specialist psi exercise module risk factors for falls (and injuries) - intrinsic - extrinsic -...

Specialist PSI Exercise Module

Risk Factors for Falls (and injuries)

- intrinsic- extrinsic

- modifiable with exercise


A Risk continuum ?

• Over 200 risk factors documented in the literature

0

10

20

30

40

50

60

70

80

0 1 2 3 4+

%Falling(12months)

D Drugs and alcohol

A Age related physiological changes

M Medical conditions

E Environment


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


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


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


Psychological risk factors

• Fear of falling

• Avoidance of activity

• Reduced quality of life

• Increased anxiety


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)


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


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”


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


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


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


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


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%


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%

specialist psi exercise module risk factors for falls (and injuries) - intrinsic - extrinsic -...

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