Lecture 21: Fall prevention Flashcards
Leading cause of fatal and non-fatal injuries among older adults?
Falls
fall definition
an event which results in a person coming to rest inadvertently on the ground or other lower level regardless of whether an injury was sustained, and not as a result of a major intrinsic event or overwhelming hazard
- intrinsic event: syncopal vs. non-syncopal - overwhelming hazard: a hazard that would result in a fall by most young, healthy persons
intrinsic risk factors for falls
- advanced age
- previous fall
- weakness
- gait and balance problems
- visual deficits
- postural hypotension
- chronic conditions
- fear
- psychoactive medication
extrinsic risk factors for falls: community-dwelling older adults
- lack of stair handrails
- poor stair design
- dim lighting or glare
- obstacles or tripping hazards
- slippery or uneven surfaces
- improper use of assistive device
- worse when the community-dweller is hurried or not paying attention
extrinsic risk factors: within hospital
- bedrails
- height and stability of seating
- low toilets
- wheelchair braking problems
- geri chairs
- portable commodes
- obstacles caused by mobility aids (WC, walker)
risk factors and function
risk factors interact with overall function. some risk factors may have a stronger influence on falls in lower-functioning older adults that independent community-dwelling older adults
- urinary incontinence
- cognitive impairment
- fear
how often should older adults be screened for falls
Physical therapists should routinely ask older adult patients if they have fallen in the last 12 months
screening should include:
-history and context of falls over the last 12 months
-at least one question about the patient’s perception of difficulty with balance or walking
a fall screen is positive when either of the following conditions is found
- the patient reports multiple falls regardless of balance and gait impairments
- the patient reports one fall and a balance or gait impairment
CDC Steadi screening
- annual for adults >65 or for pt’s who present with a fall
- stay independent brochure: >4 = risk for falling
- 3 questions:
- do you feel unsteady when standing or walking
- are you worried about falling?
- have you fallen in the past year? - how many times? were you injured?
Using post-test probability to guide history questions and balance test choice
- any history of falls? (44% if positive/26% if negative)
- psychoactive medication (38% if positive/26% if negative)
- requiring any ADL assistance (38% if positive/26% if negative)
- self-report or fear of falling (38% if positive/28% if negative)
- ambulatory assistive device use (36% if postivie/26% if negative)
Use SPLATT Model for person reporting a fall
- symptoms
- previous falls
- location
- activity
- time of day
- trauma
if you do feet together, semi-tandem, or tandem stance for less than ___s = increased risk for falls
10s
Berg Balance test
- 14 common tasks
- 0-4 scale
- lower score correlates with higher fall risk
- < 50 points
Timed up & go (TUG)
- sit, stand, walk 3m, turn return to chair, sit
- TUG is primarily is mobility measure
TUG norms
> 60: 9.4s
60-69: 8.1
70-79: 9.2
80-89: 11.3
BESTest
based on a systems approach to balance
- biomechanical
- stability limits
- postural responses
- anticipatory postural adjustments
- sensory orientation
- dynamic balance during gait and cognitive effects
Mini-BESTtest Systems:
- anticipatory
- sensory organization
- reactive postural control
- dynamic gait
Performance oriented mobility assessment (POMA)
- balance and gait component
- balance = 16
- gait = 12
- several Level I studies
Gait - comfortable gait speed cut offs
< 0.6 m/s
< 1m/s
Dynamic gait index
4 and 8 item (8 item more commonly used in older adult)
<19
MCID 4
Functional gait assessment is very similar to DGI (22/30 is a good cut off score; and MCID 4-6)
Fear of falling/falls efficacy scale
- 16 items
- range of scores 16-64 (16 - least concerned; 64 - highest score-most concerned)
Falls efficacy scale international
in one study, a score of > 24 substantially increased the probability of a future fall and a lower score substantially decreased the likelihood
in the second, a score of > 21 increased the probability of a futrue fall moderately, while a lower score moederately decreased the liklihood
how to prevent falls: minimization of medications
- withdrawl or reduction of psychotropic medication
- antipsychotics; abilify, haldol
- antidepressants; SSRIs
- sedatives; anti-anxiety - benzodiazepens
- mood stabilizers
- sleep aids - ambien
how to precent falls: vision
- expeditie cataract surgery
- insufficient evidence to recommend vision correction as stand-alone falls intervention
- advise against multifocal lenses for walking/stairs
multimodal exercise (PTs)
PTs must provide multimodal exercise for persons older than 65 years tailored to examination findings.Combine strengthening and balance training for those at lower risk and functional training for those at higher risk
group multimodal exercise can be benefical especially for those at
higher risk
components of intervention should include
a. strength training: that is individually prescribed, monitored and adjusted
b. balance training: that is individually prescribed, monitored, and adjusted
c. gait training
d. correction of environmental hazards
e. correction of footwear or structual impariments of the feet
fall rate ratio
rate of falls (falls per person per year) between intervention and control group
fall risk ratio
based on the number of people falling (fallers) in each group
Multi-modal exercise
- PTs must provide multimodal exercise for all older adults > 65 tailored to exam findings
- combo of strength and balance training (lower risk) balance and fucntional training (higher risk)
- tailored, progressive; moderate to high intensity
- balance 30-40% of activity
- 8 weeks
intensity of strength/endurance training
as per guidelines for older adults
intensity of balance training
“demanding, challenging, appropriate and increasing levels of difficulty”
- highest possible level of difficulty without falling or near-falling
- mastery of each exercise before progressing
- persons with limited mobility may be more at risk as balance training begins
Strengtehning prescription
- 2-3X/week
- 8-12 reps max begin at 20-30% 1RM progress to 80% 1RM
- 2 more days per week
- moderate intensity (60-70% 1RM)
- 10-15 reps of major muscle groups
- Power: 0-60% 1RM for LEs, 3-6 reps
Balance exercises
What works
- leaning beyond BOS and reaching
- shifting the COM
- minimzing UE support
- narrowing base of supprt
- changing BOS by stepping
- tai-chai
What doesn’t work
- lack of balance training component
- lack of functional relevance
- lack of exercise progression
Step-training
- either voluntary or protective stepping interventions reduce falls in older adults (by 50%)
- improves reaction time, gait, balance and balance recovery, but not strength
