FallsinOlderAdults:Identifyingriskandphysicaltherapymanagement

NathanDugan,SPTColumbiaUniversity

LouisStokesClevelandVAMedicalCenter12/19/2013

*  Generalfallstatistics*  Riskfactors*  AmericanGeriatricsSocietyGuidelines*  Outcomemeasures*  Interventions*  Otherresources

Outline

“…anunexpectedeventinwhichtheparticipantcomestorestontheground,floor,orlowerlevel.”1

Whatisafall?

*  30%ofcommunity-dwellingolderadultsfalleachyear*  10%offallsresultinfractureorotherseriousinjury2*  Significantsourceofmorbidity/mortality3

*  >40%ofinstitutionalizedolderadultsfalleachyear*  Leadingcauseoffatalandnonfatalinjuries*  2.4millionEDvisits*  >689,000hospitaladmissions4

GeneralFallStatisticsforOlderAdults

*  Directmedicalcosts$30billion!(2010)5*  Direct&indirectcosts$54.9billionby2020!6*  Costperfall:$9,000-$13,000!(2002)7*  Costperinjuriousfall:$20,000!(1998)8

*  Fallsareindependentpredictorforlong-termcareadmission3

GeneralFallStatisticsforOlderAdults

*  Historyoffalls****  UseofAD***  Physicaldisability***  DisabilityinIADL*  Femalegender*  Livingalone*  Increasedage

2-3xincreasedrisk

RiskFactorsforFalls-SociodemographicFactors9,10

*  Dizzinessandvertigo*  Parkinsondisease*  Fearoffalling*  Depression*  (Poor)Self-perceivedhealthstatus*  CVA*  Urinaryincontinence*  Pain

*  Rheumaticdisease*  Cognitiveimpairment*  Hypotension*  Diabetes

2-3xincreasedrisk

RiskFactorsforFalls-PsychologicalandMedicalFactors9,10

*  Antiepileptic*  Sedatives*  Antihypertensive*  Numberofmedications

2-3xincreasedrisk

RiskFactorsforFalls-MedicationFactors9,10

*  Gaitimpairment*  Visionimpairment*  Hearingimpairment

*2-3xincreasedrisk

RiskFactorsforFalls-MobilityandSensoryFactors9,10

*  Bestpracticeguidelines:*  Allolderadultsshouldbeaskediftheyhavefalleninpastyear*  Frequencyandcircumstancesoffallsshouldbeobtained

*  Olderadultsseekingmedicalcarebecauseoffall,reportingmultiplefallsordifficultywithwalkingorbalanceshouldbegivenmultifactorialriskassessment

*  Olderadultswhohavefallenshouldhaveassessmentofgaitandbalance*  Thoseperformingpoorlyshouldbegivenmultifactorialfallrisk

assessment*  Individualsreportingonly1fallanddemonstratingnodifficultywith

balanceandgaitdonotrequiremultifactorialfallriskassessment

AmericanGeriatricsSocietyClinicalGuidelines

http://www.americangeriatrics.org/files/documents/health_care_pros/Falls.Summary.Guide.pdf

*  Focusedhistory*  Falls,meds,riskfactors

*  Physicalexamination*  LEs,neuro,cardiovascular,visual*  FunctionalAssessment*  ADL/IADL,ADs,subjectivefuncability/fearoffalling*  Environmentalassessment*  Home/work/communityenvironment

MultifactorialFallRiskAssessment

http://www.americangeriatrics.org/files/documents/health_care_pros/Falls.Summary.Guide.pdf

Whatarethebestoutcomemeasurestousewhenassessingfallriskinolderadults?

AssessingRiskforFalls

*  BergBalanceScale*  FunctionalGaitAssessment*  ClinicalTestofSensoryInteraction

andBalance(CTSIB);ModifiedCTSIB

*  DynamicGaitIndex*  FourSquareStepTest*  TimedUpandGo*  RivermeadMobilityIndex*  FunctionalReachTest*  DizzinessHandicapScale*  PushandReleaseTest

*  TinettiPerformanceOrientedMobilityAssessment

*  BalanceEvaluationSystemsTest*  FullertonAdvancedBalanceScale*  FunctioninSittingTest*  BrunelBalanceAssessment*  CommunityBalanceandMobility

Scale*  TinettiFallsEfficacyScale*  Activities-SpecificBalance

ConfidenceScale*  FiveTimesSittoStand*  WalkingWhileTalking*  StepTest

CommonOutcomeMeasuresforAssessingFallRisk

Cut-OffScoresforHighFallRisk12OutcomeMeasure Cutoffforhighfallrisk(olderadults)

Timed-Up-and-Go >13.5s(>32.6sfrail*)

FunctionalReachTest <7”

5TimesSittoStand/Four-SquareStepTest

>15s

BergBalanceScale <45/56

FunctionalGaitAssessment <23/30

Tinetti-POMA <19/28(<11/16forbalancecomponent)

FullertonAdvancedBalanceScale <25/40

*3ormore:unintentionalwtloss(>10lbs1yr),self-reportedexhaustion,weakness(grip),slowwalkingspeed,lowphysicalactivity11

*  Moderatetohighlychallengingbalanceactivitysignificantlyreducesrateoffallsasasingleintervention*  Strengthtraining,stretching,walkingdonot

*  Comprehensiveinterventionshouldincludebalance,strength,andgaittrainingexercises13

BestInterventionPractices

*  ChallengeCOMwithfeetfixed*  NarrowBOS*  Repetition,progression,continuallychallengingpatientiskey

StaticBalanceTraining13

*  TaiChi*  Reachingwhilemoving*  Standingup*  Turninginacircle/circling/figure-8*  Stairstepping*  Dancesteps*  Unanticipateddirectionalchanges*  Obstaclecourses

DynamicBalance/GaitTraining13

*  Difficultywalkingwhiletalking=highriskoffalls*  Performancecanbeimproved*  Conversingwhilemaintainingwalkingspeed*  Walkingandcounting*  Walkingwhileperformingmanualtasks

*  Variableprioritymayimproveoutcomes

Dual-TaskTraining13

*  Effectiveinimprovingreactiontimesandsteppingstrategies*  Littleevidencetosupportthisalonetranslatestofewerfalls

PerturbationandCompensatorySteppingTraining13

*  Keyelementoffallprevention*  Focuson*  LEandposturalmuscles*  LimitedUEsupport*  Moderateorhighintensity

StrengthTraining13

*  Inthoseathighriskforfalls,ordonewithoutconcurrentbalancetraining…

Mayresultinincreasedriskoffalls*  Shouldnotbeincludedatbeginningoffall-preventionprogram,exceptinhigherfunctioningindividuals

Walking13

*  Accountforcontributingriskfactors*  Triagefactorsbasedonimpairments*  Implementappropriateinterventions*  Lessthan50%ofPTslinkedinterventionstoriskfactors

orreferredtootherproviders

Example:Visualimpairmenttrial

WhatComprisesanEffectiveFall-PreventionIntervention?13

*  Minimumof12weeksforoptimaloutcomes(50hours)14*  Individualsthatbeginexerciseprogrambutdonotmeet

thisminimummayincreaseriskforfalls

HowLongShouldInterventionsBe?

HowCanWeMeetThis50-HourMinimum?

*  Designedashome-basedexerciseprogram*  Meta-analysisshowed35%reductioninfallsandfall-relatedinjuriesinolderadults*  Mosteffectiveinthose80orolder*  ResultsinconfidenceincarryingoutADL/IADL*  Beneficialforindividualswithmoderateandhighfunctionalimpairment

http://www.hfwcny.org/Tools/BroadCaster/Upload/Project13/Docs/Otago_Exercise_Programme.pdf

OTAGOExerciseProgram13,14

StrengthExercise-OTAGO

BalanceExercise-OTAGO

BalanceExercises-OTAGO(cont’d)

*  Willnotreducefallsonitsown!

*  30minutes,2times/week*  PerformedatusualpacewithusualAD*  Canbebrokenupinto10minutebouts

GaitTraining-OTAGO

*  Interventionsshouldbestructured*  Interventionsshouldbetailoredtochallengepatientbasedonhis/herspecificimpairments*  Interventionsmustachieveoptimaldose

*  Managementshouldnotendatd/c,prescribeadequateHEP

TakeHomePoints

*  CDCCompendiumofEffectiveFallInterventions:http://www.cdc.gov/HomeandRecreationalSafety/pdf/CDC_Falls_Compendium_lowres.pdf*  CDCSTEADIProgram:http://www.cdc.gov/homeandrecreationalsafety/Falls/steadi/index.html*  OTAGOExerciseProgram:http://www.hfwcny.org/Tools/BroadCaster/Upload/Project13/Docs/Otago_Exercise_Programme.pdf

RelevantResources

1.  LambSE,Jorstad-SteinEC,HauerK,etal.Developmentofacommonoutcomedatasetforfallinjurypreventiontrials:thepreventionoffallsnetworkEuropeconsensus.JAmGeriatrSoc2005;53:1618-1622.

2.  TinettiME,SpeechleyM,GinterSF.Riskfactorsforfallsamongelderlypersonslivinginthecommunity.NewEngJMed1998;319(26):1701-1707.

3.  GillespieLD,RobertonMC,GillespieWJ,etal.Interventionsforpreventingfallsinolderpeoplelivinginthecommunity.TheCochraneLibrary2012;9.

4.  CentersforDiseaseControlandPrevention,NationalCenterforInjuryPreventionandControl.Web–basedInjuryStatisticsQueryandReportingSystem(WISQARS)[online].AccessedDecember19,2013.

5.  StevensJA,CorsoPS,FinkelsteinEA,MillerTR.Thecostsoffatalandnonfatalfallsamongolderadults.InjuryPrevention2006a;12:290–5.

6.  EnglanderF,HodsonTJ,TerregrossaRA.Economicdimensionsofslipandfallinjuries.JournalofForensicScience1996;41(5):733–746.

7.  CarrollNV,SlattumPW,CoxFM.Thecostoffallsamongthecommunity-dwellingelderly.JournalofManagedCarePharmacy.2005;11(4):307-16.

8.  Shumway-CookA,CiolMA,HoffmanJ,DudgeonBJ,YorstonK,ChanL.FallsintheMedicarepopulation:incidence,associatedfactors,andimpactonhealthcare.PhysicalTherapy2009.89(4):1-9.

References

9.  DeandreaS,LucenteforteE,BraviF,etal.Riskfactorsforfallsincommunity-dwellingolderpeople:asystematicreviewandmeta-analysis.Epidemiology2010;21(5):658-668.

10.  DeandreaS,BraviF,TuratiF,etal.Riskfactorsforfallsinolderpeopleinnursinghomesandhospitals:asystematicreviewandmeta-analysis.ArchivesofGerontologyandGeriatrics2013;56:407-415.

11.  FriedLP,TangenCM,WatsonJ,etal.Frailtyinolderadults:evidenceforaphenotype.JournalofGerontology2001;56A(3):M146-M156.

12.  RehabilitationMeasuresDatabase[online]www.rehabmeasures/org.AccessedDecember19,2013.13.  ShubertTE.Evidence-basedexerciseprescriptionforbalanceandfallsprevention:acurrentreviewofthe

literature.JournalofGeriatricPhysicalTherapy2011;34(3):100-108.14.  SherringtonC,WhitneyJC,LordSR,etal.Effectiveexerciseforthepreventionoffalls:asystematicreview

andmeta-analysis.JournaloftheAmericanGeriatricsSociety2008;56:2234–2243.

References