NORTHERN SYDNEY CENTRAL
COAST HEALTH MR Number ……………………………………….
Falls Risk Screening - Date of Birth ………………………………………..
Ontario STRATIFY Please fill in if no patient label available
Please read instructions for use
Item Falls Risk Screening Assessment Value Score
Did the patient present to hospital with a fall or have they
fallen since admission? No Yes ?
1. History of falls. Yes to any = 6
If not, has the patient fallen within the last 2 months?
Delirium and Falls
Falls Risk Screening Tool – Ontario STRATIFY
No Yes ?
Is the patient confused? (i.e., unable to make purposeful
decisions, disorganised thinking and memory impairment).
mistaken about time, place or person).
No Yes ?
Is the patient disorientated? (i.e. lacking awareness, being Yes to any = 14
No Yes ?
Is the patient agitated? (i.e., fearful, affect, frequent movements,
and anxious) No Yes ?
Does the patient require eyeglasses continually?
No Yes ?
Does the patient report blurred vision?
No Yes ? Yes to any = 1
3. Vision Does the patient have glaucoma, cataracts or macular
Julia Poole degeneration? No Yes ?
Are there any alterations in urination? (i.e., frequency urgency, Yes = 2
4. Toileting. incontinence, nocturia). No Yes ?
CNC Aged Care 5. Transfer score
Unable no sitting balance; mechanical lift.
Major help — one strong skilled helper or two normal people;
(TS) [ means from physical — can sit. and Mobility
RNSH bed to chair and
Minor help one person easily or needs supervision for safety.
Independent use of aids to be independent is allowed.
If value total
then score = 7
Wheelchair independent including corners, etc. 1 If values total
6. Mobility score between 4 - 6,
Walks with help of one person (verbal or physical). 2 then score = 0
Independent (but may use any aid, e.g., cane). 3
Action: total score and follow risk recommendations as per level of risk 0-5 Low risk Score
6-16 Medium risk =
17-30 High risk
(As validated tool patient at risk -If Total score ≥ 9)
= ‘At Risk’
With acknowledgement to SWAHS & GSAHS.
Falls in the Community
• Risk factors
– Tactile sensation
– Certain medications
– Environment / footwear
– Impaired cognition
Literature - delirium Delirium
• Delirium in older persons (Inouye 2006. NEJM.354:11)
– Common, life threatening, potentially preventable and reversible
• In hosp prevalence 14-24%; incidence 6-56% • Sometimes known as:
• Correlates with lower quality of hospital care
• Delirium in elderly general medical inpatients: a
prospective study (Isel 2007 Int Med J.37(12):806) •Acute Confusional State
– >49% of all USA hospital bed days on care for delirium
• Melbourne study all patients eligible >65 (n=104) – general med ward •Acute Brain Disorder
• Prevalent del 18%: incident 2%
• Pre existing cognitive impairment strong predictor •Acute Brain Syndrome
• ‘In particular, the prevention of, or appropriate
management of delirium can save up to $2.5 million
per 1000 cases’ (Lipski, P. 2007. White Paper on Geriatric Medical Services
on The NSW Central Coast 2007).
Delirium Definition DSM-IV 1994
Delirium is characterized by a disturbance of
Disturbance of consciousness, attention, cognition, and consciousness and a change in cognition that develops
perception that develops over a short period of time over a short period of time
(usually hours or days) and tends to fluctuate during the Delirium due to a general medical condition
course of the day
Substance induced Delirium
Delirium due to multiple etiologies
AHMAC. 2006. Clinical Practice Guidelines for the Management of Delirium in Older People. Vic. Govt Dept
Human Services. If Delirium not otherwise specified
American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th Ed).Washington:
American Psychiatric Association.
ICD-10-AM Disease Tabular 2003 Pathophysiology of Delirium
• F05 -Delirium, not induced by alcohol and other
decreased cerebral oxidative metabolism causing altered
psychoactive substances neurotransmitter levels
•non specific organic cerebral syndrome &/or
•concurrent disturbances of consciousness and attention, perception,
thinking, memory, psychomotor behavior, emotion, and the sleep-wake stress-induced increased plasma cortisol levels causing
schedule. altered neurotransmitter activity
Moran, J. & Dorevitch, M (2001) Delirium in the hospitalised elderly. The Australian Journal
• F05.1 Delirium superimposed on dementia of Hospital Pharmacy. 31(1):35-40.
cerebral hypo-perfusion in the frontal, temporal & occipital
Yokata, H. et al. (2003) Regional cerebral blood flow in delirious patients. Psychiarty and
PREDISPOSING CAUSES OF DELIRIUM
Delirium Risk Assessment
- Brain disease - dementia, stroke, past severe head injury
- Use of brain-active drugs - sedatives, anticholinergics
- Impairments of special senses - sight, hearing Predisposing Precipitating
- Multiple severe illnesses
- Malnutrition • Visual impairment • mechanical restraint
• Severe illness • malnutrition
PRECIPITATNG CAUSES OF DELIRIUM • 3 new medications
• Cognitive deficit
- Iatrogenic - unpleasant environmental change, invasive procedures, (AMTS <7/10; MMSE <
new medications, trauma, dehydration, ongoing malnutrition,
25/30) • Unpleasant event (eg
surgical procedure, med.
- Illnesses - infections, intracranial pathologies, impaired organ
function, abnormal metabolite function, pain, drug withdrawal
• Dehydration toxicity, falls, infections,
faecal impaction etc)
Weber, J. Coverdale, J and Kunik, M (2004) Delirium: current trends in prevention and treatment. Internal
Medicine Journal. 34:115-121.
Creasey, C. (1996) Acute confusion in the elderly. Current Therapautics. August:21-26.
CONFUSION ASSESSMENT METHOD (CAM) Delirium: What does it mean for
Consider the diagnosis of delirium if features 1 and 2 and either feature 3 or 4 are present
1. Acute and fluctuating course
Is there evidence of an acute change in mental
status from the patient's baseline? Did the
3. Disorganised thinking
Was the patient’s thinking disorganised or
incoherent, such as rambling or irrelevant
(abnormal) behaviour fluctuate during the day, conversation, unclear or illogical flow of ideas,
• Trapped in incomprehensible
that is, come and go, or increase and decrease or unpredictable switching from one subject to
in severity? another?
Uncertain (please specify) ………………. Uncertain (please specify) ……………..
– a turmoil of past & present
Royal North Shore and Ryde Health Service
2. Inattention. 4. Altered level of consciousness
Did the patient have difficulty focussing attention Overall, how would you rate this patient’s level
during the interview, e.g. being easily of consciousness?
– being in ‘borderland’
distractible, or having difficulty keeping track of Alert (normal)
what was being said? Altered
No Vigilant (hyperalert, easily startled,
– being a victim & not in control
Yes overly sensitive to stimuli)
Uncertain (please specify) ………………. Lethargic (drowsy but easily aroused)
……………………………………………… Stupor (difficult to arouse)
– feeling threatened
Delirium symptoms present
Delirium symptoms NOT present
Signature of assessor & designation:………………………………………………………………
Medical Officer's signature ………………………………………………………………………..
NOTE: Inouye, S. K. 2003. The Confusion Assessment Method CAM).
Training Manual and Coding Guide. Yale University School of Anderrson, E. M. Hallberg, I. R. Norberg, A. and Edberg, Anna-Karin. (2002) The meaning of acute confusional state
Medicine. f th ti f ld l ti t I t ti lJ l f G i t i P hi t 17 652 663
Delirium: What does it mean for Factors associated with delirium
the staff? severity among older patients
(Voyer, McCusker, Cole et al. 2007. J Clin Nurs. 16:819-831)
• Aim: investigate factors associated with
• Recognising severity of delirium
• Protecting • Method: secondary analysis of instit. older
• Strain patients admitted to acute care n = 104
– feelings of adequacy / inadequacy • Results:
• Follow up care – nurses have important role in
• preventing mild → severe delirium
– reassuring/supporting environment
Hallberg, I. R. 1999 Impact of Delirium on Professionals. Dementia & Geriatric • reducing severe delirium
Cognitive Disorders. 10(5):420-425. – role of pain management important
Prevention of Delirium
Inouye et al. 1999 NEJM 340(9):669-676. Delirium
Cognitive Orientation, therapeutic
Impairment activities • Is a medical emergency
• Incidence of up to 56% in hospitalized elderly
Sleep deprivation Pain relief, non-
• Independent predictor of adverse outcomes
– increased falls
Immobility early mobilisation, minimal – pressure sores
use of immobilising – increased LOS in acute care
equipment – decreased functional levels
– increased mortality
Sensory vision & hearing protocols
impairment Maher, S. and Almeida, O. (2002) Delirium in the elderly - another medical emergency. Current Therapeutics.
Dehydration volume repletion
Is your patient confused? Is your patient confused?
1. How do you know? 2. Why are they ‘confused’?
(state how you came to this decision in the – can’t speak the language
Integrated Notes) – can’t speak or express themselves
• 4 question AMTS – can’t hear
• SIS – 3 item recall, day, month, year.
• MiniCog – 3 item recall, Clock – can’t see
• AMTS – delirium (CAM)
• MMSE – and/or dementia ?
• GCS questions
• Other (state)
Is your patient confused? Is your patient confused?
3. What is causing the ‘confusion’?
e.g. UTI, pneumonia, pain, cellulitis, constipation,
medications, ETOH withdrawal, changed
environment, hyponatraemia, unknown, etc?
Is your patient confused? Is your patient confused?
4. What are you doing to try to reduce
the ‘confusion’ (delirium, dementia, other)? 5. How have you made sure that the
• Treat cause staff can continue these actions?
• Ask family to • Noted cause and gave instructions at handover
– visit often and filled in the Communication & Care Cues form
– bring in toiletries, dressing gown, slippers • Placed CCC form in end of bed notes
– bring in reassuring/orienting mementos – photos, books, music, cuddly
• Noted the CCC form in the patient notes and care plan
• Talk with patient often &
– referred to the information in the Communications Cues form • Role modelled reassuring, orientating communication skills
including: time / day / month / season etc
• Mary is looking after Rover your dog – you must miss him • Displayed reassuring information on the bed notice boards
• I bet you would much rather be going fishing now its autumn
• Fred knows you are here and will be here soon to see you … etc
SIS (Six Item Screen) (Borson et al Int J Geri Psych 2000 15:1021-1027)
[Callahan 2002 Medical Care 40(9):771-781]
1. Say to your patient ‘I am going
to name 3 objects. After I have 2. Clock Drawing Test
1. Say to your patient said them I want you to repeat them. Say to the subject :"Put the numbers on the clock and set the hands
at ten minutes past eleven
“I am going to name 3 objects remember what they are because I am going to ask Remember what they are because I am
going to ask you to name them again in a
you to name them again in a few minutes”. few minutes’.
“Please say the 3 items after me”. (Say clearly & slowly – 1 second for each word) ‘Please say the 3 items for me’. (Say clearly &
APPLE TABLE PENNY slowly – 1 second for each word)
Keep giving trials for the 3 words until the patient has said all 3 (up to 6 trials) APPLE TABLE PENNY
Keep giving trials for the 3 words until
the patient has said all 3 (up to 6
2. Then ask the patient to name the current trials)
– month 3. Say – Now what were the 3
objects I asked you to
– year remember?”
Give 1 point for each correct answer Give 1 point for each correct answer
≤ 3 = impairment - needs further investigation) Normal [ ] Abnormal [ ]
All numbers present in correct sequence & position and
3. Say – “Now what were the 3 objects I asked you to remember?” hands readably displayed the requested time
Give 1 point for each correct answer
Total … / 6 (≤ 4 = impairment - needs further investigation)
Abbreviated Mental Test Score (AMTS)
Hodkinson, H. (1972) Evaluation of a mental test score for assessment of mental
impairment in the elderly.
Age and Ageing. 1:233-238. Each correct answer
= I mark
1. What is your age?
2. What is the time (to the nearest hour)?
3. Address for recall at the end of the test – this should be
repeated by the patient to ensure it has been heard correctly –
42 West St.
4. What is the year?
5. What is the name of this hospital?
6. Can you recognise two people here (Dr, Nurse, carer etc)
Royal North Shore and Ryde Health Services
7. What is your date of birth?
8. What is the year of the 1st World War (1914 &/or 1918)?
9. What is the name of the present Prime Minister?
10. Please count backwards from 20 - 1?
(Remember to ask for the address stated in Q 3. TOTAL
Equal to or less than 7 = possible cognitive impairment
DATE: ……………… Signature assessor &
Strategies For Preventing Falls In Hospital
Medications: These can increase falls risk:
review for all
patients Antihypertensives Aperients Opioids
Anticonvulsants Antiparkinsonians Diuretic
Benzodiazepines Psychotropics Hypoglycaemics
Score 1. Orientation to the bed area and ward facilities, ward routine and staff
2. Lower bed if possible, except during direct clinical care. Ensure brakes are on.
Low Risk 3. Keep bedrails lowered except at appropriate patient request.
0-5 points 4. Place call bell and side table within reach, and instruct patient to call for assistance as
5. Clear area of hazards-spills, clutter, unstable furniture
6. Ensure safe footwear when mobilising ie well-fitted shoes or non-slip socks. Provide
safe footwear brochure to patient and carer
7. Place walking aids within reach
8. Clothing to be good fitting and of appropriate length
9. Fall prevention brochure provided to patient/carer
10. Ensure patient has access to adequate nutrition and hydration
11. Medication review
12. Ensure patient has glasses and hearing aid if required
Medium Risk All of the above plus (if available)
6-16 points 13. Orange falls identifiers used: sign and sticker, as appropriate
14. Supervise patient during mobilisation
15. Supervise patient during self care and toileting
16. Regular, individualised toileting plan and prior to settling for the evening
17. Referral to physiotherapy for mobility disorders, and occupational therapy for
difficulties in ADL, as per facility policy
18. For over 65’s- consider bone protection medication review: consider vitamin D and
High Risk All of the above plus (if available)
17-30 Points 19. Use orange falls bracelet identifier to denote High Risk, as appropriate
20. Do not leave patient unattended during planned toileting, self care or mobilising.
21. Locate patient close to the nurses station
22. Use lo-lo/hi-lo bed for patient where available. Ensure bed is near/on the ground if
patient is unattended
23. Consider use of IPS (independent patient specials), sitter or family to increase
frequency of observation – particularly if confused/delirious
24. Consider use of hip protectors
• Behaviour is a means of communication
• Any sudden change in behaviour warrants
a careful medical review
– AND a review of the FALL RISK