Hypertensive disease and diabetes mellitus are among the leading causes of mortality in Singapore according to the Ministry of Health (2018). Combined with osteoarthritis, these chronic conditions pose not only a financial burden to families due to cost of treatment and care over an extended period but also has detrimental effects on a person’s quality of life (Megari, 2013). The current healthcare system focuses on comprehensive management of these illnesses in the community level to alleviate these challenges.
A home visit and assessment of a family whose member has the chronic conditions mentioned above was done. The client is Mdm R, a 66-year-old Malay Muslim female who is married with a son and a daughter. She does not smoke nor drink alcohol. She lives with her husband and daughter who is a Patient Service Associate and sole breadwinner of the family. The client’s son is married and lives with his wife and son. The client lives in a 4-bedroom HDB flat with lift landing.
The client’s medical history include hypertension for over 10 years and diabetes for 36 years. She has both knee osteoarthritis with right total knee replacement done in 2015. Her left knee is managed conservatively with pain medications. She was recently diagnosed with right shoulder osteoarthritis and is due for MRI in March 2019. Her maintenance medications include Isosorbide Mononitrate 30 mg OM, Hydralazine 25mg TDS, Atenolol 50mg OM, Fenofibrate 100 mg OM, Metformin 750mg TDS, Tramadol 50mg PRN, Arcoxia 90mg OM, and Anarex 2 tablets PRN. She has no known food allergies but is allergic to Naproxen, Diclofenac, Ketoprofen, and Piroxicam.
The client and her family can cope financially at present and has good emotional support from each other. Conflicts are resolved through communication. The daughter is the client’s main caregiver and accompanies her to appointments with their family physician. Healthcare facilities, community support services, and day to day amenities are accessible and within the vicinity of the client’s home. Public transport is adequate for transportation.
After the home visit, several observations and information led to identification of fall risk as a problem for the client. A fall is common among the elderly (Rubenstein, 2019) and is described as an incident where an individual suddenly and accidentally comes to rest on the ground or to a lower level (WHO, 2019).
Factors for fall risk can be divided into intrinsic and extrinsic factors (Fumio, 2001). The extrinsic factors identified for the client include toilet floor not made of non-slip tile, inadequate placement of grab bars, unsecured rug, presence of a step between the hallway and the main entrance, being barefoot inside the house and preference to use of slippers outside. Environmental hazards such as absence of grab bars (Feldman & Chaudhury, 2008), “uneven, loose and slippery surfaces, unsecured carpets and rugs, loose cords and wires, inadequate lighting, poor step and stairway design, chairs and beds that are too high or too low, and wrong footwear” (Health Hub, 2019) contribute to risk of falls in the elderly.
An intrinsic risk factor that contribute to the client’s risk for fall is knee pain when ambulating and difficulty standing up from a seated position due to osteoarthritis. A study by Doré et al. (2015) revealed that individuals suffering from osteoarthritis symptoms such as muscle weakness, pain, and decline in functional status are at greater risk of falls. In addition, the client has hypertension and diabetes mellitus for which she has maintenance medications. Use of antihypertensive medication for control of blood pressure is associated with increased risk of fall associated injuries in elderly with hypertension and other conditions (Tinetti et al., 2014). Furthermore, a meta-analysis done by Yang, Hu, Zhang & Zou (2016) showed that elderly persons with diabetes mellitus have 64% higher risk of falls than those without, though the risk seems to be higher in patients receiving insulin than those using oral hypoglycemic agents. Hypoglycemia, diabetic retinopathy and peripheral neuropathy also contribute to the risk of falls. Lastly, side effects and drug to drug interactions due to use of multiple medications raise the client’s fall risk (Gulanick & Myers, 2017).
Falls in the elderly can lead to injuries, poorer quality of life (Boyé, Van Lieshout, Van Beeck, Hartholt, Van der Cammen & Patka, 2012), and even death (Majdan & Mauritz, 2015). In order to prevent these, a combination of strategies such as home modification, education, exercise, vision and medication checks has been found to have positive results in reduction of fall risks (Chase, Mann, Wasek & Arbesman, 2012).
Client and family education on fall risk factors
It is essential to assess the client and family’s awareness about the client’s risk for falls in the home to find out which area of information to focus on. Client and family engagement through education empower clients to participate actively in ensuring their own safety and collaboration in fall prevention (Opsahl, Ebright, Cangany, Lowder, Scott & Shaner, 2017). The content of teaching must focus on causes of fall such as environmental hazards mentioned previously and other factors such as muscle weakness, poor balance, medications that cause dizziness, vision problems, and foot pain (NHS Inform, 2019). Consequences of falls must also be highlighted to client and family to persuade them to apply strategies to reduce the risk. Health Hub (2018) has a Fall Prevention Program which can be accessed via their website, as well as a Fall Prevention Guidebook that can be downloaded or picked up from Guardian or Watson’s Pharmacy near the client’s residence. They provide easily understandable and practical ways on how to prevent falls that can the client and caregiver will be able to apply such as ways on how to keep home neat and safe among others.
Another intervention that has been found to prevent falls is home modification (Chase et al., 2012). The Enhancement for Active Seniors programme by the Housing Development Board (2019) provides subsidized home modifications for qualified elderly which include floor