FALL AND FUNCTIONAL ASSESSMENT GERIATRICGERIATRICGERIATRICGERIATRIC

Falls Falls are a major cause of morbidity and mortality in persons older than 65. Approximately two thirds of injury-related deaths are due to falls. The rate increases with advancing age. Major morbidity from falls includes hip and other fractures and serious soft tissue injuries that require immobilization or hospitalization.

Fall Sequelae A single fall often results in  a fear of falling  loss of confidence to perform ADL  restriction in activities + social isolation + increased dependence on others.  Deconditioning  joint stiffness + muscle weakness  more falls and further immobility.

Risk Factor Identification of significant risk factors is an important step toward fall prevention. Risk factors associated with falls Intrinsic. Extrinsic (environmental). Most falls are multifactorial, the result of multiple intrinsic and extrinsic.

Intrinsic/Physiological Factors 1. Age: incidence of falls increases with age. 2. Sensory changes. a) Reduced vision, hearing, cutaneous proprioceptive, and vestibular function. b) Altered sensory organization for balance. Increased dependence on support surface somatosensory inputs. 3. Musculoskeletal changes. a) Weakness. b) Decreased range of motion. c) Altered postural synergies. 4. Neuromotor changes. a) Dizziness, vertigo common. b) Timing and control problems: impaired reaction and movement times (slowed onset).

Intrinsic/Physiological Factors 5. Cardiovascular changes. Orthostatic hypotension. Hyperventilation, coughing, arrhythmias. 6. Drugs. Psychotropic agents. Cardiovascular agents Peripheral vasodilation. Conflicting evidence linking analgesics, hypoglycemics.

Intrinsic/psychosocial factors. Mental status/cognitive impairment. Depression. Denial of aging. Fear of falling: associated with self-imposed activity restriction. Relocation (moving out to new location).

Extrinsic/environmental factors Setting (changing location): three times as many falls for institutionalized or hospitalized elderly than for community dwelling. Consider ground surfaces(even/uneven), poor lighting of doors or doorways, stairs. Slippery surface, and obstacles. At home, most falls occur in bedroom (42%); bathroom (34%).

Activity-related risk factors 1. Most falls occur during normal daily activity: getting up from bed/chair, turning head/body, bending, walking, climbing/descending stairs. 2. Clearly hazardous activities, e.g. climbing on ladder. 3. Improper use of assistive device: e.g. walker, cane, wheelchair.

Fall assessment approach Studenski suggests four approaches for assessing the falling syndrome in the geriatric patient: 1. Ecological 2. Biomedical 3. Physiological 4. Functional

Ecological The ecological approach focuses the interaction between the patient and the environment. Presence of an unusual environment, e.g., Icy surface. Negotiate an uneven pathway in unfamiliar territory. Fall while walking in his home (sever impairment). This approach allows the examiner to assess the contribution and potential modification of environmental factors in fall events.

Biomedical The biomedical component of the assessment focuses on medical events that are potentially contributory to falls. Identify the diseases that result in instability: Acute (sudden fall or increase frequency). electrolyte abnormalities, infections, drug side effects, dehydration, orthostatic hypotension, blood loss, and hypoxemia. Chronic. cardiovascular conditions include arrhythmias, aortic stenosis, and carotid sinus sensitivity. Neuromuscular diseases such CVA, seizures, Parkinson’s disease, …… this approach is useful for identifying treatable disease components of the falls syndrome.

Physiological Identification of deficits in postural control that contribute to instability. Components of the postural control system that are assessed include: Sensory system Effector (strength, range of motion, biomechanical align­ment, flexibility) Central processing.

Functional Identify important routine movements with which the patient has difficulty. These movements represent the deficit of postural control system.

Careful assessment includes 1. Accurate fall history: location, activity, time, symptoms; previous falls. 2. Physical examination of patient: cognitive, sensory, neuromuscular, cardiopulmonary. 3. Standardized tests and measures for functional balance and instability: Performance-Oriented Mobility Assess­ment, POMA (Tinetti). (Get Up and Go Test, GUG (Mathias, Nayak & Isaacs); timed GUG (Podsiadlo). Functional Reach, FR (Duncan). The Balance Scale (Berg). Dynamic Gait Index (Shumway-Cook).

Goals (1)Eliminate or minimize all fall risk factors; stabilize disease states, medications. (2)Improve functional mobility. (3)Provide exercise to increase strength, flexibility. (4)Provide sensory compensation strategies. (5)Balance and gait training.

PT Role Provide functional training. 1. Focus on sit-to-stand transitions, turning, walking, stairs. 2. Modify activities of daily living for safety; provide assistive devices, adaptive equipment as needed. 3. Allow adequate time for activities; instruct in gradual position changes.

PT Role Safety education. a) Identify fall risk factors (intrinsic and/or extrinsic). b) Provide instructions in writing. c) Communicate with family and caregivers. Modify environment to reduce falls and instability: a) Ensure adequate lighting. b) Use contrasting colors to delineate hazardous areas. c) Simplify environment, reduce clutter.