This document summarizes information on falls in older adults, including risk factors, assessment, and physical therapy interventions. It discusses how 30% of community-dwelling older adults fall each year, with 10% resulting in injury. Falls are a leading cause of injury for older adults. The document reviews risk factors like history of falls, medications, mobility and sensory impairments. It provides guidelines for assessment and recommends multifactorial interventions that include balance, strength, and gait training exercises. Effective programs involve moderate to high balance challenges and last at least 12 weeks. The OTAGO exercise program is highlighted as an example of an effective home-based fall prevention program.

1. Falls in Older Adults:
Identifying risk and physical therapy management
Nathan Dugan, SPT
Columbia University
Louis Stokes Cleveland VA Medical Center
12/19/2013

2. * General fall statistics
* Risk factors
* American Geriatrics Society Guidelines
* Outcome measures
* Interventions
* Other resources
Outline

3. “…an unexpected event in which the participant comes
to rest on the ground, floor, or lower level.”1
What is a fall?

4. * 30% of community-dwelling older adults fall each year
* 10% of falls result in fracture or other serious injury2
* Significant source of morbidity/mortality3
* >40% of institutionalized older adults fall each year
* Leading cause of fatal and nonfatal injuries
* 2.4 million ED visits
* >689,000 hospital admissions4
General Fall Statistics for Older
Adults

5. * Direct medical costs $30 billion! (2010)5
* Direct & indirect costs $54.9 billion by 2020!6
* Cost per fall: $9,000-$13,000! (2002)7
* Cost per injurious fall: $20,000! (1998)8
* Falls are independent predictor for long-term care
admission3
General Fall Statistics for Older
Adults

6. * History of falls***
* Use of AD**
* Physical disability**
* Disability in IADL
* Female gender
* Living alone
* Increased age
2-3x increased risk
Risk Factors for Falls-
Sociodemographic Factors9,10

7. * Dizziness and vertigo
* Parkinson disease
* Fear of falling
* Depression
* (Poor) Self-perceived
health status
* CVA
* Urinary incontinence
* Pain
* Rheumatic disease
* Cognitive impairment
* Hypotension
* Diabetes
2-3x increased risk
Risk Factors for Falls-Psychological
and Medical Factors9,10

8. * Antiepileptic
* Sedatives
* Antihypertensive
* Number of medications
2-3x increased risk
Risk Factors for Falls-Medication
Factors9,10

9. * Gait impairment
* Vision impairment
* Hearing impairment
*2-3x increased risk
Risk Factors for Falls-Mobility and
Sensory Factors9,10

10. * Best practice guidelines:
* All older adults should be asked if they have fallen in past year
* Frequency and circumstances of falls should be obtained
* Older adults seeking medical care because of fall, reporting
multiple falls or difficulty with walking or balance should be given
multifactorial risk assessment
* Older adults who have fallen should have assessment of gait and
balance
* Those performing poorly should be given multifactorial fall risk
assessment
* Individuals reporting only 1 fall and demonstrating no difficulty with
balance and gait do not require multifactorial fall risk assessment
American Geriatrics Society Clinical
Guidelines
http://www.americangeriatrics.org/files/documents/health_care_pros/Falls.Summary.Guide.pdf

11. * Focused history
* Falls, meds, risk factors
* Physical examination
* LEs, neuro, cardiovascular, visual
* Functional Assessment
* ADL/IADL, ADs, subjective func ability/fear of falling
* Environmental assessment
* Home/work/community environment
Multifactorial Fall Risk Assessment
http://www.americangeriatrics.org/files/documents/health_care_pros/Falls.Summary.Guide.pdf

12. What are the best outcome measures to use when
assessing fall risk in older adults?
Assessing Risk for Falls

13. * Berg Balance Scale
* Functional Gait Assessment
* Clinical Test of Sensory Interaction
and Balance (CTSIB); Modified
CTSIB
* Dynamic Gait Index
* Four Square Step Test
* Timed Up and Go
* Rivermead Mobility Index
* Functional Reach Test
* Dizziness Handicap Scale
* Push and Release Test
* Tinetti Performance Oriented
Mobility Assessment
* Balance Evaluation Systems Test
* Fullerton Advanced Balance Scale
* Function in Sitting Test
* Brunel Balance Assessment
* Community Balance and Mobility
Scale
* Tinetti Falls Efficacy Scale
* Activities-Specific Balance
Confidence Scale
* Five Times Sit to Stand
* Walking While Talking
* Step Test
Common Outcome Measures for
Assessing Fall Risk

14. Cut-Off Scores for High Fall Risk12
Outcome Measure Cutoff for high fall risk (older adults)
Timed-Up-and-Go >13.5s (>32.6s frail*)
Functional Reach Test <7”
5 Times Sit to Stand/Four-Square Step
Test
>15s
Berg Balance Scale <45/56
Functional Gait Assessment <23/30
Tinetti-POMA <19/28 (<11/16 for balance component)
Fullerton Advanced Balance Scale <25/40
*3 or more: unintentional wt loss (>10lbs 1yr), self-reported exhaustion, weakness
(grip), slow walking speed, low physical activity11

15. * Moderate to highly challenging balance activity
significantly reduces rate of falls as a single
intervention
* Strength training, stretching, walking do not
* Comprehensive intervention should include balance,
strength, and gait training exercises13
Best Intervention Practices

16. * Challenge COM with feet fixed
* Narrow BOS
* Repetition, progression, continually challenging
patient is key
Static Balance Training13

17. * Tai Chi
* Reaching while moving
* Standing up
* Turning in a circle/circling/figure-8
* Stair stepping
* Dance steps
* Unanticipated directional changes
* Obstacle courses
Dynamic Balance/Gait Training13

18. * Difficulty walking while talking=high risk of falls
* Performance can be improved
* Conversing while maintaining walking speed
* Walking and counting
* Walking while performing manual tasks
* Variable priority may improve outcomes
Dual-Task Training13

19. * Effective in improving reaction times and stepping
strategies
* Little evidence to support this alone translates to
fewer falls
Perturbation and Compensatory
Stepping Training13

20. * Key element of fall prevention
* Focus on
* LE and postural muscles
* Limited UE support
* Moderate or high intensity
Strength Training13

21. * In those at high risk for falls, or done without
concurrent balance training…
May result in increased risk of falls
* Should not be included at beginning of fall-prevention
program, except in higher functioning individuals
Walking13

22. * Account for contributing risk factors
* Triage factors based on impairments
* Implement appropriate interventions
* Less than 50% of PTs linked interventions to risk factors
or referred to other providers
Example: Visual impairment trial
What Comprises an Effective Fall-
Prevention Intervention?13

23. * Minimum of 12 weeks for optimal outcomes (50
hours)14
* Individuals that begin exercise program but do not meet
this minimum may increase risk for falls
How Long Should Interventions Be?

24. How Can We Meet This 50-Hour
Minimum?

25. * Designed as home-based exercise program
* Meta-analysis showed 35% reduction in falls and fall-
related injuries in older adults
* Most effective in those 80 or older
* Results in confidence in carrying out ADL/IADL
* Beneficial for individuals with moderate and high
functional impairment
http://www.hfwcny.org/Tools/BroadCaster/Upload/Project13/Docs/
Otago_Exercise_Programme.pdf
OTAGO Exercise Program13,14

26. Strength Exercise-OTAGO

27. Balance Exercise-OTAGO

28. Balance Exercises-OTAGO (cont’d)

29. * Will not reduce falls on its own!
* 30 minutes, 2 times/week
* Performed at usual pace with usual AD
* Can be broken up into 10 minute bouts
Gait Training-OTAGO

30. * Interventions should be structured
* Interventions should be tailored to challenge patient
based on his/her specific impairments
* Interventions must achieve optimal dose
* Management should not end at d/c, prescribe
adequate HEP
Take Home Points

31. * CDC Compendium of Effective Fall Interventions:
http://www.cdc.gov/HomeandRecreationalSafety/pdf/
CDC_Falls_Compendium_lowres.pdf
* CDC STEADI Program:
http://www.cdc.gov/homeandrecreationalsafety/Falls/
steadi/index.html
* OTAGO Exercise Program:
http://www.hfwcny.org/Tools/BroadCaster/Upload/
Project13/Docs/Otago_Exercise_Programme.pdf
Relevant Resources

32. 1. Lamb SE, Jorstad-Stein EC, Hauer K, et al. Development of a common outcome data set for fall injury
prevention trials: the prevention of falls network Europe consensus. J Am Geriatr Soc 2005;53:1618-1622.
2. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community.
New Eng J Med 1998;319(26):1701-1707.
3. Gillespie LD, Roberton MC, Gillespie WJ, et al. Interventions for preventing falls in older people living in
the community. The Cochrane Library 2012;9.
4. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web–
based Injury Statistics Query and Reporting System (WISQARS) [online]. Accessed December 19, 2013.
5. Stevens JA, Corso PS, Finkelstein EA, Miller TR. The costs of fatal and nonfatal falls among older adults.
Injury Prevention 2006a;12:290–5.
6. Englander F, Hodson TJ, Terregrossa RA. Economic dimensions of slip and fall injuries. Journal of Forensic
Science 1996;41(5):733–746.
7. Carroll NV, Slattum PW, Cox FM. The cost of falls among the community-dwelling elderly. Journal of
Managed Care Pharmacy. 2005;11(4):307-16.
8. Shumway-Cook A, Ciol MA, Hoffman J, Dudgeon BJ, Yorston K, Chan L. Falls in the Medicare population:
incidence, associated factors, and impact on health care. Physical Therapy 2009.89(4):1-9.
References

33. 9. Deandrea S, Lucenteforte E, Bravi F, et al. Risk factors for falls in community-dwelling older people: a
systematic review and meta-analysis. Epidemiology 2010;21(5):658-668.
10. Deandrea S, Bravi F, Turati F, et al. Risk factors for falls in older people in nursing homes and hospitals: a
systematic review and meta-analysis. Archives of Gerontology and Geriatrics 2013;56:407-415.
11. Fried LP, Tangen CM, Watson J, et al. Frailty in older adults: evidence for a phenotype. Journal of Gerontology
2001;56A(3):M146-M156.
12. Rehabilitation Measures Database [online] www.rehabmeasures/org. Accessed December 19, 2013.
13. Shubert TE. Evidence-based exercise prescription for balance and falls prevention: a current review of the
literature. Journal of Geriatric Physical Therapy 2011;34(3):100-108.
14. Sherrington C, Whitney JC, Lord SR, et al. Effective exercise for the prevention of falls: a systematic review
and meta-analysis. Journal of the American Geriatrics Society 2008;56:2234–2243.
References