Physical Therapy & An Interprofessional Approach to Falls ...Increased fall risk was associated with increasing frequency of nocturnal enuresis worse lower limb function, worse upper

Physical Therapy & An Interprofessional Approach to Falls & Balance Screening

Presenters: Thomas Dillon PT, DPT

Teri Elliott-Burke PT, MHS, WCS, PRPC

2018 CONFERENCE & EXPO

• Participants Will:▪ Be Proficient in 3 tests to assess a patient’s risk for

falling

▪ Be aware of the APTA Clinical Guidance Statement and the CDC Algorithm to assess and formulate recommendations to address falls risk

▪ Understand 5 tools utilized by an interprofessional team (Occupational Therapy, Pharmacy, Family Medicine, Behavioral Medicine, and Optometry) to screen for falls

Material presented at IPTA 2018 REVITALIZE Conference

Objectives

I. IntroA. StatsB. Overview of Resources

a. Clinical Guidance Statementb. CDC STEADI

II. The MWU Multifactorial ScreenA. Family MedB. Behavioral MedC. Occupational TherapyD. OptometryE. PharmacyF. Physical Therapy

III. Physical Therapy Interventions for FallsIV. Case StudiesV. Final ThoughtsVI. Q&A


Outline

Title


Statistics – Older Adults ≥ 65(46 million) - CDC

Falls are the leading cause of fatal & nonfatal injuries 2014 survey

• 29 million falls o 7 million injurieso 27,000 diedo 2.8 million treated in ERo 800,000 hospitalized

• Annual Medicare cost – for non-fatal falls - $31.3 billion


• 2015

▪ Fatal Falls - $637.2 million

• $282.2 million for men

• $355.0 million for women

▪ Non-Fatal Falls – $31.3 billion

• $9.0 billion men

• $22.2 billion women

▪ Average cost of a medically treated fall = $9780


Costs of Falls

Over half of the older adults don’t discuss their fall with a health care

provider


We Need to Ask

• Management of Falls in Community-Dwelling Older Adults: A Clinical Guidance Statement from the Academy of Geriatric Physical Therapy of the American Physical Therapy Association (Alvin et al., 2015)

• Reviewed 3 CPGs

▪ NICE (National Institute for Health & Care Excellence) 2014, 2011

▪ American Geriatrics Society/British Geriatrics Society (AGS/BGS) 2001, 2010

▪ Moreland et al., 2003


Clinical Guidance Statement

• Stopping Elderly Accidents, Deaths, & Injuries (STEADI)

• Tool Kit developed by the US Preventive Services Task Force

• https://www.cdc.gov/steadi/index.html


CDC - STEADI

https://www.cdc.gov/steadi/index.html


CDC – STEADI


• Falls are preventable

• Loss of independence

• American & British Geriatric Societies recommend a multifactorial approach to prevent falls


Other Considerations

• MACRA - The Medicare Access and CHIP Reauthorization Act of 2015▪ MIPS - Merit-based Incentive Payment System

• Quality Measures for Falls Risk and Falls Plan of Care

• How are the MDs, DOs, PA, NPs you work with measuring this?

• Currently PTs are not required to report

• Life changes in 2019


Other Considerations

• Supported by a MWU Geriatric Education and Research Facilitation Grant

• Primary Investigator – Timothy Hanke, PT, PhD

• Based on the CDC STEADI Guidelines

• Subjects 65+

• Subjects received a summary to give to their PCP

▪ Highlighted areas to address to prevent falls

• Took place in Oct 2016 & July 2017


The MWU Multifactorial Screen

• Family Medicine

• Behavioral Medicine

• Occupational Therapy

• Optometry

• Pharmacy

• Physical Therapy


Interdisciplinary Team

• Focus: Cardiovascular Disease & Stroke

• Orthostatic Blood Pressure Protocol

▪ Postural Hypotension

▪ FAST test to evaluate educate on warning signs of stroke


Family Medicine

• With the exception of initial orthostatic hypotension, measures of impaired orthostatic BP recovery (delayed recovery OH or sustained ortho-static hypotension OH) are independent risk factors for future falls, unexplained falls, and injurious falls. (Funucane et al., 2017)

• Grade A Recommendation by American Geriatric Society/British Geriatric Society CPG (Avin et al., 2015)

▪ Cardiovascular functions including postural hypotension

• The presence of untreated & uncontrolled HTN is associated with orthostatic hypotension (Zia, Kamaruzzaman,

& Tan, 2015)


Evidence for Postural Hypotension

1. Have the patient lie down for 5 minutes.

2. Measure blood pressure and pulse rate.

3. Have the patient stand.4. Repeat blood pressure and

pulse rate measurements after standing 1 and 3 minutes.

Abnormal:

• A drop in systolic BP of ≥20 mm Hg, or in diastolic BP of ≥10 mm Hg

• Experiencing lightheadedness or dizziness is considered abnormal.


Postural Hypotension

• Clinical Guidance Statement – HR, BP, and postural hypotension can be conducted by a PT

• When would each be appropriate?


Implications for PTs

• Focus: Cognitive impairment, depression & anxiety

• Mini-Cog

• Geriatric Depression Scale

• Geriatric Anxiety Inventory Short Form


Behavioral Medicine

• Depression is:▪ an independent risk factor for falls ▪ associated with cognitive deficits, affecting executive function

and processing speed.▪ related to psychomotor slowing & gait disturbances

• The interaction between depression & falls may be self-perpetuating.

• Fear of falling (anxiety) is also a factor.(Iaboni & Flint, 2013)

• Moreland CPG – depression as a risk factor, recommend Geriatric Depression Scale (Avin et al., 2015)


Evidence for Behavior Med

Mini -Cog


Mini-Cog




When would a PT administer these scales?


• Anti-depressants may also impair postural control & increase postural sway.

• Older adults are at highest risk of falls & fractures shortly after starting SSRI antidepressants but break bones at a higher rate throughout their treatment.

• Cognitive behavioral therapy should be implemented to address fear of falling and overall depression.(Iaboni & Flint, 2013)



• Focus: Home Environment

• 64 items, 9 areas of the home

• Offers solutions and advice for each area

• Risk is summed for each area and totaled

• Raises awareness of home hazards


Occupational Therapy


• Remove scatter rugs

• Eliminate clutter on floor surfaces by placing them on shelves or storage

• Consider donating or throwing out items no longer used

• Run your cords behind furniture

• Increase wattage to allowable limits

• Add lamps

• Add a pillow or cushion to raise the height of the chair

• Use the clapper


Solutions for Problems in the LR

• 26% reduction in injury rate caused by falls to a home modification intervention. (3 yr period, 842 households) (Keall et al., 2015)

• AGS/BGS, Moreland and NICE CPGs recommend an assessment of the home for hazards, specifically loose rugs, mats, carpet folds and other trip hazards. (Avin et al., 2015)


Evidence for Occupational Therapy


When Would You Use the HSSAT?

Implications for PT

• Focus: Vison

• Visual Acuity

▪ Distance Vision Right & Left

• Peripheral Vision

• Contrast Sensitivity


Optometry


Optometry

• Vision▪ Plays a role in stabilizing balance by providing the nervous system with

information▪ 20-70% increased postural sway with eyes closed▪ Poor contrast sensitivity & depth perception increases postural sway

• Glasses▪ Outdated prescriptions ▪ Multifocal glasses ↑ risk for falls(Lord, 2006)

• WHI – cataract surgery associated with reduced odds of 1-2 year fall frequency, especially in women 70-80 years old (Tseng et al., 2015)

• AGS/BGS recommends an assessment of visual acuity (Avin et al, 2015)


Evidence for Optometry


What Would You Do With This Information?

Implications for PT

• Focus: Medications, Polypharmacy

• Reviewed list of medications


Pharmacy


• Lists of potentially inappropriate medications to

be avoided in older adults

• Lists of select drugs that should be avoided or

have their dose adjusted based on the individual's

kidney function and select drug–drug interactions

documented to be associated with harms in older

adults.

(Radcliff et al., 2015)

Beers Criteria

• Medications that impact falls:

▪ Sedatives & Hypnotics

▪ Antidepressants – tricyclic antidepressants, selective serotonin reuptake inhibitors & serotonin norepinphrinereuptake inhibitors

▪ Polypharmacy (6 of 14 studies positive)

▪ Anithypertensives – calcium channel blockers, beta-blockers, angiotensin system blockers (mixed results)

(Park, Satoh, Miki, Urushihara, Sawada, 2015)


Evidence for Pharmacy


What Do We Do With This Information?

Implications for PT

• Focus: Balance, Mobility, Strength & Urinary Incontinence

• Timed Up & Go Test

• 30-Second Chair Stand

• Tandem Stance

• Urinary Incontinence Questionnaire


Physical Therapy

• •Mobility: All 3 CPGs recommend muscle weakness as risk factors, with AGS/BGS and Moreland CPGs suggest specifically LE strength:• CDC recommends 30-Sec Chair Stand test

• •Balance: All 3 CPGs recommend a balance assessment, however not specifically which ones.• CDC recommends: Tandem Stance Test

• •Gait: All 3 CPGs state gait deficits increase risk for falls and recommend assessment• CDC recommends: TUG Test

• •Urinary Incontinence: All 3 CPGs recommend assessment, with NICE recommending specifically identifying urge and stress incontinence.• CDC recommends: Urinary incontinence questionnaire


Physical Therapy


Timed Up and Go Test

• CDC Materials: https://www.cdc.gov/steadi/materials.html

• Combines transfers, gait, dynamic balance, and LE strength.

• Inter- and intratester reliability is high.

• Supported construct validity when compared to gait speed tests, postural sway, Barthel Index, functional stair test, and step frequency.

• Sensitivity and Specificity found to be high: about 87% for both

• General Consensus: Utilize TUG with cluster of exams.

https://www.cdc.gov/steadi/materials.html


30-Second Chair Test


• Related to Five-Times-Sit-to-Stand Test

• Assesses deficits in LE strength, postural control, balance.

• Excellent criterion validity of the chair stand compared to weight adjusted leg press performance

• Consider chair height: many studies use between 42 and 47cm height

• Floor effect?



30-Second Chair Stand


Tandem Stance


• Related to 4-Stage Balance Test

• Assesses narrow base of support balance, static test.



Urinary Incontinence Questionnaire


Urinary Incontinence

• Urge incontinence may increase the risk of falls and fractures by necessitating multiple urgent trips to the bathroom, especially during the night.

• Brown et al. (2000):▪ "weekly or more frequent urge incontinence independently increased the

risk of falls by 26% and the risk of fractures 34%."▪ Stress incontinence was not significantly associated with risk of

falls or fractures.

• Pahwa et al (2016)▪ Increased fall risk was associated with increasing frequency of nocturnal

enuresis worse lower limb function, worse upper limb function and worse performance on a composite physical performance test of strength, gait and balance.

▪ Women with nocturnal enuresis had significantly lower physical performance test scores than women without nocturnal enuresis


Summary of Findings to Primary Care Physician

Findings Recommendations

FAMILY MEDICINE

Orthostatic Vitals

Pulse BPLying

Sitting

Standing

Orthostatic Hypotension Yes No

If yes, follow up with primary care physician

No action required

BEHAVIORALMEDICINE

Measure Score Discuss findings with your primary care provider regarding

need for further evaluation of symptoms of:

Anxiety Depression CognitionReview Psychoeducational Handout

Other ______________________________

No action required

Geriatric Anxiety

Inventory

Short Form

Geriatric Depression

Scale-5 item

Mini-Cog

OCCUPATIONALTHERAPY

____# of identified items on the Home Safety

Self-Assessment Tool (HSSAT)

Please consider:

Please continue to:

No action required


Summary of Findings for Falls Screening

OPTOMETRY

Distance vision (right eye)

__________

Distance vision (left eye)

__________

Peripheral vision: Normal

Limited

Contrast sensitivity: Normal

Impaired

Follow-up with eye care provider within

1 week

6 months

1 year

Other

No action required

PHARMACY

____ (#) out of your total _____

medications were found on your

medication list which may increase

your potential fall risk

Provide the medication summary sheet to your

primary care or family medicine physician to discuss

and review alternative medication options and or

safety precautions.

No action required


Summary of Findings for Falls Screening

• Screened 24 participants in Oct 2016

• 71% Female

• 88% Caucasian

• 83% completed education beyond HS

• All independent living

• 83% with history of falls

• 58% married, 16% single, 13% divorced, 13% widowed


Results

• Knowledge of falls improved

▪ 8.5/10

• Confidence to prevent falls

▪ 8.46/10

• Decreased fear of falling

▪ 7.09/10

• Implement recommendations

▪ 8.67/10


Results

• 87.5% found the event either very or extremely valuable

• 12.5% found the event moderately valuable

• 100% found the event very or extremely enjoyable

• 100% found the screeners made them feel very comfortable


Results


• Additional PT Balance Evaluation Tools

▪ Berg Balance Scale• Assess functional mobility and non-vestibular balance

• Consider ceiling effects

• MDC: 8 points

• <45/56 = high fall risk, < 40/56 is 100% risk for falls.

▪ Tinetti• Assess functional mobility, static balance, and gait

• Consider ceiling effects

• MDC: 4 points.

• < 18/28 is high fall risk


Additional PT Balance Evaluation Tools

• Additional PT Balance Evaluation Tools

▪ Dynamic Gait Index• Assess functional mobility, vestibular/non-vestibular balance, and

gait.

• Consider ceiling effect, especially with vestibular function

• MDC: 3 points

• <19/24 fall risk

▪ Self-report fall questionnaire: Activities-Specific Balance Confidence Scale (ABC scale).

▪ Footwear assessment: CPGs do not provide specifics.


Additional PT Balance Evaluation Tools

• Utilize clinical judgement when deciding to screen individual in your clinic.

• Utilize framework of this interprofessional screen for individualized screens at your clinic▪ Many assessment tools available to tailor your fall risk screen

• Utilize information gathered from individual screening to justify initial or continued care.

• Develop close network of healthcare professionals that can be referral sources or targets for fall risk factors outside scope of PT.▪ Marketing?


Individualized Screen

• Parameters for balance training/fall prevention not well established (2011 meta-analysis by Sherrington et al)

▪ "moderate to high challenge"

▪ Reduce base of support

▪ Reduce need for UE support

▪ Longer time period (minimum 3 months) or equilivant of 50 hours

• Utilizing rubber balance pad (uneven surface) with older adults effective to improve balance 2 months earlier than with stable surface exercise (Hirase et al).

▪ Example of exercise routine.


Physical Therapy: Treatment Options

• Group balance training can reduce direct medical cost for individuals with possible added benefit of convenience, peer support, and social interaction.

▪ Group balance training more effective in decreasing fall freq compared to no treatment.

▪ No significant difference between group balance training and PT-prescribed HEP.


Physical Therapy: Treatment Options

• Mrs. W: 81 yo female lives alone with son nearby. Recent fall in shower and visit to ER due to mild head contusion. ▪ “Too many falls to count” within the past 1-2 years

• Shower, trip on carpet, “lose balance when turning”, dizziness, etc.

▪ “Old people fall, that’s just how it is”▪ Med hx: hypertension, hyperlipidemia, DM, coronary artery disease,

depression, OA of hips and knees, osteopenia, incontinence, urinary frequency, and macular degeneration

• Med List: ▪ 12 total daily medication: Novolog, Lantus, Lisinopril, Metoprolol,

Spironolactone, Furosemide, Potassium Chloride, Digoxin, Fluoxetine, Clonazepam, Atovastatin, Aspirin

• What additional questions would you ask?• What screening tools would you utilize with this patient?


Case Review: Mrs. W.

• Mr. D is a 60 yo male who presents to PT with primary complaint of wrist pain from fall 5 days ago.

▪ He reports tripping on shoes when going to bathroom at night, falling onto outstretched arm.

▪ No other reported falls

▪ Medication history: metformin and daily vitamin

▪ Medical hx: Type II DM, otherwise unremarkable

• Would you screen for balance deficit/fall risk?

• What screening tools would you utilize/questions you would ask?


Case Review: Mr. D.


What will you implement?

▪1.

▪2.

▪3.


Conclusion


Questions

• American Medical Directors Association. Agency for Healthcare Research and Quality, National Guideline Clearinghouse. (2016) Prevention of fall-related injuries in the elderly. Retrieved from: https://www.guideline.gov/summaries/summary/50433

• Avin K, Hanke T, Kirk-Sanchez N, McDonough C, Shubert T, Hardage J, Hartley G. Management of Falls in Community-dwelling Older Adults: A Clinical Guidance Statement from the Academy of Geriatric Physical Therapy of the American Physical Therapy Association. Physical Therapy 2015. 95(6):815-34. doi: 10.2522/ptj.20140415.

• Burns ER, Stevens JA, Lee R. The direct costs of fatal and non-fatal falls among older adults—United States, Journal of Safety Research. 2016.

• Bergen G, Stevens M, Burns, E. Falls and fall injury among adults aged ≥65 –united states, 2014. Centers for Disease Control & Prevention. Retrieved from: https://www.cdc.gov/mmwr/volumes/65/wr/mm6537a2.htm?s_cid=mm6537a2_w

• Casey CM, Parker EM, Winkler G, Liu X, Lambert GH, Eckstrom, E. Lessons Learned From Implementing CDC’s STEADI Falls Prevention Algorithm in Primary Care. The Gerontologist. 2016. doi:10.1093/geront/gnw074

• Sarmiento, K. & Lee R. STEADI: CDC’s approach to make older adult fall prevention part of every primary care practice. Journal of Safety research (2017), doi.org/10.1016/j.jsr.2017.08.003


References - General

https://www.guideline.gov/summaries/summary/50433

http://www.sciencedirect.com/science/article/pii/S0022437516300172

http://gerontologist.oxfordjournals.org/content/early/2016/04/29/geront.gnw074.full

• HSSAT: https://sphhp.buffalo.edu/rehabilitation-science/research-and-facilities/funded-research/aging/home-safety-self-assessment-tool.html#title_1996957003

• CDC STEADI https://www.cdc.gov/steadi/index.html

• Beers 2015 List http://www.pcihq.com/PCI/images/Broadcast/Beers2015list.pdf

• Rehabilitation Measures Database https://www.sralab.org/rehabilitation-measures


References - Materials

https://sphhp.buffalo.edu/rehabilitation-science/research-and-facilities/funded-research/aging/home-safety-self-assessment-tool.html

https://www.cdc.gov/steadi/index.html

http://www.pcihq.com/PCI/images/Broadcast/Beers2015list.pdf

https://www.sralab.org/rehabilitation-measures

• Brown J. S., Vittinghoff, E., Wyman J. F., Stone K. L., Nevitt, M . C., Ensrud K. E., Grady, D. (2000). Urinary Incontinence: Does it increase falls and fractures? Journal of the American Geriatrics Society, 48, 721-725.

• Finucane, C., O'connell, M. D., Donoghue, O., Richardson, K., Savva, G. M., & Kenny, R. A. (2017). Impaired orthostatic blood pressure recovery is associated with unexplained and injurious falls. Journal of the American Geriatrics Society, 65(3), 474-482. doi:10.1080/00325481.2015.996505

• Iaboni, A., & Flint, A. J. (2013). The complex interplay of depression and falls in older adults: a clinical review. The American Journal of Geriatric Psychiatry, 21(5), 484-492. doi:10.1016/j.jagp.2013.01.008

• Keall, M. D., Pierse, N., Howden-Chapman, P., Cunningham, C., Cunningham, M., Guria, J., & Baker, M. G. (2015). Home modifications to reduce injuries from falls in the Home Injury Prevention Intervention (HIPI) study: a cluster-randomised controlled trial. The Lancet, 385(9964), 231-238. doi:10.1016/S0140-6736(14)61001-0


-General

References – Evidence for Components

• Lord, S. R. (2006). Visual risk factors for falls in older people. Age and ageing, 35(suppl_2), ii42-ii45. doi:10.1093/ageing/af1085

• Park, H., Satoh, H., Miki, A., Urushihara, H., & Sawada, Y. (2015). Medications associated with falls in older people: systematic review of publications from a recent 5-year period. European journal of clinical pharmacology, 71(12), 1429-1440. doi:10.1007/s00228-015-1955-3

• Pahwa, A. K., Andy, U. U., Newman, D. K., Stambakio, H, Schmitz, K. H., Arya, L. A. (2016) Noctural enuresis as a risk factor for falls in older community dwelling women with urinary incontinence. Journal of Urology, 195, 1512-1516.

• Radcliff, S., Yue, J., Rocco, G., Aiello, S. E., Ickowicz, E., Hurd, Z., ... & Beers, M. H. (2015). American Geriatrics Society 2015 updated beers criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 63(11), 2227-2246.



• Steffen, T. M., Hacker, T. A., Mollinger, L. (2002) Age- and gender-related test performance in community-dwelling elderly people: Six-minute walk test, berg balance scale, timed up& go test, and gait speeds. Physical Therapy, 82(2), 128-137.

• Tseng, V. L., Coleman, A. L., Yu, F., Cauley, J. A., Li, W., Thomas, F., & Chlebowski, R. (2015). The association between cataract surgery and falls in the Women’s Health Initiative. Investigative Ophthalmology & Visual Science, 56(7), 2124-2124.

• Whitney, S. L., Wrisley, D. M., Marchetti, G. F., Gee, M. A., Redfern, M. S., Furman, J. M. (2005). Clinical Measurement of Sit-to-Stand Performance in People With Balance Disorders: Validity of Data for the Five-Times-Sit-to-Stand Test. Physical Therapy, 85(10) 1034-1045.

• Zia, A., Kamaruzzaman, S. B., & Tan, M. P. (2015). Blood pressure lowering therapy in older people: does it really cause postural hypotension or falls?. Postgraduate medicine, 127(2), 186-193



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Physical Therapy & An Interprofessional Approach to Falls ...Increased fall risk was associated with increasing frequency of nocturnal enuresis worse lower limb function, worse upper