Slide 1

The link between Fall Risk and Sensory Decline Ana Hernando, OTR, MOT, MBA Please note: material maybe presented that is not printed in this manual. Feel free to use the note pages at the end of the manual Slide 2 Geriatric Sensory Processing and Fall Prevention Introduction http://www.youtube.com/watch?v=n5w8IfwAlGg http://www.youtube.com/watch?v=n5w8IfwAlGg Fall Statistics Whats up with the numbers? Autonomic Nervous System Whats automatic about falling? Sensory Processing Getting your 3 senses worth Factors to Falling CNS -Illness and Disease Pharmacology Whats in the fine print Environmental and Mindset External and Internal Perceptions Kinesiology- Gift of muscle memory and exercise Slide 3 Fall Assessments ABCS Current Trends Validity and Reliability Selection Process Fall Prevention/ Fall Risk Reduction Therapy Implications Treatment Plans Discharge Planning Multidisciplinary Communication Medical Team Family and Caregivers Documentation Slide 4 Introduction CMS Definition of Fall- Fall refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. CMS Manual Department of Health and Human Services Centers for Medicare and Medicaid Services August 17, 2007 Slide 5 Introduction CMS guidelines for fall intervention Educate staff Repair equipment Develop and revise policies and procedures Resident directed approach May include implementing specific interventions as part of the POC. Slide 6 Statistics 1:3 age 65+ fall each year Leading cause of injury death Most common cause of hospital admission for trauma for 65+ Death related to falls is increasing 30% of falls result in significant injury Leading cause of fractures in elderly Fear of falling increases fall risk Men >women in fall related deaths Women>men falls resulting in injury 90% of hip fractures resulted from a fall http://www.cdc.gov/HomeandRecreationalSafety/Falls/adultfalls.html Slide 7 Autonomic Nervous System Conveys sensory input and impulses Provides information to the subconscious mind Parasympathetic Nervous System Conserves energy, slows down heart rate Sympathetic Nervous System Burns energy, fight or flight response to danger Goldberg, 2007 Slide 8 Autonomic Nervous System Dysautonomia- Fainting Unexplained loss of consciousness Orthostatic hypotension ( blood pressure reduction during standing, POTS) Postprandial hypotension (blood pressure reduction after a meal) Slide 9 Sensory Processing Slide 10 Sensory Processing: Left and Right Hemispheres LEFT RIGHT Uses Logic and Reason Thinks in Words Deals in parts and specifics Will analyze Take things apart Sequential thinking Time bound Extroverted Ordered and controlled Individualality Uses intuition and emotions Thinks in pictures Deals in wholes and relationships Will synthesize Put things together Holistic thinking Time free Introverted Spontaneous and free Group mentality Slide 11 Sensory Processing SPACETIME Slide 12 Visual & Vestibular Motor Planning & Coordination Body awareness, proprioceptive input Walking, sitting, transfers, balance Slide 13 Auditory & Vestibular Speech & Sequencing Breathing Balance Slide 14 Visual & Auditory Abstract Thought, Reasoning, & Coping Skills Problem solving Humor Slide 15 Sensory Processing SPACETIME Slide 16 CNS Function Learning Modulation Habituation Sensitization Thresholds Genetic Endowment Personal Life Experiences Slide 17 Quick Review of Cranial Nerves CN1 Smells CN2Sees CN3, 4, and 6 Moves eyes, constricts pupils, accomodates CN5 Chews and feels front of head CN7 Moves the face, tastes, salivates and cries CN8 Hears and regulates balance CN9 Tastes, salivates, swallows, monitors carotid body and sinus CN10 Talks, communication to and from thoraco-abdominal viscera CN11 Turns head, lifts shoulders CN12 Moves tongue Slide 18 Factors to Falling CNS -Illness and Disease Vertigo-Central vs. peripheral Tinnitus CN8 Parkinsons reduced muscle strength (force) and power (force x velocity) Shingles is latent in cranial nerve ganglia, dorsal root ganglia and autonomic ganglia along the entire neuraxis. Neuropathies Slide 19 Factors to Falling Pharmacology :US geriatrics population : 40% take 5-9 medications and 18 % take 10+ http://www.usatoday.com/news/health/medical/health/medical/treatments/story/2011-11-25/Four-common-meds-send-thousands-of- seniors-to-hospital/51397208/1 Benzodiazepines Antipsychotic agents Non-benzodiazepine sedative-hypnotics Antidepressants and anticonvulsants Anti-arrhythmics Diuretics Beta-blockers, vasodilators, neuroleptics http://www.ncbi.nlm.nih.gov/pubmed/15972615 Slide 20 Side effects of Xanax Changes in appetite; constipation; decreased sexual desire or ability; diarrhea; dizziness; drowsiness; dry mouth; light-headedness; nausea; tiredness; weight changes. Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue; unusual hoarseness); behavior changes; blurred vision; burning, numbness, or tingling; chest pain; confusion; dark urine; decreased coordination; decreased urination; fainting; fast or irregular heartbeat; hallucinations; loss of balance or muscle control; memory or attention problems; menstrual changes; muscle twitching; new or worsening mental or mood changes (eg, depression, irritability, anxiety; exaggerated feeling of wellbeing); overstimulation; red, swollen blistered, or peeling skin; severe or persistent dizziness, drowsiness, or light-headedness; shortness of breath or trouble breathing; suicidal thoughts or actions; tremor; trouble speaking; yellowing of the eyes or skin. Slide 21 Side Effects of Coumadin pain, swelling, hot or cold feeling, skin changes, or discoloration anywhere on your body; sudden and severe leg or foot pain, foot ulcer, purple toes or fingers; sudden headache, dizziness, or weakness; unusual bleeding (nose, mouth, vagina, or rectum), bleeding from wounds or needle injections, any bleeding that will not stop; easy bruising, purple or red pinpoint spots under your skin; blood in your urine, black or bloody stools, coughing up blood or vomit that looks like coffee grounds; pale skin, feeling light-headed or short of breath, rapid heart rate, trouble concentrating; dark urine, jaundice (yellowing of the skin or eyes); pain in your stomach, back, or sides; urinating less than usual or not at all; numbness or muscle weakness; or any illness with diarrhea, fever, chills, body aches, or flu symptoms. Slide 22 Vitamin D deficiency Poor physical performance Low muscle strength Cognitive impairments Falls Fractures Slide 23 Factors to Falling Environmental and Mindset http://www.youtube.com/watch?v=5qWpXKhWXcc&feature=related http://www.youtube.com/watch?v=5qWpXKhWXcc&feature=related MOBILIZE 2010 study; 765 participants median age 78 46.7% fell outside- 23% sidewalks, 14% curbs/streets, 13% outside stairs, 6% parking lots. Kinesiology http://www.youtube.com/watch?v=hTYDBJ0kP3I&feature=related http://www.youtube.com/watch?v=hTYDBJ0kP3I&feature=related Muscle weakness Limited ROM and poor biomechanics Reaction time Slide 24 Continuous cycle FallInjuryFearImmobilityDepressionIllness Muscle weakness Slide 25 Fall ABCS A- Age >85 years old B- Bone issues C-Coagulation S-Surgery Slide 26 Fall Assessments and Screens Current Trends Morse Fall Scale Hendrich II Fall Risk Model Timed Up and Go (TUG) Berg Balance Tinetti Balance Scale 6 Minute Walk Test Survey Of Activities and Fear of Falling in the Elderly (SAFE) Adult Sensory Profile Validity and Reliability-Case studies and participants vary by setting. Selection Process- How do you choose? Slide 27 Morse Fall Scale VariablesScore History of FallingNo (0) Yes (25) Secondary DiagnosisNo (0) Yes (15) Ambulatory AidBed Rest/ Nurse assist (0) Cruches/cane /walker (15) Furniture (30) IV or IV AccessNo (0) Yes (20) GaitNormal/bedrest/immobile (0) Weak (10) Impaired (20) Mental StatusKnows own limits (0) Overestimates or forgets limits (15) Slide 28 Morse Fall Scale Risk Level MFS Score Action No Risk 0-24Good basic nursing care Low to Mod risk 25-45 Standard Fall prevention High risk 46+ High fall preventions http://www.patientsafety.gov/SafetyTopics/fallstoolkit/media/morse_falls_pocket_card.pdf Slide 29 Hendrich II Fall Risk Model http://vimeo.com/4200978 http://hfhs-formslibrary.org/forms/HFH-59-0749MR- 0907%20hendrich%20risk%20form.pdf http://hfhs-formslibrary.org/forms/HFH-59-0749MR- 0907%20hendrich%20risk%20form.pdf To be completed by Nurse Slide 30 Slide 31 Timed Up and Go http://www.fallpreventiontaskforce.org/pdf/TimedUp andGoTest.pdf http://www.fallpreventiontaskforce.org/pdf/TimedUp andGoTest.pdf Slide 32 Berg Balance http://www.aahf.info/pdf/Berg_Balance_Scale.pdfwww.aahf.info/pdf/Berg_Balance_Scale.pdf Slide 33 Tinetti Balance Scale http://www.bhps.org.uk/falls/documents/TinettiBalan ceAssessment.pdfwww.bhps.org.uk/falls/documents/TinettiBalan ceAssessment.pdf Slide 34 6 Minute Walk Test http://www.rehabmeasures.org/PDF%20Library/6%20 Minute%20Walk%20Test%20Instructions.pdfwww.rehabmeasures.org/PDF%20Library/6%20 Minute%20Walk%20Test%20Instructions.pdf Slide 35 SAFFE-Survey of Activities and Fear of Falling in Adults http://www.ecu.edu/cs-dhs/encfpc/upload/17- SAFFE.pdf http://www.ecu.edu/cs-dhs/encfpc/upload/17- SAFFE.pdf Slide 36 Adult Sensory Profile Provides insight to life long sensory issues Gives the individual opportunity to provide input Helps highlight learning preference AdolescentAdultSampleReport.pdf Slide 37 Adult Sensory Profile http://www.pearsonassessments.com/NR/rdonlyres/E DCEB5C2-F4BA-435F-B4F7- 69C4DF365B3C/0/AdolescentAdultSampleReport.pdf http://www.pearsonassessments.com/NR/rdonlyres/E DCEB5C2-F4BA-435F-B4F7- 69C4DF365B3C/0/AdolescentAdultSampleReport.pdf Slide 38 Fall Prevention/ Fall Risk Reduction Therapy Implications- Immobility is the greatest common denominator. Screens Medication changes UTIs Slide 39 Fall Risk Reduction Therapy Treatment Plans- Muscle strength Gait Balance Activity tolerance Socialization Home Safety evaluation Community settings Slide 40 Fall Risk Reduction Discharge Planning Should be address at beginning of therapy Forward thinking and problem solving WHAT HAPPENS NEXT? Structured, scheduled regular exercise/activity Slide 41 Documentation S: Pt is 75 yo referred to OT/PT home health after recent fall at dtrs home in the living room resulting in decreased mobility, increased pain with standing, and decreased independence with bathing. PLOF: Pt lives with dtr in one story home and approximately 4 inch threshold step for entry. Pt has a pet lap dog that is very friendly and runs around the house. Dtr works approximately 10 hrs a day out of the home. Pt has walker but it was her husbands, whom is now deceased. Prior to her fall pt was independent with ADLs and CGA for walking. Pt was not driving but does go to Sunday services and to the grocery store with her dtr. She usually goes to the beauty shop every 2 weeks. She is a member of the Rotary Club but reports she is not very active. PMH: HTN, CHF, UTI, GAD, Depression Slide 42 Documentation O: ADLs LB Bathing: Mod A UB Bathing: Min A LB Dressing: Mod A UB Dressing: S Grooming: S Toileting: Mod A Transfers: Min A with RW Balance Sitting s/d fair+/fair, Standing s/d fair/fair-. Pain 5/10 with movement Fear of Falling 7/10 in bathroom. BUE Strength grossly 3/5 A: Pt is pleasant lady whom states her desire is to get back to what she was doing but states she is afraid to fall again. She demonstrates decreases in her balance for both sitting and standing. Her self reported pain and fear levels are strong indicators for risk of repeat falling. Her history of depression, fall history and fear of falling indicate she is a fall risk. Pt would benefit from skilled OT to increase her participation level for ADLs, increase her overall mobility, decrease her c/o pain and fear to return her to PLOF. Slide 43 Documentation P: Pt will participate in OT 2 times a week for 4 weeks. LTG: Pt to perform bathing using AE as needed with less than 2/10 self report of fear of falling. LTG: Pt to increase dynamic standing to good to perform self care tasks with decreased c/o pain to 1/10 to facilitate mobility. LTG: Pt to complete morning ADL routine with Mod I to reduce burden of care. LTG: Pt to complete toilet hygiene with 90% accuracy to increase health and reduce risks of UTI. LTG: Pt will demonstrate understanding of fall recovery plan. STG: Pt to complete 1 set 10 reps of BUE exercises without s/s of fatigue. STG: Pt to perform 30 min of dynamic sitting balance tasks withSlide 44 Multidisciplinary Communication Medical Team- What do the therapists need to know? What do the nurses need to know? What do the CNAs need to know? What do the doctors need to know? How do we share information? Slide 45 Documentation http://www.mnhospitals.org/inc/data/tools/Safe-from-Falls-Toolkit/Post- Fall_Evaluation.pdf Slide 46 Family and Caregivers What is the patients normal? Adult Sensory Profile Empathy and respect Statistics approach What most people do Community class- Matter of Balance Slide 47 Scenarios Slide 48 Notes Slide 49 Slide 50 Slide 51 Slide 52 References Cumming, R.G., Le Couteur, DG. (2003). Benzodiazepines and risk of hip fractures in older people: a review of the evidence. CNS Drugs. 17(11), 825-837. http://www.ncbi.nih.gov.http://www.ncbi.nih.gov Freiberger, E., Haberle, L., Spirduso, W.W., Rixt Zijlstra, G.A. (2012). Long-term effects of three multicomponenet exercise interventions on physical performance and fall-related psychological outcomes in community-dwelling older adults. J Am Geriatr Soc. 60(3), 437-446. www.medscape.com/viewarticle/760670.www.medscape.com/viewarticle/760670 Goldberg,S (2007). Clinical neuroantaomy made ridiculously simple.Miami: MedMaster Inc. Hanney, W.J., Kolber, M.J., Beekhulzen, K.S. (2009). Implications for physical activity in the population with low back pain. Am J Lifestle Med. 3(1), 63-70. www.medscape.com/viewarticle/587890.www.medscape.com/viewarticle/587890 Hendrich, A. L., Bender, P.S., Nyhuis, A. (2003). Validations of the Hendrich II Fall Risk Model: A large concurrent case/control study of hospitalized patients. Applied Nursing Research. 16(1), 9-21. Inouye, S.K., Brown, C.J, Tinetti, M.E. (2009). Medicare nonpayment, hospital falls, and unintended consequences. New England Journal of Medicine. 360, 2390-2393. Kelsey, J.L., Berry, S.D., Proctor-Gray, E., Quach, L., Nguyen, U.S.D.T., Li, W., Kiel, D.P., Lipsitz, L.,A., Hannan, M.T., (2010). Indoor and outdoor falls in older adults are different: the maintenance of balance, independent living, intellect, and zest in elderly of Boston study. J Am Geriatric Soc. 58(11), 2135-2141. www.medscape.com/viewsrticle/734147.www.medscape.com/viewsrticle/734147 Kim, E.A., Mordiffi, S.Z., Bee, W.H., Devi, K., Evans, D. (2007). Evaluation of three fall-risk assessment tools in an acute care setting. Journal of Advanced Nursing. 60(4), 427-435. www.ncbi.nlm.nih.govpubmed/17919164. Kim, J.S., Lee, H. (2009). Inner ear dysfunction due to vertebrobasilar ischemic stroke. Semin Neurol. 29(5), 534-540. http://www.medscape.com/viewarticle/714338. http://www.medscape.com/viewarticle/714338 Muir, S.W., Montero-Odasso, M. (2011). Effect of vitamin D supplementation on muscle strength, gait, and balance in older adults. J Am Geriatri Soc. 59(12), 2291-2300. http://www.medscape.com/viewarticle/756254.http://www.medscape.com/viewarticle/756254 Painter, J.A., Allison, L., Dhingra, P., Duaghtery, J., Cogdill, K., Trujillo, L.,G., (2012). Fear of falling and its relationship with anxiety, depression, and activity engagement among, community-dwelling older adults. The American Journal of Occupational Therapy. 66(2), 169-176. Ruddock, B. (2004). Medications and falls in the elderly. CPJ/RPC. 137(6),17-18. Wong, J. Philip, J., Hilas, O. (2012). Management of dizziness and vertigo. US Pharmacist. http://www.medscape.com/viewarticle/758389. http://www.medscape.com/viewarticle/758389