Last reviewed 27 February 2018
There is nothing inevitable about most accidents, writes Jef Smith. Accidents have causes and most of those involve people. Far from telling ourselves that an accident could not have been stopped, we would be wiser to look carefully at what went wrong to cause the mishap.
Domiciliary care workers, thinking about the accidents which their clients might experience, should start from the fact that people over 65 are the group at highest risk of experiencing an accident in the home. They account for around a fifth of accident-related attendances at Accident and Emergency (A&E) Departments, and they tend to suffer the most severe injuries, which is a significant factor in their having the highest rate of mortality from accidents. That’s a sobering thought.
Home care workers are, of course, generally only with their service users for relatively short periods and they have very limited control over either the activities of their clients or the physical environments in which they pass their time. They do, however, have extensive opportunities both to observe and to advise on what goes on in the premises they visit. Their potential contribution to preventing accidents is therefore significant.
Mention older people’s accidents to most social care workers and the immediate reaction is to think about falls. The risk of older people falling is indeed high and the results can be serious and lasting. But only 30% of older people’s attendances at A&E following accidents were due to falls at home, and falls account for less than half of the accident-related deaths of over 65s, so there are clearly many other factors at work.
Here are a few more facts and figures worth noting for background information. 19% of the total number of A&E home accident attendances relate to older people. This actually struck me as a rather low figure, but I then noticed that the source was eight years old, so with demographic trends as they are the proportion is now probably somewhat higher. The majority of accidents in older age groups involve women rather than men, which interestingly reverses the picture for children. And it hardly needs to be said that older people’s accidents are often linked to frailty and ill health, factors which in turn contribute to their diminishing capacity to assess and avoid risks, with the inevitable consequence that the risks escalate for over 75-year-olds.
Risks of winter
Shockingly, hypothermia is the main contributing factor to cause of death for more than 400 over 65s each year. The issue of avoidable winter deaths has attracted a good deal of publicity over recent years, but the problem remains, whether the focus of the debate is on poverty, poor house insulation or loneliness. One good — though rarely cited — reason for retaining the universality of the winter warmth allowance is that it draws the issue to the attention of a wide range of older people even if many of them could easily afford to pay their fuel bills without help from the state.
Winter of course brings many hazards for older people, but first in the list of “Top Tips” from Age UK is the perhaps predictable “Keep warm”. The message may seem rather obvious but it is still necessary to warn of the risk associated with not closing a bedroom window on chilly nights; breathing in cold air can significantly increase the possibility of chest infections. Other advice on this front includes getting flu jabs, seeking an early medical opinion on minor ailments like sore throats and colds, layering clothing even indoors, and wearing sensible shoes. The fact that the need for such precautions has been regularly rehearsed does not, of course, mean that everyone will automatically take them; home care agencies still have a role in reinforcing wise messages to their clients.
Risks of fire
The same opportunity presents itself in relation to fire-related accidents, to which older people may be particularly vulnerable on account of factors such as declining mobility, a poor sense of smell, and reducing tolerance of smoke and burns. The number of fatalities in over 65s from incidents at which fire brigades attended — around 150 a year — may seem relatively low by comparison with the effects of falls and cold weather, but each one of those deaths is a dreadful and avoidable tragedy. Again, older people’s lifestyles contribute heavily to the risks. Coal fires, candles, cookers, gas and electric heaters, electric blankets, and even cigarettes can all with care be used safely, but corner-cutting and persistent misuse quickly generate dangers.
The advice which home care workers can urge on their clients includes taking care when smoking, particularly not smoking in bed, not leaving open fires unattended, fitting fireguards — but emphatically not using them or other heaters for drying clothes — and using electric blankets only according to the makers’ instructions. Smoke alarms are strongly recommended and readily available; models operated from a mains electricity supply or with a 10-year battery are clearly to be preferred.
Burns and scalds
Less dramatic than fires but often with as serious consequences are burns and scalds. Here, the increased risk associated with age is particularly marked, older people being, it is estimated, at least four times as likely as members of the population at large to sustain fatal injuries. Again, frailty and poor health increase the likely peril even if there is a pre-existing condition which also contributes to the seriousness of the accident. Only good quality hot water bottles should be used and even these should be checked regularly for signs of wear.
Over hot bath water is a major cause of scalding; 46°C, ideally ensured by a thermostatic mixer valve, is the highest recommended temperature for water at the point of delivery.
Many scald injuries involve the use of kettles or hot water in saucepans. Cordless kettles, preferably spout-filing or jug-shaped, are obviously safest, with coiled flexes the next best alternative. Older people often get into bad — that is dangerous — habits in the preparation of hot drinks so should be encouraged not to carry hot liquids further than is absolutely necessary. When using a cooker, the advice, perhaps counter-intuitively, is to put saucepans for preference onto the rear hotplates; more obviously but again some will argue inconveniently, pan handles should be turned away from the front of the cooker. A lot of us — at least I speak for myself — do not invariably follow these sensible disciplines, but that should not inhibit us from trying to spread good practice to others where we can.
Finally, in the catalogue of accident risks older people face, I was horrified to come across poisoning. This dramatic, not to say melodramatic, term includes accidental gas inhalation, against which the official advice is to have chimneys and flues swept at least annually and fuel burning devices regularly checked by an approved expert.
Poisoning also, of course, embraces drug overdosing. All care workers will be aware of this enormous source of potential danger on the bedside table of many of their clients. Where domiciliary care assistants have medication administration as part of their allocated duties, meticulous record keeping is the first essential. Every agency should have clear policies covering this issue and, of course, give its workers thorough training.
Where clients are self-medicating, a situation which in principle is naturally to be welcomed as promoting service user independence, a visiting care worker may yet have a role to play in helping, with the client’s permission, to monitor medication intake, and gently reminding and warning where appropriate. Some older people, as their capacity declines, may need to give up some of that autonomy in the interests of greater safety, a shift which requires delicate negotiation, certainly with the client and perhaps also with their families and carers.
That sensitivity in interpreting the limits but also the opportunities of their role runs through the whole discussion of how home care workers can help older people minimise their vulnerability to accidents without either overstepping their mandate or seeming to compromise the older person’s dignity. Risk-taking, it cannot often enough be stated, is an essential element of living life to the full, from off-piste skiing to simply crossing a busy street. Such outdoor activities are easily perceived as involving risks; what is not so often appreciated is that dangers also lurk in the much more mundane corners of domestic dwellings. That is precisely where home care workers exercise their trade and, therefore, where their presence can be crucial in avoiding unnecessary accidents.