1. Fall Prevention Principles in Action: The Birmingham/Atlanta GRECC Fall Prevention Clinic Cynthia J. Brown, MD, MSPH October 26, 2006

2. GRECC Fall Prevention and Mobility Clinic Objectives of the clinic –To provide care to veterans with a history of falls, near falls or other mobility problems –To develop a program which can be exported to other VA facilities –To allow research into the area of falls, fall prevention and mobility disability in a community- dwelling population –To provide an educational venue for a variety of trainees

3. Patient Population Served by the Clinic Referrals from several sources including primary care, neurology, and rehabilitation A Variety of ages, functional status abilities and medical diagnoses are represented All have a history of falls or near falls

4. Interdisciplinary Team Approach Occupational Therapist Physical Therapist Physician (Geriatrician) Referrals as needed for other resources or providers

5. Methods Adaptable for All Healthcare Providers Fall prevention strategies can be employed by all healthcare providers within the VA. Key is multicomponent, interdisciplinary interventions. Having this type of clinic is not essential.

6. Risk Factors Targeted by the Team –Muscle weakness –Mobility and balance impairments –Foot and footwear problems –Sensory and perceptive deficits –Cognitive impairments –Multiple medications –Postural hypotension and dizziness –Environmental hazards

7. Occurrence of Falls According to the Number of Risks (Tinetti, 1988)

8. Muscle Weakness Evaluation: strength testing of the upper and lower extremities functional tests like timed chair stands Treatment: referral for strength training either as an outpatient or at home, depending on severity of mobility problems

10. Mobility and Balance Impairments Mobility (gait and transfers) –Evaluation: timed chair stands, and timed 8 foot walk (Short Physical Performance Battery); or Get Up and Go test –Treatment: Physical Therapy for gait and transfer training, provision of an assistive device Balance –Evaluation: progressive static balance tests (feet together, semi-tandem, and tandem) –Treatment: referral to PT or community exercise programs (Tai Chi) for instruction in balance exercises.

14. Foot and Footwear Problems We dare to take the patients shoes off ! –Evaluation: watching gait with shoes on examining shoes for wear patterns examining feet without shoes –Treatment: Podiatry referral for nail care orthotics/prosthetics for shoe inserts, special shoes or ankle-foot orthosis (AFO)

15. Sensory and Perceptive Deficits Vision –Ask if any problems and refer as needed Hearing –Ask if problems and refer as needed Sensation/ Proprioception Problems –Check sensation to light touch and proprioception –Referral to podiatry, foot clinic

16. Cognitive Impairments Screen for depression –Geriatric Depression Scale (GDS) –Work with PMD or Mental Health, treat as needed Screen for dementia –Mini Mental State Exam (MMSE) –Referral to Geriatric Assessment Clinic –Assist family in understanding why the patient falls and target other interventions which may lower risk

17. Multiple Medications Physician review of medications –Attempt to adjust or eliminate as able –Focus on those known to be associated with high fall risk Benzodiazepines Anticholinergic medications Psychoactive medications

19. Postural Hypotension and Dizziness Evaluate by taking orthostatic blood pressures on ALL patients –Check after supine for five minutes, then standing for one and three minutes Treatment: –Review medications and adjust as able –Instruct patients to change positions slowly

20. Environmental Hazards Occupational Therapist reviews home environment with patient Handouts of hazards given and discussed Adaptive equipment provided as needed (raised toilet seats, shower chairs, grab bars) Home health can evaluate for home safety

23. Benefits of an Interdisciplinary Team Approach Research shows a multicomponent approach most likely to be successful Allows a variety of targeted interventions to be done simultaneously Educational opportunity Fun!

24. The Birmingham/Atlanta GRECC Fall Prevention and Mobility Team J. Dennis Hughes, OTR/L Claire Peel, PhD, PT Cynthia J. Brown, MD, MSPH

25. Thanks to the patients who allowed themselves to be photographed