Connecting to the next step in falls prevention

1. Connecting to the next step in falls prevention 2013 Age and Disabilities Odyssey June 17, 2013 Duluth, Minnesota

2. Today’s Presentation • Falls In Minnesota and the Falls Prevention Continuum • Pam Van Zyl York and Kris Gjerde, MN Department of Health, Division of Health Promotion and Chronic Disease • Examples of Community Programs • A Matter of Balance and Adaptations for Low Vision • Debra Laine, Arrowhead Area Agency on Aging • A Matter of Balance for Deaf Older Adults • Dave Fink, Metropolitan Area Agency on Aging • Tai Chi Moving for Better Balance • Dave Fink, Metropolitan Area Agency on Aging

3. Falls In Minnesota & the Falls Prevention Continuum:Community Programs to Maximize Impact Age & Disabilities Odyssey June 17, 2013 Pam Van Zyl York, MPH, PhD, RD, LN Kris Gjerde, PT, MPH MN Department of Health

4. Why are Falls a Concern in MN? • #1 cause of MN unintentional injury death in 2010 • Exceeded motor vehicle accidents since 2007. • 4th highest fall death rate in US 14.80/100,000; (all ages) • Nearly 2X the US rate of 8.42 • Both continue to rise. • 2010: falls by adults > 65 yrs • U.S. rate = 53.76/100,000 • MN 3rdhighest in U.S. at 101.0/100,000 • MN had 32,209 falls, causing • 690 fatalities • MN estimated cost > $245 Million (in 2005 dollars)

5. Why are our rates so high? • It’s not ice and snow – at least not directly • We can’t say precisely • Some factors we think contribute: • We live long enough to die of a fall – • With longer life come increasing impacts from multiple chronic conditions that increase fall risk • We may be less active in the winter resulting in decreased fitness and increased fall risk

6. Source: Behavioral Risk Factor Surveillance System, 2009 (red) and 2010 (blue)

7. Data Source: CDC. Prevalence and Most Common Causes of Disability Among Adults --- United States, 2005. MMWR 58(16); 421-426. *Data were collected in June-September 2005 by U.S. Census Bureau using the Survey of Income and Program Participation (SIPP); CDC and the U.S. Census Bureau analyzed the most recent data and released their findings in May 2009.

8. Factors That Affect Risk of Falling Personal • History of falls • Fear of falling • Mobility problems due to impaired balance, muscle weakness, or chronic health conditions such as arthritis, diabetes or stroke • Complications of chronic health conditions such as vision changes or loss of sensation in feet • Poor nutritional status • Medication side effects and/or interactions • Alcohol use • Incorrect size, type, or use of assistive devices (walkers, canes, crutches, etc.) Environmental • Home and environmental hazards (clutter, poor lighting, no grab bars, etc.) • Poorly designed public spaces • Weather hazards – ice, snow, slippery leaves

9. Being #1 doesn’t mean we are where we need to be - Source: United Health Foundation http://www.americashealthrankings.org/

10. CDC’s Review of the Literature • Health care providers did not identify falls & gait disorder or evaluate patients who reported falling • Only 37% of older adults were asked about falls • Only 8% of primary care physicians used any clinical guideline on fall prevention • Many physicians were interested in learning about fall risk assessment & risk reduction _____ • Rubenstein, J Am Geriatr Soc, 2004 • Wenger, Ann Intern Med, 2003 • Jones, Acc Anal & Prev, 2011 • Robinson, J Am Geriatr Soc, 2001 STEADI (Stopping Elderly Accidents, Deaths & Injuries) • Algorithm for Fall Risk Assessment and Interventions • Tool Kit • Information for clinics and providers • Information for patients • Description of validated assessment tests www.cdc.gov/injury/STEADI

11. The STEADI Toolkit Stopping Elderly Accidents Deaths & Injuries www.cdc.gov/injury/STEADI

12. STEADI Algorithm Centers for Disease Control and Prevention National Center for Injury Prevention and Control No Risk Identified Flow chart for fall risk assessment process. Adapted from AGS/BGS Clinical Practice Guidelines, 2010 www.cdc.gov/injury/STEADI

14. When No Risk Is Identified • Educate • Importance of regular exercise and maintaining balance, strength and endurance – need for exercise that incorporates balance challenge – walking alone is not enough • Opportunity to maintain health, prevent falls and other chronic conditions • Community programs - see handout for information about how to find these programs in your community • Community exercise programs • Arthritis Foundation Exercise Programs • AF Exercise • Walk With Ease • AF Tai Chi • Enhance Fitness • Tai Chi Moving for Better Balance • Silver Sneakers • Self-Management programs – Chronic Disease Self-Management Program (Stanford) • Educate patient • Refer to community exercise, balance, fitness or fall prevention programs

15. STEADI Flow Chart Centers for Disease Control and Prevention National Center for Injury Prevention and Control Risk Identified Adapted from AGS/BGS Clinical Practice Guidelines, 2010

17. 30 Second Timed Sit to Stand Assess Leg Strength & endurance: • Prescreen – Can they stand without using arms? Yes/No Test: # Repetitions of sit to stand without using arms • 30 Second time frame • Use standard chair p. 19

18. Timed Up & Go • Assess mobility: > 12 seconds is at high risk of falling* • Standard arm chair: OK to use arms in this test • May use assistive device (walker, cane, etc.) • Distance: 3 Meters (10 ft.) • Instructions: • Begin timing when tester says, “Go!” (Don’t wait.) • Participant instructions: • Stand up from the chair, • Walk to line at normal pace, turn around • Walk back to the chair and sit down. • Stop timing when client sits down. • Observe postural stability, gait, stride length, & sway • Note: Slow speed, Loss of balance, Short stride, shuffling, etc. * CDC.gov/injury/STEADI

19. 4 Stage Balance Test • Test each position for 10 seconds, progress as able • Participant may move their arms or body to maintain balance. Stop timing if feet move or they grab support. • Participant should hold the position until told to stop. • Test instructions: • Assist participant to assume position with support • Remove support when tester states, “Begin.” • Start timing when participant achieves position without support after tester says, “Begin.” • After 10 seconds, tester says, “Stop.” • Score = the time position is held

20. Four-Stage Balance Test Tandem stance www.cdc.gov/injury/STEADI

21. When Risk is Present • Educate • Opportunity to take action to improve health and reduce chances of falling • Discuss options for addressing specific problems • Discuss importance of on-going exercise • Refer • To physical therapy for further assessment and individually tailored intervention to support progression to community exercise programs, possibly for Otago Exercise Program, use of assistive devices • Community fall prevention program • A Matter of Balance • Stepping On • Stanford Chronic Disease Self-Management Program (CDSMP) to increase behavior change skills • Community exercise programs that address balance and lower body strength • Evaluate Risk • Gait • Strength • Balance • Educate patient • Refer for gait and/or balance retraining or to a community fall prevention program

22. The Otago Exercise Program • Evidence Based Falls prevention program • Requires Physical Therapy implementation • Individualized & Progressive Exercise: • Strengthening • Balance retraining • Extended duration • PT visits + monthly phone consults • Model for group exercise in AL, SNF, & community

23. Evidence Based Physical Activity Intervention • 50 hours of exercise needed to achieve significant change • Continued exercise to maintain level of function

24. STEADI Flow Chart Centers for Disease Control and Prevention National Center for Injury Prevention and Control Gait, Strength, or Balance problem identified Adapted from AGS/BGS Clinical Practice Guidelines, 2010

25. Implementing interventions – Who can assist

26. Continue Follow-up with All adults • Assess current status • Identify any changes in risk related to changes in health status or living situation • Education • Support positive opportunity to improve or maintain • Address education needs for any new issues • Assess success with current plan and recommendations • Support successful changes and encourage maintaining efforts • Identify problems that prevented follow-through • Address any new problems • Identify any additional assessment needed • Make any new referrals needed • Discuss and address barriers to carrying out plan • Consider referral to CDSMP to support self-management skills and behavior change • Referral to community program for additional social support • Consider other referrals for additional education and support • Patient follow-up • Review patient education • Assess and encourage adherence with recommendations • Discuss and address barriers to adherence

27. Contact Us: Kris Gjerde, PT, MPH kris.gjerde@state.mn.us 651-201-4065 Pam Van Zyl York, MPH, PhD, RD, LN pam.york@state.mn.us 651-201-3616

28. A Matter of Balance Accommodating People With Low Vision

29. A Matter of Balance (MOB) • Highest tier of evidence based program • Designed to reduce the fear of falling and increase activity levels of older adults • Eight 2-hour sessions • 25% presentation, 45% discussion, 30% MOB exercises • Led by two trained coaches

30. A Matter of Balance Class Designed to benefit community-dwelling older adults who: • Are concerned about falls • Have sustained a fall in the past • Restrict activities because of concerns about falling • Are interested in improving flexibility, balance and strength • Are age 60 or older, ambulatory and able to problem-solve During 8 two-hour classes, participants learn: • To view falls and fear of falling as controllable • To set realistic goals for increasing activity • To change their environment to reduce fall risk factors • To promote exercise to increase strength and balance

31. Impact in MN • Steady increase in participation • 2012; 845 participants with 721 completers • 2011; 777 participants • 2010; 444 participants • Over 99% reported improvement in: • Finding a way to get up from a fall • More steady on feet • Finding a way to reduce a fall • Protecting yourself in case of a fall • Physical activity

32. Why Low Vision? First year Matter of Balance Classes at least one participant had vision issues. One of the major risk factors for falls is poor or no vision. Create a version to for the low vision population. Received a grant for the National Eye Institute.

33. Determine Degree of Vision Loss • Cause • Macular Degeneration • Cataracts • Diabetic Retinopathy • Glaucoma • Do they still read • What kind of assistance is needed • Magnifier • Reader • Room • See posters • Glare

34. Macular Degeneration www.lighthouse.org/about-low-vision-blindness/vision-disorders/age-related-macular-degeneration-amd/

35. Cataracts www.lighthouse.org/about-low-vision-blindness/vision-disorders/age-related-macular-degeneration-amd/

36. Diabetic Retinopathy www.lighthouse.org/about-low-vision-blindness/vision-disorders/age-related-macular-degeneration-amd/

37. Glaucoma www.lighthouse.org/about-low-vision-blindness/vision-disorders/age-related-macular-degeneration-amd/

38. Project • Partnered with the Duluth Lighthouse for the Blind • Looked at needed curriculum adaptations • Made the adaptations to make it accessible to low or no vision • Piloted the adaptations • Re – worked where necessary • Sharing

39. Two Levels/Stages • Beginning • Just recognizing that they can not see as well • Just diagnosed with a chronic eye condition • Low or No Vision • Need assistance to read 20 pt font • Can not read printed material no matter what

40. A Starting Point • Helpful Hints for Sighted People Working and Socializing with People Who are Blind • Building Safety and Access • Common Reactions to Vision Loss • General Points to Remember

41. Curriculum Adaptations • Focus activities on listening • Pair up sighted and non-sighted people for activities • Provide information in both large font and electronically

42. Example of Exercise Description for Visually Impaired Touch Elbows Stretch (Front and Back) This exercise helps chest and back flexibility and torso range of motion. It is very good for posture. Place your left fingertips on your left shoulder, and your right fingertips on your right shoulder. Raise your elbows to shoulder level out to the side. Gently move your elbows together in front of you toward your body’s mid-line. Try to get them as close as possible, while still remaining comfortable. Hold for 3-5 seconds.

43. Debra Laine Special Programs Developer Arrowhead Area Agency on Aging 221 West First Street Duluth, MN 55802 218-529-7534 dlaine@ardc.org

44. A Matter of Balance forDeaf Older Adults

45. The Genesis • Deaf Community Health Workers sought health interventions for Deaf older adults • Falls identified as a significant issue • Determined MOB was good fit

46. Coach Recruitment • Deaf Community Health Workers director • Reviewed curriculum and identified 3 – 4 topics • Explained topics and class format • 6 members agreed to be trained as coaches

47. Coach Training • Master Trainer preparation • Hosted by Metropolitan Area Agency on Aging • Comprised of Deaf and hearing individuals:  • 6 DCHW coach trainees & 2 interpreters • 9 hearing coach trainees • 3 hearing Master Trainers

48. Coach Training – Success! • Reviewed tips provided by the interpreter • Address Deaf participants directly while speaking to them • Each participant raise their hand before speaking • Frequent check ins – is this working for you? • Increased time spent demonstrating exercises

49. Coach Training Follow-up • 2 day retreat to review curriculum • Maintain fidelity but address visual needs of participants • Use of visual aids e.g. flip chart content on PowerPoint • Role plays

50. Class Participant Recruitment • Classes are free of charge • Announcements sent via Minnesota Deaf Senior Citizens monthly listserv • Small events • Personal invitation • Adequate time for Q & A