Frailty and falls Flashcards
What is frailty?
A clinical state of vulnerability with inherent risks for adverse clinical outcomes
Often have poor functional reserve
What is poor functional reserve
small insults results in large, steep, sudden declines in function/cognition
What are symptoms and signs of frailty?
- Delirium
- Acute/sub-acute decline in mobility
- Unable to manage at home
- Frequent contact with services
- Not eating/drinking
- Sleep disorders & sensory deficits e.g. vision issues, peripheral neuropathy
- Falls
- Incontinence
- Pressure ulcers
- Fatigue
- Dizziness
- Weight loss
What are the 4 classifications of frailty?
Robustness
Pre-frailty
Frailty
Disability
How is a fall defined?
A fall is a sudden, unintentional change in position which causes an individual to land at a lower level on an object or the ground, not because of a sudden onset of paralysis, epileptic seizure or overwhelming external force.
Whar are intrinsic risk factors for falls?
- Vision
- Vestibular function
- Blood pressure
- Muscle strength
- Sensation
- Central processing
- Heart rate
- Joint stability
- Proprioception
- Balance
- Medication
- Gait deficit
- Hearing impairment
- Foot problems e.g. corns, calluses, bunions
- Dizziness
- Postural/orthostatic hypotension: drop in BP when getting up from lying or sitting
- Inner ear problems
- HR issues: bradycardia, tachycardia, atrial fibrillation
- Dehydration
What are extrinsic risk factors for falls?
- Inappropriate walking aids
- Inappropriate footwear
- Poor lighting
- Clothing
- Floor covering
- Low furniture
What areas should be assessed in frailty and falls
Gait
Balance
LL strength
Rockwood scoring system (7-9 indicates severe frailty)
Cognition
NICE also suggests in the community Electronic Frailty Index (eFI)
What assessments might be used for falls and frailty?
Timed up and go test
180 degree turn test
Gait speed test
2-minute walk test
Functional reach test
Unipedal stance test
4 square step test
Clock drawing test
5-minute sit to stand test
How is the functional reach test performed?
In standing stand close but not touching wall, and arm closer to wall at 90 degrees flexion. Record initial point of 3rd digit, measure difference between start and end.
- Modified version for those that can’t stand
- Yard stick taped to wall, and make final position.
What does the result of a functional reach test mean?
25cm/greater = low fall risk
15-25cm = 2x greater fall risk
15cm or less = risk of falling is 4x greater than normal
Unwilling to reach: risk of falling is 8x greater than normal
How is the unipedal stance test performed?
- Need stopwatch
- Time how long can stand on one leg
- One foot eyes open and closed
- Time how long can maintain
- Good test-retest reliability and interrater reliability found by Franchignoni et al 1998
What are average times for ages open and eyes closed?
- 20-49 28.8s open eyes, 20.7 closed
- 50-59 24.2 open, 6.1 closed
- 60-69 27.1 open, 2.0 closed
- 70-79 18.2 open, 1.0 closed
How is the 4 square step test performed?
May have demonstration and practice trial
- Meant to perform twice
- Patient steps over 4 canes that are placed in plus sign
- Told to complete as quickly as possible
- Square 1 facing square 2, square four to the right of the patient
- Time from when foot touches square 2 and last foot reaches square 1
- Go clockwise then anitclockwise
- pt unable to side step can turn
- Fail if lose balance or touch cane
What are the cut off score for 4 step test?
Older adult / geriatric: >15s (increased risk of falls)
How is the Timed up and go performed?
- Pt in chair with back on back of chair
- Command go
- Walk 3 meters at comfortable pace, turns and walks back to chair and sits down
- Should have a practice trial
- Can use assistive device
For 65+
Has excellent test-retest reliability in stroke according to Flasnbjer et al 2005)
What are the cut-off scores for populations in the timed up and go test?
Older adults at falls clinic: >15s
Frail elderly: >32.6s
How is the 2 minute walk test performed
- Walk as far as possible in 2 minutes
- Can use walking aids
- Should be independently mobile
~ 15m course
What are predicted distances for populations in the 2-minute walk test?
Women 260 - (0.7 x age) - (1.7 x BMI)
Men 280. - (0.9 x age) - (1.4 x BMI)
How is the 5-minute sit to stand test performed?
Pt in chair with arms folded across chest and back against chair (with stroke can have affected arm supported or hanging to side)
- Chair should be free from wall
- Say go and measure how long to do 5 stands
- If concern for fatigue can demonstrate to patient what plan is
What are the norms for the 5 sit to stand test?
Minimal detectable time for test is 3.6-4.2 s
60-69 normal 11.4 s
70-79 normal 12.6 s
80-89 normal 14.8 s
How is the 180 degree turn test performed?
Person has to stand up and step around till they face the other direction
If takes more than fou steps further assessment should be considered
They are likely at higher risk of falls
How is the gait speed test performed?
Gait speed test: Patient walks at a comfortable pace with appropriate walking-aid, straight path and flat surface, 9 metre total distance, with the first and last 2.5 meters used for acceleration and deceleration.
Time recorded for the middle 4 meters, fastest of 2 trials recorded, speed calculated using
Speed = distance/time
What mobility exercises can be used for frailty and falls?
Resisted walking
Unilateral step forward and back
Side-stepping (improve proprioception improving ability to walk)
Step over cones forward and side
Marching on spot (progress to forward or with hands moved)
Gait with elastic
Specific
- neck rotation
- neck stretch
Side flexion – flexibility in the lower back
Chest stretch
Upper body twist
Strengthening exercises for frailty and falls
Sideways walking
Grapevine
Heel-to-toe walk.
Single-leg stand
Step ups
Strength
Sit-to-stand
Mini squats
Calf raises
Sideways leg lift
Leg extension
Wall press-up
Bicep curls
Hip marching
What education should be provided to patients with falls and frailty?
Frailty is a LT condition of reduced resilience and increased vulnerability to deterioration as a result of minor stress factors.
It affects many aspects of a person’s life -ICF – physical health, activity, participation, mental health and their social environment.
More at risk of falls, incontinence, mobility problems and side effects of meds.
Many failing systems contribute to frailty- brain, endocrine, immune, skeletal, cardiovascular, respiratory, and renal systems.
Symptoms and signs of frailty include- dryness of mouth, lips and tongue, sunken eyes, drowsiness, confusion, concentrated urine.
what goal setting should be performed for frailty and falls?
Goal setting- track and measure using a diary or checklist, grade patients confidence of achieving this aim 1-10. Involve family and carers in discussions.
Ask personal goals, values and priorities.
What advice on medication should be provided?
Going to GP for medication review- can cause symptoms of frailty.
What may need to be put in place for safety?
Emergency care plan- pendant button to call for assistance, install rail bars, loose fittings.
What are possible themes for home exercise?
Exercise – can maintain strength and mobility not necessary increase it by a lot. – prevent deterioration.
What may you use to round out a group exercise session?
You might experience some muscle soreness later or tomorrow- as you have worked hard today and so remember to take it easy and not over work yourself. But keep up your physical activity and I will see you next week.
What are contraindications to exercise in frail people?
Safety:
Recent MI or electrocardiography changes
Complete heart block
Acute congestive heart failure
Unstable angina
Uncontrolled BP
Fractures
Sprains
Uncontrolled diabetes
Hyperthyroidism
Recent stroke
what are the aims of the session for a frailty and falls class?
improve mobility/ flexibility/ strengthen the upper and lower limb.
To increase balance and functional ability
what warm up and cool down exercises might be used?
Warm up:
Trunk twists
Cool-down:
Trunk side flexion stretch
what exercises might be used in a group class?
Mini squats + full squats
Calf raises + ankle weights
Hip abduction +holds
