Learning objectives 1) At the conclusion of the presentation, - - PDF document

3/26/2015 1 Effective clinical fall risk assessment and prevention

Els Brady, PT, MOMT, CMT Amber Walker, PT, DPT

Learning objectives

1) At the conclusion of the presentation, participants will be able to identify fall risk red flags noted on a subjective examination. 2) At the conclusion of the presentation, participants will be able to demonstrate and immediately implement the TUG and/or Tinetti functional fall risk screening tests for use in their regular office visits. 3) At the conclusion of the presentation, participants will be able to create a comprehensive fall risk plan of care to include appropriate assistive device recommendation and initial home exercise prescription for patients based on evaluation components and outcome scores. 4) At the conclusion of the presentation, participants will be able to identify patients who would benefit from a vestibular specialist or physical therapy referral.

Introduction

• Balance = the maintenance of the body’s center
• f gravity in a gravitational field within the edges
• f the current or anticipated base of support1
• Postural control system regulates relationship

between base of support and center of gravity1

– Sensory input system – Central processing control system

• integrates vestibular, visual and somatosensory info.

– Effector system

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Falls: who is at risk?

• Each year, 1 in 3 community‐dwelling adults over age

65 and 1 in 2 over age 80 experience a fall 1,2

– 5‐6% causing fracture – Primary reason for 85% of all injury‐related admissions to hospital

• Intrinsic factors: changes in visual function, gait

impairments, decreased ankle mobility/stability, medication use, cognitive disorders, nutrition, disease, neuropathy, orthostatic hypotension 1,2

• Extrinsic factors: lighting, shoe‐wear, environmental
• bstacles, improper use of or lack of assistive device 1,2

Risk Factors for Falls in Community‐dwelling Older People: A Systematic Review and Meta‐ analysis3

• History of falls
• Gait problems
• Walking aids used
• Vertigo
• Parkinson’s Disease
• Anti‐epileptic drug use

Medications that increase fall risk4

• Sedatives
• Hypnotics
• Neuroleptics
• Antidepressants
• Benzodiazepines
• Questionable: beta‐blockers, diuretics

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Gait speed and fall risk5

• Gait speed correlates well with functional

ability, future health status and the patient’s confidence in balance.

• 10 meter walk test norms have been

established to determine whether:

– The level of functional mobility is appropriate for differing environments (Household, Limited Community or Community Ambulator) – The patient has as the ability to cross the street safely

Vitamin D and fall risk6

• Vitamin D has direct effects on muscle strength

modulated by specific vitamin D receptors present in human muscle tissue.

• Myopathy from severe vitamin D deficiency presents as

muscle weakness and pain, but is reversible with vitamin D supplementation.

• In several trials of older individuals at risk for vitamin D

deficiency, vitamin D supplementation improved strength, function, and balance in a dose‐related pattern.

• Most importantly, these benefits translated into a

reduction in falls.

Vitamin D and fall risk6

• Supplemental vitamin D in a dose of 700‐1000

IU a day reduced the risk of falling among

• lder individuals by 19% and to a similar

degree as active forms of vitamin D.

• Doses of supplemental vitamin D of less than

700 IU or serum 25‐hydroxyvitamin D concentrations of less than 60 nmol/l may not reduce the risk of falling among older individuals.

3/26/2015 4 Programs supported in the evidence2

• 2 component recommendations based on

meta‐analyses

– Multi‐factorial falls risk assessment and management program

• People with history of falls
• Education, environmental modification, individual PT

treatment

– Exercise programs

• General population

Screening: patient history

• History of falls? When/how many/situation
• Co‐morbidities, orthostatic risk, osteoporosis?
• Visual, auditory or sensory impairments?
• Medication list
• Podiatrist? Regular foot inspections? Shoe‐wear?
• Assistive device use (on correct side)?
• Presence of medical alert device?
• Home environment factors – inside and outside
• Vertigo? Dizziness? Neck pain? Ankle stiffness?
• Vitamin D supplementation? Quantity

Clinical screening tools: Performance‐

• riented assessment1,3
• Berg Balance Scale and Tinetti Mobility Test

(functional measures of balance)

– Low scores significantly associated with fall incidence

• “Timed up and Go” = “Get up and Go”

– Means for average time based on age and fall risk cut‐off have been validated – High inter‐rater reliability, sensitivity, specificity

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Berg balance scale

• 14 clinical tasks with scoring system 0‐4
• Transfers, static and dynamic balance, head

rotation, upper extremity tasks, coordination

• Score interpretation

– 0‐20 HIGH fall risk – 21‐40 Medium fall risk – 41‐56 Low fall risk

Tinetti

• Balance components

– Static and dynamic, including pertubations, turning, transfers

• Gait components

– Step length, height, continuity, base of support, trunk, path

• Score interpretation

– <19 HIGH fall risk – 19‐24 Medium fall risk – 25‐28 Low fall risk

“Timed up and Go”

• Traditional TUG

– Start sitting in chair, stand up, walk 3 meters, turn around, walk back, and sit down – With use of customary assistive device; best of 3 trials

• TUG Cognitive

– While counting backwards

• TUG Manual

– Carrying full cup of water

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“Timed up and Go”7

• The mean (95% confidence interval) TUG time

for healthy individuals at least 60 years of age was 9.4 (8.9–9.9) seconds

• The mean (95% confidence intervals) for 3 age

groups were:

– 8.1 (7.1–9.0) seconds for 60 to 69 years – 9.2 (8.2–10.2) seconds for 70 to 79 years – 11.3 (10.0–12.7) seconds for 80 to 99 years

• High fall risk >13.5 seconds

Additional quick screening tools

• Functional Reach Test
• Pertubations
• Romberg

– Feet together – Eyes open/closed

• Sharpened Romberg

– Tandem stance – Eyes open/closed

• Single Leg Stance

– Eyes open/closed

Role of physical therapy

• Thorough analysis and differentiation of specific

deficit(s) contributing to fall risk

• In‐clinic training utilizing more advanced/challenging

strategies and tasks

• Home program modifications
• Education of patient and family members; support for

assistive device and home environment changes

• Motivation and accountability
• Assessment of effectiveness of a balance training

program

• Red flags/provider referrals

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Vertigo and Dizziness

• Cervicogenic dizziness or vestibular?
• Vestibular evaluation

– Neuromuscular status, muscle strength, joint integrity, proprioception, gross cerebellar functional tasks, visual ocular motor function, functional postural control, sitting and standing posture/weight shifts, dizziness, alignment, movement strategies, sensory organization test components, dynamic balance, vertigo testing

Conclusion: What can you offer?

• Falling is the leading cause of morbidity and mortality in

the elderly. Regular balance screens in older adults can save lives!

• Utilize the Tinetti and TUG in your daily practice!
• Determine appropriateness for

– Vitamin D supplementation – Vestibular specialist evaluation – Physical therapist evaluation – Assistive device – Home modification and exercise suggestions – Referral to other specialists (podiatrist, ophthalmologist, ENT, neurologist, audiologist) – Foot screening

References

1. Huo, Feng. Limits of stability and postural sway in older people. Queen’s University School of Rehabilitation Therapy. Ontario, Canada; Sept. 1999. 2. Chang, John et al. Interventions for the prevention of falls in older adult: systematic review and meta‐analysis of randomised clinical trials. BMJ 2004;328(7441):680. 3. Deandera, Silvia et al. Risk factors for falls in community‐dwelling older people: a systematic review and meta‐analysis. Epidemiology 2010;21(5):658‐668. 4. Woolcott et al. Meta‐analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med. 2009; 169(21); 1952‐1960. 5. Fritz, S, & Lusardi, M. Walking speed: the 6th vital sign. Journal of Geriatric Physical Therapy. 2009;32(2):2‐5. 6. Bischoff‐Ferrari, H A, et al. Fall prevention with supplemental and active forms of vitamin D: a meta‐analysis of randomized controlled trials. BMJ 2009;339:b3692. 7. Bohannon, Richard. Reference values for the timed up and go test: a descriptive meta‐analysis. Journal of Geriatric Physical Therapy. 2006;29(2)64‐68.