GER I ATR I C

1. GERIATRIC GERIATRIC FALL AND FUNCTIONAL ASSESSMENT

2. Falls • Falls are a major cause of morbidity and mortality in persons older than 65. • Approximately two thirdsof injury-related deaths are due to falls. • The rateincreases with advancing age. • Major morbidity from falls includes hip and other fractures and serious soft tissue injuries that require immobilization or hospitalization.

3. Fall Sequelae • A single fall often results in a fear of fallingloss of confidence to perform ADL restriction in activities + social isolation + increased dependence on others. •  Deconditioning joint stiffness + muscle weakness more falls and further immobility.

4. Risk Factor • Identification of significant risk factors is an important step toward fall prevention. • Risk factors associated with falls • Intrinsic. • Extrinsic(environmental). • Most falls are multifactorial, the result of multiple intrinsic and extrinsic.

5. Intrinsic/Physiological Factors • Age: incidence of falls increases with age. • Sensory changes. • Reduced vision, hearing, cutaneousproprioceptive, and vestibular function. • Altered sensory organization for balance. • Increased dependence on support surface somatosensory inputs. • Musculoskeletal changes. • Weakness. • Decreased range of motion. • Altered postural synergies. • Neuromotorchanges. • Dizziness, vertigo common. • Timing and control problems: impaired reaction and movement times (slowed onset).

6. Intrinsic/Physiological Factors • Cardiovascular changes. • Orthostatic hypotension. • Hyperventilation, coughing, arrhythmias. • Drugs. • Psychotropic agents. • Cardiovascular agents • Peripheral vasodilation. • Conflicting evidence linking analgesics, hypoglycemics.

7. Intrinsic/psychosocial factors. • Mental status/cognitive impairment. • Depression. • Denial of aging. • Fear of falling: associated with self-imposed activity restriction. • Relocation (moving out to new location).

8. Extrinsic/environmental factors • Setting (changing location): three times as many falls for institutionalized or hospitalized elderly than for community dwelling. • Consider ground surfaces(even/uneven), poor lighting of doors or doorways, stairs. Slippery surface, and obstacles. • At home, most falls occur in bedroom (42%); bathroom (34%).

9. Activity-related risk factors • Most falls occur during normal daily activity: • getting up from bed/chair, turning head/body, bending, walking, climbing/descending stairs. • Clearly hazardous activities, e.g. climbing on ladder. • Improper use of assistive device: e.g. walker, cane, wheelchair.

10. Fall assessment approach • Studenski suggests four approaches for assessing the falling syndrome in the geriatric patient: • Ecological • Biomedical • Physiological • Functional

11. Ecological • The ecological approach focuses the interaction between the patient and the environment. • Presence of an unusual environment, e.g., Icy surface. • Negotiate an uneven pathway in unfamiliar territory. • Fall while walking in his home (sever impairment). • This approach allows the examiner to assess the contribution and potential modification of environmental factors in fall events.

12. Biomedical • The biomedical component of the assessment focuses on medical events that are potentially contributory to falls. • Identify the diseases that result in instability: • Acute (sudden fall or increase frequency). • electrolyte abnormalities, infections, drug side effects, dehydration, orthostatic hypotension, blood loss, and hypoxemia. • Chronic. • cardiovascular conditions • include arrhythmias, aortic stenosis, and carotid sinus sensitivity. • Neuromuscular diseases such • CVA, seizures, Parkinson’s disease, …… • this approach is useful for identifying treatable disease components of the falls syndrome.

13. Physiological • Identification of deficits in postural control that contribute to instability. • Components of the postural control system that are assessed include: • Sensory system • Effector (strength, range of motion, biomechanical align­ment, flexibility) • Central processing.

14. Functional • Identify important routine movements with which the patient has difficulty. • These movements represent the deficit of postural control system.

15. Careful assessment includes • Accurate fall history: location, activity, time, symptoms; previous falls. • Physical examination of patient: cognitive, sensory, neuromuscular, cardiopulmonary. • Standardized tests and measures for functional balance and instability: • Performance-Oriented Mobility Assess­ment, POMA (Tinetti). • (Get Up and Go Test, GUG (Mathias, Nayak & Isaacs); timed GUG (Podsiadlo). • Functional Reach, FR (Duncan). • The Balance Scale (Berg). • Dynamic Gait Index (Shumway-Cook).

16. Goals • (1) Eliminate or minimize all fall risk factors; stabilize disease states, medications. • (2) Improve functional mobility. • (3) Provide exercise to increase strength, flexibility. • (4) Provide sensory compensation strategies. • (5) Balance and gait training.

17. PT Role • Provide functional training. • Focus on sit-to-stand transitions, turning, walking, stairs. • Modify activities of daily living for safety; provide assistive devices, adaptive equipment as needed. • Allow adequate time for activities; instruct in gradual position changes.

18. PT Role • Safety education. • Identify fall risk factors (intrinsic and/or extrinsic). • Provide instructions in writing. • Communicate with family and caregivers. • Modify environment to reduce falls and instability: • Ensure adequate lighting. • Use contrasting colors to delineate hazardous areas. • Simplify environment, reduce clutter.