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Falls and Mobility Problems in Older Adults Shelley B. Bhattacharya, D.O., M.P.H. Department of Family Medicine Kansas Reynolds Program in Aging University of Kansas Medical Center
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Definitions Classifications Incidence Epidemiology of falls in elderly Ageing
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An event that results in a person inadvertently coming to rest on the ground or other lower level (not as a result of loss of consciousness, violent blow, sudden onset of paralysis or seizure) (Gibson et al., Kellogg International Work Group, 1987) An event which results in a person coming to rest unintentionally on the ground or other lower level, not as a result of major intrinsic event (such as stroke) or overwhelming hazard (Tinetti et al., 1988) Unintentionally coming to rest on the ground, floor or other lower level (Ory et al, FICSIT trials, 1993) Definitions: Epidemiology of falls in elderly
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Falls Trigger Consequence Intrinsic Extrinsic Injurious Non-injurious Classifications: Epidemiology of falls in elderly Fallers Non-fallers Once-only fallers Recurrent fallers
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Epidemiology of falls in elderly Incidence: Accidents are the 5th leading cause of death in older adults 1 Falls account for 2/3 of these accidental deaths 1/3 of adults over 65 living in the community fall at least once a year This rises to ½ of adults over age 80 2,3 5% of these falls result in a fracture or hospitalization Mobility abnormalities affect 20-40% of adults over 65 and 40-50% of adults over age 85 4,5
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Mortality 46 Of those who are hospitalized, ~50% will not be alive a year later Falls constitute 2/3rd of deaths associated with unintentional injuries In 2000 traumatic brain injury (TBI) accounted for 46% of fatal falls. Cost 47 Fall-related injuries are among the most expensive health conditions In 2000 $179 million were spent on fatal falls and $19 billion were spent on injuries from non-fatal falls Epidemiology of falls in elderly Incidence:
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Location 48 Most falls occur outdoors Women are more likely to report indoor falls Indoor falls are associated with frailty Outdoor falls are associated with compromised health status in more active elderly Epidemiology of falls in elderly Incidence:
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The rate of falls and their associated complications are ~ twice over the age of 75 years. 10-25% falls induce fractures in this population Hip fractures are more common after the age of 75 years Those ≥75 years of age are more likely to report indoor falls Incidence is higher in certain populations (e.g. institutionalized elderly, diabetics, Parkinson’s disease, post-stroke etc.) 49 Epidemiology of falls in elderly Incidence:
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Fall prevention The quality of falls care in older adults is suboptimal If we can reduce the risk factors for falling, then we can reduce the incidence and the morbidity associated with falls 3 studies have found that 65-100% of older adults with 3 or more risk factors fell in a 12 month period compared with 8-12% of older adults without any risk factors 1,6-8
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ACOVE Indicators ACOVE = Assessing Care Of Vulnerable Elders The 12 new ACOVE indicators59 are designed to improve the clinical approach to falls and mobility in older adults Evidence based focus: 182 articles were reviewed to obtain these indicators Some have practice guidelines which will be shared
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ACOVE Indicator 1 ALL vulnerable elders should have ANNUAL documentation about the occurrence of recent falls …
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Because… Falls are common Preventable Frequently unreported Often cause injury Can restrict activity unnecessarily A recent fall is a potent predictor of future falls Need a multifactorial falls risk assessment for all of your vulnerable older adults
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Multifactorial Falls Risk Assessment Many studies show that a multifactorial falls risk assessment program is beneficial to assess and intervene on falls In one meta-analysis, the risk ratio for a first fall in subjects enrolled in a risk assessment program was 0.82 (95% CI 0.72-0.94) compared to controls and was 0.63 (95% CI 0.49-0.83) for any fall 9 In other words, 18% fewer 1st falls and 37% fewer of any falls with a falls risk assessment program!
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Falls Risk Assessment Features Medication review ADL and IADL assessment Orthostatic blood pressure measurement Vision assessment Gait and balance evaluation Cognitive evaluation Assessment of environmental hazards
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ACOVE Indicator 2 IF a vulnerable elder reports 2 or more falls in the previous year, THEN document a basic fall history within 3 weeks of the report … Because a basic fall history provides the necessary information to implement an individualized multifactorial falls risk intervention strategy
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What is a fall history? Circumstances? Medications? Chronic conditions? Mobility status? Alcohol intake? You can use the positives to tailor a fall prevention program specific for each of your older adults 10,11
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ACOVE Indicator 3 IF a vulnerable elder reports 2 or more falls (or 1 fall with injury) in the previous year, THEN there should be documentation of orthostatic vital signs within 3 months of the report… Because detection of orthostasis decreases the risk of future falls Is a part of the multifactorial falls prevention intervention
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Evidence Supported by 13 studies including cohort and RCT’s 12-18 Some clinical guidelines that are recommended: Correct postural hypotension 19 Assess postural vitals in all older adults that have had a recent fall, report recurrent falls or demonstrate abnormalities in gait or balance 20 Include a cardiovascular examination when doing a falls risk assessment 21
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ACOVE Indicator 4 IF a vulnerable elder reports a history of 2 or more falls in the last year, THEN there should be documentation of an eye examination in the previous year or visual acuity testing within 3 months of the report… Because detection and treatment of some forms of visual impairment reduces the risk of falls.
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Evidence 11 studies examined visual acuity as a falls risk factor One study looked at falls improvement after expedited (within 27 days) and routine (71-212 days) cataract surgery in women over age 70 22 After 1 year, 49% of adults in expedited group fell at least once compared to 45% in routine group 18% fell twice in expedited group compared to 25% in control group
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ACOVE Indicator 5 and 6 IF a vulnerable elder reports 2 or more falls in the last year, OR IF a vulnerable elder has new or worsening difficulty with ambulation, balance or mobility, THEN there should be documentation of basic gait, balance and strength evaluation within 3 months of the report…
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Because… Detection and treatment of gait and balance disorders reduces the risk of future falls as part of a multifactorial intervention
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Evidence 9 studies looked at gait and balance assessments in falls prevention Cohort and RCT’s In 3 studies, abnormal gait and balance alone were significant predictors of falls 6
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Clinical Guidelines for Gait and Balance Provide interventions to improve balance, transfers and gait 19 Do a gait and balance assessment for those requiring medical attention because of a fall, report recurrent falls in the past year or demonstrate abnormalities of gait or balance 20 Risk assessment includes assessment of gait, balance, mobility and muscle weakness 21
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Screening and Examination of Gait and Balance Timed Get Up and Go Test Single Leg Stand Test Dynamic Gait Index Berg Balance Scale
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Timed Get Up and Go Test Measures functional capacity rather than individual impairment – reflects multiple domains, useful in detecting mobility impairment . Time it takes to stand up from arm chair, walk 3 meters (10 feet), return to chair and sit down
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Timed Get Up and Go Test Interpretation of Performance on the Timed Get Up And Go Test < 10 sec. Low fall risk; clients are freely mobile; encourage regular exercise < 20 sec. Moderate fall risk; clients are independent with basic transfers; most go outside alone and climb stairs, many are independence with tub and shower transfers. PT referral may be appropriate. 20-29 sec. High fall risk; “Gray zone”; functional abilities vary. Physician or multidisciplinary team assessment recommended. >30 sec. Very high fall risk; Many are dependent with chair and toilet transfers; most are dependent with tub and shower transfers; most cannot go outside alone; few, if any, can climb stairs independently. Physician or multidisciplinary team assessment recommended.
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Timed Get Up and Go (TUG) Test Bischoff (2003) Community dwelling elderly women < 12 sec. on TUG normal Women in residential care – only 9% performed in <12 sec.; 42% were below 20 sec; 32% were between 20-30 sec. and 26% > 30sec. Suggests that community dwelling woman with TUG > 12 sec. should be referred for PT evaluation Over 50% of women in residential care at high or very high risk of falling
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Timed Get Up and Go Test Nordin (2006) Individual variation in performance high in institutionalized elderly Variation increased with slower performance. Cognitive impairment or cuing did not increase variability Could use mean of three trials to obtain a more accurate score We do not know what this variability means in terms of falls risk prediction
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Single Leg Stance Test A measure of static balance that relates to foot/ankle strategies Functional implications for gait, especially on uneven surfaces, and going up/down curbs or steps Marker of frailty in elderly persons Community dwelling older adults unable to stand for 5 sec. had a 2.1 times risk of injurious falls
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Dynamic Gait Index Developed to quantify gait dysfunction in older adults during level surface walking as well as more complex functional tasks. Dual task demands relevant to falls risk in elderly Applicable to assessing balance in other groups of patients including those with vestibular disorders, multiple sclerosis, head injury, and Parkinson’s Scores of 19 or less out of 24 indicate increased risk of falling in older adults (Shumway-Cook 1997)
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Berg Balance Scale Measure of static and dynamic balance in movements common in everyday life on 14-item scale (56 points) Useful for evaluating multiple falls risk in community living older adults No longer recommends a dichotomous 45 point cut-off Likelihood of multiple falls increases as score decreases Reliable test of balance in elderly in residential care – change of 8 points required to reveal genuine change in function Discriminates persons with Parkinson’s disease who fall vs. those who do not fall Cut-off score of 44/56 recommended by Landers, 2008
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Limitations of Balance Scales and Screening Tools Screening for falls may increase fear of falling Falls are multifactorial, no scale captures all aspects Scales and balance screening tools have not been well tested in a wide range of populations/settings Uncertainty regarding predictive scores Scales test different aspects of balance, sensitivity for prediction and examination may be best with multiple tests
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ACOVE Indicator 7 IF a vulnerable elder reports 2 or more falls in the past year, THEN there should be documentation of a cognitive assessment in the past 6 months… Because, detection and management of cognitive impairment reduces the risk of falls as part of a multifactorial intervention
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Evidence 7 studies 4 studies recommend using the MMSE 15-17,23 Clinical Practice Guideline Assess mental status as part of your fall evaluation for older adults who had a fall, report recurrent falls in the past year or show abnormal gait or balance 20
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ACOVE Indicator 8 IF a vulnerable elder reports a history of 2 or more falls in the past year, THEN there should be documentation of an assessment and modification of home hazards recommended in the previous year or within 3 months of the report…
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Because… Environmental factors can contribute to risk of falls and mobility problems An assessment and modification of home hazards may decrease fall risk
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Homes Are Not Typically Designed For Users of Various Abilities Life Span Development Acute Injury Aging-in-Place Chronic Disability
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Difficulty Moving Around at Home Hard to go up stairs 35% Difficulty walking 15% Use of cane/walker 8% Use of wheelchair/scooter 6% Difficulty bathing 3% Chair or bed transfers 3% (Source: Fixing to Stay, 2002)
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Important Housing Features Main floor, bath Main floor, bedroom Accessible climate controls Non-slip flooring Bathroom aids No step entrance Covered parking (Source: These Four Walls…, May 2003)
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Occupational Therapy considers the physical context During Assessment Understand obstacles/barrier to participation Understand supports to participation Consider individual, groups, populations who use the physical space During intervention Reduce activity demands from the environment Insure adequate supports Facilitate performance though the use of the environment Avoid further functional decline and excess disability caused by environmental factors
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3 Major Problem Areas of the Home: Outside Steps To The Entrance Inside Stairs To A Second Floor Unsafe Bathrooms Source: HUD (2001)
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Other Alternatives to Entrance with Outside Steps Ramps Earth Berms/Walkways Lifts Zero Step entrance
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Other Strategies for Getting Upstairs Chair lift Elevator Relocate rooms to main floor
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Strategies for Bathing Bath bench/chair Bath lift Grab bars Visual contrast Non slip surface Hand held showerhead Shower/wet room Curbless shower
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Evidence Many RCT’s reviewed One RCT of over 3000 older adults 24 Intervention: in home safety mobility assessment Control: no assessment Results: Odds ratio of falling in the intervention group dropped from 1.0 to 0.85 In other words, there was a 15% drop in falls in those receiving the in home safety mobility assessment
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More Evidence Environmental assessment and modification using an occupational therapist reduced 12 month relative risk of falling to 0.64 (95% CI 0.5-0.83) in older adults at higher risk of falling 25-28 Another study compared a home safety program to a home exercise program in older adults with severe visual impairment 29 Found fewer falls in the home safety program: 0.59 (95% CI 0.42-0.83) No difference with the home exercise group
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Review Study A review study looking at 3 trials found that professionally prescribed home hazard assessment and modification in older adults with a history of falling reduced the risk of falling, RR of 0.66 (95% CI 0.54-0.81) 30
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Checklists--Examples Home Safety Council www.homesafetycouncil.org/resource_center/rc_checklist_w001.aspxp Rebuilding Together --Checklist www.rebuildingtogether.org CDC Check for Safety www.cdc.gov/ncipc/pub-res/toolkit/checkforsafety.htm http://www.cdc.gov/ncipc/falls/FallPrev4.pdf http://www.cdc.gov/ncipc/duip/fallsmaterial.htm
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ACOVE Indicator 9 IF a vulnerable elder reports a history of 2 or more falls, or 1 fall with injury, in the past year, THEN there should be documentation of a discussion of related risks and assistance offered to reduce or discontinue benzodiazepine use… Because, benzodiazepine use increases the risk of future falls
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Evidence 1 RCT: 93 ambulatory adults over age 65 on a benzodiazepine, any other hypnotic, antidepressant or tranquilizer 31 Randomized to withdrawal plus exercise, withdrawal only, exercise only or no intervention Over 44 weeks, medication withdrawal group had lower rate of falls (0.52 vs. 1.16 falls per person-year. Difference 0.64, 95% CI 0.07-1.35)…NOT significant But, if adjusted for history of falls in past year and total number of meds taken, hazard for falls in the medication withdrawal group was 0.34 (0.16-0.74)
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More evidence! Meta analysis of observational studies found that odds ratio for the association between benzodiazepines and falls was 1.40 (1.11-1.76) in cohort studies 2.57 (1.46-4.51) in case control studies 1.34 (0.95-1.88) in cross sectional studies 32
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Clinical Practice Guidelines Review all medications 20 Modify psychotropic meds and discontinue, if appropriate Rationalize all drugs taken 19
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ACOVE Indicator 10 IF a vulnerable elder demonstrates poor balance or proprioception or excessive postural sway and does not have an assistive device, THEN an evaluation or prescription for an assistive device should be offered within 3 months…
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Because… Impaired balance or proprioception or excessive postural sway can contribute to instability Appropriate treatment will reduce the likelihood of falls and their complications
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ACOVE Indicator 11 IF a vulnerable elder reports a history of 2 or more falls, or 1 fall with injury, in the past year and has an assistive device, THEN there should be documentation of an assistive device review in the past 6 months or within 3 months of the report…
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Because… A poorly fitted assistive device or one used inappropriately along with impaired balance or proprioception or excessive postural sway can contribute to instability Appropriate use of an assistive device will reduce the likelihood of falls and their complications
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Evidence for Indicators 10 and 11 Many studies suggest that assistive devices can increase an older adult’s confidence, reduce fear of falling and improve independence 33-35 Some studies suggest the use of devices may increase the risk of falling 36,37 Other studies suggest that device use is a marker for fall risk 38
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Age, female gender, poor social support, H/O falls, depression and poor lower limb function In addition to older age and female gender, lower personal mastery and poor dynamic balance are associated with fear of falling 55 Fear of falling: Possible contributors
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Fear of Falling Activity restriction Poor perceived health Social withdrawal Reduced strength Poor balance Increased disability Increased fall risk Reduced independence Poor quality of life
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Fear of falling may not always precipitate activity restriction ~ half of those who report fear of falling do not restrict activities 50-53 Lack of social support, depressive symptoms, H/O multiple falls and presence of ≥ 2 chronic conditions are associated with fear-induced activity restriction 50,53-54
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ACOVE Indicator 12 IF a vulnerable elder is found to have a problem with gait, balance, strength or endurance, THEN there should be documentation of a structured or supervised exercise program offered in the previous 6 months…
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Because… These problems can contribute to falls and mobility dysfunction Exercise intervention can improve the dysfunction and reduce the likelihood of falls and their complications
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Evidence Many studies show benefits of muscle strength with gait parameters in older adults Increases of 5-15% in ambulatory function after 8-12 weeks of a walking and endurance program 39,40 Balance training improved force-plate balance parameters by 20-50% 41,42 Tai chi improved balance (postural sway) by 32% and fall risk by 49% (OR 0.51, 95% CI 0.36-0.73) 43,44 Aerobic conditioning improved balance by 20% in adults over age 70 45
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General Gait Assessment: What to look for in the elderly person at risk for falling 56 Changes in gait with aging Average gait speed declines 12% to 16% per decade past 70 yrs. Stride frequency increases Stride length decreases at a given walking speed Double support time increases
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General Gait Assessment: What to look for in the elderly person at risk for falling 57 Gait Characteristics of Fallers Decreased trunk rotation Increased knee flexion Several small steps and reduced speed prior to stepping over low obstacle (12”) Shorter step and stride length Slowed gait speeds Decreased single leg support time and increased double limb support time.
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Practice Guideline Use exercise to improve measures of balance and reduce incidence of falls Use of a multidimensional exercise program that incorporates balance training and strengthening should improve postural stability and reduce fall risk
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Exercise Recommendations for Older Adults with Chronic Disease or Frailty 58 Balance 1-7 x/week, dynamic exercises focused on mobility, static exercise focused on single leg stand, 4-10 different exercises Progressive, targeting important postural muscle groups, progress by decreasing base of support Muscle Performance 2-3 x/week, 8 to 10 exercises Aerobic Capacity Chronic Dx - 3-5 x/week, 20-60 minutes, 50-70% Hrmax Frailty - > 3 x/week, at least 20 minutes, 11-13 Borg Scale Flexibility 3-7 x/week, 3-5 reps each major muscle group, 10-30 s. hold
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Summary Extremely important to try to prevent falls in your older patients and prevent future falls from your current fallers Look at their meds, cognition, orthostasis, vision, gait, balance Encourage exercise to improve muscle strength and balance Consider assistive devices Use OT for home safety assessments Screen for fear of falling and counsel to improve mobility
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Bibliography 46. Center for Disease Control, Morbidity and Mortality Weekly Report, 2004 47 Stevens JA, Corso PS, Finklestein EA, Miller TR. The cost of fatal and non-fatal falls among older adults. Inj Prev. 12:290-295. 2006 48 Rubenstein LZ. Falls in older people: epidemiology, risk factors and strategies for prevention. Age Aging. 35-S2:i37-i41, 2006 49 Masud T and Morris RO. Epidemiology of falls. Age Aging. 30-S4:3-7, 2001 50 Howland et al., 1993 51 Lawrence et al., 1998 52 Mann et al., 2006 53 Zijlstra et al., 2007 54 Murphy et al., 2002 55 Deshpande et al., 2008a 56 Barak Y, Wagenaar RC, Hold KG. Gait characteristics of elderly people with a history of falls: a dynamic approach. Physical Therapy 2006 57 From Newstead AH et al. J Geriatric PT 2007; 30(3): 93-101 58 Section on Geriatrics, APTA, GeriNotes, vol. 15 (1), 2008 Special thanks to Dr. Nandini Deshpande, Dory Sabata and Deborah Cooke for their clinical and research expertise 59 Chang JT, Ganz, DA. Quality Indicators for Falls and Mobility Problems in Vulnerable Elders. JAGS Oct 2007 55(S2):S327-S334