staying happy on your feet tina young, msot, otr/l oota older adult msg march 2012, cleveland...
TRANSCRIPT
Staying Happy on Your Feet
Tina Young, MSOT, OTR/L
OOTA Older Adult MSG
March 2012, Cleveland District
Objectives
Review of Balance tests to assess fall risk Provide treatment strategies for Balance-client
specific Provide treatment strategies for Fall Prevention-
client and community education Educate on Ohio Older Adults Falls Prevention
Coalition: OIPP
A fall is defined as “an unintentional change in position resulting in coming to rest on the ground or at a lower level”
-J. Wells
Falls Are Not a Normal Part of the Aging Process
Falls and loss of balance are symptoms of some underlying problem
M.Robinson
Facts about Falls and Older Ohioans
30% age 65 and older living in the community fall each year
Falls are the leading cause of injury-related deaths and the most common cause of nonfatal injuries and admissions
An older adult falls in Ohio every 2.5 minutes on average, resulting in two deaths each day, two hospitalizations each hour
Ohioans age 65 and older make up 13.7% of population and account for >80% of fatal falls
Facts about Falls and Older Ohioans
Fatal fall rates increased 125% from 2000 to 2009
Most fractures among older adults are caused by falls
Risk of falling increases significantly after age 75
Falls account for more than 90% of all accidental hip fractures
1 in 3 older Ohioans' fall leads to injuries that resulted in a doctor visit or restricted activity
Ohio Injury Prevention PartnershipOIPP
Older Adults Falls Prevention Coalition
Mission
Website review
Resources
My role
Fall Prevention Day-what you can do
Facts and Statistics
Ohio Injury Prevention PartnershipOIPP
Older Adults Falls Prevention Coalition
http://www.ohiopha.org/Tabs/Publications/OPHAProjectDetails.aspx?DID=158
Aging Well, Winter 08
Safety of Seniors Act of 2007 passed authorizing new programs to help prevent falls through public education, research and safety demonstrations
Falls don’t discriminate 3 times more likely to fall again if fallen Multiple medication usage and frailty are the next
most common causes of falls
• Falling and being homebound are associated with:
Increased mortality Increased depression
Increased morbidity Increased helplessness
Reduced function Decreased confidence
Premature nursing home admissions
Journal of the American Geriatric Society, J. wells; OT Practice 2003/ California Journal 2008
Many people who fall, even those who are not injured, develop a fear of falling. This fear may cause them to limit their activities, leading to reduced mobility and physical fitness, and increasing their actual risk of falling (Vellas et al. 1997). 9 Joe wells
Fear leads to decreased activity and increased sedentary lifestyle therefore increases fall risk (AJOT, 2004)
1.Fall Risk Assessment
2.Proactive Fall Interventions
3.Patient and Caregiver Education
4.Evaluation of Fall Prevention Program
-
HHQI Best Practice: Fall Prevention Program17, J. Wells
• Identify risk factors – Pertinent medical/ fall history
– Medication review
– Assessments: • E.g.: Berg’s Balance Test, Timed-Up-Go
• Orthostatic Hypotension
• Body structures
• Body Functions
• Home Environmental Safety
• Support systemJ. Wells
Postural Control
Visual
Vestibular
Somato-sensory
Environment
Restraints
Cognition
Musculo skeletal
Lighting
Age Related Changes that Affect Balance and Falls= Natural Risk
Factors
Vision-acuity, depth perception, visual fields
Hearing Strength/flexibility Bone density Posture
Age Related Changes that Affect Balance and Falls= Natural Risk
Factors
Velocity/speed/reaction time Dual tasks Proprioception Chronic diseases and medical
complications
Fall Risk Factors
Age (>65 years and increase >75/85) Female gender Past history of a fall and/or hip fracture Weakness in lower extremities Foot disorders (bunions, ulcerations, toe or nail
problems) and footwear
Fall Risk Factors
Hearing or vision loss (4) Incontinence Restraints Faulty equipment or needing equipment Altered/impaired Cognition and dementia Balance problems
Fall Risk Factors
Blood pressure Low vitamin D levels Poly-pharmacy- over 4 medications, Tylenol pm Arthritis, Osteoporosis, Frailty Parkinson’s disease, TBI, CVA, Alzheimer's Chronic pain, foot pain Behaviors as a result of a fall, depression
Extrinsic Factors
Uncontained Incontinence Physical Restraint Environmental Obstacles Poor lighting Faulty equipment Type of Footwear
M.Robinson
Intrinsic Factors
Medication Side Effects and Interactions Visual impairment Vestibular dysfunction Somatosensory deficit Musculoskeletal deficit Orthostatic Hypotension Cognition Behavioral
M. Robinson
Typical OT Evaluation
Functional Mobility, transfers ADL’s ROM and Strength (functional-lifting, carrying) Sensation Vision Balance and posture-where are head and eyes IADL’s Cognition
EBP Standardized Balance Tests
Functional Reach Timed Up & Go Gait Speed Berg Balance Test Tinetti Modified Clinical Test for Sensory Interaction in
Balance (CTSIB) 30 sec Chair Stand and Arm Curl
• The TUG was found to have :– 87% sensitivity for predicting falls with a score >14
seconds– It was also found that measurement of mobility under multi-
task conditions was not a better indicator for the likelihood of falls.
-Shumway-Cook et al. (2000)18
– The Berg Balance Test: 83% of subjects were correctly identified as fallers (the gold standard) based upon the dichotomous rule to classify fallers at a cut-off point of <40 (BBT Score). -Riddle & Stratford (1999)19
J. Wells
• Home Safety Evaluation
• Reduce Safety Hazards- E.g.: Throw rugs, lighting, pets, oxygen tubing, clutter, extension cords, etc.
• Medication management
• Cardiac status: Orthostatic hypotension, arrhythmias
• Bowel/ bladder habit and management
• Proper footwear
• Nutrition/ hydration status- need for referral
• Physical Therapy and/ or Occupational Therapy
J. Wells
Medication Review and Education
Client example ACP example CDC example Common side effects: dizziness, drowsiness,
decreased balance Treatment suggestion: look up meds
Treatment for a Client’s Fall Prevention
AE/DME Modify ADLs/IADLs (foot wear, scanning) Modify environment (contrast, grab bars, cell
phone) ECT Life Alert, emergency numbers
Treatment for a Client’s Fall Prevention
Home Assessments:
Housing Enabler Safe at Home
Westmead ROTE
SAFER Home v3 GEM
HOMEFAST Cougar
Rebuilding Together
CASPAR
Home Assessment/checklists
Common items:
Lighting-florescent, glare
Contrasts
Foot wear
Throw rugs
Cords
Clutter
Nightlights
Handrails
No bare feet
Double sided tape
Organization
Accessible switches
Nonskid Bathmats
TTB/shower chair
Handheld shower
Non adhesive strips
Roll in shower
Loops and Lever handles
RTS
Age in Place/Universal Design
NAHB- 3 day program RT- Rebuilding Together OTs give recs on assistive products, identify
resources, evaluate safe use CAPS (Certified Aging in Place Specialists) have
relationship with contractors, assist with visitability
OT Practice 2009
Age in Place/Universal Design
Common senseIncrease lightingRemove
objects/cords/clutterGrab barsNonslip mats and footwearReduce glareNight lightIncrease contrast
CAPS
Pullout shelves
Flat panel light switches
Counter heights
Wide doors/hallways
Chair lifts
Remodel bathroom
Ramps
Flooring
Home alarm systems, exit door bells
Age in Place/Universal Design
Barriers:
Personal items in home are meaningful, perspectives
Finances/Costs
Adherence to recommendations (80%noncompliance)
Safety + aesthetics +client goal + OT goal
Treatment for a Client’s Balance
EXERCISE !!!!Standing-on one foot and twoStand in corner and move shoulders/hipsFixate on object with eyes and move head in
different directions (saccades and pursuits), walk and turn head
Extension!!!!!
Treatment for a Client’s Balance
Walk heel to toe, walk on toes, walk on heels
Walk backwards, walk sideways on stairs
Stand up and sit down without hands
Focus on LE, Core, Triceps
UE- scapular retraction, rowing
Treatment for a Client’s Balance
Improve flexibility-stretching, Tai Chi, Yoga Deep breathing Floor transfers Improve posture Cognition under 4.4 ACL- no DME Medication review-4+ meds, side effects Vision screening
Treatment for a Client’s Balance
Obstacle courses Joint mobilizations to the spine Dancing Do ADLs on one foot Begin walking programs Electrical stimulation Consider DME/AE-hip protectors, walkers,
canes, etc
Treatment for a Client’s Balance
Aquatic programs Strategies-ankle, hip, step Eyes open and closed Reaching/bending/weight shifts/lifting/carrying Balls/BAPS board
Treatment for a Client’s Balance
Do things during balance exercises:Add musicChange surface-unlevelChange footwearAdjust lighting-include low lightingDo mathCategorizeName items with letter i.e. “b”
Treatment for a Client’s Balance
“Her balance deficits became more apparent
as her ability to cognitively compensate
decreased in the face of other demands on
her attention. This balance deficit, plus her
lack of memory for a task and limited
scanning of her environment, represented
serious impediments to safe independent
function at home.” OT Practice 2004
Treatment for a Client’s Balance
Relationship of cognition and balance ACL scores with treatment direction “Deviation from the expected routine (the
hazard) becomes the challenge to overcome.” OT Practice 2004
Treatment for a Client’s Balance
How to Fall Properly: Practice it Buckle with the knees Pull arms into body Roll instead of being rigid
OT Practice 2002
Treatment for a Client’s Balance
Clients tend to only do what they can see Focus on extension exercises Do what they fear Let them design the course/treatment Routines reduce falls
Treatment for Clinic/Facility
Low bed
Hipsters
Toilet schedule
Floor mats
Alarms
AE
DME
Good lighting
Ed on call light
Free clutter
Grab bars
RTS
Visible cues
Nonslip mats
Nonslip footwear
Nightlights
Change room location
Environment set up
Best Practice– Interdisciplinary, consistent, patient specific
– Identify potential risks and interventions available
• Tools (Examples):– Safety Self-Assessments
– Teaching Sheets– Exercise Program for Maintenance J. Wells
CDC Prevention Plan
Fall Prevention strategies:
Exercise regularly, Tai Chi (strength/balance)
Medication review- side effects and interactions
Yearly eye exams
Reduce fall hazards in the home
Improve lighting throughout the home
Fall Prevention Treatment for the Community
3 levels of prevention
Primary- avoid onset of disease, no observable risk
Secondary-for those demonstrating early symptoms of condition, identified risk
Tertiary- after a disability occurs, usually in rehab settings
OT Practice 2003
Physical activity programs, particularly those
emphasizing balance and lower extremity strengthening,
are associated with a 10-20 percent reduction in falls
[AGS].4 J. Wells
Fall Prevention Treatment for Community
OOTA Fact sheets (Free) Formal Groups-Matter of Balance,
Stepping On Informal Groups Self Assessments: home safety
checklists, medication reviews Education on Exercise-strength,
flexibility, extension, dual tasks, groups, Tai Chi
Fall Prevention Treatment for the Community
Education on risk factors and myths about aging
Options of AE, DME, home modifications, resources
Vision screenings
Talks to Senior Centers, health fairs, YMCA, Area Agency on Aging
Fall Prevention Treatment for the Community
3 areas reviewed: Checklists for fall prevention-home safety, fall
risk factors, medications Options for fall prevention- AE, home
modifications, resources: websites, catalogs, demo equip, vendors, funding, Home Depot, Lowes
Balance-groups, exercise, programs
• Patient outcomes
• Organizational outcomes
• FaB (Falls Behavioral Scale for Older People)- could be used to measure effect of a program to reduce risky behaviors and enhance safety adaptations (AJOT 2003, p. 386)
J.Wells
Power Point Presentations
Monica Robinson, President of OOTA
[email protected] (sited M. Robinson) Joe Wells, OTD, DPMIR, OT/L, Vice
President of OOTA (sited J. Wells and provided his list of resources)
E-Mail: [email protected] or [email protected]
Research Articles Review
AJOT Volume 63, Number 3, May/June2009 (Falls after CVA)
AJOT 11/12, 2004, p.630-638 (who gets a home eval)
AJOT ½, 2004 p. 100-103 (3 scales reviewed) AJOT 7/8, 2003, p. 369-387 (payer
relationships with home evals/recs, FaB Scale of Older People)
Research Article Review
OT Practice 4/6/09 p. 14-17 (CAPS) OT Practice 13 (3) February 2008 (PEO, Adherence and approaches, tests,
programs) OT Practice October 9, 2006 (Safety and Psychiatric Disabilities (kitchen and
bathroom) OT Practice 12/19/2005 p. 23-30 (cognition and
fall prevention)
OT Practice November 29, 2004
(Cognition and fall prevention) OT Practice 3/8/04 p. 16-21 (SAFE AT HOME
safety screening tool) OT Practice 1/13/03 (Prevention) Advance 2/11/02, p. 4 (how to fall)
Research Article Review
Research Article Review
California Journal 2008, volume 6, issue 1, p. 87-110 (Cougar Home Safety Assessment)
AOTA Gerontology SIS Quarterly volume 28, Number 2, June 2005
(Falls and Dementia, ACL)
Continued Education Resources
Jennifer Bottomley, PT (falls and balance)
Marnie Renda, CEUs for OOTA (home modifications, home assessments)
HCR CEUs (vision, cognition, falls, older adult exercise, ACP) Robinson-Brown CEUs for OOTA (falls and balance)
Pamela Toto (exercise for aging)
OIPP Older Adults Fall Prevention Coalition 2011-2012
Miscellaneous Resources
CDC.gov Employer education materials Senior Helpers.com Asaging.org ACP Aging well 2008, p. 28-31 Area Agency on Aging
1. Journal of the American Geriatric Society, 49: 664–672, 2001
2. Hornbrook MC, Stevens VJ, Wingfield DJ, Hollis JF, Greenlick MR, Ory MG. Preventing falls among community–dwelling older persons: results from a randomized trial. The Gerontologist 1994:34(1):16–23.
3. Hausdorff JM, Rios DA, Edelber HK. Gait variability and fall risk in community–living older adults: a 1–year prospective study. Archives of Physical Medicine and Rehabilitation 2001;82(8):1050–6.
4. http://www.americangeriatrics.org/products/positionpapers/Falls.pdf . Guideline for the Prevention of Falls in Older Persons; American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopedic Surgeons Panel on Falls Prevention
5. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web–based Injury Statistics Query and Reporting System (WISQARS) [online]. (2006) [cited 2007 Jan 15]. Available from URL: www.cdc.gov/ncipc/wisqars.
6. Stevens JA, Corso PS, Finkelstein EA, Miller TR. The costs of fatal and nonfatal falls among older adults. Injury Prevention 2006;12:290–5.
7. Jager TE, Weiss HB, Coben JH, Pepe PE. Traumatic brain injuries evaluated in U.S. emergency departments, 1992–1994. Academic Emergency Medicine 2000&359;7(2):134–40.
8. Bell AJ, Talbot-Stern JK, Hennessy A. Characteristics and outcomes of older patients presenting to the emergency department after a fall: a retrospective analysis. Medical Journal of Australia 2000;173(4):176–7.
9. Vellas BJ, Wayne SJ, Romero LJ, Baumgartner RN, Garry PJ. Fear of falling and restriction of mobility in elderly fallers. Age and Ageing 1997;26:189–193.
10. http://www.cdc.gov/ncipc/pub-res/toolkit/toolkit.htm . CDC fall prevention information, statistics and resources.
11. Author unknown (n.d.). Facts about falling . Retrieved on 02/10/2006, from www.advantageseniorcareinc.com/FALL%20BROCHURE.pdf
12. Mahoney JE, Palta M, Johnson J, Jalaluddin M, Gray S, Park S, Sager M. Temporal association between hospitalization and rate of falls after discharge. Arch. Int. Med., 2000; 160:2788-2795
13. Stevens JA, Sogolow ED. Gender differences for non-fatal unintentional fall related injuries among older adults. Injury Prevention 2005;11:115–9.
14. Donald IP, Bulpitt CJ. The prognosis of falls in elderly people living at home. Age and Ageing 1999;28:121–5.
15. Stevens JA, Dellinger AM. Motor vehicle and fall related deaths among older Americans 1990–98: sex, race, and ethnic disparities. Injury Prevention 2002;8:272–5.
16. Adapted from http://www.healthinaging.org/agingintheknow 17. Quality Insights of Pennsylvania, the Medicare Quality Improvement
Organization Support Center for Home Health, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. Publication number: 8SOW-PA-HHQ07.637. App. 9/07.
18. Shumway-Cook A, Brauer S, Woollacott M. Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go test. Phys. Ther. 2000. 80(9); 896-903.
19. Riddle DL, Stratford PW. Interpreting validity indexes for diagnostic test: an illustration using the Berg Balance Test. Phys Ther. 1999; 79: 939-948.
20. Gitlin, L.N., Winter, L., Dennis, M.P., Corcoran, M., Schinfeld, S., & Hauck,W.W. (2006). A randomized trial of a multicomponent home intervention to reduce functional difficulties in older adults. Journal of the American Geriatric Society, 54(5), 809-816.