Falls: The Double-Edged Sword

Evidence-Based Perspectives

Dennis W. Klima, PT, MS, PhD, DPT, GCS, NCSDepartment of Physical Therapy

University of Maryland Eastern Shoredwklima@umes.edu

AN INTERDISCIPLINARY APPROACH TO OLDER ADULT FALL PREVENTION

APRIL 15, 20158:00 A.M. – Noon

Sheppard Pratt Conference Center

Objectives

Learning Objectives: 1. Discuss evidence base recommendations for interventions to reduce falls in older adults

2. Describe balance and gait changes associated with aging.

3. Describe major intrinsic and extrinsic causes of falls among older adults.

4. Construct fall prevention programs for older adults, which are multidimensional and address exercise, fear of falling, and floor recovery strategies.  

Falls and the Aged Population:How Serious is the Problem?

> Among older adults falls are the leading cause of both fatal and non-fatal injuries.

Over 95% of hip fractures are caused by falls.

Falls are the leading cause of traumatic brain injury.

Older men more likely to die from a falls-related injury.

(CDC, 2015 )

Question about Falls Management……..

Why a “double-edged sword?”

Risk Factors

Previous falls Balance & gait

impairments Medications

Risk increases with increasing number of risk factors

Ensrud et, 2007

Causes of Falls

Intrinsic Causes

Extrinsic Causes

Multifocal Glasses and FallsLord, JAGS, 2002

• Depth perception and distant edge-contrast sensitivity are diminished when looking through lower portion of glasses

• 15% of multifocal wearers fell on stairs vs none of non-wearers (p<.01) 0

0.5

1

1.5

2

2.53

Fall dueto trip

Falloutsidehome

Any fall

OR for wearers versus nonwearers

7

Optimizing footwear for older people at risk of falls Jasmine C. Menant, PhD;1* Julie R. Steele, PhD;2 Hylton B. Menz, PhD;3

Bridget J. Munro, PhD;2 Stephen R. Lord, PhD,DSc1

Volume 45 Number 8, 2008

   Pages 1167 — 1182 Shoes and Falls?

Medications and Falls

Psychoactive Medications Sedatives Antipsychotics Antidepressants

Movement Disorders Parkinson’s Disease Sinemet

Woolcott, Richardson, & Wiens, 2009

Indoor Vs. Outdoor FallsIndoor Falls

Risk Factors Older age

Female gender

Indicators of poorer health

Outdoor Falls

Risk Factors Younger age

Male gender

Physically active

(Kelsey, Berry, Proctor-Grey et al, 2010)

Fear of Falling Metrics…they’re all the same?

They’re not.

Benefits

Pitfalls

Single Dichotomous Question

Are you afraid of falling?

Yes No

If yes… Does this fear limit your activities?

(Tinetti, 1993; Maki, Holliday, & Topper, 1991)

Activities-Specific Balance Confidence (ABC) Scale

Measures balance confidence level during functional tasks (stepping on an escalator, walking on ice)

100 points total Denotes High Confidence

0 10 20 30 40 50 60 70 80 90 100% No __________________________________ Completely Confidence Confident

Test/Re-Test Reliability (r=.92)

Developers: Myers and Powell, University of Waterloo

Activity-Specific Balance Confidence Scale

Mid-80’s or better/Higher functional level Concurrent Validity with FES (r=.84) Test/Re-Test Reliability (r=.92) 6 Item Version (Goldberg et al, 2008) Pro’s: Community-dwelling Con's: Seasonal issues

Powell, L.E. & Myers, A.M. (1995). The Activities-specific Balance Confidence (ABC) Scale. Journal of Gerontology A:

Biological and Medical Sciences, 50, M28-34.

Falls Efficacy Scale-International(FES-I)

Developed by the members of the Prevention of Falls Network Europe (ProFaNE)

16 items/64 total points

Strong internal and test-retest reliability (ICC= .96)

Assessment of fear of falling, incorporating more challenging activities compared to the original FES in evaluating community-dwelling elderly populations

(Yardley et al, 2005)

FES-I: Multilingual Translation

Interventions(Zijlstra et al, 2007)

Systematic Review-11 Studies Identified

Multifactorial Programs (n=5) Enhance confidence and

perceived control Tai Chi Interventions (n=3) Exercise Interventions (n=2) Hip Protectors (n=1)

Fear of Falling & Balance Confidence: The Clergy

Mepkin Abbey---All “Floor Recoverers”

Why the Floor?

The Forgotten Issues Are We Addressing it and Teaching it?

Simpson & Salkin,

1993

11% PT’s

21% OT’s

-Taught floor transfers

Rising to Stand from the Floor

Terminology Floor Rise

Floor Recovery

Floor Transfer

Supine to Stand

Measurement

Timed Supine to Stand Test

Rising to Stand from the Floor within the ICF Classification

Health Condition

Environmental FactorsPhysical demands & barriers,

transportation barriers, wheelchair design, support from family, peers, &

health professionals

Personal FactorsGender, age, BMI, education,

profession, financial resources, lifestyle

Body functions & structure

( Altered circulation, aerobic capacity,

muscle performance, )

Activities(Deficits in

climbing stairs, floor rise )

Participation

Contextual factors

Floor Rise: Types of Evidence Ia- Meta Analysis of RCT’s Ib- At least 1 RCT IIa-At least 1 good controlled study-no randomization IIb-At least 1 other type of good experimental study (pre-

post design) III-Good descriptive non-experimental studies (e.g.

correlation, case study) IV-Experts’ reports, authoritative opinions

(US Agency for Health Care Policy & Research)

Historical Perspectives

(VanSant, 1988) (Ulrich, Raheja, Alexander, 2000)

The Critical Fall

Term applied when a client cannot stand following a fall

Bloch, 2009 Tinetti, 1993 Wild, 1981

DehydrationHypothermiaPressure Ulcers

Examination

The Timed Supine to Stand Test

Getting off the Floor…Hmmmmmm

Aim What motor pattern is most commonly used to

perform the supine to stand transition among community-dwelling older adults?

Frailty Measures in Older Adults:

Who Rises to Stand?

(Gilbert, Hamad, Patel, & Klima, 2010)

Fried et al CHS Frailty Screen

• Grip strength

• Walking speed

• Weight loss

• Fatigue

• Low physical

activity

• 0 = Nonfrail• 1-2 =

Intermediate• 3-5 = Frail

• Research Exclusions:

• dementia• CVA• CHF, CAD• Parkinson’s• “other”

Observations:Rising from the Floor and Categorizing

Pattern A Pattern B Pattern C

Results: Demographic Profile

Community Dwelling (n=61)

Age (yrs) 79.57 (± 8.6)

BMI (kg/m2) 27.06 (± 4.5)

Fall in past year (#) 13 (21.3%) yes

Co-morbid conditions Heart Disease Depression Diabetes

13 (21.3%) 6 (8.9%) 8 (13.1%)

Floor Rise: Timed Supine to Stand

Mean Time : 8.0 seconds (+ 5.7) Patterns:

5 Subjects (9%): Pattern B 48 Subjects (91%) : Pattern C

(n=53)

Correlates of Rising from the Floor

Pearson Product Moment Coefficients

*Significance: p<.01 †Significance: p<.05

Timed Supine to Stand Performance: Correlation with demographic and performance variables (n=61)

Timed Supine to Stand

Age 0.57*

Normal Gait 0.61†

Physical Activity 0.29*

Timed Up and Go 0.71*

ABC Score -0.51*

Grip Strength -0.30†

Prognosis: Supine to Stand-Predictors

48% of the variance in floor rise could be attributed to TUG performance (p<0.001)

Reliability > .90 on all ICC’s.

INTERVENTIONS

Floor Rise Strategy Training

RCT Training Group (n=17) Control Group (n=18) Intervention

6 sessions

Training Group (n=17) Floor Transfers

Control Group (n=18) Chair Flexibility

Improved in rise ability

and less difficulty reported (p<0.05)

Interventions

How about Dance?

Keeping the Older Adults Moving:

What’s dance got to do with it?

Danielle Ethier, Kristen Fiackos, Ellen Kuhn, Rupa PatelDennis W. Klima, PT, PhD, DPT, GCS, NCS

and Margarita Treuth, PhD

InterventionFrequency• 60 min sessions• 1-2x/week • 12 wks

Dance Routine• Warm-up

• Gentle aerobics and breathing• Stretching• Seated and standing positions

• Choreography• Continuous movement• Set to music

• Cool down• Stretching on floor mats• Performed in a circle

Dance ProgressionPreparation Phase •Established positive interactions between dance participants

•Dance aimed at improving functional balance and LE strength

Transitional Phase •Progressed choreography with outcome measures in mind•Squats and sit-to-stand transitions implemented

Culmination Phase •Completed choreography•Encouraged stand-supine-stand transfers during cool-down

Physical Performance

Physical Performance Variable (N=11)

Pre-Test Value

Post-Test Value

P value

Normal Gait Velocity (m/s)

1.3±0.3 1.3±0.1 0.66

Fast Gait Velocity (m/s)

1.7±0.3 1.7±0.2 0.42

Five Times Sit to Stand (s)

11.8±2.2 9.2±1.9 0.006

Timed Supine to Stand (s)

6.3±2.0 5.6±1.5 0.03

COMMUNITY-BASED FALL PREVENTION PROGRAMS

Interventions:

Community-Based Interventions-Floor Recovery

Stepping On 7 Weeks Exercise Component

Balance and strength Floor Transfer Guest Instructors

PT or PTA Pharmacist Optometrist Community Safety

A Matter of Balance 8 two hour session Take control of fall risk Make changes to

reduce fall risk at home Exercise to increase

strength and balance Targets fear issue Floor transfer by PT

Multidimensional ProgramsFall Risk

“Stepping On”

Weekly Classes

PT Participation

Target Muscle Groups

“Stepping On” Program

Community-based fall prevention course

7 weeks

Contribution by physical therapy

Target Muscles

Quadriceps

Hip Abductors

Ankle Dorsiflexors/Plantarflexors

Follow-Up 45 Participants (mean age 75.4; range-61-91) 77.8% noted they had a better plan to rise from

the floor following the program. 82.2% had a better understanding of fall causes.

Clinical Bottom LineTake Home Message

When you fall…..

And involve your students!!!!!

Medical alert systems Buddy checks Plan

Floor transfer Signals Scream Practice

Gait Velocity-Consideration for Generational Differences

1.2 m/sec – Traditionalists

Community Navigator

Can traverse streets and curb negotiation

.8 m/sec – Millenials

Limited Community Ambulator

Needs Interventions for Fall Risk

A Final Parable ABC Score= 63% So What!!!