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Falls Prevention and Treatment

Hilary C. Siebens MDSiebens Patient Care Communications

Consultant, PM&RS Long Beach VA Health System

2nd Annual UCSD Clinical Geriatrics Interprofessional Symposium

San DiegoOctober 25, 2015

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Objective Practical

• Appreciate a few key epidemiology facts.• Learn overarching assessment strategies.• Explain 3 or more factors contributing to falls

in each of 4-domains: medical, cognitive, functional, and environmental realms.

• Identify 2 practical interventions to improve your care of patients with fall risk factors for those who

1) haven’t fallen yet are at high risk and 2) those who have fallen.

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Disclosures

A model used in consulting with health care organizations will be

mentioned.

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Epidemiology 1. What % of community residing

older adults fall each year?

2. What percentage of falls cause serious injury?

3. What are the most frequent causes of TBI in the elderly – pedestrian vs car accidents, driving car accidents, muggings, falls, or other?

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EpidemiologyAnswers

1. 25%2. 5-10%, causing lacerations,

traumatic brain injury (TBI), fractures (most frequent one is of the hip)

3. Falls are THE MOST frequent cause of traumatic brain injury (TBI) in the elderly

6Preparing a 21st Century Work Force: The Challenge of Chronic Conditions, WHO 2005

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Overarching Concepts inAssessment of Fall Risk

4. What is the single most important

topic to ask your patients?

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4. Answer- About falls!

Three questions to ask:• Have you fallen in the past year?• Do you feel unsteady when standing or

walking?• Do you worry about falling?

Odds ratio for another fall if a fall – 2.8

See cdc.gov/steadi/; Michael Y et al. Ann Intern Med 2010.

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Understanding Balance Self-insight and Reflection

5. Do you have a balance problem?

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5. AnswerIt depends!

• Dynamic balance and falls – falls occur when activities overpower individuals’ ability to keep upright dynamically

See cdc.gov/steadi/ for information on screening tests for fall risks – Timed Up & Go, 30 sec chair stand, 4-stage balance test.

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A practical model for assessing falls

INDIVIDUAL Cognition 3 sensory system inputs brain/CNS

processing neuromusculoskeletal output

ACTIVITY CHOSEN* What/how/when an individual is doing it

* Occupational Therapy – The PEO Model : person, environment, occupation

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Overarching Concepts in Assessment and Management

• Many patients don’t understand balance, don’t know they have a “balance” problem

Dizziness/unsteadinessTaking extra steps, shorter stepsMore trouble in dark, on grass or uneven surfacesLosing balance with turning, reaching, sit to standFurniture surfing requiredFree falling into a chairFeeling that “I walk like I’m drunk”

• Patients often believe “nothing can be done” or believe “I don’t have a problem but my friend does” (see cdc.gov/steadi/ for brochure, how to talk to patients)

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Overarching Concepts in Assessments

and Management• Critical to focus on screening for risk of INJURY• Several key factors: Older age Medical - Oseoporosis, anti-

coagulation, polypharmacy, etc. Cognition - Impaired judgment Function - High risk activity for the

individual Environment - Living alone

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Overarching Concepts in Assessments

and Management• Etiologies of falls usually multifactorial• Strategy is to address identified risk factors• Most all treatment strategies involve

exercise of some sort (community-based or physical therapy)

• Strategies limited to date in fall prevention in setting of cognitive impairment in community-dwelling individuals (projects underway in nursing facilities, etc)

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Identifying Treatable Diagnoses/Risk Factors

Medical • Cardiac - relative hypotension (overtreated HTN) BP systolic goals for seniors now <140 mm Hg if under 80

yrs old,140-150 if over 80 yrs old - go by pt symptoms

- terazosin for treatment of BPH• Neurological – CNS (subdural, stroke, traumatic brain injury…) vestibular (BPPV, acoustic neuroma…) peripheral neuropathy• Musculoskeletal – deformities back, knees, ankles,

feet, pain• Polypharmacy • Nutrition - Vitamin D deficiency

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Identifying Treatable Diagnoses/Risk Factors

Mental, Functional, Environmental

• Cognitive, Emotional (depression, anxiety - fear of falling)

• Function – abnormalities of gait; unsafe ADLs

• Environment – physical hazards, social supports,

financial resources

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Assessing A Patient – History 1

• Have them describe balance problem (what feels like, how long present, rate of progression)

• Describe most recent fall (circumstances, then perhaps one, or two prior falls)(visualize the scene…)

• Describe mobility/devices used (easier to walk when pushing shopping cart – early sign rollator might help, for physical activity at least)

• Focused ROS for cardiovascular, neurological, orthopedic contributors, pain, vision, alcohol

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Assessing Patient – History 2• Function (other than walking) – showering, on/off toilet

(and whether grab bars, etc); general physical activity habits

• Consider Kemp QOL screen – “Taking everything in your life into account, please rate your overall Quality of Life on the following 7-point scale…”

1 life is very distressing, 7 life is great, 4 life is so-so

CAVEATS for KQOL – Please read reference(s) before using.Siebens H et al Correlates of a single-item quality of life measure inpeople aging with disabilities. Am J Phys Med Rehabil 2015 (open access

for anyone)

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Assessing Patient – History 3

• Social - who living with (to help, support)

- any pets (trip hazzard) - finances - “In terms of your finances, are you comfortable, making do, or is it a struggle?”

• ROS – quick screen of sleep, appetite, other

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Physical Exam - Seated

• Cognition screen – IF suspect problems Mini-cog – recall of 5 words, clock drawing• Health Literacy – special considerations • HEENT – depending on suspected dx (re

cranial nerves or visual neglect)

active neck lateral range of motion

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Clock drawing “Please draw a clock for me. Make it big. Set the time to 10 after 11.” see Borson S et al Int J Geriatr Psychiatry 2000;15:1021-1027 on Mini-cog – 3-item recall and clock drawing as cognitive screen.

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Physical Exam - Seated

• Motor tone (cogwheeling at elbow, clonus -? myelopathy)

• Muscle strength screen upper extremity (pronator drift)

lower extremity• Joint exam as indicated (hip, knee)• FEET KEY – watch taking off socks (one foot if time

short)

check hygiene (clue to cognition problem, etc) sensation (to identify peripheral neuropathy)

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Physical Exam - Standing• Sit to stand - with or without arms?• Romberg• Sternal push• Watch walking pattern, watch number of

steps to turn (normal is 3 steps) and if touch wall for balance

• Special physical exam – if suspect vestibular component, Dix-Hallpike and Epley See You Tube (Kim et al. Benign paroxysmal positional vertigo. NEJM;2014;370:12 – excellent review.)

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Labs and Therapy

• Be sure general internal medicine/family medicine recent evaluation (thyroid, lytes, CBC, etc to screen for systemic disease/infections as contributor to balance problems)

• If peripheral neuropathy, consider Vit B12, folate levels, A1C if not done already, consider referral for work up

• Vitamin D – 25-hydroxy level• Balance testing/gait assessment by Physical Therapy• ADLs review for safety, devices by Occupational Therapy

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Assessment/Plans• If unclear what’s causing problem, refer to

specialist to help (ENT for vestibular, neurology for ? Parkinson’s, degenerative process, etc)

• If multifactorial (deconditioning, prior stroke, superimposed on aging, OA of knees, kyphosis, etc):

1. treat individual identified risk factors 2. focus on compensatory strategies 3. encourage community exercise program or PT if more

severe impairment 4. recommend assistive device (“have cane at home just in

case…”); - if bilateral balance support, consider rollator for exercise and/or all the time

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Clinical Case – 75 yo Man

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Current Status• Adaptive bicycle on retail market – pedal-

forward

• Quality of Life – KQOL 5.5 - Good!

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In Summary

• Balance, fall problems complex• Good assessments key: team of physician/NP, other specialties, rehab therapies• Treatments – in health care & community over time• From single factor(s) to multiple “treatable” factors to late-life disability (keep patient as safe as possible)

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Observations, Questions?

THANK YOU.

www.siebenspcc.com

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Supplemental Slides

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Activities-specific Balance Confidence (ABC) Scale

• “How confident are you that you will not lose your balance or become unsteady when you….”

• Response scale from 0% (no confidence) to 100% (completely confident)

• 16 self-report functional items – walk around the house, walk up or down stairs… sweep the floor… walk across a parking lot to the mall…

• Can indicate early balance problems for patients who feel they don’t have a problem

Powell, LE & Myers AM. The Activities-specific BalanceConfidence (ABC) Scale J Gerontol Med Sci 1995;50:M28-34.

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Assessment/Plan – a Standardized Synthesis

I. Medical/Surgical Issues1

Contributing diagnoses to balance problem (peripheral neuropathy, severe knee OA, Vit D deficiency, etc) and plan for w/u, tx.

II. Mental Status/Emotions/Coping- Comment on safety judgment, evidence of good coping or not

(changing behaviors to be safer), Preferences- Suggest education classes on balance if available, give CDC

brochure on fall prevention (Patients need to understand how balance works, so can choose safer ways of doing things)- Suggest patients keep health information organized, take to all

appointments

1 Using the Siebens Domain Management Model domain headings; Siebens H. Top Stroke Rehabil 2011; see guidelines for use at www.siebenspcc.com; © Hilary C. Siebens 2005

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Assessment/Plan – a Standardized Synthesis

III. Physical Function1

Mobility - assistive device? - 1:1 Physical Therapy? or exercise class in

community?ADLs – safe or unsafe? Occupational Therapy assessment?

(toileting, showering, foot care, meal prep, etc)Physical Activity – coaching/motivational interviewing,

encourage walking program with safe assistive device, 30 min 5 times a week!

IV. Living EnvironmentA. Physical – grab bars in shower? rails by front steps?B. Social – involve/educate of family members? C. Financial/Community Resources – financial needs?

Community education programs for fall prevention?1 Using the Siebens Domain Management Model domain headings;

Siebens H. Top Stroke Rehabil 2011; see guidelines for use at www.siebenspcc.com;

© Hilary C. Siebens 2005