Transcript Geriatric Sensory Processing and Fall Prevention

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
Geriatric Sensory Processing
and Fall Prevention
 Introduction http://www.youtube.com/watch?v=n5w8IfwAlGg
 Fall Statistics What’s up with the numbers?
 Autonomic Nervous System What’s automatic about falling?
 Sensory Processing Getting your 3 senses worth
 Factors to Falling
 CNS -Illness and Disease
 Pharmacology What’s in the fine print
 Environmental and Mindset External and Internal Perceptions
 Kinesiology- Gift of muscle memory and exercise
 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
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
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 .
Statistics
 1:3 age 65+ fall each year
 Leading cause of injury death
 Most common cause of hospital admission for trauma
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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
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
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)
Sensory Processing
Sensory Processing:
Left and Right Hemispheres
LEFT
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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
RIGHT
 Uses intuition and emotions
 Thinks in pictures
 Deals in wholes and
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relationships
Will synthesize
Put things together
Holistic thinking
Time free
Introverted
Spontaneous and free
Group mentality
Sensory Processing
SPACE
TIME
Visual & Vestibular
 Motor Planning & Coordination
 Body awareness, proprioceptive
input
 Walking, sitting, transfers, balance
Auditory & Vestibular
 Speech &
Sequencing
 Breathing
 Balance
Visual & Auditory
 Abstract Thought,
Reasoning, & Coping
Skills
 Problem solving
 Humor
Sensory Processing
SPACE
TIME
CNS Function
Learning
Modulation
• Habituation
• Sensitization
Thresholds
• Genetic Endowment
• Personal Life Experiences
Quick Review of Cranial Nerves
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CN1 Smells
CN2 Sees
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
Factors to Falling
 CNS -Illness and Disease
 Vertigo-Central vs. peripheral
 Tinnitus CN8
 Parkinson’s 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
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-ofseniors-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
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.
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.
Vitamin D deficiency
 Poor physical performance
 Low muscle strength
 Cognitive impairments
 Falls
 Fractures
Factors to Falling
 Environmental and Mindset
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
 Muscle weakness
 Limited ROM and poor biomechanics
 Reaction time
Continuous cycle
Fall
Muscle
weakness
Injury
Illness
Fear
Depression
Immobility
Fall ABCS
 A- Age >85 years old
 B- Bone issues
 C-Coagulation
 S-Surgery
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?
Morse Fall Scale
Variables
History of Falling
Secondary Diagnosis
Ambulatory Aid
IV or IV Access
Gait
Mental Status
Score
No (0)
Yes (25)
No (0)
Yes (15)
Bed Rest/ Nurse assist (0)
Cruches/cane /walker (15)
Furniture (30)
No (0)
Yes (20)
Normal/bedrest/immobile (0)
Weak (10)
Impaired (20)
Knows own limits (0)
Overestimates or forgets limits (15)
Morse Fall Scale
Risk Level
MFS Score
Action
No Risk
0-24
Good 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
Hendrich II Fall Risk Model
 http://vimeo.com/4200978
 http://hfhs-formslibrary.org/forms/HFH-59-0749MR-
0907%20hendrich%20risk%20form.pdf
 To be completed by Nurse
Timed Up and Go
 http://www.fallpreventiontaskforce.org/pdf/TimedUp
andGoTest.pdf
Berg Balance
 http://www.aahf.info/pdf/Berg_Balance_Scale.pdf
Tinetti Balance Scale
 http://www.bhps.org.uk/falls/documents/TinettiBalan
ceAssessment.pdf
6 Minute Walk Test
 http://www.rehabmeasures.org/PDF%20Library/6%20
Minute%20Walk%20Test%20Instructions.pdf
SAFFE-Survey of Activities and Fear
of Falling in Adults
 http://www.ecu.edu/cs-dhs/encfpc/upload/17-
SAFFE.pdf
Adult Sensory Profile
 Provides insight to life long sensory issues
 Gives the individual opportunity to provide input
 Helps highlight “learning preference”
 AdolescentAdultSampleReport.pdf
Adult Sensory Profile
 http://www.pearsonassessments.com/NR/rdonlyres/E
DCEB5C2-F4BA-435F-B4F769C4DF365B3C/0/AdolescentAdultSampleReport.pdf
Fall Prevention/ Fall Risk Reduction
 Therapy Implications- Immobility is the greatest
common denominator.
 Screens
 Medication changes
 UTIs
Fall Risk Reduction
 Therapy Treatment Plans-
Muscle strength
Gait
Balance
Activity tolerance
Socialization
Home Safety evaluation
Community settings
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
Documentation
 S: Pt is 75 yo referred to OT/PT home health after recent fall at
dtr’s 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 husband’s,
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
Documentation
 O: ADL’s 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.
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 with <5/10 fear of falling.
STG: Pt to increase toileting to min A.
STG: Pt will verbalize sequencing steps for fall recovery plan with 75% accuracy.
STG: Family will verbalized understanding of fall recovery plan with 100% accuracy.
STG: pt and family to demonstrate understanding of fall risk reduction
recommendations.
Multidisciplinary Communication
 Medical Team What do the therapists need to know?
 What do the nurses need to know?
 What do the CNA’s need to know?
 What do the doctor’s need to know?
 How do we share information?
Documentation
Fall_Evaluation.pdf
http://www.mnhospitals.org/inc/data/tools/Safe-from-Falls-Toolkit/Post-
Family and Caregivers
 What is the patient’s “normal”? Adult Sensory Profile
 Empathy and respect
 Statistics approach
 “What most people do…”
 Community class- Matter of Balance
Scenarios
Notes
Notes
Notes
Notes
References
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