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fall-prevention-dr-erica-pitsch
Fall Prevention for Community Dwelling Older Adults: An Update on Assessment and Intervention Strategies Erica A. Pitsch, PT, MPT, DPT, NCS UCSF/SFSU Graduate Program in Physical Therapy Objectives •Be able to screen community dwelling older adults for fall risk and frailty -sit to stand, gait speed, new standards for timed up and go -be able to describe types of falls •Be able to answer questions about fall prevention programs- including this. . . Stevens,IHS Prim Care Provid 2013 The STEADI protocol: Stop Elderly Accidents, Deaths, and Injuries Please ask your patient •If they fell in the past year •Feels unsteady when standing or walking •Afraid of falling •Scored > 4 on the Stay Independent* brochure *Free from the CDC! www.cdc.gov/steadi/ What kind of fall was it? •“Yes but it wasn’t that bad.” •“No but I trip a lot” •In order to establish a common language for fall recording, a grading scale has been validated by the folks at Johns Hopkins University: Figure 1. Hopkins Falls Grading Scale. © Johns Hopkins University Davalos-Bichara et al.Page 8 J Geriatr Phys Ther. Author manuscript; available in PMC 2014 April 01. NI H - P A A u t h o r M a n u s c r i p t N I H - P A A u t h o r M a n u s c r i p t N I H - P A A u t h o r M a n u s c r i p t (Davalos-Bicharra et al J Geriatric PT 2013) If yes, then: •Timed up and go •30 second chair stand •four stage balance test Stand next to the patient for Timed Up and Go details •Normal pace, any device •tape line, not a cone •NEW standards > 12 seconds indicative of increased falls (Lusardi et al J Geriatric PT 2017) •AND people who took longer than 9 seconds had a “higher risk of developing disability” in the next 2 years (Makizako et al Physical Therapy 2017) 30 second chair stand 5 x Sit to Stand •If you have a lap button, you can do both •have the chair against the wall if possible •30 s chair stand has norms by age •NEW standard for 5x sit to stand >12 seconds for falls, >9 seconds for developing disability in 2 years (Lusardi et al J Geriatric PT 2017, Makizako et al Physical Therapy 2017) A below average score indicates a risk for falls. Chair Stand Below Average Scores SCORING 60-64 < 14 < 12 65-69 < 12 < 11 70-74 < 12 < 10 75-79 < 11 < 10 80-84 < 10 < 9 85-89 < 8 < 8 90-94 < 7 < 4 AGE MEN WOMEN 30 second chair stand 5 x Sit to Stand Needs hands to stand? Gait velocity Berg Balance Scale 🚫 Why gait velocity as well? ★Gait speeds below 1.0 m/s are considered a marker of sarcopenia, predictor of frailty and disability (Pamoukdjian et al J Geri Onc 2016) •Among hospitalized older adults, those that walked <.6 m/s were 2.5x more likely to die in the next 2 years (Ostir et al Arch Phys Med Reh 2015) ✴Predictor of all-cause mortality in men but not in women (Liu et al Gait & Posture 2016) Change in gait speed over time matters •Older adults who slow down more than 2.4% per year (.03 m/s)! had 2.1 times the risk of all-cause mortality •n=2,364 aged 70-79 followed for 8 years •Modifiable features of those who slowed down: High BMI, knee pain, muscular weakness, low physical activity (White et al J Gerontology 2013) Best practice for gait speed •Runway at least 4 m with 2 m “buffer zone” at each end (so you are not getting start / stop slowdown) •Calculate distance ➗ time •No talking Why are they falling or walking slow? •Multifactorial assessment •Meds •rule out orthostatic hypotension •environment •shoes •physical assessments Level 1: Functional Mobility Able to stand no hands? Berg Balance Scale 5X Sit to Stand 30 s chair stand miniBEST YESNO 16 Level 2: Independent Gait Gait velocity (10 mwt or other distance) Berg Balance Scale TUG DT TUG FGA / DGI Four square step test miniBEST BBS / miniBEST DGI / FGA TUG/ DT TUG ABC 17 .4 -‐.8 m/s Limited Community >.8 m/s Community <.4 m/s Household the miniBEST is the best •Core Outcome Set consensus paper on balance measures for older adults •2 made the cut: Berg and Mini-BEST •but the miniBEST “may be considered a more comprehensive measure” (Sibley et al PLOS One 2015) •go to www.bestest.us what makes the mini best the best? •It just makes sense. •Identifies fall risk •Helps explain why- is it an input (sensory) or output (motor) problem? •what to do next- remediate or compensate? •If it’s too hard, then use the Berg (Sibley et al PLOS One 2015) Resources required for postural stability and orientation Biomechanical constraints Sensory strategies Control of Dynamics Orientation to Gravity Cognitive Processing Movement Strategies Horak 2006 20 sensory inputs for balance •sensory weighting of vision, vestibular, and proprioceptive •standing eyes open and on foam, eyes closed •orientation to gravity •on 10 degree ramp, eyes closed motor output strategies: Dynamic •gait with speed change •gait with head turns •gait with pivot turn •step over obstacle (9 inches high) •dual task timed up and go motor output of balance: anticipatory •rise on toes •sit to stand •single leg stance Stand next to the patient for motor output strategies: reactive •compensatory stepping correction * -forward -backward -laterally Figure 1. Hopkins Falls Grading Scale. © Johns Hopkins University Davalos-Bichara et al.Page 8 J Geriatr Phys Ther. Author manuscript; available in PMC 2014 April 01. NI H - P A A u t h o r M a n u s c r i p t N I H - P A A u t h o r M a n u s c r i p t N I H - P A A u t h o r M a n u s c r i p t Mini-BESTest: Balance Evaluation Systems Test © 2005-2013 Oregon Health & Science University. All rights reserved. _________________________________________________________________________________________________ 1. SIT TO STAND Instruction: “Cross your arms across your chest. Try not to use your hands unless you must. Do not let your legs lean against the back of the chair when you stand. Please stand up now.” (2) Normal: Comes to stand without use of hands and stabilizes independently. (1) Moderate: Comes to stand WITH use of hands on first attempt. (0) Severe: Unable to stand up from chair without assistance, OR needs several attempts with use of hands. 2. RISE TO TOES Instruction: “Place your feet shoulder width apart. Place your hands on your hips. Try to rise as high as you can onto your toes. I will count out loud to 3 seconds. Try to hold this pose for at least 3 seconds. Look straight ahead. Rise now.” (2) Normal: Stable for 3 s with maximum height. (1) Moderate: Heels up, but not full range (smaller than when holding hands), OR noticeable instability for 3 s. (0) Severe: < 3 s. 3. STAND ON ONE LEG Instruction: “Look straight ahead. Keep your hands on your hips. Lift your leg off of the ground behind you without touching or resting your raised leg upon your other standing leg. Stay standing on one leg as long as you can. Look straight ahead. Lift now.” Left: Time in Seconds Trial 1:_____Trial 2:_____ (2) Normal: 20 s. (1) Moderate: < 20 s. (0) Severe: Unable. Right: Time in Seconds Trial 1:_____Trial 2:_____ (2) Normal: 20 s. (1) Moderate: < 20 s. (0) Severe: Unable To score each side separately use the trial with the longest time. To calculate the sub-score and total score use the side [left or right] with the lowest numerical score [i.e. the worse side]. _________________________________________________________________________________________________ 4. COMPENSATORY STEPPING CORRECTION- FORWARD Instruction: “Stand with your feet shoulder width apart, arms at your sides. Lean forward against my hands beyond your forward limits. When I let go, do whatever is necessary, including taking a step, to avoid a fall.” (2) Normal: Recovers independently with a single, large step (second realignment step is allowed). (1) Moderate: More than one step used to recover equilibrium. (0) Severe: No step, OR would fall if not caught, OR falls spontaneously. 5. COMPENSATORY STEPPING CORRECTION- BACKWARD Instruction: “Stand with your feet shoulder width apart, arms at your sides. Lean backward against my hands beyond your backward limits. When I let go, do whatever is necessary, including taking a step, to avoid a fall.” (2) Normal: Recovers independently with a single, large step. (1) Moderate: More than one step used to recover equilibrium. (0) Severe: No step, OR would fall if not caught, OR falls spontaneously. 6. COMPENSATORY STEPPING CORRECTION- LATERAL Instruction: “Stand with your feet together, arms down at your sides. Lean into my hand beyond your sideways limit. When I let go, do whatever is necessary, including taking a step, to avoid a fall.” Left (2) Normal: Recovers independently with 1 step (crossover or lateral OK). (1) Moderate: Several steps to recover equilibrium. (0) Severe: Falls, or cannot step. Right (2) Normal: Recovers independently with 1 step (crossover or lateral OK). (1) Moderate: Several steps to recover equilibrium. (0) Severe: Falls, or cannot step. Use the side with the lowest score to calculate sub-score and total score. _________________________________________________________________________________________________ 7. STANCE (FEET TOGETHER); EYES OPEN, FIRM SURFACE Instruction: “Place your hands on your hips. Place your feet together until almost touching. Look straight ahead. Be as stable and still as possible, until I say stop.” Time in seconds:________ (2) Normal: 30 s. (1) Moderate: < 30 s. (0) Severe: Unable. REACTIVE POSTURAL CONTROL ANTICIPATORY SENSORY ORIENTATION / 6 SUB SCORE: / 6 SUB SCORE: / 6 SUB SCORE: Mini-BESTest Instructions Subject Conditions: Subject should be tested with flat-heeled shoes OR shoes and socks off. Equipment: Temper® foam (also called T-foamTM 4 inches thick, medium density T41 firmness rating), chair without arm rests or wheels, incline ramp, stopwatch, a box (9” height) and a 3 meter distance measured out and marked on the floor with tape [from chair]. Scoring: The test has a maximum score of 28 points from 14 items that are each scored from 0-2. “0” indicates the lowest level of function and “2” the highest level of function. If a subject must use an assistive device for an item, score that item one category lower. If a subject requires physical assistance to perform an item, score “0” for that item. For Item 3 (stand on one leg) and Item 6 (compensatory stepping-lateral) only include the score for one side (the worse score). For Item 3 (stand on one leg) select the best time of the 2 trials [from a given side] for the score. For Item 14 (timed up & go with dual task) if a person’s gait slows greater than 10% between the TUG without and with a dual task then the score should be decreased by a point. 1. SIT TO STAND Note the initiation of the movement, and the use of the subject’s hands on the seat of the chair, the thighs, or the thrusting of the arms forward. 2. RISE TO TOES Allow the subject two attempts. Score the best attempt. (If you suspect that subject is using less than full height, ask the subject to rise up while holding the examiners’ hands.) Make sure the subject looks at a non-moving target 4-12 feet away. 3. STAND ON ONE LEG Allow the subject two attempts and record the times. Record the number of seconds the subject can hold up to a maximum of 20 seconds. Stop timing when the subject moves hands off of hips or puts a foot down. Make sure the subject looks at a non-moving target 4-12 feet ahead. Repeat on other side. 4. COMPENSATORY STEPPING CORRECTION-FORWARD Stand in front of the subject with one hand on each shoulder and ask the subject to lean forward (Make sure there is room for them to step forward). Require the subject to lean until the subject’s shoulders and hips are in front of toes. After you feel the subject’s body weight in your hands, very suddenly release your support. The test must elicit a step. NOTE: Be prepared to catch subject. 5. COMPENSATORY STEPPING CORRECTION - BACKWARD Stand behind the subject with one hand on each scapula and ask the subject to lean backward (Make sure there is room for the subject to step backward.) Require the subject to lean until their shoulders and hips are in back of their heels. After you feel the subject’s body weight in your hands, very suddenly release your support. Test must elicit a step. NOTE: Be prepared to catch subject. 6. COMPENSATORY STEPPING CORRECTION- LATERAL Stand to the side of the subject, place one hand on the side of the subject’s pelvis, and have the subject lean their whole body into your hands. Require the subject to lean until the midline of the pelvis is over the right (or left) foot and then suddenly release your hold. NOTE: Be prepared to catch subject. 7. STANCE (FEET TOGETHER); EYES OPEN, FIRM SURFACE Record the time the subject was able to stand with feet together up to a maximum of 30 seconds. Make sure subject looks at a non-moving target 4-12 feet away. 8. STANCE (FEET TOGETHER); EYES CLOSED, FOAM SURFACE Use medium density Temper® foam, 4 inches thick. Assist subject in stepping onto foam. Record the time the subject was able to stand in each condition to a maximum of 30 seconds. Have the subject step off of the foam between trials. Flip the foam over between each trial to ensure the foam has retained its shape. 9. INCLINE EYES CLOSED Aid the subject onto the ramp. Once the subject closes eyes, begin timing and record time. Note if there is excessive sway. 10. CHANGE IN SPEED Allow the subject to take 3-5 steps at normal speed, and then say “fast”. After 3-5 fast steps, say “slow”. Allow 3-5 slow steps before the subject stops walking. 11. WALK WITH HEAD TURNS- HORIZONTAL Allow the subject to reach normal speed, and give the commands “right, left” every 3-5 steps. Score if you see a problem in either direction. If subject has severe cervical restrictions allow combined head and trunk movements. 12. WALK WITH PIVOT TURNS Demonstrate a pivot turn. Once the subject is walking at normal speed, say “turn and stop.” Count the number of steps from “turn” until the subject is stable. Imbalance may be indicated by wide stance, extra stepping or trunk motion. 13. STEP OVER OBSTACLES Place the box (9 inches or 23 cm height) 10 feet away from where the subject will begin walking. Two shoeboxes taped together works well to create this apparatus. 14. TIMED UP & GO WITH DUAL TASK Use the TUG time to determine the effects of dual tasking. The subject should walk a 3 meter distance. TUG: Have the subject sitting with the subject’s back against the chair. The subject will be timed from the moment you say “Go” until the subject returns to sitting. Stop timing when the subject’s buttocks hit the chair bottom and the subject’s back is against the chair. The chair should be firm without arms. TUG With Dual Task: While sitting determine how fast and accurately the subject can count backwards by threes starting from a number between 100-90. Then, ask the subject to count from a different number and after a few numbers say “Go”. Time the subject from the moment you say “Go” until the subject returns to the sitting position. Score dual task as affecting counting or walking if speed slows (>10%) from TUG and or new signs of imbalance. So what do we do about it?? what to do about it: APTA position statement (Avin et al PTJ 2015) Key ingredients •Salient! •Social •Strengthening •Safe! •Skillful (Challenging!) •Super Fun! Strength training: progression is key •Minimum requirement for “healthy” older adults •2 or more nonconsecutive days a week •1 set each 8-10 exercises, resistance to allow 10-15 reps •Progress by # of sets •Increase resistance from 15 RM to 10 RM (Peterson & Gordon, Am J Med 2011, Raymond et al Arch Phys Med Rehabil 2013-meta) Which exercises, exactly? •“Whole body”, body weight to machines to free weights •Often quoted or tested: Leg press, knee extension, lat pull, chest press The basics: Otago Program Example: otago Program don’t forget core strength •small but significant association with fall risk •Core strength or Pilates based programs can be an effective adjunct (Granacher et al Sports Med 2013) Resources required for postural stability and orientation Biomechanical constraints Sensory strategies Control of Dynamics Orientation to Gravity Cognitive Processing Movement Strategies Horak 2006 37 What about cognition? •Impairments in dual tasking and executive function increases fall risk (Coppin et al Age Aging 2006, Hsu et al Osteoporosis Int 2012, Shumway-Cook, Motor Control 2007) •Does dual task training help reduce fall risk? •Not enough conclusive evidence yet (Agmon et al Clinical Interventions in Aging 2014) pragmatic two prong strategy •Don’t dual task when you can avoid it! •Dual task training and extinguishing “posture second” strategy •Fun! The rehab merits of dual tasking with tongue twisters? •seventy-seven benevolent elephants •You know New York, you need New York, You know you need unique New York •Challenges response monitoring, attentional vigilance, response inhibition! Parting thoughts If you are afraid you will fall, it’s tempting to not walk at all, but stay strong and stay fit, and for gosh sakes don’t sit! Get out, get moving, and stand tall!