motor neurons
• Replacement of muscle tissue by
connective tissue and eventually, fat
tissue
• Deterioration of muscle cell membranes
and a subsequent escape of fluid and
potassium
•  protein synthesis
 predispose older people to
sarcopenia

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 Definition of sarcopenia
• A geriatric syndrome characterized by
progressive & generalized loss of skeletal
muscle mass, strength & quality associated
with ageing
• One of the hallmarks of ageing process
(Cruz-Jentoft et al.2010)

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Factors contributing to sarcopenia and its consequence

Undesirable outcome! 17
 Diagnosis of sarcopenia
Diagnostic criteria for age-related sarcopenia:
1. Low muscle mass Bio-impedance analysis (BIA)
2. Low muscle strength Handgrip strength
3. Low physical performance Timed get-up-and-go test
(EWCSOP, 2010)
Diagnosis of sarcopenia must require criterion 1+
either criteria 2 or 3
 Age-related changes of CNS that
affect mobility

• Diminished somatosensory functions

• Diminished vestibular sensation
• Diminished vibratory sensation
• Impaired proprioception
• Changes in cognitive & perceptual process
• Slow reaction time

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 Functional consequences affecting
musculoskeletal wellness
- Experience more muscle fatigue
- Decreased ROM in the upper arms, hips, knees,
ankles, etc.
- Decreased lower back flexion
- Gait changes: reduced walking speed and spend
more time in the support phase of gait than in the
swing phase
- Susceptible to falls and fractures

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 Definition of falls
• A fall is defined as an event which results in a
person coming to rest unintentionally on the
ground or floor or other lower levels
• Falls in older people is multifactorial

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How much you understand your pre-readings?

https://kahoot.it/
 Risk factors for falls
• Age • Stroke
• Sex • Incontinence
• Previous fall** • Depression*
• Balance impairment • Visual impairment
• Gait and impairment of • Home hazards
walking difficulty • Orthostatic hypotension*
• Functional limitations, ADL • Pain*
disabilities
• Wandering*
• Medical condition*
• Parkinson’s disease*
• Cognitive impairment*
• Dizziness*
Risk factors for falls (unsafe mobility)

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 Risk factors for falls
Bio-medical risk factors
-Age-related conditions
-Pathologic conditions that
- can cause functional impairments (e.g. mobility impairment
after stroke, vision impairment due to glaucoma or macular
degeneration)
- may be treated with medications that create risk for falling
(e.g. orthostatic hypotension after taking anti-hypertensive drugs)
- may cause metabolic disturbances that create risk for falls
(dehydration, electrolyte imbalance)
- may manifest to falls (e.g. Parkinsonism, CVA)
- may interfere with habit of regular exercise and other healthy
practices that are important in promoting safe mobility 25
 Risk factors for falls
Use of physical restraints
•Increased evidence shows the use of physical restraints
(including bedrails) increase the risk of falls plus other
problems such as bed sore, contractures, more serious
fall-related injuries, muscle wasting, and deconditioning,
etc.
•Many western countries have already abandoned the
use of physical restraints

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 Consequences of falls and fractures

Consequences of falls Consequences of fractures in

 Fractures
 Frequent doctor visit and
hospitalization
 Nursing home admission
 Fall recurrent
 Decline in functional abilities their independence  are
 Fear of falling
– Psychosocial problems
such as anxiety,
depression, decreased
social engagement /
autonomy / independence
older adults
• 18 % to 33% of elderly
people who fracture a hip
die within a year
• 75% of elderly people lose
transferred to long term
care settings
(Kannegaard , et al., 2010)
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 Impacts of FOF on older people
Definition: “ a lasting concern about falling that leads to an individual avoiding
activities that he / she remains capable of performing.” (Tinetti ,1993, p. 36)

FOF  40% Self-imposed activity restriction

Reduced physical capabilities

Restricts more activities

Functional decline (Gagnon et al., 2005)

Increased risk of falling (Zijlstra et al., 2007)

Social withdrawal (Gagnon & Flint, 2003)

Decreased quality of life (Scheffer et al., 2008)

Institutionalization
(Visschedijk et al., 2010)

Older people with FOF & self-imposed activity restriction enter

a downward spiral of negative outcomes
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Summary of the Updated
American Geriatrics
Society/British
Geriatrics Society Clinical
Practice Guideline for Prevention
of Falls in Older Persons
Developed by the Panel on Prevention of Falls in
Older Persons, American Geriatrics Society and British
Geriatrics Society (2011)

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 Assessment of Falls

Ideal fall assessment should also

observe
•a person in his or her usual
environment (home settings)
•a person’s awareness of and
attention to the environmental
fall-related risk factors

Start with basic-Morse fall score learnt

in Fundamental nursing therapeutics
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Assessment of Falls

Stapleton et al, 2009

 Assessment of Falls

Other: Any neurological impairments, muscle strength, Heart rate and rhythm,
postural hypotension,
Stapleton et al, 2009
Timed Up and Go Test (Podsiadlo & Richardson, 1991)

• < 14 seconds for community-dwelling older people

• > 20 seconds = the person needs assistance outside and indicates further
examination and intervention
• > 30 seconds = the person may be prone to falls

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 Measuring orthostatic blood pressure
1. Having the patient lie down for 5 minutes
2. Measure BP and pulse
3. Have the patient stand
4. Repeat blood pressure and pulse rate measurement after
standing 1 and 3 minutes

Considering as abnormal if:

• A drop of > 20 mmHg in systolic BP, or > 10 mmHg in diastolic
BP after changing the position from lying to standing
• Experiencing lightheadedness or dizziness

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Assessment of musculoskeletal function

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 Planning for wellness outcomes
Short term goal: Maintain safety
Long term goal: Promote safe mobility patterns
AIMS
• Promote healthy musculoskeletal function so as to
obtain optimal level of safe mobility
• Incorporate preventive measure in daily life to
ensure safety and eliminate negative functional
consequences
• Avoid complications associated with impaired
mobility (Falls, Fractures, Disability, etc.)

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 Interventions for musculoskeletal wellness
Promoting 1. Encourage various types of exercise particular, gait &
Healthy balance training
musculoskeletal Positive effects of regular exercise include
• Increased bone strength, total body calcium
• Improved coordination, balance and overall body functioning
• Improve ROM and flexibility of joints
• Improve muscle mass and endurance
Fall prevention Addressing intrinsic risk factors: e.g.
• Teaching about the selection of proper footwear, proper use
of walking aids
• Reviewing medication regimens regularly
• Correcting visual impairment
• Managing diseases that may create risks of falls (such as DM,
cardiovascular diseases)
• Considering vitamin D and calcium supplements – reduced #
Addressing extrinsic risk factors: e.g.
•Referring to have environmental home assessments
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 Case study
• Questions to discuss:
• What are the possible risk factors specific to these cases?
• Which points does this case raise your concern the most?
• Base on your experience/possible risk factors, how would you
manage to prevent further falls for these clients?
• What more information do you want in order to provide
better care to prevent fall?
• What are the fall prevention interventions implemented?

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 Grandma Lam (F/84)
She has a history of angina, dementia, hypertension, asthma and right eye
blindness with prosthesis. She is taking amlodipine, donepezil,
bendroflumethiazide and prn ventoline.

Baseline mobility level: history of falls and need to use physical restraint. In a
nursing home, she had six fall accidents of which 5 were occurred in 2015 and
once in 2016. Four falls were occurred at bedside and 2 falls were occurred in
the toilet. One fall was associated with multiple injuries (abrasion on right
third finger, pain at right hand and left ankle, bruise on right face) and had to
admitted in hospital. Moreover, 5 falls were occurred within five months
(from April 2015 to August 2016).

After her 6th falls, she started to use walking stick and avoiding going to a
toilet on her own, using a call bell and use physical restraint were the fall
prevention strategies after the 6th fall.

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 Grandma Yip(F/94)
You are Grandma Yip CNS nurse. She complains of Rt shoulder pain
when you are visiting her. She says that she fell 3 days ago at home
while walking out of her bathroom. She landed on her R shoulder
and denies hitting her head. She says she might have slipped on a
rug, but she doesn’t remember. She has a past medical history of
type 2 diabetes with peripheral neuropathy, hypertension, and
osteoarthritis. She takes glipizide for her diabetes, lisinopril for her
hypertension, and acetaminophen as needed for joint pain. On
exam, her postural vital signs are borderline. An evaluation of her
gait shows her to have some mild swaying on ambulation.

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 Grandma Ho (F/86)
A client of your nurse-led clinic, has a history of falls 7 times within the past 2
years. There were six times when she was transferring herself from bed to chair
and once occurred when she was doing exercise at her living room. There were
three time associated with injuries (hematoma at right occiput, sacral pain, and
bruise at right hand). In these 3 injuries, 2 times caused hospital admission.

She also has a history of stoke, depression, congestive heart failure, coronary
artery disease, and hypertension.

She is taking mirtazapine, zopiclone, furosemide, lisinopril, aspirin, metoprolol,

olanzapine, and simvastatin. She lives by herself in an apartment she has lived in
for 40 years and has help with housekeeping once a week. Her physical
examination is remarkable for decreased lower-extremity muscle strength.

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Fall prevention for institutionalized older people

Identification of patients/residents who are at

risk of falling
• Use a nursing judgment and a fall risk assessment tool;
• Address any factors for falls;
• Reassess the risks of falls and fall-related injuries
regularly;
• Use signs or color-coded items to identify those in the
fall-prevention program.

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Fall prevention for institutionalized older people
Education of the staff, patient/resident, and
family
• Instruct and provide patients/residents and their
families with written information about fall-prevention
program;
• Provide staff education about the fall-prevention
program and risk factors, especially those risk factors
can be eliminated by staff;
• Alert staff the fall-prevention program with posters
and fliers.

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 Fall prevention for institutionalized older people
Interventions for high-risk patients/residents
• Keep call bell within reach;
• Ensure wearing nonslip footwear when out of bed
• Offer assistance whenever needed or before needed.;
• Encourage to call for help when needed;
• Check patients / residents frequently
• Adjust bed to the lowest position and wheel locked;
• Assess the environment for risk factors for falls carefully &
frequently
• Consider to use movement detection device;
• Minimize the use of physical restraints (including bedrail);
• Document fall-prevention interventions on the person’s chart.
(refer to textbook box 22-5, p478)
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Two myths

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 Highlight of this lecture
– explain age-related changes in 1) joint – osteoarthritis ; 2) bone –
osteoporosis ; 3) Muscle – sarcopenia -- that may affect mobility
and safety of older people
– Understand how the above mentioned age-related changes in
musculoskeletal system together with risk factors predispose
older people to negative functional consequences related
mobility and safety (i.e. falls, fractures, disability)
– conduct a nursing assessment of musculoskeletal performance
and risks for falls
– Identify interventions directed toward safe mobility and the
elimination of risks for the negative functional consequences
related to unsafe mobility and immobility

47
 Reference
• Chu LW, Chi I, Chiu AY. Falls and fall-related injuries in community-dwelling elderly persons in Hong
Kong: a study on risk factors, functional decline, and health services utilisation after falls. Hong
Kong Med J 2007;13:S8-12.
• Gagnon, N., Flint, A. J., Naglie, G., & Devins, G. M. (2005). Affective correlates of fear of falling in
elderly persons. The American journal of geriatric psychiatry, 13(1), 7-14.
• Gill TM, Murphy TE, Gahbauer EA, et al. Association of injurious falls with disability outcomes and
nursing home admissions in community-living older persons. Am J Epidemiol 2013;178:418-25.
• Hairi NN et al. (2012). Sarcopenia in older people, Geriatrics, Prof. Craig Atwood (Ed.). ISBN: 978-
953-51-0080-5, InTech, Available from: http://www.intechopen.com/books/geriatrics/sarcopenia-
in-older-people
• Jang SN, Cho SI, Oh SW, et al. Time since falling and fear of falling among community-dwelling
elderly. Int Psychogeriatr 2007;19:1072-83.
• Kannegaard,P.N., Van Der Mark, S.,Eiken, P., & Abrahamsen, B. (2010). Excess mortality in men
compared with women following a hip fracture. National analysis of co-medications, comorbidity
and survival. Age and Ageing, 39(2), 203-209

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 Reference
• Lee JS, Kwok T, Leung PC, et al. Medical illnesses are more important than medications as risk
factors of falls in older community dwellers? A cross-sectional study. Age Ageing 2006;35:246-51.
• Miller, C. A. (2015). Nursing for Wellness in Older Adults (6th ed). Lippincott Williams & Wilkins:
Philadelphia. (Ch. 22) -Must Read.
• Stapleton, C., Hough, P., Bull, K., Hill, K., Greenwood, K., Oldmeadow, L. (2009). A four-item falls
risk screening tool for sub-acute and residential aged care: the first step in fall prevention.
Australasian Journal of Ageing, 28(3), 139-143.
• Tinetti, M. E., & Powell, L. (1993). Fear of falling and low self-efficacy: A cause of dependence in
elderly persons. Journal of gerontology
• Ungar A et al., (2013). Fall prevention in the elderly. Clinical Cases in Mineral and Bone
Metabolism, 10(2), 91-95.
• WHO Global Repot on Falls Prevention in Older Age. Geneva: World Health Organization; 2007.
• Zijlstra GA, van Haastregt JC, van Eijk JT, et al. Prevalence and correlates of fear of falling, and
associated avoidance of activity in the general population of community-living older people. Age
Ageing 2007;36:304-9.

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