Falls: The Double-Edged Sword

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Falls: The Double-Edged Sword




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Presentations text content in Falls: The Double-Edged Sword

Slide1

Falls: The Double-Edged Sword Evidence-Based Perspectives

Dennis W. Klima, PT

, MS, PhD, DPT, GCS, NCSDepartment of Physical TherapyUniversity of Maryland Eastern Shoredwklima@umes.edu

AN INTERDISCIPLINARY APPROACH TO

OLDER ADULT FALL PREVENTION

APRIL 15, 2015

8:00 A.M. – Noon

Sheppard Pratt Conference

Center

Slide2

Objectives

Learning Objectives:

1.

Discuss

evidence base recommendations for interventions to reduce falls in older adults

2. Describe

balance and gait changes associated with aging.

3. Describe

major intrinsic and extrinsic causes of falls among older adults.

4. Construct

fall prevention programs for older adults, which are multidimensional and address exercise, fear of falling, and floor recovery strategies.  

Slide3

Falls and the Aged Population:How Serious is the Problem?

> Among older adults falls are the leading cause of both fatal and non-fatal injuries. Over 95% of hip fractures are caused by falls. Falls are the leading cause of traumatic brain injury. Older men more likely to die from a falls-related injury. (CDC, 2015 )

Slide4

Question about Falls Management……..

Why a “double-edged sword?”

Slide5

Risk Factors

Previous fallsBalance & gait impairmentsMedications

Risk increases with increasing number of risk factors

Ensrud et, 2007

Slide6

Causes of Falls

Intrinsic Causes Extrinsic Causes

Slide7

7

Slide8

Optimizing footwear for older people at risk of falls Jasmine C. Menant, PhD;1* Julie R. Steele, PhD;2 Hylton B. Menz, PhD;3 Bridget J. Munro, PhD;2 Stephen R. Lord, PhD,DSc1 Volume 45 Number 8, 2008   Pages 1167 — 1182

Shoes and Falls?

Slide9

Medications and Falls

Psychoactive Medications

Sedatives

Antipsychotics

Antidepressants

Movement Disorders

Parkinson’s Disease

Sinemet

Woolcott, Richardson, & Wiens, 2009

Slide10

Indoor Vs. Outdoor Falls

Indoor Falls

Risk FactorsOlder ageFemale genderIndicators of poorer health

Outdoor Falls

Risk Factors

Younger age

Male gender

Physically active

(Kelsey, Berry, Proctor-Grey et al, 2010)

Slide11

Fear of Falling Metrics…they’re all the same?

They’re not.BenefitsPitfalls

Slide12

Single Dichotomous Question

Are you afraid of falling?

Yes

No

If yes…

Does this fear limit your activities?

(Tinetti, 1993; Maki, Holliday, & Topper, 1991)

Slide13

Activities-Specific Balance Confidence (ABC) Scale

Measures balance confidence level during functional tasks (stepping on an escalator, walking on ice)100 points totalDenotes High Confidence0 10 20 30 40 50 60 70 80 90 100% No __________________________________ Completely Confidence Confident Test/Re-Test Reliability (r=.92) Developers: Myers and Powell, University of Waterloo

Slide14

Activity-Specific Balance Confidence Scale

Mid-80’s or better/Higher functional level

Concurrent Validity with FES (r=.84)

Test/Re-Test Reliability (r=.92)

6 Item Version (Goldberg et al, 2008)

Pro’s: Community-dwelling

Con's: Seasonal issues

Powell, L.E. & Myers, A.M. (1995). The Activities-specific Balance Confidence (ABC) Scale.

Journal of Gerontology A: Biological and Medical Sciences, 50

, M28-34.

Slide15

Falls Efficacy Scale-International(FES-I)

Developed by the members of the Prevention of Falls Network Europe (ProFaNE)16 items/64 total points Strong internal and test-retest reliability (ICC= .96)Assessment of fear of falling, incorporating more challenging activities compared to the original FES in evaluating community-dwelling elderly populations (Yardley et al, 2005)

Slide16

FES-I: Multilingual Translation

Slide17

Interventions(Zijlstra et al, 2007)

Systematic Review-11 Studies Identified Multifactorial Programs (n=5)Enhance confidence and perceived controlTai Chi Interventions (n=3)Exercise Interventions (n=2)Hip Protectors (n=1)

Slide18

Fear of Falling & Balance Confidence: The Clergy

Mepkin Abbey---All “Floor Recoverers”

Slide19

Why the Floor?

The Forgotten Issues

Are We Addressing it and Teaching it?

Simpson &

Salkin

,

1993

11% PT’s

21% OT’s

-Taught floor transfers

Slide20

Rising to Stand from the Floor

Terminology

Floor RiseFloor RecoveryFloor TransferSupine to Stand

Measurement

Timed Supine to Stand Test

Slide21

Rising to Stand from the Floor within the ICF Classification

Health Condition

Environmental Factors

Physical demands & barriers, transportation barriers, wheelchair design, support from family, peers, & health professionals

Personal Factors

Gender, age, BMI, education, profession, financial resources, lifestyle

Body functions & structure

(

Altered circulation, aerobic capacity, muscle performance,

)

Activities

(Deficits in

climbing stairs,

floor rise

)

Participation

Contextual factors

Slide22

Floor Rise: Types of Evidence

Ia- Meta Analysis of RCT’s Ib- At least 1 RCTIIa-At least 1 good controlled study-no randomizationIIb-At least 1 other type of good experimental study (pre-post design)III-Good descriptive non-experimental studies (e.g. correlation, case study)IV-Experts’ reports, authoritative opinions(US Agency for Health Care Policy & Research)

Slide23

Historical Perspectives

(VanSant, 1988)

(Ulrich, Raheja, Alexander, 2000)

Slide24

The Critical Fall

Term applied when a client cannot stand following a fall

Bloch, 2009Tinetti, 1993Wild, 1981

Dehydration

Hypothermia

Pressure Ulcers

Slide25

Examination

The Timed Supine to Stand Test

Slide26

Getting off the Floor…Hmmmmmm

Aim

What motor pattern is most commonly used to perform the supine to stand transition among community-dwelling older adults?

Slide27

Frailty Measures in Older Adults:Who Rises to Stand?

(Gilbert, Hamad, Patel, & Klima, 2010)

Slide28

Fried et al CHS Frailty Screen

Grip strengthWalking speedWeight lossFatigueLow physical activity

0 = Nonfrail1-2 = Intermediate3-5 = FrailResearch Exclusions:dementiaCVACHF, CADParkinson’s“other”

Slide29

Observations:Rising from the Floor and Categorizing

Pattern A

Pattern B

Pattern C

Slide30

Results: Demographic Profile

Community Dwelling

(n=61)

Age (yrs)

79.57 (± 8.6)

BMI (kg/m

2

)

27.06 (± 4.5)

Fall in past year (#)

13 (21.3%) yes

Co-morbid conditions

Heart Disease

Depression

Diabetes

13 (21.3%)

6 (8.9%)

8 (13.1%)

Slide31

Floor Rise: Timed Supine to Stand

Mean Time : 8.0 seconds (+ 5.7)Patterns:5 Subjects (9%): Pattern B48 Subjects (91%) : Pattern C(n=53)

Slide32

Correlates of Rising from the Floor

Pearson Product Moment Coefficients *Significance: p<.01 †Significance: p<.05

Timed Supine to Stand Performance: Correlation with demographic and performance variables (n=61)

Timed Supine to Stand

Age

0.57*

Normal Gait

0.61

Physical Activity

0.29*

Timed Up and Go

0.71*

ABC Score

-0.51*

Grip

Strength

-0.30

Slide33

Prognosis: Supine to Stand-Predictors

48% of the variance in floor rise could be attributed to TUG performance (p<0.001)Reliability > .90 on all ICC’s.

Slide34

Interventions

Slide35

Floor Rise Strategy Training

RCTTraining Group (n=17)Control Group (n=18)Intervention6 sessions

Training Group (n=17)

Floor Transfers

Control Group (n=18)

Chair Flexibility

Improved in

rise ability

and

less difficulty reported

(p<0.05)

Slide36

Interventions How about Dance?

Slide37

Keeping the Older Adults Moving: What’s dance got to do with it?

Danielle Ethier, Kristen Fiackos, Ellen Kuhn, Rupa PatelDennis W. Klima, PT, PhD, DPT, GCS, NCS and Margarita Treuth, PhD

Slide38

Intervention

Frequency

60 min sessions

1-2x/week

12 wks

Dance Routine

Warm-up

Gentle aerobics and breathing

Stretching

Seated and standing positions

Choreography

Continuous movement

Set to music

Cool down

Stretching on floor mats

Performed in a circle

Slide39

Dance Progression

Slide40

Physical Performance

Physical Performance Variable (N=11)Pre-Test ValuePost-Test ValueP valueNormal Gait Velocity (m/s) 1.3±0.31.3±0.10.66Fast Gait Velocity (m/s) 1.7±0.31.7±0.20.42Five Times Sit to Stand (s)11.8±2.29.2±1.90.006Timed Supine to Stand (s)6.3±2.05.6±1.50.03

Slide41

Community-Based Fall Prevention Programs

Interventions:

Slide42

Community-Based Interventions-Floor Recovery

Stepping On7 WeeksExercise ComponentBalance and strength Floor TransferGuest InstructorsPT or PTAPharmacist OptometristCommunity Safety

A Matter of Balance

8 two hour session

Take control of fall risk

Make

changes to reduce fall risk at home

Exercise to increase strength and

balance

Targets fear issue

Floor transfer by PT

Slide43

Multidimensional ProgramsFall Risk

“Stepping On”

Weekly Classes

PT Participation

Target Muscle Groups

Slide44

“Stepping On” Program

Community-based fall prevention course7 weeksContribution by physical therapy

Slide45

Target Muscles

Quadriceps

Hip Abductors

Ankle Dorsiflexors/

Plantarflexors

Follow-Up

45 Participants (mean age 75.4; range-61-91)

77.8% noted they had a better plan to rise from the floor following the program.

82.2% had a better understanding of fall causes.

Slide46

Clinical Bottom LineTake Home Message

When you fall…..And involve your students!!!!!

Medical alert systems

Buddy checks

Plan

Floor transfer

Signals

Scream Practice

Slide47

Gait Velocity-Consideration for Generational Differences

1.2 m/sec – Traditionalists Community NavigatorCan traverse streets and curb negotiation .8 m/sec – Millenials Limited Community AmbulatorNeeds Interventions for Fall Risk

Slide48

A Final Parable

ABC Score= 63% So What!!!

Slide49


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