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Fall Prevention Program for Older Adults With a Fear of Falling

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Title: Fall Prevention Program for Older Adults With a Fear of Falling


1
Fall Prevention Program for Older Adults With a
Fear of Falling
  • Julie A. Honaker, Ph.D
  • Robert W. Keith, Ph.D.
  • Laura Kretschmer, Ed.D.
  • Daniel Choo, M.D.
  • Patrick Shumrick, DPT

2
An Aging Society
  • Prediction for the US
  • By 2010, 40 million 65 years
  • By 2040, 80 million 65 years

1. Girardi, M., Konrad, H.R., Amin, M.,
Hughes, L.F. (2001)
3
Boston, Massachusetts
  • Population Estimates1
  • 680,000
  • Mean age 32 years
  • 55-59 years 27,380
  • 60-64 years 22,160
  • gt 65 years 76,160

1. http//censtats.census.gov/
4
Epidemiology of Falls
  • 30 to 50 of people 60 years or older will fall
  • 10-20 repeatedly
  • Elderly in nursing homes (rate rises to 50 will
    fall twice or more per year)

1. Rubenstein, L.Z. and Josephson, K.R.
(2002).
5
Hip Fractures
  • Major cause of morbidity and mortality
  • In 1999, hip fractures resulted in nearly 338,000
    hospital admissions 1
  • By 2050, hip fractures will exceed 600,000 2
  • 1. Popovic, J.R.(2001).
  • 2. American Academy of Orthopaedic Surgeons
    (2006)

6
Risk Factors for Falls
  • Broad range of risk factors identified in the
    literature (between 130 and 400) 1
  • Likelihood of falling increases with four or more
    risk factors 2
  • Classified as extrinsic or intrinsic
  • McMurdo, M. (2001).
  • Masud, T., Morris, O. (2001)
  • 2. Nevitt, M.C., Cummings, S.R., Kidd, S.,
    Black, D. (1989).

7
Risk Factors for Falls
  • Extrinsic
  • Environmental Factors
  • Poor lighting
  • Unsafe stairways
  • Irregular floor surfaces

8
Risk Factors for Falls
  • Intrinsic
  • Decline in sensory system
  • Vestibular, vision and proprioception

9
Risk Factors for Falls
  • Decline in motor
  • Strength, coordination and endurance
  • Increased age
  • History of Falls
  • Slow walking speed
  • Decline in function and integration (response
    time/reaction time)

10
Risk Factors for Falls
  • 50 of falls are due to a medical condition1
  • Diabetes, Parkinsons disease, stroke, arthritis,
    osteoporosis
  • Any acute or chronic disease
  • Visual disorders
  • Cataracts, glaucoma, macular degeneration
  • Medications
  • Type and number
  • CNS disorder
  • Balance disorders and dizziness
  • Steinweg, K.K,, (1997).

11
Falls and the Older Adult
  • Unfortunately, some older adults fail to seek
    help for falls
  • Attribute these to normal aging
  • Many older adults fear falling and do not realize
    that many falls they associate with aging can be
    prevented

12
Fear of Falling (FoF)
  • Injuries can be treated/fear of another fall is
    persistent
  • Fear of falling can
  • Create excessive anxiety
  • Restrict participation in activities of daily
    living
  • Decrease quality of life
  • Increase dependence on others

13
Fear of Falling Definitions
  • 1. Unusual variation of agoraphobia1
  • 2. Ptophobia 2 or post-fall syndrome 3
  • 3. A lasting concern about falling that leads to
    individuals avoiding activities that he/she
    remains capable of performing 4
  • Marks, I., Bebbington, P. (1976).
  • Bhala, R.P., ODonnell, J., Thoppil, E. (1982).
  • Murphy, S.L., Isaacs, B. (1982).
  • Tinetti, M.E., Powell, L. (1993).

14
Fear of Falling Assessment Instruments
15
Risk of Falling Programs
16
Risk of Falling Programs
  • Multidisciplinary care (Fall Clinics)
  • Exercise intervention programs
  • Home hazard assessment/environment modification
  • Studies incorporating these elements have
    established that falls and fall related injuries
    can be prevented
  • Not easily replicated in most clinical settings
  • Few have included FoF as an outcome of interest

17
Summary of Research Findings in the Reduction of
Falling Concerns in Older Adults
18
Summary of Research Findings in the Reduction of
Falling Concerns in Older Adults
  • Majority of studies were group programs
  • Frail elderly (gt75 years average age of
    inclusion)
  • Few studies provided multidisciplinary fall
    prevention/risk of falling clinics,
  • No audiologist/physical therapist/neurotologist
    (or otolaryngologist) for the initial evaluation

19
Summary of Research Findings in the Reduction of
Falling Concerns in Older Adults
  • Few included home hazard assessment
  • Excluded patients with complaints of vertigo,
    lightheadedness, etc
  • Only 1 study provided qualitative descriptions
    from the subjectlimited to patient satisfaction
    of the program
  • None of the studies examined the impact of FoF on
    the patient or caregivers

20
Purpose of My Research
  • To determine if intervention with a team approach
    risk of falling assessment and remediation
    program reduces fear of falling in older
    independent living individuals with a balance
    disorder.
  • Evaluate the impact of FoF due to a balance
    disorder on the patients activities of daily
    living
  • Determine the impact of FoF on a selected family
    member, significant other, or spouse of the
    patient

21
Specific Aims
  • Establish/evaluate the impact of FoF due to a
    balance problem on selected family member,
    significant other or spouse
  • Verify level of anxiety and depression in the
    patient, due to FoF
  • Reveal the patients present attitude toward
    their balance problem/activity level before FoF
  • Verify the effectiveness of the risk of falling
    intervention program designed to reduce FoF
  • Determine via the (ABC) Scale if the risk of
    falling program reduced FoF

22
Methods
  • Male and female patients were recruited from
    individuals referred to the Balance Disorder
    Center (Group 1)
  • Completed a balance disorder questionnaire
  • One family member, significant other, or spouse
    of the patient was recruited for the study (Group
    2)

23
Methods
  • (Group 1) scheduled for 2 half days of risk of
    falling assessment
  • Audiology and Physical therapist
  • Testing was performed in 2 clinical settings
  • Medical evaluation with neurotologist
  • Remediation Portion (balance/vestibular
    rehabilitation with PT)
  • Audiologist observed and interviewed
    patient/selected family member, spouse, or
    significant other before and after the
    remediation portion

24
Audiology Assessment (Group 1)
  • Reviewed balance questionnaire answers
  • Mini Mental State Exam
  • Geriatric Depression Scale
  • Beck Anxiety Inventory
  • Home Safety Checklist for Detection of Fall
    Hazards
  • Activities Specific Balance Confidence (ABC)
    Scale
  • Near vision acuity testing
  • With and w/o corrective lenses
  • Determined date of last eye examination

25
Audiology Assessment (Group 1)
  • 8. Audiometric exam
  • Tympanometry
  • Acoustic reflexes
  • Pure tone and speech audiometry
  • 9. Balance assessment
  • Platform Posturography
  • Clinical Test of Sensory Integration and Balance
    (CTSIB)
  • 10. Impaired balance function
  • VNG

26
Significant Other Assessment (Group 2)
  • Mini-Mental State Examination
  • Home Safety Checklist for Detection of Fall
    Hazards
  • Modified ABC scale

27
Physical Therapy Assessment (Group 1)
  • Review of symptoms (fall history etc)
  • Type and number of medications
  • Dizziness Handicap Inventory
  • Musculoskeletal examination
  • Lower extremity strength, flexibility, reflex and
    sensation testing
  • Functional Reach Test
  • Timed Up and Go test
  • Examination of gait length and velocity
  • Berg Balance Test
  • Dynamic Gait Index

28
Neurotologist Assessment (Group 1)
  • Review of all risk of falling assessment
    results/Case History
  • Head and neck examination
  • Cranial nerve function/neurologic exam
  • All results integrated to yield diagnosis
  • Referral to PT for balance disorder remediation

29
Qualitative Assessment (Group 1 and 2) In home
interview/observation
  • 1st interview scheduled prior to remediation
    portion of the program
  • Separately interviewed (Group 1) and (Group 2)
    subjects
  • w/ audiotape recorder
  • Counseled/educated participants on the results of
    home hazard checklist
  • Addressed home hazard issues

30
Remediation Program (Group 1)
  • Balance/Vestibular Rehabilitation
  • Designed to incorporate concerns/goals agreed
    upon by the PT and patient
  • habituation, gaze stability, balance mobility,
    strength and endurance training
  • Therapy sessions based on assessment results
  • Length of program depended on indiv. objectives
    (on average 6-10 weeks)

31
Completion of Risk of Falling Program (Group 1
and 2)
  • Follow-up observation/interview
  • Separate interviews
  • (Group 1) post questionnaires
  • Geriatric Depression Scale
  • Beck Anxiety Inventory
  • ABC Scale
  • (Group 2) post questionnaire
  • Modified ABC scale

32
Results Subject Characteristics
  • Originally 32 subjects
  • 2 participants spouses dropped out
  • N 28
  • 14 from each group

33
Description of Balance Problems
  • Primary symptom
  • Unsteadiness
  • Standing or walking
  • Constant symptoms (57)
  • Moderate disability (35)

34
Fall History
  • FoF, fall, near fall (100)
  • 78 avoided activities inside the house
  • 92 avoided activities outside the house

35
Physical therapy assessment results (Pre)
36
Audiology Assessment Results
64 indicated last visual exam gt 1 year ago
37
Audiology Assessment Results
  • 93 sensorineural loss in both ears
  • VNG results
  • 29 both peripheral and central
  • 29 peripheral only
  • 21 central only
  • 21 normal
  • Platform/CTSIB results
  • 2 severe dysfunction pattern
  • 1 visual/vestibular dysfunction pattern
  • 8 vestibular dysfunction pattern
  • 3 unable to perform test

38
Questionnaire results
  • Mini Mental
  • Group 1 (mean 27.6, SD 2.21)
  • Group 2 (mean 28.1, SD 2.50)
  • Home Hazard
  • Overall scores indicated good rating
  • Only 3 out of 4 families scored w/in the same
    range

39
Questionnaire results (Group 1)
  • ABC, Geriatric Depression, Beck Anxiety
  • Compared pre/post
  • Wilcoxon signed ranks test

a .05
40
Questionnaire results (Group 2)
  • ABC scale
  • Compared pre/post
  • Wilcoxon signed ranks test

a .05
41
Spearman r Correlation Coefficients between ABC
scale, Geriatric Depression scale, and Beck
Anxiety Inventory (Group 1)
  • Significant negative correlation between change
    in FoF and depression
  • Significant negative correlation between change
    in FoF and anxiety

42
Spearman r Correlation Coefficients between ABC
(Post) Scores and Age and Co-Morbidities for
(Group 1)
  • Significant negative correlation between change
    in ABC scores and age
  • No significant association between number of
    co-morbidities and change in ABC scores

43
Qualitative ResearchExample of Open Ended
Questions
  • Sample interview questions for patient with fear
    of falling
  • 1. Tell me about a typical day at home.
  • 2. How has your life changed since the fear of
    falling?
  • Sample interview questions for family
    member/spouse
  • 1. Describe for me some activities your
    spouse/family
  • member is afraid to perform to due the fear
    of falling.
  • 2. Describe what activities your spouse/family
    member
  • depends on you to perform due to his/her
    fear of falling.

44
Qualitative Results
  • 1. Phenomenological approach
  • 2. Open ended interview questions
  • 30 40 minutes (Group 1 2)
  • 3. Content Analysis
  • Transcribed (350 total pages)
  • Group 1 172 pages , Group 2 178 pages)
  • Coded
  • Coding example No, I can walk through the
    house. Then sometimes I cant. It just depends
    on my day or if Im overly tired.
  • Codes description of balance problems, fatigue,
    limiting activities

45
Qualitative Results
  • Content Analysis of 28 interviews yielded two
    Main Themes
  • Impact of a Fear of Falling/Balance Disorder on
    Daily Living
  • Role of Risk of Falling Program

46
Data DisplayImpact of a Fear of Falling/Balance
Disorder on Daily Living
47
Data DisplayRole of Risk of Falling Program
48
Summary of Results
  • 1. All reported fall, FoF
  • 2. High risk of falling
  • 3. Statistically significant reduction in FoF
  • (group 1 and 2)
  • 4. Significant reduction in depression/anxiety
  • (group 1)
  • 5. Qualitative results

49
Summary of Results Evidence of Improvement Post
Treatment
  • 1. Patients advocate
  • 2. Vestibular/balance rehabilitation component

50
Limitations
  • Assessment appointments
  • Short follow-up period

51
Other Interesting Findings
  • Depression scores
  • Family member falling concerns post program
  • 66.7 (mean ABC post) Group 2
  • 77.9 (mean ABC post) Group 1

52
Future Directions
  • 1. Greater public awareness/education on reducing
    falls/fear of falling
  • Screening tests for risk of falling
  • 2. Primary Care Physicians Role

53
Conclusion
  • Team approach risk of falling program
  • (audiology, PT, neurotology)
  • with vestibular/balance rehab, counseling
    education on balance disorders/falls
  • effective way to deal with fears about falling
    and improve quality of life.
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