Denise Winters

Pima Medical Institute

PTA-490 Professional Capstone

Mary Jo Rodriquez

May 9, 2015

Who?

According to CDC and Prevention:

One third of people 65 and older fall each year.

Less than half of those who fell talked to their

healthcare provider about it.

1 out of 5 falls causes a serious injury such as a

head trauma or fracture.

(see handout #1)

Unintentional Falls

Males: Unintentional Falls

Females: Unintentional Falls

Age: 65-74 Age: 75-84 Age: >85

168,369 196,573 119,797

Age: 65-74 Age: 75-84 Age: >85

326,598 445,894 384,738

Evaluations are Needed

Nonfatal, >65 years Falls

Overexertion

Struck by or against

Cut/pierced

Natrual/environmental

Motorvehicle traffic

occupant

Other unspecified

Falls Related to Animals

Falls are the leading cause of nonfatal injuries in the United States. In 2006, nearly 8 million persons were treated in emergency departments (EDs) for fall injuries.

An estimated average of 86,629 fall injuries each year were associated with cats and dogs, for an average annual injury rate of 29.7 per 100,000 population.

CDC-MMWR. Nonfatal Fall-Related Injuries Associated with Dogs and Cats – United States, 2001-2006. Information retrieved from: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5811a1.htm

Why? Falls among older adults, unlike other ages tend to occur from

multifactorial etiology such as acute and chronic illness, and

medications. Because the rate of falling increases proportionally

with increased number of pre-existing conditions and risk factors,

fall risk assessment is a useful guideline for practitioners.

• Discover the underlying etiology of why a fall occurred

• Follow up with a comprehensive post-fall assessment.

Fall risk assessment and post-fall assessment are two interrelated,

but distinct approaches to fall evaluation, both recommended by

national professional organizations.

(see handout #2

Communication The goal in therapy is the suggestion to the aging adult to stay active and maintain as much of their previous lifestyle as possible; however, modification will be required to prevent a fall injury secondary to the patients inability to recognize their own declining cognitive state.

Communication is important too. Therefore, the next handout available provides information to help that communication process happen between the healthcare provider and the patient.

(see handout #3)

Barbara Fischer – Declining Cognition and

Falls: Role of Risky Performance of Everyday

Mobility Activities

- Fischer’s team examined 245 individuals with a mean age of 79 years of age that still lived independently in their own homes.

- There were a total of 500 individuals selected for the study; they were divided in half (controlled group and an intervention group).

- They used tools such as interviewing and in-home assessment data to determine if the individuals were a fall risk while performing mobility-related activities of daily living.

-This research data was collected over a one year span.

Screening and Assessment

The examining tests that were performed during the

examination included a Depression Scale, Rhomberg

Test, relative balance, Modified clinical test of

sensory interaction, and a balance portion of the Berg

Balance Scale, Tinetti Performance-Oriented

Mobility Assessment-gait test, Dynamic Gait Index,

and a Timed "Up & Go" test with and without a

cognitive task.

Martina Mancini Studied Relevance

An in-depth look into the basic balance system was

performed by Mancini (2010, June). The research of

Mancini et. al. discusses the basic balance system of

maintenance of postural alignment in all positions,

activation of voluntary movement when transitioning

between postures, and reactive time when an external

force is applied.

Relevance The primary reasons for a clinical evaluation of balance are:

1) does a balance problem exists;

2) determining the underlying cause of the balance issue.

Mancini (2010, June) provided a research document that is a quick reference table providing a brief look at common balance tests that are used in the clinical setting already.

(see handout #4)

Which is the Bestest tool? This research article identifies a common complaint that Physical Therapists have when testing a patients' balance. The patient clearly needs continued balance therapy to be safe, however, they "ceiling" out on the basic balance tests.

This makes it difficult for a therapist to validate to the doctor or insurance company that continued care is needed. Without incurring the expensive cost of purchasing a Posturography for advanced testing, Mancini et. al. developed the BESTest balance test. There is a short and long version to the test.

(see handouts 5 & 6)

Functional, Affordable, Valid,

Reliable, and Sensitive

The ceiling affect was depicted in a study performed

by Leddy (2011, January) where she evaluated the

reliability, validity, sensitivity, and specificity for

identifying individuals with Parkinsons Disease who

fall.

Continued….

Leddy et. al. tested the Berg (BBS), Functional Gait

(FGA), and the BESTest on 80 individuals with

Parkinsons Disease (PD).

- The study concluded that the FGA and FGA were

the most reliable and indicated the most validity for

assessing patients with PD.

- The study indicated that PD comes in all stages and

degrees of progression and is no different than most

with any kind of balance/proprioception issues.

- The study determine that these two specific tests can

validate the need for early intervention with a patient

that is a risk for falls, however, is in early stages of

PD

Integrating Fall Prevention into the

Practice

As a team of healthcare professionals, we all work together and assess our patients for improvement, gains, and losses. However, we can also help reduce falls by screening the older population for previous falls or balance problems.

The handout provided next will provide helpful ways to integrate this system into the clinic setting.

(see handout #7)

Fall Risk Assessment &

Interventions

The next handout is a simple graph that helps identify when it

would be an appropriate time to intergrade additional risk

assessment tools, such as the “BESTest Test” and the “Cognitive

Questionnaire Screening Tool.”

(see handout #8)

Conclusion

Ask about falls

Ask how often

Ask if walking is difficult

Patients that have suffered multiple falls within a year should have a fall risk assessment performed

Patients suffering from a single fall in the last year should be assessed for gait and balance.

If the patient performs poorly on the gait test, they should have a fall risk assessment.

For a full list see handout #9

References Abigail L. Leddy, B. E. (2011, January). Functional Gait Assessment and Balance Evaluation System Test:

Reliability, Validity, Sensitivity, and Specificity, for Identifying Individuals With Parkinson Disease Who Fall.

Journal of the American Physical Therapy Association, pp. Vol 91, No. 1, pgs. 102-113.

Anne Shumway-Cook, M. B. (1997, August). Predicting the Probability for Falls in Community-Dwelling

Older Adults. Physical Therapy, Journal of the American Physical Therapy Association, pp. Vol. 77 No. 8 pgs.

812-819.

Barbara L. Fischer, C. E. (2014, March). Declining Cognition and Falls: Role of Risky Performance of

Everyday Mobility Activities. Journal of the American Physical Therapy Association, pp. Vol. 94, No. 3, pgs

355-362.

Centers for Disease Control and Prevention. National Center for Injury Prevention and Control (2014).

www.cdc.gov/injury/STEADI

Diane M. Wrisley, M. L. (2003, October). Reliability of the Dynamic Gait index in People with Vestibular

Disorders. Physical Medicine and Rehabilitation, pp. Vol. 84, Issue 10, pgs. 1528-1533.

Horak, M. M. (2010, June). The relevance of clinical balance assessment tools to differentiate balance deficits.

NIH Public Access. Eur J Phys Rehabil Med., pp. vol 46 No. 2: pgs 239-248.

Sara B. Vyrostek, J. L. (2004, September). Surveillance for Fatal and Nonfatal Injuries - United States, ,2001.

Morbidity and Mortality Weekly Report - Surveillance Summaries -MMWR, pp. Vol. 53/ SS-7 1-57.

Steffen T, Seney M. Test-retest Reliability and minimal detectable change on balance and ambulation tests, the

36-item short-form health survey, and the unified Parkinsons disease rating scale in people with parkinsonism

[erratum in Phys Ther. 2010;90:462]. Phys Ther. 2008;88:733-746