An Interdisciplinary Approach to the Falls Assessment

1. An Interdisciplinary Approach to the Falls Assessment Mary Russell, PT Ericka E. Tung, MD

2. Mr. Jones • 74 year old man • Past medical history • Hypertension • Depression • Hyperlipidemia • Presents to his primary care physician’s office for his annual check-up

3. Mr. Jones • In addition to his chronic disease maintenance issues, his doctor asks about falls in the past year • “I guess that I stumble once in a while…. but isn’t that normal for old guys like me?

4. Objectives • Understand risk factors that put older adults at risk for falls • Know how to screen older adults for falls and gait disorders • Understand the elements of a comprehensive falls assessment • Understand YOUR role in preventing falls in your community

5. Top Causes of Falls • “Accident”, tripping over something in the environment • Gait or balance disorder • Dizziness • Drop attack • Confusion • Postural Hypotension • Vision disorder • Unknown

6. Rarely due to a single cause May be due to the accumulated effect of impairments in multiple domains Complex interaction of: Intrinsic factors Extrinsic factors Behaviors (risk taking, etc.) Etiology of Falls

7. Intrinsic Factors Extrinsic Factors Medical conditions Sensory impairment Weakness & imbalance Age related changes Medications Improper use of assistive devices Environmental hazards Risk taking behavior FALLS

8. Multifactorial Risk Factor Assessment • Falls are multifactorial therefore the approach needs to be: • Holistic • Interdisciplinary • Practical • Evidence-based

9. Guidelines for Fall Prevention • Guideline for the Prevention of Falls in Older Persons • American Geriatrics Society • British Geriatrics Society • American Academy of Orthopaedic Surgeons • JAGS 49:664–672, 2001

10. JAGS 49:664–672, 2001

11. Screening • Who? • When? • Where? • What?

12. Screening Questions • Have you fallen in the past year? • How many times have you fallen in the past year? • Are you afraid of falling?

13. Yes… I did fall once at my home JAGS 49:664–672, 2001

14. Timed Up and Go Test: TUG • Directions: • Have patient sit in a standard armchair • Instruct the patient to fold their arms when risking from the chair • On the instruction “GO”, have the patient stand up, walk comfortably to a line 3 meters away, turn around and sit down again.

15. Timed Up and Go Test: TUG • Interpretation • Under 20 seconds: independence for basic transfers • 20-29: Intermediate probability for dependence in transfers • 30+: Unlikely to be able to climb stairs or go outside alone Diane Podsiadlo, BScPT, and Sandra Richardson, M.D. J Am Geriatric Soc 39:142-148,1991

16. Approach to the Individual with Multiple Falls • Comprehensive Falls Evaluation • Interdisciplinary approach is best • Social worker • Therapist • Physician • Nurse • Pharmacist

17. Recurrent Falls JAGS 49:664–672, 2001

18. Comprehensive Falls Evaluation Step 1: Take a good history • Circumstances • Frequency • Injuries

19. Comprehensive Falls Evaluation Step 2: Functional Status Assessment • Activities of Daily Living • Instrumental Activities of Daily Living • Current home health support system • Review of Risk Factors

20. Comprehensive Falls Evaluation Step 3: Medication Review • “High risk” medications • >4 medications • Potential strategies to combat polypharmacy

21. Comprehensive Falls Evaluation Step 4: Physical Examination • Orthostatic Blood Pressure • Cardiovascular system • Neurologic system • Visual acuity • Foot examination • Musculoskeletal system

22. But what about Mr. Jones? • At the office visit • Multiple falls • Risk factors were identified • Medications • Evening “night cap” • Orthostasis • Mild peripheral neuropathy • Prolonged TUG (30 seconds)

23. But what about Mr. Jones? • Now what?? • Action planning strategy • Multifactorial approach • Interdisciplinary approach • Importance of patient involvement

24. Creating an Individualized Intervention • Identify modifiable and non-modifiable risk factors • Target treatment plan toward these risk factors • Mr. Jones’ risk factors • High risk medication regimen • Lower extremity weakness, gait dysfunction • Risk taking behaviors • ? Home hazards

25. Physical Therapy Consultation • Location • Outpatient clinic • Patient’s home • SNF • Cost Issues

26. Physical Therapy Consultation • Start with THE 3 questions: • “Have you fallen in the past year?” • “How many times have you fallen in the past year?” • “Are you afraid of falling?

27. Balance and Strength • Assess strength and balance • Provide recommendations for long term exercise program for strength and balance • Gait training and appropriate use of assistive devices

28. Home Environment Assessment • Room by room; inside and outside • Clutter, cords, lighting, width of walk ways, and condition of flooring • Grab bars for bathroom, tub bench or shower chair, non skid tub surface, raised toilet seat • Night light in bedroom, phone and flash light next to bed • Frequently used items in kitchen should be within reach • Stairs both inside and outside should have adequate lighting and be free from clutter

33. Mr. Jones’ Individualized Intervention • Simplification of Medication Regimen • Counsel him about risk taking behaviors and alcohol use • New gait aid • Home modifications • Utilization of community exercise program

34. MNfallsprevention.org • Overview of the site • For the public • For health care professionals • Navigation • Tools

35. Assessment Tools • Types • Fall risk factor assessments • Focus on intrinsic risks • Typically performed by nursing staff in the hospital or NH setting • Functional assessment instruments • Focus on gait/balance • Typically performed by therapists, rehab specialists in the outpatient setting

36. Assessment Tools • Assessment tools • Pros • Cons • Limitations

37. Assessment Tools • Factors for consideration • Setting • Time limitations • Skill set of the professional • Sensitivity/Specificity

38. Interdisciplinary Team Approach • Role of the social service or public health professional • Screening • Risk factor identification • Preparing older adult for upcoming appointments • Inspection of living environment

39. Interdisciplinary Team Approach • Role of the primary care provider • History and physical examination • Identification of risk factors • Action planning • What is the patient actually willing to do? • Appropriate referrals

40. Interdisciplinary Team Approach • Role of the therapist • Physical therapist • Strengthening, balance, and gait training • Occupational therapist • Home modifications, cognitive assessment, compensatory strategies • Team approach • Coordination and continuum of care between all disciplines in all settings • Patient/Caregivers

41. Interdisciplinary Team Approach • Role of the skilled nursing facility professional • Staff training • Identification of modifiable risk factors • Target interventions • Bed alarms • Hip protectors • Environmental modifications

42. Questions