L15: Falls in Older People Part 2 Flashcards
What are 8 falls risk factors?
What 4 psychological risk factors?
- Dementia/Alzheimer’s
- Depression
- Delirum
- Fear of falling
What are 3 reasons why older people with dementia is a risk for falls?
- 70-80% will fall each year (x2 incidence of cognitively intact)
- x3 increased risk of sustaining a fracture
- Fallers with dementia: x5 more likely to be institutionalised
What test is used to diagnose the level of dementia?
What are 5 risk factors for people that are cognitively intacted, with particular relevance in old people with dementia?
- Postural instability (impairment of gait and balance) both static and dynamic
- Medication- particularly psychotrophics
- Neurocardiovascular instability (orthostatic hypotension)
- Environmental fall hazard
- Visual impairment
What are 3 risk factors specific to older people with cognitive impairment dementia?
- Wandering (eg. residents leaving there aged-care facility)
- Agitation or aggression
- Perceptual difficulties
What are 5 characteristics that will be seen in a dementia patient’s chart?
- Agitation
- Tendency to wander
- Behavioural problems ◦ → Psychotropic drugs
- Perceptual deficits
- ↓Visuospatial awareness
- ↓ Fear
- Inability to deal with environmental hazards
What are 4 gait impairments in older people with dementia?
- Slower walking speed
- Reduced step frequency
- Shorter step length
- Increased postural flexion
What are 5 balance impairments in older people with dementia?
- Increased double support time
- Increased sway path (in ant/post and medial/lateral directions
- Increased unsteadiness
- Impaired one/two leg balance, eyes open/closed
- Poor dual tasking
There is a relationship between ______, falls, #
depression
Depression is associated with post-________decline in function after fall
discharge
What are the 3 impacts of depression on physical activity?
Reduced physical activity
- ↓ Muscle strength
- ↓ Coordination
- ↓ Balance
Antidepressant ______are also a risk factor for falls.
medications
What is the test that can be used to test geriatric depression?
What are 3 characteristics of delirium?
- Medical emergency
- Rapid onset (usually hours/days)
- Variable & fluctuating changes in mental status
Why is delirium a risk factor for falls?
Risk factor for falls in hospitalised older people:
- 14-24% prevalence on admission
- 6-56% incidence during hospital stay
- 15-53% postoperatively
When do patients shows delirium?
- Prior to a heart ache, patient will show delirium
- Presented when there is low quality of care (eg. dehydration since nurses are busy)
What are 7 predisposing factors for delirium?
- existing cognitive impairment, (eg. dementia)
- Depression
- Age 70 years and older
- Visual impairment
- Hearing impairment
- History of alcohol abuse
- Previous episode of delirium
What are 8 precipitating factors for delirium?
- Malnutrition
- Dehydration
- Addition of 3+ medication during hospitalisation
- Severe medical illness (eg. heart attack)
- Infection
- Abnormal serum sodium
- Use of indwelling catheter
- Use of mechanical restraint
Why is the use of mechanical restraint or indwelling catheter a risk for delirium?
more restrained position –> increase agitation
What are the 4 characteristics of delirium?
- Unable to negotiate environment
- Poor Balance
- Muscle Weakness
- Postural Hypotension
What are 5 independent predictors of adverse outcomes?
- Decreased functional levels
- Increased mortality
- Incontinence
- Increase falls
- Pressure sores
What is the fear of falling?
‘Ongoing concern about falling that ultimately limits performance of ADLs’
What are 4 features that the fear of falling is associated with?
- Previous Falls
- Poor Health Status
- Functional Decline
- Frailty
What are 6 features that fear of falling correlates to?
- Activity Restriction
- Quality of Life
- Pain
- Anxiety
- Depression
- Social Isolation
What are 4 features that the falls efficacy is associated with?
- ↓ Leaning balance
- Poor Strength
- ↓ Physical performance
- Impaired gait:
- ↓ Stride length
- ↓ Speed
- ↑ Double-support time
What is falls efficacy?
‘Perceived ability to confidently undertake ADLs without falling’
What are 3 characteristics of impaired gait due to falls efficacy?
- ↓ Stride length
- ↓ Speed
- ↑ Double-support time
What test is used to determine the level of fear of falling?
The Activities-Specific Balance Confidence (ABC) Scale
What are 2 test is used to determine the level of falls efficacy?
- Falls Efficacy Scale-International (FES-I)
- Iconographical Falls Efficacy Scale
What is the Iconographical Falls Efficacy Scale?
Using visual cards –> activities are present –> help them to imagine the content and put themselves in the position
What is the Falls Efficacy Scale-International (FES-I)?
What test is used to measure activity participation/engagement?
Low FES- I score?
Appropriate activities
Risky behaviours?
What was the Frenchay Activities Index originally designed for?
originally developed for stroke patients - now for other groups
What are 4 attentional limitations?
- Impaired information processing ability
- Can affect balance when performing ≥2 tasks simultaneously
- Finite attentional resources → task prioritisation
- Implications when primary postural task is impaired
What is the best test to observe attentional levels for impairments/limitations?
TUG used to assess these attentional limitations
- Eg. do they stop walking when talking
What is selective attention?
Can be so focused on one thing that can miss other things that can be going in the environment
What are 4 ways to improve dual tasking?
Why do you want to improve dual tasking?
Is a predictor for falls More functional for ADL
What are 2 measures of postural sway when staying?
- Cross-sectional studies: ↑ sway in elders with a history of falls vs. non-fallers
- Prospective studies: ‘Sway’ is a useful predictor of risk of falling during follow-up
What are 3 characteristics of mediolateral sway?
- Greater in fallers vs age-matched non-fallers
- Predictor of recurrent
- Failure to recover balance in lateral direction – linked to falls
_____ sway is a greater predictor of falls than _____sway
M-L; A-P
What are 3 characteristics of tandem stance on falls?
- ↑ mediolateral sway in fallers
- Fallers more likely to take protective step with eyes closed
- Inability to stand for 10 s – predictor of future falls
What are 3 characteristics of reaching on falls?
- Age-related decline in functional reach
- Lateral reach: unable to identify fallers vs. non-fallers
- Multi-directional reach: has not yet been used in prospective falls study
What are 2 characteristics of voluntary stepping on falls?
- Max. step length: ↓ distance in fallers
- Rapid stepping: ↓ stepping speed/responses in fallers
Why are functional and lateral reach no good predictors of falls?
so many ways that patients can cheat
What are functional and lateral good for if not predictors for falls?
pre and post interventions (outcome measures)
What are 3 functional test that are suitable for postural stability in regards to falls?
- Berg Balance Scale
- Tinetti Performance Oriented Balance &Mobility Assessment
- Timed Up and Go Test
What are 3 external perturbations that are suitable for postural stability in regards to falls?
- Pastor, Day and Marsden Test
- Sternal Push
- Hold and Release Looking for step responses
What are 10 gait characteristics in level walking in older people?
- Arrhythmic vertical & AP head, trunk & pelvic accelerations
- ↓ Ankle plantarflexor torque
- ↓ Step length
- ↓ Cadence
- ↑ Cadence variability
- ↓ Velocity
- ↓ Peak hip extension
- ↑ Hip flexor torque
- ↑ Knee flexor torque
- ↑ Ankle dorsiflexor torque
What are 2 reasons why hip extension is important for gait?
- Propulsion
- Adequate step length
When there are decreased spatiotemporal gait parameters, what are 2 impairments?
- Physiological
- Cognitive
What are 2 cognitive impairments on gait as a result of decrease spatiotemporal gait parameters?
- Cautious gait pattern
- Fear of Falling Anxiety
What are 5 physiological impairments on gait as a result of decrease spatiotemporal gait parameters?
- Slow Reaction Times
- Impaired Peripheral Sensation
- ↑ Postural Sway
- ↓ Joint ROM
- ↓ Lower Limb Strength
What are 4 gait characteristics that can all lead to increased risk of falls if they are poor?
- Obstacle negotiation
- Stairs
- Tripping response
- Slipping response
What are 3 characteristics of obstacle negotiation that are important for gait?
- Precise planning
- Cognitive problems
- Ability to maintain balance
- Foot clearance
- Good distance between obstacle
- Trailing
What are 2 characteristics of stairs that are important for gait?
- ↑ Risk of falls during descent vs ascent
- Accurate foot placement
What are 3 characteristics of tripping responses that are important for gait?
- Ability to respond to perturbation Internal or externally
- Prior exposure to hazards
- Due to the learned experience (better to react in the future)
- Seeing hazards in advance
What are 3 characteristics of slipping responses that are important for gait?
- Ability to detect sliding motion
- Rapid planning of response
- Execution of corrective step/s
What are 7 sensory/neuromuscular risk factors?
- Ankle Dorsiflexion ROM & Strength
- Reaction Time
- Vestibular Function
- Visual Acuity, Depth Perception, Contrast Sensitivity
- Knee Flexion/ Extension Strength
- Joint Position Sense
- Tactile Sensitivity
What are 5 features that should be included in an exercise program to improve balance/reduce falls?
What are 2 important things that should be added to be beneficial for improving balance?
- High level balance training (challenging)
- At least 3 hrs of exercise each week
What are 5 characteristics/problems that multifocal wearers experience?
- Involved in more edge-of step accidents
- Viewing environment through reading segments
- Blurred and magnified lower visual field
- ↓ Contrast sensitivity &depth perception at critical focal ( 1.5-2 ms) distances
- Discrimination of floor-level obstacles
What happens if you are looking into the wrong portion of the focals?
Impaired judgement
- Blur and magnify the environment
- Possible trip hazard
What are 3 intervention studies when using multifocals?
- Single lens glasses (↓ falls / improves gait performance)
- Visual assessment (appropriate spectacle prescription)
- Education (Spectacle use…..at time of fall?)
What are 4 reasons to refer to the podiatrist?
- Foot Pain
- Swelling, arthritis, bunions, toe deformities, corns, calluses
- Conditions affecting balance/posture/proprioception (diabetes, PVD…)
- Orthotics for deformity
What is a cause of foot pain?
Inappropriate footwear worn by older people
Footewear selection should not be based on ________ rather than safety
comfort
What are 5 footwear features in older fallers?
- Narrow heels
- Slippery soles
- Inadequate fixation
- Poorly fitting shoes
- Soft heel counters
What does the idea shoe look like?
What are 7 management strategies of incontience?
- Address all comorbidities
- MDT approach:
- Doctors, Nurse Continence Advisors, PT, OT
- Habit training, prompted voiding, timed voiding programs (Urge incontinence –> ask them to hold a bit longer (get them to increase the time when they have the urge and when they need to go)
- ↓ Caffeine/carbonated drink intake
- Pelvic floor exercises
- Use of continence aids
- ↓ Environmental hazards
What are 7 ways to avoid postural hypotension?
- Good hydration
- Sit up/stand up slowly from lying/sitting
- Minimise exposure to high temperatures
- Minimise vasodilation
- ↑ Salt intake
- Medication review
- Peripheral compression devices
- Monitor postural blood pressure
What are 10 processes to do when you have a cognitive impairment?
- Detailed assessment of cognitive impairment
- Acute (e.g. delirium) or progressive (e.g. dementia)
- Treat reversible causes, symptoms (e.g. agitation, wandering)
- Encourage participation in exercise
- Medication review
- Dehydration
- Treat postural hypotension
- Address incontinence
- Modification of environment
- Mobility aids/assistive devices
- Avoid using restraints/immobilising equipment
- Use of fall-alarm devices
- Have a mat on the floor
- Nursing staff are alerted if they are mobilising independently and need to go assist
What are 2 ways to minimise injury?
- Hip protectors
- Vitamin D (+- calcium) supplementation
What are hip protectors for?
Absorbs / disperses forces away from hip joint
- Worn over greater trochanter of femur
What are 3 situations where hip fractures can still occur, despite having hip protectors?
- Weak bones / Spontaneous fractures
- Rotational forces
- Fall onto buttocks
What is the 4 supporting evidence for hip protectors?
- Doesn’t decrease falls just decrease severity
- May slightly ↓ hip fractures in RACF residents / hospital patients
- Little or no effect in community-dwelling older adults
- May slightly ↑ small risk of pelvic fractures
- Problems with acceptance & long-term adherence
What are 3 things that vitamin D (+- calcium) supplementation are associated with?
- ↓ BMD
- High bone turnover
- ↑ Risk of hip #
_____ may prevent falls by improving muscle strength & psychomotor performance, independent of effects on BMD
Vitamin D
“The active vitamin D metabolite (25-hydroxyvitamin D) binds to a highly specific nuclear receptor in muscle tissue. This improves ______ function, which in turn may be why vitamin D reduces the risk of falling”
muscle
Why does vitamin D reduce the risk of falling?
“The active vitamin D metabolite (25-hydroxyvitamin D) binds to a highly specific nuclear receptor in muscle tissue. This improves muscle function, which in turn may be why vitamin D reduces the risk of falling
