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2015: Fall Prevention and Treatment-Siebens


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Fall Prevention and Treatment

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2015: Fall Prevention and Treatment-Siebens

  1. 1. 1 Falls Prevention and Treatment Hilary C. Siebens MD Siebens Patient Care Communications Consultant, PM&RS Long Beach VA Health System 2nd Annual UCSD Clinical Geriatrics Interprofessional Symposium San Diego October 25, 2015
  2. 2. 2 Objective Practical • Appreciate a few key epidemiology facts. • Learn overarching assessment strategies. • Explain 3 or more factors contributing to falls in each of 4-domains: medical, cognitive, functional, and environmental realms. • Identify 2 practical interventions to improve your care of patients with fall risk factors for those who 1) haven’t fallen yet are at high risk and 2) those who have fallen.
  3. 3. 3 Disclosures A model used in consulting with health care organizations will be mentioned.
  4. 4. 4 Epidemiology  1. What % of community residing older adults fall each year?  2. What percentage of falls cause serious injury?  3. What are the most frequent causes of TBI in the elderly – pedestrian vs car accidents, driving car accidents, muggings, falls, or other?
  5. 5. 5 Epidemiology Answers 1. 25% 2. 5-10%, causing lacerations, traumatic brain injury (TBI), fractures (most frequent one is of the hip) 3. Falls are THE MOST frequent cause of traumatic brain injury (TBI) in the elderly
  6. 6. 6Preparing a 21st Century Work Force: The Challenge of Chronic Conditions, WHO 2005
  7. 7. 7 Overarching Concepts in Assessment of Fall Risk  4. What is the single most important topic to ask your patients?
  8. 8. 8 4. Answer - About falls! Three questions to ask: • Have you fallen in the past year? • Do you feel unsteady when standing or walking? • Do you worry about falling? Odds ratio for another fall if a fall – 2.8 See; Michael Y et al. Ann Intern Med 2010.
  9. 9. 9 Understanding Balance Self-insight and Reflection  5. Do you have a balance problem?
  10. 10. 10 5. Answer It depends! • Dynamic balance and falls – falls occur when activities overpower individuals’ ability to keep upright dynamically See for information on screening tests for fall risks – Timed Up & Go, 30 sec chair stand, 4-stage balance test.
  11. 11. 11 A practical model for assessing falls INDIVIDUAL Cognition 3 sensory system inputs brain/CNS processing neuromusculoskeletal output ACTIVITY CHOSEN* What/how/when an individual is doing it * Occupational Therapy – The PEO Model : person, environment, occupation
  12. 12. 12 Overarching Concepts in Assessment and Management • Many patients don’t understand balance, don’t know they have a “balance” problem Dizziness/unsteadiness Taking extra steps, shorter steps More trouble in dark, on grass or uneven surfaces Losing balance with turning, reaching, sit to stand Furniture surfing required Free falling into a chair Feeling that “I walk like I’m drunk” • Patients often believe “nothing can be done” or believe “I don’t have a problem but my friend does” (see for brochure, how to talk to patients)
  13. 13. 13 Overarching Concepts in Assessments and Management • Critical to focus on screening for risk of INJURY • Several key factors: Older age Medical - Oseoporosis, anti-coagulation, polypharmacy, etc. Cognition - Impaired judgment Function - High risk activity for the individual Environment - Living alone
  14. 14. 14 Overarching Concepts in Assessments and Management • Etiologies of falls usually multifactorial • Strategy is to address identified risk factors • Most all treatment strategies involve exercise of some sort (community-based or physical therapy) • Strategies limited to date in fall prevention in setting of cognitive impairment in community- dwelling individuals (projects underway in nursing facilities, etc)
  15. 15. 15 Identifying Treatable Diagnoses/Risk Factors Medical • Cardiac - relative hypotension (overtreated HTN) BP systolic goals for seniors now <140 mm Hg if under 80 yrs old, 140-150 if over 80 yrs old - go by pt symptoms - terazosin for treatment of BPH • Neurological – CNS (subdural, stroke, traumatic brain injury…) vestibular (BPPV, acoustic neuroma…) peripheral neuropathy • Musculoskeletal – deformities back, knees, ankles, feet, pain • Polypharmacy • Nutrition - Vitamin D deficiency
  16. 16. 16 Identifying Treatable Diagnoses/Risk Factors Mental, Functional, Environmental • Cognitive, Emotional (depression, anxiety - fear of falling) • Function – abnormalities of gait; unsafe ADLs • Environment – physical hazards, social supports, financial resources
  17. 17. 17 Assessing A Patient – History 1 • Have them describe balance problem (what feels like, how long present, rate of progression) • Describe most recent fall (circumstances, then perhaps one, or two prior falls)(visualize the scene…) • Describe mobility/devices used (easier to walk when pushing shopping cart – early sign rollator might help, for physical activity at least) • Focused ROS for cardiovascular, neurological, orthopedic contributors, pain, vision, alcohol
  18. 18. 18 Assessing Patient – History 2 • Function (other than walking) – showering, on/off toilet (and whether grab bars, etc); general physical activity habits • Consider Kemp QOL screen – “Taking everything in your life into account, please rate your overall Quality of Life on the following 7-point scale…” 1 life is very distressing, 7 life is great, 4 life is so-so CAVEATS for KQOL – Please read reference(s) before using. Siebens H et al Correlates of a single-item quality of life measure in people aging with disabilities. Am J Phys Med Rehabil 2015 (open access for anyone)
  19. 19. 19 Assessing Patient – History 3 • Social - who living with (to help, support) - any pets (trip hazzard) - finances - “In terms of your finances, are you comfortable, making do, or is it a struggle?” • ROS – quick screen of sleep, appetite, other
  20. 20. 20 Physical Exam - Seated • Cognition screen – IF suspect problems Mini-cog – recall of 5 words, clock drawing • Health Literacy – special considerations • HEENT – depending on suspected dx (re cranial nerves or visual neglect) active neck lateral range of motion
  21. 21. 21 Clock drawing “Please draw a clock for me. Make it big. Set the time to 10 after 11.” see Borson S et al Int J Geriatr Psychiatry 2000;15:1021-1027 on Mini-cog – 3-item recall and clock drawing as cognitive screen.
  22. 22. 22 Physical Exam - Seated • Motor tone (cogwheeling at elbow, clonus -? myelopathy) • Muscle strength screen upper extremity (pronator drift) lower extremity • Joint exam as indicated (hip, knee) • FEET KEY – watch taking off socks (one foot if time short) check hygiene (clue to cognition problem, etc) sensation (to identify peripheral neuropathy)
  23. 23. 23 Physical Exam - Standing • Sit to stand - with or without arms? • Romberg • Sternal push • Watch walking pattern, watch number of steps to turn (normal is 3 steps) and if touch wall for balance • Special physical exam – if suspect vestibular component, Dix-Hallpike and Epley See You Tube (Kim et al. Benign paroxysmal positional vertigo. NEJM;2014;370:12 – excellent review.)
  24. 24. 24 Labs and Therapy • Be sure general internal medicine/family medicine recent evaluation (thyroid, lytes, CBC, etc to screen for systemic disease/infections as contributor to balance problems) • If peripheral neuropathy, consider Vit B12, folate levels, A1C if not done already, consider referral for work up • Vitamin D – 25-hydroxy level • Balance testing/gait assessment by Physical Therapy • ADLs review for safety, devices by Occupational Therapy
  25. 25. 25 Assessment/Plans • If unclear what’s causing problem, refer to specialist to help (ENT for vestibular, neurology for ? Parkinson’s, degenerative process, etc) • If multifactorial (deconditioning, prior stroke, superimposed on aging, OA of knees, kyphosis, etc): 1. treat individual identified risk factors 2. focus on compensatory strategies 3. encourage community exercise program or PT if more severe impairment 4. recommend assistive device (“have cane at home just in case…”); - if bilateral balance support, consider rollator for exercise and/or all the time
  26. 26. 26 Clinical Case – 75 yo Man
  27. 27. 27 Current Status • Adaptive bicycle on retail market – pedal-forward • Quality of Life – KQOL 5.5 - Good!
  28. 28. 28 In Summary • Balance, fall problems complex • Good assessments key: team of physician/NP, other specialties, rehab therapies • Treatments – in health care & community over time • From single factor(s) to multiple “treatable” factors to late-life disability (keep patient as safe as possible)
  29. 29. 29 Observations, Questions? THANK YOU.
  30. 30. 30 Supplemental Slides
  31. 31. 31 Activities-specific Balance Confidence (ABC) Scale • “How confident are you that you will not lose your balance or become unsteady when you….” • Response scale from 0% (no confidence) to 100% (completely confident) • 16 self-report functional items – walk around the house, walk up or down stairs… sweep the floor… walk across a parking lot to the mall… • Can indicate early balance problems for patients who feel they don’t have a problem Powell, LE & Myers AM. The Activities-specific Balance Confidence (ABC) Scale J Gerontol Med Sci 1995;50:M28-34.
  32. 32. 32 Assessment/Plan – a Standardized Synthesis I. Medical/Surgical Issues1 Contributing diagnoses to balance problem (peripheral neuropathy, severe knee OA, Vit D deficiency, etc) and plan for w/u, tx. II. Mental Status/Emotions/Coping - Comment on safety judgment, evidence of good coping or not (changing behaviors to be safer), Preferences - Suggest education classes on balance if available, give CDC brochure on fall prevention (Patients need to understand how balance works, so can choose safer ways of doing things) - Suggest patients keep health information organized, take to all appointments 1 Using the Siebens Domain Management Model domain headings; Siebens H. Top Stroke Rehabil 2011; see guidelines for use at; © Hilary C. Siebens 2005
  33. 33. 33 Assessment/Plan – a Standardized Synthesis III. Physical Function1 Mobility - assistive device? - 1:1 Physical Therapy? or exercise class in community? ADLs – safe or unsafe? Occupational Therapy assessment? (toileting, showering, foot care, meal prep, etc) Physical Activity – coaching/motivational interviewing, encourage walking program with safe assistive device, 30 min 5 times a week! IV. Living Environment A. Physical – grab bars in shower? rails by front steps? B. Social – involve/educate of family members? C. Financial/Community Resources – financial needs? Community education programs for fall prevention? 1 Using the Siebens Domain Management Model domain headings; Siebens H. Top Stroke Rehabil 2011; see guidelines for use at; © Hilary C. Siebens 2005