The link between Fall Risk and Sensory Decline Ana Hernando,
OTR, MOT, MBA Please note: material maybe presented that is not
printed in this manual. Feel free to use the note pages at the end
of the manual Slide 2 Geriatric Sensory Processing and Fall
Prevention Introduction http://www.youtube.com/watch?v=n5w8IfwAlGg
http://www.youtube.com/watch?v=n5w8IfwAlGg Fall Statistics Whats up
with the numbers? Autonomic Nervous System Whats automatic about
falling? Sensory Processing Getting your 3 senses worth Factors to
Falling CNS -Illness and Disease Pharmacology Whats in the fine
print Environmental and Mindset External and Internal Perceptions
Kinesiology- Gift of muscle memory and exercise Slide 3 Fall
Assessments ABCS Current Trends Validity and Reliability Selection
Process Fall Prevention/ Fall Risk Reduction Therapy Implications
Treatment Plans Discharge Planning Multidisciplinary Communication
Medical Team Family and Caregivers Documentation Slide 4
Introduction CMS Definition of Fall- Fall refers to unintentionally
coming to rest on the ground, floor, or other lower level, but not
as a result of an overwhelming external force (e.g., resident
pushes another resident). An episode where a resident lost his/her
balance and would have fallen, if not for staff intervention, is
considered a fall. A fall without injury is still a fall. Unless
there is evidence suggesting otherwise, when a resident is found on
the floor, a fall is considered to have occurred. CMS Manual
Department of Health and Human Services Centers for Medicare and
Medicaid Services August 17, 2007 Slide 5 Introduction CMS
guidelines for fall intervention Educate staff Repair equipment
Develop and revise policies and procedures Resident directed
approach May include implementing specific interventions as part of
the POC. Slide 6 Statistics 1:3 age 65+ fall each year Leading
cause of injury death Most common cause of hospital admission for
trauma for 65+ Death related to falls is increasing 30% of falls
result in significant injury Leading cause of fractures in elderly
Fear of falling increases fall risk Men >women in fall related
deaths Women>men falls resulting in injury 90% of hip fractures
resulted from a fall
http://www.cdc.gov/HomeandRecreationalSafety/Falls/adultfalls.html
Slide 7 Autonomic Nervous System Conveys sensory input and impulses
Provides information to the subconscious mind Parasympathetic
Nervous System Conserves energy, slows down heart rate Sympathetic
Nervous System Burns energy, fight or flight response to danger
Goldberg, 2007 Slide 8 Autonomic Nervous System Dysautonomia-
Fainting Unexplained loss of consciousness Orthostatic hypotension
( blood pressure reduction during standing, POTS) Postprandial
hypotension (blood pressure reduction after a meal) Slide 9 Sensory
Processing Slide 10 Sensory Processing: Left and Right Hemispheres
LEFT RIGHT Uses Logic and Reason Thinks in Words Deals in parts and
specifics Will analyze Take things apart Sequential thinking Time
bound Extroverted Ordered and controlled Individualality Uses
intuition and emotions Thinks in pictures Deals in wholes and
relationships Will synthesize Put things together Holistic thinking
Time free Introverted Spontaneous and free Group mentality Slide 11
Sensory Processing SPACETIME Slide 12 Visual & Vestibular Motor
Planning & Coordination Body awareness, proprioceptive input
Walking, sitting, transfers, balance Slide 13 Auditory &
Vestibular Speech & Sequencing Breathing Balance Slide 14
Visual & Auditory Abstract Thought, Reasoning, & Coping
Skills Problem solving Humor Slide 15 Sensory Processing SPACETIME
Slide 16 CNS Function Learning Modulation Habituation Sensitization
Thresholds Genetic Endowment Personal Life Experiences Slide 17
Quick Review of Cranial Nerves CN1 Smells CN2Sees CN3, 4, and 6
Moves eyes, constricts pupils, accomodates CN5 Chews and feels
front of head CN7 Moves the face, tastes, salivates and cries CN8
Hears and regulates balance CN9 Tastes, salivates, swallows,
monitors carotid body and sinus CN10 Talks, communication to and
from thoraco-abdominal viscera CN11 Turns head, lifts shoulders
CN12 Moves tongue Slide 18 Factors to Falling CNS -Illness and
Disease Vertigo-Central vs. peripheral Tinnitus CN8 Parkinsons
reduced muscle strength (force) and power (force x velocity)
Shingles is latent in cranial nerve ganglia, dorsal root ganglia
and autonomic ganglia along the entire neuraxis. Neuropathies Slide
19 Factors to Falling Pharmacology :US geriatrics population : 40%
take 5-9 medications and 18 % take 10+
http://www.usatoday.com/news/health/medical/health/medical/treatments/story/2011-11-25/Four-common-meds-send-thousands-of-
seniors-to-hospital/51397208/1 Benzodiazepines Antipsychotic agents
Non-benzodiazepine sedative-hypnotics Antidepressants and
anticonvulsants Anti-arrhythmics Diuretics Beta-blockers,
vasodilators, neuroleptics
http://www.ncbi.nlm.nih.gov/pubmed/15972615 Slide 20 Side effects
of Xanax Changes in appetite; constipation; decreased sexual desire
or ability; diarrhea; dizziness; drowsiness; dry mouth;
light-headedness; nausea; tiredness; weight changes. Severe
allergic reactions (rash; hives; itching; difficulty breathing;
tightness in the chest; swelling of the mouth, face, lips, or
tongue; unusual hoarseness); behavior changes; blurred vision;
burning, numbness, or tingling; chest pain; confusion; dark urine;
decreased coordination; decreased urination; fainting; fast or
irregular heartbeat; hallucinations; loss of balance or muscle
control; memory or attention problems; menstrual changes; muscle
twitching; new or worsening mental or mood changes (eg, depression,
irritability, anxiety; exaggerated feeling of wellbeing);
overstimulation; red, swollen blistered, or peeling skin; severe or
persistent dizziness, drowsiness, or light-headedness; shortness of
breath or trouble breathing; suicidal thoughts or actions; tremor;
trouble speaking; yellowing of the eyes or skin. Slide 21 Side
Effects of Coumadin pain, swelling, hot or cold feeling, skin
changes, or discoloration anywhere on your body; sudden and severe
leg or foot pain, foot ulcer, purple toes or fingers; sudden
headache, dizziness, or weakness; unusual bleeding (nose, mouth,
vagina, or rectum), bleeding from wounds or needle injections, any
bleeding that will not stop; easy bruising, purple or red pinpoint
spots under your skin; blood in your urine, black or bloody stools,
coughing up blood or vomit that looks like coffee grounds; pale
skin, feeling light-headed or short of breath, rapid heart rate,
trouble concentrating; dark urine, jaundice (yellowing of the skin
or eyes); pain in your stomach, back, or sides; urinating less than
usual or not at all; numbness or muscle weakness; or any illness
with diarrhea, fever, chills, body aches, or flu symptoms. Slide 22
Vitamin D deficiency Poor physical performance Low muscle strength
Cognitive impairments Falls Fractures Slide 23 Factors to Falling
Environmental and Mindset
http://www.youtube.com/watch?v=5qWpXKhWXcc&feature=related
http://www.youtube.com/watch?v=5qWpXKhWXcc&feature=related
MOBILIZE 2010 study; 765 participants median age 78 46.7% fell
outside- 23% sidewalks, 14% curbs/streets, 13% outside stairs, 6%
parking lots. Kinesiology
http://www.youtube.com/watch?v=hTYDBJ0kP3I&feature=related
http://www.youtube.com/watch?v=hTYDBJ0kP3I&feature=related
Muscle weakness Limited ROM and poor biomechanics Reaction time
Slide 24 Continuous cycle FallInjuryFearImmobilityDepressionIllness
Muscle weakness Slide 25 Fall ABCS A- Age >85 years old B- Bone
issues C-Coagulation S-Surgery Slide 26 Fall Assessments and
Screens Current Trends Morse Fall Scale Hendrich II Fall Risk Model
Timed Up and Go (TUG) Berg Balance Tinetti Balance Scale 6 Minute
Walk Test Survey Of Activities and Fear of Falling in the Elderly
(SAFE) Adult Sensory Profile Validity and Reliability-Case studies
and participants vary by setting. Selection Process- How do you
choose? Slide 27 Morse Fall Scale VariablesScore History of
FallingNo (0) Yes (25) Secondary DiagnosisNo (0) Yes (15)
Ambulatory AidBed Rest/ Nurse assist (0) Cruches/cane /walker (15)
Furniture (30) IV or IV AccessNo (0) Yes (20)
GaitNormal/bedrest/immobile (0) Weak (10) Impaired (20) Mental
StatusKnows own limits (0) Overestimates or forgets limits (15)
Slide 28 Morse Fall Scale Risk Level MFS Score Action No Risk
0-24Good basic nursing care Low to Mod risk 25-45 Standard Fall
prevention High risk 46+ High fall preventions
http://www.patientsafety.gov/SafetyTopics/fallstoolkit/media/morse_falls_pocket_card.pdf
Slide 29 Hendrich II Fall Risk Model http://vimeo.com/4200978
http://hfhs-formslibrary.org/forms/HFH-59-0749MR-
0907%20hendrich%20risk%20form.pdf
http://hfhs-formslibrary.org/forms/HFH-59-0749MR-
0907%20hendrich%20risk%20form.pdf To be completed by Nurse Slide 30
Slide 31 Timed Up and Go
http://www.fallpreventiontaskforce.org/pdf/TimedUp andGoTest.pdf
http://www.fallpreventiontaskforce.org/pdf/TimedUp andGoTest.pdf
Slide 32 Berg Balance
http://www.aahf.info/pdf/Berg_Balance_Scale.pdfwww.aahf.info/pdf/Berg_Balance_Scale.pdf
Slide 33 Tinetti Balance Scale
http://www.bhps.org.uk/falls/documents/TinettiBalan
ceAssessment.pdfwww.bhps.org.uk/falls/documents/TinettiBalan
ceAssessment.pdf Slide 34 6 Minute Walk Test
http://www.rehabmeasures.org/PDF%20Library/6%20
Minute%20Walk%20Test%20Instructions.pdfwww.rehabmeasures.org/PDF%20Library/6%20
Minute%20Walk%20Test%20Instructions.pdf Slide 35 SAFFE-Survey of
Activities and Fear of Falling in Adults
http://www.ecu.edu/cs-dhs/encfpc/upload/17- SAFFE.pdf
http://www.ecu.edu/cs-dhs/encfpc/upload/17- SAFFE.pdf Slide 36
Adult Sensory Profile Provides insight to life long sensory issues
Gives the individual opportunity to provide input Helps highlight
learning preference AdolescentAdultSampleReport.pdf Slide 37 Adult
Sensory Profile http://www.pearsonassessments.com/NR/rdonlyres/E
DCEB5C2-F4BA-435F-B4F7-
69C4DF365B3C/0/AdolescentAdultSampleReport.pdf
http://www.pearsonassessments.com/NR/rdonlyres/E
DCEB5C2-F4BA-435F-B4F7-
69C4DF365B3C/0/AdolescentAdultSampleReport.pdf Slide 38 Fall
Prevention/ Fall Risk Reduction Therapy Implications- Immobility is
the greatest common denominator. Screens Medication changes UTIs
Slide 39 Fall Risk Reduction Therapy Treatment Plans- Muscle
strength Gait Balance Activity tolerance Socialization Home Safety
evaluation Community settings Slide 40 Fall Risk Reduction
Discharge Planning Should be address at beginning of therapy
Forward thinking and problem solving WHAT HAPPENS NEXT? Structured,
scheduled regular exercise/activity Slide 41 Documentation S: Pt is
75 yo referred to OT/PT home health after recent fall at dtrs home
in the living room resulting in decreased mobility, increased pain
with standing, and decreased independence with bathing. PLOF: Pt
lives with dtr in one story home and approximately 4 inch threshold
step for entry. Pt has a pet lap dog that is very friendly and runs
around the house. Dtr works approximately 10 hrs a day out of the
home. Pt has walker but it was her husbands, whom is now deceased.
Prior to her fall pt was independent with ADLs and CGA for walking.
Pt was not driving but does go to Sunday services and to the
grocery store with her dtr. She usually goes to the beauty shop
every 2 weeks. She is a member of the Rotary Club but reports she
is not very active. PMH: HTN, CHF, UTI, GAD, Depression Slide 42
Documentation O: ADLs LB Bathing: Mod A UB Bathing: Min A LB
Dressing: Mod A UB Dressing: S Grooming: S Toileting: Mod A
Transfers: Min A with RW Balance Sitting s/d fair+/fair, Standing
s/d fair/fair-. Pain 5/10 with movement Fear of Falling 7/10 in
bathroom. BUE Strength grossly 3/5 A: Pt is pleasant lady whom
states her desire is to get back to what she was doing but states
she is afraid to fall again. She demonstrates decreases in her
balance for both sitting and standing. Her self reported pain and
fear levels are strong indicators for risk of repeat falling. Her
history of depression, fall history and fear of falling indicate
she is a fall risk. Pt would benefit from skilled OT to increase
her participation level for ADLs, increase her overall mobility,
decrease her c/o pain and fear to return her to PLOF. Slide 43
Documentation P: Pt will participate in OT 2 times a week for 4
weeks. LTG: Pt to perform bathing using AE as needed with less than
2/10 self report of fear of falling. LTG: Pt to increase dynamic
standing to good to perform self care tasks with decreased c/o pain
to 1/10 to facilitate mobility. LTG: Pt to complete morning ADL
routine with Mod I to reduce burden of care. LTG: Pt to complete
toilet hygiene with 90% accuracy to increase health and reduce
risks of UTI. LTG: Pt will demonstrate understanding of fall
recovery plan. STG: Pt to complete 1 set 10 reps of BUE exercises
without s/s of fatigue. STG: Pt to perform 30 min of dynamic
sitting balance tasks withSlide 44 Multidisciplinary Communication
Medical Team- What do the therapists need to know? What do the
nurses need to know? What do the CNAs need to know? What do the
doctors need to know? How do we share information? Slide 45
Documentation
http://www.mnhospitals.org/inc/data/tools/Safe-from-Falls-Toolkit/Post-
Fall_Evaluation.pdf Slide 46 Family and Caregivers What is the
patients normal? Adult Sensory Profile Empathy and respect
Statistics approach What most people do Community class- Matter of
Balance Slide 47 Scenarios Slide 48 Notes Slide 49 Slide 50 Slide
51 Slide 52 References Cumming, R.G., Le Couteur, DG. (2003).
Benzodiazepines and risk of hip fractures in older people: a review
of the evidence. CNS Drugs. 17(11), 825-837.
http://www.ncbi.nih.gov.http://www.ncbi.nih.gov Freiberger, E.,
Haberle, L., Spirduso, W.W., Rixt Zijlstra, G.A. (2012). Long-term
effects of three multicomponenet exercise interventions on physical
performance and fall-related psychological outcomes in
community-dwelling older adults. J Am Geriatr Soc. 60(3), 437-446.
www.medscape.com/viewarticle/760670.www.medscape.com/viewarticle/760670
Goldberg,S (2007). Clinical neuroantaomy made ridiculously
simple.Miami: MedMaster Inc. Hanney, W.J., Kolber, M.J.,
Beekhulzen, K.S. (2009). Implications for physical activity in the
population with low back pain. Am J Lifestle Med. 3(1), 63-70.
www.medscape.com/viewarticle/587890.www.medscape.com/viewarticle/587890
Hendrich, A. L., Bender, P.S., Nyhuis, A. (2003). Validations of
the Hendrich II Fall Risk Model: A large concurrent case/control
study of hospitalized patients. Applied Nursing Research. 16(1),
9-21. Inouye, S.K., Brown, C.J, Tinetti, M.E. (2009). Medicare
nonpayment, hospital falls, and unintended consequences. New
England Journal of Medicine. 360, 2390-2393. Kelsey, J.L., Berry,
S.D., Proctor-Gray, E., Quach, L., Nguyen, U.S.D.T., Li, W., Kiel,
D.P., Lipsitz, L.,A., Hannan, M.T., (2010). Indoor and outdoor
falls in older adults are different: the maintenance of balance,
independent living, intellect, and zest in elderly of Boston study.
J Am Geriatric Soc. 58(11), 2135-2141.
www.medscape.com/viewsrticle/734147.www.medscape.com/viewsrticle/734147
Kim, E.A., Mordiffi, S.Z., Bee, W.H., Devi, K., Evans, D. (2007).
Evaluation of three fall-risk assessment tools in an acute care
setting. Journal of Advanced Nursing. 60(4), 427-435.
www.ncbi.nlm.nih.govpubmed/17919164. Kim, J.S., Lee, H. (2009).
Inner ear dysfunction due to vertebrobasilar ischemic stroke. Semin
Neurol. 29(5), 534-540. http://www.medscape.com/viewarticle/714338.
http://www.medscape.com/viewarticle/714338 Muir, S.W.,
Montero-Odasso, M. (2011). Effect of vitamin D supplementation on
muscle strength, gait, and balance in older adults. J Am Geriatri
Soc. 59(12), 2291-2300.
http://www.medscape.com/viewarticle/756254.http://www.medscape.com/viewarticle/756254
Painter, J.A., Allison, L., Dhingra, P., Duaghtery, J., Cogdill,
K., Trujillo, L.,G., (2012). Fear of falling and its relationship
with anxiety, depression, and activity engagement among,
community-dwelling older adults. The American Journal of
Occupational Therapy. 66(2), 169-176. Ruddock, B. (2004).
Medications and falls in the elderly. CPJ/RPC. 137(6),17-18. Wong,
J. Philip, J., Hilas, O. (2012). Management of dizziness and
vertigo. US Pharmacist. http://www.medscape.com/viewarticle/758389.
http://www.medscape.com/viewarticle/758389