Transcript Slide 1
An Interdisciplinary Approach to the Falls Assessment Mary Russell, PT Ericka E. Tung, MD Mr. Jones • 74 year old man • Past medical history – Hypertension – Depression – Hyperlipidemia • Presents to his primary care physician’s office for his annual check-up Mr. Jones • In addition to his chronic disease maintenance issues, his doctor asks about falls in the past year • “I guess that I stumble once in a while…. but isn’t that normal for old guys like me? Objectives • Understand risk factors that put older adults at risk for falls • Know how to screen older adults for falls and gait disorders • Understand the elements of a comprehensive falls assessment • Understand YOUR role in preventing falls in your community Top Causes of Falls • “Accident”, tripping over something in the environment • Gait or balance disorder • Dizziness • Drop attack • Confusion • Postural Hypotension • Vision disorder • Unknown Etiology of Falls • Rarely due to a single cause • May be due to the accumulated effect of impairments in multiple domains • Complex interaction of: Intrinsic factors Extrinsic factors Behaviors (risk taking, etc.) Intrinsic Factors Extrinsic Factors Medical conditions Sensory impairment Weakness & imbalance Age related changes Medications FALLS Improper use of assistive devices Environmental hazards Risk taking behavior Multifactorial Risk Factor Assessment • Falls are multifactorial therefore the approach needs to be: • Holistic • Interdisciplinary • Practical • Evidence-based Guidelines for Fall Prevention • Guideline for the Prevention of Falls in Older Persons – American Geriatrics Society – British Geriatrics Society – American Academy of Orthopaedic Surgeons • JAGS 49:664–672, 2001 JAGS 49:664– 672, 2001 Screening • • • • Who? When? Where? What? Screening Questions • Have you fallen in the past year? • How many times have you fallen in the past year? • Are you afraid of falling? Yes… I did fall once at my home JAGS 49:664–672, 2001 Timed Up and Go Test: TUG • Directions: – Have patient sit in a standard armchair – Instruct the patient to fold their arms when risking from the chair – On the instruction “GO”, have the patient stand up, walk comfortably to a line 3 meters away, turn around and sit down again. Timed Up and Go Test: TUG • Interpretation – Under 20 seconds: independence for basic transfers – 20-29: Intermediate probability for dependence in transfers – 30+: Unlikely to be able to climb stairs or go outside alone Diane Podsiadlo, BScPT, and Sandra Richardson, M.D. J Am Geriatric Soc 39:142-148,1991 Approach to the Individual with Multiple Falls • Comprehensive Falls Evaluation – Interdisciplinary approach is best • • • • • Social worker Therapist Physician Nurse Pharmacist Recurrent Falls JAGS 49:664–672, 2001 Comprehensive Falls Evaluation Step 1: Take a good history – Circumstances – Frequency – Injuries Comprehensive Falls Evaluation Step 2: Functional Status Assessment – – – – Activities of Daily Living Instrumental Activities of Daily Living Current home health support system Review of Risk Factors Comprehensive Falls Evaluation Step 3: Medication Review – “High risk” medications – >4 medications – Potential strategies to combat polypharmacy Comprehensive Falls Evaluation Step 4: Physical Examination – – – – – – Orthostatic Blood Pressure Cardiovascular system Neurologic system Visual acuity Foot examination Musculoskeletal system But what about Mr. Jones? • At the office visit – Multiple falls – Risk factors were identified • • • • • Medications Evening “night cap” Orthostasis Mild peripheral neuropathy Prolonged TUG (30 seconds) But what about Mr. Jones? • Now what?? • Action planning strategy – Multifactorial approach – Interdisciplinary approach – Importance of patient involvement Creating an Individualized Intervention • Identify modifiable and non-modifiable risk factors – Target treatment plan toward these risk factors – Mr. Jones’ risk factors • • • • High risk medication regimen Lower extremity weakness, gait dysfunction Risk taking behaviors ? Home hazards Physical Therapy Consultation • Location – Outpatient clinic – Patient’s home – SNF • Cost Issues Physical Therapy Consultation • Start with THE 3 questions: • “Have you fallen in the past year?” • “How many times have you fallen in the past year?” • “Are you afraid of falling? Balance and Strength • Assess strength and balance • Provide recommendations for long term exercise program for strength and balance • Gait training and appropriate use of assistive devices Home Environment Assessment • Room by room; inside and outside • Clutter, cords, lighting, width of walk ways, and condition of flooring • Grab bars for bathroom, tub bench or shower chair, non skid tub surface, raised toilet seat • Night light in bedroom, phone and flash light next to bed • Frequently used items in kitchen should be within reach • Stairs both inside and outside should have adequate lighting and be free from clutter Mr. Jones’ Individualized Intervention 1. Simplification of Medication Regimen 2. Counsel him about risk taking behaviors and alcohol use 3. New gait aid 4. Home modifications 5. Utilization of community exercise program MNfallsprevention.org • Overview of the site – – – – For the public For health care professionals Navigation Tools Assessment Tools • Types – Fall risk factor assessments • Focus on intrinsic risks • Typically performed by nursing staff in the hospital or NH setting – Functional assessment instruments • Focus on gait/balance • Typically performed by therapists, rehab specialists in the outpatient setting Assessment Tools • Assessment tools – Pros – Cons – Limitations Assessment Tools • Factors for consideration – – – – Setting Time limitations Skill set of the professional Sensitivity/Specificity Interdisciplinary Team Approach • Role of the social service or public health professional – – – – Screening Risk factor identification Preparing older adult for upcoming appointments Inspection of living environment Interdisciplinary Team Approach • Role of the primary care provider – History and physical examination – Identification of risk factors – Action planning • What is the patient actually willing to do? – Appropriate referrals Interdisciplinary Team Approach • Role of the therapist – Physical therapist • – Occupational therapist • – Strengthening, balance, and gait training Home modifications, cognitive assessment, compensatory strategies Team approach • • Coordination and continuum of care between all disciplines in all settings Patient/Caregivers Interdisciplinary Team Approach • Role of the skilled nursing facility professional – Staff training – Identification of modifiable risk factors – Target interventions • Bed alarms • Hip protectors • Environmental modifications Questions