L6/7 Falls & Exercise Flashcards
Screening tools
- CPG recommend all adults 65+ be screened
- commonly used at community health events or if pt is being seen for something else
- screening tests need HIGH SENSITIVITY so that they don’t miss individuals at risk
- tests should be brief
- examples for falls include “fallen in the past year”, MAHC-10, feel unsteady
Assessment for Falls
- CPG recommend only if indicated based on screening results
- often occur after a fall has already happened
- need tests with high SPECIFICITY
- tests often more time consuming than screening tests
- commonly used performance based functional measures are Berg, mini-best, 4SQ, TUG
SPINS
4 SQ Spin = 100%
Berg Spin = 90%
TUG = 85%
3 Key Qs = 75%
Mini-Best = 75%
Gait Speed = 70%
STEADI = 63%
Mahc-10 = 13%
SNOUTS
Mahc-10 = 97%
3 Questions = 94%
Gait Speed = 89%
4SQ = 85%
Mini Best = 85%
Berg = 73%
STEADI = 70%
TUG = 31%
Stopping elderly accidents, deaths, and injuries (STEADI)
Developed in 2012 by the CDC
* based on CPG, geared towards PCP and pts
* recommends that all adults age 65 yo + be screened for falls annually
Three parts of STEADI
- SCREEN = pts to identify their fall risk with stay indpendent and STEADI
- ASSESS = pts modifiable fall risk factors
- INTERVENE = to reduce fall risk by using effective clinical and community based strategies
Questions asked on STEADI
- falls
- ADs
- unsteadiness
- concern for falls
- B/B function
- neuropathy
- medicine
- mood
12 Q total, scoring 4 or more indicates increased risk
Three key questions for patients falling on STEADI
- Feels unsteady when standing or walking
- Worries about falling
- Has fallen in past year –> how many times, were you injured
Screen all adults ___ for falls risk
over 65
should ask if they have fallen the past year, their fear of falling. PT will note balance or mobility impairments or neuro
PTs should do for falls…
- home safety assessment and recommendations
- assessments or performance outcomes as necessary
- set goals and provide interventions within PT scope of practice
- refer to provides outside PT scope of practice
- give advice about community exercise or ways to prevent falls
- intervene with evidence based exercise and education
Beers Criteria
- lists potentially inappropriate medications for 65+
- does not forbid from takin gthese meds
- meds on the beers criteria are usually becuase they sedate or cause confusion, increasing fall risk
- PTs have ability and obligation to advise PCP about pt’s fall risk and medication ADRs
- it is important to do medication review and reconciliation especially after hospitalization
Medication Intervention Strategies
- evaluate polypharmacy
- drug to drug interactions
- help recommend med minders
- eliminate psychotropics (rf for fall injuries) includes antipsychotics, antidepressants, sedatives
Approx ___ of american adults…
1/3
in their 60s to 70s use 5+ meds regularly
CDC PA Guidlines for 65 yo+
- at least 150 min a week of moderate intensity or 75 min week of vigorous intensity, at 10 min at least a bout
- 2 days a week of activities that strengthen muscles
- activities to improve balance
- RPE 13-16, somewhat hard
- large muscle groups
Less than __ of americans aged 65+ achieve CDC guidelines
15%
37% of older adults meet aerobic
19% of older adults meet strength
Physical Stress Theory
predictable response of tissues, organs, and systems to mechanical and physiological stressors
changes in relative level of physical stress causes a predictable adaptive response in all biological tissues
helps explain overload and underload effects as well as lack of change if usual load is placed
Underload
tissues that lose thier ability to absorb and dissipate stress, results in atrophy
<40% of maximum
examples: bed rest, sedentary activity
Overload
tissue responds with increased ability to absorb and dissipate stress, causes hypertrophy
60-100% of max, resulting in adaptation
ex: strength training with 1 RM max
Excessive Stress
susceptible to injury or death
> 100% of max
ex: weight bearing on osteoporotic bone
Usual Stress
40-60% of maximum, causes no change. More of maintenance of muscles
ex: walking 5000-7000 steps a day
No stress
0% of max, loss of ability to adapt, resulting in death
ex: prolonged bed rest such as coma
Sarcopenia and Frailty
- sarcopenia is a normal age related loss of skeletal muscle
- sarcopenia thought to be main driver of frailty
- sarcopenia 2x common as frailty
- both increase risk for medical and disabling conditions
- both are amenable to interventions and are reversible
Most common symptoms of frailty
muscle weakness
decreased gait speed
Frail Adults and Exercise
start with strength and balance training before aerobic to build up reserve
Strengthening for Older Adults
- can do 70-80% of 1 RM safely
- 8-12 reps is 70-80% of 1 RM
- true 1 RM testing is not recommended for adults
- should do 8-10 exercises that target major muscle groups
- 2-3 days a week that are non-consecutive
- significant improvements in muscle strength and functional performance despite advanced age presence of chronic disease, sedentary habits, and functional disabilities
The ___ weight that can be lifted ___ with number of repetitions
MAX
DECREASES
Flexibility Principles for older adults
- higher dose has same effects as younger adults
- best to stretch after aerobic or strength b/c tissue is vascularized
- at least 30-60s hold with slight resistance and mild discomfort
- breathing during the stretch helps to minimize activation of muscle spindles
Joint mobs and osteoporosis
- osteoporosis is a precaution for grade 1-4
- no clear evidence of harm
- grade 5 is contraindicated with osteoporosis
Frid Frailty Phenotype
- weight loss > 10 lbs in past year
- Self-reported exhaustion
- Slow walking speed <.76 m/s
- Weak grip strength
- Low physical activity
0/5 = robust
1-2/5 = pre-frail
≥ 3/5 = frail
Falls are the leading cause of
injury for adults 65+
visits to ER
hospital admissions
death
Injuries and Falls
- fractures are most common injury, specifically hip, wrist, humerus, pelvis
- other serious injuries include hematoma, jt dislocation, laceration
- most falls don’t cause injuries that are severe enough for medical attention
Intrinsic Risk Factors for Falls
- age
- previous falls and fear of falling
- age related somatosensory and neuro changes
- congitive
- mental health
- behvaior and life choices
- medications
Extrinsic Factors for Falls
- environment
- clothing, shoes, glasses
- equipment
- social influences
- siutational
*medications
Medical history questions that predict falls
- any previous falls
- psychoactive meds
- requiring any ADL assistance
- self-reported fear of falling
- AD device used
Berg Balance Cut off
≤ 50
Mini best cut off
< 16
TUG Cut off
≥ 12 sec
Gait Speed Cut off
< 1.0m/s
Measurements of Thoracic Kyphosis
Kyphotic Index
Occiput to Wall distance
Interventions to address fall risk factors
rehab
environment
medical
Interventions to address fall risk need to include
- strength training
- balance training
- gait training
- correction of environmental hazards
- correction of footwear
Ramps that are ADA approved
1/12 slope
for every 1 inch of rise, you need 1 foot of ramp
Physical Activity
- not just exercise
- voluntary body movement that involves skeletal muscle contraction that results in energy expenditure
- encompasses all activities and intensity levels
- typically low intensity
Exercise definition
higher intensity
sub category of PA
planned, structured, repetitive
involves improvement or maintenance of PF
Physical Fitness
state of well-being and overall health
can be measured with 5xSTS, TUG, etc
Physical Inactivity
- significant rf for developing chronic health condition
- can cause sedentary death syndrome
- 9.9% of deaths for 40-70 and 7.8% of deaths for 70+ are attributed to not meeting CDC PA guidelines
Imediate Benefits of Exercise
- improves sleep
- reduces anxiety
- reduces BP
Other benefits of exercise
- reduces risk of dementia and depression
- lowers risk of heart disease, diabetes, stroke
- lowers risk of cancers
- reduces risk of weight gain
- helps people live independently longer
- improves bone health
- reduces risk of falls
- boosts immune function
Don’t underdose older adults. Instead…
match frequency, intensity, and duration of exercise to abilities and goals
Frailty Definition
- decreased reserve across organ systems leading to alterations in function
- multidimensional, gives rise to vulnerability
Failty Prevalence
- F > M
- higher incidence in racial minorities
- higher incidence in lower income
in high risk adults, interval training
- reduces BP
- improves endothelial function
- improves lipid profiles
- improves VO2 max
- improves LV function
- improves myocardial function
- reverses left ventricular modeling
When is lower intensity better for older adults?
- acute conditions
- post surgical
- extremely frail
- RA
- other medical conditions that limit intensity
Bone Mineral Density
- RET and AET both positively impact BMD
- higher intensity, progressive, and novel are best
- avoid spinal flexion and rotation, initially supervise other actions
Aquatic Exercise
- buoyancy allows deconditioned individuals to exercise by lessening impact
- can improve all aspects of fitness
- reduces pain, good for those with OA, balance disorder, obesity, post surgical
- use RPE not HR for aquatic
Home Health Exercise
- similar to healthy individuals
- maximize home space for safety
- think about how to best use environment for the pt
Exercise in Inpatient
- restorative or maintenace programs
- may benefit from group exercise for socialization
Frail Individuals should perform
Mostly Aerobic exercise, and 45 minutes a session
