Falls, Posture, and Gait Disorders Flashcards
What is a Fall?
“An event, which results in a person coming to rest inadvertently on the ground or other lower level.”
Falls include…
- slips
- trips
- falling into other people
- loss of balance and
- legs giving way
When should you presume that a patient has fallen?
If a patient is found on the floor, presume they have fallen unless they are cognitively unimpaired and indicate that they put themselves there on purpose.
Fall statistics
- Each year, millions of older people, those 65 and older, fall.
- 1 out of 4 older people falls each year, but less than half tell their doctor***
- Falling once doubles your chances of falling again
- 1 out of every 5 falls causes serious injury
- Over 95% of hip fractures are caused by falls
- Is it the fall that causes the fracture or did the broken hip cause the fall?
- Fall injuries are among the 20 most expensive medical conditions
- The average hospital cost for a fall injury is over $30,000
- The cost of treating falls injuries goes up with age.
How many elderly fall each year? Which population has a significantly higher rate?
- Approximately 1/3 of community-dwelling elderly people fall each year.
- Institutionalized elderly people have a significantly higher rate of falls, more than 2/3 of them fall every year.**
Define balance
“a complex process involving the reception and integration of sensory inputs and the planning and execution of movement to achieve a goal requiring upright posture.”
-simply: the ability to keep one’s center of gravity over one’s base of support in any given sensory environment
List the 5 aspects of balance
- environment
- motor output
- sensory input
- cognition
- task
List the components of postural control
- musculoskeletal
- neuromuscular
- individual sensory systems
- tasks
- anticipatory mechanisms
- adaptive mechanisms
- internal representations
Who is at risk for a fall? Those with…
- Lower body and trunk weakness
- Difficulties with gait and balance
- Limitations in postural control and range of motion
- Dizziness
- Vision problems
- Foot pain and/or poor footwear
- Home hazards***
- Vitamin D deficiency
- Postural blood pressure changes
- Orthostatic hypotension
- Low mental status score
- Low depression score
- > or = 3 falls in the past 12 months
- Multiple medications
Environmental contributors to falling
- Dim lights
- Throw rugs
- Slippery floors
- Uneven or non-level surfaces: pavement/sidewalk/driveway
Disease precursor reasons for falling
- Poor Vision/Hearing
- Infection
- Congestive Heart Failure (CHF)
- Transient ischemic attacks (TIAs) “mini stroke”
- Chronic kidney disease (CKD) – elevated BUN/Creat
- Chronic liver disease (CLD) – elevated Ammonia
- Peripheral neuritis
- Parkinson disease
- Electrolyte disturbance
- Delirium
- Dementia
Other Reasons for Falling
- Dizziness and vertigo: multiple causes –> can lead to falls regardless of cause
- Alcohol
Other reasons for falling - medications
- Sedatives: Benzos, Antihistamines – dizziness/ drowsiness, leads to fall
- Anti-seizure/Depression – dizziness/ drowsiness/ electrolyte imbalance: weakness, leads to fall
- HTN meds cause hypotension: dizziness, leads to fall
- Diuretics can cause hypotension: dizziness/weakness, leads to fall
List the medications related to fall
- Anticholinergics
- Antidepressants
- Antihistamines
- Antihypertensives
- Antipsychotics
- Benzodiazepines
- Corticosteroids
- Diuretics
- Hypoglycemics
- NSAIDs
- Sedative/Hypnotics
- Topical ophthalmics
What are the psychological consequences of a fall?
- Loss of function = loss of independence
- Loss of confidence - fear of falling again
- Dependency
- Institutionalization
- Social isolation
- Depression
- Anxiety
- Confusion
List the consequences of immobility
- Decreased PO intake
- Deep vein thrombosis (DVT)
- Pulmonary embolism (PE)
- Pressure sores
- Constipation
- Fecal impaction
- Urinary incontinence
- Urinary Tract Infection (UTI)
- Pneumonia
- Atelectasis
- Orthostatic hypotension
- Deconditioning
- Contractures
- Osteoporosis
Traumatic consequences of falling
-soft tissue injuries
- Hematoma
- Sprains
- Skin Tears/Lacerations
Traumatic consequences of falling
-fractures
- Hip, Wrist, Ribs, Shoulders, Vertebrae are most common
- Dislocation of Joint
- Hemarthrosis
Traumatic consequences of falling
-major injuries
- Subdural hematomas
- Fracture of Neck or Spine
**Death
What is another physical finding of falls?
Skin tears d/t loss of pliability as we age.
Fall-related death statistics
- Men are more likely than women to die from a fall (they have more severe falls d/t riskier work, lifestyle, etc.)
- Increasing among all persons aged ≥ 65 years, but fastest among those aged ≥ 85 years
- Oklahoma had the 2nd largest average annual percent change in mortality rates from falls (10.9%)
- Death rates from falls were higher among white, non-Hispanic than any other race/ethnic group
- Older white females were 2.4 times more likely to die from falls as their black counterparts.
- Older non-Hispanics have higher fatal fall rates than Hispanics.
Define sentinel event
Any unanticipatedevent in a healthcare setting resulting in death or serious physical or psychological injury to a patient or patients, not related to the natural course of the patient’s illness.
*defined by the joint commission
What are the physiological changes of aging?
- Decline in posture, gait, and balance
- Muscle weakness, atrophy, and stiffness, resulting in loss of movement, stamina, strength.
- Osteoporosis, arthritis (OA and RA)
- Decreased skin integrity, poor nutrition, poor absorption of nutrients
- Impairments of sensory systems – sight, smell, sound, touch/sensation.
Gait changes as aging occurs
-cadence
Cadence = # of steps per unit of time
- normal is 100-115 steps/min
- cultural/social variations
- some authors report decreases with age, others report no change
Gait changes as aging occurs
-velocity
Velocity = distance covered in unit of time
- avg = 80 m/min (~5km/h or 3mph)
- decreased velocity without change in cadence
Other gait changes as aging occurs
- Shorter step length: 75 year olds’ is 10% shorter than 25 y.o. when adjusted for leg length
- Greater stance/swing ratio
- Less percentage of gait cycle in single limb stance (34.5% versus normal of 38%)
- Decrease push off (decreased plantarflexion power)
- Flat foot landing
- Decrease pelvic rotation
Contributors to Abnormal Posture, Gait, and Balance
-Pain
- Bunions/corns/callouses/toenails
- Badly fitting shoes
- Degenerative joint disease
- Peripheral neuropathy
- Chronic pain syndrome
- Stress /Compression Fracture
Contributors to Abnormal Posture, Gait, and Balance
- Stiffness or spasm
- Poor posture
- Stiffness or Spasm: Rheumatoid/Osteoarthritis
- Poor posture: Scoliosis/Kyphosis/Lordosis
Contributors to Abnormal Posture, Gait, and Balance
-Contractures
- Achilles tendons
- Knee and Hip flexors (wheelchair or recliner)
- Paralysis s/p stroke (CVA)
- Parkinson’s
How do contractures lead to hyperlordosis?
Weak pelvic extensor muscles = hip flexor contractions = hyperlordosis
Contributors to Abnormal Posture, Gait, and Balance
-Muscle weakness
Proximal muscle weakness - waddling gait
–seen in osteomalacia – softening of bone typically d/t Vitamin D deficiency.
Distal muscle weakness (seen in peripheral neuritis) – foot drop, high stepping gait.
Contributors to Abnormal Posture, Gait, and Balance
-Incoordination
Ataxia:
- Vestibular disease
- Cerebellar Ataxia in MS
- Peripheral neuritis
- Tabes dorsalis in late stages of syphilis
- Diffuse cerebral damage in demented patients
- Stroke with paralysis – flaccid or contractures
What does the mnemonic SPLATT mean?
S- symptoms before the fall P- previous falls L- location of the fall A- activity at the time of the fall T- time of day when the fall occurred T- trauma acquired from the fall
*These will all give you clues about the severity of the patient’s condition.
Management and Prevention of Falls
- Comprehensive Exam/Testing
- Evaluate/Treat existing diseases: avoid polypharmacy
- Provide pain relief: PT before prescribing medication
- Review/Reduce medication: risk vs benefit of each medication (include Vitamins, Homeopathic, Over the counter meds, creams; Label each medication/vitamin/OTC medication with its purpose!)
- Correct painful conditions: hip/knee/shoulder replacement
- Cataract removal with lens replacement
List the special attention in PE for vital signs, skin, eyes, cardio
- Vital signs: BP (consider orthostatic hypotension), Temp
- Skin: Turgor (elasticity), pallor (blanching), trauma, tears, lacerations
- Eyes: Acuity, Funduscopic
- Cardiovascular: Arrhythmias, bruits, murmurs, pulses
List the special attention in PE for extremities and neurological
- Extremities: Degenerative joint disease (DJD), range of motion (ROM), podiatric problems, edema
- Neurological: Focal signs, cerebellar, resting tremor, bradykinesias
List the special attention in PE for gait and balance
- Timed up and go
- Clinical Test of Sensory Interaction in Balance
- Berg Balance Measure
- Tinetti
- Dynamic gait Index
List the special attention in PE for psych
- Depression scale
- Mini-Mental State Exam (MMSE)
- Clock drawing
- “CAGE” questionnaire (cut, annoyed, guilty, eye)
Fall Prevention Diagnostic Testing
-Labs
- Complete blood count (CBC),
- Thyroid function – TSH/FT4
- Complete metabolic panel (CMP)
- Lipid panel
- B12/Folate
- Vitamin D3
- Urinalysis (UA)
- Therapeutic Drug Levels
- Urine drug screen (UDS)
Fall Prevention Diagnostic Testing
- Xrays
- CT/MRI
- Dexa scan
- Xrays: Hips, Knees, Arthritic Joints
- CT/MRI Brain: Rule out other pathology, IF clinical findings warrant further examination
- Dexa Scan: Bone Density Study
Which gait and balance testing should you begin with?
- Administer the “shorter” tests first, i.e. TUG
- Then, if the tests show balance concerns, administer the longer tests, such as Berg.
- Isolates where the problem is in the systems contributing to balance
Explain timed up and go (TUG) testing
Record time it takes for person to:
- Rise from chair without using arms
- Walk 10 feet
- Turn
- Return to chair
- Sit down
*Start the stopwatch as soon as you say go, even if the patient hasn’t moved from their chair yet.
What does TUG help determine?
- Risk of falling
- Balance deficits
- Gait speed and stride length
- Proper use of assistive device
- Functional capacity for household and community mobility
What are the time frames for TUG?
- Most adults can complete in 10 seconds or less
- Most frail adults can complete in 11-20 seconds
- > 14 seconds = high fall risk (assistive device?)
- > 20 seconds = Need for Comprehensive evaluation (referral to PT)
- Results strongly associated with IADLs**
What is the purpose of the Clinical Test of Sensory Interaction and Balance?
to assess the individual’s balance under a variety of conditions to infer the source of instability
Explain the Berg test and meaning of its scores
- 14 step test to measure risk of falling in the elderly.
- Score of 45 or less: person is at greater risk for falling
- Score of 40 or less: person is a significant fall risk
- Score of 36 or less: fall risk close to 100%
- Score of 50-56 – no assistive device
- 47/48-49 – no mobility device indoors/cane outdoors
- 45-47 – safe mobility with cane indoors and outdoors
- 41-44 – front wheeled walker
Explain the Tinetti test
2 sections:
- -Balance- 16 total points
- -Gait- 12 total points
- Collective Scores < 19 are high risk for falls
- Scores 19-24 indicate a risk for falls
- Helps determine use for assistive devices/rehab referrals
Explain the Dynamic Gait Index
- Was developed as a clinical tool to assess gait, balance and fall risk. It evaluates not only usual steady-state walking, but also walking during more challenging tasks.
- 8 functional walking tests are performed by the subject
- -Each scored on scale of 0-3
- -24 is the highest possible score
- -Scores of 19 or less have been related to increase incidence of falls.
List ways to Modify Extrinsic Fall Risk
Environmental alterations:
- Remove throw rugs
- Secure carpet edges, repair flooring
- Remove clutter
- Address lighting-Night lights
- Install handrails/grab bars/raised toilet seats
- Eliminate low chairs
- Avoid waxed floors
- Use rubber mats in tub/shower
- Repair cracked sidewalks
- Keep phone within reach
- Lever door handles
- Pets!
List Info on Rehabilitation/Modify Environment
-Encourage training in balance, gait, transfers, strengthening
-Encourage exercise – walking, Tia Chi, swimming and water aerobics, stretching, light weights
-Occupational therapy - Reacher, Sock/shoe tools
-Assistive Devices – Cane, Walker, Wheelchair, Power chair
-Home safety inspection – Home Health, Counsel on Aging
-Shower chair, roll in shower, elevated toilet seat
Alarm device to call for help when needed
Summary of falls
- Falls are common and result in significant morbidity, mortality and utilization of healthcare resources
- Most falls are multi-factorial
- 1 fall can be a sentinel event
- TREAT injuries, but don’t forget to assess risk factors and implement prevention strategies
- Many falls are preventable
- Pay close attention to medications, especially when multiple medications are involved (AVOID whenever possible)
