Balance and the Older Adult

Falls: Be Aware, Promote Safety, and Stay VerticalIowa Assisted Living Association8/25/15

Dave Tornabane OTR/L&Zach Kanis DPT, MHA

Gentiva Home HealthObjectivesIdentify recent US statistics regarding falls and associated healthcare costsIdentify general fall risk factorsIdentify systemic fall risk factorsIdentify environmental fall risk factorsIdentify standardized tests available to assess at risk individualsIdentify fall prevention interventionsAging PopulationNearly 1 in 3 older adults over the age of 65 will fall each year. This increases to 1 in 2 older adults over the age of 80 that will fall each year. 3Annual Cost of FallsThe average healthcare cost of a fall injury for those aged 72 and older is approximately $20,0004Healthcare CostsA Medicare Current Beneficiary Survey conducted on Medicare recipients found that home health was the most cost effective method to address falls and fall risk factors5Who is at Risk?Age?History of falls?Multiple medications?Unsteadiness?Dizziness?Weak?Poor sensation?Poor vision?Diabetes, stroke, neuropathy, arthritis, or joint disease?

Dizzy? Lightheadedness? Vertigo? Fear of falling? Who has had a fall? Who has had a fall and not told anyone about it? Or waiting to tell anyone about it?6Affected SystemsVestibular SystemSensory system that provides information regarding sense of balance and spatial orientation needed for coordinating movement with balance.Central vs. peripheral80% of patients with falls of unknown cause displayed symptoms of vestibular dysfunctionDizziness affects 30% of individuals over the age of 658 million patients/year visit a physician for dizziness

Affected SystemsVision SystemSensory system that provides input to the CNS with respect to the position of the body within its surrounding environmentNot absolutely necessary for balanceThe older adult tends to rely on their vision for balanceIncreased fall risk: failing eyesight, macular degeneration, glaucomaAffected SystemsSomatosensory SystemSensory system that relates information about the bodys position in space relative to the support surface and the surrounding environmentInformation about the relationship of the bodys segments to one anotherPeripheral neuropathiesDiabetic, drug-induced, age-related, and idiopathic neuropathies

Affected SystemsMusculoskeletal SystemMuscles, tendons, bones, ligaments, jointsAge-related changes in the musculoskeletal system can increase fall riskNatural degenerationOsteoporotic/arthritic postural changesDecreased joint movementMuscle weakness

Environmental Risk Factors60% of falls among adults over the age of 65 occur in the homeMost falls occur when an individual is performing or attempting to perform an activity of daily livingWhat can you do prevent a fall?Remove obstacles and dangersImprove lighting in the homeEnsure safety and fitProper patient/resident transfer strategiesPrepare for emergencies

Remove Obstacles and DangersClear pathways between high traffic areas, such as bedroom to bathroom.Remove items on the floor that they may trip over.Make sure rugs and mats are skid-proof and secured, with edges flush with the floor.Improve Lighting in the HomeInstall brighter bulbs and additional lightingIlluminate entryways, outdoor walkways and other shadowed areas.Use of Contrast

Ensure Safety and FitAssist with choosing shoes that are easy to walk in, supportive, low-heeled, closed back and non-slip.If they use a cane or walker, have it properly fitted by a healthcare professional.Durable Medical Equipment (DME)Tub bench, shower chair, toilet safety frame, bed-side commode, etcUse of adaptive equipmentReacher, dressing stick, sock aid, long shoe horn, grab bars, etc

Proper Patient/Resident Transfer Strategies Body MechanicsEnvironment PreparationPatient/Resident PreparationProper use of equipment/devicesPrepare for EmergenciesMake sure phones are easy to reach.Encourage daily contact with family and friendsPlace emergency and family contact numbers next to the phone.If they have a fall, do not hesitate to call 911 Standardized TestingShort Physical Performance Battery (SPPB)Timed Standing BalanceFeet togetherSemi-tandemTandemGait Speed-Timed 13.12 ft walkChair Stands-Timed 5 sit-to-stands

Standardized TestingBerg Balance Scale (BBS)Modified Clinical Test of Sensory Integration in Balance (mCTSIB)Dynamic Gait Index (DGI)Functional Reach TestBarthel Index

Berg Balance ScaleDescription: 14-item scale designed to measure balance of the older adult in a clinical setting.Equipment needed: Ruler, two standard chairs (one with arm rests, one without), footstool or step, stopwatch or wristwatch, 15 ft walkwayCompletion:Time: 15-20 minutesScoring: A five-point scale, ranging from 0-4. 0 indicates the lowest level of function and 4 the highest level of function. Total Score = 56Interpretation: 41-56 = low fall risk21-40 = medium fall risk0 20 = high fall riskA change of 8 points is required to reveal a genuine change in function between 2 assessments.Berg Balance ScaleSITTING TO STANDINGINSTRUCTIONS: Please stand up. Try not to use your hand for support.( ) 4 able to stand without using hands and stabilize independently( ) 3 able to stand independently using hands( ) 2 able to stand using hands after several tries( ) 1 needs minimal aid to stand or stabilize( ) 0 needs moderate or maximal assist to standSTANDING UNSUPPORTEDINSTRUCTIONS: Please stand for two minutes without holding on.( ) 4 able to stand safely for 2 minutes( ) 3 able to stand 2 minutes with supervision( ) 2 able to stand 30 seconds unsupported( ) 1 needs several tries to stand 30 seconds unsupported( ) 0 unable to stand 30 seconds unsupportedIf a subject is able to stand 2 minutes unsupported, score full points for sitting unsupported. Proceed to item #4.SITTING WITH BACK UNSUPPORTED BUT FEET SUPPORTED ON FLOOR OR ON A STOOLINSTRUCTIONS: Please sit with arms folded for 2 minutes.( ) 4 able to sit safely and securely for 2 minutes( ) 3 able to sit 2 minutes under supervision( ) 2 able to able to sit 30 seconds( ) 1 able to sit 10 seconds( ) 0 unable to sit without support 10 secondsSTANDING TO SITTINGINSTRUCTIONS: Please sit down.( ) 4 sits safely with minimal use of hands( ) 3 controls descent by using hands( ) 2 uses back of legs against chair to control descent( ) 1 sits independently but has uncontrolled descent( ) 0 needs assist to sitBerg Balance ScaleTRANSFERSINSTRUCTIONS: Arrange chair(s) for pivot transfer. Ask subject to transfer one way toward a seat with armrests and one way toward a seat without armrests. You may use two chairs (one with and one without armrests) or a bed and a chair.( ) 4 able to transfer safely with minor use of hands( ) 3 able to transfer safely definite need of hands( ) 2 able to transfer with verbal cuing and/or supervision( ) 1 needs one person to assist( ) 0 needs two people to assist or supervise to be safeSTANDING UNSUPPORTED WITH EYES CLOSEDINSTRUCTIONS: Please close your eyes and stand still for 10 seconds.( ) 4 able to stand 10 seconds safely( ) 3 able to stand 10 seconds with supervision( ) 2 able to stand 3 seconds( ) 1 unable to keep eyes closed 3 seconds but stays safely( ) 0 needs help to keep from fallingSTANDING UNSUPPORTED WITH FEET TOGETHERINSTRUCTIONS: Place your feet together and stand without holding on.( ) 4 able to place feet together independently and stand 1 minute safely( ) 3 able to place feet together independently and stand 1 minute with supervision( ) 2 able to place feet together independently but unable to hold for 30 seconds( ) 1 needs help to attain position but able to stand 15 seconds feet together( ) 0 needs help to attain position and unable to hold for 15 seconds

Berg Balance ScaleREACHING FORWARD WITH OUTSTRETCHED ARM WHILE STANDINGINSTRUCTIONS: Lift arm to 90 degrees. Stretch out your fingers and reach forward as far as you can. (Examiner places a ruler atthe end of fingertips when arm is at 90 degrees. Fingers should not touch the ruler while reaching forward. The recorded measure isthe distance forward that the fingers reach while the subject is in the most forward lean position. When possible, ask subject to useboth arms when reaching to avoid rotation of the trunk.)( ) 4 can reach forward confidently 25 cm (10 inches)( ) 3 can reach forward 12 cm (5 inches)( ) 2 can reach forward 5 cm (2 inches)( ) 1 reaches forward but needs supervision( ) 0 loses balance while trying/requires external supportPICK UP AN OBJECT FROM THE FLOOR FROM A STANDING POSITIONINSTRUCTIONS: Pick up a shoe or slipper, which is in front of your feet( ) 4 able to pick up slipper safely and easily( ) 3 able to pick up slipper but needs supervision( ) 2 unable to pick up but reaches 2-5 cm(1-2 inches) from slipper and keeps balance independently( ) 1 unable to pick up and needs supervision while trying( ) 0 unable to try/needs assist to keep from losing balance or fallingTURNING TO LOOK BEHIND OVER LEFT AND RIGHT SHOULDERS WHILE STANDINGINSTRUCTIONS: Turn to look directly behind you over toward the left shoulder. Repeat to the right. (Examiner may pick an objectto look at directly behind the subject to encourage a better twist turn.)( ) 4 looks behind from both sides and weight shifts well( ) 3 looks behind one side only other side shows less weight shift( ) 2 turns sideways only but maintains balance( ) 1 needs supervision when turning( ) 0 needs assist to keep from losing balance or fallingTURN 360 DEGREESINSTRUCTIONS: Turn completely around in a full circle. Pause. Then turn a full circle in the other direction.( ) 4 able to turn 360 degrees safely in 4 seconds or less( ) 3 able to turn 360 degrees safely one side only 4 seconds or less( ) 2 able to turn 360 degrees safely but slowly( ) 1 needs close supervision or verbal cuing( ) 0 needs assistance while turningBerg Balance ScalePLACE ALTERNATE FOOT ON STEP OR STOOL WHILE STANDING UNSUPPORTEDINSTRUCTIONS: Place each foot alternately on the step/stool. Continue until each foot has touched the step/stool four times.( ) 4 able to stand independently and safely and complete 8 steps in 20 seconds( ) 3 able to stand independently and complete 8 steps in > 20 seconds( ) 2 able to complete 4 steps without aid with supervision( ) 1 able to complete > 2 steps needs minimal assist( ) 0 needs assistance to keep from falling/unable to trySTANDING UNSUPPORTED ONE FOOT IN FRONTINSTRUCTIONS: (DEMONSTRATE TO SUBJECT) Place one foot directly in front of the other. If you feel that you cannot placeyour foot directly in front, try to step far enough ahead that the heel of your forward foot is ahead of the toes of the other foot. (Toscore 3 points, the length of the step should exceed the length of the other foot and the width of the stance should approximate thesubjects normal stride width.)( ) 4 able to place foot tandem independently and hold 30 seconds( ) 3 able to place foot ahead independently and hold 30 seconds( ) 2 able to take small step independently and hold 30 seconds( ) 1 needs help to step but can hold 15 seconds( ) 0 loses balance while stepping or standingSTANDING ON ONE LEGINSTRUCTIONS: Stand on one leg as long as you can without holding on.( ) 4 able to lift leg independently and hold > 10 seconds( ) 3 able to lift leg independently and hold 5-10 seconds( ) 2 able to lift leg independently and hold L 3 seconds( ) 1 tries to lift leg unable to hold 3 seconds but remains standing independently.( ) 0 unable to try of needs assist to prevent fallmCTSIBThe mCTSIB is a modification of the CTSIB that eliminates the use of the visual conflict dome (Cohen et al 1993). It includes conditions 1,2,4,5 of the original CTSIB. To perform the test the patient stands with their hands at their side and performs the following 4 conditions:1. (CTSIB condition 1) Stand on firm surface with the eyes open.2. (CTSIB condition 2) Stand on firm surface with the eyes closed.3. (CTSIB condition 4) Stand on compliant surface (foam) with the eyes open4. (CTSIB condition 5) Stand on compliant surface (foam) with the eyes closed.

Functional Reach Test

Barthel IndexFEEDING0 = unable5 = needs help cutting, spreading butter, etc., or requires modified diet10 = independent ______BATHING0 = dependent5 = independent (or in shower) ______GROOMING0 = needs to help with personal care5 = independent face/hair/teeth/shaving (implements provided) ______DRESSING0 = dependent5 = needs help but can do about half unaided10 = independent (including buttons, zips, laces, etc.) ______BOWELS0 = incontinent (or needs to be given enemas)5 = occasional accident10 = continent ______BLADDER0 = incontinent, or catheterized and unable to manage alone5 = occasional accident10 = continent ______Barthel IndexTOILET USE0 = dependent5 = needs some help, but can do something alone10 = independent (on and off, dressing, wiping) ______TRANSFERS (BED TO CHAIR AND BACK)0 = unable, no sitting balance5 = major help (one or two people, physical), can sit10 = minor help (verbal or physical)15 = independent ______MOBILITY (ON LEVEL SURFACES)0 = immobile or < 50 yards5 = wheelchair independent, including corners, > 50 yards10 = walks with help of one person (verbal or physical) > 50 yards15 = independent (but may use any aid; for example, stick) > 50 yards ______STAIRS0 = unable5 = needs help (verbal, physical, carrying aid)10 = independent ______TOTAL (0100): ______

Fall Prevention Skilled InterventionExercisesBalance TrainingCoordination trainingGait TrainingStrength TrainingEndurance TrainingTai Chi

Fall Prevention Skilled InterventionVisionHabituation/Adaptation ExercisesVestibular ManeuversHabituation/Adaptation ExercisesModalitiesMonochromatic Infrared Energy (MIRE)Fall Prevention Walking programsRegular exercise classesHealthy diet and proper hydrationPromote use of assistive devicesDont ignore their signs or symptoms of decreasing functional balanceTalk to other staff and familyRefer to a Physical Therapist and/or an Occupational Therapist

ConclusionBE AWAREPROMOTE SAFETYSTAY VERTICALQuestions?Dave Tornabane OTR/LGentiva Home Health515-277-0977david.tornabane@gentiva.com

Zach Kanis DPT, MHAGentiva Home Health515-277-0977zachary.kanis@gentiva.com