Staying Happy on Your Feet
Tina Young, MSOT, OTR/L
OOTA Older Adult MSG
March 2012, Cleveland District
Objectives
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Review of Balance tests to assess fall risk
Provide treatment strategies for Balance-client
specific
Provide treatment strategies for Fall Preventionclient and community education
Educate on Ohio Older Adults Falls Prevention
Coalition: OIPP
A fall is defined as “an
unintentional change in position
resulting in coming to rest on the
ground or at a lower level”
-J. Wells
Falls Are Not a Normal Part of the Aging
Process
Falls and loss of balance are symptoms
of some underlying problem
M.Robinson
Facts about Falls and Older Ohioans
30% age 65 and older living in the community fall each
year
Falls are the leading cause of injury-related deaths and
the most common cause of nonfatal injuries and
admissions
An older adult falls in Ohio every 2.5 minutes on
average, resulting in two deaths each day, two
hospitalizations each hour
Ohioans age 65 and older make up 13.7% of population
and account for >80% of fatal falls
Facts about Falls and Older Ohioans
Fatal fall rates increased 125% from 2000 to 2009
Most fractures among older adults are caused by falls
Risk of falling increases significantly after age 75
Falls account for more than 90% of all accidental hip
fractures
1 in 3 older Ohioans' fall leads to injuries that resulted
in a doctor visit or restricted activity
Ohio Injury Prevention Partnership
OIPP
Older Adults Falls Prevention Coalition
Mission
Website review
Resources
My role
Fall Prevention Day-what you can do
Facts and Statistics
Ohio Injury Prevention Partnership
OIPP
Older Adults Falls Prevention Coalition
http://www.ohiopha.org/Tabs/Publications/OPHAProjectDetails.aspx?DID=158
FALLS_2011_Symposium10711Beeghly.pdf
OIPP Falls Coalition
2011 Factsheet Falls Among Older Adults in
Ohio[1].ppdf
AGS_06_falls_general_inf
ormation[1].pdf
Aging Well, Winter 08

Safety of Seniors Act of 2007 passed authorizing
new programs to help prevent falls through public
education, research and safety demonstrations

Falls don’t discriminate

3 times more likely to fall again if fallen

Multiple medication usage and frailty are the next
most common causes of falls
• Falling and being homebound are associated with:
Increased mortality
Increased depression
Increased morbidity
Increased helplessness
Reduced function
Decreased confidence
Premature nursing home admissions
Journal of the American Geriatric Society, J. wells; OT Practice 2003/ California Journal 2008


Many people who fall, even those who are not injured,
develop a fear of falling. This fear may cause them to limit
their activities, leading to reduced mobility and physical
fitness, and increasing their actual risk of falling (Vellas et
al. 1997). 9 Joe wells
Fear leads to decreased activity and increased sedentary
lifestyle therefore increases fall risk (AJOT, 2004)
1.Fall Risk Assessment
2.Proactive Fall Interventions
3.Patient and Caregiver Education
4.Evaluation of Fall Prevention Program
-
HHQI Best Practice: Fall Prevention Program17,
J. Wells
• Identify risk factors
• Pertinent medical/ fall history
• Medication review
• Assessments:
•
•
•
•
•
•
J. Wells
E.g.: Berg’s Balance Test, Timed-Up-Go
Orthostatic Hypotension
Body structures
Body Functions
Home Environmental Safety
Support system
Environment
Lighting
Visual
Cognition
Somatosensory
Restraints
Postural
Control
Musculo
skeletal
Vestibular
Age Related Changes that Affect
Balance and Falls= Natural Risk
Factors

Vision-acuity, depth perception, visual
fields
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Hearing
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Strength/flexibility

Bone density

Posture
Age Related Changes that Affect
Balance and Falls= Natural Risk
Factors
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Velocity/speed/reaction time
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Dual tasks
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Proprioception
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Chronic diseases and medical
complications
Fall Risk Factors
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Age (>65 years and increase >75/85)
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Female gender
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Past history of a fall and/or hip fracture
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Weakness in lower extremities
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Foot disorders (bunions, ulcerations, toe or nail
problems) and footwear
Fall Risk Factors
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Hearing or vision loss (4)
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Incontinence
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Restraints
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Faulty equipment or needing equipment
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Altered/impaired Cognition and dementia
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Balance problems
Fall Risk Factors
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Blood pressure
Low vitamin D levels
Poly-pharmacy- over 4 medications, Tylenol pm
Arthritis, Osteoporosis, Frailty
Parkinson’s disease, TBI, CVA, Alzheimer's
Chronic pain, foot pain
Behaviors as a result of a fall, depression
Client Identified Fall Risk Factors

Hurrying
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Carelessness
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Inattention
AJOT 2003
Extrinsic Factors

Uncontained Incontinence
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Physical Restraint
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Environmental Obstacles
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Poor lighting
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Faulty equipment

Type of Footwear
M.Robinson
Intrinsic Factors
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Medication Side Effects and Interactions
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Visual impairment
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Vestibular dysfunction
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Somatosensory deficit
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Musculoskeletal deficit
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Orthostatic Hypotension
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Cognition
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Behavioral
Typical OT Evaluation

Functional Mobility, transfers
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ADL’s
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ROM and Strength (functional-lifting, carrying)
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Sensation
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Vision
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Balance and posture-where are head and eyes
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IADL’s
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Cognition
Gericareonline.net_Falls_Tool_5_Stor
y_of_Your_Falls[1].pdf
Falls & Allen GSISJUNE05.pdf
EBP Standardized Balance Tests

Functional Reach
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Timed Up & Go
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Gait Speed
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Berg Balance Test
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Tinetti
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Modified Clinical Test for Sensory Interaction in
Balance (CTSIB)
30 sec Chair Stand and Arm Curl
• The TUG was found to have :
• 87% sensitivity for predicting falls with a score >14
seconds
• It was also found that measurement of mobility under multitask conditions was not a better indicator for the likelihood
of falls.
-Shumway-Cook et al. (2000)18
• The Berg Balance Test: 83% of subjects were correctly
identified as fallers (the gold standard) based upon the
dichotomous rule to classify fallers at a cut-off point of <40
19
(BBT
Score).
-Riddle
&
Stratford
(1999)
J. Wells
Fall Prevention
Assessment TUG 1107.pdf
Gericareonline.net_Falls_Tool_2_Get_U
p_and_Go_Test[1].pdf
• Home Safety Evaluation
• Reduce Safety Hazards- E.g.: Throw rugs, lighting, pets,
oxygen tubing, clutter, extension cords, etc.
• Medication management
• Cardiac status: Orthostatic hypotension, arrhythmias
• Bowel/ bladder habit and management
• Proper footwear
• Nutrition/ hydration status- need for referral
• Physical Therapy and/ or Occupational Therapy
J. Wells
Medication Review and Education

Client example

ACP example
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CDC example
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
Common side effects: dizziness, drowsiness,
decreased balance
Treatment suggestion: look up meds
AGS_14_put_your_best_fo
ot_forward[1].pdf
Treatment for a Client’s
Fall Prevention

AE/DME
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Modify ADLs/IADLs (foot wear, scanning)
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Modify environment (contrast, grab bars, cell
phone)
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ECT
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Life Alert, emergency numbers
Treatment for a Client’s
Fall Prevention

Home Assessments:
Housing Enabler
Safe at Home
Westmead
ROTE
SAFER Home v3
GEM
HOMEFAST
Cougar
Rebuilding Together
CASPAR
Home Assessment/checklists

Common items:
Double sided tape
Lighting-florescent, glare
Organization
Contrasts
Accessible switches
Foot wear
Nonskid Bathmats
Throw rugs
TTB/shower chair
Cords
Handheld shower
Clutter
Non adhesive strips
Nightlights
Roll in shower
Handrails
Loops and Lever handles
Home
AssessmentTool
SS0610.xls
Home Safety Checklist
Clermont County 2008.xls
Home
AssessmentTool
SS0610.xls
Age in Place/Universal Design
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NAHB- 3 day program
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RT- Rebuilding Together
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OTs give recs on assistive products, identify
resources, evaluate safe use
CAPS (Certified Aging in Place Specialists) have
relationship with contractors, assist with
visitability
OT Practice 2009
Age in Place/Universal Design

Common sense
CAPS
Increase lighting
Pullout shelves
Remove
objects/cords/clutter
Flat panel light switches
Grab bars
Nonslip mats and footwear
Reduce glare
Night light
Increase contrast
Counter heights
Wide doors/hallways
Chair lifts
Remodel bathroom
Ramps
Flooring
Age in Place/Universal Design

Barriers:
Personal items in home are meaningful,
perspectives
Finances/Costs
Adherence to recommendations
(80%noncompliance)
Safety + aesthetics +client goal + OT goal
Treatment for a Client’s Balance
EXERCISE !!!!
Standing-on one foot and two
Stand in corner and move shoulders/hips
Fixate on object with eyes and move head in
different directions (saccades and pursuits), walk
and turn head
Extension!!!!!
Treatment for a Client’s Balance
Walk heel to toe, walk on toes, walk on heels
Walk backwards, walk sideways on stairs
Stand up and sit down without hands
Focus on LE, Core, Triceps
UE- scapular retraction, rowing
Treatment for a Client’s Balance
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Improve flexibility-stretching, Tai Chi, Yoga
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Deep breathing
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Floor transfers
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Improve posture
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Cognition under 4.4 ACL- no DME
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Medication review-4+ meds, side effects
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Vision screening
Treatment for a Client’s Balance
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Obstacle courses
Joint mobilizations to the spine
Dancing
Do ADLs on one foot
Begin walking programs
Electrical stimulation
Consider DME/AE-hip protectors, walkers,
canes, etc
Treatment for a Client’s Balance

Aquatic programs
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Strategies-ankle, hip, step
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Eyes open and closed
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Reaching/bending/weight shifts/lifting/carrying
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Balls/BAPS board
Treatment for a Client’s Balance

Do things during balance exercises:
Add music
Change surface-unlevel
Change footwear
Adjust lighting-include low lighting
Do math
Categorize
Name items with letter i.e. “b”
Treatment for a Client’s Balance
“Her balance deficits became more apparent
as her ability to cognitively compensate
decreased in the face of other demands on
her attention. This balance deficit, plus her
lack of memory for a task and limited
scanning of her environment, represented
serious impediments to safe independent
function at home.” OT Practice 2004
Treatment for a Client’s Balance

Relationship of cognition and balance
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ACL scores with treatment direction

“Deviation from the expected routine (the
hazard) becomes the challenge to overcome.”
OT Practice 2004
Treatment for a Client’s Balance

How to Fall Properly:
Practice it
Buckle with the knees
Pull arms into body
Roll instead of being rigid
OT Practice 2002
Treatment for a Client’s Balance

Clients tend to only do what they can see
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Focus on extension exercises
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Do what they fear
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Let them design the course/treatment

Routines reduce falls
Treatment for Clinic/Facility
Low bed
Free clutter
Hipsters
Grab bars
Toilet schedule
RTS
Floor mats
Visible cues
Alarms
Nonslip mats
AE
Nonslip footwear
DME
Nightlights
Good lighting
Change room location
Ed on call light
Environment set up
Best Practice
• Interdisciplinary, consistent, patient specific
• Identify potential risks and interventions available
• Tools (Examples):
• Safety Self-Assessments
• Teaching Sheets
• Exercise Program for Maintenance
J. Wells
CDC Prevention Plan

Fall Prevention strategies:
Exercise regularly, Tai Chi (strength/balance)
Medication review- side effects and interactions
Yearly eye exams
Reduce fall hazards in the home
Improve lighting throughout the home
Fall Prevention Treatment for the
Community

3 levels of prevention
Primary- avoid onset of disease, no observable risk
Secondary-for those demonstrating early symptoms
of condition, identified risk
Tertiary- after a disability occurs, usually in rehab
settings
OT Practice 2003
Possible Fall
Prevention
Partners.doc
Physical activity programs, particularly those
emphasizing balance and lower extremity
strengthening,
are associated with a 10-20 percent reduction in
falls
[AGS].4 J. Wells
Fall Prevention Treatment for
Community
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OOTA Fact sheets (Free)
Formal Groups-Matter of Balance,
Stepping On
Informal Groups
Self Assessments: home safety
checklists, medication reviews
Education on Exercise-strength,
flexibility, extension, dual tasks, groups,
Tai Chi
Fall Prevention Treatment for the
Community
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Education on risk factors and myths
about aging
Options of AE, DME, home
modifications, resources
Vision screenings
Talks to Senior Centers, health fairs,
YMCA, Area Agency on Aging
Fall Prevention Treatment for the
Community
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3 areas reviewed:
Checklists for fall prevention-home safety, fall
risk factors, medications
Options for fall prevention- AE, home
modifications, resources: websites, catalogs,
demo equip, vendors, funding, Home Depot,
Lowes
Balance-groups, exercise, programs
AGS_falls_consumer
pamphlet[1].pdf
AGS_19_avoiding_falls_
low_vision[1].pdf
AGS_10_canes_w
alkers[1].pdf
AGS_11_choosing_starting_an_exe
rcise_program[1].pdf
AGS_12_improve_your_
balance[1].pdf
AGS_07_medical_evalua
tion_falls[1].pdf
AGS_15_can_you_
get_help[1].pdf
AGS_16_after
the_fall[1].pdf
AGS_17_steady_as_you_goLo
w_Bl_Press[1].pdf
Osteoporosis_falls_andbroken-bones[1].doc
• Patient outcomes
• Organizational outcomes
• FaB (Falls Behavioral Scale for Older People)could be used to measure effect of a program to
reduce risky behaviors and enhance safety
adaptations (AJOT 2003, p. 386)
J.Wells
Falls_Prevention_Lessons_Learned_FINAL127-10-WEBVIEW[1][1].pdf
Power Point Presentations

Monica Robinson, President of OOTA
robinson@oota.org (sited M. Robinson)

Joe Wells, OTD, DPMIR, OT/L, Vice
President of OOTA (sited J. Wells and
provided his list of resources)
E-Mail: joewells@americare-health.com or
wells@oota.org
Research Articles Review




AJOT Volume 63, Number 3, May/June2009
(Falls after CVA)
AJOT 11/12, 2004, p.630-638 (who gets a home
eval)
AJOT ½, 2004 p. 100-103 (3 scales reviewed)
AJOT 7/8, 2003, p. 369-387 (payer relationships
with home evals/recs, FaB Scale of Older
People)
Research Article Review
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

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OT Practice 4/6/09 p. 14-17 (CAPS)
OT Practice 13 (3) February 2008
(PEO, Adherence and approaches, tests,
programs)
OT Practice October 9, 2006
(Safety and Psychiatric Disabilities (kitchen and
bathroom)
OT Practice 12/19/2005 p. 23-30 (cognition and
fall prevention)
Research Article Review

OT Practice November 29, 2004
(Cognition and fall prevention)
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OT Practice 3/8/04 p. 16-21 (SAFE AT HOME
safety screening tool)
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OT Practice 1/13/03 (Prevention)

Advance 2/11/02, p. 4 (how to fall)
Research Article Review


California Journal 2008, volume 6, issue 1, p.
87-110 (Cougar Home Safety Assessment)
AOTA Gerontology SIS Quarterly volume 28,
Number 2, June 2005
(Falls and Dementia, ACL)
Continued Education Resources

Jennifer Bottomley, PT (falls and balance)

Marnie Renda, CEUs for OOTA (home modifications,
home assessments)

HCR CEUs (vision, cognition, falls, older adult exercise, ACP)

Robinson-Brown CEUs for OOTA (falls and balance)

Pamela Toto (exercise for aging)

OIPP Older Adults Fall Prevention Coalition
2011-2012
Miscellaneous Resources

CDC.gov

Employer education materials

Senior Helpers.com

Asaging.org

ACP

Aging well 2008, p. 28-31

Area Agency on Aging
1.
2.
3.
4.
5.
6.
Journal of the American Geriatric Society, 49: 664–672, 2001
Hornbrook MC, Stevens VJ, Wingfield DJ, Hollis JF, Greenlick MR, Ory MG.
Preventing falls among community–dwelling older persons: results from a
randomized trial. The Gerontologist 1994:34(1):16–23.
Hausdorff JM, Rios DA, Edelber HK. Gait variability and fall risk in community–
living older adults: a 1–year prospective study. Archives of Physical Medicine and
Rehabilitation 2001;82(8):1050–6.
http://www.americangeriatrics.org/products/positionpapers/Falls.pdf . Guideline
for the Prevention of Falls in Older Persons; American Geriatrics Society, British
Geriatrics Society, and American Academy of Orthopedic Surgeons Panel on Falls
Prevention
Centers for Disease Control and Prevention, National Center for Injury Prevention
and Control. Web–based Injury Statistics Query and Reporting System
(WISQARS) [online]. (2006) [cited 2007 Jan 15]. Available from URL:
www.cdc.gov/ncipc/wisqars.
Stevens JA, Corso PS, Finkelstein EA, Miller TR. The costs of fatal and nonfatal
falls among older adults. Injury Prevention 2006;12:290–5.
7. Jager TE, Weiss HB, Coben JH, Pepe PE. Traumatic brain injuries evaluated in
U.S. emergency departments, 1992–1994. Academic Emergency Medicine
2000&359;7(2):134–40.
8. Bell AJ, Talbot-Stern JK, Hennessy A. Characteristics and outcomes of older
patients presenting to the emergency department after a fall: a retrospective
analysis. Medical Journal of Australia 2000;173(4):176–7.
9. Vellas BJ, Wayne SJ, Romero LJ, Baumgartner RN, Garry PJ. Fear of falling
and restriction of mobility in elderly fallers. Age and Ageing 1997;26:189–
193.
10. http://www.cdc.gov/ncipc/pub-res/toolkit/toolkit.htm . CDC fall prevention
information, statistics and resources.
11. Author unknown (n.d.). Facts about falling . Retrieved on 02/10/2006, from
www.advantageseniorcareinc.com/FALL%20BROCHURE.pdf
12. Mahoney JE, Palta M, Johnson J, Jalaluddin M, Gray S, Park S, Sager M.
Temporal association between hospitalization and rate of falls after
discharge. Arch. Int. Med., 2000; 160:2788-2795
13. Stevens JA, Sogolow ED. Gender differences for non-fatal unintentional fall
related injuries among older adults. Injury Prevention 2005;11:115–9.
14. Donald IP, Bulpitt CJ. The prognosis of falls in elderly people living at home.
Age and Ageing 1999;28:121–5.
15. Stevens JA, Dellinger AM. Motor vehicle and fall related deaths among older
Americans 1990–98: sex, race, and ethnic disparities. Injury Prevention
2002;8:272–5.
16. Adapted from http://www.healthinaging.org/agingintheknow
17. Quality Insights of Pennsylvania, the Medicare Quality Improvement
Organization Support Center for Home Health, under contract with the
Centers for Medicare & Medicaid Services (CMS), an agency of the U.S.
Department of Health and Human Services. Publication number: 8SOW-PAHHQ07.637. App. 9/07.
18. Shumway-Cook A, Brauer S, Woollacott M. Predicting the probability for
falls in community-dwelling older adults using the Timed Up & Go
test. Phys. Ther. 2000. 80(9); 896-903.
19. Riddle DL, Stratford PW. Interpreting validity indexes for diagnostic test: an
illustration using the Berg Balance Test. Phys Ther. 1999; 79: 939-948.
20. Gitlin, L.N., Winter, L., Dennis, M.P., Corcoran, M., Schinfeld, S., &
Hauck,W.W. (2006). A randomized trial of a multicomponent home
intervention to reduce functional difficulties in older adults. Journal of the
American Geriatric Society, 54(5), 809-816.