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Title: FALLS IN THE ELDERLY Author: donna Last modified by: Vania L. Yu Created Date: 1/10/2007 12:55:17 PM Document presentation format: On-screen Show – PowerPoint PPT presentation

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  • Vania L. Yu, MD

  • 25 at 70 years of age
  • 35 after 75 years of age
  • 40 after 80 years of age
  • Women fall twice as much as men until the age of
    75 after which the frequency equalizes.
  • Institutionalized elderly fall more often than
    community elderly.

  • One third of elderly who live at home have at
    least one fall a year.
  • Falls and its sequela are the fifth most common
    cause of death among the aged.
  • The most-feared consequence of a fall is a broken
  • Less than 5 of falls among older adults lead to
    a bone fracture.

Common Types Of Fracture From A Fall
  1. Hip
  2. Wrist
  3. Upper arm
  4. Pelvis

  • A fall is an event which leads to the conscious
    subject coming to rest inadvertently on the
    ground. (J. Miller)
  • regardless of whether an injury was sustained.
    (J. Jensen)

Classification of Injuries( Abbreviated
Injury Scale )
  1. MINOR - superficial wounds and bruises
  2. MODERATE - intermediate injuries such as
    vertebral and wrist fractures
  3. SERIOUS - major fractures such as hip and femur

3 Stages of Falling( WC Hayes )
  1. Fall initiation
  2. Fall descent
  3. Fall impact

Main Reasons forHigh Incidence of Falls in
The Elderly( J. Sheldon )
  1. Increased liability to trip over trivial objects
  2. Difficulty in maintaining erect posture once
    balance is disturbed
  3. Susceptibility to a sudden collapse of the
    postural controlling mechanism leading to a drop

  • Sudden loss of muscular tone without loss of
  • (Kremer, Sheldon, Clark)
  • Pressure exerted on the soles of the feet appears
    to restore neurologic integrity.
  • (Sheldon)

Sensory Systems that Control Posture
  1. Vestibular
  2. Visual
  3. Somatosensory

Risk Factors For Falls
  • Extrinsic (environment)
  • Physical environment
  • Visual environment
  • Intrinsic (individual)
  • Age
  • Cardiovascular disorders (orthostatic
  • Neurologic disorders (dementia, stroke,
  • Metabolic derangements (hyponatremia,
  • Musculoskeletal deficits (gait abnormalities)
  • Medication (sedatives, psychotropic drugs,
    alcohol intake)

Most Important Intrinsic Predictors for
Falls(AM Tromp)
  1. Decreased mobility
  2. Cognitive impairment
  3. Medication use
  4. Depression
  5. Urinary incontinence
  6. Stroke
  7. Postural hypotension
  8. Dizziness
  9. Fear of falling
  10. Impaired vision
  11. History of previous falls

Predictors Significantly Associated with
Recurrent Falls(AM Tromp)
  1. Previous falls
  2. Urinary incontinence
  3. Visual impairment
  4. Functional limitation

Types Of Falls(H Wieman)
  1. Slips and trips
  2. Falls while attempting a difficult maneuver
  3. Syncope LOC precedes falls
  4. Seizure LOC accompanies falls
  5. Drop attack no LOC
  6. Vertigo
  7. Sliding off furniture

Psychosocial Manifestations of Fall
  1. Anxiety
  2. Loss of consciousness
  3. Social withdrawal
  4. Restrictions in ADLs
  5. Postfall syndrome
  6. Fallaphobia
  7. Loss of independence and control
  8. Depression
  9. Feelings of vulnerability and fragility
  10. Concerns regarding death and dying

  • Inability to stand or walk unsupported in the
    absence of any neurological or orthopedic
    abnormalities that would influence gait and
    balance (clutch and grab).
  • Fearful anticipation of a fall.

Common Environmental Hazards
  1. Poorly designed or unstable furniture
  2. Floor surfaces
  3. Inadequate lighting
  4. General clutter
  5. Pets in the house
  6. Electrical cords
  7. Loose or uneven stair treads

General Management of Falls in The Elderly
  • Primary prevention
  • minimize the risk of falling among elderly
    people and prevent a fall.
  • Secondary prevention prevent the elderly person
    from having another fall.

Complications of Fall Related to Immobility
  1. Dehydration
  2. Bronchial pneumonia
  3. Contractures
  4. Constipation
  5. Decubitus ulcers
  6. Hypothermia
  7. Iatrogenic complications
  8. Disability
  9. Institutionalization
  10. Loss of independence

  1. Fall History
  2. Medication History
  3. Mental Status
  4. Cardiovascular and neurological functions
  5. Mobility and balance

Position Changes, Balance Maneuvers and Gait
Components in Functional Mobility Assessment (ME
Tinetti and SF Ginter)
  1. Position change or balance maneuver

Get up from chair Does not get up with single movement
Sitting down in chair Plops down
Withstanding nudge on sternum Moves feet, grabs for support
Eyes closed ditto
Neck turning ditto plus dizziness
Reaching up Unable to reach to full shoulder flexion while on tiptoe, grabs for support
Bending over Unable to bend over to pick up objects from floor, grabs object to pull up on, multiple attempts to arise
  1. Gait component or maneuver

Initiation Hesitates, stumbles, grabs object for support
Step height Does not clear floor consistently or raises foot too high ( gt 2 inches )
Step continuity After first few steps, does not consistently begin raising one foot as other foot touches floor
Step symmetry Unequal step length
Path deviation Does not walk in straight line, weaves from side to side
Turning Stops before initiating turn, staggers, sways, grabs object for support
Feasibility Measurement Properties of the
Functional Reach the Timed Up Go Tests in the
Canadian Study of Health AgingK Rockwood et
alJ of Gerontology Feb 2000
  • Problems in gait and balance may lead to an
    individuals inability to meet the daily
    requirements of life.
  • Physical performance measures was seen to meet
    problems inherent in self report, such as errors
    in memory or judgment.

  • The Functional Reach (FR) is a simple measure of
    standing balance, which correlates well with
    traditional measures of balance and is a
    predictor of falls in elderly people.
  • (PW Duncan)
  • The Timed Up and Go (TUG) is a measure of
    self-selected gait speed, balance and function,
    and is predictive of nursing home placement.
  • (T Nikolaus)

  • The TUG is conducted using a standard kitchen
    chair with no armrests. The interviewer stands 3
    meters away (10 feet) and times the subject
    (secs) as they rose from the chair, walked the 3
    meters to the interviewer, turned, walked back
    and sat down again.
  • Three trials are allowed with the shortest timed
    trial (best performance) as the final score.

  • For the FR, a leveled measuring device is mounted
    on the wall at shoulder height. The subject
    holds his arm out straight at shoulder height to
    establish normal reach, and then asked to reach
    as far as possible without taking a step, in a
    plane parallel with the measuring device. The
    reach distance is recorded.
  • Three trials are allowed, with the farthest
    reach recorded as the final score.

  • 2,305 community-dwelling elderly people of Canada
    were surveyed for cognitive impairment, followed
    by the TUG and FR during the clinical
  • Comparative measures were used to validate the
    results (Frailty Scale, Cumulative Illness Rating
    Scale, Activities of Daily Living and Older
    Americans Resources and Services Instrumental

  1. The TUG and FR tests are not feasible in a survey
  2. The tests are more feasible when administered to
    a cognitively intact subject.
  3. Moderate correlation of FR and TUG with ADLs and
  4. There is still a role for self-reported measures.

Validity of the Multi-Directional Reach Test A
Practical Measure for Limits of Stability
in Older AdultsR Newton et alJ of Gerontology
Apr 2001
  • Daily activities require shifting the center of
    gravity (COG) within the base of support (BOS).
    Once the COG moves outside the BOS, the limits of
    stability (LOS) are exceeded.
  • Falls occur not only in the forward direction,
    but also to the side and backward.
  • The Multi-Directional Reach Test (MDRT) measures
    the LOS in four directions.

  • A yardstick affixed to a telescoping tripod is
    placed at the subjects acromion process level.
    Subject lifts an outstretched arm to shoulder
    height and an initial reading is done. He then
    reaches as far forward as possible without moving
    his feet. For the backward direction, subject
    leans as far back as possible. The start and end
    positions of the index finger is recorded and the
    difference represents the total reach for that
    direction. Left and right reaches were recorded
    using the respective arm. Two trials were
    recorded in each direction.

  • 254 community-dwelling older persons were
    administered the Berg Balance Test (BBT), TUG and
  • BBT assesses performance on 14 routinely
    performed activities. A 0-4 point rating system
    is used for each task with a maximum score of 56.
    Customary assistive device was permitted during
    the TUG test.
  • Pearson correlation statistics were used to
    compare scores on the MDRT to scores of the BBT
    and TUG.

  1. Sitting to standing
  2. Standing unsupported
  3. Sitting unsupported
  4. Standing to sitting
  5. Transfers
  6. Standing with eyes closed
  7. Standing with feet together
  8. Reaching forward with outstretched arm
  1. Retrieving object from floor
  2. Turning to look behind
  3. Turning 360 degrees
  4. Placing alternate foot on stool
  5. Standing with one foot in front
  6. Standing on one foot

  1. MDRT scores demonstrated a positive relationship
    with BBT scores.
  2. MDRT scores demonstrated an inverse relationship
    with TUG scores.
  3. MDRT is a valid and reliable clinical measure for
    limits of stability.

Long-term Home Exercise Program Effect in
Women atHigh Risk of FractureK
Kerschan-Schindl et alArch Phys Med Rehab Mar
  • Falling is a manifestation of failure of the
    neuromuscular system in the elderly.
  • Measurements of balance are strong predictors of
    falling in the elderly, while poor performance on
    neuromuscular function testing was associated
    with an increased risk of hip fracture.
  • Neuromuscular deficits are associate with an
    increased likelihood of falling.

Neuromuscular Tests
  • One leg stance
  • standing on one leg with eyes open, repeated
    three times for each leg, alternating from left
    to right. Test is timed, stopped after 30 secs.
  • Chair rise
  • arms folded across chest, stand up and sit down
    five times in a row, from a straight-backed chair
    as quickly as possible. Time is recorded.
  • Tandem walk
  • 2 meter line, 5 cm wide walk. In addition to
    time, number of errors are also counted.

  • Body sway
  • 40 cm rod extending anteriorly is attached to
    subjects waist level. A pen is fixed at end of
    this rod. Subject stands in front of table where
    a paper with a convoluted track is placed.
    Subjects are to trace the track with the pen.
    Number of errors are recorded.
  • Tapping test
  • Tests coordination of the upper extremities. Two
    electrostatic contact sensors are fixed, 50 cm
    from each other. Subject asked to tap the
    sensors alternately as quickly as possible. Time
    needed for 20 tap cycles is registered.

  1. Correct causes of fall
  2. Exercise
  3. Education on home safety

Fall and Injury Preventionin Older
PeopleLiving in Residential Care
FacilitiesJ Jensen et alAnnals of Internal
Medicine May 2002
  • An intervention program that targeted multiple
    risk factors for falls in older people living in
    residential care facilities would reduce falls
    and fall related injuries.
  • 439 subjects, 65 years and older, living in 9
    residential care facilities in Sweden. Study
    design is cluster randomized, controlled,
    nonblinded trial. Subjects divided into control
    and intervention groups.

  • 11 week multidisciplinary program that targeted
    general and resident-specific risk factors for
  • 34 weeks follow-up of residents.
  • Staff education on risk factors for falls and
    intervention strategies.
  • Environmental modification.
  • Exercise for strength, balance, gait and safe

  1. Supply or repair of mobility aids, including
    walkers, wheelchairs and footwear.
  2. Change in medication
  3. Provision of hip protectors
  4. Post-fall problem-solving conferences
  5. Staff guidance

  • Number of residents sustaining a fall
  • Number of falls
  • Time of occurrence of the first fall
  • Number of injuries resulting from falls

  1. 44 of intervention group had a fall vs 56 of
    control group.
  2. 26 of intervention group sustained more than one
    fall vs 33 in the control group.
  3. Incidence of falls was 6.7 / 1000 person days in
    the intervention group vs 8.3 / 1000 days in the
    control group.
  4. Time to first fall was longer for the
    intervention group than the control group.
  5. 1.6 of the intervention group had a femoral
    fracture vs 6.1 in the control group.

  • An interdisciplinary, multifactorial fall
    prevention program that avoids the use of
    physical restraints and that targets older
    people, staff and residential care environment
    may reduce the number of residents who fall, the
    total number of falls and femoral fractures.

Randomized Factorial Trial of Falls Prevention
among Older People Living in their Own HomesL
Day et alBMJ July 2002
  • 1,090 Australians, aged 70 and over were divided
    into three intervention groups (group based
    exercise, home hazard management and vision
    improvement). Design is randomized controlled
    with full factorial trial.
  • Main outcome measure is time to first fall
    ascertained by an 18 month falls calendar.
    Participants reported falls using a monthly
    postcard calendar system.

  • Group based exercises
  • weekly one hour exercise class for 15 weeks
  • Home hazards
  • home hazards removed or modified by participants
    or a professional home maintenance group
  • Vision
  • participants vision were tested then treatment

  1. Group based exercise was the most potent single
    intervention tested, with a reduction in falls.
  2. Effects of the interventions were additive.

Exercise Training for Rehabilitation Secondary
Prevention of Falls in Geriatric Patients with a
History of Injurious FallsK Hauer et alJ Am
Geriatric Society Jan 2001
  • 57 female geriatric patients admitted in acute
    care or inpatient rehabilitation with history of
  • Intervention included ambulatory strength
    training, functional performance and balance
    training 3x/week for 3 months.
  • Patients were measured for strength, functional
    ability, motor function, psychological parameters
    and fall rates at the start, end, and 3 months
    post intervention

  • Strength training
  • resistance at 70-90 of maximum workload. Load
    is increased at each training session.
  • Each session lasting 1.5 hours.
  • Progressive functional-balance training
  • performed in static and dynamic positions. (Ball
    throwing and catching, group games, basic dance,
    tai chi).
  • Each session lasting 45 minutes.

Physical Function Measurements
  1. Maximal gait speed over 15 meter course
  2. Stair climbing performance
  3. Ability to rise from a standard chair
  4. Maximal step height with a stepping platform
  5. Timed up and go test
  6. Functional Reach test
  7. Balance performance in 5 positions (feet apart,
    feet parallel side by side, semi-tandem, tandem,
    one leg stance left and right under different
    conditions eyes open with and without front
    outstretched hands eyes closed with and without
    front outstretched hands).

  • Patients in the intervention group increased
    strength, functional motor performance and
    balance significantly.
  • Fall related behavioral and emotional
    restrictions were also reduced significantly.

A Focused Exercise Regimen Improves Clinical
Measures of Balance in Patients with Peripheral
NeuropathyJ Richardson et alArch Phys Med Rehab
Feb 2001
  • Peripheral neuropathy is common among older
    persons, particularly those with diabetes
  • Older persons with PN are less able to perceive
    ground irregularities and subtle shifts in their
    center of mass, thus predisposing to falls.
  • Improved balance can be manifested by increased
    functional reach, increased tandem and unipedal
    stance times.

  1. 2 groups of 10 subjects, 50-80 years age range,
    with PN.
  2. Intervention group underwent 3 weeks of specific
    exercise regimen.
  3. Control group underwent 3 weeks of standard
    strength training exercises in a seated position.
  4. All subjects underwent 3 trials of tandem stance,
    functional reach and unipedal stance before and
    after the exercise programs.

Intervention Exercises
  • Warm up
  • open chain AROM ankle exercises
  • Bipedal toe raises and heel raises
  • 3 sets of 10 reps
  • Bipedal inversion and eversion
  • closed-chain ankle inversion and eversion, to
    shift center of mass laterally
  • Unipedal toe raises and heel raises
  • 2 sets of 10 reps
  • Unipedal inversion and eversion
  • Wall slides
  • bipedal slides initially with knee flexion
    maximum of 45 degrees.
  • Unipedal slides by the 6th session.
  • Unipedal balance for time

  1. Intervention subjects showed significant
    improvement in all 3 clinical measures of
  2. Impairment in unipedal stance and functional
    reach have been associated with injurious falls.

Tai Chi Improves Standing Balance Control under
Reduced or Conflicting Sensory ConditionsW Tsang
et alArch Phys Med Rehab Jan 2004
  • Tai Chi emphasized strength, balance, flexibility
    and speed as a martial art. Present form with
    slow and deliberate movements.
  • 20 elderly tai chi practitioners (mean 7 years
    experience) were compared with 20 elderly non-tai
    chi practitioners and 20 young healthy university

  • Amplitude of anteroposterior body sway under
    different somatosensory visual and vestibular
    conditions was measured using a computerized
    dynamic posturography. Subjects underwent 6
    combinations of visual and support surface

  1. Non-Tai Chi practitioners exhibited more sway and
    significantly lower visual and vestibular ratios
    than the young subjects.
  2. Tai Chi practitioners swayed significantly less
    and achieved significantly higher visual and
    vestibular ratios than non-Tai Chi practitioners.
  3. Elderly Tai Chi practitioners achieved the same
    level of balance performance as young healthy

  1. Tai Chi requires constant shifting between
    double-stance and single stance.
  2. Many Tai Chi forms require to focus eyes on hand
    movements through head and/or trunk rotation.
  3. Tai Chi involves head movements that will
    stimulate the vestibular system.

A Prehabilitation Program for Physically Frail
Community-living Older PersonsT Gill et alArch
Phys Med Rehab March 2003
  • Preventive, home-based, physical therapy program.
  • Key features
  • Home-based.
  • Targets older persons at high risk for functional
  • Defines high risk as having impairments in
    physical capability.
  • Links assessment of risk with an
    individually-tailored intervention.
  • Automates the linkage between identified
    impairments and recommended interventions.
  • Uses special procedures to enhance adherence to
    the intervention.

Principles of PREHAB program6 months training
  1. Program identifies and ameliorates impairment in
    mobility and other ADLs.
  2. Assessment protocol identifies interventions
    relevant for individual participants.
  3. Intervention protocol tailored to combination of
    co-morbidities, contraindications and personal
    preferences of individuals, involving
    instructions by therapist on training and
  4. Training and exercise program is safe for frail
    older persons, should not include equipment that
    is not feasible for home-based therapy.

Advantages of home-based program
  1. Strong relation between environment and function.
    Disability is a gap between personal capacity
    and environment demand.
  2. Home-based program more appealing to the target
  3. Easily incorporated into home-care services

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