Beyond Balance: Evidence Based Practice Enhancing Quality of Life in the Geriatric Patient

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Beyond Balance Evidence Based Practice
Enhancing Quality of Life in the Geriatric
Patient

• Jenny Zimney, MPT, GCS
• jenny_at_northwestrehab.com
• Northwest Rehabilitation Associates
• 1380 Liberty St. SE
• Salem, OR 97302
• [phone]

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Beyond Balance

• What factors create safety and balance?
• Can I really impact the frequent faller?
• Can fear of falling be overcome?

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Course Objectives

• Following todays session you will be able to
• Choose and implement the appropriate functional
  scale for their patient status and setting.
• Develop objective measurable treatment
  interventions and goals based on the functional
  scales used.
• Discuss the rationale and purpose for each
  functional scale presented.

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Course Objectives contd

• Quantify a geriatric patients balance, fear of
  falling and fall risk using the functional scales
  presented.
• Identify reliable reimbursement and marketing
  options for fall prevention programs in your
  community.
• Make a greater impact on reducing falls in your
  community!

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Systems of Balance
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Balance and Motor Planning

• What is my plan/objective?
• What am I feeling?
• What am I going to do about it?
• Was this successful last time?
• What is my plan this time?
• Can my body do this (or) do this in time?

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Allum et al 2002 J Phys

• Changes in Postural Control with Age
• Results
• With perturbation on sway board
• Younger Trunk rolls toward from
  perturbation (uphill)
• Older Trunk rolls away from perturbation
  (downhill)

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Sensory Systems
Vision
Somatosensory
Vestibular
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Age Related Changes Vision

• ? visual acuity
• Impaired dark adaptation
• ? response to peripheral field visual stimuli
• ? contrast sensitivity
• Difficulties with accommodation
• Abnormal visual perception

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Age Related Changes Vestibular

• Loss of hair cells in semicircular canals
• Calcification in cupula
• Thinning of vestibular afferent axons

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Age-Related Changes Somatosensory

• 10-15 ? nerve conduction velocity
• ? Sensory detection thresholds
• ? Central processing time
• ? latency of automatic postural responses

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Age related changes Efferent System

• ? Active muscle stiffness
• ? Muscle force and power generation capacity
• ? Variability of contraction amplitudes for
  proximal/distal muscles of a synergy
• ? of trials to adapt strategy for perturbation

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Age Related Changes Etiology

• Normal changes associated w/ aging
• Decrease in physical activity/stimulation
• Disease states Diabetes, PVD, CVA, vestibular
  dysfunctions, macular degeneration
• OR
• Learned non-use

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Common medications related to falls

• Benzodiazapines (Valium, Ativan)
• Sedatives (Benadryl, Buspar)
• Hypnotics (Xanax)
• Antipsychotics (Thorazine, Haldol)
• Antidepressants (Elavil)
• Antihypertensives (Lopressor, Catapress)
• Antianxiety (Librium)
• Diuretics (Lasix, Diuril)

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Balance Review More thoughts

• Environmental Demands
• Cognition/Attentional Demands
• Self-Efficacy/Fear of Falling

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Environmental Demands and Balance/Mobility

• 36 older adults self reported trip log and
• videotaped weekly (tracking 8 environ dimensions)
  
• Results Temporal (speed), physical load, terrain
  and postural transitions (head mvmt)
  distinguished those w/ disabilities, 1/2 as many
  activities and had to be accompanied.
• (Shumway-Cook A, et al. Phys Ther.
  200282670-681)

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Attentional Demands

• Static vs. Dynamic Equilibrium
• 6 healthy young subjects (20-30 yo)
• Tested reaction time to auditory cue with
  sitting, standing upright (broad and narrow base,
  walking (SLS and DLS)
• Standing gt sitting Walking gt sit or stand SLS gt
  DLS
• Conclusion Balance control w/in gait is not
  automatic.
• Lojoie, Teasdale, Bard, Fleury. Exp Brain Res.
  199397139-144.

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Attentional Demands of Obstacle Negotitation

• 15 older adults vs. 15 younger adults
• Testing reaction time to auditory cue with
  walking level and over foam block when in SLS
• Results Pre-crossing and Crossing were in
  older adults
• Brown, McKenzie, Doan. J Geron.
  200560A(7)924-927

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Attentional Demands

• Dual-task Methodology
• Limited Central Processing Capacity
• Task performance requires part the limited
  capacity within the CNS
• If performing 2 tasks and that capacity is
  exceeded, 1 or both tasks can be disturbed.

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Voluntary Step and Cognitive Task

• 66 healthy elderly vs. healthy young adults
• Tested voluntary stepping on force plate single
  task and w/ modified Stroop test
• Results Older adults with
• Single task 42-52 slower step initiation
• Dual task 190-256 slower, 41 no reaction
• Melzer, Oddsson. JAGS. 200458(8)1255-1262

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Fear of Falling Influences Gait

• 95 com-dwell older adults
• Gait parameters speed, stride length, step
  width, double limb support time
• In fearful group, speed was slower, stride
  shorter, step width larger and double limb
  support time was 6 longer.
• Chamberlin ME, Fulwider BD, Sanders SL, Medeiros
  JM. J Geron Med Sci. 200560A91163-1167

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Fear of Falling Predisposing Factors

• 6. No Emotional Support
• 5. Sedentary Lifestyle
• 4. Chronic Dizziness
• 3. Fall history w/ in previous year
• 2. Vision gt 50 impaired
• 1 Age gt 80 Anxiety Trait
• Murphy, Dubin, Gill. J Geron 200358A(10)M943-947
  .

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Assessing Balance Falls History

• How often do you lose your balance, i.e. slip,
  trip or stumble?
• When was your most recent fall?
• Did the fall occur inside or outside?
• How did the fall occur?
• Were you injured?
• Were you dizzy when you fell?

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Why use Functional Testing?

• Evidence-based
• Demonstrate skill
• Establish Goals
• Guide to treatment
• Objective measure of progress
• Prediction of future events

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Types of Reporting

• Self-Report
• Clinician observation and rating
• Equipment-based testing
• Focus of Functional Test presented

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• Which is best?

Self-Report
Clinical Observation
Proxy-Report
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The Activities-specific Balance Confidence Scale
(ABC)

• Developed by Powell and Myers with input from 15
  clinicians and 12 older outpatients to quantify
  fear of falling
• Type of Information Self Report
• Components 16 items of varying difficulty
• rated on
  0-100 scale
• Equipment needed Paper and pencil
• Time to Complete Test 5-10 minutes

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The Activities-specific Balance Confidence Scale
(ABC)

• Scoring
• gt 80 high functioning older adult (I com.
  Dwelling)
• 50-80 moderate level of functioning (Chronic
  Health Conditions or ALF)
• lt 50 low physical functioning (Home care)
• Myers AM et al, J of GerontolMedical Sci, 1998

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The Activities-specific Balance Confidence Scale
(ABC)

• Strengths
• Inexpensive
• Self Testing
• Examines community mobility
• Variety of situations and environments assists in
  treatment and goal setting

• Weaknesses
• Cannot use w/ significant cognitive impairment
• Imagination needed if not regularly performed
• Very high ceiling
• Nearly no floor effects

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Modified Falls Efficacy Scale (mFES)

• Adapted from Tinettis FES to quantify fear of
  falling
• Type of Information Self Report
• Components 16 items of varying difficulty
• rated on
  0-100 scale
• Equipment needed Paper and pencil
• Time to Complete Test 5-10 minutes

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Modified Falls Efficacy Scale (mFES)

• Scoring
• Items are scored from 0 to 10.
• Total the ratings (possible range 0 140) and
  divide by 14 to get each subjects mFES score.
• Scores of lt 8 indicate fear of falling, 8 or
  greater indicate lack of fear.

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Modified Falls Efficacy Scale (mFES)

• Weaknesses
• Cannot be used w/ significant cognitive
  impairment

• Strengths
• Inexpensive
• Self Testing
• Assesses indoor and outdoor situations
• More realistic activities then ABC

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ABC
mFES
VS
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Timed Up and Go

• Developed by Richardson and Podsiadlo to assess
  basic mobility skills in older adults
• Type of Information Clinician Observation and
• 
  rating
• Components One Item- stand, walk 10 ft, turn
  come back and sit down.
• Equipment needed Stopwatch, Chair (46cm)w/ arms
  (65 cm)
• Time to Complete Test 1-2 minutes

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Timed Up and Go

• Scoring
• gt30 sec people that are more dependent, unable to
  climb stairs, require AD, help with transfers,
  dependent in most activities
• lt10 sec freely independent
• lt20 sec( I) transfers, I toilet, able to climb
  most stairs, go out alone

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Timed Up and Go

• Strengths
• Can use assistive device
• Quick, easy, inexpensive
• Incorporates most aspects of mobility
• Sensitive to change
• Not diagnosis dependent

• Weaknesses
• Not usable for non-ambulatory patients
• Ceiling not challenging for community dwellers
• Must be able to follow directions
• Only a few aspects of balance are challenged

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Normal Values of Balance Tests in Women Aged 20-80

• 456 women in 6 age cohorts
• Tests TUG, Step, FR, LR
• Results
• Linear change with Step and TUG
• FR started to decline in 40s
• LR started to decline in 30s!!!!!
• Isles, Choy, Steer, Nitz JAGS 200452(8)1367-1372
  .

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Berg Balance Scale

• Developed to measure balance of the older adult
  in a clinical setting
• Type of Information Clinician observation
• Components 14 items of everyday tasks
• rated on 0-4 scale
• Equipment needed Ruler, Watch, 2 standard
  chairs, footstool or step, object
• Time to Complete Test 15-20 minutes

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Berg Balance Scale

• Specifics of testing
• No assistive device can be used
• Must be able to stand unsupported
• Forward reach w/ fingers outstretched (36 cannot
  do this)

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Berg Balance Scale

• Scoring
• 41-56 low fall risk
• 21-40 medium fall risk
• 0-20 high fall risk
• Additionally
• gt 45 safe, independent ambulator
• lt 36 fall risk near 100

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Berg Balance Scale

• Strengths
• Challenging for healthy, Com. Dweller
• Wide range of difficulty and patients
• Reliable for PD or CVA

• Weaknesses
• Cannot use assistive device
• Ceiling effect for high level functioning

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Physical Performance Test

• Developed to assess function in community
  dwelling older adults
• Type of Information Clinician observation and
  rating
• Components 3 Versions (7,8,9 item tests) rated
  on 0-4 scale
• Equipment needed Stopwatch, paper pen, bowl
  and 5 kidney beans, spoon, coffee can, heavy
  book, jacket or sweater, penny, 25-foot walkway,
  flight of stairs
• Time to Complete Test 15-20 minutes
• Reuben, Siu. JAGS 199038(10)1105-1112

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Physical Performance Test

• Specifics of testing
• Timing is from the word Go
• Incorporates stair climbing

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Physical Performance Test

• Scoring
• lt 15 predictor of recurrent falls
• Treatments, goals and other referrals can be
  designed from each item.

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Physical Performance Test

• Strengths
• Can use assistive device
• High ceiling
• Measure multiple areas of function
• Responsive to change w/ functional training

• Weaknesses
• Requires equipment
• Scale is ordinal- decreased sensitivity to change
• May fail to challenge multiple facets of balance

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Physical Performance Test

• Schmidt et al
• Predictive of frail elderly dropout rates in
  exercise program (JAGS 200048(8)952-960)
• Brown et al
• Differentiates Mild to Moderate Frailty
• (J Geron 200055A(6)M350-355.)

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Dynamic Gait Index

• Developed by Shumway-Cook and Wollacott to assess
  likelihood of falling in older adults
• Type of Information Clinician observation and
  rating
• Components 8 facets of gait, 0-3 scale
• Equipment needed box, 2 cones, stairs, at least
  25 ft walkway
• Time to Complete Test 15 minutes
• Shumway-Cook A, Woollacott A, Motor Control
  Theory and Practical Applications. Williams
  Wilkins, 1995

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Dynamic Gait Index

• Specifics of the test
• Test gait at different speeds
• Stepping over and around obstacles
• Gait w/ head turns (horizontal and vertical)

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Dynamic Gait Index

• Scoring
• lt 19 related to falls
• gt 22 safe

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Dynamic Gait Index

• Strengths
• Can use assistive device
• Examines 8 facets of gait including speed, head
  turns and over obstacles

• Weaknesses
• Only looks at gait
• Not tested in many populations

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Whitney, Hudak, Marchetti 2000

• Studied 247 patients with vestibular disorders
  and found
• DGI effective to ID fall risk with older and
  younger adults with vestibular disorders
• J Vest Research 200010(2)99-105

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DGI
"New and Improved"
Functional Gait Assessment

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Functional Gait Assessment (FGA)

• Developed by Wrisley et al. to increase the
  sensitivity of DGI.
• Type of Information Clinician observation and
  rating
• Components
• Equipment needed 2 boxes, 2 cones, stairs, at
  least 25 ft walkway, stop watch
• Time to Complete Test 15 minutes

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Functional Gait Assessment (FGA)

• Strengths
• Can use assistive device
• More sensitive to change than DGI
• Walking backward
• Dual-task
• Environmental barrier

• Weaknesses
• Only looks at gait
• No scores published yet

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6-Minute Walk Test

• Developed to assess exercise tolerance in
  cardio-pulmonary patients
• Type of Information Clinician observation and
  rating
• Component Gait distance
  
• Equipment needed Stopwatch, sphygmomanometer,
  stethoscope
• Time to Complete Test 6-10 minutes

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6-Minute Walk Test

• Specifics of testing
• Encourage patient to not talk during test
• Take vital signs pre and post
• Patient can take standing rests
• Termination of testing

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6-Minute Walk Test

• Scoring
• Few published norms
• lt 1000 ft (300m) indicative of morbidity w/in 6
  months in heart disease
• Median w/ healthy older adults

Mean distance by age 60-69 years male 572m,
female 538m 70-79 years male 527m, female
471m 80-89 years male 417m, female 392m
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6-Minute Walk Test

• Strengths
• Can use assistive device
• Sensitive to change w/ exercise training
• Safe due to patients self-limiting during test
• Easy to perform, little equipment needed

• Weaknesses
• Must be able to stand and/or walk 6 minutes

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Kristjansdottir et al 2004

• Compared 6-MWT to Limited Graded Exercise Test
• 6-MWT effectively identified cardiopulmonary
  concerns as did graded test.
• Conclusion Good test for cardiopulmonary
  rehab.Conditioning????

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Timed Stands

• Designed to assess strength, mobility and
  endurance
• Type of Information Clinician observation
• Component Repeated standing up from seated
  position
• Equipment needed Stopwatch, chair or mat
• Time to Complete Test 1-2 minutes

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Timed Stands

• Specifics of testing
• Can be time to complete 5 reps, reps completed in
  30 or 60 seconds.
• Patient is allowed to use any means necessary for
  standing up. (record need for UEs)

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Timed Stands

• Scoring 30 second timed stands

Normal Range 60-64 65-69 70-74 75-79 80-84 85-89 90-94
Men 14-19 12-18 12-17 11-17 10-15 8-14 7-12
Women 12-17 11-16 10-15 10-15 9-14 8-13 4-11
Normal range of scores is defined as the middle
50 percent of each age group. Scores above the
range would be considered above average for the
age group and those below the range would be
below average.
Jones CJ, Rikli RE, Beam W. Res Q Exerc Sport.
199970113-119
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Timed Stands

• Scoring 5 second timed stands

Sit to Stand Time (Seconds) by Age and Gender
75-79 80-84 85-89 90 Total
Men 12.1 (5.4) 12.9 (5.5) 13.7 (7.2) 17.2 (8.0) 12.8 (5.9)
Women 12.2 (4.1) 13.4 (5.6) 14.1 (6.5) 15.1 (6.5) 12.9 (5.1)
(SD) standard deviation
Lord, S.R. et al. J Gerontol A Biol Sci Med Sci.
2002 57A(8)M539-M543.
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Chair Stands as a Measure of LE Strength in
Sexagenarian Women

• 47 women performed 5STS, 30STS, Isokinetic
  testing of hip, knee and ankle
• Results
• 5STS Ankle PF, Hip Flex Knee Ext.
• 30STS Ankle PF
• But both only moderate predictors of LE strength.
• Other factors sensorimotor, balance,
  psychological
• McCarthy et al. J Geron. 200459A(11)1207-1212.

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Other Functional Assessments

• Short Physical Performance Battery tandem
  stance, 5STS, gait speed
• (Guralnik et al. J Geron. 199449(2)M85-M94)
• UAB Life-Space Assessment Assesses mobility in
  5 designated environments
• (Peel et al. Phys Ther. 2005851008-1019)
• NWRA Obstacle Course UE dual task w/ gait over
  obstacles

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Clinical Decision Making

• Tests are chosen based on
• 1. Facet of gait, balance or mobility noted to
  possibly be deficient
• 2. Possible need for referral
• 3. To support care plan, treatment, skilled
  therapy, or establish objective goals

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More on Clinical Decision Making

• Individual patient needs guide assessment choice
  but setting distinctions may include
• Acute care, ALF, SNF, LTC HH
• TUG, 6MWT, Timed Stands, PPT
• Outpatient BBS, ABC, mFES, PPT, DGI, TUG, Timed
  Stands, 6MWT
• Community Outreach/Screening TUG, Timed Stands,
  ABC, mFES
• NOTE These are only generalities, do NOT limit
  the choice of test based on setting.

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What do we do now?
What treatments work?
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What therapeutic interventions work?

• Strength and Conditioning
• Flexibility
• Speed/power training
• Dual-task/attention training
• Functional training
• Cognitive Training

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Land vs. Aquatic Exercise

• 11 older adults (ALF and outpatient) Berg Balance
  Scale lt47/56
• Comparable exercises on land and in water. 2x/wk
  x 6 weeks.
• Results Significant improvements but no
  difference between H2O and land-based.
• Douris et al. J Ger PT. 200326(1)3-6.

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Eccentric Work

• LaStayo et al. compared cardipulmonary rehab with
  LE eccentric resistance in frail elderly.
• Results Eccentric work group showed
• ? in TUG (16.65 to 11.96 seconds)
• ? in Berg (49.7 to 53.4)
• LaStoya et al. J Geron. 200358A(5)M419-424.

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Innovative treatment ideas

• Dynadiscs (static vs. dynamic balance)
• ? One-legged stance
• Corner vs. Countertop
• Eyes closed or not?
• Lite Gait
• Dual tasking
• Backward gait
• Speed training
• Conditioning and strengthening

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Fall Prevention and You!

• Falls Free Promoting A National Falls Prevention
  Plan
• V15.88 History of Fall, new diagnosis codes to be
  implemented on October 1, 2005
• Falls Free Program

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Case Studies
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Case Study 1 Earl

• 78 yo male 5 days post prostate surgery onset of
  LE weakness
• PMH CABG, CVAs, Seizures
• PLOF Highly active, Lived I, Walked dog in park
  daily, Phase III cardiac rehab.

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Case Study 2 Julia

• 82 yo female fell 6/04 w/ L hip fx w/ THA
• No falls since but is very afraid
• Meds Plendil, Diovan, Lexipro
• PMHx CVA 11 years ago, HTN

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Case Study 3 Bill

• 75 yo male w/ hx 4-5 falls in last 6 mos. Latest
  fall, reached to floor and just rolled.
• PMHx MVA w/ TBI R LE fx 60, R RTC repair,
  C5-6 discectomy, CABG x 4, NIDDM
• Wife and dau assist prn

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Case Study 4 Shirley

• 64 yo female w/ severe onset of dizziness that
  lasted 3-4 days, no just very unsteady.
• PMHx dizziness onset 5 yrs ago, Hypothyroidism,
  Breast CA
• Meds Synthroid
• No Health Insurance

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Case Study 5 Myrt

• 84 yo female 7/4/04 reaching to close trunk when
  struck by car, fell w/ pelvic fx.
• 3 weeks in nursing home
• Sister reports multiple falls
• c/o back pain, using quad cane, FWW
• PMHx nothing significant
• Meds Zetia, Multivitamin, Naproxyn