Fall Prevention

February 20, 2018 Mom MD Hawaii

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

$clavicle fracture$

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

Seek Medical help and advice
- Evaluate for diseases and medication side effects
Exercise (Keep Moving!)
- Physical Therapy & Tai Chi – with good evidence
- Senior exercise groups focused on balance strategies
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