Falls Prevention & Management

1. Falls Prevention & Management Lecture 2 Jessie Morris MSc Fit For Life 28.3.14

2. Recap lecture 1 Knowledge on role of falls prevention with PT practice Understanding of Irish falls prevention strategy Knowledge on FOF and ax tools to assist in initial ax

3. PBL Lec 1 “What programme format is most appealing to senior centres?” “How can falls prevention be incorporated into clinical practice?” “What resources or tools are needed to help therapists incorporate falls risk assessment and referral into their clinical practices?”

4. Learning Outcomes Demonstrate and explain application of falls risk assessment Explain commonly used risk assessment tools for the practice of Physical Therapy Justify falls prevention strategies for the older person

5. Objectives To apply appropriate falls ax to client To know when to refer to allied HCP with certain risks To support pt with evidence based interventions for falls prevention

6. Cause of falls • Loose rugs • Unstable balance • Dizziness • Medication • Inactivity Clutter Improper shoes Muscle weakness Vision problems Dehydration

7. Lord et al 2008

8. Systems that affect balance Visual Vestibular Somatosensory Musculoskeletal Systems work together to prevent falls by controlling balance

9. Balance Visual: a response to light that tells us about the layout of the environment around us & the spatial relationship of objects in that environment. Vestibular: a response to movement that triggers sensors in the inner ear to tell us when we are moving or stationary, or when we are upright or reclining. Somatosensory: sensory feedback that tells us about our spatial location & movement of the body relative to the support surface and to each body part. Musculoskeletal: a complex system involving the body's muscles and skeleton, & including the joints, ligaments, tendons, and nerves.

10. With knowledge of the factors that affect these balance systems, we can: understand the causes of falling; help identify risk factors that can be modified; and help identify people at increased risk of falling.

11. Postural Stability ‘the ability of an individual to maintain the position of the body, or more specifically it’s centre of mass, within specific boundaries of space, referred to as stability limits’ Shumway- Cook & Woollacott 1995

12. What is Postural Stability? When demands on the body are greater than the person’s capability, a fall will occur. Postural stability is the ability of a person to control the position and action of their body against the demands put upon it.

13. Risk Factors • Broadly classified into 3 categories • Intrinsic • Extrinsic • Exposure to risk Combination of risks – not single risk Age increases risk

14. Psychological risk factors FOF Attentional limitations Cognitive impairment Depression Associated with impaired stability and risk of falls. FOF and CI age related – more prevalent

15. Sensory & NeuromuscularRisk Factors • Reaction Time • Simple • choice • Vision • Visual acuity • - contrast sensitivity • - depth perception • glare sensitivity • - dark adaptation • Vestibular function • Caloric testing • -rotational testing • - optical testing • - vestibulospinal reflexes • Muscular strength. Power & endurance • Knee fx • Knee ext • Ankle dorsifx • Peripheral sensation • Tactile sensitivity • -vibration sense • -propioception

16. Vision Acuity -  with age (Snellen scale) Contrast sensitivity – higher sensitivity to acuity (Lord et al 1994) (Melbourne Edge Test) Depth perception - sig risk factor Glare sensitivity Dark adaptation

17. Muscular Strength Power & Endurance 14% of women over 75 yr – calf muscle not able to exert sufficient force to support body weight (Pearson et al 1985) Community studies  knee ext strength & ankle dorsiflexion strength , risk of falls &  knee extension strength  risk of hip # (Lord et al 1994)

18. Peripheral sensation Age related decline in vibration sense, tactile sensitivity & propioception Decline associated with increased falls risk

19. Reaction Time Independent risk factor Fallers significantly slower than non-fallers in complex motor tasks (choice reaction) Sensorimotor factors that contribute to balance show age-related declines. Modifiable........

20. Medical Conditions Vision impairments Parkinson’s Disease Stroke Alz’s and related dementias Diabetes CVD Foot disorders

21. Medications Sedatives/hypnotics including Benzodiazepines Antidepressants Anticonvulsants Antipsychotic Antihypertensives Polypharmacy (4+) and central acting meds = increase falls risk

22. Meds side effects: Postural hypotension Reduced balance Confusion Gait disorders Drowsiness Withdrawal syndromes Dehydration As we age, the way some medications affect us can change and increase the risk of falling. Meds can interact with another and change the way they work. – MED REVIEW

24. Falls Risk Ax – multifactorial a hx of fall circumstances and medical problems review of medications mobility assessment an examination of vision, gait and balance, and lower extremity joint function a basic neurological examination testing of psychological and mental status Assessment of: cardiovascular status foot problems and footwear continence environmental risk factors or home hazards. MTD approach to risk ax

25. Risk Ax Physical Therapist • Functional • BERG • EMS • Functional Reach • TUG • 2min step test • 6min walk • 5xSTS • Sits and reach • Psychological - FOF • FES • iConFes • ABC • ConfBal • Gait • DGI • POMA • Aids/appliances • Posture/Pressure • Braden Scale • Waterlow Scale

26. Best practice Intervention Common interventions = exercise as a single & multifactorial intervention Interventions that reduced RATE of falls: Multiple-component group exercise Multiple-component home-based exercise Tai Chi Home safety assessment & modification Gradual withdrawal of psychotropic medication

27. Best practice Intervention Interventions that reduced RISK of falls: Tai Chi Exercise intervention (risk of #) AUTHOUR CONCLUSION: Group and home-based exercise programmes, and home safety interventions reduce rate of falls and risk of falling. Multifactorial assessment and intervention programmes reduce rate of falls but not risk of falling; Tai Chi reduces risk of falling. Overall, vitamin D supplementation does not appear to reduce falls but may be effective in people who have lower vitamin D levels before treatment. Cochrane review - Interventions for preventing falls in older people living in the community (Review)

28. Exercise Intervention Clear evidence that falls in older people can be prevented with appropriately designed intervention programmes. 42% of falls can be prevented by well-designed exercise programmes & exercises with the biggest effect on fall rates involved a challenge to balance abilities and were undertaken frequently (e.g. for more than 2 hours a week over a 6-month period). Sherrington et al 2008.

29. Recommendations • Exercise must provide a moderate or high challenge to balance • Reduce BOS • COG movement • Reduce need for UL support • Must be of a sufficient dose to have an effect – 2 hrs/week • Ongoing is necessary • Falls prevention exercise should be targeted at the general community as well as those at high risk for falls

30. Recommendations Falls prevention exercise may be undertaken in a group or home-based setting Walking training may be included in addition to balance training but high risk individuals should not be prescribed brisk walking programmes Strength training may be included in addition to balance training Exercise providers should make referrals for other risk factors to be addressed Sherrington et al 2008

31. OTAGO

36. Physical Therapist Role in Falls Management • 1st step - Awareness – assist pt to see and know of services available – importance of risk awareness • 2nd step – Screening – falls risk ax tools by PT (HCP) Need to screen and see if at risk – then they need further ax to establish risk factors that are modifiable and interventions can be applied to reduce risk • 3rd step – Falls Risk Ax by PT and referral to falls risk ax services. • to identify modifiable risk factors, • to target and tailor interventions , • to implement falls & injury risk management strategies for individuals identified with high risk of fall.

37. References Shumway –Cook, A. & Woollacorr, M. Motor Control: Theory and Practical Application (Baltimore: Williams and Wilkins, 1995) Lord, S., Sherrington, C., Menz, H., Close, J. 2008 Falls in Older People – Risk Factors and Strategies to Prevention (2nd edition) Cambridge. Lord, S.R., Ward, J.A., Williams, P & Anstey, K. Physiological factors associated with falls in older community dwelling women. Journal of the American Geriatrics Society, 42 (1994) , 1110/17. Pearson, M.B., Bassey, E.J.& Bendall, M.J. Muscle strength and anthropometric indices in elderly men and women. Age and Ageing, 14 (1985), 49-54

38. References American Academy of Orthopaedic Surgeons Panel on Falls Prevention. Guideline for the prevention of falls in older persons. J Am Geriatr Soc 2001;49:664–672. Rubenstein LZ, Powers CM, MacLean CH. Quality indicators for the management and prevention of falls and mobility problems in vulnerable elders. Ann Intern Med 2001;135:686–693. Sherrington C, Whitney JC, Lord SR, Herbert RD, Cumming RG, Close JC. Effective exercise for the prevention of falls: a systematic review and meta-analysis. J Am Geriatr Soc 2008; 56(12): 2234–43.

39. References Barry M. Drug expenditure in Ireland 1991–2001. Ir Med J 2002; 95: 294–5.