Comprehensive Fall Prevention Management for Older Adults

1
Comprehensive Fall Prevention Management for
Older Adults

• Holly Lookabaugh-Deur, PT, GCS, CWS, ABD
• President Generation Care

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Unrecognized Public Health Problem

• Injuries relating to falls are growing in
  incidence, prevalence, and severity, and they are
  only expected to continue to grow as our
  populations average life expectancy continues to
  rise.
• Falling is defined as a sudden, uncontrolled drop
  to a lower surface.

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Facts on Falls Demographics

• Injuries relating to falling are the leading
  cause of accidental death in older adults over
  the age of 65.
• Falls account for 80-95 of hip fractures in
  older adults.
• More than 1/3 of healthy adults over age 65 fall
  every year.
• Nearly 20-30 of those who fall sustain a
  moderate to severe injury, such as a head injury.

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More Demographics

• Half of all older adults hospitalized for hip
  fractures cannot return home to live
  independently, and 20 die within one year of the
  fall.
• Hip fractures lead to an overall 5-20 reduction
  in life expectancy for older adults (National
  Osteoporosis Foundation, 2001).

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More Facts

• Every year, 300,000 Americans suffer from fall
  related hip fractures.
• Every week, nearly 200 Americans die of
  complications following a fall.
• Every day, more than 400 Americans suffer
  permanent loss of mobility from damage following
  a fall.
• Of persons aged 75 and older, those who fall are
  4-5 times more likely to be admitted to an ECF
  for a year or longer.

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Centers for Disease Control and Prevention (CDC)
Recommendations

• All adults over the age of 75 should receive a
  comprehensive risk factor analysis.
• Older adults may be able to age in place if
  appropriate fall prevention strategies are
  initiated with the onset
• of frailty.

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More Demographics

• Since 1990, the death rate from falls has doubled
• Highest fall risk and incidence white females
  over age 80 years
• 350-400 people die from falls each year in
  Michigan
• In Michigan, 21 more women than men fall
• 25 of people who fall require medical attention

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Frightening Facts

• For every elderly fall injury death in Michigan,
  there are 33 non-fatal hospitalizations, about
  200 seniors seeking non-inpatient medical care,
  and nearly 900 who fall and do not receive care.
  Elderly falls in Michigan have estimated medical
  costs of 649 million, including lost work time,
  with a total cost of 2.5 billion per year (25
  billion nationally).

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A Note about Michigan

• More than a million adults over the age of 65
• In 2002, falls were the cause of 80 of all
  hospitalizations due to injury
• 13 of Michigan seniors report falling within the
  last month 28 within the last year
• Falls were reported as occurring most frequently
  on porch steps and during carrying times

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The Good News

• Utilizing a comprehensive fall risk assessment
  and specific interventions to reduce risk, fall
  frequency can be reduced by 4372, depending on
  the setting.

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Why should the health care team work together on
this growing health issue?

• 2/3 of falls may be preventable (Yale University,
  2005)
• FP programs help older adults age in place as
  long as possible
• FP programs build consumer loyalty as older
  adults need more services
• FP is needed across the older adult health care
  continuum

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Generation Care and FP Research

• Part of a four-year CDC grant studying the impact
  of health care training, FRAT use (Fall Risk
  Assessment Tool) and interventions
• To date, we have helped lower repeat falls by 72
  at Crittendon Hospital (Detroit) and Genesys
  Health Care Systems (Flint)

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Fall Risk Factors

• Intrinsic and Extrinsic Risk Factorswhat we can
  and cant impact with our interventions

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To be truly effective with fall prevention efforts

• Assessments need to be comprehensive
• We need to be able to CONNECT with our
  patientslistening, exploring, adding value to
  their lives
• We need a 24 hour approach
• Interventions need to be individualized AND
  focused on the patients goals, not a score or
  what is on paper

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Intrinsic Risk Factors

• Age
• History of falls
• Awareness and acceptance
• Pathological conditions and existing diseases
• Postural hypotension
• Vision deficits
• Hearing deficits
• Nutrition and hydration status (both intrinsic
  and extrinsic)

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More Intrinsic Risk Factors

• Strength deficits specific groups
• Quads, triceps, foot intrinsics, etc.
• ROM or loss of symmetry
• Postural recovery strategy issue/ balance
  problems
• Gait pattern and mobility dysfunction
• ADL disability six key areas
• Cognitive and attention issues
• Possible correlation with urinary incontinence

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Extrinsic Risk Factors

• Shoe style and fit
• Assistive device and fit/use
• Home environment and home safety
• Nutrition and hydration (both intrinsic and
  extrinsic)
• Medication use
• Lack of health professionals knowledge
  assessment tools, treatment interventions,
  communication and connection skills with clients

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The Greatest Risk Factor

• The single greatest risk factor for falls is
  the lack of health professional knowledge and
  awareness of the use of assessment tools,
  intervention strategies, and effective
  communication skills with older adults.
  (Healthy Aging, 2005)

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Review of Risk Factor Details

• Key points relating to individual intrinsic
  and extrinsic risk factors follow however, a
  detailed understanding of each is beyond the
  scope of this program.

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Age

• Normal loss of 1 percent of strength per year
  after age 60
• Shifts in normal center of gravity to more
  anterior position
• Increased postural sway
• Tendency for the foot arch to drop elongation of
  the foot shoes dont fit
• Decreased overall reaction time, slowing
  coordination and motor learning

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History of Falls

• Tinettis work indicates that fall history is a
  significant risk factor for the likelihood of
  repeated falls.
• A two-year historical picture of falls is
  critical to the fall risk assessment process
• Remember that history taking is actually quite
  unreliable due to under reporting

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Cognitive Changes

• Still under study as a risk factor for falls,
  but early evidence indicates attention span,
  tendency toward distraction, ability to sort
  environmental clutter, perceptual deficits
  relating to interpretation of risk or danger,
  spatial perceptual changes, and inability to
  inhibit impulsive or poorly planned motor
  activities do play a significant role in fall
  risk.

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Co-morbidities and Pathologies

• These conditions are correlated to fall risk in
  the literature
• OA and RA
• Parkinson's disease
• Although osteoporosis is not a risk factor for
  falling, it is correlated to the degree of injury
  severity following a fall
• Alzheimer's disease
• Clinically significant postural hypotension
• Peripheral neuropathy

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Vision Deficits

• Decreased acuity (less than 20/60)
• Impaired reaction to light and dark inability to
  change pupil size abruptly to aid in focus
• Decreased contrast sensitivity, particularly with
  grays, browns, and neutral colors
• Decreased peripheral field
• Decreased depth perception, with both close and
  far away objects

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Hearing Deficits

• Decreased hair cells
• Calcification of cupula less sensitive to change
• Speed of axon transmission decreased
• Increased vibratory threshold
• Temporal perception delays, along with relays to
  and from the cerebellum, making responses to
  change in body and head righting reactions
  delayed and slower

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Orthopedic Changes

• Strength df/pf hip abductors quads toe
  intrinsics trunk triceps hip extensors
• Collagen levels increase in soft tissue as we
  age, impacting flexibility
• Gait changes wider base of support, slower
  cadence, less toe to heel excursion, limited
  trunk rotation and arm swing, shorter step
  length, less weight shifting, anterior shift of
  gravity

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Postural Recovery and Balance Changes

• Normal balance requires three systems to work
  perfectly in sync vision, vestibular, and
  somatosensory (joint proprioception input)
• We become more visually dependent,
  hypofunctioning vestibular system
• Inadequate ankle-foot reaction hip flexion
  response and step response

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ADL Changes in the last Six Mo.

• Difficulty with bathing
• Difficulty with dressing, particularly lower
  extremities shoes and socks
• Instrumental ADL changes
• Fear or difficulty entering and exiting the home,
  such as getting the mail
• Reduced frequency or complexity of preparing a
  hot meal
• Difficulty with bed mobility skills, rolling,
  getting in/out bed

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Extrinsic Factors Start with Feet

• Chronic heel cord tightness, uncompensated by a
  shoe does not allow ankle-foot recovery strategy
• Shoe fit flexible toe box
• Intrinsic toe muscle strengthour first line of
  defense!

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Assistive Devices

• We are too quick to assume a walker will help.
  Many older adults borrow from a friend poor
  fit, wrong choice, not using correctly
• Can lead to increased weakness can lead to
  progressive hip weakness if leaning too far
  forward, never extending hip or using trunk

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Home Environment

• Lighting particularly in middle of night
• Bathroom setup with bars
• Rugs floor transitions
• Stairs with narrow or low rise, only one rail
• Highly polished floors
• Clutter
• Low tables and chairs toilet seat
• No non-slip surface in tub
• Irregular or raised sidewalks
• Oil on garage floor

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Nutrition and Hydration

• Considered both an intrinsic and extrinsic risk
  factor
• Dehydration is the single most common method of
  managing incontinence
• Dehydration affects mental function
• High fat, high sodium diet with frozen foods,
  etc.
• Low calcium contributes to osteoporosis
• Low vitamin B related to fatigue
• Limited vitamin C strength, muscle recovery
  problems

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Homebound Status

• Limited endurance and activity levels
• Nutritional compromise due to infrequent shopping
  trips
• Less stimulation of all of the senses
• If out of home infrequently, more likely to feel
  startle reaction, more likely to be deconditioned

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Medication Use

• Falling and dizziness are the most commonly
  listed side effects of meds
• Psychotropic drugs are most associated with falls
• Recent studies show just four or more concurrent
  medications are significant to fall risk
• Tricyclic antidepressants, sleep aids, and
  antiarrhythmia drugs significantly contribute to
  fall risk

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Comprehensive Medication Guide

• A comprehensive list of medicines related to
  fall risk and highly correlated with dizziness/
  balance dysfunction as a side effect is available
  through
• Anne Esdale Fall Prevention Coordinator
  Michigan Department of Community Health, Injury
  Prevention Section, at
• EsdaleA_at_michigan.gov

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Incontinence Under Study

• Stress UI affects pelvic floor weakness, which
  impacts hip strength directly
• Urge type UI can affect judgment and focus. May
  have panic gait issues
• Functional UI
• In general, UI can distract and lower activity
  level and cause the individual to move about less
  

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Again, WE are the greatest risk!

• Client and health professional awareness is the
  single best step we can make toward reducing risk
  
• Look for signs of fear of falling
• Be dramatic to get your point across!

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Brief Case Review

• 72 y/o female dx arthritis and mild CHF. Lost
  husband within last year. Afraid to drive
• Not sleeping well
• Afraid to drive, to be alone
• Less active, limited social exposure
• Minimal shopping
• Nutrition and hydration decline

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Case Study (cont.)

• Weakness is progressing no assistive device is
  prescribed. Does not see doctor
• Endurance is declining
• EVENT Attempts to repair something that has been
  neglected in the home falls fractures wrist and
  ankle cannot care for self enters ECF
• Rapid loss of will, desire continues to decline
  pneumonia within six months death six weeks
  later
• Discuss intrinsic and extrinsic synergy and
  decline

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Break time!

• Hope you are beginning to fully understand how
  impactive your work can be
• You can experience the difference right away
• LISTEN first!!!