Fall Prevention Program for Older Adults With a Fear of Falling

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Fall Prevention Program for Older Adults With a
Fear of Falling

• Julie A. Honaker, Ph.D
• Robert W. Keith, Ph.D.
• Laura Kretschmer, Ed.D.
• Daniel Choo, M.D.
• Patrick Shumrick, DPT

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An Aging Society

• Prediction for the US
• By 2010, 40 million 65 years
• By 2040, 80 million 65 years

1. Girardi, M., Konrad, H.R., Amin, M.,
Hughes, L.F. (2001)
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Boston, Massachusetts

• Population Estimates1
• 680,000
• Mean age 32 years
• 55-59 years 27,380
• 60-64 years 22,160
• gt 65 years 76,160

1. http//censtats.census.gov/
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Epidemiology of Falls

• 30 to 50 of people 60 years or older will fall
• 10-20 repeatedly
• Elderly in nursing homes (rate rises to 50 will
  fall twice or more per year)

1. Rubenstein, L.Z. and Josephson, K.R.
(2002).
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Hip Fractures

• Major cause of morbidity and mortality
• In 1999, hip fractures resulted in nearly 338,000
  hospital admissions 1
• By 2050, hip fractures will exceed 600,000 2

• 1. Popovic, J.R.(2001).
• 2. American Academy of Orthopaedic Surgeons
  (2006)

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Risk Factors for Falls

• Broad range of risk factors identified in the
  literature (between 130 and 400) 1
• Likelihood of falling increases with four or more
  risk factors 2
• Classified as extrinsic or intrinsic

• McMurdo, M. (2001).
• Masud, T., Morris, O. (2001)
• 2. Nevitt, M.C., Cummings, S.R., Kidd, S.,
  Black, D. (1989).

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Risk Factors for Falls

• Extrinsic
• Environmental Factors
• Poor lighting
• Unsafe stairways
• Irregular floor surfaces

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Risk Factors for Falls

• Intrinsic
• Decline in sensory system
• Vestibular, vision and proprioception

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Risk Factors for Falls

• Decline in motor
• Strength, coordination and endurance
• Increased age
• History of Falls
• Slow walking speed
• Decline in function and integration (response
  time/reaction time)

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Risk Factors for Falls

• 50 of falls are due to a medical condition1
• Diabetes, Parkinsons disease, stroke, arthritis,
  osteoporosis
• Any acute or chronic disease
• Visual disorders
• Cataracts, glaucoma, macular degeneration
• Medications
• Type and number
• CNS disorder
• Balance disorders and dizziness

• Steinweg, K.K,, (1997).

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Falls and the Older Adult

• Unfortunately, some older adults fail to seek
  help for falls
• Attribute these to normal aging
• Many older adults fear falling and do not realize
  that many falls they associate with aging can be
  prevented

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Fear of Falling (FoF)

• Injuries can be treated/fear of another fall is
  persistent
• Fear of falling can
• Create excessive anxiety
• Restrict participation in activities of daily
  living
• Decrease quality of life
• Increase dependence on others

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Fear of Falling Definitions

• 1. Unusual variation of agoraphobia1
• 2. Ptophobia 2 or post-fall syndrome 3
• 3. A lasting concern about falling that leads to
  individuals avoiding activities that he/she
  remains capable of performing 4

• Marks, I., Bebbington, P. (1976).
• Bhala, R.P., ODonnell, J., Thoppil, E. (1982).
  
• Murphy, S.L., Isaacs, B. (1982).
• Tinetti, M.E., Powell, L. (1993).

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Fear of Falling Assessment Instruments
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Risk of Falling Programs
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Risk of Falling Programs

• Multidisciplinary care (Fall Clinics)
• Exercise intervention programs
• Home hazard assessment/environment modification
• Studies incorporating these elements have
  established that falls and fall related injuries
  can be prevented
• Not easily replicated in most clinical settings
• Few have included FoF as an outcome of interest

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Summary of Research Findings in the Reduction of
Falling Concerns in Older Adults
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Summary of Research Findings in the Reduction of
Falling Concerns in Older Adults

• Majority of studies were group programs
• Frail elderly (gt75 years average age of
  inclusion)
• Few studies provided multidisciplinary fall
  prevention/risk of falling clinics,
• No audiologist/physical therapist/neurotologist
  (or otolaryngologist) for the initial evaluation

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Summary of Research Findings in the Reduction of
Falling Concerns in Older Adults

• Few included home hazard assessment
• Excluded patients with complaints of vertigo,
  lightheadedness, etc
• Only 1 study provided qualitative descriptions
  from the subjectlimited to patient satisfaction
  of the program
• None of the studies examined the impact of FoF on
  the patient or caregivers

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Purpose of My Research

• To determine if intervention with a team approach
  risk of falling assessment and remediation
  program reduces fear of falling in older
  independent living individuals with a balance
  disorder.
• Evaluate the impact of FoF due to a balance
  disorder on the patients activities of daily
  living
• Determine the impact of FoF on a selected family
  member, significant other, or spouse of the
  patient

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Specific Aims

• Establish/evaluate the impact of FoF due to a
  balance problem on selected family member,
  significant other or spouse
• Verify level of anxiety and depression in the
  patient, due to FoF
• Reveal the patients present attitude toward
  their balance problem/activity level before FoF
• Verify the effectiveness of the risk of falling
  intervention program designed to reduce FoF
• Determine via the (ABC) Scale if the risk of
  falling program reduced FoF

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Methods

• Male and female patients were recruited from
  individuals referred to the Balance Disorder
  Center (Group 1)
• Completed a balance disorder questionnaire
• One family member, significant other, or spouse
  of the patient was recruited for the study (Group
  2)

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Methods

• (Group 1) scheduled for 2 half days of risk of
  falling assessment
• Audiology and Physical therapist
• Testing was performed in 2 clinical settings
• Medical evaluation with neurotologist
• Remediation Portion (balance/vestibular
  rehabilitation with PT)
• Audiologist observed and interviewed
  patient/selected family member, spouse, or
  significant other before and after the
  remediation portion

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Audiology Assessment (Group 1)

• Reviewed balance questionnaire answers
• Mini Mental State Exam
• Geriatric Depression Scale
• Beck Anxiety Inventory
• Home Safety Checklist for Detection of Fall
  Hazards
• Activities Specific Balance Confidence (ABC)
  Scale
• Near vision acuity testing
• With and w/o corrective lenses
• Determined date of last eye examination

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Audiology Assessment (Group 1)

• 8. Audiometric exam
• Tympanometry
• Acoustic reflexes
• Pure tone and speech audiometry
• 9. Balance assessment
• Platform Posturography
• Clinical Test of Sensory Integration and Balance
  (CTSIB)
• 10. Impaired balance function
• VNG

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Significant Other Assessment (Group 2)

• Mini-Mental State Examination
• Home Safety Checklist for Detection of Fall
  Hazards
• Modified ABC scale

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Physical Therapy Assessment (Group 1)

• Review of symptoms (fall history etc)
• Type and number of medications
• Dizziness Handicap Inventory
• Musculoskeletal examination
• Lower extremity strength, flexibility, reflex and
  sensation testing
• Functional Reach Test
• Timed Up and Go test
• Examination of gait length and velocity
• Berg Balance Test
• Dynamic Gait Index

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Neurotologist Assessment (Group 1)

• Review of all risk of falling assessment
  results/Case History
• Head and neck examination
• Cranial nerve function/neurologic exam
• All results integrated to yield diagnosis
• Referral to PT for balance disorder remediation

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Qualitative Assessment (Group 1 and 2) In home
interview/observation

• 1st interview scheduled prior to remediation
  portion of the program
• Separately interviewed (Group 1) and (Group 2)
  subjects
• w/ audiotape recorder
• Counseled/educated participants on the results of
  home hazard checklist
• Addressed home hazard issues

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Remediation Program (Group 1)

• Balance/Vestibular Rehabilitation
• Designed to incorporate concerns/goals agreed
  upon by the PT and patient
• habituation, gaze stability, balance mobility,
  strength and endurance training
• Therapy sessions based on assessment results
• Length of program depended on indiv. objectives
  (on average 6-10 weeks)

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Completion of Risk of Falling Program (Group 1
and 2)

• Follow-up observation/interview
• Separate interviews
• (Group 1) post questionnaires
• Geriatric Depression Scale
• Beck Anxiety Inventory
• ABC Scale
• (Group 2) post questionnaire
• Modified ABC scale

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Results Subject Characteristics

• Originally 32 subjects
• 2 participants spouses dropped out
• N 28
• 14 from each group

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Description of Balance Problems

• Primary symptom
• Unsteadiness
• Standing or walking
• Constant symptoms (57)
• Moderate disability (35)

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Fall History

• FoF, fall, near fall (100)
• 78 avoided activities inside the house
• 92 avoided activities outside the house

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Physical therapy assessment results (Pre)
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Audiology Assessment Results
64 indicated last visual exam gt 1 year ago
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Audiology Assessment Results

• 93 sensorineural loss in both ears
• VNG results
• 29 both peripheral and central
• 29 peripheral only
• 21 central only
• 21 normal

• Platform/CTSIB results
• 2 severe dysfunction pattern
• 1 visual/vestibular dysfunction pattern
• 8 vestibular dysfunction pattern
• 3 unable to perform test

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Questionnaire results

• Mini Mental
• Group 1 (mean 27.6, SD 2.21)
• Group 2 (mean 28.1, SD 2.50)
• Home Hazard
• Overall scores indicated good rating
• Only 3 out of 4 families scored w/in the same
  range

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Questionnaire results (Group 1)

• ABC, Geriatric Depression, Beck Anxiety
• Compared pre/post
• Wilcoxon signed ranks test

a .05
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Questionnaire results (Group 2)

• ABC scale
• Compared pre/post
• Wilcoxon signed ranks test

a .05
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Spearman r Correlation Coefficients between ABC
scale, Geriatric Depression scale, and Beck
Anxiety Inventory (Group 1)

• Significant negative correlation between change
  in FoF and depression
• Significant negative correlation between change
  in FoF and anxiety

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Spearman r Correlation Coefficients between ABC
(Post) Scores and Age and Co-Morbidities for
(Group 1)

• Significant negative correlation between change
  in ABC scores and age
• No significant association between number of
  co-morbidities and change in ABC scores

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Qualitative ResearchExample of Open Ended
Questions

• Sample interview questions for patient with fear
  of falling
• 1. Tell me about a typical day at home.
• 2. How has your life changed since the fear of
  falling?
• Sample interview questions for family
  member/spouse
• 1. Describe for me some activities your
  spouse/family
• member is afraid to perform to due the fear
  of falling.
• 2. Describe what activities your spouse/family
  member
• depends on you to perform due to his/her
  fear of falling.

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Qualitative Results

• 1. Phenomenological approach
• 2. Open ended interview questions
• 30 40 minutes (Group 1 2)
• 3. Content Analysis
• Transcribed (350 total pages)
• Group 1 172 pages , Group 2 178 pages)
• Coded
• Coding example No, I can walk through the
  house. Then sometimes I cant. It just depends
  on my day or if Im overly tired.
• Codes description of balance problems, fatigue,
  limiting activities

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Qualitative Results

• Content Analysis of 28 interviews yielded two
  Main Themes
• Impact of a Fear of Falling/Balance Disorder on
  Daily Living
• Role of Risk of Falling Program

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Data DisplayImpact of a Fear of Falling/Balance
Disorder on Daily Living
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Data DisplayRole of Risk of Falling Program
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Summary of Results

• 1. All reported fall, FoF
• 2. High risk of falling
• 3. Statistically significant reduction in FoF
• (group 1 and 2)
• 4. Significant reduction in depression/anxiety
• (group 1)
• 5. Qualitative results

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Summary of Results Evidence of Improvement Post
Treatment

• 1. Patients advocate
• 2. Vestibular/balance rehabilitation component

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Limitations

• Assessment appointments
• Short follow-up period

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Other Interesting Findings

• Depression scores
• Family member falling concerns post program
• 66.7 (mean ABC post) Group 2
• 77.9 (mean ABC post) Group 1

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Future Directions

• 1. Greater public awareness/education on reducing
  falls/fear of falling
• Screening tests for risk of falling
• 2. Primary Care Physicians Role

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Conclusion

• Team approach risk of falling program
• (audiology, PT, neurotology)
• with vestibular/balance rehab, counseling
  education on balance disorders/falls
• effective way to deal with fears about falling
  and improve quality of life.