Instability and Falls in Elderly Population Flashcards
The prevalence of falls among the elderly is linked to what?
increased morbidity and mortality
What can predispose an individual for future falls?
fear of falling
Balance confidence (perceived self-efficacy) is investigated fore its clinical implications for what?
fall screening and prevention stages
How many people 65+ fall every year?
1 out of 3 people
How likely is a person to fall again after experiencing a pervious fall?
twice as likely
Of the elderly that fall how many cause serious injury?
1 out of 5 falls cause serious injury
What is the leading cause of accidental death in the home?
Falls
what happens to an elderly patient who are hospitalized after a fall?
hospital stays are almost twice as long in elderly patient who are hospitalized after a fall than those admitted for other reasons
what % of people 65years old and over fall in a given year
35-40%
what % of people 80 years old and older fall in a year
50%
what % of people 65 years or older visit the ED because of a fall related injury?
8%
Falls account for what % of all fractures and what % of hip fractures in this group
falls account for 87% of all fractures and for more than 95% of hip fractures
What are risk Factors for Falling?
Gait/Balance deficit Visual/Hearing deficit MSK impairment Neuro/Cognitive Impairment Depression Using Assistive devices Meds Age>80 years old
What are Intrinsic Risk Factors for falls?
Weakness, Fall Hx Balance/Gait instability Assistive device use Visual Impairment Arithritis, ADL deficits Depression Cognitive Impairment Over 80 years old Lifestyle factors
Where do most falls occur with the Elderly population?
What are environment risk factors for falls
85% of falls occur in the Home RF: clutter/hazards support surface railing safety Poor lighting Obstacles Clothing
what is the risk of falling in an elderly with 0-1 risk factors
27% risk of falling
what happens to a patient risk of falling if they have 4 or more risk factors
78% risk of falling
what is postural control
Maintaining balance during body movements requires a reaction to restore the person’s displaced center of mass over the base of support
what is needed to maintain adequate postural control
requires keeping COG and BOS (base of support) during both static and dynamic situations
the body must be able to respond to changes in COG d/t:
intentional movement
Involuntary or unexpected movement
postural control is dependent on what?
on the integration of visual, verstibular and proprioceptive input from the CNS
Loss of balance results from?
- speed or magnitude of displacement
- Inability to quickly detect the displacement b/c sensory impairment, slowing of the CNS sensory info into motor response
- muscle weakness or joint pain causing slow motor response
motor strategies for postural control?
organized movement appropriate for controlling body’s position
sensory strategies for postural control?
organizes sensory info from visual somato-sensory, and vestibular systems for postural control
sensorimotor strategies
reflect rule for coordinating sensory and motor aspects of postural control
what are parts of anteroposterior stability?
ankle strategy
Hip strategy
stepping strategy
ankle strategy
response to small pertubation on a firm surface
hip strategy
response to larger faster pertubation on a smaller or compliant surface
stepping strategy
response to strong pertubation, enough to displace COM outside Base of support
Sensory input and balance
Vison is affected by age and disease
Hearing loss
Vestibular function
proprioception
what happens with an elderly persons reaction time as their sensory input changes
as sensory information is decreased reaction time is significantly longer in older adults compared with young adults
Central processing
neurologic disease Parkinsons stroke normal pressure hydrocephalus dementia depression- causes decreased concentration or awareness of potential environment hazards
MSK affecting balance
Muscle mass/strength no longer capable of generating the strength and accuracy of response to a balance disturbance
Weakness of hip abductors/adductors- decreased ability to maintain balance while stepping to avoid a fall
Osteoarthritis- pain deformity, limited range or motion, affect ability to beak impact of fall
foor problems- calluses, bunions affect sensory input
what happens to muscle strength as we age
strength declines with age for many adults
endurance decreases
muscle power is more highly correlated with physical function than muscle strength
Skeletal muscles loses both Type I&II fibers, number of motor units declines, number of myelinated fibers is reduced
what happens with range of motion as we age
spinal flexibility shows greatest decline with age compared with all other joints (spinal stenosis, throacic kyphosis etc)
Ankle joint flexibility, critical for postural control declines
Neuromuscular system contributes to postural control
Postural hypotension occurs in what percent of the elderly?
occurs in 10-30% of elderly community >65years old
what is postural hypotension defined
drop in systolic BP of 20mmHg or more with change in position from lying to standing
postural hypotension can be secondary to?
Meds
Dehydration
Age- associated with autonomic control of vasculature
bandura described self efficacy as what?
person’s perception of their ability to master a given type or level of performance in certain settings.
Tinetti decribed fear of falling as what?
as a diminished perceived self-efficacy at preventing a fall during normally non-hazardous activities of daily living.
reduced self-efficacy for balance/ fear of falling can lead to?
self imposed restrictions to activity
deconditioning and loss of muscle mass
decreased mobility
fall-related anxiety which leads to muscle tension
Fear of falling can predispose an individual to future falls without ever having experienced a fall
How do meds affects elderly’s risk of falls
use of > 4 meds impairs cognitive function Electrolyte balance BP dizziness fatigue
what meds put elderly patients at risk for falls
Anti-depressant Diuretics Neuroleptics/sedatives Digoxin Anti-arrhythmics Sedative Narcotic analgesics Anti-HTN
measurement of balance confidence/ self efficacy
first attempts to measure fear of falling used dichotomous variable: are you afraid of falling? Yes/No
What does SAFE stand for
Survey of Activities and Fear of falling in Elderly.
Multiple level of questions on specific activities
tools used to measurement of self-efficacy?
Falls Efficacy Scale (FES)
Activities-specific balance confidence scale (ABC)
what is the ABC
Activities specific balance confidence scale
based on bandura’s concept of self efficacy and task avoidance
developed by powell and myers for community dwelling older adults
required subjects to rate their confidence in completing 16 activities of daily living
ABC results/interpretation
overall confidence percentage is average of all 16 responses
-Scores 80% high functioning for active older adults
67% confidence level determined as falls risk with 84.4 sensitivity
benefits of ABC
provides insight into fear of falling syndrome
facilitates active participation in interventions for falls risk reductions through acknowledgment of self-efficacy
ABC limitations
not appropriate for all setting as some activities may not have been experienced by participant
not a replacement for physical performance measures
what is the purpose of measurement of physical performance?
physical performance toll measures as person’s risk for falls
developed around assessing normal functional tasks that require good balance
need to be easily administered, evidence based and clinically significant
what is the timed up and go (TUG)
developed as a measure of balance based on participants risk for falling
modified later to include timing and used to examine functional mobility in community dwelling, older adults 70-84 years of age
how is the Timed Up and Go measured?
time is taken to rise to stand up from a chair walk 3 meters, turn, walk back to chair and sit down.
TUG results/interpretation
older adults who take longer than 14 seconds have high risk of falls
other studies include TUG use in specific population/conditions
TUG score >16 seconds predicted falls in a 5yr period
TUG score of 24 or > for elderly persons post hip Fx valid predictor of fallin in the 1st 6 months after discharge
disadvantage of TUG
researchers have found instructions for speed, number of trails, seat height and cuing varies in literature
Timing should commence with command “GO” but researchers found inconsistencies
what is the Berg balance test
established by Berg as functional balance measure in geriatric patients
How does the Berg balance test preformed?
14 balance items rated by observer on 5 points ordinal scale for each item
Participant cannot use assistive devices
Requires 10-20min and only requires minimal equipment
(2 chairs- one with arm rests and one without, foot stool/step, stop watch, ruler)
Can be used in pts who can not ambulate
Benefits of berg balance test?
well known test: score may have meaning to multi-disciplinary team
may detect cognitive impairment because they may not be able to follow multi-step commands
valid measure in a variety of patient populations including stroke
looks at functional activities
low cost to administer
Berg balance test results
41-56
21-40
0-20
41-56 Independent
21-40 walking with assistance
0-20 wheelchair bound
What are multidisciplinary treatment in reducing risk factors for falling
Exercise/training to improve deficits in balance, mobility and strength
Correct sensory deficits (vision, hearing, vestibular, proprioceptive function)
Evaluate& Tx Hypotension
Review Meds
Treat foot problems
Environmental modification and use adaptive equipment
Education to patient and caretaker
what are intervention strategies?
address physical status with interventions to address strength, balance, gait
Wellness,med review, life modifications
ED/Tx of medical conditions
reduce home hazards
Interventions
Modify home environment Minimize Meds Manage Postural hypotension Manage foot problems Strength, balance, gait training proper hydration & nutrition
How can fall risks be reduced
repair uneven pavement install railings keep shrubs trimmed remove throw rugs remove clutter keep cords near walls Emergency call device Adequate lighting Light switches at top and bottom of stairs install grab bars in bath and near toilet install raised toilet use rubber matt in shower do not use cupboards that are out of reach
learning to fall
key is relaxation
more likely to roll with impact
more likely to sustain least amount of injury
difficulty getting up after a fall
associated with substantial morbidity
51% of community dwelling elderly were unable to get up unassisted
85% of those who were not associated with serious injury
>20% remain on floor for >1hour
how to reduce risk of hospital falls/ nursing home falls
physical restraint chemical restraint bed alarms call bell low beds arm bad to signify fall risk Mats scheduled toileting use of assistive devices
evaluation of a patient who fell
unit personnel and healthcare providers are made aware in order to perform exam/tx note associated symptoms perform PE Note any neuro findings or trauma med review lab or diagnostic studies
Osteoporosis
Osteoporosis increases an older person’s risk of fracture
A decrease of one standard deviation in femoral neck bone mineral density increases the risk of hip fracture 2.7 times
Low body mass index and low weight increase the force of impact with a fall b/c of lack of cushioning effect of muscle and subcutaneous tissue
