staying happy on your feet tina young, msot, otr/l oota older adult msg march 2012, cleveland...

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Staying Happy on Your Feet Tina Young, MSOT, OTR/L OOTA Older Adult MSG March 2012, Cleveland District

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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

FALLS_2011_Symposium1-0711Beeghly.pdf

OIPP Falls Coalition

2011 Factsheet Falls Among Older Adults in Ohio[1].ppdf

AGS_06_falls_general_information[1].pdf

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

Client Identified Fall Risk Factors

Hurrying Carelessness Inattention

AJOT 2003

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

Gericareonline.net_Falls_Tool_5_Story_of_Your_Falls[1].pdf

Falls & Allen - GSISJUNE05.pdf

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

Fall Prevention Assessment TUG 1107.pdf

Gericareonline.net_Falls_Tool_2_Get_Up_and_Go_Test[1].pdf

• 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

AGS_14_put_your_best_foot_forward[1].pdf

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

Home AssessmentTool

SS0610.xls

Home Safety Checklist Clermont County 2008.xls

Home AssessmentTool

SS0610.xls

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

Possible Fall Prevention

Partners.doc

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

AGS_falls_consumerpamphlet[1].pdf

AGS_19_avoiding_falls_low_vision[1].pdf

AGS_10_canes_walkers[1].pdf

AGS_11_choosing_starting_an_exercise_program[1].pdf

AGS_12_improve_your_balance[1].pdf

AGS_07_medical_evaluation_falls[1].pdf

AGS_15_can_you_get_help[1].pdf

AGS_16_afterthe_fall[1].pdf

AGS_17_steady_as_you_goLow_Bl_Press[1].pdf

Osteoporosis_falls_and-broken-bones[1].doc

• 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

Falls_Prevention_Lessons_Learned_FINAL1-27-10-WEBVIEW[1][1].pdf

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.