the 4-stage balance test toolkit.pdf · 2015. 7. 15. · unsupported without postural sway. history...

Patient: Date: Time: AM/PM

The 4-Stage Balance Test Purpose: To assess static balance

Equipment: A stopwatch

Directions: There are four progressively more challenging positions. Patients should not use an assistive device (cane or walker) and keep their eyes open.

Describe and demonstrate each position. Stand next to the patient, hold his/her arm and help them assume the correct foot position.

When the patient is steady, let go, but remain ready to catch the patient if he/she should lose their balance.

If the patient can hold a position for 10 seconds without moving his/her feet or needing support, go on to the next position. If not, stop the test.

Instructions to the patient: I’m going to show you four positions.

Try to stand in each position for 10 seconds. You can hold your arms out or move your body to help keep your balance but don’t move your feet. Hold this position until I tell you to stop.

For each stage, say “Ready, begin” and begin timing.

After 10 seconds, say “Stop.”

See next page for detailed patient instructions and illustrations of the four positions.

For relevant articles, go to: www.cdc.gov/injury/STEADI

Centers for Disease Control and Prevention National Center for Injury Prevention and Control

www.cdc.gov/injury/STEADI

Instructions to the patient:

1. Stand with your feet side by side. Time: __________ seconds

2. Place the instep of one foot so it is touching the big toe of the other foot. Time: __________ seconds

3. Place one foot in front of the other, heel touching toe. Time: __________ seconds

4. Stand on one foot. Time: __________ seconds

An older adult who cannot hold the tandem stance for at least 10 seconds is at increased risk of falling.

Notes:

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Patient: Date: Time:

AM/PM

The 30-Second Chair Stand Test Purpose: To test leg strength and endurance

Equipment:

A chair with a straight back without arm rests (seat 17” high)

A stopwatch


1. Sit in the middle of the chair.

2. Place your hands on the opposite shoulder crossed at the wrists.

3. Keep your feet flat on the floor.

4. Keep your back straight and keep your arms against your chest.

5. On “Go,” rise to a full standing position and then sit back down again.

6. Repeat this for 30 seconds.

On “Go,” begin timing.

If the patient must use his/her arms to stand, stop the test. Record “0” for the number and score.

Count the number of times the patient comes to a full standing position in 30 seconds.

If the patient is over halfway to a standing position when 30 seconds have elapsed, count it as a stand.

Record the number of times the patient stands in 30 seconds.

Number: Score ___________ See next page.

A below average score indicates a high risk for falls.

Notes:



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Chair Stand—Below Average Scores Age Men Women

60-64 < 14 < 12

65-69 < 12 < 11

70-74 < 12 < 10

75-79 < 11 < 10

80-84 < 10 < 9

85-89 < 8 < 8

90-94 < 7 < 4

Algorithm for Fall Risk Assessment & Interventions

Waiting room: Patient completes Stay Independent brochure

Identify main fall risk factors

Clinical visit: Identify patients at risk

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Fell in past yearFeels unsteady when standing or walkingWorries about fallingScored ≥4 on Stay Independent brochure

No to all

Evaluate gait, strength & balance No gait, strength or

balance problems

• Timed Up and Go30-Sec Chair Stand4 Stage Balance Test

Educate patientRefer to community exercise, balance, fitness or fall prevention program

Gait, strength or balance problem

0 falls in past year

Educate patient Refer for gait and/or balance retraining or to a community fall prevention program

1 fall in past year

Determine circumstances

of fall

≥2 falls or a fall injury

Determine circumstances of latest fall

Conduct multifactorial risk assessment

Review Stay Independent brochureFalls historyPhysical examPostural dizziness/postural hypotensionCognitive screeningMedication reviewFeet & footwearUse of mobility aidsVisual acuity check

Implement key fall interventions

Educate patientEnhance strength & balanceImprove functional mobilityManage & monitor hypotensionManage medicationsAddress foot problemsVitamin D +/- calciumOptimize visionOptimize home safety

Patient follow-up Review patient education

Assess & encourage adherence with recommendations

Discuss & address barriers to adherence


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CASE STUDY 1 Mrs. Booker is a 76 year-old woman who lives independently in her own home. She has come in to your primary care clinic for a wellness visit.

Self-Risk Assessment Mrs. Booker completes the Stay Independent brochure in the waiting room. She circles “Yes” to the questions, “I have fallen in the last 6 months” and “I take medicine to help me sleep or improve my mood.” Her risk score is 3.

Gait, Strength & Balance Assessment (Completed and documented by medical assistant) Timed Up and Go: 12 seconds. Gait: decreased arm swing but

otherwise normal.

30-Second Chair Able to rise from the chair without using Stand Test: her arms to push herself up. Score of 14 stands.

4-Stage Able to hold a full tandem stance for 10 seconds Balance Test: unsupported without postural sway.

History When asked, Mrs. Booker reports she fell the previous week but wasn’t hurt and so didn’t seek medical attention. She says she was out walking with a friend, they were talking and she wasn’t looking where she was going, and she tripped over a crack in the sidewalk. This was her first fall.

Mrs. Booker reports that she usually walks about 2 miles each day around her neighborhood. She feels steady when walking at all times, even when out of doors. She tries to avoid potholes and usually watches out for cracks in the sidewalk so she won’t trip. She’s not afraid of falling. Walking is her only form of exercise.

Medical Problem List Seizure disorder

Schizoaffective disorder

Chronic kidney disease stage 3

Hypothyroidism

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CASE STUDY 1 (cont.)

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Medications 1. Depakote 250 mg twice daily

2. Zyprexa 12.5 mg daily

3. Ativan 0.5 mg twice daily

4. Levothyroxine 750 mcg daily

5. Colace 250 mg daily

6. Tylenol 500 mg 4 times daily as needed for pain

Review of Systems Positive for poor eyesight, urinary incontinence, and nocturia >2 times a night.

Physical Exam Constitutional: Well-developed, well-nourished, irritable but cooperative with exam.

Vitals: Supine – 130/91, 107; Sitting – 138/78, 107; Standing – 146/95, 115. BMI 21.0.

Head: Normocephalic / atraumatic.

ENMT: Wearing glasses. Acuity 20/30 R, 20/40 L.

CV: Regular rhythm, tachycardic S1/S2 without murmurs, rubs, or gallops.

Respiratory: Clear to auscultation bilaterally.

GI: Normal bowel tones, non-tender, non-distended.

Musculoskeletal: Strength: 5/5 throughout UE; LE strength 5/5 throughout except 4-/5 at bilateral hip flexors. No knee joint laxity. Foot exam shows no calluses, ulcerations, or deformities.

Neurology: Cognitive screen: recalls 3/3 items.

Tone/abnormal No tremor, bradykinesia, or rigidity. Sensation, proprioception, and movements: DTRs normal.

Psych: PHQ-2 = 0/6.

Identified Fall Risk Factors Mrs. Booker’s answers on the Stay Independent brochure indicate she has fallen in the past year. The results of the assessment tests indicate that her gait speed is somewhat slower than normal but her balance and strength tests are both within normal limits.

She is taking two psychoactive medications, Zyprexa and Ativan.

She is complaining of vision problems.

She has issues with incontinence and gets up during the night to void.


Fall Prevention Recommendations

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Discuss fall prevention, tailoring your suggestions based on the “Stages of Change” model. Emphasize that a fall is not simply “bad luck” or an “accident” that will never happen again.

Provide the CDC fall prevention brochures, What You Can Do to Prevent Falls and Check for Safety.

Provide the Chair Rise Exercise handout and suggest she begin doing this exercise daily.

Refer to a community exercise, fitness, or fall prevention program to optimize leg strength and balance by including strength and balance exercises as part of her exercise routine.

Consider whether doses of her psychoactive medications could be reduced or any eliminated.

Refer to an ophthalmologist for eye exam and updated prescription. Suggest she discuss with her ophthalmologist getting a pair of single lens distance glasses for walking outside.

Recommend night lights or leaving hall and/or bathroom lights on overnight to reduce the risk of falling when getting up to void.

Recommend DEXA scan to assess her bone mineral density and add 1,000 IU vitamin D as a daily supplement for both osteoporosis and fall risk reduction.

Recommend having grab bars installed inside and outside the tub or shower.

CASE STUDY 2 Mr. Ying is an 84 year-old Asian male who lives in an apartment that adjoins his son’s house. Mr. Ying is accompanied to this clinic visit by his son, who assists with the history. Although previously outgoing and social, Mr. Ying recently has been limiting his outside activities.

Self-Risk Assessment Mr. Ying completes the Stay Independent brochure in the waiting room. He circles “Yes” to the questions, “I use or have been advised to use a cane or walker to get around safely,” “Sometimes I feel unsteady when I am walking,” and “I am worried about falling.” His risk score is 4.

Gait, Strength & Balance Assessment (Completed and documented by medical assistant)

Timed Up and Go: 15 seconds using his cane. Gait: slow with shortened stride and essentially no arm swing. No tremor, mild bradykinesia.

30-Second Chair Stand Test:

Able to rise from the chair without using his arms to push himself up. Score of 9 stands in 30 seconds.

4-Stage Balance Test:

Able to stand with his feet side by side for 10 seconds but in a semi-tandem stance loses his balance after 3 seconds.

History Mr. Ying stated that for the past year he has felt dizzy when he stands up after sitting or lying down and that he often needs to “catch himself” on furniture or walls shortly after standing. His dizziness is intermittent but happens several times per week.

Mr. Ying cannot identify any recent changes in his medications or other changes to his routine that would explain his symptom. He says there is no pattern and he experiences dizziness at different times during the day and evening. He denies experiencing syncope, dyspnea, vertigo, or pain accompanying his dizziness.



Mr. Ying also remarks that, independent of his dizziness symptoms, he feels unsteady on his feet when walking. His son mentions that he often sees his father “teetering.” Mr. Ying requires help with bathing. He has started using a cane but doesn’t like to use it inside.

When asked about previous falls, he says he hasn’t fallen. However, he says his elderly neighbor recently fell and is now in a nursing home. Now he’s fearful about falling and becoming a burden to his family.

Although Mr. Ying has spinal stenosis, a recent steroid injection has relieved severe low back pain. Now he suffers only from lower back stiffness for several hours in the morning. He denies any specific weakness in his legs.

Medical Problem List

Hypertension

L3-5 spinal stenosis and chronic low back pain and leg numbness/paresthesias

Depression

Benign prostatic hypertrophy, with 3-4x/night nocturia and occasional incontinence

Hyperlipidemia

Gastroesophageal reflux disease

B12 deficiency

Allergic rhinitis

Glaucoma

Nummular eczema

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Medications

1. Valsartan 80 mg daily

2. Citalopram 40 mg daily

3. Flomax 0.8 mg at bedtime

4. Finasteride 5 mg daily

5. Lipitor 40 mg at bedtime

6. Omeprazole 20 mg daily

7. Cyanocobalamin 1 mg daily

8. Claritin 10 mg daily

9. Flonase nasal spray two puffs to each nostril daily


10. Gabapentin 300 mg tabs 2 tabs three times daily

11. Tylenol 500 mg one to two four times daily prn

12. Brimonidine tartrate 0.15% ophth 1 drop OU twice daily

13. Cosopt 2%-0.5% 1 drop OU at hs

14. Latanoprost 0.005% 2 drops OU at hs

15. Trazodone 25 mg at hs

16. Calcium carbonate 500 mg 1-2 tabs three times daily

Review of Systems

Positive for fatigue, poor vision in his left eye, constipation, nocturia 3-4 times a night, frequent urinary incontinence, low back stiffness, difficulty concentrating, depression, dry skin, hoarseness, and nasal congestion.

Physical Exam

Constitutional: This is a thin, alert, older Asian male in no apparent distress, pleasant and cooperative, but with a notably flat affect.

Vitals: Supine – 135/76, 69; Sitting – 112/75, 76; Standing – 116/76, 75. BMI 19.

Head: Normocephalic / atraumatic.

ENMT: Wearing glasses. Acuity 20/30 R, 20/70 L.

CV: Regular rate and rhythm normal S1/S2 without murmurs, rubs, or gallops.

Respiratory: Clear to auscultation bilaterally.

GI: Normal bowel tones, soft, non-tender, non-distended.

Musculoskeletal: Strength: UE strength 5/5 B biceps, triceps, deltoids; LE strength 4+/5 bilateral hip flexors and abductors; 4+/5 bilateral knee flexors/extensors; 5/5 bilateral AF/AE; 5/5 bilateral DF and PF.

No knee joint laxity. Foot exam shows no calluses, ulcerations, or deformities.

Neurology: Cognitive screen: recalled 3/3 items.

Whisper test for hearing: Intact.

Tone/abnormal movements:

Tone is mildly increased in both legs; normal tone in both arms. Sensation is intact to light touch and pain throughout. Reflexes are normal and symmetric.

Psych: PHQ-2 = 4/6.


Identified Fall Risk Factors Mr. Ying’s answers on the Stay Independent brochure and the results of the assessment tests indicate gait, strength, and balance impairments and a fear of falling.

He is currently taking two sedating medications, Claritin and Gabapentin.

His orthostatic blood pressure results indicate postural hypotension. Other fall risk factors are poor vision, nocturia >2 times a night, incontinence, and depression.

Fall Prevention Recommendations Discuss fall prevention, tailoring your suggestions using the “Stages of Change” model.


Attempt to lower the dose of the blood pressure medication Valsartan.

Counsel on self-management of orthostatic hypotension (drink 6-8 glasses of water a day, do ankle pumps and hand clenches for a minute before standing, do not walk if dizzy), and provide the patient brochure, Postural Hypotension: What It Is and How to Manage It.

Attempt to lower the dose and/or eliminate the sedating medications.

Refer for physical therapy for gait assessment, to increase leg strength and improve balance, and for instruction on how to use a cane correctly.

Add 1,000 IU vitamin D as a daily supplement to help optimize muscle strength.

Refer to an ophthalmologist for eye exam, glaucoma assessment, and updated prescription.

Recommend using night lights or leaving the hall and/or bathroom lights on overnight to reduce the risk of falling when getting up to void.

Recommend having grab bars installed inside and outside the tub, next to the toilet, and in the hallway that leads from his bedroom to the bathroom.

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CASE STUDY 3 Mrs. White is an outgoing 81 year-old white woman who lives in an assisted living facility. She has come in with her son for a routine follow-up visit. Her son reports that she was just seen in the hospital emergency room a week ago because she fell when she was getting out of the shower. She fell backwards and bumped the back of her head against the wall.

Her son remarks that in the past year his mother has had “too many falls to count.” Mrs. White agrees that she falls a lot but she’s fatalistic. “Old people fall, that’s just how it is,” she says.

Mrs. White has a history of hypertension, hyperlipidemia, diabetes, coronary artery disease, and congestive heart failure.

Self-Risk Assessment Mrs. White completes the Stay Independent brochure in the waiting room. She circles “Yes” to the following questions, “I have fallen in the last 6 months,” “I use or have been advised to use a cane or walker to get around safely,” “I am worried about falling,” “I need to push with my hands to stand up from a chair,” “I have some trouble stepping up onto a curb,” “I often have to rush to the toilet,” and “I take medicine to help me sleep or improve my mood.” Her risk score is 9.

Gait, Strength & Balance Assessment (Completed and documented by medical assistant) Timed Up and Go: 18 seconds with her rollator walker. Gait: wide-based

with minimal hip extension and arm swing and markedly kyphotic posture.

30-Second Chair Stand Test:

Unable to rise from the chair without using her arms.

4-Stage Balance Test:

Able to stand with her feet side by side for 10 seconds but in a semi-tandem stance loses her balance after 4 seconds.



History Mrs. White reports that she used to walk “just fine,” but about two years ago, she began falling for no apparent reason. Sometimes she’ll trip on a carpet, other times she just loses her balance when she’s walking or turning. Once she fell off a chair face first into a wall. Another time she rolled out of bed.

Mrs. White has fallen indoors both during the day and at night. Sometimes she’s fallen at night when she’s gotten up to void. She sleeps deeply but is restless, so for the past eight years has been taking Clonazepam to help her sleep.

For the past two years, she has been using a rollator walker. Before that she had a front-wheeled walker but couldn’t get used to it. She used to go to the Silver Sneakers exercise classes at her local gym but stopped going about five years ago when she developed numbness in her feet and knee pain. She used to enjoy walking but reports that she hardly ever goes outside now because she’s so afraid of falling and breaking her hip.

Medical Problem List Type 2 diabetes

Coronary artery disease status post myocardial infarction

Paroxysmal atrial fibrillation

Congestive heart failure

Hypertension

Hypertriglyceridemia

Depression

Osteoarthritis of hips and knees

Chronic kidney disease stage 3

Macular degeneration

Rotator cuff syndrome

Sciatica

Diverticulosis

Osteopenia

Gastroesophageal reflux disease

Cognitive disorder not otherwise specified

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Medications 1. Novolog 3 units subq before meals and at bedtime

2. Lantus 20 units subcutaneous in the morning and at bedtime

3. Lisinopril 20 mg daily


4. Metoprolol 200 mg daily

5. Eplerenone 50 mg daily

6. Furosemide 20 mg daily

7. KCl 20 milli-equivalents daily at bedtime

8. Digoxin 125 mcg daily

9. Gemfibrozil 600 mg twice daily

10. Fluoxetine 50 mg daily

11. Clonazepam 0.5 mg at hs for sleep

12. Aggrenox 200/25 mg twice daily for stroke prevention

Review of Systems Constitutional: Lack of energy.

Eyes:

Wears bifocals. Prescription recently updated but still has occasional blurriness despite new prescription. Sometimes glasses slip down her nose, causing her to have problems judging depth.

ENMT: Has hearing difficulty subjectively but has passed hearing tests.

GI: Frequent bladder infections, incontinence of urine, urinary frequency, and nocturia 4 times a night.

Neurology: Balance problems when walking, memory problems.

Musculoskeletal:

Orthopedists have recommended knee replacements but she has declined. She wears braces on her knees to manage the pain and reports these help.

Psych: Afraid of falling, difficulty concentrating, feeling blue, memory trouble.

Physical Exam Constitutional: This is a frail, alert, elderly woman, very pleasant and in no apparent

distress.

Vitals: Supine – 129/53, 59; Sitting – 103/40, 60; Standing – 101/51, 62. BMI 18.5.

Head: Contusion with resolving ecchymosis and swelling at the posterior occiput on the right side.

ENMT: Wearing glasses. Acuity testing deferred due to recent eye exam/new glasses.

CV: Regular rate and rhythm normal S1/S2 without murmur, rub, gallop, lift, or heave.

Respiratory: Clear to auscultation throughout.


GI: Normal bowel tones, soft, non-tender, non-distended.

Musculoskeletal: No knee joint laxity or joint swelling. Feet with diffuse clawing of toes.

Neurology: Alert and oriented x 3. Cranial nerves II-XII grossly intact.

Tone/abnormal movements:

Tone normal throughout. She has diminished sensation and proprioception in both feet. Deep tendon reflexes are normal and symmetric.

Psych: PHQ-2 depression screen = 6/6. Cognitive screen 0/3 items recalled.

Identified Fall Risk Factors Mrs. White’s answers on the Stay Independent brochure and the results of the assessment tests indicate decreased lower body strength, serious impairments in her gait and balance, and a fear of falling.

Other fall risk factors are postural hypotension, vision issues (depth perception difficulty and blurry vision) despite corrective lenses, foot problems including diminished sensation in both feet, incontinence, urinary frequency, and nocturia >2 times a night.

She is moderately cognitively impaired and her depressive symptoms are not controlled despite prescription of the antidepressant Fluoxetine.

Fall Prevention Recommendations Discuss fall prevention, tailoring your suggestions using the “Stages of Change” model. Emphasize that many falls can be prevented.


Refer for physical therapy for gait assessment, to increase leg strength and improve balance, and for instruction on how to use the rollator walker most effectively.

Consider whether dose of either Lisinopril or Metoprolol can be reduced.

Consider whether dose of Furosemide can be reduced.

Consider tapering off the Clonazepam.

Refer to podiatrist for foot exam and prescription/customized footwear.

Add 1,000 IU vitamin D as a daily supplement to help optimize muscle strength.

Consider screening for B12 deficiency as a cause of the diminished sensation in her lower extremities.

Refer to her optician to have her glasses adjusted so they don’t slip.

Discuss home modifications such as removing tripping hazards to reduce her chances of falling.

Recommend having grab bars installed inside and outside the tub and next to the toilet.

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Chair Rise Exercise What it does: Strengthens the muscles in your thighs & buttocks.

Goal: To do this exercise without using your hands as you become stronger.

How to do it:

1. Sit toward the front of a sturdy chair with your knees bent & feet flat on the floor, shoulder-width apart.

2. Rest your hands lightly on the seat on either side of you, keeping your back & neck straight & chest slightly forward.

3. Breathe in slowly. Lean forward & feel your weight on the front of your feet.

4. Breathe out & slowly stand up, using your hands as little as possible.

5. Pause for a full breath in & out.

6. Breathe in as you slowly sit down. Do not let yourself collapse back down into the chair. Rather, control your lowering as much as possible.

7. Breathe out.

Repeat 10–15 times. If this number is too hard for you when you first start practicing this exercise, begin with fewer & work up to this number.

Rest for a minute & then do a final set of 10–15.


FALLSFalls are a Major Threat for Your Patients

One-third of people 65 and older fall each year.

Less than half of the Medicare beneficiaries who fell in the previous year talked to their healthcare provider about it.

Every 29 minutes an older adult dies from a fall.

1 out of 5 falls causes a serious injury such as a head trauma or fracture.

Over 2 million older adults are treated in emergency departments for nonfatal fall injuries each year.

Direct medical costs for fall injuries total over $28 billion annually. Hospital costs account for two-thirds of the total.

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The good news—as a healthcare provider, your efforts can prevent many of these injuries!

For more information, go to: www.cdc.gov/injury/STEADI

CeCenters for Disease nters for Disease CoContntrol and Prrol and Prevevention ention National Center for Injury National Center for Injury Prevention and ControPrevention and Control l

Fall Risk Checklist



Fall Risk Factor Identified Factor Present? Notes

Falls History

Any falls in past year? Yes No

Worries about falling or feels unsteady when standing or walking? Yes No

Medical Conditions

Problems with heart rate and/or rhythm Yes No

Cognitive impairment Yes No

Incontinence Yes No

Depression Yes No

Foot problems Yes No

Other medical conditions (Specify) Yes No

Medications

Any psychoactive medications, medications with anticholinergic side effects, and/or sedating OTCs? (e.g., Benadryl, Tylenol PM)

Yes No

Gait, Strength & Balance

Timed Up and Go (TUG) Test ≥12 seconds

Yes No

30-Second Chair Stand Test Below average score (See table on back) Yes No

4-Stage Balance Test Full tandem stance <10 seconds Yes No

Vision

Acuity <20/40 OR no eye exam in >1 year Yes No

Postural Hypotension

A decrease in systolic BP ≥20 mm Hg or a diastolic bp of ≥10 mm Hg or lightheadedness or dizziness from lying to standing?

Yes No

Other Risk Factors (Specify)

Yes No

Yes No

Chair Stand—Below Average ScoresAge Men Women

60-64 < 14 < 12

65-69 < 12 < 11

70-74 < 12 < 10

75-79 < 11 < 10

80-84 < 10 < 9

85-89 < 8 < 8

90-94 < 7 < 4

Integrating Fall Prevention into Practice

Working together, many types of healthcare providers can help identify and manage patients at risk of falling.

You can help reduce falls by screening all older persons once a year for previous falls and/or balance problems.

For those who screen positive, perform a fall risk assessment and help patients understand and act upon the findings using proven prevention strategies.

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Assessments and/or Interventions

Identify who in your practice can do this What it involves

Screen all older patients for falls •

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Have each patient complete the Stay Independent brochure—help if necessary.

Identify modifiable fall risk factors Review Stay Independent brochure & take a falls history.

Evaluate gait, lower body strength & balance

Address identified deficits

Administer one or more gait, strength & balance tests: Timed Up & Go Test (Recommended) Observe & record patient’s postural stability, gait, stride length & sway. 30-Second Chair Stand Test (Optional) 4-Stage Balance Test (Optional)

• As needed, refer to physical therapist or recommend community exercise or fall prevention program. PTs can assess gait & balance, provide one-on-one progressive gait & balance retraining, strengthening exercises, & recommend & teach correct use of assistive devices.

Conduct focused physical exam

Address modifiable and/or treatable risk factors

In addition to a customary medical exam: •

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Assess muscle tone, look for increased tone, hypertonia (cogwheeling). Screen for cognitive impairment & depression. Examine feet & evaluate footwear. Look for structural abnormalities, deficits in sensation & proprioception. If needed, refer to podiatrists or pedorthists. These specialists can identify & treat foot problems & can prescribe corrective footwear & orthotics.

Assess for & manage postural hypotension

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Check supine & standing blood pressure using 1-page protocol, Measuring Orthostatic Blood Pressure. Recommend medication changes to reduce hypotension. Monitor patient as he/she makes recommended changes. Counsel patient & give the brochure, Postural Hypotension, What It Is and How to Manage It.

Review & manage medications Taper & stop psychoactive medications if there are no clear indications. Try to reduce doses of necessary psychoactive medications. Recommend changes to reduce psychoactive medications. Monitor patient as he/she makes recommended changes.

Increase vitamin D Recommend at least 800 IU vitamin D supplement.

Assess visual acuity & optimize vision

Administer brief vision test. Refer to ophthalmologists or optometrists. These specialists can identify & treat medical conditions contributing to vision problems & address problems with visual acuity & contrast sensitivity.

Address home safety & how to reduce fall hazards

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Counsel patient about reducing fall hazards. Give CDC brochure, Check for Safety. Refer to OT to assess safety & patient’s ability to function in the home.

Educate about what causes falls & how to prevent them

Educate patient about fall prevention strategies. Give CDC brochure, What YOU Can Do to Prevent Falls. Recommend exercise or community fall prevention program.

Identify community exercise & fall prevention programs

Contact senior services providers & community organizations that provide exercise & fall prevention programs for seniors. Compile a resource list of available programs.


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Measuring Orthostatic Blood Pressure 1. Have the patient lie down for 5 minutes.

2. Measure blood pressure and pulse rate.

3. Have the patient stand.

4. Repeat blood pressure and pulse rate measurements after standing 1 and 3 minutes.

A drop in bp of ≥20 mm Hg, or in diastolic bp of ≥10 mm Hg, or experiencing lightheadedness or dizziness is considered abnormal.

Position Time BP Associated Symptoms

Lying Down 5 Minutes BP /

HR

Standing 1 Minutes

BP /

HR

Standing 3 Minutes BP /

HR

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STEADI Stopping Elderly

Accidents, Deaths & Injuries

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CeCenters for Disease nters for Disease CoContntrol and Prrol and Prevevention ention National Center for Injury National Center for Injury Prevention and ControPrevention and Control l

FALLSMedications Linked to Falls Although many medication classes have been linked to falls, the evidence is strongest for a few drug categories. Medication management can reduce interactions and side effects that may lead to falls.

Medication management means: Eliminating medications if there is no active indication

Reducing doses of necessary medications (e.g., antihypertensives) to the lowest effective dose

Avoiding prescribing medications for an older person where the risk from side effects outweighs the benefit (e.g., skeletal muscle relaxants)

The MOST important intervention is to reduce or eliminate:

Psychoactive drugs, especially any benzodiazepines

Any medications that have anticholinergic side effects

Sedating OTCs, specifically Tylenol PM (which contains Benadryl) and Benadryl

For more information about geriatric medication management, go to the American Society of Consultant Pharmacists website at: www.ascp.com

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Fall Prevention Patient Referral Form

Patient: Referred to:

Sex: DOB:

Address: Address:

Phone: Phone:

Email: Email:

Diagnosis:

Type of Referral

Type of specialist (See back of form):

Exercise or fall prevention program (See nurse for options):

Reason for Referral

Gait or mobility problems Medication review & consultation

Balance difficulties Inadequate or improper footwear

Lower body weakness Foot abnormalities

Postural hypotension Vision <20/40 in R L Both

Suspected neurological condition (e.g., Parkinson’s disease, dementia)

Home safety evaluation

Other reason:

Other relevant information:

Referrer signature: Date:

Reasons for referral Suggested specialists

Gait or mobility problems, balance difficulties, lower body weakness

Physical therapist

Postural hypotension, medication review & consultation

Subspecialty provider

Foot abnormalities, inadequate or improper footwear

Podiatrist or pedorthist

Suspected neurological condition Neurologist or geriatrician

Vision impairment Ophthalmologist or optometrist

Home safety evaluation Occupational therapist

Other

Fall Prevention Patient Referral Form

Patient: Referred to:

Sex: DOB:

Address: Address:

Phone: Phone:

Email: Email:

Diagnosis:

Type of Referral

Type of specialist (See back of form):

Exercise or fall prevention program (See nurse for options):

Reason for Referral

Gait or mobility problems Medication review & consultation

Balance difficulties Inadequate or improper footwear

Lower body weakness Foot abnormalities

Postural hypotension Vision <20/40 in R L Both

Suspected neurological condition (e.g., Parkinson’s disease, dementia)

Home safety evaluation

Other reason:

Other relevant information:

Referrer signature: Date:

Reasons for referral Suggested specialists

Gait or mobility problems, balance difficulties, lower body weakness

Physical therapist

Postural hypotension, medication review & consultation

Subspecialty provider

Foot abnormalities, inadequate or improper footwear

Podiatrist or pedorthist

Suspected neurological condition Neurologist or geriatrician

Vision impairment Ophthalmologist or optometrist

Home safety evaluation Occupational therapist

Other


Preventing Falls in Older Patients Provider Pocket Guide

Key Facts about Falls:

1/3 of older adults (age 65+) fall each year.

Many patients who have fallen do not talk about it.

This is What You Can Do:

RITUAL:

•

•

Review self-assessment brochure Identify risk factors Test gait & balance Undertake multifactorial assessment Apply interventions Later, follow-up

Talking with your Patient about Falls

If you hear: You can say:

Precontemplation Stage

Falling is just a matter of bad luck.

As we age, falls are more likely for many reasons, including changes in our balance and how we walk.

Contemplation Stage

My friend down the street fell and ended up in a nursing home.

Preventing falls can prevent broken hips & help you stay independent.

Preparation Stage

I’m worried about falling. Do you think there’s anything I can do to keep from falling?

Let’s look at some factors that may make you likely to fall & talk about what you could do about one or two of them.

Action Stage

I know a fall can be serious. What can I do to keep from falling and stay independent?

I’m going to fill out a referral form for a specialist who can help you improve your balance.


http://www.cdc.gov/injury/steadi

•

•

•

•

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Key Steps for Fall Prevention

1. Be proactive—ask all patients 65+ if they’ve fallen in the past year.

2. Identify & address fall risk factors:

Lower body weakness

Gait and balance problems

Psychoactive medications

Postural dizziness

Poor vision

Problems with feet and/or shoes

Home safety

3. Refer as needed to specialists or community programs.

4. Follow-up with patient within 30 days.

Key Fall Interventions

Educate patient

Enhance strength & balance

Manage medications

Manage hypotension

Supplement vitamin D +/- calcium

Address foot problems

Optimize vision

Optimize home safety

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Postural Hypotension What It Is and How to Manage It

Postural hypotension (or orthostatic hypotension) is when your blood pressure drops when you go from lying down to sitting up or from sitting to standing. When your blood pressure drops, less blood can go to your organs and muscles. This can make you likely to fall.

For information about fall prevention, go to: www.cdc.gov/injury

For more information about hypotension, go to:

www.mayoclinic.com

www.webmd.com

http://www.cdc.gov/injury

http://www.mayoclinic.com

http://www.webmd.com

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•

•

•

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•

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•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

What can I do to manage my postural hypotension?

Tell your healthcare provider about any symptoms.

Ask if any of your medicines should be reduced or stopped.

Get out of bed slowly. First sit up, then sit on the side of the bed, then stand up.

Take your time when changing position, such as when getting up from a chair.

Try to sit down when washing, showering, dressing or working in the kitchen.

Exercise gently before getting up (move your feet up and down and clench and unclench your hands) or after standing (march in place).

Make sure you have something to hold onto when you stand up.

Do not walk if you feel dizzy.

Drink 6-8 glasses of water or low-calorie drinks each day, unless you have been told to limit your fluid intake.

Avoid taking very hot baths or showers.

Try sleeping with extra pillows to raise your head.

What are the symptoms? Although many people with postural hypotension have no symptoms, others do. These symptoms can differ from person to person and may include:

Dizziness or lightheadedness

Feeling about to faint, passing out or falling

Headaches, blurry or tunnel vision

Feeling vague or muddled

Feeling pressure across the back of your shoulders or neck

Feeling nauseous or hot and clammy

Weakness or fatigue

When do symptoms tend to happen?

When standing or sitting up suddenly

In the morning when blood pressure is naturally lower

After a large meal or alcohol

During exercise

When straining on the toilet

When you are ill

If you become anxious or panicky

What causes postural hypotension? Postural hypotension may be caused by or linked to:

High blood pressure

Diabetes, heart failure, atherosclerosis or hardening of the arteries

Taking some diuretics, antidepressants or medicines to lower blood pressure

Neurological conditions like Parkinson’s disease and some types of dementia

Dehydration

Vitamin B12 deficiency or anemia

Alcoholism

Prolonged bed rest

Recommended Fall Prevention Programs

Programs Location Day & Time Cost

Notes:

Research shows that to reduce falls, exercises MUST focus on improving balance and strength, be progressive (get more challenging over time), and be practiced for at least 50 hours. This means, for example, taking a 1-hour class 3 times a week for 4 months, or a 1-hour class 2 times a week for 6 months.

The National Institute on Aging has created an exercise guide for healthy older adults to use at home. You can order this free book by going to: www.nia.nih.gov/HealthInformation/Publications/ExerciseGuide.

www.nia.nih.gov/HealthInformation/Publications/ExerciseGuide

FALLS Risk Factors For Falls Research has identified many risk factors that contribute to falling—some of these are modifiable.

Most falls are caused by the interaction of multiple risk factors. The more risk factors a person has, the greater their chances of falling. Healthcare providers can lower a person’s risk by reducing or minimizing that individual’s risk factors.

To prevent falls, providers should focus FIRST on these modifiable risk factors:

Lower body weakness Difficulties with gait and balance Use of psychoactive medications Postural dizziness

Poor vision Problems with feet and/or shoesHome hazards

■

■

■

■

■

■

■

Fall risk factors are categorized as intrinsic or extrinsic. Intrinsic Extrinsic

Advanced age Lack of stair handrails

Previous falls Poor stair design

Muscle weakness Lack of bathroom grab bars

Gait & balance problems Dim lighting or glare

Poor vision Obstacles & tripping hazards

Postural hypotension Slippery or uneven surfaces

Chronic conditions including arthritis, diabetes, stroke, Parkinson’s, incontinence, dementia

Psychoactive medications

Fear of falling Improper use of assistive device



http://www.cdc.gov/injury/STEADI

Stay IndependentFalls are the main reason why older people lose their independence.

Are you at risk?

Contact your local community or senior center for information on exercise, fall prevention programs, or options for

improving home safety.

For more information on fall prevention, please visit:

www.cdc.gov/injurywww.stopfalls.org

This brochure was produced in collaboration with the following organizations:

VA Greater Los Angeles Healthcare SystemDivision of VA Desert Pacific

Healthcare NetworkFall Prevention Center of Excellence

“ People who use canes are brave. They can be more independent and enjoy their lives.”

Shirley Warner, age 79

Four things you can do to prevent falls:

Begin an exercise program to improve your leg strength & balance

Ask your doctor or pharmacist to review your medicines

Get annual eye check-ups & update your eyeglasses

Make your home safer by:

1

2

3

4

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� Removing clutter & tripping hazards

� Putting railings on all stairs & adding grab bars in the bathroom

� Having good lighting, especially on stairs

http://www.cdc.gov/injury

http://www.stopfalls.org

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Your doctor may suggest:

• Having other medical tests

• Changing your medicines

• Consulting a specialist

• Seeing a physical therapist

• Attending a fall prevention program

*This checklist was developed by the Greater Los Angeles VA Geriatric

Research Education Clinical Center and affiliates and is a validated fall risk self-

assessment tool (Rubenstein et al. J Safety Res; 2011:42(6)493-499). Adapted with

permission of the authors.

Talking about Fall Prevention with Your Patients Many fall prevention strategies call for patients to change their behaviors by:

Attending a fall prevention program

Doing prescribed exercises at home

Changing their home environment

•

•

•

We know that behavior change is difficult. Traditional advice and patient education often does not work.

The Stages of Change model is used to assess an individual’s readiness to act on a new, healthier behavior. Research on the change process depicts patients as always being in one of the five “stages” of change.

Behavior change is seen as a dynamic process involving both cognition and behavior, that moves a patient from being uninterested, unaware, or unwilling to make a change (precontemplation); to considering a change (contemplation); to deciding and preparing to make a change (preparation); to changing behavior in the short term (action); and to continuing the new behavior for at least 6 months (maintenance).

The Stages of Change model has been validated and applied to a variety of behaviors including:

Exercise behavior

Smoking cessation

Contraceptive use

Dietary behavior

•

•

•

•

Stages of Change model

Stage of change Patient cognition and behavior

Precontemplation Does not think about change, is resigned or fatalistic

Does not believe in or downplays personal susceptibility

Contemplation Weighs benefits vs. costs of proposed behavior change

Preparation Experiments with small changes

Action Takes definitive action to change

Maintenance Maintains new behavior over time

From: Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promot 1997;12(1):38-48.


When talking with a patient, applying the Stages of Change model can help you match your advice about fall prevention to your patient’s stage of readiness.

The following sections give examples of patient-provider exchanges for each of the first four stages and offer possible responses to help move the patient from one stage to another. The maintenance stage is not included because older adults are most often in the early stages of behavior change for fall prevention.

Examples of Conversations about Fall Prevention

Precontemplation stage Patient says: Provider says:

The patient doesn’t view him or herself as being at risk of falling.

Goal: The patient will begin thinking about change.

To move the patient to the contemplation stage, provide information and explain the reasons for making changes.

Falls just happen when you get old.

It’s true that falling is very common. About a third of all seniors fall each year. But you don’t have to fall. There are specific things you can do to reduce your chances of falling.

Falling is just a matter of bad luck. I just slipped. That could have happened to anybody.

As we age, falls are more likely for many reasons, including changes in our balance and how we walk.

My 92 year-old mother is the one I’m worried about, not myself.

Taking steps to prevent yourself from falling sooner rather than later can help you stay independent.

It was an accident. It won’t happen again because I’m being more careful.

Being careful is always a good idea but it’s usually not enough to keep you from falling. There are many things that you can do to reduce your risk of falling.

I took a Tai Chi class but it was too hard to remember the forms.

Maybe you’d enjoy taking a balance class instead.

Contemplation stage Patient says: Provider says:

The patient is considering the possibility that he or she may be at risk of falling.

Goal: Patient will examine benefits and barriers to change.

To move the patient to the preparation stage, make specific suggestions, be encouraging, and enlist support from the family.

I’d like to exercise but I don’t because I’m afraid I’ll get too tired.

You can reduce your chances of falling by doing strength and balance exercises as little as 3 times a week. And you don’t have to overexert yourself to benefit.

You can do these exercises at home or I can recommend some exercise classes near you.

My friend down the street fell and ended up in a nursing home.

Preventing falls can prevent broken hips and help you stay independent.

I have so many other medical appointments already.

I have patients very much like you who do these exercises to prevent falls.

These types of exercises only take a few minutes a day.

I already walk for exercise. Walking is terrific exercise for keeping your heart and lungs in good condition, but it may not prevent you from falling.

I don’t want to ask my daughter to drive me to the exercise class.

Getting to the senior center is so hard now that I don’t drive.

I have to take care of my husband. I don’t have time for this.

There are quite a few simple exercises you can do to keep yourself from falling.

They don’t take a lot of time and you don’t have to rely on other people. You don’t even have to leave your own home.

Note: The National Institute on Aging has a free exercise book for healthy older adults to use at home. Go to: www.nia.nih.gov/HealthInformation/Publications/ExerciseGuide.

www.nia.nih.gov/HealthInformation/Publications/ExerciseGuide

Preparation stage Patient says: Provider says:

The patient considers him or herself to be at risk of falling and is thinking about doing something about it.

Goal: Patient will begin to consider specific changes.

To move the patient to the action stage, help the patient set specific goals and create an action plan. Reinforce the progress the patient has made.

I’m worried about falling. Do you think there’s anything I can do to keep from falling?

Let’s look at some factors that may make you likely to fall and talk about what you could do about one or two of them.

Here’s a brochure from the CDC about preventing falls. Why don’t you go over it with your spouse?

I read that some medicines can make you dizzy. Do you think any of mine might be a problem?

Many seniors say they’d prefer to take fewer medicines.

Let’s go over yours and see if we can reduce or eliminate any of them.

Action stage Patient says: Provider says:

The patient considers him or herself to be at risk of falling and is ready to do something about it.

Goal: Patient will take definite action to change.

Facilitate change. Provide specific resources, support, and encouragement to help the patient to adopt new behaviors.

I know a fall can be serious. What can I do to keep from falling and stay independent?

I’m going to fill out a referral form for a specialist who can help you [Increase your balance; improve your vision; find shoes that make walking easier].

Someone from the office will call you in about a month to see how you’re doing.

I want to take a fall prevention class. What do you recommend?

I’m glad that you’re interested in taking a class. Please see the nurse before you leave. She’ll give you a list of recommended programs near you.

I know I’d feel safer if I had grab bars put in my shower.

I’m glad that you’re thinking of installing grab bars.

Here’s the CDC home safety checklist. It can help you identify home hazards and suggest ways to make other changes to prevent falls.

Adapted from: Zimmerman GL, Olsen CG, Bosworth MF. A ‘Stages of Change’ approach to helping patients change behavior. American Family Physician 2000;61(5):1409-1416.

Centers for Disease Control and Prevention

Patient: Date: Time:

AM/PM

The Timed Up and Go (TUG) Test Purpose: To assess mobility

Equipment: A stopwatch

Directions: Patients wear their regular footwear and can use a walking aid if needed. Begin by having the patient sit back in a standard arm chair and identify a line 3 meters or 10 feet away on the floor.


When I say “Go,” I want you to:

1. Stand up from the chair

2. Walk to the line on the floor at your normal pace

3. Turn

4. Walk back to the chair at your normal pace

5. Sit down again

On the word “Go” begin timing.

Stop timing after patient has sat back down and record.

_________Time: seconds

An older adult who takes ≥12 seconds to complete the TUG is at high risk for falling.

Observe the patient’s postural stability, gait, stride length, and sway.

Circle all that apply: Slow tentative pace Loss of balance Short strides Little or no arm swing Steadying self on walls

Shuffling En bloc turning Not using assistive device properly

Notes:


National Center for Injury Prevention and Control


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