Prevention, Assessment and Intervention for Falls in Adults with Developmental Disabilities

1. Prevention, Assessment and Intervention for Falls in Adults with Developmental Disabilities Victoria Lamb, SDPT Doctor of Physical Therapy Student Duke University Georgetown University Health Resources Partnership

2. Objectives • Identify 3 common risk factors for falls. • Participate in falls risk assessment. • Name at least two fall assessment tools. • Contribute to the development of DC HRP falls risk pamphlet.

3. Developmental Disability • Developmental disability (DD) is a term used to describe • severe • life-long disabilities • attributable to mental and/or physical impairments • before the age of 22. • Common developmental disabilities: • Cerebral Palsy • Down Syndrome • Mental Retardation • Autism • More Information • http://en.wikipedia.org/wiki/Developmental_disability

4. Developmental Disability Can Result in… • substantial functional limitations in two or more of the following areas of major life activities: • self-care • receptive and expressive language development and use • learning • mobility • self direction • capacity for independent living or economic self-sufficiency http://ddrb.org/about/index.html

5. What is a Fall? An event which results: • In a person coming to rest • Non-purposely to the ground or other lower level and • Is not the result of the following: Sustaining a violent blow, loss of consciousness; sudden onset of paralysis, as in a stroke; or an epileptic seizure (Kellogg International Working Group)

6. Who Falls • 1/3 of older adults living in the community (>65 y.o.) fall each year. • Men are more likely to die from a fall. • Women are more likely to have nonfatal fall injuries. • Rates of fall-related fractures among older adults are more than twice as high for women as for men (Stevens et al. 2005).

7. Consequences of Falls • Death • Injuries • i.e. hip fractures • Hospitalization • Traumatic Brain Injury

8. What about falls and developmental disabilities? • Individuals with moderate and profound intellectual disability (ID) were at a higher risk for injury than those with mild or severe ID (Spreat & Baker-Potts, 1983). • Higher fracture rates for residents of an intermediate care facility for people with mental retardation than the general US population (Tannenbaum et al., 1989).

9. So…. • There is a significant lack of knowledge of falls in adults with DD. • Less evidence on assessment, intervention and prevention for people with DD. • Falls are a significant health risk. • Therefore, we must be PROACTIVE vs. reactive!

10. Common Risk Factors • Seizures, behavior and medications • History of Falls • Muscle Weakness • Gait Deficit • Balance Deficit • Use of Assistive Device • Visual Deficit

11. 1. Research focusing on people with developmental disabilities • Seizures • i.e. seizures on a monthly basis→4x at risk for falls • Destructive behavior • Antipsychotic medications

12. 2. History of Falls • There are two important things to consider when someone previously suffered a fall: 1. Predisposition 2. Previous Fall

13. Therefore, we need… • Documentation • Tracking method • Periodical check-up

14. Signs of a Fall • Fracture • Bruising • Soreness • Limping • Inactivity Any others?

15. Decrease strength can lead to inability to support ones self when changing positions. Going to the bathroom Getting out of bed Signs of muscle weakness Unable to stand without help Noticeable muscle atrophy and/or wasting Poor breathing Poor body posture Pressure ulcers 3. Muscle Weakness

16. 4. Walking Difficulties • Compromises stability and balance and leads to increase risk for falls. • Common developmental disabilities that affect walking: • Cerebral Palsy • Down’s Syndrome • Mental Retardation • Autism

17. Common Walking Problems • Scissoring gait • Walking on toes • Inability for leg to clear the floor • Hip drop • Shuffling

18. Dynamic Gait Index Profile • Clinical measurement of walking function in people with balance and vestibular disorders. • 8 item or 4 item (short form) test

19. Gait Video Assessment • Profile: 25 y.o. male with autism • Walking Assessment: • What do you see? • What do you think are his impairments and functional limitations? • Compare his walking on the track vs. the pool deck?

20. 5. Balance Deficit • Decrease balance reduces stability and makes it difficult to recover from sudden disturbances. • Balance can be impaired in many ways: • Ear infections • Vision deficits • Poor body movement

21. Balance Assessments • Balance Berg Scale • Tinetti • Timed Up and Go (TUG)

22. Balance Berg Scale • Scale used to identify balance impairment in the older adults. • Consist of 14 tasks that are scored on a 0-4 scale. • Predictive: A score <45 was predictive of multiple falls. • Estimated time to complete: 15-20

23. Tinetti • Measures gait and balance. • Scoring done on a three point ordinal scale (0 to 2). • Maximum gait score: 12 • Maximum balance score: 16 • Time to complete: 10-15 minutes • Interpretation: • < 19 high risk • 19-24 at risk for falls.

24. The Timed Up & Go Test (TUG) • To identify and screen older individuals who are prone to falls. • Tested in 3 different conditions: (alone, manual, and cognitive) • Predictive: TUG (alone) is 13.5s; TUG (manual) is 14.5s; TUG (cognitive) is 15s.

25. 6. Use of Assistive Device • Assistive Devices become a risk factor for falls when there is: • Improper use • Faulty mechanics • Household obstacles and floor coverings • Broken or faulty equipment • Solutions: proper equipment, education and home modifications

26. 7. Visual Deficit • For those of us who wear glasses or contacts, how great is our vision when we removed those things from eyes? • Vision deficits can affect: • depth perception with stairs • inability to detect subtle changes in ground elevations • difficulty seeing potential obstacles

27. Signs of Visual Deficits • Red eyes • Squinting • Inability to read signs and/or identify objects near or far away. • Delay or avoidance of task • Increased tearing and watering of the eye • http://www.aoa.org/documents/QRG-20.pdf

28. Breakout Session • Each table has been given a test or measure. • Each person should try to perform at least one task or skill on the test. • Record your scores and assess your ability. • Be able to discuss: • How well you think this test could accurately assess individuals with Developmental Disabilities? • What did you like and dislike about the test? • What do you think should be added to the test or measure?

29. Test and Measure Table (Give Handouts)

30. Interventions • Interventions should be: • Comprehensive • Performed by trained individuals • Accessible to those who need it

31. Comprehensive Interventions • Home modification • Exercise • Balance • Strength • Aerobics • Education • Medical Intervention

32. 1. Home Modifications Should address: • Wet, slippery surfaces • Uneven, cluttered surfaces • Unexpected obstacles • Stairs and curbs • Improper or inadequate lighting, or sudden changes in lighting • Footwear • Poorly fitted assistive devices for walking Birge, 1993

33. 2. Exercise • Have been shown to improve function • Target: • Balance • Strength • Aerobic endurance

34. Exercise Cont’d. • Balance training produced functional improvement for older adults with ID (Carmeli et al, 2004). • Participation in low-impact aerobic dance program increased the cardiovascular endurance of adults with ID.

35. 3. Education Should include education on the following: • Proper use of assistive device • Falls prevention • What to do in the event of a fall

36. Physicians Nurses Physical Therapists Occupational Therapists Psychologists Family Caregivers Who could be involved?

37. Transferring Tips

38. Transfers • Transfers: Involve moving a person from one place to another location. • Can include, but is not limited to: • bed wheelchair • wheelchair chair • chair toilet • chair car seat

39. Key Tips • Equipment locked • Establish clear path • Get close to where you are going • Keep your back straight (use your legs!) • Establish a wide base of support • Get close to the person (you should move as one unit!) • Avoid twisting motions as much as possible (pivot instead) • Do NOT grab on the person’s clothing and do NOT have them grab onto your clothes as leverage.

40. Key Tips Cont’d. • If possible have person relax their arms over your shoulder (NOT AROUND NECK) • Give a count (1-2-3-move) • REQUEST HELP IF YOU NEED IT!

41. Let’s Practice!

42. What IF Someone Falls? • Asses the environment • Make sure it’s safe to help • If a person has suffered a serious fall, DO NOT MOVE THEM, CALL 911.

43. Getting Up From a Fall • Can be done: • Independently • With the assistance of 1 or more persons • With the assistance of sturdy support • Let’s practice: • Safe ways to get up from a fall • How 1 or more people can safely and properly provide assistance.

44. Coming Soon • DC HRP Falls Risk Algorithm • DC HRP Transfer Video • American Physical Therapy Association (APTA) pocket guide to falls risks assessment, intervention and prevention.

46. Additional Resources • http://www.neuropt.org/csm07/13957.pdf • Falls: The assessment and prevention of falls in older people. (Developed by the National Collaborating Centre for Nursing and Supportive Care) • http://www.cdc.gov/ncipc/factsheets/adultfalls.htm • http://www.aoa.org/documents/QRG-20.pdf

47. THANK YOU! Contact Info: www.dchrp.info VRL2@DUKE.EDU