My grandparents are getting older and they are getting more unstable on their feet, whether they like to acknowledge it or not.  Everyone knows someone who is at risk for falls.  Whether it is a parent, grandparent, or other loved one, it is scary to think about falls because of all the injuries that can occur from them.  The most important thing for falls is fall prevention before they even happen.  This article will review important fall prevention information, like why it is so important and how to prevent them.

The information in this article is from a presentation given by my husband and his business partner from Central Oahu Physical Specialists.  I helped a little putting all this information together and the handsome guy in the exercise photos is my husband.  I think fall prevention is so important and prevalent that I wanted to share this valuable knowledge to help prevent as many falls as possible.

 

Outline

• Prevalence
• Causes
• Risk Factors
  • Intrinsic and Extrinsic
• Falls Assessment Measures
• Patient Education
• Exercises

 

Prevalence

• US Center for Disease Control and Prevention
  • 1 in 4 Americans aged 65+ fall each year
  • Every 11 seconds someone age 65+ is treated in ER for fall
  • Leading cause of fatal injury and most common cause of nonfatal trauma-related hospital admission age 65+
  • 2014 total cost of fall injuries was $31 billion
  • By 2020 expected to be 67.7 billion

Photo by Harlie Raethel on Unsplash

Causes

• Rarely due to a single cause
• May be due to the accumulated effect of impairments in multiple domains (such as other geriatric illnesses, diseases, or syndromes)
• Complex interaction of:
  • Intrinsic factors (eg, chronic disease, weakness)
  • Challenges to postural control (eg, changing position), movement impairments
  • Extrinsic factors (eg, hazards)

 

Risk Factors – Intrinsic (Internal)

• Age > 65
• Fall hx ≥ 1 fall
• Mental Status- confusion, disorientation
• Sensory Deficits (hearing, vision, proprioceptive, visual-vestibular)
• Weakness, poor coordination, impaired balance reactions
• Multiple Medication- sedatives, tranquilizers, pain meds
• Postural Hypotension
• Chronic conditions- CVA, Parkinsons, Arthritis, DM, Dementia
• Fear of Falling
• Vestibular dysfunction

 

Risk Factors – Extrinsic (External)

• Home Hazards
• Lack of stair handrails
• Poor Stair Design
• Lack of bathroom grab bars or dim lighting
• Obstacles/tripping hazards
• Uneven/slippery surfaces
• Improper use of assistive devices (AD) – wheelchair, cane
• Indoor pets

 

Photo by Sasint on Pixaby

Falls Assessment: History

• Screen all older adults about falls in the past year
• Single fall: check for balance or gait disturbance
• Recurrent falls or gait or balance disturbance: perform complete falls evaluation (by doctor or physical therapist)
  • Lower limb joints
  • Neurologic
  • Cardiovascular
  • Gait and balance
  • History
  • Medications
  • Vision
  • Vestibular

 

Falls Assessment: Physical Examination

• Blood pressure and pulse, both supine and standing
• Vision screening
• Vestibular screen
• Cardiovascular exam
• Neurologic exam
  • Cerebellar tests: Finger to nose, Heel to shin, RAM
• Musculoskeletal exam
  • Manual Muscle Testing: common strength deficits: Gluteals, Transverse abdominis, Middle and Lower Trapezius, Hamstrings, Soleus, Extensor Digitorum Longus, tibialis anterior
  • Common ROM Limitations: hip extension, hip internal rotation, ankle dorsiflexion, shoulder flexion/abduction, thoracic extension

 

Gait and Balance Assessment Tools

• Get Up and Go (GUG) test
• Nudge Test
• Romberg test
• Gait assessment – specialized by physical therapy or physician
  • However you can identify Trendelenburg, lateral sway, use of upper extremity support, safety concerns

 

Photo by rawpixel on Pixaby

 

Assessment Tools: Get Up and Go

• GUG (Get UP and Go)
  • Easy to perform: need a chair, cleared straight pathway, marker for distance, timer
  • Even for pts with poor cognition (low mini-mental status exam) due to its ease of performance
  • Sit to stand→ walk 3 meters about 10 ft → turn → walk back to chair→ sit down
  • Cueing is to have patient walk at their normal pace
  • > than 12 sec means a high fall risk

 

Assessment Tools: Balance Reaction – Nudge

• Balance Reaction Test (Nudge Test)
  • Patient is pushed in a variety of directions
  • Anterior/lateral/posterior nudging
  • Nudges should be random with light pressure, only one push in 1 direction
  • Scoring:
    • 4 independent
    • 3 verbal cues/increased time
    • 2 upper extremity support
    • 1 needs assistance
    • 0 dependent

 

Assessment Tools: Romberg

• Romberg Test
  • Standing with feet together – no shoe wear, begin with eyes open x 20-30 sec then eyes closed
  • 1 minute no sway test is negative
  • Positive test is if patient has increased body sway, placing one foot in direction of fall or even falling

 

Photo by Jake Hills on Unsplash

 

Assessment: Labs and Testing

• Labs and testing to be ordered as deemed appropriate by your physician, and may include
• Hemoglobin, serum BUN, creatinine, glucose: can exclude anemia, dehydration, or hyperglycemia
• Holter monitoring: no proven value for routine evaluation
• Carotid sinus massage with continuous heart rate and BP monitoring: can uncover carotid sinus hypersensitivity
• Other tests based on history & physical exam: echocardiogram, brain imaging, radiographic studies of spine

 

Patient Education Prevents Falls

• These studies show how education and interventions helps fall prevention
• Michael YL, Lin JS, Whitlock EP, Gold R, Fu R, O’Connor EA, Zuber SP, Beil TL, Lutz KW. Interventions to Prevent Falls in Older Adults: An Updated Systematic Review. Evidence Synthesis No. 80. AHRQ Publication No. 11-05150-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; December 2010.
  • strong evidence that comprehensive multifactorial assessment and management, exercise/physical therapy interventions, and vitamin D supplementation reduce falls for high risk with minimal harms
• Chase CA, Mann K, Wasek S, & Arbesman M. Systematic review of the effect of home modification and fall prevention programs on falls and the performance of community-dwelling older adults. American Journal of Occupational Therapy, 66, 284–291. (2012).
  • Multifactorial interventions reduce falls: home modifications, education on health and safety, medication management, vision management, gait and balance training, and exercise

 

3 Easy Steps for Fall Prevention

1. Seek Medical help and advice
   • Evaluate for diseases and medication side effects
2. Exercise (Keep Moving!)
   • Physical Therapy & Tai Chi – with good evidence
   • Senior exercise groups focused on balance strategies
3. Remove Home Hazards

 

 

Seek Medical Help

• Review prescriptions, over-the-counter meds and supplements
• Consider med side effects and interactions
• Get details of falls and near falls: when, where, how
• Identify health conditions can cause falls: musculoskeletal, neurological, eye, and ear disorders
  • Such as any dizziness, joint pain, shortness of breath, or numbness in your feet and legs when walking?
• Evaluate strength, balance and gait

 

Exercise Interventions

• Specific to patient presentation –
  • Many variables to consider
    • Other illnesses, cognition, home set up, home support system, history of falls
• Generally, for HEP (home exercise program), need to consider safety first, then progress accordingly

 

Exercise Prescription

• To progress/regress/modify exercises, may alter several different variables:
  • BOS (base of support)
  • Vision
  • COG (center of gravity)
  • Movement of limbs within or outside BOS
  • Static vs dynamic
  • Time/duration
  • Distance
  • External perturbations and/or resistance
• Exercises need to  be progressive/more challenging over time

 

 

Balance Exercise Guidelines

• Always perform cool environment
• If you require a wheel chair or walker make sure someone is within arms reach away
• If you have fallen 1x this yr someone needs to be in arm’s reach away
• Start with 2 hands of support on sturdy surface: countertop, table
• Breathe throughout – do not hold your breath
• If you have shortness of breath, chest pain, dizziness do not perform without consulting your doctor
• Always make sure you hydrated
• Perform when most alert: mid-morning, after nap.  
• Perform repetitions of 10 x.  And perform up 1 -2 x per day

 

Balance Exercise Progression

• Begin with eyes open, with 2 upper extremity (arm) support
• Progress to eyes open, 1 upper extremity (arm) support
• Eyes open, no upper extremity (arm) support
• Eyes closed, 2 arm upper extremity (arm) support
• Eyes closed, 1 arm upper extremity (arm) support
• Eyes closed, no upper extremity (arm) support

 

Standing Balance – Feet Together

• Stand near solid surface and/or wall for support
• Neutral standing position
  • Cervical and lumbar spines neutral
  • Feet together
• Start with eyes open
• Goal:
  • 30 seconds continuous, without use of hands
  • Once able to accomplish this, perform with eyes closed and aim for 30 seconds without use of hands

 

Standing Balance – Tandem Stance

• Stand near solid surface and/or wall for support
• Neutral standing position
  • Cervical and lumbar spines neutral
  • Heel to toe position
• Start with eyes open
• Goal:
  • 30 seconds continuous, without use of hands
  • Once able to accomplish this, perform with eyes closed and aim for 30 seconds without use of hands

 

Standing Balance – Single Leg Stance

• Stand near solid surface and/or wall for support
• Neutral standing position
  • Cervical and lumbar spines neutral
  • One foot in air
• Start with eyes open
• Goal:
  • 30 seconds continuous, without use of hands
  • Once able to accomplish this, perform with eyes closed and aim for 30 seconds without use of hands

 

Ankle Strategy Exercise

• Forward –
  • Stand tall with bilateral UE’s approximately 6 inches from wall
  • Lean forward so that finger tips touch wall
  • Only move through the ankles
  • Keep hip and spine neutral
• Backward –
  • Stand with heels approximately 6 inches from wall
  • Maintain neutral hip, spine
  • Lean backward so that shoulder blades touch wall
  • Toes may rise up from floor

 

Hip Strategy Exercise

• Stand approximately 3 ft from wall.
• Reach forward toward the wall at the same time bending hips and knees – squatting movement

 

Forward Step Strategy Exercise

• Stand in front of a cane/broomstick/towel
• Step over object making sure to land with heel first then rock forward onto rest of foot

 

Lateral Step Strategy Exercise

• Stand next to cane/broomstick/towel
• Step over object with one foot
• Return to starting position

 

Reduce Home Hazards

• Good Lighting in your home.  Night lights, light switch close to bed, stairwell well lighted
• Hand rails on both sides of stairs
• Eliminate throw rugs
• Move electrical wires from walkway
• Handrail in bath, shower, toilet
• Phone or lifeline nearby at all times
• Home Hazard Movement Reduction
  • Sit for 30 sec-1 min before standing
  • Make sure no dizziness before standing
  • Carry bags or objects opposite to the hand rail when going up/down stairs
  • Stay away from wet/slippery flooring
  • Use corrective lenses and hearing aids at all times when walking, standing up, pivoting
  • Firm backed, non-skid sole shoes; avoid loose slippers

 

Fall Prevention Education Web Resources

• CDC’s fall risk self-assessment brochure, Stay Independent; What You Can Do to Prevent Falls and Check for Safety, A Home Safety Checklist; Falls Prevention page www.cdc.gov/STEADI
• American Geriatrics Society Clinical Practice Guideline: Prevention of Falls in Older Persons www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/prevention_of_falls_summary_of_recommendations
• American Academy of Orthopaedic Surgeons www.orthoinfo.aaos.org/menus/safety.cfm
• Fall Prevention Center of Excellence www.stopfalls.org
• National Council on Aging, Center for Healthy Aging www.ncoa.org/improve-health/centerfor-healthy-aging
• National Institute on Aging, AgePage: Preventing Falls and Fractures www.nia.nih.gov/sites/default/files/falls_and_fractures_0.pdf
• National Safety Council: Prevent Falls In and Outside of Your Home www.nsc.org/learn/safety-knowledge/Pages/safety-at-home-falls.aspx
• Fall hazards HomeSafetyChecklist_Fallsfrom the American Physical Therapy Association

 

Questions?

Please let me know through the contact form, or through my Facebook, Twitter, or Instagram pages.

 

Other Posts You May Be Interested In: