Falls management for the older adult: An interdisciplinary ...

LeadingAge Michigan & PACE Association of Michigan ~ 2016 Annual Conference

Falls management for the older adult: An interdisciplinary approach

Dr. Amanda Scott, OTD, OTR/LAssistant Professor/Residency CoordinatorHuntington University


Learning ObjectivesParticipants will be able to describe the fundamental components of balance and the impact on mobilityParticipants will be able to identify patient specific strategies based on physical performance and cognitive level to address falls.Participants will be able to design an interdisciplinary approach using evidence-based interventions for falls prevention.Participants will be able to select outcome evaluations using both standardizes and non-standardized assessments.Participants will be able to analyze effective documentation for state and federal compliance.


Influence of Age on Postural Control

Distal to proximal muscle activation in response to perturbation appears to be the predominant pattern, a higher incidence of proximal to distal activation occurs in the older adult.

Elderly subjects show muscle response latencies of 20-30 msec. Inability to fire fibers fast enough, regardless of activation sequence, may be a significant factor in the patient who presents with instability. In addition, concurrent disease processes and increased utilization of medication commonly seen in the elderly adult, further compromise their postural control systems.


Relationship between Postural Control and FallsClearly, the issue of balance and falls is a complex and multifaceted problem in the aging adult. Falls in the elderly usually occur in those with physical impairment. Yet, the relationship between physical impairment and falls is not linear. Factors outside of physical function –psychological, cognitive, environmental – can modify the risk of falling for those with severely impaired mobility. Thus, these factors must not be forgotten in a falls prevention program.


Balance and Falls Stats♦Women>men in frequency of falls

♦Men had greater mortality rate

♦ Aging and living alone = increased

risk of falls

♦ Intrinsic factors contributed more

to falls vs. environmental factors

♦ Elderly women with Diabetes mellitus (DM) have an increased risk of falling.

♦ 1.6 falls per Nursing Home bed per year.

♦ About one third of the population age 65 and over reports some difficulty with balance or ambulation; incidences increase in frequency and severity in the over age 75

population.

♦ Nearly 20% of Americans between the ages of 65 and 75 suffer from balance disorders; by age 75, that figure rises to 25%.


Falls & Hip Fracture Stats♦More than 300,000 hospitalizations for hip fractures occur annually in the United States; 86% occur in individuals aged 65 and older.

♦Many of the hip fractures sustained in elderly Americans as a result of falls are related to balance disorders .


Proprioceptive/Sensory Changes

♦ Increased vibration threshold

♦ Decrease in position sense

♦ Reduced light touch and 2-pt discrimination

♦Most common condition in the elderly: DM>>Peripheral Neuropathy


Risk FactorsIntrinsic

♦ Neural (sensory, perceptual, motor, higher

level adaptive, cognitive)

♦Musculoskeletal (strength, ROM, postural

alignment)

♦ Cardiovascular (postural hypotension)

Extrinsic

♦ Assistive Devices

♦ Environmental Hazards

♦ Pharmacological (diuretics, antihypertensives, antidepressants, antipsychotics, antiparkinsonism, aminoglycosides)


Risk FactorsPharmacology

♦ Decreased alertness – narcotics, hypnotics, sedatives, tranquilizers

♦ Retard central conduction – narcotics, hypnotics, sedatives, tranquilizers, analgesics

♦ Impair cerebral perfusion – vasodilators, anti-hypertensives, some antidepressants

♦ Affect postural control – diuretics, digitalis, some beta blockers, and some anti-hypertensives

Environmental Hazards

♦Wet, slippery surfaces

♦ Uneven, cluttered surfaces

♦ Stairs, curbs

♦ Lighting – improper or inadequate

♦ Sudden changes in surfaces or lighting

♦ Trips, obstacles

♦ Jostle in crowd


Medication ChangesBackground: In 2004, a study conducted at Johns Hopkins University focused on the effect of medication changes on the risk of falls among residents of three nursing homes who fell during 2002–2003. The study measured the effect of medication changes that occurred 1 to 9 days prior to the fall. This case-crossover design captured measurements of the odds ratio of falling after a start, stop, or dose change in medication in the case time period versus the control time period.

Results: The results indicated that the short-term risk of single and recurring falls may triple within two days after a medication change (odds ratio = 3.0, 95% CI = 1.1, 25.9).

Application: These results could be used to develop a more effective fall risk identification system within facilities in order to enact a more proactive approach to falls prevention.


Physiology of BalanceSensory: continually acquire information about the body’s position in space and the surrounding environment This is done through the sensory system.

Central Processing: interpretation of sensory input in order to effectively create a response

Motor: output of movement that occurs from receiving the sensory information and central processing. This includes range of motion, flexibility, and endurance.

Postural control theory states that we need the ability to maintain adequate postural control while maintaining alignment of the COG over the BOS.


Sensory SystemComponents◦ Vision: detect slight postural shifts by providing information to the central nervous system

(CNS) about the position and movements of the body parts in relation to each other and the external environment. Components of vision that have clinical significance in balance control are acuity (the ability to detect subtle differences) and depth perception (the ability to distinguish distance).

◦ Vestibular: input is used to generate compensatory eye movements and postural responses during head movements and helps to resolve conflicting information from visual images and actual movement.

◦ Proprioception: inputs provided to the CNS by joint, tendon, and muscle receptors give information regarding the motion of the body with respect to the support surface and motion of the body segments with respect to each other.


Central ProcessingComponents◦ Central Nervous System: receives sensory information, interprets the information in order to create a

motor response.


Motor SystemComponents ◦ Biomechanics of movement: range of motion, muscle strength, postural alignments and endurance

◦ Muscle strength, power and endurance are all required◦ In one study, fallers were found to be 7.5 times weaker in dorsiflexion than non-fallers.


Central Motor

Peripheral Motor

MovementEnvironment

Peripheral Sensory

Central Sensory

Modified SensoryIntegration Test

2-point DiscriminationMVPTVisual AcuityHalpike-Dix

TinettiBergGet Up and GoFunctional ReachFour square test

Motor / Joint TestsMuscle functionChair rise testROM

Functional ReachTests of Pertubation- compensatory- anticipatory

Assessment of Balance/ Postural Stability

Home AssessmentADL Performance

Process begins with understanding this system, and identifying the patient’sbaseline


InterventionsRestoration

• Therapeutic Exercise

• Gait training

• ROM/Stretching

Compensatory Strategies • Self-monitoring

• Energy conservation

• Consistent routine

• Assistive devices• Ambulation• ADL• Memory aids

Environmental Adaptations• Organization of functional task items

• Eliminating/reducing clutter and distractions

• Caregiver’s responsibility to utilize strategies instead of patient

• Caregiver education of specific cueing strategies

• Using visual cues to promote a safe environment


Sensory Input Is Key

Too Little Just Right Too Much


Automatic Movement Strategies♦ Ankle Strategy

♦ Hip Strategy

♦ Stepping Strategy

♦ Suspensory Strategy


Ankle Strategy

♦ disturbance is slow/small

♦ surface is firm, wide, and longer than feet

♦Muscle contraction sequence will be distal-to-proximal

♦ Head movements small and in-phase with hips


Hip Strategy

♦When the disturbance is large and fast

♦When the surface is unstable or shorter than the feet

♦Muscle contraction sequence is proximal-to-distal

♦ Head movements is large and out of phase with the hips

Climbing stairs


Stepping Strategy

♦ A step in any direction to prevent a fall

♦ COG exceeds the BOS

♦ Re-establish new BOS underneath the shifted COG


Suspensory Strategy

♦ Bilateral hip and knee flexion

♦ Lower COG to make balance easier


Mobility1000 feet of locomotion are required on average per errand

Typically complete 2-3 errands at one time.

Average older adult carries 6-7lbs during outings including walking on inclines, negotiating curbs, with frequent postural changes

Normal gait speed: 1.2-1.3 meters/sec

MINIMUM REQUIREMENTS for safe D/C home:◦ Household ambulation .23-.27 m/s (~ 50 feet/min)◦ Community ambulation .4-.8 m/s ( ~120 feet/min)

Why do we frequently tell ours patients to slow down?


Gait SpeedImportant indicator related to :◦ transfers◦ Ascending/ descending stairs ◦ ankle PF and knee extension power◦ hip power and strength

gait speeds less than .25 m/sec typically indicates dependence in at least 1 area of ADLs.

Need ~.45 m/sec. to be Independent in ADL’s

Gait speed has been shown to be the single best predictor of functional decline and disability (Gill et all 1995)

patients 75-80 yrs of age, mean time to complete 10 meters is 7.7 sec


Patient IdentificationVisual impairments including cataract, macular degeneration, glaucomaRecent surgical proceduresUnstable cardiopulmonary conditions Vitamin D deficiencyRecent adjustments of psychotropic medicationsMobility deficits

Patients over the age of 80Diagnosis of depression or dementiaTaking diuretics, sedatives, narcotics, psychotropic, antihypertensive drugsSignificant medication changes in the last 7 daysHistory of falls


IDT Team

Therapy• OT

• PT

• SLP

Nursing• DON/ADON

• Nurse Educator

• MDS

• Unit Manager

• CNA

Administration• Administrator

• Social Services

• Activities Director

• Attending Physician


Roles of IDT Members

Nursing• Assess for extrinsic risk factors and

institute corrective action

• Document details leading up to the LOB or fall

• Generate referrals to the appropriate disciplines

• Assess/screen patients for multifactorial risk factors to falls including changes in medical status, cognitive decline, urinary incontinence, medication changes, and environmental changes.

• Communicate findings with IDT members.

• Enact protocol for identifying patients who are at risk of falls

Activities• Conduct group activities that

assist in maintaining function

• Assist in identification of patients at risk of falls

• Assist in reinforcing strategies determined by the IDT.

• Motivate patients to continue to be active in order to maintain mobility

Social Services• Communicate with patient, the

family and caregivers

• Include patient and family in discussions about fall prevention measures

• Upon transfer to another unit, communicate the risk assessment and interventions

• Upon discharge, review fall risk factors and measures to be implemented in the home setting

• Explore resources available to assist in maintaining gains made after therapy

• Assist in acquisition of adaptive equipment to prevent future falls


Therapy Referrals

Occupational Therapy

• Wheelchair positioning

• Pain

• Decline in bathing/dressing

• Decline in ADL transfers

• Urinary Incontinence

• Improper posture

• Cognitive decline

• Assess environment

Physical Therapy

• Stumbling/ Shuffling gait

• Pain

• Noncompliance with ambulation device

• Decline in transfers

• Footwear assessment

• Wounds

• Improper posture

Speech Therapy • Decline in nutritional intake

• Swallowing difficulties

• Cognitive decline

• Communication deficits


Falls Prevention IDTInterdisciplinary approach to falls management and prevention

Purpose:◦ Falls prevention◦ Identification of risk factors◦ Collaboration of various assessments◦ Team approach to intervention identification◦ Ensures effective implementation of interventions/strategies◦ Assess effectiveness and quality of intervention strategies◦ Educate patient and/or caregivers.


Falls Prevention IDTWeekly MeetingTypically meets 2-3x/wkEstablish a clear agendaReview new admissionsReview new fallsTypically a brief meeting (15 minutes or less)

Monthly/Quarterly Meeting

Review # of falls

Review reasons for falls

Identify effective interventions/strategies

Review patients to ensure strategies are still appropriate


Care Plan Considerations

Therapy Referral Environmental analysis

Medication analysis and adjustments

Review of Medical and nutritional status.

Footwear assessment

Restorative program for falls prevention Implementation of an individualized activities program

Structure environment based on patient’s behavior patterns

Establish ADL routine/ toileting program based on patient’s behavior patterns


Prevention Program ComponentsComprehensive standardized multi-factorial risk assessment

Individualized plan of care that emphasizes patient’s abilities

Multi-disciplinary approach to interventions

Programs that emphasize strength training, endurance, and balance

Staff/Patient/Family education

Home assessments and home modifications

Environmental safety assessments completed on a routine basis


Effective EBP InterventionsMultidisciplinary, multi-factorial, health/environmental risk factor screening/intervention programs in the community both for an unselected population of older people (4 trials, 1651 participants, pooled RR 0.73, 95%CI 0.63 to 0.85), and for older people with a history of falling or selected because of known risk factors (5 trials, 1176 participants, pooled RR 0.86, 95%CI 0.76 to 0.98), and in residential care facilities (1 trial, 439 participants, cluster-adjusted incidence rate ratio 0.60, 95%CI 0.50 to 0.73)

A program of muscle strengthening and balance retraining, individually prescribed at home by a trained health professional (3 trials, 566 participants, pooled relative risk (RR) 0.80, 95% confidence interval (95%CI) 0.66 to 0.98)

Home hazard assessment and modification that is professionally prescribed for older people with a history of falling (3 trials, 374 participants, RR 0.66, 95% CI 0.54 to 0.81)

Withdrawal of psychotropic medication (1 trial, 93 participants, relative hazard 0.34, 95%CI 0.16 to 0.74)

Cardiac pacing for fallers with cardio-inhibitory carotid sinus hypersensitivity (1 trial, 175 participants, WMD -5.20, 95%CI -9.40 to -1.00)

A 15 week Tai Chi group exercise intervention (1 trial, 200 participants, risk ratio 0.51, 95%CI 0.36 to 0.73). Results last up to 1 year with good carryover of interventions. Exercise can also help reduce fear, depression and associated avoidance of activities


Facility AnalysisThe Assessing Care of Vulnerable Elders (ACOVE) quality indicator (QI) set ◦ developed in 2000 by Rand Healthcare and UCLA ◦ comprehensive method for assessing the quality of care of vulnerable

elderly patients.

PEPPER Reports

CASPER Reports


DocumentationDiscipline specific assessments

Referrals

IDT meeting minutes

Daily documentation◦ Current mobility/ADL status◦ Vital signs◦ Identified interventions◦ Effectiveness of interventions◦ Environmental factors◦ Medication changes


ReferencesBonder, B. & Dal Bello-Haas, V. Functional performance in older adults. 3rd ed. (2009). F.A. Davis. Philadelphia

Nyman, S.R. &Victor, C.R. Older people's recruitment, sustained participation, and adherence to falls prevention interventions in institutional settings: a supplement to the Cochrane systematic review. Age Ageing. 2011 Jul;40(4):430-6

Rand D, Miller WC, Yiu J, Eng JJ. Interventions for addressing low balance confidence in older adults: a systematic review and meta-analysis. Age Ageing. 2011 May;40(3):297-306.

Fairhall N, Sherrington C, Clemson L, Cameron ID. Do exercise interventions designed to prevent falls affect participation in life roles? A systematic review and meta-analysis. Age Ageing. 2011 Nov;40(6):666-74.

Hsu CL, Nagamatsu LS, Davis JC, Liu-Ambrose T. Examining the relationship between specific cognitive processes and falls risk in older adults: a systematic review. Osteoporos Int. 2012 Oct;23(10):2409-24.

McPhate L, Simek EM, Haines TP. Program-related factors are associated with adherence to group exercise interventions for the prevention of falls: a systematic review. J Physiother. 2013 Jun;59(2):81-92.

Additional References Available Upon Request

http://www.ncbi.nlm.nih.gov/pubmed/21502163





Falls management for the older adult: An interdisciplinary ...

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