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An Interdisciplinary Approach to the Falls Assessment. Mary Russell, PT Ericka E. Tung, MD. Mr. Jones. 74 year old man Past medical history Hypertension Depression Hyperlipidemia Presents to his primary care physician’s office for his annual check-up. Mr. Jones.

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Presentation Transcript
mr jones
Mr. Jones
  • 74 year old man
  • Past medical history
    • Hypertension
    • Depression
    • Hyperlipidemia
  • Presents to his primary care physician’s office for his annual check-up
mr jones1
Mr. Jones
  • In addition to his chronic disease maintenance issues, his doctor asks about falls in the past year
  • “I guess that I stumble once in a while…. but isn’t that normal for old guys like me?
objectives
Objectives
  • Understand risk factors that put older adults at risk for falls
  • Know how to screen older adults for falls and gait disorders
  • Understand the elements of a comprehensive falls assessment
  • Understand YOUR role in preventing falls in your community
top causes of falls
Top Causes of Falls
  • “Accident”, tripping over something in the environment
  • Gait or balance disorder
  • Dizziness
  • Drop attack
  • Confusion
  • Postural Hypotension
  • Vision disorder
  • Unknown
etiology of falls
Rarely due to a single cause

May be due to the accumulated effect of impairments in multiple domains

Complex interaction of:

Intrinsic factors

Extrinsic factors

Behaviors (risk taking, etc.)

Etiology of Falls
slide7
Intrinsic Factors

Extrinsic Factors

Medical conditions

Sensory impairment

Weakness & imbalance

Age related changes

Medications

Improper use of assistive devices

Environmental hazards

Risk taking behavior

FALLS

multifactorial risk factor assessment
Multifactorial Risk Factor Assessment
  • Falls are multifactorial therefore the approach needs to be:
      • Holistic
      • Interdisciplinary
      • Practical
      • Evidence-based
guidelines for fall prevention
Guidelines for Fall Prevention
  • Guideline for the Prevention of Falls in Older Persons
    • American Geriatrics Society
    • British Geriatrics Society
    • American Academy of Orthopaedic Surgeons
  • JAGS 49:664–672, 2001
screening
Screening
  • Who?
  • When?
  • Where?
  • What?
screening questions
Screening Questions
  • Have you fallen in the past year?
  • How many times have you fallen in the past year?
  • Are you afraid of falling?
yes i did fall once at my home
Yes… I did fall once at my home

JAGS 49:664–672, 2001

timed up and go test tug
Timed Up and Go Test: TUG
  • Directions:
    • Have patient sit in a standard armchair
    • Instruct the patient to fold their arms when risking from the chair
    • On the instruction “GO”, have the patient stand up, walk comfortably to a line 3 meters away, turn around and sit down again.
timed up and go test tug1
Timed Up and Go Test: TUG
  • Interpretation
    • Under 20 seconds: independence for basic transfers
    • 20-29: Intermediate probability for dependence in transfers
    • 30+: Unlikely to be able to climb stairs or go outside alone

Diane Podsiadlo, BScPT, and Sandra Richardson, M.D. J Am Geriatric Soc 39:142-148,1991

approach to the individual with multiple falls
Approach to the Individual with Multiple Falls
  • Comprehensive Falls Evaluation
    • Interdisciplinary approach is best
      • Social worker
      • Therapist
      • Physician
      • Nurse
      • Pharmacist
recurrent falls
Recurrent Falls

JAGS 49:664–672, 2001

comprehensive falls evaluation
Comprehensive Falls Evaluation

Step 1: Take a good history

  • Circumstances
  • Frequency
  • Injuries
comprehensive falls evaluation1
Comprehensive Falls Evaluation

Step 2: Functional Status Assessment

  • Activities of Daily Living
  • Instrumental Activities of Daily Living
  • Current home health support system
  • Review of Risk Factors
comprehensive falls evaluation2
Comprehensive Falls Evaluation

Step 3: Medication Review

  • “High risk” medications
  • >4 medications
  • Potential strategies to combat polypharmacy
comprehensive falls evaluation3
Comprehensive Falls Evaluation

Step 4: Physical Examination

  • Orthostatic Blood Pressure
  • Cardiovascular system
  • Neurologic system
  • Visual acuity
  • Foot examination
  • Musculoskeletal system
but what about mr jones
But what about Mr. Jones?
  • At the office visit
    • Multiple falls
    • Risk factors were identified
      • Medications
      • Evening “night cap”
      • Orthostasis
      • Mild peripheral neuropathy
      • Prolonged TUG (30 seconds)
but what about mr jones1
But what about Mr. Jones?
  • Now what??
  • Action planning strategy
    • Multifactorial approach
    • Interdisciplinary approach
    • Importance of patient involvement
creating an individualized intervention
Creating an Individualized Intervention
  • Identify modifiable and non-modifiable risk factors
    • Target treatment plan toward these risk factors
    • Mr. Jones’ risk factors
      • High risk medication regimen
      • Lower extremity weakness, gait dysfunction
      • Risk taking behaviors
      • ? Home hazards
physical therapy consultation
Physical Therapy Consultation
  • Location
    • Outpatient clinic
    • Patient’s home
    • SNF
  • Cost Issues
physical therapy consultation1
Physical Therapy Consultation
  • Start with THE 3 questions:
  • “Have you fallen in the past year?”
  • “How many times have you fallen in the past year?”
  • “Are you afraid of falling?
balance and strength
Balance and Strength
  • Assess strength and balance
  • Provide recommendations for long term exercise program for strength and balance
  • Gait training and appropriate use of assistive devices
home environment assessment
Home Environment Assessment
  • Room by room; inside and outside
  • Clutter, cords, lighting, width of walk ways, and condition of flooring
  • Grab bars for bathroom, tub bench or shower chair, non skid tub surface, raised toilet seat
  • Night light in bedroom, phone and flash light next to bed
  • Frequently used items in kitchen should be within reach
  • Stairs both inside and outside should have adequate lighting and be free from clutter
mr jones individualized intervention
Mr. Jones’ Individualized Intervention
  • Simplification of Medication Regimen
  • Counsel him about risk taking behaviors and alcohol use
  • New gait aid
  • Home modifications
  • Utilization of community exercise program
mnfallsprevention org
MNfallsprevention.org
  • Overview of the site
    • For the public
    • For health care professionals
    • Navigation
    • Tools
assessment tools
Assessment Tools
  • Types
    • Fall risk factor assessments
      • Focus on intrinsic risks
      • Typically performed by nursing staff in the hospital or NH setting
    • Functional assessment instruments
      • Focus on gait/balance
      • Typically performed by therapists, rehab specialists in the outpatient setting
assessment tools1
Assessment Tools
  • Assessment tools
    • Pros
    • Cons
    • Limitations
assessment tools2
Assessment Tools
  • Factors for consideration
    • Setting
    • Time limitations
    • Skill set of the professional
    • Sensitivity/Specificity
interdisciplinary team approach
Interdisciplinary Team Approach
  • Role of the social service or public health professional
    • Screening
    • Risk factor identification
    • Preparing older adult for upcoming appointments
    • Inspection of living environment
interdisciplinary team approach1
Interdisciplinary Team Approach
  • Role of the primary care provider
    • History and physical examination
    • Identification of risk factors
    • Action planning
      • What is the patient actually willing to do?
    • Appropriate referrals
interdisciplinary team approach2
Interdisciplinary Team Approach
  • Role of the therapist
    • Physical therapist
      • Strengthening, balance, and gait training
    • Occupational therapist
      • Home modifications, cognitive assessment, compensatory strategies
    • Team approach
      • Coordination and continuum of care between all disciplines in all settings
      • Patient/Caregivers
interdisciplinary team approach3
Interdisciplinary Team Approach
  • Role of the skilled nursing facility professional
    • Staff training
    • Identification of modifiable risk factors
    • Target interventions
      • Bed alarms
      • Hip protectors
      • Environmental modifications
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