Falls Assessment

Transcript

• 00:17So we're going to talk today about the
• 00:20assessment and prevention of falls.
• 00:26So why do we worry about falls?
• 00:29Who falls and why do they fall?
• 00:32Can we prevent falls?
• 00:35What are the consequences of falls?
• 00:38Well, in older people,
• 00:4010% of falls result in serious injuries.
• 00:44Falls are associated
• 00:46with decreased function,
• 00:47decreased mobility and increased
• 00:50nursing home placement.
• 00:53We're going to mention today
• 00:56predictors of falls, the evaluation
• 00:58of a patient with falls and how
• 01:00we attempt to prevent falls.
• 01:05Falls are a geriatric syndrome.
• 01:07So when we have geriatric syndromes
• 01:09like dizziness, falls, Delirium,
• 01:11we think of risk factors and the risk
• 01:14factors are predisposing factors
• 01:16and then precipitating factors.
• 01:18So the predisposing factors for falls,
• 01:21some of them are immutable
• 01:25and others are modifiable.
• 01:28So immutable predisposing factors are age,
• 01:32past falls, arthritis,
• 01:36stroke and Parkinson's disease.
• 01:40Modifiable predisposing factors includes
• 01:44such features as decreased strength,
• 01:48impaired balance and gait,
• 01:52and visual problems such as depth
• 01:55perception and contrast sensitivity.
• 01:58Precipitating factors that actually produce
• 02:02the falls include inappropriate footwear,
• 02:05multifocal eyeglass lenses,
• 02:10acute illness, stares,
• 02:13tripping hazards, unsafe behaviors,
• 02:18and importantly, medications.
• 02:22So risk factors for falls include gait
• 02:26and balance impairment medications,
• 02:29orthostatic hypotension,
• 02:33visual impairment,
• 02:35limitation in activities of daily
• 02:39living and cognitive impairment.
• 02:42So when you evaluate somebody with a fall,
• 02:45you first want to know the circumstances
• 02:47of the fall and then you want to
• 02:50do in a variety of maneuvers.
• 02:52First and very important is have
• 02:55the medical assistant and nurse
• 02:57check postural blood pressure,
• 02:59assess the patient for high risk medications,
• 03:05do a brief cognitive screen such as the
• 03:08mini cog or a Montreal cognitive assessment,
• 03:11a so-called mocha and then do
• 03:14balance and gait assessment.
• 03:16So I like the get up and go test
• 03:18which we'll talk about and then
• 03:20for balance a very simple test
• 03:22called the four stage balance test.
• 03:25And then finally,
• 03:26we want to evaluate the individual for
• 03:29foot problems and inappropriate footwear,
• 03:32and we want to arrange a home
• 03:36safety evaluation,
• 03:37usually best done by a physical
• 03:40or occupational therapist from
• 03:42a home health agency.
• 03:43What are the circumstances of the fall?
• 03:46Did the patient have any Vertigo or
• 03:50Lightheadedness before he or she fell?
• 03:52Did the fall occur after rising
• 03:55from a bed or a chair?
• 03:58Does the patient use an assistive
• 04:00device such as a cane or a Walker,
• 04:03and if so,
• 04:04were they using that device when they fell?
• 04:08Did the patient have a sensation of tripping?
• 04:11Was alcohol involved in the fall?
• 04:14Had there been a recent change
• 04:16in the patient's mental status?
• 04:18Had there been a new medication,
• 04:21or did the patient notice any
• 04:25pain before he or she fell?
• 04:28Where did the fall occur?
• 04:30Most falls in the home occur in the bathroom.
• 04:33Second is the bedroom and then
• 04:35other rooms in the house.
• 04:37Was the fall outside the home?
• 04:40Was the patient able to get up by
• 04:42him or herself after the fall?
• 04:45How long was the patient on the
• 04:47floor and did the patient have
• 04:50to use a medical alert device?
• 04:53Was alcohol involved in the fall?
• 04:57Did the patient drink two or
• 05:00more alcoholic drinks per day?
• 05:02Was there a history of an alcohol problem
• 05:06which would be evidenced by family concern,
• 05:09a history of alcohol withdrawal,
• 05:12a history of hospitalizations
• 05:15for alcohol problems or a history
• 05:19of driving while intoxicated?
• 05:22Was the patient on a high risk medication?
• 05:24Now we're going to talk about
• 05:26medications in two situations,
• 05:27overall risk for falls and then
• 05:31risk for postural hypotension.
• 05:33So overall risk for falls.
• 05:35The high risk medications are
• 05:39benzodiazepines, antidepressants and
• 05:40the SSRIs have as great a risk as
• 05:44tricyclic and other antidepressants,
• 05:48antipsychotics, antihypertensive medications,
• 05:52anticholinergic medications, narcotics,
• 05:58and the number of medications taken.
• 06:00Simply taking four or more medications a
• 06:04day increases your risk for having a fall.
• 06:07So the first step in the evaluation
• 06:10is have your medical assistant or
• 06:12nurse obtain postural blood pressure.
• 06:15The patient should lie down for
• 06:17two minutes and then supine blood
• 06:19pressure should be checked.
• 06:21The patient should then stand for
• 06:23one minute and a standing blood
• 06:26pressure should be checked.
• 06:27There should be a test,
• 06:29a simple test of visual acuity.
• 06:33If the patient has postural hypertension,
• 06:36then reviewing the medications
• 06:38is very important.
• 06:40So the medications associated
• 06:42with postural hypertension include
• 06:45alpha blockers such as tamsulosin,
• 06:47antidepressant drugs,
• 06:49anti hypertensive drugs,
• 06:52anti parkinsonian drugs,
• 06:55antipsychotic drugs, benzodiazepines,
• 06:58beta or blocker drugs, diuretics,
• 07:04muscle relaxants, narcotics,
• 07:10phosphodiesterase inhibitors such as Viagra,
• 07:15Trazodone,
• 07:17and vasodilating drugs such as hydralazine,
• 07:20nitroglycerin and calcium channel blockers.
• 07:25Always want to do a very simple get up
• 07:28and go test to evaluate the patient's gait.
• 07:32Very simple test.
• 07:33The clinician should do this test,
• 07:35not the MA or be a nurse.
• 07:39So you ask the patient to rise from a chair,
• 07:42walk 10 feet, turn around,
• 07:46walk 10 feet back to the chair,
• 07:49and then sit down in the chair.
• 07:50And you observe any problems the
• 07:53person's having with their mobility.
• 07:56So you look for such abnormalities
• 07:59as deviating from a normal path,
• 08:03spending less time on one leg than the other,
• 08:05a so-called limp consistently leading
• 08:09with the same leg difficulty,
• 08:12initiating the stride,
• 08:14short steps,
• 08:16a wide base gate or signs of a
• 08:20Parkinsonian gate.
• 08:21Further evaluation includes a balance
• 08:23test and we're going to talk in a
• 08:26minute about the four stage balance
• 08:28test and the way to read about that
• 08:31is on the CDC Steady STEDI website.
• 08:33We also should do a complete
• 08:37neurological evaluation,
• 08:39focusing on the presence of a
• 08:41peripheral neuropathy, focal weakness,
• 08:44spasticity or abnormal reflexes.
• 08:48Also perform a complete musculoskeletal
• 08:50exam looking for causes of limitations
• 08:53of transferring out of a chair,
• 08:56walking,
• 08:56turning,
• 08:57getting on or off an examining
• 09:00table and finally perform a
• 09:03complete evaluation of the feet.
• 09:05So the four stage balance test is
• 09:08a very simple test of balance.
• 09:10The patient should not be
• 09:12using an assistive device.
• 09:14Their eyes should be open and then
• 09:16you stand next to the patient,
• 09:18holding his or her arm and helping
• 09:21them assume the correct foot position.
• 09:25When the patient is steady,
• 09:27you let go,
• 09:28but you're ready to help should the
• 09:31patient lose his or her balance.
• 09:33So these are sequential tests.
• 09:36If the patient can hold the position
• 09:38for 10 seconds without moving
• 09:40their feet or needing support,
• 09:42you move on to the next position so
• 09:44they can move their hands around,
• 09:46but not move their feet.
• 09:48So they start by standing with their
• 09:51feet side by side for 10 seconds.
• 09:55If they can do that,
• 09:57they place the insep of 1 foot so it's
• 10:00touching the big toe of the other
• 10:02foot and do that for 10 seconds.
• 10:05If they can do that part,
• 10:07they go on to a tandem stance that
• 10:09is placing 1 foot in front of the
• 10:12other foot heel touching toe for 10
• 10:15seconds and if they can do that then
• 10:18they stand on one foot for 10 seconds.
• 10:22Patients who cannot hold a tandem stance
• 10:26for 10 seconds have increased fall risk.
• 10:30So just to go over these,
• 10:31so the first step,
• 10:33you can see here the feet are side by side.
• 10:36The second step,
• 10:37the toe of 1 foot touches the instep
• 10:39of the other foot for 10 seconds.
• 10:42If the patient can do that,
• 10:43they do a tandem stance that is
• 10:45the heel of 1 foot at the toe of
• 10:48the other foot for 10 seconds.
• 10:49And if they can do that,
• 10:51they simply stand on one foot for 10 seconds.
• 10:55How can we prevent falls?
• 10:58We need to identify the patients at risk.
• 11:02We need to assess the health
• 11:05problems known to increase fall risk.
• 11:07We then need to manage those health
• 11:10problems that increase fall risk.
• 11:12What does prevent falls?
• 11:14Well,
• 11:14there are different strategies that do work.
• 11:18Reduction of medications,
• 11:21management of postural hypotension,
• 11:24management of visual and foot problems,
• 11:28balance, gait and strength training,
• 11:32and reducing hazards in the home.
• 11:38So for patients identified as
• 11:40being risk for falls because of
• 11:43polypharmacy or high risk medications,
• 11:46you need to contact the prescribing physician
• 11:49to either remove the prescription or change
• 11:52the medication to one with less fall risk.
• 11:55If your patient has significant
• 11:58postural hypertension, again,
• 11:59you review and try to remove medications
• 12:03associated with postural hypertension.
• 12:05You try to ensure an
• 12:08appropriate level of hydration.
• 12:09You instruct the patient on moving slowly
• 12:12when changing positions and if necessary,
• 12:14consider medications to
• 12:17treat postural hypotension.
• 12:19Interventions that have been demonstrated
• 12:22to prevent falls include exercises,
• 12:25home safety assessments,
• 12:27management of postural hypotension,
• 12:31Podiatry,
• 12:32interventions for disabling foot pain.
• 12:36Exercise programs are effective
• 12:39in decreasing the risk of falls.
• 12:42They include gait and balance training,
• 12:46strength training,
• 12:47movement training such as Tai chi or dance,
• 12:52and aerobic exercises.
• 12:55Most effective programs are
• 12:58exercises that emphasize balance
• 13:00training with resistive training,
• 13:03are integrating integrative such as Tai chi,
• 13:06and are progressive in their intensity.
• 13:10Exercise programs that involve
• 13:12at least three hours per week are
• 13:15associated with the greatest effects.
• 13:17General exercise programs and
• 13:19older patients do not in themselves
• 13:23decrease the risk of fall injuries.
• 13:26For balance training,
• 13:28we want to make sure it's progressive,
• 13:31that it challenges stability yet is safe,
• 13:36that it's fun or at least not too boring.
• 13:39And examples of balance training include
• 13:41Tai chi dance and the Gottschalt exercises,
• 13:45which I'm going to talk about in a minute.
• 13:48So when Doctor Mary Tonetti was doing her
• 13:53landmark studies on the prevention of Falls,
• 13:56she worked with an outstanding
• 13:58physical therapist,
• 13:59Margaret Gotschalt,
• 14:00who with Mary developed a series of
• 14:03exercises that are now considered
• 14:06the Connecticut Collaboration for
• 14:08Fall Prevention Balance Exercises
• 14:10developed by Margaret Gotschalt.
• 14:13And they can be obtained by accessing
• 14:16a copy of the exercises on the
• 14:20Yale Coach Video Library looking
• 14:23for balance exercises.
• 14:24So the level one exercises are the
• 14:27first one is a sink sidestep and the
• 14:30major piece of equipment you need,
• 14:33it's a kitchen sink and a counter.
• 14:35So you stand facing the kitchen sink.
• 14:38You hold on with both hands.
• 14:41You move your hands along the kitchen
• 14:43sink as you step to the left five steps,
• 14:47and then you step with both feet
• 14:49to the right five steps.
• 14:50And you do that five times.
• 14:53The next step is your leg out and in.
• 14:57You stand facing the kitchen sink.
• 15:00You hold on with both hands.
• 15:02You stand with your left leg and move
• 15:06your right leg out to the side and back.
• 15:09You repeat on the opposite side
• 15:11and you do that.
• 15:13You continue to alternate each
• 15:15leg and do that for 10 times.
• 15:17So there's a series of exercises.
• 15:19Start with these two and then
• 15:21go on to different levels.
• 15:22And again is available through
• 15:25the Coach website.
• 15:26So here's a picture of somebody
• 15:28using the kitchen sink to stabilize
• 15:31themselves as they stand on one leg.
• 15:34Now,
• 15:34there are a number of hazards
• 15:36that you can
• 15:37find in the home, so we'll often ask a
• 15:40physical occupational therapist to do
• 15:42what's called a home Safety evaluation.
• 15:45And hazards of the stairs and steps
• 15:48include papers, shoes, books,
• 15:50and other objects on the stairs.
• 15:53Are there some stairs broken or uneven?
• 15:56Is there a light and light switch at
• 15:58the top and the bottom of the stairs?
• 16:01Has a stairway light bulb burned out?
• 16:04Is the carpet on the steps loose or torn?
• 16:08Are there hand rails loose or broken?
• 16:11Is there a handrail on both sides
• 16:14of the stairs on the floors?
• 16:17When you walk through the room,
• 16:19do you have to walk around furniture?
• 16:22Do you have throw rugs on the floor?
• 16:26Are there papers, shoes, books,
• 16:28or other objects on the floor?
• 16:30Do you have to walk over or around?
• 16:32Wires or cords like lamp,
• 16:35telephone or extension?
• 16:37Cords in the kitchen are the things
• 16:41that you use often on high shelves.
• 16:44If you use a step stool,
• 16:45is it a sturdy one in the bedroom?
• 16:49Is the light near the bed easy to reach?
• 16:54Is the path from the bed to the bathroom
• 16:57illuminated in the bathroom very important?
• 17:00Most dangerous place in the house
• 17:02as far as falls are concerned.
• 17:04Is the bath or shower floor slippery?
• 17:08Do you need some support when you get in
• 17:10and out of the tub or up from the toilet?
• 17:13So do you need to have grab rails
• 17:15placed in the bathroom to help you in?
• 17:17Both with toileting and with bathing,
• 17:21stairs can be very problematic,
• 17:24and 75% of falls that occur on stairs
• 17:27occur when you're going down the stairs,
• 17:30so that's the most dangerous time.
• 17:32And if you are carrying a large object
• 17:37with both hands and can't see your feet,
• 17:40that's a recipe for disaster.
• 17:42So a large laundry basket can
• 17:45be very problematic.
• 17:46So we suggest if you have to put
• 17:48laundry down, one flight of stairs,
• 17:50you put in the bag and throw it down,
• 17:52which markedly decreases your
• 17:54risk for falling on stairs.
• 17:57So how do you manage fall
• 18:00risk you have to do.
• 18:02For foot issues,
• 18:03you want to advise the patient
• 18:06on safe and appropriate footwear.
• 18:09For patients with disabling foot pain,
• 18:11you refer to Podiatry.
• 18:13If the person has difficulty with balance,
• 18:17gait, and transfers,
• 18:18a physical therapy referral
• 18:20can be extremely helpful.
• 18:22If there is a regional fall
• 18:24clinic in your area,
• 18:25a referral can be quite
• 18:27helpful to the patient.
• 18:29Exercise programs.
• 18:30The most effective programs are exercises
• 18:34that emphasize balance training with
• 18:37resistance training and are integrative,
• 18:40like Tai chi and progressive.
• 18:42Exercise programs that involve
• 18:44at least three hours a week are
• 18:46associated with the greatest effect,
• 18:48and you want to encourage the patient
• 18:51to get on a daily walking regimen
• 18:54and identify a daily mobility goal.
• 18:56So falls and older adults are
• 19:01extremely common.
• 19:02They're associated with serious morbidity.
• 19:06They're the result of multiple predisposing
• 19:11factors plus precipitating events.
• 19:14They're predictable and preventable.
• 19:18The best way to prevent falls
• 19:20is by looking for and reducing
• 19:22as many of the predisposing and
• 19:26precipitating factors as possible.
• 19:29The essentials are medication review,
• 19:31a safe environment and safe mobility,
• 19:35making sure that your balance,
• 19:36your gait and your strength
• 19:38are as good as possible.
• 19:40Thank you very much.
• 21:06So falls are extremely common.
• 21:11They're associated with serious morbidity.
• 21:15They're the result of multiple
• 21:18precipitating factors.
• 21:19I'm sorry, predisposing factors
• 21:22plus precipitating events.
• 21:24They're predictable and preventable.
• 21:28The best way to prevent falls
• 21:31is by looking for and reducing
• 21:34as many of the predisposing and
• 21:37precipitating factors as possible.
• 21:39The essentials are medication review,
• 21:43make the environment safe,
• 21:44and make sure that you are safe with
• 21:47your mobility, that your balance,
• 21:49your gait, and your strength are
• 21:51all in as good a shape as possible.
• 21:55Thank you very much,
• 22:01Ryan. Can we?