Holly: Thank you, everyone, for joining me today to discuss a very relevant topic for the older adult population.
Introduction
- Fall defined: An unexpected event in which the participants come to rest on the ground, floor, or lower level (Lamb, Jørstad-Stein, Hauer, & Becker, 2005)
- Recurrent falls: More than 1 fall in a given period of time (usually 12 months) (Palmer & Watkins, 2017)
- The cause is only clear in ~15% of cases; otherwise “idiopathic” (Barban et al., 2017)
- Falls in older adults are seldom due to a single cause (Palmer & Watkins, 2017)
A fall is an unexpected event in which the participant comes to rest on the ground, floor, or lower level. Recurrent falls are defined as more than one fall in a given period of time, usually 12 months. Using this definition, approximately 15% of people over the age of 65 are recurrent fallers, and according to Barban et al., the cause of a fall is only clear in about 15% of those cases. For example, these are falls due to syncope, neurological disease, vestibular deficits, muscular weakness, or vision impairment. All other falls are idiopathic. It also is important to know that falls in older adults are seldom due to one single cause so this makes an assessment of fall risk and implementation of fall prevention and intervention strategies very important.
In community-dwelling older adults, falls typically occur during regular activities and involve situational hazards, like stumbling on uneven ground, getting on and off of an escalator or elevator, walking on a slippery floor, or tripping over an obstacle at home or outdoors. In nursing home residents, falls may involve environmental hazards, but more often are associated with what Palmer and Watkins (2017) call an uncontrolled transfer from the bed to a chair or from sitting to standing. Mobility restrictions due to lower extremity weakness, balance, proprioception deficits, and gait impairments contribute to falls in the institutionalized elderly population.
- Fall injuries cost >$50 billion in 2015
- 800,000+ people per year are hospitalized due to a fall injury
- Fall injuries are among the 20 most expensive medical conditions
http://www.cdc.gov/homeandrecreationalsafety/falls/fallcost.html
According to the CDC, the total cost of falls in the United States was more than $50 billion in 2015, with Medicare and Medicaid paying 75% of these costs. Over 800,000 people are hospitalized per year because of an injury from a fall. Most often this is a hip fracture or a head injury. Fall injuries are among the 20 most expensive medical conditions in the United States. Mary Tinetti, a name that many of you will recognize, describes the fear of falling as a lasting concern about falling that leads to an individual avoiding activities that he or she remains capable of performing. Tinetti goes on further to explain that an operationalized fear of falling as being a loss of self-efficacy or confidence to perform certain activities without falling. Following a fall, older people often voluntarily restrict their activity fearing another fall. This reduction in exercise and activity leads to further weakness and decreased mobility, which increases the risk of another fall.
According to the World Health Organization, both fallers and non-fallers alike can find themselves in this vicious cycle (Figure 1), where the fear of falling leads to inactivity and social isolation. This in turn can cause deconditioning and functional decline exacerbating a fall risk.
Figure 1. Fear of falling vicious cycle. (O’Halloran et al., 2011; WHO, 2004)
Now that we have briefly defined falls, let's move on to our focus for today.
Screening
We need to prevent falls by mitigating and managing risk. Step one is screening.
- Screen to determine if a multifactorial assessment is necessary or not
- “Have you fallen in the previous 12 months?”
- “Do you have difficulty with your balance or with walking?”
- For each person who reports a fall or reports difficulty with walking/balance, observe gait and balance
- The screen is positive if the individual reports multiple falls regardless of balance/gait OR he/she reports one fall and balance/gait impairment is observed
(Avin et al., 2015)
All older adults that we are going to define today are over the age of 65. They should be screened for fall risk to determine if a multifactorial fall risk assessment is necessary or not. A screen can be completed very easily, simply by asking the questions, "Have you fallen in the previous 12 months?" and "Do you have difficulty with your balance or with walking?" For each individual who reports a fall or reports difficulty with walking or balance, the therapist should then observe their gait and balance. According to Avin et al. (2015), a screen is considered positive if the individual reports multiple falls in the past 12 months (regardless of any deficit with gait or balance) or if they report one fall and a gait or balance impairment is observed by the therapist. If the screen is positive, then a complete multi-factorial fall risk assessment should be completed to ensure all potential deficits are identified and can be addressed.
Fall Risk Assessment
- Medication review
- Medical history
- Impairments/functional deficits – strength, balance, cognition, dizziness, vision
- Activity and participation – gait/ambulation, ADL
- Environmental factors – hazards, home safety
- Personal factors – fear, health perception
(Avin et al., 2015; Hartley & Kirk-Sanchez, 2013)
You will notice the items listed on this slide are not only part of a comprehensive fall risk assessment, but they are also part of a comprehensive occupational therapy evaluation. When your patient has a positive fall risk screen, you will want to be sure to cover all of the potential risk areas during your initial evaluation.
The patient's medications should be carefully reviewed. The use of multiple medications concurrently should be specially noted. Polypharmacy typically means taking five or more medications, and as demonstrated in a large longitudinal study in England by Dhalwani et al. (2017), older adults who took five or more medications had a 21% higher rate of falls, and this increased to a 50% higher rate if they took 10 or more medications. In addition, during your medication review, pay close attention to antihypertensives, antidepressants, benzodiazepines, and opioids as these classifications of medications are associated with an increased risk of falls.
Review the patient's medical history with an emphasis on new or unmanaged risk factors for falls such as osteoporosis, depression, and cardiovascular function. In particular, the assessment of blood pressure and postural hypotension is essential. Postural hypotension can be defined as a decrease of 20 millimeters of mercury in systolic blood pressure, or 10 millimeters of mercury in diastolic blood pressure with a change in position. A history of a stroke, Parkinson's Disease, or other neurological impairment are independent risk factors for falls and should be noted.
Strength, balance, cognition, dizziness, and vision should also all be carefully assessed. Hartley and Kirk-Sanchez (2013) recommend using a functional strength test, like the Five Times Sit-to-Stand Test (5TSTS) or the 30 Second Chair Stand Test as a measure of functional strength. They note that the inability to perform the 5TSTS more than doubles the risk of falling in high-risk older adults. From a balance perspective, people who cannot stand on one foot for at least five seconds are at significantly greater risk for injurious falls than those who can stand longer than five seconds.
From an activity participation perspective, ambulation and ADL performance should also be assessed. Does the patient use an assistive device or adaptive equipment, and if so, does he or she use it correctly and consistently? Does the patient require assistance with activities of daily living and if so, how much?
Assess the environment for safety and potential hazards. This applies both to the home environment and the environment where the patient currently finds him or herself, whether that be in the hospital, a rehab facility, or a nursing home. We will talk a bit more about home assessment in a few minutes.
Finally, consider personal factors such as the patient's perceived functional ability and the fear of falling. It is important to recognize the relationship between the fear of falling and balance confidence to function. Patients who are fearful of falling or who are not confident in their ability to perform certain activities display deficits in balance and function. Fall risk factors are often divided into intrinsic or internal, and extrinsic or external. Depending on the source, these lists can vary a little. This list is from the CDC's STEADI program, Stopping Elderly Accidents, Deaths, and Injuries.
- Intrinsic
- Age
- Previous falls
- Muscle weakness
- Gait/balance problems
- Poor vision
- Postural hypotension
- Chronic conditions
- Fear of falling
Intrinsic risk factors include things like age, previous falls, muscle weakness, gait and balance problems, poor vision, postural hypotension, chronic conditions, and fear of falling.
- Extrinsic
- Dim lighting/glare
- Lack of handrail/grab bars
- Obstacles/tripping hazards
- Slippery/uneven surfaces
- Psychoactive meds
- Improper use of a device
Extrinsic factors include things like dim lighting or glare, the lack of handrails or grab bars, obstacles and tripping hazards, slippery or uneven surfaces, psychoactive medications, and the improper use of devices. Per the World Health Organization Europe's Health Evidence Network, intrinsic factors are more important among people 80 years old and older, and falls among older adults under the age of 75 are more likely to be due to extrinsic factors. Several studies have shown that the risk of falling for both community and residential care dwellers increases exponentially as the number of risk factors increases. In addition to the elements of the risk assessment that we just discussed, which truly are elements of a comprehensive therapy evaluation, a fall risk assessment tool should be used to help clarify not only the level of risk but also the specific deficit areas to be addressed during treatment. In choosing a tool, you want to be sure that it applies to your patient population. There are tools that are intended to be used for community-dwelling older adults, and there are tools that are better suited for those in a nursing home or other residential care facility. The test will not give you the information you need to successfully treat your patient if it does not directly apply to your patient. For example, using the Berg Balance Scale or the Timed Up and Go would not be appropriate for a patient who cannot stand or ambulate without significant assistance, or for a patient who is wheelchair-bound. Using a test intended for community-dwelling adults who live alone and participate in social activities outside the home, like the Survey of Activities and Fear of Falling in the Elderly (SAFE) or potentially the Dynamic Gait Index, would likely not be appropriate for a resident of a nursing home or a home-bound individual who requires the assistance of their spouse for basic ADLs. Also, you'll want to consider whether you should use a self-reported measure or a performance-based measure, or maybe you want to use both. Use the results of your evaluation to help you determine which test or tests are likely to help you identify and quantify risk and to clarify the patient's specific deficit areas so that you can effectively focus your treatment interventions.
Self-reported Assessment Tools
Self-reported tools focus on fear or falling, balance confidence, or self-efficacy, and fear avoidance behavior, or activity curtailment. Self-reported unsteadiness is independently associated with increased fear of falling, fear-related activity restriction, recurrent falls, and disability, and should be included in the routine assessment of older adults, especially those at risk for falls. There are several self-reported assessment tools available, a few of which I want to mention today.
Falls Efficacy Scale (FES) and the Falls Efficacy Scale-International (FES-I) (Tinetti, 1990; Yardley et al., 2005)
This tool has been validated cross-culturally, and it can be used for patients with and without cognitive impairment and for those with Parkinson's Disease. It has been translated into multiple languages. The FES-I is a great test for home health patients as it includes home activities. The original Falls Efficacy Scale (FES) was developed by Mary Tinetti in the 1990s. It included 10 items, with each item being rated zero to high and looked at low to high self-efficacy or confidence when performing various tasks. The FES-I has 16 items. Instructions for both tests are as follows. On a scale from one to 10 with one being very confident and 10 being not confident at all, how confident are you that you could do the following activities without falling? The activities include things like taking a bath or shower, reaching into cabinets or closets, walking around the house, and getting dressed and undressed. The FES-I also added items like visiting your friends and relatives, going out to a social event, and going up and down stairs. The FES-I is scored between 16 and 64 points, with scores ranging from 28 to 64, equating to a high risk for falls.
The Activities-Specific Balance Confidence Scale (ABC) (Powell & Myers, 1995)
The Activities-Specific Balance Confidence Scale, or ABC, is a pretty well-known self-reported test of balance and fall risk. It measures the patient's level of confidence with performing certain activities on a scale of zero to 100% confidence. The questions begin with how confident are you that you will not lose your balance or become unsteady when you walk around the house, go up and down stairs, bend over to pick up a slipper from the front of the closet floor, sweep the floor, and get in and out of the car just to name a few. A score of 67 is the cut-off for fall risk, and a score in the mid-80s indicates the individual is at a high functional level. A cut-off score designates the score that represents either a positive or a negative outcome for a given test. In this case, the outcome is a high falls risk.
Survey of Activities and Fear of Falling in the Elderly (SAFE) (Lachman et al., 1998)
The Survey of Activities and Fear of Falling in the Elderly, or SAFE, sometimes called the S-A-F-F-E, examines 11 ADLs, IADLs, and social activities. It examines whether the individual is worried about a fall within these activities. It also asks if the individual does certain activities more, the same, or less than he or she used to five years ago. Some of the initial questions ask the individual if they go to the store, prepare simple meals, take a tub bath, get out of bed, take a walk for exercise, and reach for something over their head. And if the individual answers yes to performing the activity currently, the test then looks at how worried they are completing those tasks. For example, "When you prepare simple meals, how worried are you that you might fall?" The individual rates their level of worry on a one to four scale, where one is very worried and four is not at all. If the individual says they do not perform the activity, you ask if that is because they are worried they will fall. You also have an opportunity to explore other possible reasons that they do not perform a given activity. Finally, the interviewer asks about past activities. For example, "When compared to five years ago, would you say you prepare simple meals more, about the same, or less than you used to?" There are several indicators that can be obtained from the SAFE: their activity level, activity avoidance level, and a fear score.
