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Falls and Mobility Problems in Older Adults

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Title: Falls and Mobility Problems in Older Adults


1
Falls and Mobility Problems in Older Adults
  • Shelley B. Bhattacharya, D.O., M.P.H.
  • Department of Family Medicine
  • Kansas Reynolds Program in Aging
  • University of Kansas Medical Center

2
Epidemiology of falls in elderly
  • Definitions
  • Classifications
  • Incidence

Ageing
3
Epidemiology of falls in elderly
Definitions
  • An event that results in a person inadvertently
    coming to rest on the ground or other lower level
    (not as a result of loss of consciousness,
    violent blow, sudden onset of paralysis or
    seizure) (Gibson et al., Kellogg International
    Work Group, 1987)
  • An event which results in a person coming to rest
    unintentionally on the ground or other lower
    level, not as a result of major intrinsic event
    (such as stroke) or overwhelming hazard (Tinetti
    et al., 1988)
  • Unintentionally coming to rest on the ground,
    floor or other lower level (Ory et al, FICSIT
    trials, 1993)

4
Epidemiology of falls in elderly
Classifications
  • Falls
  • Trigger
  • Consequence
  • Fallers
  • Non-fallers
  • Once-only fallers
  • Recurrent fallers

5
Epidemiology of falls in elderly
  • Incidence
  • Accidents are the 5th leading cause of death in
    older adults 1
  • Falls account for 2/3 of these accidental deaths
  • 1/3 of adults over 65 living in the community
    fall at least once a year
  • This rises to ½ of adults over age 80 2,3
  • 5 of these falls result in a fracture or
    hospitalization
  • Mobility abnormalities affect 20-40 of adults
    over 65 and 40-50 of adults over age 85 4,5

6
Epidemiology of falls in elderly
Incidence
  • Mortality 46
  • Of those who are hospitalized, 50 will not be
    alive a year later
  • Falls constitute 2/3rd of deaths associated with
    unintentional injuries
  • In 2000 traumatic brain injury (TBI) accounted
    for 46 of fatal falls.
  • Cost 47
  • Fall-related injuries are among the most
    expensive health conditions
  • In 2000 179 million were spent on fatal falls
    and 19 billion were spent on injuries from
    non-fatal falls

7
Epidemiology of falls in elderly
Incidence
  • Location 48
  • Most falls occur outdoors
  • Women are more likely to report indoor falls
  • Indoor falls are associated with frailty
  • Outdoor falls are associated with compromised
    health status in more active elderly

8
Epidemiology of falls in elderly
Incidence
  • The rate of falls and their associated
    complications are twice over the age of 75
    years.
  • 10-25 falls induce fractures in this population
  • Hip fractures are more common after the age of 75
    years
  • Those 75 years of age are more likely to report
    indoor falls
  • Incidence is higher in certain populations (e.g.
    institutionalized elderly, diabetics, Parkinsons
    disease, post-stroke etc.) 49

9
Fall prevention
  • The quality of falls care in older adults is
    suboptimal
  • If we can reduce the risk factors for falling,
    then we can reduce the incidence and the
    morbidity associated with falls
  • 3 studies have found that 65-100 of older adults
    with 3 or more risk factors fell in a 12 month
    period compared with 8-12 of older adults
    without any risk factors 1,6-8

10
ACOVE Indicators
  • ACOVE Assessing Care Of Vulnerable Elders
  • The 12 new ACOVE indicators59 are designed to
    improve the clinical approach to falls and
    mobility in older adults
  • Evidence based focus 182 articles were reviewed
    to obtain these indicators
  • Some have practice guidelines which will be
    shared

11
ACOVE Indicator 1
  • ALL vulnerable elders should have ANNUAL
    documentation about the occurrence of recent
    falls

12
Because
  • Falls are common
  • Preventable
  • Frequently unreported
  • Often cause injury
  • Can restrict activity unnecessarily
  • A recent fall is a potent predictor of future
    falls
  • Need a multifactorial falls risk assessment for
    all of your vulnerable older adults

13
Multifactorial Falls Risk Assessment
  • Many studies show that a multifactorial falls
    risk assessment program is beneficial to assess
    and intervene on falls
  • In one meta-analysis, the risk ratio for a first
    fall in subjects enrolled in a risk assessment
    program was 0.82 (95 CI 0.72-0.94) compared to
    controls and was 0.63 (95 CI 0.49-0.83) for any
    fall 9
  • In other words, 18 fewer 1st falls and 37 fewer
    of any falls with a falls risk assessment
    program!

14
Falls Risk Assessment Features
  • Medication review
  • ADL and IADL assessment
  • Orthostatic blood pressure measurement
  • Vision assessment
  • Gait and balance evaluation
  • Cognitive evaluation
  • Assessment of environmental hazards

15
ACOVE Indicator 2
  • IF a vulnerable elder reports 2 or more falls in
    the previous year, THEN document a basic fall
    history within 3 weeks of the report
  • Because a basic fall history provides the
    necessary information to implement an
    individualized multifactorial falls risk
    intervention strategy

16
What is a fall history?
  • Circumstances?
  • Medications?
  • Chronic conditions?
  • Mobility status?
  • Alcohol intake?
  • You can use the positives to tailor a fall
    prevention program specific for each of your
    older adults 10,11

17
ACOVE Indicator 3
  • IF a vulnerable elder reports 2 or more falls (or
    1 fall with injury) in the previous year, THEN
    there should be documentation of orthostatic
    vital signs within 3 months of the report
  • Because detection of orthostasis decreases the
    risk of future falls
  • Is a part of the multifactorial falls prevention
    intervention

18
Evidence
  • Supported by 13 studies including cohort and
  • RCTs 12-18
  • Some clinical guidelines that are recommended
  • Correct postural hypotension 19
  • Assess postural vitals in all older adults that
    have had a recent fall, report recurrent falls or
    demonstrate abnormalities in gait or balance 20
  • Include a cardiovascular examination when doing a
    falls risk assessment 21

19
ACOVE Indicator 4
  • IF a vulnerable elder reports a history of 2 or
    more falls in the last year, THEN there should be
    documentation of an eye examination in the
    previous year or visual acuity testing within 3
    months of the report
  • Because detection and treatment of some forms of
    visual impairment reduces the risk of falls.

20
Evidence
  • 11 studies examined visual acuity as a falls risk
    factor
  • One study looked at falls improvement after
    expedited (within 27 days) and routine (71-212
    days) cataract surgery in women over age 70 22
  • After 1 year, 49 of adults in expedited group
    fell at least once compared to 45 in routine
    group
  • 18 fell twice in expedited group compared to 25
    in control group

21
ACOVE Indicator 5 and 6
  • IF a vulnerable elder reports 2 or more falls in
    the last year, OR
  • IF a vulnerable elder has new or worsening
    difficulty with ambulation, balance or mobility,
  • THEN there should be documentation of basic gait,
    balance and strength evaluation within 3 months
    of the report

22
Because
  • Detection and treatment of gait and balance
    disorders reduces the risk of future falls as
    part of a multifactorial intervention

23
Evidence
  • 9 studies looked at gait and balance assessments
    in falls prevention
  • Cohort and RCTs
  • In 3 studies, abnormal gait and balance alone
    were significant predictors of falls 6

24
Clinical Guidelines for Gait and Balance
  • Provide interventions to improve balance,
    transfers and gait 19
  • Do a gait and balance assessment for those
    requiring medical attention because of a fall,
    report recurrent falls in the past year or
    demonstrate abnormalities of gait or balance 20
  • Risk assessment includes assessment of gait,
    balance, mobility and muscle weakness 21

25
Screening and Examination of Gait and Balance
  • Timed Get Up and Go Test
  • Single Leg Stand Test
  • Dynamic Gait Index
  • Berg Balance Scale

26
Timed Get Up and Go Test
  • Measures functional capacity rather than
    individual impairment reflects multiple
    domains, useful in detecting mobility impairment
  • . Time it takes to stand up from arm chair, walk
    3 meters (10 feet), return to chair and sit down

27
Timed Get Up and Go Test
  • Interpretation of Performance on the Timed Get Up
    And Go Test
  • lt 10 sec.
  • Low fall risk clients are freely mobile
    encourage regular exercise
  • lt 20 sec.
  • Moderate fall risk clients are independent with
    basic transfers most go outside alone and climb
    stairs, many are independence with tub and shower
    transfers. PT referral may be appropriate.
  • 20-29 sec.
  • High fall risk Gray zone functional abilities
    vary. Physician or multidisciplinary team
    assessment recommended.
  • gt30 sec.
  • Very high fall risk Many are dependent with
    chair and toilet transfers most are dependent
    with tub and shower transfers most cannot go
    outside alone few, if any, can climb stairs
    independently. Physician or multidisciplinary
    team assessment recommended.

28
Timed Get Up and Go (TUG) Test
  • Bischoff (2003)
  • Community dwelling elderly women lt 12 sec. on TUG
    normal
  • Women in residential care only 9 performed in
    lt12 sec. 42 were below 20 sec 32 were between
    20-30 sec. and 26 gt 30sec.
  • Suggests that community dwelling woman with TUG gt
    12 sec. should be referred for PT evaluation
  • Over 50 of women in residential care at high or
    very high risk of falling

29
Timed Get Up and Go Test
  • Nordin (2006)
  • Individual variation in performance high in
    institutionalized elderly
  • Variation increased with slower performance.
  • Cognitive impairment or cuing did not increase
    variability
  • Could use mean of three trials to obtain a more
    accurate score
  • We do not know what this variability means in
    terms of falls risk prediction

30
Single Leg Stance Test
  • A measure of static balance that relates to
    foot/ankle strategies
  • Functional implications for gait, especially on
    uneven surfaces, and going up/down curbs or steps
  • Marker of frailty in elderly persons
  • Community dwelling older adults unable to stand
    for 5 sec. had a 2.1 times risk of injurious
    falls

31
Dynamic Gait Index
  • Developed to quantify gait dysfunction in older
    adults during level surface walking as well as
    more complex functional tasks.
  • Dual task demands relevant to falls risk in
    elderly
  • Applicable to assessing balance in other groups
    of patients including those with vestibular
    disorders, multiple sclerosis, head injury, and
    Parkinsons
  • Scores of 19 or less out of 24 indicate increased
    risk of falling in older adults (Shumway-Cook
    1997)

32
Berg Balance Scale
  • Measure of static and dynamic balance in
    movements common in everyday life on 14-item
    scale (56 points)
  • Useful for evaluating multiple falls risk in
    community living older adults
  • No longer recommends a dichotomous 45 point
    cut-off
  • Likelihood of multiple falls increases as score
    decreases
  • Reliable test of balance in elderly in
    residential care change of 8 points required to
    reveal genuine change in function
  • Discriminates persons with Parkinsons disease
    who fall vs. those who do not fall
  • Cut-off score of 44/56 recommended by Landers,
    2008

33
Limitations of Balance Scales and Screening Tools
  • Screening for falls may increase fear of falling
  • Falls are multifactorial, no scale captures all
    aspects
  • Scales and balance screening tools have not been
    well tested in a wide range of populations/setting
    s
  • Uncertainty regarding predictive scores
  • Scales test different aspects of balance,
    sensitivity for prediction and examination may be
    best with multiple tests

34
ACOVE Indicator 7
  • IF a vulnerable elder reports 2 or more falls in
    the past year, THEN there should be documentation
    of a cognitive assessment in the past 6 months
  • Because, detection and management of cognitive
    impairment reduces the risk of falls as part of a
    multifactorial intervention

35
Evidence
  • 7 studies
  • 4 studies recommend using the MMSE 15-17,23
  • Clinical Practice Guideline
  • Assess mental status as part of your fall
    evaluation for older adults who had a fall,
    report recurrent falls in the past year or show
    abnormal gait or balance 20

36
ACOVE Indicator 8
  • IF a vulnerable elder reports a history of 2 or
    more falls in the past year, THEN there should be
    documentation of an assessment and modification
    of home hazards recommended in the previous year
    or within 3 months of the report

37
Because
  • Environmental factors can contribute to risk of
    falls and mobility problems
  • An assessment and modification of home hazards
    may decrease fall risk

38
Homes Are Not Typically Designed For Users of
Various Abilities
  • Life Span Development
  • Acute Injury
  • Aging-in-Place
  • Chronic Disability

39
Difficulty Moving Around at Home
  • Hard to go up stairs 35
  • Difficulty walking 15
  • Use of cane/walker 8
  • Use of wheelchair/scooter 6
  • Difficulty bathing 3
  • Chair or bed transfers 3

(Source Fixing to Stay, 2002)
40
Important Housing Features
  • Main floor, bath
  • Main floor, bedroom
  • Accessible climate controls
  • Non-slip flooring
  • Bathroom aids
  • No step entrance
  • Covered parking

(Source These Four Walls, May 2003)
41
Occupational Therapy considers the physical
context
  • During Assessment
  • Understand obstacles/barrier to participation
  • Understand supports to participation
  • Consider individual, groups, populations who use
    the physical space
  • During intervention
  • Reduce activity demands from the environment
  • Insure adequate supports
  • Facilitate performance though the use of the
    environment
  • Avoid further functional decline and excess
    disability caused by environmental factors

42
3 Major Problem Areas of the Home
  • Outside Steps To The Entrance
  • Inside Stairs To A Second Floor
  • Unsafe Bathrooms

Source HUD (2001)
43
Other Alternatives to Entrance with Outside Steps
  • Ramps
  • Earth Berms/Walkways
  • Lifts
  • Zero Step entrance

44
Other Strategies for Getting Upstairs
  • Chair lift
  • Elevator
  • Relocate rooms to main floor

45
Strategies for Bathing
  • Bath bench/chair
  • Bath lift
  • Grab bars
  • Visual contrast
  • Non slip surface
  • Hand held showerhead
  • Shower/wet room
  • Curbless shower

46
Evidence
  • Many RCTs reviewed
  • One RCT of over 3000 older adults 24
  • Intervention in home safety mobility assessment
  • Control no assessment
  • Results Odds ratio of falling in the
    intervention group dropped from 1.0 to 0.85
  • In other words, there was a 15 drop in falls in
    those receiving the in home safety mobility
    assessment

47
More Evidence
  • Environmental assessment and modification using
    an occupational therapist reduced 12 month
    relative risk of falling to 0.64 (95 CI
    0.5-0.83) in older adults at higher risk of
    falling 25-28
  • Another study compared a home safety program to a
    home exercise program in older adults with severe
    visual impairment 29
  • Found fewer falls in the home safety program
    0.59 (95 CI 0.42-0.83)
  • No difference with the home exercise group

48
Review Study
  • A review study looking at 3 trials found that
    professionally prescribed home hazard assessment
    and modification in older adults with a history
    of falling reduced the risk of falling, RR of
    0.66 (95 CI 0.54-0.81) 30

49
Checklists--Examples
  • Home Safety Council
  • www.homesafetycouncil.org/resource_center/rc_check
    list_w001.aspxp
  • Rebuilding Together --Checklist
  • www.rebuildingtogether.org
  • CDC Check for Safety
  • www.cdc.gov/ncipc/pub-res/toolkit/checkforsafety.h
    tm
  • http//www.cdc.gov/ncipc/falls/FallPrev4.pdf
  • http//www.cdc.gov/ncipc/duip/fallsmaterial.htm

50
ACOVE Indicator 9
  • IF a vulnerable elder reports a history of 2 or
    more falls, or 1 fall with injury, in the past
    year, THEN there should be documentation of a
    discussion of related risks and assistance
    offered to reduce or discontinue benzodiazepine
    use
  • Because, benzodiazepine use increases the risk of
    future falls

51
Evidence
  • 1 RCT 93 ambulatory adults over age 65 on a
    benzodiazepine, any other hypnotic,
    antidepressant or tranquilizer 31
  • Randomized to withdrawal plus exercise,
    withdrawal only, exercise only or no intervention
  • Over 44 weeks, medication withdrawal group had
    lower rate of falls (0.52 vs. 1.16 falls per
    person-year. Difference 0.64, 95 CI
    0.07-1.35)NOT significant
  • But, if adjusted for history of falls in past
    year and total number of meds taken, hazard for
    falls in the medication withdrawal group was 0.34
    (0.16-0.74)

52
More evidence!
  • Meta analysis of observational studies found that
    odds ratio for the association between
    benzodiazepines and falls was
  • 1.40 (1.11-1.76) in cohort studies
  • 2.57 (1.46-4.51) in case control studies
  • 1.34 (0.95-1.88) in cross sectional studies 32

53
Clinical Practice Guidelines
  • Review all medications 20
  • Modify psychotropic meds and discontinue, if
    appropriate
  • Rationalize all drugs taken 19

54
ACOVE Indicator 10
  • IF a vulnerable elder demonstrates poor balance
    or proprioception or excessive postural sway and
    does not have an assistive device, THEN an
    evaluation or prescription for an assistive
    device should be offered within 3 months

55
Because
  • Impaired balance or proprioception or excessive
    postural sway can contribute to instability
  • Appropriate treatment will reduce the likelihood
    of falls and their complications

56
ACOVE Indicator 11
  • IF a vulnerable elder reports a history of 2 or
    more falls, or 1 fall with injury, in the past
    year and has an assistive device, THEN there
    should be documentation of an assistive device
    review in the past 6 months or within 3 months of
    the report

57
Because
  • A poorly fitted assistive device or one used
    inappropriately along with impaired balance or
    proprioception or excessive postural sway can
    contribute to instability
  • Appropriate use of an assistive device will
    reduce the likelihood of falls and their
    complications

58
Evidence for Indicators 10 and 11
  • Many studies suggest that assistive devices can
    increase an older adults confidence, reduce fear
    of falling and improve independence 33-35
  • Some studies suggest the use of devices may
    increase the risk of falling 36,37
  • Other studies suggest that device use is a marker
    for fall risk 38

59
Fear of falling Possible contributors
  • Age, female gender, poor social support, H/O
    falls, depression and poor lower limb function
  • In addition to older age and female gender, lower
    personal mastery and poor dynamic balance are
    associated with fear of falling 55

60
Fear of Falling Activity restriction
Poor perceived health Social withdrawal
Reduced strength
Poor balance Increased
disability Increased fall risk
Reduced
independence

Poor
quality of life
61
Fear of falling may not always precipitate
activity restriction
  • half of those who report fear of falling do not
    restrict activities 50-53
  • Lack of social support, depressive symptoms, H/O
    multiple falls and presence of 2 chronic
    conditions are associated with fear-induced
    activity restriction 50,53-54


62
ACOVE Indicator 12
  • IF a vulnerable elder is found to have a problem
    with gait, balance, strength or endurance, THEN
    there should be documentation of a structured or
    supervised exercise program offered in the
    previous 6 months

63
Because
  • These problems can contribute to falls and
    mobility dysfunction
  • Exercise intervention can improve the dysfunction
    and reduce the likelihood of falls and their
    complications

64
Evidence
  • Many studies show benefits of muscle strength
    with gait parameters in older adults
  • Increases of 5-15 in ambulatory function after
    8-12 weeks of a walking and endurance program
    39,40
  • Balance training improved force-plate balance
    parameters by 20-50 41,42
  • Tai chi improved balance (postural sway) by 32
    and fall risk by 49 (OR 0.51, 95 CI 0.36-0.73)
    43,44
  • Aerobic conditioning improved balance by 20 in
    adults over age 70 45

65
General Gait Assessment What to look for in the
elderly person at risk for falling 56
  • Changes in gait with aging
  • Average gait speed declines 12 to 16 per decade
    past 70 yrs.
  • Stride frequency increases
  • Stride length decreases at a given walking speed
  • Double support time increases

66
General Gait Assessment What to look for in the
elderly person at risk for falling 57
  • Gait Characteristics of Fallers
  • Decreased trunk rotation
  • Increased knee flexion
  • Several small steps and reduced speed prior to
    stepping over low obstacle (12)
  • Shorter step and stride length
  • Slowed gait speeds
  • Decreased single leg support time and increased
    double limb support time.

67
Practice Guideline
  • Use exercise to improve measures of balance and
    reduce incidence of falls
  • Use of a multidimensional exercise program that
    incorporates balance training and strengthening
    should improve postural stability and reduce fall
    risk

68
Exercise Recommendations for Older Adults with
Chronic Disease or Frailty 58
  • Balance
  • 1-7 x/week, dynamic exercises focused on
    mobility, static exercise focused on single leg
    stand, 4-10 different exercises
  • Progressive, targeting important postural muscle
    groups, progress by decreasing base of support
  • Muscle Performance
  • 2-3 x/week, 8 to 10 exercises
  • Aerobic Capacity
  • Chronic Dx - 3-5 x/week, 20-60 minutes, 50-70
    Hrmax
  • Frailty - gt 3 x/week, at least 20 minutes, 11-13
    Borg Scale
  • Flexibility
  • 3-7 x/week, 3-5 reps each major muscle group,
    10-30 s. hold

69
Summary
  • Extremely important to try to prevent falls in
    your older patients and prevent future falls from
    your current fallers
  • Look at their meds, cognition, orthostasis,
    vision, gait, balance
  • Encourage exercise to improve muscle strength and
    balance
  • Consider assistive devices
  • Use OT for home safety assessments
  • Screen for fear of falling and counsel to improve
    mobility

70
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