Falls Prevention And Management Flashcards
Define elderly
WHO defines a person as old from the age of 60
What are the general changes caused by aging ?
- accumulation of molecular and cellular damage over time
- no difference between the process of aging and a degenerative process
- age is a poor indicator of these changes
- associated with life transitions:
Retirement, housing adaptations, death of relatives, diminution of physical activities, reduction in social participation
What are the functional changes caused by aging ?
- reduction of reaction time
- gait impairment
- reduced adaptative strategies
- difficulties in double tasks
- reduced perception of obstacles and adaptation to light
- balance impairment
- sarcopenia
- hormonal changes: sleep growth factor, osteoporosis (ex: sleep disturbances)
What is sarcopenia ?
The loss of muscle mass, quality and strength linked with aging. Rate is 4% to 6% per decade, starting at 40 yo for women and at 60 yo for men. It strictly correlates with physical impairment, quality of life and life expectancy.
What aggravates sarcopenia ?
- poor diet
- physical inactivity
- comorbidities
- genetics
- hormones
- trauma
Is the risk of falling related to age ?
No it’s influenced by several factors, not only age
The risk of falling is not strictly related to age
It relates more to frailty
No consensus
Conjunction of multiple interacting conditions
Inescapable process
Consequences of sub-clinical elements that are difficult to observe on clinical examination
Assessed by functional scales
What are the 4 major components to be assess in cas of suspicion of frailty ?
- muscle function
- balance and walking function
- cognitive function
- nutritional status
What are the 5 areas of frailty operational definition ?
- mobility
- physical impairments
- sensory ability
- memory
- energy
To which specific factor is frailty correlated ?
It is correlated with socio-economic level because it impacts the access to health care
Is frailty correlated with gender ?
No
Is frailty correlated with region of residence ?
No
Is frailty correlated with marital status ?
No
Is frailty correlated with age ?
No
What is the most affected area by frailty ?
Energy
Where do people fall the most frequently ?
The most autonomous ones fall outside of their house, while the most fragile ones fall at home. Interior housing counts for 67% of falls.
Define falling
An event in which a person inadvertently lands on the ground or other surface at a lower level than previously. The person was unable to regain balance.
This definition excludes loss of consciousness, stroke, major extrinsic accidents.
What are the consequences of falling ?
It leads to significant and lasting functional decline even in the absence of sever physical trauma. It causes an increase in the mortality rate the worst being for hip fractures (10 to 20% increase risk within 12 months)
What is the relapses risk after the first fall event ?
> 50% within a year
What is the post-fall syndrome ?
It caused by the trauma of the fall or the fall of a relative.
This fear of falling may predate the fall and causes psychomotor maladjustments:
- spontaneous reduction in activities
- decreased functional abilities
- postural disorders
- gait disorders
- increased risk for further falls
It is a vicious circle:
Fall=> fear of falling => voluntary restriction from participating in activities => physical diconditionning
What is the physiotherapist’s mission in post fall rehabilitation ?
- functional rehabilitation
- adjustments of the environment
What are the 3 categories of predictive factors for fall ?
- multi factorial factors
- intrinsic factors
- extrinsic factors
List the multi factorial predictive factors of falls ?
- aging
- pathology affecting the equilibrium function
- medication
- environment
- behavior (avoiders vs. per sisters)
List the extrinsic predictive factors of falls
- environment
- behavior
- activities
Give examples of behavioral extrinsic predictive factors of falls
- alcohol
- sedentary life
- nutrition
- risk taking
Give examples of environment extrinsic factors for falls
- object on the ground
- poor lighting
- slippery or uneven ground
- steps
- chairs
Bed height
Risk of falling not generally associated with the number of hazards but with the relevance of hazard to the elder.
What are the intrinsic factors of falls with a high level of incidence ?
-Demographics = > 80 yo
-Health & function = > reduction in ADL, reduction in mobility
-Pathology => Parkinson, dementia, incontinence
-MSK => sarcopenia
-Sensory => reduced visual acuity
-Gait/ balance/ physical capacity => gait dysfunction, reduced walking speed, altered dynamic balance, sit to stand difficulty
- cognitive => Mini Mental State / depression
- medication => sedative, hypnotic, anxiolytic, poly medication (>4 medications)
What are the recurrence factors of falls ?
- history of falls >2 (but 1 fall is already considered as a red flag)
- time spent on the ground >3 hours
- Tinetti test score less than 20 points
- TUG test greater than 20 seconds
- unipodal hold less than 5 seconds
- impaired postural adaptation reactions
- stopping walking when the examiner asks the person so speak
Explain the prevention of fall algorithm
Medical appointment without prior fall during the past year => geriatric assessment => no problems or problem solved => education and yearly assessment
Medical appointment because of a fall => geriatric assessment => risks or persistent problem => personalized multi factorial intervention, exercise prescription (gait+balance), medication prescription adaptation, intrinsic risk factors adaptation, environment adaptation
What is your strategy in case of a good health, living at home patient ?
Assessment : fall assessment + risk factors
Specific start : promote physical activities, specific rehab if impairments
Common start: neurosensory correction, shoeing, nutritional advice, preventive measures against osteoporosis, assessment of iatrogenic factors, reduce medication
What is your strategy in case of a frail, living at home or in institution patient ?
Assessment : fall assessment and risk factors
Specific start: household adaptation, specific rehab including how to get back up after a fall
Common start: neurosensory correction, shoeing, nutritional advice, preventive measures agains osteoporosis, assessment of iatrogenic factors, reduce medication
What is your strategy in case of dependent, living institution patient ?
Assessment: fall assessment and risk factors
Specific start: address poly pathology, restraint measure
Common start: neurosensory correction, shoeing, nutritional advice, preventive mesures agains osteoporosis, assessment of iatrogenic factors, reduce medication
What are the 5 criteria to assess frailty, what is the cluster’s name ?
Fried’s criteria
- physical inactivity
- low muscle strength
- slow walking speed
- exhaustion/fatigue (self reported)
- weight loss (> 4,5 kg or more in 1 year)
Explain Fried’s criteria of physical inactivity
Less than 150 mn of moderate activity per week
Explain Fried’s criteria of low muscle strength
- grip strength < 21 kg in men and <14 kg in women
- Sit to stand
Explain Fried’s criteria of slow walking speed
- less than 0,8 m/s with or without walking aids
- predictor of mortality
Explain Fried’s criteria of exhaustion/fatigue
Self reported
Explain Fried’s criteria of weight loss
Loss of 4,5 kg or more (=5%) in one year
How to assess frailty in muscle function ?
- grip strength
- sit to stand test
How to assess frailty in balance and walk function ?
- TUG
- 6mn walking test
- Tinetti
- Unipodal balance
How to assess frailty in cognitive function ?
- Mini Mental State
- CODEX (dementia)
- Geriatric Depression Scale
How to assess nutritional status in case of frailty suspision ?
Nutritional Screening Initiative
How to assess dependency in frail patient ?
- KATZ: ADLs
- IADL
What defines dependency ?
The need for third party to carry out basic ADLs
How to assess dependency ?
Use the ADL-KATZ Questionnaire
Used to assess functional status by measuring patient’s ability to perform ADLs independently
Assesses 6 functions:
- bathing, dressing, toileting, transferring, continence, feeding
- result : full function =6/ moderate function =4/ severe impairment <2
Important to perform it multiple time by different and many health allies
How to assess nutritional status ?
The combination of hypoalbuminemia (below 35g/l) and hypercholesterolemia constitues an increased risk of either function decline or mortality.
How to assess cognitive status ?
Include the questions of mini mental state in the normal conversation. Score below 24 indicates a disorder without prejudging its origin.
Give examples of questions of the MMSE
“What is the year”
“What is the season”
“What is the date”
“What is the day of the week”
“Which month is it”
“Where are we now”
Can you remember 3 unrelated objects.
Can you name this object
How to assess the depressive status ?
Use the geriatric depression scale (long form)
Interpretation :
0-9=Norma
10-19= moderate depression
20-30= severe depression
>12 existence of depressive state
How to assess muscular function (related to sarcopenia)
Grip strength measure
Sit to stand test for 30 seconds
How to assess gait and balance ?
- 6mn walking test
Peu ou pas de mobilité si inférieur à 150m - TUG where walking aids are authorized
>12s is a predictive of risk of falls - Tinetti Balance Assessment Tool
Is the Tinetti Balance Assessment tool accurate ? If no, which one is more accurate ?
No because it’s a fusion of several tests (ex: TUG..etc) therefore it gives a global idea of balance status but not an idea of what PT should focus on.
Battery test is more accurate
What are the components of the Battery tests ?
Short Physical Performances battery test
Balance tests :
- side by side stand
- semi-tandem stand
- tandem stand
Gait speed test :
- 4m speed walk test
Chair stand test
How to interpret the Short Physical performance battery test ?
SPPB > 10/12
No sarcopenia
No mobility disability
SPPB BETWEEN 3/12 AND 9/12
Sarcopenia
No mobility disability
SPPB < 3/12
Sarcopenia (cachexia)?
Name another Battery test similar to Tinetti
EquiMOG test
What is the role of the physio in fall management ?
To work within an interdisciplinary team and investigate possible causes of falls through subjective history.
Goals are:
- to prevent future falls by ensuring the living environment is safe
- to prevent future falls by working on mobility, balance and strength
- restoring confidence to improve quality of life and reduce fear of falling
- training patients to cope with future falls and minimise complications
What are the possible interventions in the field of correction of deficiencies ?
—> address visual impairment: correction, exercise programme, home design
—> address the importance of shoes : heel/toe increases risk, high shoes, hard soles
—> hip protectors: does not reduce the risk of falling, reduces the number of hip fractures, always included in a multi factorial intervention
What are the possible interventions regarding housing ?
Floor mats
Slippery floor
Insufficient lightning
Height of furniture
Stairs
What are the recommandations for physical activity for adults and older adults ?
At least 150 mn of moderate intensity per week such as swimming, brisk walking, cycling.
Or
At least 75 mn of vigorous intensity per week such as running, stairs climbing, playing sports
And
Build strength on at least 2 days a week, such as gym, yoga, weight lifting
Minimise sedentary time
Improve balance such as dance, bowl games, tai chi
How to address fear ? Give an example
Through a desensitization process :
1- thing about doing the exercise
2- try to do the exercise
3- do it
4- repeat
5- reinforce automation
Break down the exercise and address each component
Example: EXERGAMES
What are the components of Otago Home Exercise Program ?
It is designed specifically for fall prevention
- strengthening (moderate intensity)
- balance exercises
- walking
Exercise must match the impairment
give examples of exercises improving balance and flexibility
- dancing
- gym cessions
- group exercises classes
- home exercise program
- lawn bowling
- Pilates
- tai chi
- yoga
- hydrotherapy
