Screening Tools and Evidence-Based Exercise for the Patient At Risk for Falls

1. Screening Tools and Evidence-Based Exercise for the Patient At Risk for Falls NCPTA Fall Conference October, 2012

2. Contact Information • Christina Weaver, PT, MPT Cone Health Outpatient Neurorehab PH: (336) 271-2054 Christina.weaver@conehealth.com • Craig DeBussey, PT, DPT ElderFit In Home Rehab PH: (919) 419-8333 craig2008@mindspring.com

3. Acknowledgements • Falls Practice Improvement Network • Tiffany Shubert, PT, PhD at Center for Aging and Health • tshubert@med.unc.edu(919) 360-1970 • Carolina Geriatric Education Consortium • DHHS, Health Resources & Services Administration (HRSA) • Dr. Jane Painter, OT, PhD; Dr. Leslie Allison, PT, PhD, Paula Josey, MSN, RN

4. How can we help?

5. Course Objectives • Appreciate the impact of falls on the public health of seniors in North Carolina • Understand the network of NC fall reduction programs • Identify key risk factors for falls in older adults • Perform tests that can be used to screen older adults for fall risk

6. Course Objectives • Understand the key components of a multi-disciplinary program to reduce falls • Describe the three evidenced-based exercise programs selected by the CDC to reduce falls risk • Discuss effective models for physical therapy clinicians to partner with other providers to reduce falls by their patients and in their community

7. Why Falls??? The Perfect Storm

8. The Facts • 1 in 3 older adults in the U. S. fall each year -Half of these fall repeatedly • 20% of fallers are injured • Leading cause of ED visits in older adults • 40% of long term care admissions • 65% increase in death rate due to falls since 2000 (CDC, 2009)

9. 12% or less 12.1% to 13.0% 13.1% to 14.4% 14.5% to 15.9% More than 16% Population Age 65+ in North Carolina, 2000 Mean = 12.0%. Range = 6.3% to 23.6%

10. Population Age 65+ in North Carolina, 2030* Mean = 17.7%. Range = 10.5% to 35.2% *Based on July 2006 population projections

11. Data Limitations: Fall Deaths are only the Tip of the Iceberg 837 Deaths 25,588 Hospitalizations 182,313 ED Visits ???,??? Outpatient Visits ?,???,??? Medically Unattended Injury (Home, Work)

12. Falls Coalitions • What is a falls prevention coalition? • Group of people worried about falls who get together to do something about it!

13. NC Local and Regional Coalitions Raleigh Winston-Salem Greensboro Asheville Northampton Alleghany Gates Warren Currituck Ashe Surry Stokes Camden Caswell Vance Rockingham Person Granville Hertford Pasquotank Watauga Halifax Wilkes Perquimans Yadkin Chowan Forsyth Guilford Bertie Franklin Orange Avery Durham Alamance Mitchell Caldwell Nash Edgecombe Davie Alexander Yancey Madison Washington Iredell Martin Tyrrell Wake Davidson Dare Chatham Randolph Burke Wilson McDowell Catawba Rowan Buncombe Pitt Beaufort Haywood Johnston Hyde Swain Greene Lee Lincoln Rutherford Cabarrus Harnett Cleveland Henderson Wayne Montgomery Graham Jackson Stanly Moore Gaston Mecklenburg Polk Lenoir Craven Transylvania Macon Cherokee Pamlico Cumberland Clay Hoke Jones Richmond Sampson Anson Union Duplin Scot land Carteret Onslow Robeson Bladen Charlotte Pender Columbus New Hanover Brunswick

14. NC Falls Prevention Coalition (NCFPC) Established in 2009 Brings together researchers, planners, health care providers, and others, representing more than 60 organizations whose goal is to reduce the number of falls and fall-related injuries among seniors in North Carolina

15. NC Falls Prevention Coalition 6 Goals: • Infrastructure Development and Maintenance • Community Awareness and Education • Provider Education • Risk Assessment and Behavioral Intervention • Surveillance and Evaluation • Advocacy for Supportive Policies and Environments

16. The Impact of NC Falls Coalitions • Falls = one of 5 priority areas in the State Injury Prevention Plan • Falls prevention a priority in NC Institute of Medicine plan (a first!) • Falls prevention a priority in the NC State Aging Services Plan (a first!)

17. The worlds are colliding!

18. Questions?

19. Who is Falling? Why? High Function High Risk Low/Moderate Risk Moderate Risk Physical Risk Factors Medical Risk Factors Moderate to poor validity of assessment tools Physical Risk Factors Medical Risk Factors Good validity of assessment tools Greatest number of risk factors Greatest number of medical risk factors Poor validity of assessment tools Transitionally Frail

20. Who Falls? • Clients in transition from hospital to home • The first 2 weeks after hospitalization falls rate significantly higher than at 12 weeks (8.0 vs. 1.7 per 1000 person-days) • 15% of re-hospitalizations happen in first month (Mahoney, 2002)

21. Who Falls? Clients in transition • Falls rates highest (81%) and greatest injuries • Fair standing balance • Able to rise from a chair • Falls rates lowest • Worst standing balance • Unable to rise from a chair (Lord, 2003)

22. Who Falls? • Clients transitioning from rehabilitation • Clients post-rehab at highest risk • 73% incidence of falls • 4 - fold increase in falls risk Pouwelset al: Stroke 2009; Whitson, et al: JAGS 2006

23. Multi-Dimensional Problem • Older adults • See falls as unpredictable & unavoidable • Often don’t admit, or forget, falls • Stigma associated with falling & fear-of-falling • Providers • May see falls as “normal” & unavoidable with aging • Unsure how to screen, assess, manage • Pressed for time & resources

24. Risk Factors

25. Fall Risk Factors Bath Urchin The first ever move to incorporate the bath. Empty the bath of water and dry thoroughly, to eliminate the risk of slippage. Climb into the bath and place feet on the far end, either side of the taps. Brace the sides of the bath with both hands at shoulder level. Push upwards and arch your back to complete the move. -from Harrison and Ford ‘House Gymnastics”

26. Risk Factors Tinetti, M. E. et al. JAMA 2010;303:258-266

27. Risk Factors Tinetti, M. E. et al. JAMA 2010;303:258-266

28. Increase Factors = Increased Risk (Tinetti et al, 1988)

29. Who Falls? Our patients!!!

30. Analysis Paralysis =The challenge for the NC Falls Prevention Coalition With so many studies, which screening method do you use?

31. So many choices… When fishing – • What are you trying to catch? • Who is doing the fishing? • What kind of tackle do you use?

32. Similar choices… When screening for falls – • Who is falling? • Who will perform falls screening? • What screening tools do you use?

33. Step 1: Standardized Screening • AGS Clinical Practice Guidelines All older adults screened for falls risk • Have you fallen in the past year? • Do you have problems with mobility? • Are you worried you might fall? • Any trained provider able to safely and accurately perform a risk screen

34. CDC Screening & Algorithm

35. Falls Assessment Tool

36. Timed Up and Go • Easy, reliable, and valid indicator of functional mobility and falls risk • Predictive of morbidity, mortality, functional status (Studenski, 2011)

37. Rise from a standard height chair, walk 3 meters (9.8 feet) turn around, walk back and sit Walk at normal pace Timing starts on ‘go’, stops when they sit Can use arms to rise and device to walk Timed Up and Go

38. TUG: What it tells us • Does the person have difficulty performing the task? • Is the person slow? • 7-9 sec: low risk, typically a fit & active older adult • 10-12 sec: moderate risk, an ‘average’ older adult • > 13.5 sec: high risk for future falls( Bohannon, 2005)

39. TUG: What it tells us • Best reliability and validity with independently mobile, healthy older adults • Poor reliability in hospital settings • Timing task can provide baseline measure of performance • KEY – Does the person have difficulty performing????

40. 30 Second Chair Rise • Indicator of strength and endurance • Poor performance associated with increased falls risk

41. 30 Second Chair Rise • Sit in middle of chair • Cross arms, hands on shoulders • Feet flat on floor • On ‘go’ rise to full standing and sit • Repeat for 30 seconds

42. 30 Second Chair rise • Begin timing on ‘go’ • Count number of times the patient comes to full standing in 30 seconds • Record number of repetitions

43. 30 second chair rise

44. 30 second chair rise: What it tells us • Indicator of: • Postural control • Lower extremity strength • Proprioception • Measure of disability

45. 4 – Stage Balance Test • Describe the position • Demonstrate • Have patient assume position • No practice sessions • Let go and time • Hold each position for 10 seconds • Can start with hardest position first

47. 4 stage balance test:What it tells us • Can the person stand with a narrowing base of support? • Indicator of • Postural control • Single limb stance • Proprioception • Measure of disability

48. Gait Velocity • Walking speed is “almost the perfect measure.” • Reliable, valid, sensitive and specific • Measure, self-selected walking speed • Correlates with functional ability and balance confidence

49. Gait Velocity • Allow for acceleration and deceleration • Patient can use assistive device White Paper: “Walking Speed: the Sixth Vital Sign” Stacy Fritz, PT, PhD; Michelle Lusardi, PT, PhD

50. Gait Velocity Norms Schmid et al 2007