MSU PartI ppt edits2 03 06 FINAL

Comprehensive Fall Prevention Management for Older Adults: 

Comprehensive Fall Prevention Management for Older Adults Holly Lookabaugh-Deur, PT, GCS, CWS, ABD President; Generation Care

Unrecognized Public Health Problem…: 

Unrecognized Public Health Problem… Injuries relating to falls are growing in incidence, prevalence, and severity, and they are only expected to continue to grow as our populations’ average life expectancy continues to rise. Falling is defined as a sudden, uncontrolled drop to a lower surface.

Facts on Falls: Demographics: 

Facts on Falls: Demographics Injuries relating to falling are the leading cause of accidental death in older adults over the age of 65. Falls account for 80-95% of hip fractures in older adults. More than 1/3 of healthy adults over age 65 fall every year. Nearly 20-30% of those who fall sustain a moderate to severe injury, such as a head injury.

More Demographics: 

More Demographics Half of all older adults hospitalized for hip fractures cannot return home to live independently, and 20% die within one year of the fall. Hip fractures lead to an overall 5-20% reduction in life expectancy for older adults (National Osteoporosis Foundation, 2001).

More Facts: 

More Facts Every year, 300,000 Americans suffer from fall related hip fractures. Every week, nearly 200 Americans die of complications following a fall. Every day, more than 400 Americans suffer permanent loss of mobility from damage following a fall. Of persons aged 75 and older, those who fall are 4-5 times more likely to be admitted to an ECF for a year or longer.

Centers for Disease Control and Prevention (CDC) Recommendations: 

Centers for Disease Control and Prevention (CDC) Recommendations All adults over the age of 75 should receive a comprehensive risk factor analysis. Older adults may be able to 'age in place' if appropriate fall prevention strategies are initiated with the onset of frailty.

More Demographics: 

More Demographics Since 1990, the death rate from falls has doubled Highest fall risk and incidence: white females over age 80 years 350-400 people die from falls each year in Michigan In Michigan, 21% more women than men fall 25% of people who fall require medical attention

Frightening Facts: 

Frightening Facts For every elderly fall injury death in Michigan, there are 33 non-fatal hospitalizations, about 200 seniors seeking non-inpatient medical care, and nearly 900 who fall and do not receive care. Elderly falls in Michigan have estimated medical costs of $649 million, including lost work time, with a total cost of $2.5 billion per year ($25 billion nationally).

A Note about Michigan: 

A Note about Michigan More than a million adults over the age of 65 In 2002, falls were the cause of 80% of all hospitalizations due to injury 13% of Michigan seniors report falling within the last month; 28% within the last year Falls were reported as occurring most frequently on porch steps and during 'carrying times'

The Good News: 

The Good News Utilizing a comprehensive fall risk assessment and specific interventions to reduce risk, fall frequency can be reduced by 43%–72%, depending on the setting.

Why should the health care team work together on this growing health issue?: 

Why should the health care team work together on this growing health issue? 2/3 of falls may be preventable (Yale University, 2005) FP programs help older adults age in place as long as possible FP programs build consumer loyalty as older adults need more services FP is needed across the older adult health care continuum

Generation Care and FP Research: 

Generation Care and FP Research Part of a four-year CDC grant studying the impact of health care training, FRAT use (Fall Risk Assessment Tool) and interventions To date, we have helped lower repeat falls by 72% at Crittendon Hospital (Detroit) and Genesys Health Care Systems (Flint)

Fall Risk Factors: 

Fall Risk Factors Intrinsic and Extrinsic Risk Factors—what we can and can’t impact with our interventions

To be truly effective with fall prevention efforts: 

To be truly effective with fall prevention efforts Assessments need to be comprehensive We need to be able to CONNECT with our patients—listening, exploring, adding value to their lives We need a 24 hour approach Interventions need to be individualized AND focused on the patient’s goals, not a score or what is on paper

Intrinsic Risk Factors: 

Intrinsic Risk Factors Age History of falls Awareness and acceptance Pathological conditions and existing diseases Postural hypotension Vision deficits Hearing deficits Nutrition and hydration status (both intrinsic and extrinsic)

More Intrinsic Risk Factors: 

More Intrinsic Risk Factors Strength deficits – specific groups Quads, triceps, foot intrinsics, etc. ROM or loss of symmetry Postural recovery strategy issue/ balance problems Gait pattern and mobility dysfunction ADL disability: six key areas Cognitive and attention issues Possible correlation with urinary incontinence

Extrinsic Risk Factors: 

Extrinsic Risk Factors Shoe style and fit Assistive device and fit/use Home environment and home safety Nutrition and hydration (both intrinsic and extrinsic) Medication use Lack of health professional’s knowledge: assessment tools, treatment interventions, communication and connection skills with clients

The Greatest Risk Factor: 

The Greatest Risk Factor 'The single greatest risk factor for falls is the lack of health professional knowledge and awareness of the use of assessment tools, intervention strategies, and effective communication skills with older adults.' (Healthy Aging, 2005)

Review of Risk Factor Details: 

Review of Risk Factor Details Key points relating to individual intrinsic and extrinsic risk factors follow; however, a detailed understanding of each is beyond the scope of this program.

Age: 

Age Normal loss of 1 percent of strength per year after age 60 Shifts in 'normal' center of gravity to more anterior position Increased postural sway Tendency for the foot arch to drop; elongation of the foot; shoes don’t fit Decreased overall reaction time, slowing coordination and motor learning

History of Falls: 

History of Falls Tinetti’s work indicates that fall history is a significant risk factor for the likelihood of repeated falls. A two-year historical picture of falls is critical to the fall risk assessment process Remember that history taking is actually quite unreliable due to under reporting

Cognitive Changes: 

Cognitive Changes Still under study as a risk factor for falls, but early evidence indicates attention span, tendency toward distraction, ability to sort 'environmental clutter,' perceptual deficits relating to interpretation of risk or danger, spatial perceptual changes, and inability to inhibit impulsive or poorly planned motor activities do play a significant role in fall risk.

Co-morbidities and Pathologies: 

Co-morbidities and Pathologies These conditions are correlated to fall risk in the literature: OA and RA Parkinson's disease Although osteoporosis is not a risk factor for falling, it is correlated to the degree of injury severity following a fall Alzheimer's disease Clinically significant postural hypotension Peripheral neuropathy

Vision Deficits: 

Vision Deficits Decreased acuity (less than 20/60) Impaired reaction to light and dark; inability to change pupil size abruptly to aid in focus Decreased contrast sensitivity, particularly with grays, browns, and neutral colors Decreased peripheral field Decreased depth perception, with both close and far away objects

Hearing Deficits: 

Hearing Deficits Decreased hair cells Calcification of cupula; less sensitive to change Speed of axon transmission decreased Increased vibratory threshold Temporal perception delays, along with relays to and from the cerebellum, making responses to change in body and head righting reactions delayed and slower

Orthopedic Changes: 

Orthopedic Changes Strength: df/pf; hip abductors; quads; toe intrinsics; trunk; triceps; hip extensors Collagen levels increase in soft tissue as we age, impacting flexibility Gait changes: wider base of support, slower cadence, less toe to heel excursion, limited trunk rotation and arm swing, shorter step length, less weight shifting, anterior shift of gravity

Postural Recovery and Balance Changes: 

Postural Recovery and Balance Changes Normal balance requires three systems to work perfectly in sync: vision, vestibular, and somatosensory (joint proprioception input) We become more visually dependent, hypofunctioning vestibular system Inadequate ankle-foot reaction; hip flexion response and step response

ADL Changes in the last Six Mo.: 

ADL Changes in the last Six Mo. Difficulty with bathing Difficulty with dressing, particularly lower extremities – shoes and socks Instrumental ADL changes Fear or difficulty entering and exiting the home, such as getting the mail Reduced frequency or complexity of preparing a hot meal Difficulty with bed mobility skills, rolling, getting in/out bed

Extrinsic Factors: Start with Feet: 

Extrinsic Factors: Start with Feet Chronic heel cord tightness, uncompensated by a shoe; does not allow ankle-foot recovery strategy Shoe fit; flexible toe box Intrinsic toe muscle strength—our first line of defense!

Assistive Devices: 

Assistive Devices We are too quick to assume a walker will help. Many older adults 'borrow' from a friend – poor fit, wrong choice, not using correctly Can lead to increased weakness – can lead to progressive hip weakness – if leaning too far forward, never extending hip or using trunk

Home Environment: 

Home Environment Lighting – particularly in middle of night Bathroom setup with bars Rugs; floor transitions Stairs with narrow or low rise, only one rail Highly polished floors Clutter Low tables and chairs; toilet seat No non-slip surface in tub Irregular or raised sidewalks Oil on garage floor

Nutrition and Hydration: 

Nutrition and Hydration Considered both an intrinsic and extrinsic risk factor Dehydration is the single most common method of managing incontinence Dehydration affects mental function High fat, high sodium diet with frozen foods, etc. Low calcium; contributes to osteoporosis Low vitamin B – related to fatigue Limited vitamin C – strength, muscle recovery problems

Homebound Status: 

Homebound Status Limited endurance and activity levels Nutritional compromise due to infrequent shopping trips Less stimulation of all of the senses If out of home infrequently, more likely to feel startle reaction, more likely to be deconditioned

Medication Use: 

Medication Use Falling and dizziness are the most commonly listed side effects of meds Psychotropic drugs are most associated with falls Recent studies show just four or more concurrent medications are significant to fall risk Tricyclic antidepressants, sleep aids, and antiarrhythmia drugs significantly contribute to fall risk

Comprehensive Medication Guide: 

Comprehensive Medication Guide A comprehensive list of medicines related to fall risk and highly correlated with dizziness/ balance dysfunction as a side effect is available through Anne Esdale; Fall Prevention Coordinator; Michigan Department of Community Health, Injury Prevention Section, at: EsdaleA@michigan.gov

Incontinence: Under Study: 

Incontinence: Under Study Stress UI affects pelvic floor weakness, which impacts hip strength directly Urge type UI can affect judgment and focus. May have 'panic' gait issues Functional UI In general, UI can distract and lower activity level and cause the individual to move about less

Again, WE are the greatest risk!: 

Again, WE are the greatest risk! Client and health professional awareness is the single best step we can make toward reducing risk Look for signs of fear of falling Be dramatic to get your point across!

Brief Case Review: 

Brief Case Review 72 y/o female; dx: arthritis and mild CHF. Lost husband within last year. Afraid to drive Not sleeping well Afraid – to drive, to be alone Less active, limited social exposure Minimal shopping Nutrition and hydration decline

Case Study (cont.): 

Case Study (cont.) Weakness is progressing; no assistive device is prescribed. Does not see doctor Endurance is declining EVENT: Attempts to repair something that has been neglected in the home; falls; fractures wrist and ankle; cannot care for self; enters ECF Rapid loss of will, desire; continues to decline; pneumonia within six months; death six weeks later Discuss intrinsic and extrinsic synergy and decline

Break time!: 

Break time! Hope you are beginning to fully understand how impactive your work can be You can experience the difference right away LISTEN first!!!