Transcript Balance and the Older Adult - Iowa Assisted Living Association

Iowa Assisted Living Association
8/25/15
Dave Tornabane OTR/L
&
Zach Kanis DPT, MHA
Gentiva® Home Health
Objectives
 Identify recent US statistics regarding falls and
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associated healthcare costs
Identify general fall risk factors
Identify systemic fall risk factors
Identify environmental fall risk factors
Identify standardized tests available to assess at risk
individuals
Identify fall prevention interventions
Aging Population
US Population Age 65 and Older
80
70
60
50
40
US Population Age 65
and Older
30
20
10
0
2000(35 Million)
2030 (70 Million)
Annual Cost of Falls
Annual Cost of Falls in Older Adults
60
50
40
30
Annual Cost of Falls in
Older Adults
20
10
0
2000 ($1.9 billion)
2020 ($54.9 billion)
Healthcare Costs
Healthcare Costs for 2 or More Falls (N=867)
40%
35%
30%
25%
20%
15%
10%
5%
0%
Healthcare Costs for 2 or
More Falls (N=867)
Who is at Risk?
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Age?
History of falls?
Multiple medications?
Unsteadiness?
Dizziness?
Weak?
Poor sensation?
Poor vision?
Diabetes, stroke, neuropathy, arthritis, or joint
disease?
Affected Systems
 Vestibular System
 Sensory system that provides information regarding
sense of balance and spatial orientation needed for
coordinating movement with balance.
 Central vs. peripheral
 80% of patients with falls of unknown cause displayed
symptoms of vestibular dysfunction
 Dizziness affects 30% of individuals over the age of 65
 8 million patients/year visit a physician for dizziness
Affected Systems
 Vision System
 Sensory system that provides input to the CNS with
respect to the position of the body within its
surrounding environment
 Not absolutely necessary for balance
 The older adult tends to rely on their vision for balance
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Increased fall risk: failing eyesight, macular degeneration,
glaucoma
Affected Systems
 Somatosensory System
 Sensory system that relates information about the
body’s position in space relative to the support surface
and the surrounding environment
 Information about the relationship of the body’s
segments to one another
 Peripheral neuropathies
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Diabetic, drug-induced, age-related, and idiopathic
neuropathies
Affected Systems
 Musculoskeletal System
 Muscles, tendons, bones, ligaments, joints
 Age-related changes in the musculoskeletal system can
increase fall risk
 Natural degeneration
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Osteoporotic/arthritic postural changes
Decreased joint movement
Muscle weakness
Environmental Risk Factors
 60% of falls among adults over the age of 65 occur in
the home
 Most falls occur when an individual is performing or
attempting to perform an activity of daily living
 What can you do prevent a fall?
 Remove obstacles and dangers
 Improve lighting in the home
 Ensure safety and fit
 Proper patient/resident transfer strategies
 Prepare for emergencies
Remove Obstacles and Dangers
 Clear pathways between high traffic areas, such as
bedroom to bathroom.
 Remove items on the floor that they may trip over.
 Make sure rugs and mats are skid-proof and secured,
with edges flush with the floor.
Improve Lighting in the Home
 Install brighter bulbs and additional lighting
 Illuminate entryways, outdoor walkways and other
shadowed areas.
 Use of Contrast
Ensure Safety and Fit
 Assist with choosing shoes that are easy to walk in,
supportive, low-heeled, closed back and non-slip.
 If they use a cane or walker, have it properly fitted by a
healthcare professional.
 Durable Medical Equipment (DME)
 Tub bench, shower chair, toilet safety frame, bed-side
commode, etc…
 Use of adaptive equipment
 Reacher, dressing stick, sock aid, long shoe horn, grab
bars, etc…
Proper Patient/Resident Transfer
Strategies
 Body Mechanics
 Environment Preparation
 Patient/Resident Preparation
 Proper use of equipment/devices
Prepare for Emergencies
 Make sure phones are easy to reach.
 Encourage daily contact with family and friends
 Place emergency and family contact numbers next to
the phone.
 If they have a fall, do not hesitate to call 911
Standardized Testing
 Short Physical Performance Battery (SPPB)
 Timed Standing Balance
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Feet together
Semi-tandem
Tandem
 Gait Speed-Timed 13.12 ft walk
 Chair Stands-Timed 5 sit-to-stands
Standardized Testing
 Berg Balance Scale (BBS)
 Modified Clinical Test of Sensory Integration in
Balance (mCTSIB)
 Dynamic Gait Index (DGI)
 Functional Reach Test
 Barthel Index
Berg Balance Scale
 Description: 14-item scale designed to measure balance of the older
adult in a clinical setting.
 Equipment needed: Ruler, two standard chairs (one with arm rests, one
without), footstool or step, stopwatch or wristwatch, 15 ft walkway
 Completion:
 Time: 15-20 minutes
 Scoring: A five-point scale, ranging from 0-4. “0” indicates the lowest
level of function and “4” the highest level of function. Total Score = 56
 Interpretation:
 41-56 = low fall risk
 21-40 = medium fall risk
 0 –20 = high fall risk
 A change of 8 points is required to reveal a genuine change in function
between 2 assessments.
Berg Balance Scale
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SITTING TO STANDING
INSTRUCTIONS: Please stand up. Try not to use your hand for support.
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( ) 4 able to stand without using hands and stabilize independently
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( ) 3 able to stand independently using hands
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( ) 2 able to stand using hands after several tries
( ) 1 needs minimal aid to stand or stabilize
( ) 0 needs moderate or maximal assist to stand
STANDING UNSUPPORTED
INSTRUCTIONS: Please stand for two minutes without holding on.
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( ) 4 able to stand safely for 2 minutes
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( ) 3 able to stand 2 minutes with supervision
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( ) 2 able to stand 30 seconds unsupported
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( ) 1 needs several tries to stand 30 seconds unsupported
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( ) 0 unable to stand 30 seconds unsupported
If a subject is able to stand 2 minutes unsupported, score full points for sitting unsupported. Proceed to item #4.
SITTING WITH BACK UNSUPPORTED BUT FEET SUPPORTED ON FLOOR OR ON A STOOL
INSTRUCTIONS: Please sit with arms folded for 2 minutes.
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( ) 4 able to sit safely and securely for 2 minutes
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( ) 3 able to sit 2 minutes under supervision
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( ) 2 able to able to sit 30 seconds
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( ) 1 able to sit 10 seconds
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( ) 0 unable to sit without support 10 seconds
STANDING TO SITTING
INSTRUCTIONS: Please sit down.
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( ) 4 sits safely with minimal use of hands
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( ) 3 controls descent by using hands
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( ) 2 uses back of legs against chair to control descent
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( ) 1 sits independently but has uncontrolled descent
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( ) 0 needs assist to sit
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Berg Balance Scale
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TRANSFERS
INSTRUCTIONS: Arrange chair(s) for pivot transfer. Ask subject to transfer one way toward a seat with armrests and
one way toward a seat without armrests. You may use two chairs (one with and one without armrests) or a bed and a
chair.
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STANDING UNSUPPORTED WITH EYES CLOSED
INSTRUCTIONS: Please close your eyes and stand still for 10 seconds.
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( ) 4 able to transfer safely with minor use of hands
( ) 3 able to transfer safely definite need of hands
( ) 2 able to transfer with verbal cuing and/or supervision
( ) 1 needs one person to assist
( ) 0 needs two people to assist or supervise to be safe
( ) 4 able to stand 10 seconds safely
( ) 3 able to stand 10 seconds with supervision
( ) 2 able to stand 3 seconds
( ) 1 unable to keep eyes closed 3 seconds but stays safely
( ) 0 needs help to keep from falling
STANDING UNSUPPORTED WITH FEET TOGETHER
INSTRUCTIONS: Place your feet together and stand without holding on.
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( ) 4 able to place feet together independently and stand 1 minute safely
( ) 3 able to place feet together independently and stand 1 minute with supervision
( ) 2 able to place feet together independently but unable to hold for 30 seconds
( ) 1 needs help to attain position but able to stand 15 seconds feet together
( ) 0 needs help to attain position and unable to hold for 15 seconds
Berg Balance Scale
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REACHING FORWARD WITH OUTSTRETCHED ARM WHILE STANDING
INSTRUCTIONS: Lift arm to 90 degrees. Stretch out your fingers and reach forward as far as you can. (Examiner places a ruler at
the end of fingertips when arm is at 90 degrees. Fingers should not touch the ruler while reaching forward. The recorded measure is
the distance forward that the fingers reach while the subject is in the most forward lean position. When possible, ask subject to use
both arms when reaching to avoid rotation of the trunk.)
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( ) 4 can reach forward confidently 25 cm (10 inches)
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( ) 3 can reach forward 12 cm (5 inches)
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( ) 2 can reach forward 5 cm (2 inches)
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( ) 1 reaches forward but needs supervision
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( ) 0 loses balance while trying/requires external support
PICK UP AN OBJECT FROM THE FLOOR FROM A STANDING POSITION
INSTRUCTIONS: Pick up a shoe or slipper, which is in front of your feet
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( ) 4 able to pick up slipper safely and easily
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( ) 3 able to pick up slipper but needs supervision
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( ) 2 unable to pick up but reaches 2-5 cm(1-2 inches) from slipper and keeps balance independently
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( ) 1 unable to pick up and needs supervision while trying
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( ) 0 unable to try/needs assist to keep from losing balance or falling
TURNING TO LOOK BEHIND OVER LEFT AND RIGHT SHOULDERS WHILE STANDING
INSTRUCTIONS: Turn to look directly behind you over toward the left shoulder. Repeat to the right. (Examiner may pick an object
to look at directly behind the subject to encourage a better twist turn.)
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( ) 4 looks behind from both sides and weight shifts well
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( ) 3 looks behind one side only other side shows less weight shift
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( ) 2 turns sideways only but maintains balance
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( ) 1 needs supervision when turning
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( ) 0 needs assist to keep from losing balance or falling
TURN 360 DEGREES
INSTRUCTIONS: Turn completely around in a full circle. Pause. Then turn a full circle in the other direction.
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( ) 4 able to turn 360 degrees safely in 4 seconds or less
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( ) 3 able to turn 360 degrees safely one side only 4 seconds or less
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( ) 2 able to turn 360 degrees safely but slowly
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( ) 1 needs close supervision or verbal cuing
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( ) 0 needs assistance while turning
Berg Balance Scale
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PLACE ALTERNATE FOOT ON STEP OR STOOL WHILE STANDING UNSUPPORTED
INSTRUCTIONS: Place each foot alternately on the step/stool. Continue until each foot has touched the step/stool four times.
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( ) 4 able to stand independently and safely and complete 8 steps in 20 seconds
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( ) 3 able to stand independently and complete 8 steps in > 20 seconds
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( ) 2 able to complete 4 steps without aid with supervision
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( ) 1 able to complete > 2 steps needs minimal assist
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( ) 0 needs assistance to keep from falling/unable to try
STANDING UNSUPPORTED ONE FOOT IN FRONT
INSTRUCTIONS: (DEMONSTRATE TO SUBJECT) Place one foot directly in front of the other. If you feel that you cannot place
your foot directly in front, try to step far enough ahead that the heel of your forward foot is ahead of the toes of the other foot. (To
score 3 points, the length of the step should exceed the length of the other foot and the width of the stance should approximate the
subject’s normal stride width.)
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( ) 4 able to place foot tandem independently and hold 30 seconds
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( ) 3 able to place foot ahead independently and hold 30 seconds
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( ) 2 able to take small step independently and hold 30 seconds
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( ) 1 needs help to step but can hold 15 seconds
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( ) 0 loses balance while stepping or standing
STANDING ON ONE LEG
INSTRUCTIONS: Stand on one leg as long as you can without holding on.
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( ) 4 able to lift leg independently and hold > 10 seconds
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( ) 3 able to lift leg independently and hold 5-10 seconds
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( ) 2 able to lift leg independently and hold L 3 seconds
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( ) 1 tries to lift leg unable to hold 3 seconds but remains standing independently.
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( ) 0 unable to try of needs assist to prevent fall
mCTSIB
 The mCTSIB is a modification of the CTSIB that eliminates
the use of the visual conflict dome (Cohen et al 1993). It
includes conditions 1,2,4,5 of the original CTSIB. To
perform the test the patient stands with their hands at their
side and performs the following 4 conditions:
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(CTSIB condition 1) Stand on firm surface with the eyes
open.
 2. (CTSIB condition 2) Stand on firm surface with the eyes
closed.
 3. (CTSIB condition 4) Stand on compliant surface (foam)
with the eyes open
 4. (CTSIB condition 5) Stand on compliant surface (foam)
with the eyes closed.
Functional Reach Test
Barthel Index
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FEEDING
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BATHING
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0 = dependent
5 = needs help but can do about half unaided
10 = independent (including buttons, zips, laces, etc.) ______
BOWELS
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0 = needs to help with personal care
5 = independent face/hair/teeth/shaving (implements provided) ______
DRESSING
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0 = dependent
5 = independent (or in shower) ______
GROOMING
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0 = unable
5 = needs help cutting, spreading butter, etc., or requires modified diet
10 = independent ______
0 = incontinent (or needs to be given enemas)
5 = occasional accident
10 = continent ______
BLADDER
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0 = incontinent, or catheterized and unable to manage alone
5 = occasional accident
10 = continent ______
Barthel Index
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TOILET USE
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TRANSFERS (BED TO CHAIR AND BACK)
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0 = immobile or < 50 yards
5 = wheelchair independent, including corners, > 50 yards
10 = walks with help of one person (verbal or physical) > 50 yards
15 = independent (but may use any aid; for example, stick) > 50 yards ______
STAIRS
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0 = unable, no sitting balance
5 = major help (one or two people, physical), can sit
10 = minor help (verbal or physical)
15 = independent ______
MOBILITY (ON LEVEL SURFACES)
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0 = dependent
5 = needs some help, but can do something alone
10 = independent (on and off, dressing, wiping) ______
0 = unable
5 = needs help (verbal, physical, carrying aid)
10 = independent ______
TOTAL (0–100): ______
Fall Prevention→ Skilled Intervention
 Exercises
 Balance Training
 Coordination training
 Gait Training
 Strength Training
 Endurance Training
 Tai Chi
Fall Prevention Skilled Intervention
 Vision
 Habituation/Adaptation Exercises
 Vestibular
 Maneuvers
 Habituation/Adaptation Exercises
 Modalities
 Monochromatic Infrared Energy (MIRE)
Fall Prevention
 Walking programs
 Regular exercise classes
 Healthy diet and proper hydration
 Promote use of assistive devices
 Don’t ignore their signs or symptoms of decreasing
functional balance
 Talk to other staff and family
 Refer to a Physical Therapist and/or an Occupational
Therapist
Conclusion
 BE AWARE
 PROMOTE SAFETY
 STAY VERTICAL
Questions?
 Dave Tornabane OTR/L
 Gentiva® Home Health
 515-277-0977
 [email protected]
 Zach Kanis DPT, MHA
 Gentiva® Home Health
 515-277-0977
 [email protected]