Falls and Mobility Problems in Older Adults

1
Falls and Mobility Problems in Older Adults

• Shelley B. Bhattacharya, D.O., M.P.H.
• Department of Family Medicine
• Kansas Reynolds Program in Aging
• University of Kansas Medical Center

2
Epidemiology of falls in elderly

• Definitions
• Classifications
• Incidence

Ageing
3
Epidemiology of falls in elderly
Definitions

• An event that results in a person inadvertently
  coming to rest on the ground or other lower level
  (not as a result of loss of consciousness,
  violent blow, sudden onset of paralysis or
  seizure) (Gibson et al., Kellogg International
  Work Group, 1987)
• An event which results in a person coming to rest
  unintentionally on the ground or other lower
  level, not as a result of major intrinsic event
  (such as stroke) or overwhelming hazard (Tinetti
  et al., 1988)
• Unintentionally coming to rest on the ground,
  floor or other lower level (Ory et al, FICSIT
  trials, 1993)

4
Epidemiology of falls in elderly
Classifications

• Falls
• Trigger
• Consequence

• Fallers
• Non-fallers
• Once-only fallers
• Recurrent fallers

5
Epidemiology of falls in elderly

• Incidence
• Accidents are the 5th leading cause of death in
  older adults 1
• Falls account for 2/3 of these accidental deaths
• 1/3 of adults over 65 living in the community
  fall at least once a year
• This rises to ½ of adults over age 80 2,3
• 5 of these falls result in a fracture or
  hospitalization
• Mobility abnormalities affect 20-40 of adults
  over 65 and 40-50 of adults over age 85 4,5

6
Epidemiology of falls in elderly
Incidence

• Mortality 46
• Of those who are hospitalized, 50 will not be
  alive a year later
• Falls constitute 2/3rd of deaths associated with
  unintentional injuries
• In 2000 traumatic brain injury (TBI) accounted
  for 46 of fatal falls.
• Cost 47
• Fall-related injuries are among the most
  expensive health conditions
• In 2000 179 million were spent on fatal falls
  and 19 billion were spent on injuries from
  non-fatal falls

7
Epidemiology of falls in elderly
Incidence

• Location 48
• Most falls occur outdoors
• Women are more likely to report indoor falls
• Indoor falls are associated with frailty
• Outdoor falls are associated with compromised
  health status in more active elderly

8
Epidemiology of falls in elderly
Incidence

• The rate of falls and their associated
  complications are twice over the age of 75
  years.
• 10-25 falls induce fractures in this population
• Hip fractures are more common after the age of 75
  years
• Those 75 years of age are more likely to report
  indoor falls
• Incidence is higher in certain populations (e.g.
  institutionalized elderly, diabetics, Parkinsons
  disease, post-stroke etc.) 49

9
Fall prevention

• The quality of falls care in older adults is
  suboptimal
• If we can reduce the risk factors for falling,
  then we can reduce the incidence and the
  morbidity associated with falls
• 3 studies have found that 65-100 of older adults
  with 3 or more risk factors fell in a 12 month
  period compared with 8-12 of older adults
  without any risk factors 1,6-8

10
ACOVE Indicators

• ACOVE Assessing Care Of Vulnerable Elders
• The 12 new ACOVE indicators59 are designed to
  improve the clinical approach to falls and
  mobility in older adults
• Evidence based focus 182 articles were reviewed
  to obtain these indicators
• Some have practice guidelines which will be
  shared

11
ACOVE Indicator 1

• ALL vulnerable elders should have ANNUAL
  documentation about the occurrence of recent
  falls

12
Because

• Falls are common
• Preventable
• Frequently unreported
• Often cause injury
• Can restrict activity unnecessarily
• A recent fall is a potent predictor of future
  falls
• Need a multifactorial falls risk assessment for
  all of your vulnerable older adults

13
Multifactorial Falls Risk Assessment

• Many studies show that a multifactorial falls
  risk assessment program is beneficial to assess
  and intervene on falls
• In one meta-analysis, the risk ratio for a first
  fall in subjects enrolled in a risk assessment
  program was 0.82 (95 CI 0.72-0.94) compared to
  controls and was 0.63 (95 CI 0.49-0.83) for any
  fall 9
• In other words, 18 fewer 1st falls and 37 fewer
  of any falls with a falls risk assessment
  program!

14
Falls Risk Assessment Features

• Medication review
• ADL and IADL assessment
• Orthostatic blood pressure measurement
• Vision assessment
• Gait and balance evaluation
• Cognitive evaluation
• Assessment of environmental hazards

15
ACOVE Indicator 2

• IF a vulnerable elder reports 2 or more falls in
  the previous year, THEN document a basic fall
  history within 3 weeks of the report
• Because a basic fall history provides the
  necessary information to implement an
  individualized multifactorial falls risk
  intervention strategy

16
What is a fall history?

• Circumstances?
• Medications?
• Chronic conditions?
• Mobility status?
• Alcohol intake?
• You can use the positives to tailor a fall
  prevention program specific for each of your
  older adults 10,11

17
ACOVE Indicator 3

• IF a vulnerable elder reports 2 or more falls (or
  1 fall with injury) in the previous year, THEN
  there should be documentation of orthostatic
  vital signs within 3 months of the report
• Because detection of orthostasis decreases the
  risk of future falls
• Is a part of the multifactorial falls prevention
  intervention

18
Evidence

• Supported by 13 studies including cohort and
• RCTs 12-18
• Some clinical guidelines that are recommended
• Correct postural hypotension 19
• Assess postural vitals in all older adults that
  have had a recent fall, report recurrent falls or
  demonstrate abnormalities in gait or balance 20
• Include a cardiovascular examination when doing a
  falls risk assessment 21

19
ACOVE Indicator 4

• IF a vulnerable elder reports a history of 2 or
  more falls in the last year, THEN there should be
  documentation of an eye examination in the
  previous year or visual acuity testing within 3
  months of the report
• Because detection and treatment of some forms of
  visual impairment reduces the risk of falls.

20
Evidence

• 11 studies examined visual acuity as a falls risk
  factor
• One study looked at falls improvement after
  expedited (within 27 days) and routine (71-212
  days) cataract surgery in women over age 70 22
• After 1 year, 49 of adults in expedited group
  fell at least once compared to 45 in routine
  group
• 18 fell twice in expedited group compared to 25
  in control group

21
ACOVE Indicator 5 and 6

• IF a vulnerable elder reports 2 or more falls in
  the last year, OR
• IF a vulnerable elder has new or worsening
  difficulty with ambulation, balance or mobility,
• THEN there should be documentation of basic gait,
  balance and strength evaluation within 3 months
  of the report

22
Because

• Detection and treatment of gait and balance
  disorders reduces the risk of future falls as
  part of a multifactorial intervention

23
Evidence

• 9 studies looked at gait and balance assessments
  in falls prevention
• Cohort and RCTs
• In 3 studies, abnormal gait and balance alone
  were significant predictors of falls 6

24
Clinical Guidelines for Gait and Balance

• Provide interventions to improve balance,
  transfers and gait 19
• Do a gait and balance assessment for those
  requiring medical attention because of a fall,
  report recurrent falls in the past year or
  demonstrate abnormalities of gait or balance 20
• Risk assessment includes assessment of gait,
  balance, mobility and muscle weakness 21

25
Screening and Examination of Gait and Balance

• Timed Get Up and Go Test
• Single Leg Stand Test
• Dynamic Gait Index
• Berg Balance Scale

26
Timed Get Up and Go Test

• Measures functional capacity rather than
  individual impairment reflects multiple
  domains, useful in detecting mobility impairment
• . Time it takes to stand up from arm chair, walk
  3 meters (10 feet), return to chair and sit down

27
Timed Get Up and Go Test

• Interpretation of Performance on the Timed Get Up
  And Go Test
• lt 10 sec.
• Low fall risk clients are freely mobile
  encourage regular exercise
• lt 20 sec.
• Moderate fall risk clients are independent with
  basic transfers most go outside alone and climb
  stairs, many are independence with tub and shower
  transfers. PT referral may be appropriate.
• 20-29 sec.
• High fall risk Gray zone functional abilities
  vary. Physician or multidisciplinary team
  assessment recommended.
• gt30 sec.
• Very high fall risk Many are dependent with
  chair and toilet transfers most are dependent
  with tub and shower transfers most cannot go
  outside alone few, if any, can climb stairs
  independently. Physician or multidisciplinary
  team assessment recommended.

28
Timed Get Up and Go (TUG) Test

• Bischoff (2003)
• Community dwelling elderly women lt 12 sec. on TUG
  normal
• Women in residential care only 9 performed in
  lt12 sec. 42 were below 20 sec 32 were between
  20-30 sec. and 26 gt 30sec.
• Suggests that community dwelling woman with TUG gt
  12 sec. should be referred for PT evaluation
• Over 50 of women in residential care at high or
  very high risk of falling

29
Timed Get Up and Go Test

• Nordin (2006)
• Individual variation in performance high in
  institutionalized elderly
• Variation increased with slower performance.
• Cognitive impairment or cuing did not increase
  variability
• Could use mean of three trials to obtain a more
  accurate score
• We do not know what this variability means in
  terms of falls risk prediction

30
Single Leg Stance Test

• A measure of static balance that relates to
  foot/ankle strategies
• Functional implications for gait, especially on
  uneven surfaces, and going up/down curbs or steps
• Marker of frailty in elderly persons
• Community dwelling older adults unable to stand
  for 5 sec. had a 2.1 times risk of injurious
  falls

31
Dynamic Gait Index

• Developed to quantify gait dysfunction in older
  adults during level surface walking as well as
  more complex functional tasks.
• Dual task demands relevant to falls risk in
  elderly
• Applicable to assessing balance in other groups
  of patients including those with vestibular
  disorders, multiple sclerosis, head injury, and
  Parkinsons
• Scores of 19 or less out of 24 indicate increased
  risk of falling in older adults (Shumway-Cook
  1997)

32
Berg Balance Scale

• Measure of static and dynamic balance in
  movements common in everyday life on 14-item
  scale (56 points)
• Useful for evaluating multiple falls risk in
  community living older adults
• No longer recommends a dichotomous 45 point
  cut-off
• Likelihood of multiple falls increases as score
  decreases
• Reliable test of balance in elderly in
  residential care change of 8 points required to
  reveal genuine change in function
• Discriminates persons with Parkinsons disease
  who fall vs. those who do not fall
• Cut-off score of 44/56 recommended by Landers,
  2008

33
Limitations of Balance Scales and Screening Tools

• Screening for falls may increase fear of falling
• Falls are multifactorial, no scale captures all
  aspects
• Scales and balance screening tools have not been
  well tested in a wide range of populations/setting
  s
• Uncertainty regarding predictive scores
• Scales test different aspects of balance,
  sensitivity for prediction and examination may be
  best with multiple tests

34
ACOVE Indicator 7

• IF a vulnerable elder reports 2 or more falls in
  the past year, THEN there should be documentation
  of a cognitive assessment in the past 6 months
• Because, detection and management of cognitive
  impairment reduces the risk of falls as part of a
  multifactorial intervention

35
Evidence

• 7 studies
• 4 studies recommend using the MMSE 15-17,23
• Clinical Practice Guideline
• Assess mental status as part of your fall
  evaluation for older adults who had a fall,
  report recurrent falls in the past year or show
  abnormal gait or balance 20

36
ACOVE Indicator 8

• IF a vulnerable elder reports a history of 2 or
  more falls in the past year, THEN there should be
  documentation of an assessment and modification
  of home hazards recommended in the previous year
  or within 3 months of the report

37
Because

• Environmental factors can contribute to risk of
  falls and mobility problems
• An assessment and modification of home hazards
  may decrease fall risk

38
Homes Are Not Typically Designed For Users of
Various Abilities

• Life Span Development
• Acute Injury

• Aging-in-Place
• Chronic Disability

39
Difficulty Moving Around at Home

• Hard to go up stairs 35
• Difficulty walking 15
• Use of cane/walker 8
• Use of wheelchair/scooter 6
• Difficulty bathing 3
• Chair or bed transfers 3

(Source Fixing to Stay, 2002)
40
Important Housing Features

• Main floor, bath
• Main floor, bedroom
• Accessible climate controls
• Non-slip flooring
• Bathroom aids
• No step entrance
• Covered parking

(Source These Four Walls, May 2003)
41
Occupational Therapy considers the physical
context

• During Assessment
• Understand obstacles/barrier to participation
• Understand supports to participation
• Consider individual, groups, populations who use
  the physical space
• During intervention
• Reduce activity demands from the environment
• Insure adequate supports
• Facilitate performance though the use of the
  environment
• Avoid further functional decline and excess
  disability caused by environmental factors

42
3 Major Problem Areas of the Home

• Outside Steps To The Entrance
• Inside Stairs To A Second Floor
• Unsafe Bathrooms

Source HUD (2001)
43
Other Alternatives to Entrance with Outside Steps

• Ramps
• Earth Berms/Walkways
• Lifts
• Zero Step entrance

44
Other Strategies for Getting Upstairs

• Chair lift
• Elevator
• Relocate rooms to main floor

45
Strategies for Bathing

• Bath bench/chair
• Bath lift
• Grab bars
• Visual contrast
• Non slip surface
• Hand held showerhead
• Shower/wet room
• Curbless shower

46
Evidence

• Many RCTs reviewed
• One RCT of over 3000 older adults 24
• Intervention in home safety mobility assessment
• Control no assessment
• Results Odds ratio of falling in the
  intervention group dropped from 1.0 to 0.85
• In other words, there was a 15 drop in falls in
  those receiving the in home safety mobility
  assessment

47
More Evidence

• Environmental assessment and modification using
  an occupational therapist reduced 12 month
  relative risk of falling to 0.64 (95 CI
  0.5-0.83) in older adults at higher risk of
  falling 25-28
• Another study compared a home safety program to a
  home exercise program in older adults with severe
  visual impairment 29
• Found fewer falls in the home safety program
  0.59 (95 CI 0.42-0.83)
• No difference with the home exercise group

48
Review Study

• A review study looking at 3 trials found that
  professionally prescribed home hazard assessment
  and modification in older adults with a history
  of falling reduced the risk of falling, RR of
  0.66 (95 CI 0.54-0.81) 30

49
Checklists--Examples

• Home Safety Council
• www.homesafetycouncil.org/resource_center/rc_check
  list_w001.aspxp
• Rebuilding Together --Checklist
• www.rebuildingtogether.org
• CDC Check for Safety
• www.cdc.gov/ncipc/pub-res/toolkit/checkforsafety.h
  tm
• http//www.cdc.gov/ncipc/falls/FallPrev4.pdf
• http//www.cdc.gov/ncipc/duip/fallsmaterial.htm

50
ACOVE Indicator 9

• IF a vulnerable elder reports a history of 2 or
  more falls, or 1 fall with injury, in the past
  year, THEN there should be documentation of a
  discussion of related risks and assistance
  offered to reduce or discontinue benzodiazepine
  use
• Because, benzodiazepine use increases the risk of
  future falls

51
Evidence

• 1 RCT 93 ambulatory adults over age 65 on a
  benzodiazepine, any other hypnotic,
  antidepressant or tranquilizer 31
• Randomized to withdrawal plus exercise,
  withdrawal only, exercise only or no intervention
• Over 44 weeks, medication withdrawal group had
  lower rate of falls (0.52 vs. 1.16 falls per
  person-year. Difference 0.64, 95 CI
  0.07-1.35)NOT significant
• But, if adjusted for history of falls in past
  year and total number of meds taken, hazard for
  falls in the medication withdrawal group was 0.34
  (0.16-0.74)

52
More evidence!

• Meta analysis of observational studies found that
  odds ratio for the association between
  benzodiazepines and falls was
• 1.40 (1.11-1.76) in cohort studies
• 2.57 (1.46-4.51) in case control studies
• 1.34 (0.95-1.88) in cross sectional studies 32

53
Clinical Practice Guidelines

• Review all medications 20
• Modify psychotropic meds and discontinue, if
  appropriate
• Rationalize all drugs taken 19

54
ACOVE Indicator 10

• IF a vulnerable elder demonstrates poor balance
  or proprioception or excessive postural sway and
  does not have an assistive device, THEN an
  evaluation or prescription for an assistive
  device should be offered within 3 months

55
Because

• Impaired balance or proprioception or excessive
  postural sway can contribute to instability
• Appropriate treatment will reduce the likelihood
  of falls and their complications

56
ACOVE Indicator 11

• IF a vulnerable elder reports a history of 2 or
  more falls, or 1 fall with injury, in the past
  year and has an assistive device, THEN there
  should be documentation of an assistive device
  review in the past 6 months or within 3 months of
  the report

57
Because

• A poorly fitted assistive device or one used
  inappropriately along with impaired balance or
  proprioception or excessive postural sway can
  contribute to instability
• Appropriate use of an assistive device will
  reduce the likelihood of falls and their
  complications

58
Evidence for Indicators 10 and 11

• Many studies suggest that assistive devices can
  increase an older adults confidence, reduce fear
  of falling and improve independence 33-35
• Some studies suggest the use of devices may
  increase the risk of falling 36,37
• Other studies suggest that device use is a marker
  for fall risk 38

59
Fear of falling Possible contributors

• Age, female gender, poor social support, H/O
  falls, depression and poor lower limb function
• In addition to older age and female gender, lower
  personal mastery and poor dynamic balance are
  associated with fear of falling 55

60
Fear of Falling Activity restriction
Poor perceived health Social withdrawal
Reduced strength
Poor balance Increased
disability Increased fall risk
Reduced
independence

Poor
quality of life
61
Fear of falling may not always precipitate
activity restriction

• half of those who report fear of falling do not
  restrict activities 50-53
• Lack of social support, depressive symptoms, H/O
  multiple falls and presence of 2 chronic
  conditions are associated with fear-induced
  activity restriction 50,53-54

62
ACOVE Indicator 12

• IF a vulnerable elder is found to have a problem
  with gait, balance, strength or endurance, THEN
  there should be documentation of a structured or
  supervised exercise program offered in the
  previous 6 months

63
Because

• These problems can contribute to falls and
  mobility dysfunction
• Exercise intervention can improve the dysfunction
  and reduce the likelihood of falls and their
  complications

64
Evidence

• Many studies show benefits of muscle strength
  with gait parameters in older adults
• Increases of 5-15 in ambulatory function after
  8-12 weeks of a walking and endurance program
  39,40
• Balance training improved force-plate balance
  parameters by 20-50 41,42
• Tai chi improved balance (postural sway) by 32
  and fall risk by 49 (OR 0.51, 95 CI 0.36-0.73)
  43,44
• Aerobic conditioning improved balance by 20 in
  adults over age 70 45

65
General Gait Assessment What to look for in the
elderly person at risk for falling 56

• Changes in gait with aging
• Average gait speed declines 12 to 16 per decade
  past 70 yrs.
• Stride frequency increases
• Stride length decreases at a given walking speed
• Double support time increases

66
General Gait Assessment What to look for in the
elderly person at risk for falling 57

• Gait Characteristics of Fallers
• Decreased trunk rotation
• Increased knee flexion
• Several small steps and reduced speed prior to
  stepping over low obstacle (12)
• Shorter step and stride length
• Slowed gait speeds
• Decreased single leg support time and increased
  double limb support time.

67
Practice Guideline

• Use exercise to improve measures of balance and
  reduce incidence of falls
• Use of a multidimensional exercise program that
  incorporates balance training and strengthening
  should improve postural stability and reduce fall
  risk

68
Exercise Recommendations for Older Adults with
Chronic Disease or Frailty 58

• Balance
• 1-7 x/week, dynamic exercises focused on
  mobility, static exercise focused on single leg
  stand, 4-10 different exercises
• Progressive, targeting important postural muscle
  groups, progress by decreasing base of support
• Muscle Performance
• 2-3 x/week, 8 to 10 exercises
• Aerobic Capacity
• Chronic Dx - 3-5 x/week, 20-60 minutes, 50-70
  Hrmax
• Frailty - gt 3 x/week, at least 20 minutes, 11-13
  Borg Scale
• Flexibility
• 3-7 x/week, 3-5 reps each major muscle group,
  10-30 s. hold

69
Summary

• Extremely important to try to prevent falls in
  your older patients and prevent future falls from
  your current fallers
• Look at their meds, cognition, orthostasis,
  vision, gait, balance
• Encourage exercise to improve muscle strength and
  balance
• Consider assistive devices
• Use OT for home safety assessments
• Screen for fear of falling and counsel to improve
  mobility

70
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