specialist psi exercise module risk factors for falls (and injuries) - intrinsic - extrinsic -...
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Specialist PSI Exercise Module
Risk Factors for Falls (and injuries)
- intrinsic- extrinsic
- modifiable with exercise
Specialist PSI Exercise Module
A Risk continuum ?
• Over 200 risk factors documented in the literature
0
10
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0 1 2 3 4+
%Falling(12months)
D Drugs and alcohol
A Age related physiological changes
M Medical conditions
E Environment
Specialist PSI Exercise Module
Intrinsic vs Extrinsic
- we are all ‘trippers’• Over HALF the falls experienced in the home are due to
environmental hazards - trips, slips, unsafe or unlit
stairways
• A decline in a person’s intrinsic risk factors (declining
function and balance) mean that the extrinsic risk
factors (loose mats, slippery floors) no longer just cause
a correctable trip - they cause an injurious fall
Specialist PSI Exercise Module
D - Drugs and Alcohol
• Cumulative effect of medication / time of day
• Prescribed medications / multiple drug regimes– Analgesics - Antidepressants– Sedatives - Antipscyhotics– Diuretics - ANY 4 OR MORE
MEDICATIONS
• Heavy drinkers (>7 units per week) (Campbell et al., 1989, O’Loughlin et al., 1993)
• Mixing medications with alcohol
Specialist PSI Exercise Module
A - Age related physiological changes
• Deterioration in physical functions and systems (strength, power, endurance, coordination, reaction,
balance, proprioception and neural control, asymmetry)
• Decrease in functional capacity, mobility and
activity
• Deterioration in feet (bunions, corns, circulation,
neuropathies)
• Increase in cognitive impairment and depression
Specialist PSI Exercise Module
Psychological risk factors
• Fear of falling
• Avoidance of activity
• Reduced quality of life
• Increased anxiety
Specialist PSI Exercise Module
M - Medical• Acute Infections• Cardiovascular control - postural hypotension, drop
attacks, heart disease, stroke, tia’s• Dementia, Alzheimer’s Disease• Parkinson’s Disease• Thyroid dysfunction Peripheral Neuropathies or myopathies Malignancies Impaired hearing or vestibular function (Menieres
Disease, Tinnitus)
Impaired vision (macular degeneration, glaucoma, cataracts, visual acuity, contrast sensitivity, adaptation to dark)
Specialist PSI Exercise Module
M - Medical 2• Foot deformities – pain, bunions, corns, hard skin, arthritis,
oedema
Urinary incontinence or urgency
Receiving community health or social services
Recent discharge from hospital
Use of assistive walking aids - cane, zimmer
• Malnutrition / Anaemia - Nutritional recommendations are 10-20g rda Vitamin D and 1,000mg rda calcium, Vit B12 deficiency leads to sensory abnormalities
Specialist PSI Exercise Module
E - Environment
Personal risk factors:
• glasses (bifocals and varifocals)
• footwear and clothing
Outdoors:
• Poorly lit pathways
• Uneven pavements
• Slippery leaves
• Rubbish, building materials, obstacles
• Bus drivers!
Indoors:• Loose carpets
• Wires and cables
• Unstable furniture
• Change of level
• Poor lighting
• Cold roomsSentimentality or “never been a problem before”
Specialist PSI Exercise Module
Not modifiable with tailored exercise
• vision problems • gender
• multiple medications • social class
• chronic medical conditions • poor housing
• hypothermia • poor heating
• malnutrition • poor footwear
• ageexercise may not have a major effect
Specialist PSI Exercise Module
Modifiable with tailored exercise
• low strength • depression• low power • postural
hypotension• poor gait • cognitive
impairment• poor mobility • urinary urgency• poor balance • fear of falling
• arthritis
exercise is likely to have a major positive effect
Specialist PSI Exercise Module
How can we identify older people at high risk of falling?
• AGS/BGS guidelines - “get up and go” test as a filter for a full assessment by a specialist clinician for people who have fallen at least once. J Am Geriatr Soc 2001; 49: 664 – 672.
• Falls Risk Assessment Tool (FRAT) –
5 questions to assess risk. J Public Health 2004;
26:138-143.
?? Usefulness in residential/nursing settings
Specialist PSI Exercise Module
Is there a history of any fall in the previous year?How assessed? Ask the person.
Is the patient / client on four or more medications per day?How assessed? Identify number of prescribed medications.
Does the patient / client have a diagnosis of stroke or Parkinson's Disease?How assessed? Ask the person.Does the patient / client report any problems with their balance?How assessed? Ask the person.Is the patient/client unable to rise from a chair of knee height? How assessed? Ask the person to stand up from a chair of knee height without using their arms.
FRAT - Assessment of falls risk in older
people
Specialist PSI Exercise Module
PROFET: targeting risk factors (Close et al. Lancet 1999)
• Medical assessment• General medical• Postural hypotension• Visual acuity• Balance• Cognition and affect• Corotid sinus syndrome
• Occupational Therapy• Function• Physical handicap• Psychological handicap• Environmental hazards
• Referral / intervention– Day hospital– GP– O/P– Optician– Social services
– Supply minor equipment
The rate of falls was reduced by 60%
Specialist PSI Exercise Module
Tinetti (1994) - Multifactorial
Risk factor Intervention Postural hypotension (N) - postural exercise (ankle pump)
- medication review and adjust
Use of sedative-hypnotic medication (N)
- taper-off and discontinue - non-pharm. treatment of sleep problems
Use of 4+ medications (N) - medication review and adjustment
Unsafe bath or toilet transfers (N)
- transfer training - environmental adjustment
Gait / balance impairment (P) - gait, balance and/or strength exercise - use of aids
Less than full range of motion against resistance (P)
- resistance exercises
The rate of falls was reduced by 30%