Lecture 21: Fall prevention

Question 1

Leading cause of fatal and non-fatal injuries among older adults?

Answer 1

Falls

Question 2

fall definition

Answer 2

an event which results in a person coming to rest inadvertently on the ground or other lower level regardless of whether an injury was sustained, and not as a result of a major intrinsic event or overwhelming hazard

   - intrinsic event: syncopal vs. non-syncopal 
  - overwhelming hazard: a hazard that would result in a fall by most young, healthy persons

Question 3

intrinsic risk factors for falls

Answer 3

• advanced age
• previous fall
• weakness
• gait and balance problems
• visual deficits
• postural hypotension
• chronic conditions
• fear
• psychoactive medication

Question 4

extrinsic risk factors for falls: community-dwelling older adults

Answer 4

• lack of stair handrails
• poor stair design
• dim lighting or glare
• obstacles or tripping hazards
• slippery or uneven surfaces
• improper use of assistive device
• worse when the community-dweller is hurried or not paying attention

Question 5

extrinsic risk factors: within hospital

Answer 5

• bedrails
• height and stability of seating
• low toilets
• wheelchair braking problems
• geri chairs
• portable commodes
• obstacles caused by mobility aids (WC, walker)

Question 6

risk factors and function

Answer 6

risk factors interact with overall function. some risk factors may have a stronger influence on falls in lower-functioning older adults that independent community-dwelling older adults

• urinary incontinence
• cognitive impairment
• fear

Question 7

how often should older adults be screened for falls

Answer 7

Physical therapists should routinely ask older adult patients if they have fallen in the last 12 months
screening should include:
-history and context of falls over the last 12 months
-at least one question about the patient’s perception of difficulty with balance or walking

Question 8

a fall screen is positive when either of the following conditions is found

Answer 8

1. the patient reports multiple falls regardless of balance and gait impairments
2. the patient reports one fall and a balance or gait impairment

Question 9

CDC Steadi screening

Answer 9

• annual for adults >65 or for pt’s who present with a fall
• stay independent brochure: >4 = risk for falling
• 3 questions:
  
  1. do you feel unsteady when standing or walking
  2. are you worried about falling?
  3. have you fallen in the past year? - how many times? were you injured?

Question 10

Using post-test probability to guide history questions and balance test choice

Answer 10

1. any history of falls? (44% if positive/26% if negative)
2. psychoactive medication (38% if positive/26% if negative)
3. requiring any ADL assistance (38% if positive/26% if negative)
4. self-report or fear of falling (38% if positive/28% if negative)
5. ambulatory assistive device use (36% if postivie/26% if negative)

Question 11

Use SPLATT Model for person reporting a fall

Answer 11

• symptoms
• previous falls
• location
• activity
• time of day
• trauma

Question 12

if you do feet together, semi-tandem, or tandem stance for less than ___s = increased risk for falls

Answer 12

10s

Question 13

Berg Balance test

Answer 13

• 14 common tasks
• 0-4 scale
• lower score correlates with higher fall risk
• < 50 points

Question 14

Timed up & go (TUG)

Answer 14

• sit, stand, walk 3m, turn return to chair, sit

- TUG is primarily is mobility measure

Question 15

TUG norms

Answer 15

> 60: 9.4s
60-69: 8.1
70-79: 9.2
80-89: 11.3

Question 16

BESTest

Answer 16

based on a systems approach to balance

• biomechanical
• stability limits
• postural responses
• anticipatory postural adjustments
• sensory orientation
• dynamic balance during gait and cognitive effects

Question 17

Mini-BESTtest Systems:

Answer 17

• anticipatory
• sensory organization
• reactive postural control
• dynamic gait

Question 18

Performance oriented mobility assessment (POMA)

Answer 18

• balance and gait component
• balance = 16
• gait = 12
• several Level I studies

Question 19

Gait - comfortable gait speed cut offs

Answer 19

< 0.6 m/s

< 1m/s

Question 20

Dynamic gait index

Answer 20

4 and 8 item (8 item more commonly used in older adult)
<19
MCID 4
Functional gait assessment is very similar to DGI (22/30 is a good cut off score; and MCID 4-6)

Question 21

Fear of falling/falls efficacy scale

Answer 21

• 16 items

- range of scores 16-64 (16 - least concerned; 64 - highest score-most concerned)

Question 22

Falls efficacy scale international

Answer 22

in one study, a score of > 24 substantially increased the probability of a future fall and a lower score substantially decreased the likelihood

in the second, a score of > 21 increased the probability of a futrue fall moderately, while a lower score moederately decreased the liklihood

Question 23

how to prevent falls: minimization of medications

Answer 23

• withdrawl or reduction of psychotropic medication
• antipsychotics; abilify, haldol
• antidepressants; SSRIs
• sedatives; anti-anxiety - benzodiazepens
• mood stabilizers
• sleep aids - ambien

Question 24

how to precent falls: vision

Answer 24

• expeditie cataract surgery
• insufficient evidence to recommend vision correction as stand-alone falls intervention
• advise against multifocal lenses for walking/stairs

Question 25

multimodal exercise (PTs)

Answer 25

PTs must provide multimodal exercise for persons older than 65 years tailored to examination findings.Combine strengthening and balance training for those at lower risk and functional training for those at higher risk

Question 26

group multimodal exercise can be benefical especially for those at

Answer 26

higher risk

Question 27

components of intervention should include

Answer 27

a. strength training: that is individually prescribed, monitored and adjusted b. balance training: that is individually prescribed, monitored, and adjusted c. gait training d. correction of environmental hazards e. correction of footwear or structual impariments of the feet

Question 28

fall rate ratio

Answer 28

rate of falls (falls per person per year) between intervention and control group

Question 29

fall risk ratio

Answer 29

based on the number of people falling (fallers) in each group

Question 30

Multi-modal exercise

Answer 30

- PTs must provide multimodal exercise for all older adults > 65 tailored to exam findings - combo of strength and balance training (lower risk) balance and fucntional training (higher risk) - tailored, progressive; moderate to high intensity - balance 30-40% of activity - 8 weeks

Question 31

intensity of strength/endurance training

Answer 31

as per guidelines for older adults

Question 32

intensity of balance training

Answer 32

"demanding, challenging, appropriate and increasing levels of difficulty" - highest possible level of difficulty without falling or near-falling - mastery of each exercise before progressing - persons with limited mobility may be more at risk as balance training begins

Question 33

Strengtehning prescription

Answer 33

- 2-3X/week - 8-12 reps max begin at 20-30% 1RM progress to 80% 1RM - 2 more days per week - moderate intensity (60-70% 1RM) - 10-15 reps of major muscle groups - Power: 0-60% 1RM for LEs, 3-6 reps

Question 34

Balance exercises

Answer 34

What works - leaning beyond BOS and reaching - shifting the COM - minimzing UE support - narrowing base of supprt - changing BOS by stepping - tai-chai

Question 35

What doesn't work

Answer 35

- lack of balance training component - lack of functional relevance - lack of exercise progression

Question 36

Step-training

Answer 36

- either voluntary or protective stepping interventions reduce falls in older adults (by 50%) - improves reaction time, gait, balance and balance recovery, but not strength