falls in older adults
TRANSCRIPT
FallsinOlderAdults:Identifyingriskandphysicaltherapymanagement
NathanDugan,SPTColumbiaUniversity
LouisStokesClevelandVAMedicalCenter12/19/2013
* Generalfallstatistics* Riskfactors* AmericanGeriatricsSocietyGuidelines* Outcomemeasures* Interventions* Otherresources
Outline
“…anunexpectedeventinwhichtheparticipantcomestorestontheground,floor,orlowerlevel.”1
Whatisafall?
* 30%ofcommunity-dwellingolderadultsfalleachyear* 10%offallsresultinfractureorotherseriousinjury2* Significantsourceofmorbidity/mortality3
* >40%ofinstitutionalizedolderadultsfalleachyear* Leadingcauseoffatalandnonfatalinjuries* 2.4millionEDvisits* >689,000hospitaladmissions4
GeneralFallStatisticsforOlderAdults
* Directmedicalcosts$30billion!(2010)5* Direct&indirectcosts$54.9billionby2020!6* Costperfall:$9,000-$13,000!(2002)7* Costperinjuriousfall:$20,000!(1998)8
* Fallsareindependentpredictorforlong-termcareadmission3
GeneralFallStatisticsforOlderAdults
* Historyoffalls**** UseofAD*** Physicaldisability*** DisabilityinIADL* Femalegender* Livingalone* Increasedage
2-3xincreasedrisk
RiskFactorsforFalls-SociodemographicFactors9,10
* Dizzinessandvertigo* Parkinsondisease* Fearoffalling* Depression* (Poor)Self-perceivedhealthstatus* CVA* Urinaryincontinence* Pain
* Rheumaticdisease* Cognitiveimpairment* Hypotension* Diabetes
2-3xincreasedrisk
RiskFactorsforFalls-PsychologicalandMedicalFactors9,10
* Antiepileptic* Sedatives* Antihypertensive* Numberofmedications
2-3xincreasedrisk
RiskFactorsforFalls-MedicationFactors9,10
* Gaitimpairment* Visionimpairment* Hearingimpairment
*2-3xincreasedrisk
RiskFactorsforFalls-MobilityandSensoryFactors9,10
* Bestpracticeguidelines:* Allolderadultsshouldbeaskediftheyhavefalleninpastyear* Frequencyandcircumstancesoffallsshouldbeobtained
* Olderadultsseekingmedicalcarebecauseoffall,reportingmultiplefallsordifficultywithwalkingorbalanceshouldbegivenmultifactorialriskassessment
* Olderadultswhohavefallenshouldhaveassessmentofgaitandbalance* Thoseperformingpoorlyshouldbegivenmultifactorialfallrisk
assessment* Individualsreportingonly1fallanddemonstratingnodifficultywith
balanceandgaitdonotrequiremultifactorialfallriskassessment
AmericanGeriatricsSocietyClinicalGuidelines
http://www.americangeriatrics.org/files/documents/health_care_pros/Falls.Summary.Guide.pdf
* Focusedhistory* Falls,meds,riskfactors
* Physicalexamination* LEs,neuro,cardiovascular,visual* FunctionalAssessment* ADL/IADL,ADs,subjectivefuncability/fearoffalling* Environmentalassessment* Home/work/communityenvironment
MultifactorialFallRiskAssessment
http://www.americangeriatrics.org/files/documents/health_care_pros/Falls.Summary.Guide.pdf
Whatarethebestoutcomemeasurestousewhenassessingfallriskinolderadults?
AssessingRiskforFalls
* BergBalanceScale* FunctionalGaitAssessment* ClinicalTestofSensoryInteraction
andBalance(CTSIB);ModifiedCTSIB
* DynamicGaitIndex* FourSquareStepTest* TimedUpandGo* RivermeadMobilityIndex* FunctionalReachTest* DizzinessHandicapScale* PushandReleaseTest
* TinettiPerformanceOrientedMobilityAssessment
* BalanceEvaluationSystemsTest* FullertonAdvancedBalanceScale* FunctioninSittingTest* BrunelBalanceAssessment* CommunityBalanceandMobility
Scale* TinettiFallsEfficacyScale* Activities-SpecificBalance
ConfidenceScale* FiveTimesSittoStand* WalkingWhileTalking* StepTest
CommonOutcomeMeasuresforAssessingFallRisk
Cut-OffScoresforHighFallRisk12OutcomeMeasure Cutoffforhighfallrisk(olderadults)
Timed-Up-and-Go >13.5s(>32.6sfrail*)
FunctionalReachTest <7”
5TimesSittoStand/Four-SquareStepTest
>15s
BergBalanceScale <45/56
FunctionalGaitAssessment <23/30
Tinetti-POMA <19/28(<11/16forbalancecomponent)
FullertonAdvancedBalanceScale <25/40
*3ormore:unintentionalwtloss(>10lbs1yr),self-reportedexhaustion,weakness(grip),slowwalkingspeed,lowphysicalactivity11
* Moderatetohighlychallengingbalanceactivitysignificantlyreducesrateoffallsasasingleintervention* Strengthtraining,stretching,walkingdonot
* Comprehensiveinterventionshouldincludebalance,strength,andgaittrainingexercises13
BestInterventionPractices
* ChallengeCOMwithfeetfixed* NarrowBOS* Repetition,progression,continuallychallengingpatientiskey
StaticBalanceTraining13
* TaiChi* Reachingwhilemoving* Standingup* Turninginacircle/circling/figure-8* Stairstepping* Dancesteps* Unanticipateddirectionalchanges* Obstaclecourses
DynamicBalance/GaitTraining13
* Difficultywalkingwhiletalking=highriskoffalls* Performancecanbeimproved* Conversingwhilemaintainingwalkingspeed* Walkingandcounting* Walkingwhileperformingmanualtasks
* Variableprioritymayimproveoutcomes
Dual-TaskTraining13
* Effectiveinimprovingreactiontimesandsteppingstrategies* Littleevidencetosupportthisalonetranslatestofewerfalls
PerturbationandCompensatorySteppingTraining13
* Keyelementoffallprevention* Focuson* LEandposturalmuscles* LimitedUEsupport* Moderateorhighintensity
StrengthTraining13
* Inthoseathighriskforfalls,ordonewithoutconcurrentbalancetraining…
Mayresultinincreasedriskoffalls* Shouldnotbeincludedatbeginningoffall-preventionprogram,exceptinhigherfunctioningindividuals
Walking13
* Accountforcontributingriskfactors* Triagefactorsbasedonimpairments* Implementappropriateinterventions* Lessthan50%ofPTslinkedinterventionstoriskfactors
orreferredtootherproviders
Example:Visualimpairmenttrial
WhatComprisesanEffectiveFall-PreventionIntervention?13
* Minimumof12weeksforoptimaloutcomes(50hours)14* Individualsthatbeginexerciseprogrambutdonotmeet
thisminimummayincreaseriskforfalls
HowLongShouldInterventionsBe?
HowCanWeMeetThis50-HourMinimum?
* Designedashome-basedexerciseprogram* Meta-analysisshowed35%reductioninfallsandfall-relatedinjuriesinolderadults* Mosteffectiveinthose80orolder* ResultsinconfidenceincarryingoutADL/IADL* Beneficialforindividualswithmoderateandhighfunctionalimpairment
http://www.hfwcny.org/Tools/BroadCaster/Upload/Project13/Docs/Otago_Exercise_Programme.pdf
OTAGOExerciseProgram13,14
StrengthExercise-OTAGO
BalanceExercise-OTAGO
BalanceExercises-OTAGO(cont’d)
* Willnotreducefallsonitsown!
* 30minutes,2times/week* PerformedatusualpacewithusualAD* Canbebrokenupinto10minutebouts
GaitTraining-OTAGO
* Interventionsshouldbestructured* Interventionsshouldbetailoredtochallengepatientbasedonhis/herspecificimpairments* Interventionsmustachieveoptimaldose
* Managementshouldnotendatd/c,prescribeadequateHEP
TakeHomePoints
* CDCCompendiumofEffectiveFallInterventions:http://www.cdc.gov/HomeandRecreationalSafety/pdf/CDC_Falls_Compendium_lowres.pdf* CDCSTEADIProgram:http://www.cdc.gov/homeandrecreationalsafety/Falls/steadi/index.html* OTAGOExerciseProgram:http://www.hfwcny.org/Tools/BroadCaster/Upload/Project13/Docs/Otago_Exercise_Programme.pdf
RelevantResources
1. LambSE,Jorstad-SteinEC,HauerK,etal.Developmentofacommonoutcomedatasetforfallinjurypreventiontrials:thepreventionoffallsnetworkEuropeconsensus.JAmGeriatrSoc2005;53:1618-1622.
2. TinettiME,SpeechleyM,GinterSF.Riskfactorsforfallsamongelderlypersonslivinginthecommunity.NewEngJMed1998;319(26):1701-1707.
3. GillespieLD,RobertonMC,GillespieWJ,etal.Interventionsforpreventingfallsinolderpeoplelivinginthecommunity.TheCochraneLibrary2012;9.
4. CentersforDiseaseControlandPrevention,NationalCenterforInjuryPreventionandControl.Web–basedInjuryStatisticsQueryandReportingSystem(WISQARS)[online].AccessedDecember19,2013.
5. StevensJA,CorsoPS,FinkelsteinEA,MillerTR.Thecostsoffatalandnonfatalfallsamongolderadults.InjuryPrevention2006a;12:290–5.
6. EnglanderF,HodsonTJ,TerregrossaRA.Economicdimensionsofslipandfallinjuries.JournalofForensicScience1996;41(5):733–746.
7. CarrollNV,SlattumPW,CoxFM.Thecostoffallsamongthecommunity-dwellingelderly.JournalofManagedCarePharmacy.2005;11(4):307-16.
8. Shumway-CookA,CiolMA,HoffmanJ,DudgeonBJ,YorstonK,ChanL.FallsintheMedicarepopulation:incidence,associatedfactors,andimpactonhealthcare.PhysicalTherapy2009.89(4):1-9.
References
9. DeandreaS,LucenteforteE,BraviF,etal.Riskfactorsforfallsincommunity-dwellingolderpeople:asystematicreviewandmeta-analysis.Epidemiology2010;21(5):658-668.
10. DeandreaS,BraviF,TuratiF,etal.Riskfactorsforfallsinolderpeopleinnursinghomesandhospitals:asystematicreviewandmeta-analysis.ArchivesofGerontologyandGeriatrics2013;56:407-415.
11. FriedLP,TangenCM,WatsonJ,etal.Frailtyinolderadults:evidenceforaphenotype.JournalofGerontology2001;56A(3):M146-M156.
12. RehabilitationMeasuresDatabase[online]www.rehabmeasures/org.AccessedDecember19,2013.13. ShubertTE.Evidence-basedexerciseprescriptionforbalanceandfallsprevention:acurrentreviewofthe
literature.JournalofGeriatricPhysicalTherapy2011;34(3):100-108.14. SherringtonC,WhitneyJC,LordSR,etal.Effectiveexerciseforthepreventionoffalls:asystematicreview
andmeta-analysis.JournaloftheAmericanGeriatricsSociety2008;56:2234–2243.
References