Transcript Don`t Let a Fall Be Your Last Trip: Who`s At Risk?

Don't Let a Fall Be Your
Last Trip: Who's At Risk?
H2U - Health, Happiness, You
April 15, 2009
Brian Werner, MPT
President – Werner Institute
Question?
• How many of you in the
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audience know that for injury
related deaths, the number
one (1) reason in people over
70 is due to a serious fall?
– Why is Fall Prevention
Programs not a primary
focus in medicine?
How many of you have
been formally assessed in
your doctors office for
FALL RISK?
– If so, what did they do to
determine your risk?
Brian K. Werner, PT, MPT
• Master’s Degree in Physical Therapy
– Northern Arizona University –
Flagstaff, AZ
• National Certification of
Competency – Vestibular Assessment
and Treatment
– Miami School of Medicine: Physical
Therapy Department – Miami, Fl
(2000)
• Service
– Director and Lead Clinician of
Balance Centers of America: Las
Vegas and Henderson (2001-2005)
• Service
– Lead Clinician and Owner of the
Werner Institute of Balance and
Dizziness, Inc. (11/05 to present)
Scenario
• Dorothy, an energetic 68-year old, had an
active life that involved family, church,
community volunteer work and lots of
social time with friends. That is, until she
broke her hip from a fall she took in her
own home. Her daughter found Dorothy
one morning lying helplessly on the
kitchen floor unable to call for help.
Learning Objectives for
Presentation
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You should really be aware of your risks
Is this really a big problem or this really just an age issue
Why Seniors Don’t Tell Their Doctors
What is a fall
How can falls be reduced
The Tipping Point
What is balance and is it really something that can be
treated
Dizziness Defined
How Do You Treat Dizziness
Most Common Form of Dizziness - BPPV
Does the therapy actually work
What can you do to prevent a fall
Should You Be Aware…
• On average, a person
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loses about one-half a
percent of their overall
balance every year
starting from about the
age of 20 mostly due to
decreasing levels of
activity, not aging.
Inactivity causes the
balance system to
weaken much like a
muscle that isn't used.
Is This Really a Big Problem…
• 1 in 4 Americans over 40 have a
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balance disorder developing!
Falls are the leading cause of
fatal and nonfatal injuries to older
people in the U.S.
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Treatment of the injuries and
complications associated with these
falls costs the U.S. approx. $20.2
billion annually.
• A serious national problem now, falls
could reach epidemic levels as the
population ages in the future.
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The total cost for all fall
injuries in older
Americans was $27.3
billion in 1994, and is
expected to reach $43.8
billion by 2020.
Why Seniors Don’t Tell Their Physician
About Their Balance Issues
• They DON’T KNOW they have a problem!
– Loss of balance can be insidious over decades…
– By the age of 40, 40% of the population has a balance
disorder developing or developed
– By the age of 65, the 3rd leading physician visit is a balance
disorder
• By 75  it is the leading physician visit
• They DON’T KNOW there is anything that can be
done for balance despite having a problem!
– How many of you have been in a formal balance therapy
program?
• They DON’T WANT anyone to know!
– Why?
• Could mean losing their home or driving (Loss of independence)
• Embarrassed because a sign of aging or weakness
What Constitutes a Fall…
• Most people think they have to hit the ground to
“count” that as a fall.
– A fall can be as simple as a loss of balance, hitting the walls
at home, grabbing furniture or a rail going up stairs
– A Serious Fall (defined by NIH):
• an unexpected event in which the participant comes to rest
on the ground, floor, or lower level " and accompanied by a
fracture or another serious injury
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head injuries requiring hospitalization,
joint dislocations,
severe sprains, other non-specified serious joint injuries,
and lacerations requiring suturing.
• It is recommended that you “count” all your falls.
– More than two falls in six months is a sign of a balance
disorder developing.
The Tipping Point
• The point where you
must make a change
• Average cost per hip fracture =
$50K – total hip fractures (2006)
≈ 400K
– What if we could prevent 12 a
year…save Medicare $90 million
annually in Nevada
• Medicare Cap
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Started in 1999 for Balance Budget Act
of 1996
Repealed by congress 3 times
Re-implemented 2006
• Medicare Cap - $1,810 for PT
and Speech
– Ex. Stroke
 Do you want to talk or
walk
• The Trend Towards
Concierge Services with
Physicians
Recent Reviews on Falls…Physical
Therapists
• Many elderly people who have fallen don’t
want to tell anyone, she said. “I saw a
patient recently. She told me she’d fallen
in the bathtub, but said, ‘Don’t tell my
daughter.’ She was so afraid her daughter
would put her in a nursing home,” Martin
said.
• Your thoughts on this…
Recent Reviews on Falls…MD
Perspective
• A Family Physician recently stated it was impractical to
treat all patients with dizziness or imbalance…
– Is this fair to you the patient who may need help?
• Shouldn’t you expect best care
– 12 patients a year proposal per Werner Institute (handout for your
MD)
– Is this really a problem – why aren’t we expecting our
physicians to protect us or at least ID or problem
• Gait disorders in the elderly are common and in
most cases cannot be treated medically or
surgically.
– What about physically treating with therapy versus putting
people on canes or walkers alone...?
• Would you be happy about going on a cane or
Front-wheeled walker…?
What is Your Balance System
• Composed of three
systems
– Sensory
• Visual
• Vestibular (inner ear)
• Touch, pressure, pain
(somatosensory)
– Integration
• Brainstem/Brain
• Past memories
– Motor
• Muscles
• Nerves
What Happens When The
Balance System Becomes
Injured
• Dizziness is primary
symptom:
– Vertigo – Illusion of
movement
– Lightheadedness –
Impending passing out
– Motion Sickness – Genetic
weakness of balance
– Dysequilibrium Unsteadiness
– Fear, Anxiety
– Combination
– Other Issues:
• Fatigue
• Loss of Strength
• Dizziness is not a natural
What Can We Do For Dizziness?
What Can We Do For
Dizziness?
• Nothing
– Do no harm – patients get better over time
• Yardley study found 40 % of patients with
vertigo/dizziness continue to complain of
symptoms in 2 year follow-up
– Most patients believe not moving improves
symptoms but in fact prolongs the symptoms
– Waiting for grandma to get her balance back
at home may be too late
• 35% of hip fractures occur at home
What Can We Do For
Dizziness?
• Medicate
– PROS – may need medication (PRN)
• Meniere’s disease
• Acute vestibular disorders
• Severe intolerance to motion
– CONS – may retard the natural compensation
process of the brain
• Over 70% of all patients diagnosed with dizziness get a
prescription of Meclizine
• Meclizine reduces reaction times equal to a blood alcohol
level of 0.04 to 0.06
– Would you put a senior on this medication at risk for falls?
What Can We Do For
Dizziness?
• Surgery
– Used in very rare cases
• Ex. Meniere’s Disease –
Ablative surgery
• Ex. Perilyphatic Fistula
– Repairs a hole in the oval
and/or round window
• Ex. Acoustic Neuroma –
Evacuation of the tumor
from the inner ear nerve.
What Can We Do For
Dizziness?
• Therapies
– Naturopathy - Uses an herb or
natural remedy
– Homeopathy – Uses a micro
dosage of irritative remedy that
helps the body develop a tolerance
to the symptoms
– Chiropractor – Manipulation of
the spine
– Chinese Medicine – Herbal
remedies and acupuncture
– Allopathic – treat the symptoms
with drugs or surgery
– ***EBM – Evidence Based
Medicine uses objective testing
and treatments to identify the
cause and treat the disorder
Who’s At Increased Risk for
Falling?
• Fallen Previously
• Age (> 65 years
old)
• Loss of Cognition
• Lots of Obstacles
• Spills and pills
Where Do Falls Occur the Most?
• 60 percent: home
• 30 percent: in the
community
• 10 percent: in
institutions, such as
nursing homes
Forty percent of nursing
home admissions are
due to falls.
KEY: We want you to
stay in your homes.
Why Do People Fall?
• Some of the reasons people fall are:
– Tripping or slipping due to loss of footing or
traction
– Slow reflexes, which make it hard to keep your
balance or move out of the way of a hazard
– Balance problems
– Reduced muscle strength
– Poor vision
– Illness
– Taking medicines
– Drinking alcohol.
What Can You Do…Get Balance
Tested
• Its Just Like a Blood Pressure Test
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to R/O Hypertension…
Get assessed for your fall risk annually
– This is no different than getting a test for
blood pressure or diabetes
• A Fall and subsequent hip fracture could
cause death quicker than BP or DM
• Why are we not getting balance tested
more regularly?
– Cost – Free…
– Ease – 2 Minute10 minutes
– Not knowing balance should be test
(ignorance is bliss until you break your hip)
– Fear of unknown
– Problem: Another test… is this really
that important?
• Remember, the leading cause of
injury death over the age of 70 is a
balance problem.
What Can you Do to Prevent
Falls …Footwear
• Koepsell, 2005
(American Journal of
Gerentology)
– The study found that
people not wearing
shoes (i.e. barefoot or
in stockings) had an 8to 11-fold greater risk
of falling than those
wearing athletic or
canvas shoes.
What Can You Do to Prevent
Falls…
• Balance Retraining
Therapy
– Form of physical therapy
– Challenging the imbalance
improves your function
• Similar to learning to hit a
golf ball
– Over 400 peer review articles
currently support its
effectiveness
– Covered by your insurance in
most cases
• Tai Chi Craze!!!
– Great for those with existing
“good” balance – can be
challenging for those with
balance problems
Falls are not natural
occurrences. Many falls can be
prevented.
• Eliminate tripping hazards in your home
• Install handrails, grab bars and other safety devices.
• Engage in regular, moderate amounts of physical activity to
maintain
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Your strength, coordination, agility and balance.
• Get an eye examination and physical each year.
• Check with your PCP about side effects of all your prescription and
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over-the-counter medications.
Wear properly-fitting shoes with nonskid soles.
Obtain adequate intake of calcium and vitamin D.
Avoid excessive alcohol intake.
What Exercises Can I Do To
Prevent Falls Now?
• AARP study (2003)
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found lower extremity
strength key to
balance.
Tai Chi or Yoga for
coordination/balance
Swiss Ball Courses
Flexibility (stretching)
– Hips
– Ankles
Most Common Diagnosis We
Find Causing Falls - BPPV
• Loose calcium
particles in the inner ear
– Crystals/Rocks
• Creates an illusion of
vertigo when changing
head position
– Causes dysequilibrium
and off-balance
• Sign of a diseased or
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injured inner ear
Patients can have for
years and not know it
– By 60 - #1 cause of
vertigo is BPPV
Treatment of BPPV at Werner
Institute
• OMNIAX
– Designed by John
Epley, MD
• Epley maneuver (1983)
• Only 8 systems in the
world
– Takes the place of the
table maneuver
• Safer
– Patient is safely secure
in 5-point harness
• More Reliable
• Easier to perform
– Patient
– Treating clinician
• Treat difficult cases
– With less stimulus on
patient
Does the Therapy Really Work?
• We are not going to get
you back to a 20 year
old.
• Therapy reduces fall
risk – does not eliminate
it
• Therapy for vertigo
commonly eliminates it
• All the patients
improve with the
program to some degree
– Really up to the
individual
What Are Your RESULTS!!!
Number of
Return to ADL
Patients (2008) equivalent
BPPV (99%)
2,545 patients
BPPV+ (90%)
1,234 patients
Dysequilibrium
(80%)
2,457 patients
2,539 patients
return to prior
ADL (Age/Ht)
1,111 patients
return to ADL
(Age/Ht)
1,969 patients
return to prior
ADL (Age/Ht)
How do I get to See You…
• Referral from MD is
needed in most cases
• Most insurances pay for
the therapy and testing
– Medicare, etc.
• Free Balance Assessment
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available annually.
You can come as a direct
patient without referral
– Cash basis – runs around
$2,000 for 8 weeks of
concentrated therapy.
Questions and Answers