Situation: Ruby Hemstock is 91 and lives alone at home. She receives some support, mainly with shopping from her two granddaughters who live close by. She has a very active mind and has never used social services and hates being away from her home in which she has lived for more than 60 years. Two years ago she fractured her hip but was discharged home from the hospital with some equipment and physiotherapy and could continue to live independently.
Problem: Six months ago Ruby started to experience occasional falls. Usually, she has been able to pick herself up again. However, while getting out of the bath recently she fell again, badly bruising her hip and head. Although taken to hospital where it was not felt she should be admitted, the discharge team worried about her ability to transfer to and from a seating position. Regrettably, neither of her granddaughters could take her in, as both have family and careers to manage. Ruby wanted to return home but grudgingly accepted a four-week intermediate care programme at a local care home. Although fiercely independent and mostly capable, for the first two weeks she has been falling at least twice a day – although nothing serious other than a few cuts and bruises have resulted. Despite staff concerns, she is now demanding to return home early – saying it is her right to “bloody well fall if she wants to”.
Patient choice is paramount for Ruby in order for her to remain in control of her medical and social care. If Ruby had been admitted into one of our community intermediate care beds she would not have waited two weeks for the investigations to be started to identify causes for her deteriorating physical health and frequent falling.
On admission it would be discussed with Ruby and her granddaughters the course and plan of care while in the community care bed. The importance of including Ruby and her granddaughters in agreeing and planning her care cannot be overstated.
Assessments would incorporate a full interdisciplinary assessment of Ruby’s medical and physical needs by the intermediate care team’s nurse, physiotherapist and occupational therapist.
The intermediate care nurse assessments would include a thorough medical and social history. This nursing assessment would lead to the recording and monitoring of Ruby’s lying and standing blood pressure. A sample of Ruby’s urine would be taken for analysis as this may uncover an underlying urinary tract infection. Recordings of Ruby’s “baseline” observations, including blood pressure, pulse, respiration and a random blood sugar test, would also be made to determine risk factors that might be contributing to her falling.
All patients admitted to a community intermediate care bed would have a medication review carried out by the intermediate care team nurse alongside the community pharmacist. Once all the initial investigations have been completed a consultation with the ICT community geriatrician would take place which may result in Ruby visiting a falls clinic for further intensive investigations into her falling. These investigations would include assessment by the geriatrician.
Should all the investigations fail to identify a cause for Ruby’s falling and she remained adamant about returning home, a care planning meeting would be organised to discuss the possibility of this happening. The case would be referred to a joint care manager who would work closely with the multidisciplinary intermediate care team to facilitate her discharge home.
During Ruby’s stay in the local care home as part of the intermediate care programme, she would be assessed by a multi-disciplinary team which includes physiotherapy and occupational therapy. A care plan would be drawn up and agreed with Ruby, the care home staff and Ruby’s granddaughters. After discussing the care plan, a referral to the falls clinic, within the acute trust, would be made. Tests are carried out within the clinic to determine, if possible, why Ruby is falling so regularly and to rule out any physical reasons.
Included in the physiotherapy assessment would be a mobility assessment to determine her ability, at the present time, to transfer and to mobilise with or without walking aids. After the assessment, a therapy plan would be determined. This would include an individually planned exercise programme to try to improve her balance and co-ordination in order to reduce or eliminate her falls.
Ideally, an out-patient falls programme would work with Ruby on her exercise, balance and falls education. The exercises from this programme would form the basis of Ruby’s exercise plan. Such programmes are now being developed in community settings and, on discharge from intermediate care, Ruby could continue the exercise classes.
The occupational therapist would assess Ruby’s ability to carry out daily living tasks and determine her level of independence, which might lead to personal aids being provided. It would be important for Ruby to continue therapy, working towards making her more mobile and independent in her home. It is likely that clinical assistants from the intermediate care team would continue this therapy under supervision of the therapists within the team.
Before or on discharge from the care home, the occupational therapist would assess Ruby’s home situation and re-assess the equipment given previously to her and any extra equipment that may be required. For a short while the team would continue the care plan at home. The need for any further care requirements would be discussed with Ruby and her family and would be in place before discharge from intermediate care. In the future, should Ruby’s health deteriorate, the GP could re-refer her to the team.
As Ruby is an independent lady, we feel more harm than good could come from trying to persuade her to accept services she does not want, write members from Knowsley Older People’s Voice. Taking into consideration that Ruby has “a very active mind” and that there is no hint that she is unable to make decisions for herself, her choices need to be respected. We would suggest more options could be offered to Ruby to help her return home and help her remain independent.
Our greatest concern is that there has been no cause identified for all of Ruby’s falls. It is felt that more should be done to investigate the reasons for this. There was an ideal opportunity to look at this in detail while Ruby was in the intermediate care programme.
On discharge from intermediate care, services should be in place to continue any input from occupational therapists or physiotherapists. It is hoped that a referral be made to the local accident prevention service for an environmental check at Ruby’s home.
At this point a range of falls prevention initiatives could be explained to Ruby that may help her reduce the risks; these should include identifying any trip hazards or areas of flooring and carpet which need to be nailed down. It could be the case that additional lighting or night lights would help.
It is possible that Ruby has a visual impairment and that this could be contributing to her constant falling. It would be worth suggesting to Ruby that she has an eye test. It is also important that checks are carried out to ensure that any medication she is taking is not causing dizzy spells or weakness that may result in falls. Another practical issue to be considered is correctly fitting footwear or the need to have access to a podiatry service.
It is possible that poor diet is making Ruby weak, leading to falls, in which case she may benefit from a meals on wheels service.
The level of service and support that Ruby will accept is key to this case. It is vital that some form of monitoring of Ruby’s well-being is in place for the future, even if Ruby makes the choice to decline any help.
Sheila Bersin, Derek McEgan, Tom Best, Bill Bailey, Cathy Ericksen, Kate Holt and Paul Mavers are members of Knowsley Older People’s Voice, an advocacy service run by older people for older people in Knowsley, Merseyside.