Falls Among Older Falls Among Older AdultsAdults

• DATA: DATA: prevalence, risk factors and costsprevalence, risk factors and costs

• FEAR: Falls Self-Efficacy and Fear of Falling FEAR: Falls Self-Efficacy and Fear of Falling

• INTERVENTIONSINTERVENTIONS: Physical Therapy, Vision, : Physical Therapy, Vision, Hearing, Medication Mgt, Home Safety / Hearing, Medication Mgt, Home Safety / Environmental Safety, EducationEnvironmental Safety, Education

• RESOURCESRESOURCES

–Education (Home safety/medication safety)–Balance/Exercise

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FALLS – Prevalence/Consquences Leading preventable cause of functional

disability and mortality among older adults 1/3 of Community-Dwelling people over age

65 fall each year (Tinetti) yet less than half of those who fall discuss this with health care providers. (Stevens et al., 2012)

Falls are the leading cause of death due to injury for people 65 years and older (NCIPC 2002)

Mortality 12 months after a hip fracture ranges from 12 to 67%.

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Falls Rates - chances of falling and serious injury increase with age People age 75 and older who fall are four to

five times more likely than those age 65 to 74 to be admitted to a long-term care facility for a year or longer. (Donald IP, Bulpitt CJ. The prognosis of falls in elderly people living at home. Age and Ageing 1999; 28:121–5; CDC website accessed Feb 2015)

Fall rate injuries for adults 85 and older is almost four times that for adults 65 to 74. (Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web–based Injury Statistics Query and Reporting System (WISQARS)

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Fall Rates / Fatalities increasing 2012 vs 2002 2012: Nearly 24,000 people over 65 died

after a fall - almost double that # in 2002 (CDC http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html )

2012: More than 2.4 million people over 65 were treated in emergency departments for injuries from falls, an increase of 50% since 2002.

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Alameda Co. Hospital Data 2013 of7,098 non-fatal unintentional injuries: ~ 40% from elders falling

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Falls COSTS – Direct Medical Costs In 2012, the direct medical costs of falls,

adjusted for inflation, were $30 billion in 2009 Cost for inpatient and outpatient

medical care for non-fatal falls: $19 billion 1997 study of people age 72 and older:

fall-injury medical cost averaged $19,440 (hospital, nursing home, emergency room, and home health care, but not doctors’ services)

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Impact on individuals and families Detrimental impacts on quality of life are not included in cost

analyses Direct costs do not account for the long-term effects such as

disability, dependence on others, lost time from work and household duties, and reduced quality of life as well as effect on family caregivers.

Economic systems: Elders who offered child care Q of L: For those who survive, fewer than one-third of older adults

who were hospitalized return to their pre-fall level of activity.

Beers & Berkow, 2000; Roudsari et al. (2005);

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Consequence of Falls Reduced Activity: Isolation, Loneliness,

Depression Costs: Medical & Non-Medical Fear of falling (ptophobia) reduces

participation in life activities, exacerbates functional declines, and has psychosocial ramifications (Davison & Marriman, 2007; Dugan & Bonds, 2002,

Lach, 2005). 22% – 43% of community-dwelling older

adults have a fear of falling. (Lach, 2005)

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Fear of Falling …

Not a good feeling… inhibits activities

can make things worse due to inactivity

stiffness… less strength…

balance gets worse

…then falls risk is HIGHER

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Fear of Falling - Ptophobia Fear of falling is a topic in the NIH’s guide:

Can I Really Talk About That? Discussing Sensitive Subjects in “Talking with Your Doctor: A Guide for Older People” http://www.nia.nih.gov/HealthInformation/Publications/TalkingWithYourDoctor/chapter08.htm

Studies: Ptophobia: intense fear of standing or walking as a result of accidental falls and also in those who have not fallen. Patients demonstrate reduction of anxiety and functional improvement in walking following behavioral desensitization and physical therapy. http://www.ncbi.nlm.nih.gov/pubmed/6120526

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Falls: Causes are Multifactorial

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Risk Factors: Additional Lists

American Geriatrics Society Panel on Falls in Older Persons (2001). 12

Risk Factors ~ Predictive Value

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Balance SystemsNervous System Functions including

• Vision and Hearing

• Proprioception

• Vestibular function

• Orthostatic hypotension

Fatigue “disturbs the functioning of the protective reactions and impairs perception, making them liable to injurious falls” (Koski, Luukinen, Laippala, & Kivelä, 1998).

DECONDITIONING: impairs strength. This occurs RAPIDLY in older adults.

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Neuropathies & Balance (Chemo-related –a topic where I work) Deep tendon reflexes are impaired

unsteady gait loss of sensation vestibular and ocular changes (newer info) (Holley 2002; Paice, 2009; Wampler et al., 2007)

CNS also affected (Weiss, 2008; Wolf 2008).

Age-related changes compounded by deficits incurred during treatments can persist for months and years post-treatment and sometimes is permanent (Holley, 2002; Galea, Wright & Barr 2003 Nielsen & Brandt, 2002; Weiss, 2008; Wilkes, 2007).

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Not aware of balance / falls risk People don’t recognize gradual changes

Not discussed during medical visits RCFEs/Senior Centers offer programs to

improve balance and fitness, yet people avoid (NY Times Nov 3, 2014)

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• Exploratory study: Interviews to discern key words/phrases that might indicate balance problems.

• Unexpected Result: Half of the referred patients denied a balance problem yet described ambulation difficulties normally attributed to balance deficits.

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Recognize risks…….. Balance changes slowly over time Might not be aware of changes Ability to get up from the floor – this also

changes over time Surgeries / Prior Falls: ‘Vicious cycle’:

deconditioned / more likely to fall / greater fears / reduced self-efficacy

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Medications / Polypharmacopia Meds: antipsychotics, benzodiazepines and other

anticonvulsants, Parkinson disease medications, muscle relaxants anti-hypertensives, cardiac medications, analgesics, antihistamines, anti-emetics, gastrointestinal- histamine antagonists.

Side Effects: blurred vision, sedation/drowsiness, compromised neuromuscular function, hypotension leading to dizziness lightheadedness

Some meds: Sarcopenia / Osteopenia (LHRH agonists, some statins)

Internal Bleeding! Anti-coagulants (e.g. Coumadin!)Fabre, J.M. et al. (2010) Falls Risk Factors and a Compendium of Falls Risk Screening Instruments.

The Section on Geriatrics of the American Physical Therapy Association.

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Medications (from the Nat’l Institute on Aging / NIH) Exercise can affect how medications work. Medications can affect balance! Be careful

when starting a new medication. Example: Beta Blockers tend to slow the heart rate, so you might end up exerting yourself too much if trying to reach a target heart rate. www.nia.nih.gov/HealthInformation/Publications/ExerciseGuide/chapter07.htm

The Aerobics and Fitness Association of America recommends waiting an hour after taking a Beta blocker before engaging in aerobic exercise.

Don’t exercise right after eating (post-prandial hypotension)

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Medication Safety Links (from Alice K Hwe) www.pharmacyfoundation.org www.talkaboutrx.orgwww.talkaboutrx.org www.bemedwise.orgwww.bemedwise.org www.aarp.org/health/rx_drugs/usingmedswww.aarp.org/health/rx_drugs/usingmeds www.ascp.com/consumers/tips/index.cf www.ascp.com/consumers/tips/index.cf www.fda.gov/medsinmyhomewww.fda.gov/medsinmyhome www.fda.gov/cder/consumerinfo/www.fda.gov/cder/consumerinfo/

buyOnlineGuide_text.htmbuyOnlineGuide_text.htm

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Rx

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Interventions: Multi-Factorial

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Raise Awareness / Assess Assess periodically by a professional

PT/OT, Doctor, Nurse, Exercise Physiologist/Kinesiologist, skilled trainer)Many tools: Berg, Tinetti, Timed Up & Go, Romberg, Fullerton etc

Open Dialogue: Ask about walking down stairs (need to use railing?) or crossing curbs; Can you get up from the floor? (practical question!)

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Studies consistently conclude that Multifactorial assessments and

individualized exercise/balance programs are the most successful, yielding decreased fall rates and decreased use of the medical system

In group settings, adherence among exercise program participants is reinforced by the benefits of the social context, enhanced with peer-mentoring (music also helpful)

Education and advice are useful only as an adjunct to a multifactorial program

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Why doctors don’t assess balance lack of evaluation time in primary care

settings (Dugan & Bonds, 2002) lack of awareness among health

professionals of the multifactorial nature of falls and the need to assess for falls risks (Brown, Gottschalk, Van Ness, Fortinsky, & Tinetti, 2005; Tinetti et al., 2008),

lack of program availability or accessibility (physical or financial) (Robertson, Devlin, Gardner, & Campbell 2001).

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If falls were on the MD’s radar. . . Connecticut Collaboration for Falls Prevention

(CCFP): education for health care providers raised awareness of risks and resources Result: Emergency room admissions for falls

declined in the 26 intervention zip codes versus the control zip codes

Brown et al. (2005) Chou et al., (2006) and Tinetti et al., (2008) analyzed aspects of the interventions

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Assess for Appropriate Interventions:Be Realistic per client’s Needs/Abilities Client Sets Functional Goals (to walk again w/o fear) Assist with resource lists (examples)

Home Safety Services Referral to PT for eval Consult with MD re: issues related to medications

Motivational Discussions: “Baby Steps” “Assignment” example: Put on shoes and jacket and

walk outside for 2 minutes. Or just stand outside. Find “walking buddy”

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Safety (short list ) Remove Hazards from walking paths:

wires/cords, low tables, clutter on floorScatter Rugs! Bedspreads! Long skirts! Bathrobes!

Pets (yes, pets causing falls has been measured…) Improve Lighting Grab Bars Remember: “Slippery when wet!” Storage of items used on a regular basis:

eliminate using a step-stool to reach items (move things so you don’t have to reach up high or bend down and reach into a cabinet)

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Safety Shoes (poor shoe design can contribute to risk) Walking aids are important ….However, make sure

you use these devices safely. Have a physical therapist fit the walker or cane to you.

“Some forms of vision loss increase risk of falling and injury. Have your eyes checked and update your eyeglasses” (NCOA 2011).

Hearing can affect balance Fatigue! Poor Nutrition / Dehydration Alcohol; Medications (separately and in

combination)

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External Hazards elevated tree root along a sidewalk, Problems with curb/sidewalk climbing on a ladder

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Behavior Modification – Focus and ConcentrateFocus and Concentrate Walk & Talk … sometimes not a good idea Concentrate while holding items and walking Stop climbing on chairs/step stools/ladders SLOWLY get out of bed / up from a chair IF TIRED: Be Extra Careful! ! ! !

Understand that you are changing … what you could easily do 10 years ago might not be safe today.

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Home Safety Assessment & Modification Resources

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City of Alameda

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Home Safety Assessment and Modification Resources

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High Tech Residential Communities: Lights activated by

motions (from bed to bathroom);Stair edges defined

“Magic Carpet” to assess for gait disturbances (TRIL centre in Ireland) http://www.ict-ageing.eu/?page_id=1589

Home Safety monitoring (in case of a fall) – passive alert systems for quicker response

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Resources for Neuropathy

The Pacific Chapter of The Neuropathy Association (PCNA). http://www.pnhelp.org EMAIL: info@pnhelp.org

PN Local Support Groups: organized by the PCNAPhone: (877) 622-6298 Bev Anderson (main office of PCNA)

Berkeley 3rd Monday of the month 3pm-4pm; North Berkeley Senior Center / contact Kathleen Nagel (510) 653-8625

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Interventions And Successful Outcomes

Multifactorial Assessments: include gait/strength analysis; medical review; home safety assess

INTERVENTIONS Physical Therapy Individualized Exercise and Balance Training Group Exercise: Tai Chi has the best outcomes for

improved balance and strength. Studies of Tai Chi as an intervention overwhelmingly find it reduces falls risks and actual rates of falls

(Davison & Marinan, 2007;

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At any age Muscle Strength People in their 80s and 90s can acquire greater muscle strength, (although perhaps not muscle mass) with a strength program. (Campbell & Robertson, 2005 BMJ; Gillespie et al., 2009, Cochrane; Lord, S. et al, 2003 JAGS; Robertson et al, 2001, BMJ)

“While we do lose muscle as we age, exercise can partially restore strength and flexibility. It’s never too late to start an exercise program.” © 2011. National Council on Aging

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From the NCOA & NIH“Strength and balance exercises, managing

your medications, having your vision checked and making your living environment safer are all steps you can take to prevent a fall.” (Nat’l Council on Aging, Sept. 2011)

“Balance exercises help prevent a commonproblem in older adults: falls. Falling is a major cause of broken hips and otherinjuries that often lead to disability and lossof independence. Some balance exercisesbuild up your leg muscles; others require youto do simple activities like briefly standing on one leg.”

(NIA/NIH 2011)

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From the Nat’l Institute on Aging / NIH

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Resources – Referrals to TherapyAll professionals need to “tune in” to the

client’s concerns, needs, how to motivate REFER to Physical Therapy for Evaluation

Customized Program to address Deficits Personal Trainer skilled in older-adult needs

(physiological and psychosocial)

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Referrals to PT for Evaluation and Tx INSURANCE:

Rx authorization for PT Evaluation depends on insurance carrier.

Criteria for Coverage (two examples):

Patient-Reported Fall(s) Change in level of assistance needed: Could walk independently, but now

requires assistance (human or any device) such as having wall/table nearby

Evaluations & Treatments: What Patients Could Expect

Different assessment tools evaluate patient for static (standing still) and dynamic (in motion) balance, flexibility, strength, and sensation.

They help patients learn what it means to feel balanced, in particular when neuropathy results in a change in sensation in their feet.

“passive ROM exercise enhances re-innervations in muscle” (Visovsky 2003)

2 to 4 visits depending on the patients needs; expected to work independently on a home program.

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Resources – balance/strength Balance Clinics ABSMC

5700 Telegraph ($10); PT & Infrared Tx 510 204-17882001 Dwight Way (MD referral) PT/OT 510-204-4599

Falls Prevention Center at Highland Assessments - Screenings - Referrals Stefania Kaplanes 510-535-7648 IDT approach: pharmacy, physical therapy, geriatrics

Seated Exercise (chairs, w/c) esp. for arthritis, good for PN North Oakland Senior Center 510-597-5085;

5714 Martin Luther King Jr. Way Thursdays – 11:30 am – 12:30pm

Spectrum Community Svcs (congregate sites in South Alameda County)

Sit & Be Fit (DVD and on broadcast TV stations locally)

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Resources – Balance & Gentle Exercise

• SENIOR CENTERS: (Mastik, Downtown Oakland, North Oakland, North Berkeley)

• Balance Clinic 5700 Telegraph Ave; Oakland 510-204-1788 (every Wednesday) http://altabatessummit.org/rehab/outpatient/balance.html

• Alta Bates Summit Health Access and the Independent Gym http://altabatessummit.org/health/cpsg_healthaccess.html $50 for three months. (510) 204-1788 5700 Telegraph Ave, Oakland; M-F . Lockers and showers

• ABSMC Cardiac Rehab Program (Physician referral required) 510 204-1554 RehabABS@sutterhealth.org 3030 Telegraph Ave. Berkeley

• Outpatient Neuro Rehab (including balance and strength and audiology) 510-204-4599 2nd Floor Herrick; 2001 Dwight Way; Berkeley http://altabatessummit.org/rehab/outpatient/neuro.html

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Intervention Programs – ‘packaged’

• A Matter of Balance incorporates cognitive behavior therapy, setting realistic goals, making safety modifications to the home, and teaching exercises that increase strength and balance. Improved outcomes: reduced fear of falling and improved confidence in performing everyday tasks without fear of falling.

• FIT & STRONG! For osteoarthritis teaches strength exercises and provides an educational component

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Alameda County DPH / EMS / SIPP Partnership among multiple non-profits that

serve older adults. Funded by AC County supervisors (and other funds)

Components of three local programs: exercise/balance training; medications review; referrals for minor home modifications and grab-bar installation (high-risk clients)

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Personal Trainer ($ but effective)

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What might balance exercise look like?(two examples)

NOTE: do these with a professional!

• Heel-to-Toe walking(dynamic balance)

• One Foot Stands (static balance)

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Good news: Most risks are modifiableBest Practices Summary: Assessment by PT Multiple program types for balance

improvement (individualize or group settings) Group Settings

Integrate exercise programs with social context to enhance adherence.

Provide Education to also enhance safety Home Safety/Modifications

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Web Resources http://www.ncoa.org/assets/files/pdf/center-for-healthy-aging/KS-2010_Falling_Links_T

oolkit.pdf

http://waystohelp.ncoa.org/site/MessageViewer?em_id=12941.0&dlv_id=20041 Alameda County Senior Injury Prevention Program: (five stars; please visit this!!)

http://www.acgov.org/PublicHealth/organization/divisions/ems/ems_SIPP.htm Website has useful documents such as home safety, medication safety, fitness.

Fall Prevention Center of Excellence: http://alameda.networkofcare.org/aging/library/fall_prevention.cfm (and a link to the ‘parent’ organization’s website http://stopfalls.org/individuals_families/index.shtml )

NCOA: http://www.ncoa.org/assets/files/pdf/center-for-healthy-aging/KS-2010_Falling_Links_Toolkit.pdf

Medscape (medical bulletins website with summaries of journal articles, usually rather technical) http://www.medscape.com/resource/sportsmed/rc-sportsmed3 articles such as these:

Moderate Exercise Improves Memory in Older Adults: Aerobic exercise training that gets sedentary older adults up and walking for 40 minutes 3 times a week boosts the size of the hippocampus and improves memory. http://www.medscape.com/viewarticle/736797 , (Proc Natl Academy of Science Jan 31, 2011)

Music-Based Exercise Class Cuts Seniors' Fall Risk: Exercises that combine music and rhythmic movement may help curb the rate of falls among older adults who are at increased risk. http://www.medscape.com/viewarticle/733020

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