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Geriatrics > Falls, Posture, and Gait Disorders > Flashcards

Falls, Posture, and Gait Disorders Flashcards

1
Q

What is a Fall?

A

“An event, which results in a person coming to rest inadvertently on the ground or other lower level.”

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2
Q

Falls include…

A
  • slips
  • trips
  • falling into other people
  • loss of balance and
  • legs giving way
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3
Q

When should you presume that a patient has fallen?

A

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.

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4
Q

Fall statistics

A
  • 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.
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5
Q

How many elderly fall each year? Which population has a significantly higher rate?

A
  • 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.**
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6
Q

Define balance

A

“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

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7
Q

List the 5 aspects of balance

A
  • environment
  • motor output
  • sensory input
  • cognition
  • task
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8
Q

List the components of postural control

A
  • musculoskeletal
  • neuromuscular
  • individual sensory systems
  • tasks
  • anticipatory mechanisms
  • adaptive mechanisms
  • internal representations
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9
Q

Who is at risk for a fall? Those with…

A
  • 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
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10
Q

Environmental contributors to falling

A
  • Dim lights
  • Throw rugs
  • Slippery floors
  • Uneven or non-level surfaces: pavement/sidewalk/driveway
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11
Q

Disease precursor reasons for falling

A
  • 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
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12
Q

Other Reasons for Falling

A
  • Dizziness and vertigo: multiple causes –> can lead to falls regardless of cause
  • Alcohol
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13
Q

Other reasons for falling - medications

A
  • 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
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14
Q

List the medications related to fall

A
  • Anticholinergics
  • Antidepressants
  • Antihistamines
  • Antihypertensives
  • Antipsychotics
  • Benzodiazepines
  • Corticosteroids
  • Diuretics
  • Hypoglycemics
  • NSAIDs
  • Sedative/Hypnotics
  • Topical ophthalmics
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15
Q

What are the psychological consequences of a fall?

A
  • Loss of function = loss of independence
  • Loss of confidence - fear of falling again
  • Dependency
  • Institutionalization
  • Social isolation
  • Depression
  • Anxiety
  • Confusion
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16
Q

List the consequences of immobility

A
  • 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
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17
Q

Traumatic consequences of falling

-soft tissue injuries

A
  • Hematoma
  • Sprains
  • Skin Tears/Lacerations
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18
Q

Traumatic consequences of falling

-fractures

A
  • Hip, Wrist, Ribs, Shoulders, Vertebrae are most common
  • Dislocation of Joint
  • Hemarthrosis
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19
Q

Traumatic consequences of falling

-major injuries

A
  • Subdural hematomas
  • Fracture of Neck or Spine

**Death

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20
Q

What is another physical finding of falls?

A

Skin tears d/t loss of pliability as we age.

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21
Q

Fall-related death statistics

A
  • 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.
22
Q

Define sentinel event

A

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

23
Q

What are the physiological changes of aging?

A
  • 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.
24
Q

Gait changes as aging occurs

-cadence

A

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
25
Q

Gait changes as aging occurs

-velocity

A

Velocity = distance covered in unit of time

  • avg = 80 m/min (~5km/h or 3mph)
  • decreased velocity without change in cadence
26
Q

Other gait changes as aging occurs

A
  • 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
27
Q

Contributors to Abnormal Posture, Gait, and Balance

-Pain

A
  • Bunions/corns/callouses/toenails
  • Badly fitting shoes
  • Degenerative joint disease
  • Peripheral neuropathy
  • Chronic pain syndrome
  • Stress /Compression Fracture
28
Q

Contributors to Abnormal Posture, Gait, and Balance

  • Stiffness or spasm
  • Poor posture
A
  • Stiffness or Spasm: Rheumatoid/Osteoarthritis

- Poor posture: Scoliosis/Kyphosis/Lordosis

29
Q

Contributors to Abnormal Posture, Gait, and Balance

-Contractures

A
  • Achilles tendons
  • Knee and Hip flexors (wheelchair or recliner)
  • Paralysis s/p stroke (CVA)
  • Parkinson’s
30
Q

How do contractures lead to hyperlordosis?

A

Weak pelvic extensor muscles = hip flexor contractions = hyperlordosis

31
Q

Contributors to Abnormal Posture, Gait, and Balance

-Muscle weakness

A

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.

32
Q

Contributors to Abnormal Posture, Gait, and Balance

-Incoordination

A

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
33
Q

What does the mnemonic SPLATT mean?

A 
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.

34
Q

Management and Prevention of Falls

A
  • 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
35
Q

List the special attention in PE for vital signs, skin, eyes, cardio

A
  • Vital signs: BP (consider orthostatic hypotension), Temp
  • Skin: Turgor (elasticity), pallor (blanching), trauma, tears, lacerations
  • Eyes: Acuity, Funduscopic
  • Cardiovascular: Arrhythmias, bruits, murmurs, pulses
36
Q

List the special attention in PE for extremities and neurological

A
  • Extremities: Degenerative joint disease (DJD), range of motion (ROM), podiatric problems, edema
  • Neurological: Focal signs, cerebellar, resting tremor, bradykinesias
37
Q

List the special attention in PE for gait and balance

A
  • Timed up and go
  • Clinical Test of Sensory Interaction in Balance
  • Berg Balance Measure
  • Tinetti
  • Dynamic gait Index
38
Q

List the special attention in PE for psych

A
  • Depression scale
  • Mini-Mental State Exam (MMSE)
  • Clock drawing
  • “CAGE” questionnaire (cut, annoyed, guilty, eye)
39
Q

Fall Prevention Diagnostic Testing

-Labs

A
  • 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)
40
Q

Fall Prevention Diagnostic Testing

  • Xrays
  • CT/MRI
  • Dexa scan
A
  • Xrays: Hips, Knees, Arthritic Joints
  • CT/MRI Brain: Rule out other pathology, IF clinical findings warrant further examination
  • Dexa Scan: Bone Density Study
41
Q

Which gait and balance testing should you begin with?

A
  • 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
42
Q

Explain timed up and go (TUG) testing

A

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.

43
Q

What does TUG help determine?

A
  • Risk of falling
  • Balance deficits
  • Gait speed and stride length
  • Proper use of assistive device
  • Functional capacity for household and community mobility
44
Q

What are the time frames for TUG?

A
  • 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**
45
Q

What is the purpose of the Clinical Test of Sensory Interaction and Balance?

A

to assess the individual’s balance under a variety of conditions to infer the source of instability

46
Q

Explain the Berg test and meaning of its scores

A
  • 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
47
Q

Explain the Tinetti test

A

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
48
Q

Explain the Dynamic Gait Index

A
  • 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.
49
Q

List ways to Modify Extrinsic Fall Risk

A

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!
50
Q

List Info on Rehabilitation/Modify Environment

A

-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

51
Q

Summary of falls

A
  • 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)

Geriatrics (14 decks)

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