Transcript Community exercise programs

Connecting to the next step
in falls prevention
2013 Age and Disabilities Odyssey
June 17, 2013
Duluth, Minnesota
Today’s Presentation
• Falls In Minnesota and the Falls
Prevention Continuum
• Pam Van Zyl York and Kris Gjerde, MN Department of Health, Division
of Health Promotion and Chronic Disease
• Examples of Community Programs
• A Matter of Balance and Adaptations for Low Vision
• Debra Laine, Arrowhead Area Agency on Aging
• A Matter of Balance for Deaf Older Adults
• Dave Fink, Metropolitan Area Agency on Aging
• Tai Chi Moving for Better Balance
• Dave Fink, Metropolitan Area Agency on Aging
FALLS IN MINNESOTA & THE
FALLS PREVENTION CONTINUUM:
COMMUNITY PROGRAMS TO MAXIMIZE IMPACT
Age & Disabilities Odyssey
June 17, 2013
Pam Van Zyl York, MPH, PhD, RD, LN
Kris Gjerde, PT, MPH
MN Department of Health
Why are Falls a Concern in MN?
• #1 cause of MN unintentional injury
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death in 2010
Exceeded motor vehicle accidents
since 2007.
4th highest fall death rate in US
14.80/100,000; (all ages)
Nearly 2X the US rate of 8.42
Both continue to rise.
2010: falls by adults > 65 yrs
• U.S. rate = 53.76/100,000
• MN 3rd highest in U.S. at 101.0/100,000
• MN had 32,209 falls, causing
• 690 fatalities
• MN estimated cost > $245 Million
(in 2005 dollars)
•
Why are our rates so high?
• It’s not ice and snow • We can’t say precisely
– at least not directly • Some factors we think
contribute:
• We live long enough to die of
a fall –
• With longer life come
increasing impacts from
multiple chronic conditions
that increase fall risk
• We may be less active in the
winter resulting in decreased
fitness and increased fall risk
Source: Behavioral Risk Factor Surveillance System, 2009 (red) and 2010 (blue)
Data Source: CDC. Prevalence and Most Common Causes of Disability Among Adults --- United States,
2005. MMWR 58(16); 421-426.
*Data were collected in June-September 2005 by U.S. Census Bureau using the Survey of Income and
Program Participation (SIPP); CDC and the U.S. Census Bureau analyzed the most recent data and
released their findings in May 2009.
Factors That Affect Risk of Falling
Personal
• Alcohol use
• History of falls
• Incorrect size, type, or use of
• Fear of falling
• Mobility problems due to impaired
balance, muscle weakness, or
chronic health conditions such as
arthritis, diabetes or stroke
• Complications of chronic health
conditions such as vision changes
or loss of sensation in feet
• Poor nutritional status
• Medication side effects and/or
interactions
assistive devices (walkers,
canes, crutches, etc.)
Environmental
• Home and environmental hazards
(clutter, poor lighting, no grab
bars, etc.)
• Poorly designed public spaces
• Weather hazards – ice, snow,
slippery leaves
Being #1 doesn’t
mean we are
where we need
to be -
Source: United Health Foundation
http://www.americashealthrankings.org/
CDC’s Review of the Literature
• Health care providers did not
identify falls & gait disorder or
evaluate patients who reported
falling
• Only 37% of older adults were
asked about falls
• Only 8% of primary care physicians
used any clinical guideline on fall
prevention
• Many physicians were interested in
learning about fall risk assessment
& risk reduction
_____
• Rubenstein, J Am Geriatr Soc, 2004
• Wenger, Ann Intern Med, 2003
• Jones, Acc Anal & Prev, 2011
• Robinson, J Am Geriatr Soc, 2001
STEADI (Stopping Elderly
Accidents, Deaths & Injuries)
• Algorithm for Fall Risk
Assessment and Interventions
• Tool Kit
• Information for clinics and providers
• Information for patients
• Description of validated assessment tests
www.cdc.gov/injury/STEADI
The STEADI Toolkit
Stopping Elderly Accidents Deaths & Injuries
www.cdc.gov/injury/STEADI
STEADI
Algorithm
Centers for Disease
Control and Prevention
National Center for Injury
Prevention and Control
No Risk
Identified
Flow chart for fall risk
assessment process.
Adapted from AGS/BGS
Clinical Practice Guidelines,
2010
www.cdc.gov/injury/STEADI
When No Risk Is Identified
• Educate patient
• Refer to community
exercise, balance,
fitness or fall prevention
programs
Educate
•Importance of regular exercise and maintaining
balance, strength and endurance – need for exercise
that incorporates balance challenge – walking alone is
not enough
•Opportunity to maintain health, prevent falls and other
chronic conditions
Community programs - see handout for information
about how to find these programs in your community
•Community exercise programs
• Arthritis Foundation Exercise Programs
• AF Exercise
• Walk With Ease
• AF Tai Chi
• Enhance Fitness
• Tai Chi Moving for Better Balance
• Silver Sneakers
•Self-Management programs – Chronic Disease SelfManagement Program (Stanford)
STEADI
Flow Chart
Centers for Disease
Control and Prevention
National Center for Injury
Prevention and Control
Risk Identified
Adapted from AGS/BGS
Clinical Practice Guidelines,
2010
30 Second Timed Sit to Stand
Assess Leg Strength & endurance:
• Prescreen – Can they stand without using arms? Yes/No
Test: # Repetitions of sit to stand without using arms
• 30 Second time frame
• Use standard chair
p. 19
Timed Up & Go
• Assess mobility: > 12 seconds is at high risk of falling*
• Standard arm chair: OK to use arms in this test
• May use assistive device (walker, cane, etc.)
• Distance: 3 Meters (10 ft.)
• Instructions:
• Begin timing when tester says, “Go!” (Don’t wait.)
• Participant instructions:
• Stand up from the chair,
• Walk to line at normal pace, turn around
• Walk back to the chair and sit down.
• Stop timing when client sits down.
• Observe postural stability, gait, stride length, & sway
• Note: Slow speed, Loss of balance, Short stride, shuffling, etc.
* CDC.gov/injury/STEADI
4 Stage Balance Test
• Test each position for 10 seconds, progress as able
• Participant may move their arms or body to maintain
balance. Stop timing if feet move or they grab support.
• Participant should hold the position until told to stop.
• Test instructions:
• Assist participant to assume position with support
• Remove support when tester states, “Begin.”
• Start timing when participant achieves position without support after
tester says, “Begin.”
• After 10 seconds, tester says, “Stop.”
• Score = the time position is held
Four-Stage Balance Test
Tandem stance
www.cdc.gov/injury/STEADI
When Risk is Present
Evaluate Risk
• Gait
• Strength
• Balance
• Educate patient
• Refer for gait and/or
balance retraining or to a
community fall prevention
program
Educate
• Opportunity to take action to improve health and
reduce chances of falling
• Discuss options for addressing specific
problems
• Discuss importance of on-going exercise
Refer
• To physical therapy for further assessment and
individually tailored intervention to support
progression to community exercise programs,
possibly for Otago Exercise Program, use of
assistive devices
• Community fall prevention program
• A Matter of Balance
• Stepping On
• Stanford Chronic Disease Self-Management
Program (CDSMP) to increase behavior change
skills
• Community exercise programs that address
balance and lower body strength
The Otago Exercise Program
• Evidence Based Falls prevention program
• Requires Physical Therapy implementation
• Individualized & Progressive Exercise:
• Strengthening
• Balance retraining
• Extended duration
• PT visits + monthly phone consults
• Model for group exercise in AL, SNF, &
community
Evidence Based Physical Activity
Intervention
• 50 hours of exercise
needed to achieve
significant change
• Continued exercise
to maintain level of
function
STEADI
Flow Chart
Centers for Disease
Control and Prevention
National Center for Injury
Prevention and Control
Gait,
Strength, or
Balance
problem
identified
Adapted from AGS/BGS
Clinical Practice Guidelines,
2010
Implementing interventions – Who can assist
-Enhance strength and balance
-Improve functional mobility
-Physical therapist – assessment and one-on-one training for
strength and balance, use of assistive devices
-Community exercise programs – continue to build and
maintain strength and balance
-Manage and monitor hypotension
-Manage medications
-Nursing
-Pharmacist
-Address foot problems
-Podiatrist, Pedorthist – to treat foot problems and prescribe
corrective foot wear and orthotics
-Home nursing care – assistance with foot care
-Vitamin D/ Calcium
-Dietitian – assess dietary status and needs
-Optimize vision
-Opthamologist, Optometrist – to identify and treat medical
conditions contributing to vision problems
-Occupational therapist – to assist in identifying strategies
for managing daily tasks
-Optimize home safety
-Occupational therapist – to assess safety and patient needs
to function in the home
-Community service providers for home safety assessment
and home modification
Continue Follow-up with All adults
Patient follow-up
• Review patient
education
• Assess and
encourage adherence
with recommendations
• Discuss and address
barriers to adherence
Assess current status
• Identify any changes in risk related to changes in
health status or living situation
Education
• Support positive opportunity to improve or maintain
• Address education needs for any new issues
Assess success with current plan and recommendations
• Support successful changes and encourage
maintaining efforts
• Identify problems that prevented follow-through
Address any new problems
• Identify any additional assessment needed
• Make any new referrals needed
Discuss and address barriers to carrying out plan
• Consider referral to CDSMP to support selfmanagement skills and behavior change
• Referral to community program for additional social
support
• Consider other referrals for additional education and
support
Contact Us:
Kris Gjerde, PT, MPH
[email protected]
651-201-4065
Pam Van Zyl York, MPH, PhD, RD, LN
[email protected]
651-201-3616
A Matter of Balance
Accommodating People With
Low Vision
A Matter of Balance (MOB)
• Highest tier of evidence based program
• Designed to reduce the fear of falling
and increase activity levels of older
adults
• Eight 2-hour sessions
• 25% presentation, 45% discussion,
30% MOB exercises
• Led by two trained coaches
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A Matter of Balance Class
Designed to benefit community-dwelling older adults who:
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Are concerned about falls
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Have sustained a fall in the past
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Restrict activities because of concerns about falling
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Are interested in improving flexibility, balance and strength
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Are age 60 or older, ambulatory and able to problem-solve
During 8 two-hour classes, participants learn:
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To view falls and fear of falling as controllable
To set realistic goals for increasing activity
To change their environment to reduce fall risk factors
To promote exercise to increase strength and balance
Impact in MN
• Steady increase in participation
2012; 845 participants with 721 completers
• 2011; 777 participants
• 2010; 444 participants
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Over 99% reported improvement in:
• Finding a way to get up from a fall
• More steady on feet
• Finding a way to reduce a fall
• Protecting yourself in case of a fall
• Physical activity
Why Low Vision?
• First year Matter of Balance Classes at
least one participant had vision issues.
• One of the major risk factors for falls is
poor or no vision.
• Create a version to for the low vision
population.
• Received a grant for the National Eye
Institute.
Determine Degree of Vision Loss
• Cause
• Macular Degeneration
• Cataracts
• Diabetic Retinopathy
• Glaucoma
• Do they still read
• What kind of assistance is needed
• Magnifier
• Reader
• Room
• See posters
• Glare
Macular Degeneration
www.lighthouse.org/about-low-vision-blindness/visiondisorders/age-related-macular-degeneration-amd/
Cataracts
www.lighthouse.org/about-low-vision-blindness/visiondisorders/age-related-macular-degeneration-amd/
Diabetic Retinopathy
www.lighthouse.org/about-low-vision-blindness/visiondisorders/age-related-macular-degeneration-amd/
Glaucoma
www.lighthouse.org/about-low-vision-blindness/visiondisorders/age-related-macular-degeneration-amd/
Project
• Partnered with the Duluth Lighthouse
for the Blind
• Looked at needed curriculum
adaptations
• Made the adaptations to make it
accessible to low or no vision
• Piloted the adaptations
• Re – worked where necessary
• Sharing
Two Levels/Stages
• Beginning
• Just recognizing that they can not
see as well
• Just diagnosed with a chronic eye
condition
• Low or No Vision
• Need assistance to read 20 pt font
• Can not read printed material no
matter what
A Starting Point
• Helpful Hints for Sighted People
Working and Socializing with
People Who are Blind
• Building Safety and Access
• Common Reactions to Vision Loss
• General Points to Remember
Curriculum Adaptations
• Focus activities on listening
• Pair up sighted and non-
sighted people for activities
• Provide information in both
large font and electronically
Example of Exercise Description
for Visually Impaired
Touch Elbows Stretch (Front and Back)
This exercise helps chest and back flexibility
and torso range of motion. It is very good for
posture.
Place your left fingertips on your left shoulder,
and your right fingertips on your right shoulder.
Raise your elbows to shoulder level out to the
side. Gently move your elbows together in
front of you toward your body’s mid-line.
Try to get them as close as possible, while still
remaining comfortable. Hold for 3-5 seconds.
Debra Laine
Special Programs Developer
Arrowhead Area Agency on Aging
221 West First Street
Duluth, MN 55802
218-529-7534
[email protected]
A Matter of Balance
for
Deaf Older Adults
The Genesis
• Deaf Community Health Workers
sought health interventions for Deaf
older adults
• Falls identified as a significant issue
• Determined MOB was good fit
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Coach Recruitment
• Deaf Community Health Workers
director
• Reviewed curriculum and identified 3 –
4 topics
• Explained topics and class format
• 6 members agreed to be trained as
coaches
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Coach Training
• Master Trainer preparation
• Hosted by Metropolitan Area Agency on
Aging
• Comprised of Deaf and hearing
individuals:
• 6 DCHW coach trainees & 2 interpreters
• 9 hearing coach trainees
• 3 hearing Master Trainers
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Coach Training – Success!
• Reviewed tips provided by the interpreter
• Address Deaf participants directly while speaking to
them
• Each participant raise their hand before speaking
• Frequent check ins – is this working for
you?
• Increased time spent demonstrating
exercises
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Coach Training Follow-up
• 2 day retreat to review curriculum
• Maintain fidelity but address visual needs of
participants
• Use of visual aids e.g. flip chart content on
PowerPoint
• Role plays
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Class Participant Recruitment
• Classes are free of charge
• Announcements sent via Minnesota Deaf
Senior Citizens monthly listserv
• Small events
• Personal invitation
• Adequate time for Q & A
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Fall 2010 - Present
• First in the U.S. to offer MOB entirely
in American Sign Language
• April 2011 Deaf coach trained as
Master Trainer
• To date - 6 workshops, 39 participants
• Offer 1 – 2 MOB classes per year
Participants’ Experience
• Learned to be assertive self advocates
• Enjoyed session topics - home safety
tips
• Increased physical activity – focus on
staying healthy and fit!
“Wonderful!” “Enjoyed it a lot!” “Hope other
Deaf people can take the class too!”
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Getting Started – Key Factors
• Interpreters for:
- Planning
- Coach training (initial and follow-up/refresh)
- Fidelity monitoring
• Acknowledgement of language
differences between ASL and English
• Visuals – use of PowerPoint
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Keys to Success
• Established Deaf community partner
organization with trusted ties to Deaf
seniors
• Health promotion / disease prevention was
high priority
• Sufficient planning time
• Planning for sustainability
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Keys to Success
• Trusted ASL interpretation contractor
• Capacity to translate concepts in order for
program to be accessible to Deaf older
adults
• Flexibility to accommodate visual needs
• Sufficient funds to support interpretation
needs for start up
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Dave Fink
Program Developer
Metropolitan Area Agency on Aging
2365 North McKnight Road
North St. Paul, MN 55109
651-917- 4633
[email protected]
The Question:
Is there an evidence-based fall
prevention program that would be
culturally appropriate for and
accessible to non-English speaking
older adults?
Tai Chi: Moving For Better Balance
• Developed by Dr. Fuzhong Li, Oregon Research
Institute
• 8 forms of Yang style Tai Chi adapted specifically
for fall prevention
• Reduces the risk of falls by improving balance,
muscle strength, flexibility and mobility
• Twice/week for 1 hour plus practice, 2 twelve week
sessions
• One certified leader
Tai Chi Origins
• Monks in the mountains of China 600 years ago
• Created as a self-defense martial art
• Evolved into a health & wellness exercise program
“Moving meditation”
• 8 forms that emphasize
- weight shifting
- postural alignment
- coordinated movements
• 4 S’s
- slow
- soft
- smooth
- safe
- Integrated breathing
Seated
&
Standing
Leader qualifications
• No previous Tai Chi
experience required
• Experience working with
older adults & group exercise
programs very helpful
• Enjoy leading groups
• Willing to learn, practice
and continually improve
Leader training
• 2 day intensive
workshop
• Led by Dr. Li
• Follow-up sessions
with local leader
• Leader sharing
sessions
• DVD and tips
2012 pilot test
• Timeframe: April – December, 2012
• 10 bilingual leaders trained:
• Initial 2-day training
• 3 two hr. follow-up sessions
• Quarterly leader sharing and updates
• 7 languages: Laotian, Korean, Khmer, Hmong, Somali and
Vietnamese and English
• Classes: Two 12 week sessions, twice/week for 1 hour
• Stipends: To organizations @ $30/class
Pilot test results
• Participants: 124 first session, 129 second
• Retention: 64% attended half or more, 49%
attended 3/4 or more
• Retention higher in organizations with active
existing programming and leaders - 86% attended
half or more, 68% attended 3/4 or more
• Participation and retention higher with Asian older
adults than East African older adults
• “Timed up and go” test – avg. 2 second
improvement
What participants said…
• “The Tai Chi class helped me be able to use old muscles I
have not used in a while. Now I can stretch my arms up
very high.”
• “I was walking with a cane for a couple of years. After I join
the class I am able to walk without a cane.”
• “The Tai Chi exercise program helped me a lot with
emotional stress and physical improvement.”
• “Because of a stroke, I couldn’t use my arm. But I am able
to move and use my arm and lift up to my head.”
What we learned
Bilingual leaders are effective
Organizations with existing active older
adult programs had stronger
participation/retention
Cultural backgrounds may make a
difference in participation/retention
Older adults will attend and do benefit
A word on funding
• MAAA Title IIID funds target non-English
speaking older adults
• MAAA pays IIID organizations to host Tai Chi
classes and funds the leader training
• As space allows, other organizations attend
leader training and reimburse MAAA for costs
2013 participating organizations
• Brian Coyle Center
• Centro
• Common Bond
• Korean Service Center
• Lao Advancement Org. of Am.
• Presbyterian Homes & Services
• United Cambodian Assn. of MN
• VOA/Park Elder Center
• Vietnamese Social Services
Oromo, Somali
Spanish
English, Somali, Spanish
Korean
Laotian
English
Khmer
Hmong
Vietnamese
Also, Mahube-Otwa RSVP in Land of the Dancing Sky AAA and
Central MN Council on Aging (both in English)
What’s next…
• Metropolitan Area Agency on Aging
 3rd training, new organizations and leaders
• Land of the Dancing Sky AAA & Mahube-Otwa
RVSP

2nd training, more leaders
• Central MN Council on Aging
 Getting started
Additional TCMFBB info
NCOA link to TCMFBB: http://www.ncoa.org/improve-health/center-forhealthy-aging/tai-chi-moving-for-better.html
Research basis for TCMBB:
 “Tai Chi and fall reductions in older adults: a randomized
controlled trial,” Journal of Gerontology, 2005:
http://www.ncbi.nlm.nih.gov/pubmed/15814861
 “Translation into Community-based Falls Prevention Program,”
2008, American Journal of Public Health:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2424086/
“Tai Chi and Postural Stability in Patients with Parkinson's
Disease,” 2012, New England Journal of Medicine:
http://www.nejm.org/doi/full/10.1056/NEJMoa1107911
Dave Fink
Program Developer
Metropolitan Area Agency on Aging
2365 North McKnight Road
North St. Paul, MN 55109
651-917- 4633
[email protected]