Running head: DECREASING HOSPITALIZATIONS IN DEMENTIA PATIENTS 1

Decreasing Hospitalizations in Dementia Patients: A Community Wellness Program

Allie Ritchie

Megan Johnson

University of Utah
DECREASING HOSPITALIZATIONS IN DEMENTIA PATIENTS 2

Health Risks

According to the Center for Disease Control and Prevention, dementia is an umbrella

term for a group of cognitive disorders typically characterized by memory impairment, as well as

marked difficulty in the domains of language, motor activity, object recognition, and disturbance

of executive function the ability to plan, organize, and abstract (2013). Generally, dementia is

an illness of older adults, which suggests as our general population continues to increase and

live longer, the importance to address dementia health risks increases. Approximately 13.9% of

people over the age of 71 have been diagnosed with dementia, comprising about 3.4 million

individuals in the United States (Plassman et al., 2007). Dementia can vary from mild to severe,

and may eventually progress to Alzheimers disease, which can cause severe memory

impairments, neuropsychiatric symptoms, profound cognitive deficits, sleep disturbances, motor

deficiencies, and increased mortality rates (Mayo Clinic, 2015).

Individuals with dementia have higher rates of hospitalization than the average

population, with reasons for hospitalizations that include falls, infections, pressure wounds,

chronic illness complications, dehydration (Puisieux, Pardessus, & Bombois, 2005). The

majority of reasons for hospitalizations, especially falls, are preventable with proper education

(Benner, Steiner & Pierce, 2016). According to Jensen and Padilla (2011), fall-related injuries

are a significant cause of morbidity and mortality in older adults, with falls being the leading

cause of death from injury in people aged 65 or older (p. 532). Falls can also lead to decreased

confidence, strain on family members and caregivers, self-restricted activity levels, and

decreased physical function and social interaction (Jensen & Padilla, 2011). People with

dementia are 3-8 times as likely to fall compared to the typical older adult population due to

increased impairments in judgement, gait and balance, visual-spatial perceptions, medication

management, fear of falling, behavior disturbances, and the inability to recognize and avoid

hazards (Jensen & Padilla., 2011, p. 533).

DECREASING HOSPITALIZATIONS IN DEMENTIA PATIENTS 3

The purpose of developing this wellness program is to help reduce the number of

preventable hospitalizations due to falling in patients with mild dementia. Throughout this

program, individuals with dementia and their caregivers will be educated about dementia and its

associated health risks, as well as trained in ways to reduce the risk of falls and subsequent

hospitalizations.

Evidence

There are several programs that have been used in hopes of preventing falls in older

adults with dementia. Based on a review done by Health Quality Ontario (2008), high-quality

evidence indicates that long-term exercise programs and home modifications are the most

effective in reducing falls and injury related falls. Other interventions in that review that were

proven to be moderately effective include calcium and vitamin D supplementation, gait

stabilizing devices, and psychotropic medication withdrawal (Health Quality Ontario, 2008).

A systematic review conducted by Jensen and Padilla (2011) investigated numerous

studies that implemented interventions to prevent falls in older adults with dementia. The review

concluded that most of the research on the subject involved exercise-based interventions,

environmental interventions, and staff-directed interventions. Gillespie et al. (as cited in Jensen

& Padilla, 2011, p. 533) found that participants who engaged in exercises that targeted balance,

strength, and endurance had a significant reduction in overall number of falls and the number of

times people fell in community-dwelling older adults. The same study also investigated home

safety evaluations and found that they were effective in people at high-risk for falls. Jensen and

Padilla (2011) also found four studies that demonstrated the efficacy of using therapeutic

exercises and activities such as balance activities, positioning during ADL training, and strength

exercises as preparatory methods for facilitating participation in meaningful occupations (p.

534). Finally, two studies found that educating staff and/or caregivers about the risk factors of
DECREASING HOSPITALIZATIONS IN DEMENTIA PATIENTS 4

falling and environmental modifications led to a 50% reduction in the number of participants who

experienced a fall (Jensen & Padilla, 2011, p. 535).

The Lifestyle Approach to Reducing Falls (LiFE) was developed by occupational

therapists and differs from traditional exercise programs in that it addresses strength and

balance through the use of meaningful daily activities, rather than strength-building and exercise

(Clemson et al., 2010). The LiFE program consists of teaching four balance strategies and

seven strength strategies. The participants start with simpler strategies. Once those are

mastered, they progress to a more challenging strategy to master. These strategies are

practiced using occupation-based and purposeful activities such as standing on one leg while

folding laundry to improve balance or using objects commonly found in the home as the weight

for strengthening. The LiFE program was proven to be successful in decreasing falls in

individuals who were considered at risk (Clemson et al., 2010).

In an article by Peterson and Clemson (2008), several considerations were identified for

evaluating fall risks including factors at the person, environment, and occupation level. In

addition, the article identified effective multifactorial interventions such as environmental

modifications, improving mobility skills, and group-based interventions that can reduce the risk

of falls among older adults (Peterson & Clemson, 2008).

A multimedia educative approach has become increasingly popular for OTs to

implement in treatment. In a study done by Schepens, Panzer & Goldberg (2011), multimedia

fall prevention education was used. Participants received multimedia education which included

verbally identifying fall threats, and the results suggested an increase of knowledge in fall risks

and fall prevention behaviors.

Description of Occupation-Based Community Program

This program will take place at the Tenth East Senior Center in Salt Lake City, Utah. It

will be offered to anybody who has mild dementia and they must be accompanied by a
DECREASING HOSPITALIZATIONS IN DEMENTIA PATIENTS 5

caregiver or family member. The participants must register for the class, which will ensure an

appropriate attendance level as well as a form of commitment on the part of the participants.

Occupational therapists will be conducting the program because they are educated in the

assessment and treatment of many factors associated with falls (Jensen & Padilla, 2011, p.

533). Predictors of falls come from all levels of the person, environment, and occupation, and

thus OTs have the most experience with addressing the holistic nature of people and their

interactions with the environments. In turn, they can better identify specific areas in which to

apply interventions.

This program will focus on reducing the risk of falls in people with dementia through

strength-building exercises and balance training, environmental modifications, and adaptations

to occupations for safety. As mentioned in the review done by Jensen and Padilla (2011), there

is a large amount of evidence supporting the use of exercise programs in fall preventions in the

general adult population as well as at-risk populations such as people with dementia. Following

along with that evidence, this program will include strength and flexibility training as well as

balance activities in order to provide the motor and praxis skills necessary to participate in

occupations. These activities will be done with an occupation-based approach that includes the

incorporation of these exercises into ADL training (Jensen & Padilla, 2011). To further support

the use of balance and strength training within the program, the principles outlined in the LiFE

article (Clemson et al., 2010) will be used as a means for participants and caregivers to apply

balance and strength strategies during performance of occupations (Clemson et al., 2010, p. 2-

3) in order to facilitate improvement within those performance skills. For example, Clemson et

al. (2010) suggests that reducing the base of support during an activity is one of the principles

that should be used when targeting balance training. Additionally, by using the Falls Efficacy

Scale as a pre and post-assessment measure, the program is inherently targeting the
DECREASING HOSPITALIZATIONS IN DEMENTIA PATIENTS 6

improvement of the person-centered factor of confidence, which can be considered a behavioral

risk-factor of falls (Leland, Elliott, OMalley, & Murphy, 2012, p. 150).

Modifying the environment has been a traditional role for OTs in fall prevention (Leland,

et al., 2012), so this program will provide education and training to participants and caregivers

about changing their physical environments to be safer and reduce the risk of falling. The

strategy to accomplish this will be following the article by Peterson and Clemson (2008) which

discusses minimizing tripping hazards, using cues to target risky behavior, and improving

awareness and knowledge about environmental safety and mobility strategies. The use of

multimedia will also be utilized to identify environmental risk factors, in accordance with the

2011 study done by Schepens et al.

Finally, this program will be utilizing recommendations by Leland et al. (2008) in regards

to addressing the occupation aspect of performance. Through the use of providing adaptive

equipment and safe compensatory strategies during performance, the program will improve

participation and performance within the participants occupations while ensuring increased

awareness of safety precautions.

Supporting Practice Models

The broad, occupation-based model that will be applied with this program is the Person-

Environment-Occupation (PEO) model. The main targeted outcomes with the fall-prevention

program are health and wellness and prevention, which are aligned with the outcomes of the

PEO model (Law et al., 1996). According to Law et al. (1996), the PEO model is appropriate for

people who are experiencing barriers to occupation performance, and these barriers can be at

the person, environment, or occupation level. Applying interventions to any or all of these levels

can improve their transaction with one another and ultimately improve occupational

performance (Law et al., 1996). In the context of this wellness program, occupational

performance can be defined as the ability to complete daily occupations without falling.
DECREASING HOSPITALIZATIONS IN DEMENTIA PATIENTS 7

According to Puisieux et al. (2005), falls associated with dementia are the result of a

combination of intrinsic, situational, and environmental factors (p. 271). Translating that into

PEO terms, risk factors for falls in people with dementia are at the person, environment, and

occupation level. By implementing an intervention, in this case a wellness program, that

addresses the risk factors at each of these levels may prevent the risk of falling and thus

improve occupational performance.

The Social Ecological model can be applied to this program because of its focus on

environmental causes of behavior (Reitz, Scaffa, Campbell, & Rhynders, 2010). The Social

Ecological model also emphasizes health-promotive environments (Reitz et al., 2010, p. 61)

which include injury resistant, ergonomically sound physical spaces . . . adequate social

support networks (p. 61). As mentioned previously, environmental hazards have been found to

increase the risk of falls in older adults, particularly with those who have dementia, therefore this

program will be aiming to reduce those barriers to safety in the participants physical

environments. The program is also designed to improve caregiver knowledge and

understanding of fall prevention techniques, which will hopefully promote a supportive and

collaborative social environment for the participants. Finally, the Social Ecological model

promotes a healthy lifestyle through forming supportive environments, and suggests

interventions at multiple levels, including intrapersonal, interpersonal, and contextual aspects of

health behavior (Reitz et al., 2010). Due of the multivariate nature of the risk factors for falling, it

will be necessary to address those factors holistically to provide the best wellness intervention.

Through the combined use of PEO and Social Ecological model, our program will improve the

education and skills of participants and caregivers in order to reduce those risk factors and

ultimately help prevent falls in the participants.

DECREASING HOSPITALIZATIONS IN DEMENTIA PATIENTS 8

Relation to OTPF and AOTA Position Paper

The Occupational Therapy Practice Framework (OTPF) describes several intervention

approaches that can be used to direct the process of evaluation and intervention planning,

selection, and implementation (AOTA, 2014, p. S33). This wellness program is mostly using the

prevent approach because it is addressing the needs of clients who are at-risk for performance

problems. Older adults alone are at a higher risk for falls, and having the diagnosis of dementia

creates an even higher risk. The program will also be approaching this problem using

modifications to the environment in order to decrease hazards promote a context that reduces

the risk of falls. Finally, establish/restore of strength and balance skills among the clients is

another crucial approach this program will be taking in order to decrease the number of falls that

could result in hospitalizations.This program will also be primarily targeting the outcomes of

occupational performance (i.e. engagement in occupations without falls), prevention, and health

and wellness. The program will be using the interventions of education and training (both with

caregiver and client), and occupations and activities. By using the PEO model, the program is

inherently addressing all of the domains of the OTPF and their influence on behavior and

performance.

This program directly relates to the AOTAs position on the promotion of health and well-

being in that it identifies assessments for health risks related to potential for falls (Scaffa,

Slyke, & Brownson, 2008, p. 418) as one of the many ways that occupational therapists can

promote health and well-being. In addition, Scaffa et al. (2008) lists community-based fall

prevention programs for seniors (p. 419) as an example of an occupation-based health

promotion program. The program described in this paper directly falls into that category, with the

addition of a diagnosis of dementia.

DECREASING HOSPITALIZATIONS IN DEMENTIA PATIENTS 9

Program Value

Preventing falls and resulting hospitalizations among patients with dementia is inherently

valuable to the safety, health and wellness, and quality of life of the participants involved in this

program. Through education and training, participants and caregivers will benefit by improving

their self-efficacy in preventing falls, gaining the ability to modify home environments to

maximize safety, and improve overall strength and balance in order to reduce the risk of falling

and associated injuries. In addition, dementia is associated with prolonged hospital stays

(Bynum et al., 2004, p. 188) and by increasing knowledge and training around fall prevention,

participants can decrease their risk of falling and avoid hospitalizations in order to maintain their

quality of life as community-dwelling individuals.

In terms of payers, this program will benefit Medicare payers by reducing the number of

hospitalizations, and thus help with the disproportionate health care costs associated with

dementia patients (Bynum et al., 2004, p. 187). According to Zhu et al. (2015), hospitalizations

are the largest component of total healthcare expenditures, accounting for 47% of all Medicare

fee-for-service expenditures (p. 834). Bynum et al. (2004) concluded that while dementia was

associated with higher payments for each type of expenditure (outpatient, skilled nursing

facilities, home health, etc.), the highest Medicare expenditures were due to increased

hospitalization (p. 187). Dementia patients have three times the expenditures, three times the

odds of hospitalization, and more than two times the odds of preventable admissions (Bynum et

al., 2004, p. 1919). Because falls and resulting injuries are preventable, it would be valuable to

invest resources in designing fall prevention programs within this population in order to save

money that would otherwise be spent, often times at much higher costs, on the treatment of

these individuals in the hospital.

DECREASING HOSPITALIZATIONS IN DEMENTIA PATIENTS 10

Goals and Objectives

LTG: In accordance with the healthy people 2020 objective, the goal of this program is to

decrease hospitalizations in patients with mild dementia through preventing falls.

STG 1: Within 2 weeks, 90% of participants will decrease their score on the FES by at least 8

points.

STG 2: Within 2 weeks, all of the participants and/or caregivers will write down at least three

strategies to implement outside of the program to reduce the risk of falling.

Group Design

The group will gather two times a week for four weeks, with one hour sessions to

accommodate the potential lack of attention due to cognitive impairments in dementia. The

classes will include education, demonstrations, discussions, training, and homework

assignments. The schedule will be as follows:

Session 1: Introduction on dementia and risk factors associated with the disease

Session 2: Environmental modifications

Session 3: Strength exercises part 1 and nutrition

Session 4: Strength exercises part 2 and flexibility training

Session 5: Balance strategies

Session 6: Improving safety in occupations

Session 7: Falling safely, what to do in the event of a fall

Session 8: Wrap up, strategy planning

Session Outline

Second session: Thursday, August 4th, 2016 from 10:00-11:00 AM

10:00-10:10am - Review homework- pictures of home environment

10:10-10:20am - Discussion of environmental hazards, how they can cause falls

DECREASING HOSPITALIZATIONS IN DEMENTIA PATIENTS 11

10:20-10:35am - Multimedia educational activity and discussion where participants identify

potential hazards and falls risks in photos and videos

10:35-10:40am - Break time

10:40-10:55am - Discussion about how to modify environments to improve safety and reduce

hazards

10:55-11:00am - Assignment of homework: complete a home safety checklist and identify one

area that can be addressed to improve safety

Measuring Effectiveness

To measure the effectiveness of our community program, the Falls Efficacy Scale (FES)

will be used a pre and post-assessment tool in order to evaluate the participants beliefs about

the possibilities of falling. Because the participants have mild dementia, it is important to have

the caregivers complete the FES as well, as they are an important part of the falls prevention

process and they may provide more accurate results due to their unimpaired cognition. A

qualitative survey will also be used at the end of the six-week program and will include open-

ended questions related to the caregivers feelings about their knowledge regarding fall

prevention, how they benefited from this program, and what would be useful for future

programs.

In addition, a more long-term measure of effectiveness will include a 6-month and 12-

month follow-up via telephone with the caregivers about the number of falls and subsequent

hospitalizations among the participants in the program.

DECREASING HOSPITALIZATIONS IN DEMENTIA PATIENTS 12

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