The Assessment of Falls Risk in the Elderlystorage.googleapis.com/wzukusers/user-18795294... · • Bone vibrator is placed at the great toe, ankle, and tibial tuberosity (lower)

Vanderbilt Bill Wilkerson Center for Otolaryngology and Communication Disorders

Gary P. Jacobson, Ph.D.Gary P. Jacobson, Ph.D.Vanderbilt Bill Wilkerson Vanderbilt Bill Wilkerson

CenterCenter

Vanderbilt Bill Wilkerson Center for Otolaryngology Vanderbilt Bill Wilkerson Center for Otolaryngology and Communication Sciencesand Communication Sciences

The Assessment of The Assessment of Falls Risk in the ElderlyFalls Risk in the Elderly

Vanderbilt Bill Wilkerson Center

Risk of Falls in the ElderlyRisk of Falls in the Elderly


S. 1531 S. 1531 -- ““Keeping Senior Safe Keeping Senior Safe From Falls Act of 2005From Falls Act of 2005””



•• Develop effective public education Develop effective public education strategiesstrategies……to reduce falls among older to reduce falls among older adultsadults

•• Conduct research to determine the most Conduct research to determine the most effective approaches to preventing and effective approaches to preventing and treating falls among older adultstreating falls among older adults

•• Require the Secretary to elevate the effect Require the Secretary to elevate the effect of falls on health care costs, the potential of falls on health care costs, the potential for reducing falls, and the most effective for reducing falls, and the most effective strategies for reducing health care costs strategies for reducing health care costs associated with fallsassociated with falls





Falls Free CoalitionFalls Free Coalition






American Geriatrics Society Lauds American Geriatrics Society Lauds "Welcome" Proposals for"Welcome" Proposals for

Preventive Services Under MedicarePreventive Services Under Medicare•• ““The AGS is excited that the proposed The AGS is excited that the proposed

benefit includes several of the benefit includes several of the components of a geriatric assessmentcomponents of a geriatric assessment…”…”(including)(including)

•• ……review of the individual's functional review of the individual's functional abilityability……

•• ……level of safety, including factors level of safety, including factors e.ge.g……. . •• hearing impairmenthearing impairment•• activities of daily living, activities of daily living, •• falls risk and home safetyfalls risk and home safety based on the based on the

use of an "appropriate screening use of an "appropriate screening instrument" as determined by the instrument" as determined by the physician or other qualified provider. physician or other qualified provider.


Epidemiology of Falls in the Epidemiology of Falls in the Elderly: How Big is the Problem?Elderly: How Big is the Problem?

•• 30% to 50% of patients over age 30% to 50% of patients over age 65 yrs will fall next year (~ 7 65 yrs will fall next year (~ 7 million falls annually) million falls annually) •• 33% of falls will occur at home33% of falls will occur at home•• 4545--70% of falls will occur in 70% of falls will occur in

nursing homesnursing homesCoogler, C.E. (1992)



•• 10% of those who fall will fall 10% of those who fall will fall againagain•• 50% of these patients will die 50% of these patients will die

within the next yearwithin the next year



•• Of those elderly who fall, 5% will Of those elderly who fall, 5% will sustain a hip fracture sustain a hip fracture •• 20%20% of patients will die within the of patients will die within the

next yearnext year•• 20%20% of patients will be moved to a of patients will be moved to a

nursing home for the first timenursing home for the first time

American Academy of Orthapedic Surgeons (1998)



•• 350,000 hip fractures were 350,000 hip fractures were predicted in 2000predicted in 2000

•• Cost of repairing hip fractures.Cost of repairing hip fractures.•• $35,000 per patient.$35,000 per patient.

American Academy of Orthapedic Surgeons (1998)

Nyburg et al. (1996)



•• Cost of caring for elderly who fall Cost of caring for elderly who fall in the United States is est. to be:in the United States is est. to be:•• $20.2 billion/year$20.2 billion/year

•• Falls are associated with Falls are associated with significant significant morbiditymorbidity and and mortalitymortality and and expenseexpense to our to our health care systemhealth care system


Goals of theGoals of theRisk of Falls Assessment ClinicRisk of Falls Assessment Clinic

•• To prevent potentially injurious falls. To prevent potentially injurious falls.

•• To identify elderly at greatest risk for To identify elderly at greatest risk for falling through an assessment of falling through an assessment of factors known to be associated with factors known to be associated with highest riskhighest risk

•• To provide recommendations to the To provide recommendations to the referring physician for decreasing referring physician for decreasing the risk of fallsthe risk of falls


Sources of Postural Instability Sources of Postural Instability in the Elderlyin the Elderly






Complexity of the ProblemComplexity of the Problem


Assessment of Falls Risk Assessment of Falls Risk (3 hours)(3 hours)

•• Focused historyFocused history•• Cognitive functionCognitive function•• DepressionDepression•• Reaction timeReaction time•• Postural hypotensionPostural hypotension•• Postural stabilityPostural stability•• GaitGait•• Vestibular functionVestibular function•• Visual functionVisual function•• SomesthesiaSomesthesia (e.g. (e.g. proprioceptionproprioception, ,

vibration sense)vibration sense)


Focused HistoryFocused History


Focused HistoryFocused History•• History of major illnessesHistory of major illnesses•• Medication historyMedication history•• History of gait problems or History of gait problems or

weaknessweakness•• History of dizziness/LOCHistory of dizziness/LOC•• History of previous fallsHistory of previous falls•• Environmental risksEnvironmental risks


•• Prescription medicationsPrescription medications ((TinettiTinetti et et al., 1988; Richardson, 2002)al., 1988; Richardson, 2002)•• e.g. minor tranquilizers (increase e.g. minor tranquilizers (increase

comfort but reduce vigilance). comfort but reduce vigilance). •• In a recent study of risk factors, In a recent study of risk factors,

ageage and and prescription medicationsprescription medicationswere found to be strong predictors were found to be strong predictors of falls.

Risk Factors Associated with Falls Risk Factors Associated with Falls in the Elderly (endogenous)in the Elderly (endogenous)

of falls.


•• Diseases:Diseases: e.g. Parkinsone.g. Parkinson’’s d., s d., osteoporosis, cardiac disease osteoporosis, cardiac disease (arrhythmias, atherosclerotic d.), (arrhythmias, atherosclerotic d.), diabetes, diabetes, cerebrovascularcerebrovascular diseases diseases including stroke.including stroke.

•• General risk factors:General risk factors: impaired impaired somesthesia (e.g. proprioception), somesthesia (e.g. proprioception), vision, & balance function, postural vision, & balance function, postural hypotension, use of hypotension, use of anxiolyticanxiolytic or or sedative meds., sedative meds., use of 4 or more use of 4 or more prescription meds.

Risk factors associated with falls Risk factors associated with falls in the elderly in the elderly (endogenous)(endogenous)

prescription meds.


Risk factors associated with Risk factors associated with falls in the elderly falls in the elderly (exogenous)(exogenous)Environmental factors including:Environmental factors including: poor poor

lighting, loose rugs, power cords, lighting, loose rugs, power cords, unstable furniture, stairs with poor unstable furniture, stairs with poor railings or poorly visualized edges, railings or poorly visualized edges, low beds and toilets.low beds and toilets.


Cognitive Cognitive FunctionFunction


Assessment of Cognitive FunctionAssessment of Cognitive Function(Odds ratios = 1.4(Odds ratios = 1.4--3.5)3.5)

•• MiniMini--mental Status Examination mental Status Examination (MMSE)(MMSE)-- FolsteinFolstein et al., 1975)et al., 1975)•• 11 sections, total score = 30 pts, 11 sections, total score = 30 pts, <<

23 pts = abnormal23 pts = abnormal


Effect of Decreased Cognitive Effect of Decreased Cognitive FunctionFunction

•• Dementia affects 6Dementia affects 6--10% of 10% of communitycommunity--dwelling elderlydwelling elderly

•• Demented elderly are 3X more likely Demented elderly are 3X more likely to die within 6 mos. of hip fractures to die within 6 mos. of hip fractures than nonthan non--demented elderly demented elderly

•• Demented patients are less aware of Demented patients are less aware of their environment (e.g. their environment (e.g. environmental hazards)environmental hazards)


MiniMini--mental Status Examinationmental Status Examination--FolsteinFolstein et al. 1975et al. 1975


DepressionDepression


Effects of DepressionEffects of Depression•• Clinical depression is associated Clinical depression is associated

with:with:•• use of antidepressant meds use of antidepressant meds (risk (risk

factor)factor)•• lower levels of physical activity lower levels of physical activity

((deconditioningdeconditioning) resulting in ) resulting in reduced strength, coordination and reduced strength, coordination and balance balance (risk factor)(risk factor)

•• altered gait patterns altered gait patterns (risk factor)(risk factor)


Assessment of DepressionAssessment of Depression(Odds ratios for meds to treat depression = 1.4(Odds ratios for meds to treat depression = 1.4--7.5)7.5)

•• Geriatric Depression ScaleGeriatric Depression Scale-- GDS GDS ((YesavageYesavage et al. 1983)et al. 1983)•• 30 items answered in 30 items answered in ““yesyes”” and and

““nono”” formatformat•• CutCut--off score of 11 pts. off score of 11 pts.

•• Yields 84% sensitivity and 95% Yields 84% sensitivity and 95% specificityspecificity


Sample ItemsSample ItemsGeriatric Depression ScaleGeriatric Depression Scale

((YesavageYesavage et al. 1983)et al. 1983)


Reaction TimeReaction Time


Effect of Increased Reaction Effect of Increased Reaction TimesTimes

•• Reaction timeReaction time•• Independent risk factor for fallsIndependent risk factor for falls•• Fallers show longer simple and Fallers show longer simple and

choice choice RTsRTs than nonthan non--fallersfallers•• Increased Increased RTsRTs are associated are associated

with delayed responses to with delayed responses to changes in postural stability & changes in postural stability & increased body sway with eyes increased body sway with eyes closed on a compliant surface closed on a compliant surface (Lord et al. 1991)(Lord et al. 1991)


Reaction TimesReaction Times(upper)(upper)


Assessment of Reaction Time Assessment of Reaction Time ((msecmsec) Hand) Hand

•• HandHand•• Excellent =Excellent =

< 200 < 200 msecmsec•• Good = 200Good = 200--

250 250 msecmsec•• Fair = 250Fair = 250--300300•• Poor = 300 + Poor = 300 +

msecmsec


Reaction TimesReaction Times(lower)(lower)


Assessment of Reaction Time Assessment of Reaction Time ((msecmsec) Foot) Foot

•• FootFoot•• Excellent = Excellent =

•• < 250 < 250 msecmsec•• Good = 250Good = 250--

300 300 msecmsec•• Fair = 300Fair = 300--350350•• Poor = 350+ Poor = 350+

msecmsec


Orthostatic Orthostatic HypotenstionHypotenstion


Postural HypotensionPostural Hypotension


Assessment of Orthostatic Assessment of Orthostatic HypotensionHypotension(Odds ratio = 1.3)(Odds ratio = 1.3)

•• Defined as decrease in systolic blood Defined as decrease in systolic blood pressure on standingpressure on standing……

by by >> 20 mm Hg, or, 20 mm Hg, or, to < 90 mm Hgto < 90 mm Hg


Effects of Orthostatic Effects of Orthostatic HypotensionHypotension

•• OHOH-- affects 6% of community affects 6% of community dwelling elderly when dwelling elderly when confounding factors are confounding factors are controlled (e.g. medications controlled (e.g. medications known to cause OH)known to cause OH)

•• OHOH-- can be symptomatic or can be symptomatic or asymptomaticasymptomatic

•• OHOH-- can be postcan be post--prandialprandial


SomesthesiaSomesthesia


Assessment of Assessment of SomesthesiaSomesthesia

•• ProprioceptionProprioception•• Vibration SenseVibration Sense


Assessment of Somesthesia in Assessment of Somesthesia in the Elderlythe Elderly

•• Age results in decreased ability Age results in decreased ability to detect passive movement of to detect passive movement of the foot (direction and position).the foot (direction and position).

•• Associated with disorders Associated with disorders causing distal peripheral causing distal peripheral neuropathiesneuropathies•• e.g. diabetese.g. diabetes



Effects of Impaired SomesthesiaEffects of Impaired SomesthesiaLord et al. (1991)Lord et al. (1991)

•• Somesthesia is the most Somesthesia is the most important sensory system for important sensory system for staticstatic postural stabilitypostural stability

•• Increased body sway with eyes Increased body sway with eyes open is associated with:open is associated with:•• Decreased tactile sensitivityDecreased tactile sensitivity•• Decreased joint position senseDecreased joint position sense•• Decreased vibration senseDecreased vibration sense


Assessment of Assessment of ProprioceptionProprioception((SomatosenorySomatosenory EPs)EPs)

•• TibialTibial nerve nerve SomatosensorySomatosensory Evoked Evoked Potentials (SEP)Potentials (SEP)•• Permits as assessment of neural Permits as assessment of neural

conduction through the conduction through the neuraxisneuraxis•• Assessment of:Assessment of:

•• Distal sensory nerve conductionDistal sensory nerve conduction•• Conduction in dorsal columns Conduction in dorsal columns

((proprioceptionproprioception), and), and•• Central Central somestheticsomesthetic pwypwy rostral to rostral to

dorsal column nucleidorsal column nuclei



Normal Tibial n. SEPNormal Tibial n. SEP

Received by Received by the brain herethe brain here

Passing through Passing through the knee herethe knee here

Time


Assessment of Vibration Assessment of Vibration SenseSense

•• Bone vibrator is placed at the great Bone vibrator is placed at the great toe, ankle, and toe, ankle, and tibialtibial tuberositytuberosity(lower) and thumb, wrist, and elbow (lower) and thumb, wrist, and elbow (upper).(upper).

•• A threshold is obtained in 5dB steps A threshold is obtained in 5dB steps (ascending).(ascending).

•• This procedure is repeated six timesThis procedure is repeated six times


Assessment of Vibration Assessment of Vibration SenseSense


Assessment of Assessment of Vibration SenseVibration Sense


VestibuloVestibulo--ocular ocular ReflexReflex


Effects of Impaired VOR in Effects of Impaired VOR in ElderlyElderly

•• Age reduces numbers of hair cells Age reduces numbers of hair cells and vestibular neuronsand vestibular neurons

•• VOR gain decreases by 35% when VOR gain decreases by 35% when pts < 40 yrs are compared to pts < 40 yrs are compared to >>40 yrs 40 yrs for high velocity signalsfor high velocity signals

•• Causes progressive bilateral deficitCauses progressive bilateral deficit•• Results in retinal slip and poor visual Results in retinal slip and poor visual

acuity during head movementsacuity during head movements


Assessment of VORAssessment of VOR(Odds ratios = 1.09(Odds ratios = 1.09--6.0)6.0)

•• Electronystagmography (ENG)Electronystagmography (ENG)

•• Rotary Chair testingRotary Chair testing


Assessment of VORAssessment of VORENGENG

•• Electronystagmography (ENG)/(VNG)Electronystagmography (ENG)/(VNG)•• ““GoldGold--standardstandard”” for identification for identification

of canal paresis (unilateral, of canal paresis (unilateral, bilateral)bilateral)

•• Assesses function of vestibular Assesses function of vestibular system at ~ 0.003 Hzsystem at ~ 0.003 Hz

•• Provides a means of identification Provides a means of identification of disorders of ocular motilityof disorders of ocular motility


VNGVNG


Electronystagmography: Electronystagmography: Bithermal Caloric TestBithermal Caloric Test


Assessment of VORAssessment of VORRotary Chair TestingRotary Chair Testing

•• Permits an assessment of the VOR Permits an assessment of the VOR over a broader area of its operating over a broader area of its operating range (.01range (.01--.64 Hz), and can .64 Hz), and can document:document:•• ……central compensation for central compensation for

unilateral peripheral deficitsunilateral peripheral deficits•• ……bilateral reductions in peripheral bilateral reductions in peripheral

vestibular system function.vestibular system function.


Rotational Chair SystemRotational Chair System


Rotary Chair ReportRotary Chair Report


•• Computerized Dynamic Computerized Dynamic Posturography (CDP)Posturography (CDP)•• Measure of ability of patient to Measure of ability of patient to

make use of vestibular, visual, make use of vestibular, visual, and proprioceptive inputs to and proprioceptive inputs to remain upright

Assessment of Postural StabilityAssessment of Postural Stability(Odds ratio = 1.4(Odds ratio = 1.4--8.0 depending on disease causing 8.0 depending on disease causing

instability)instability)

remain upright


Computerized Dynamic Computerized Dynamic PosturographyPosturography (CDP)(CDP)


SwaySway--referenced Platform and referenced Platform and SurroundSurround

Condition 3Condition 3

Condition 4Condition 4


Sensory Organization SubtestSensory Organization SubtestEquitestEquitest ProtocolProtocol


SOT SOT –– Schematic Representation of Schematic Representation of Condition 1Condition 1


SOT Normal ExaminationSOT Normal Examination


SOT Bilateral Vestibular SOT Bilateral Vestibular End Organ ParesisEnd Organ Paresis


Functional Assessment Functional Assessment of Gait and Balanceof Gait and BalanceTimed Timed ““Up and GoUp and Go”” Test Test

((PodsiadloPodsiadlo and Richardson, 1991)and Richardson, 1991)•• Simple functional measure that is Simple functional measure that is

predictive of fallspredictive of falls•• ““Get up out of a chair, walk 3 meters Get up out of a chair, walk 3 meters

as quickly and safely as possible, as quickly and safely as possible, cross a line marked on the floor, turn cross a line marked on the floor, turn around, walk back, sit down.around, walk back, sit down.””


Timed Timed ““Up and GoUp and Go”” TestTest


Common Factors Affecting Common Factors Affecting GaitGait

•• Neurological diseasesNeurological diseases (e.g. stroke, (e.g. stroke, ParkinsonParkinson’’s D.)s D.)

•• OsteoarthritisOsteoarthritis•• Peripheral neuropathiesPeripheral neuropathies (e.g. (e.g.

diabetic, traumatic)diabetic, traumatic)•• PeriventricularPeriventricular white matter diseasewhite matter disease

((““white matter signal abnormalitywhite matter signal abnormality”” T2 T2 weighted MRI; e.g. weighted MRI; e.g. MasdeuMasdeu et al. et al. 1989; Benson et al. 2002)1989; Benson et al. 2002)


VisionVision


Assessment of Visual FunctionAssessment of Visual Function(Odds ratio = .73(Odds ratio = .73--5.5)5.5)

•• CorneoCorneo--retinal potentialretinal potential (derived (derived indirectly from ENGindirectly from ENG

•• Ocular motilityOcular motility (obtained from ENG (obtained from ENG examination)examination)

•• Visual acuity (Visual acuity (SnellenSnellen))

•• More recently = Contrast SensitivityMore recently = Contrast Sensitivity(Melbourne Edge Test)(Melbourne Edge Test)


Assessment of Vision in the Assessment of Vision in the ElderlyElderly

•• Visual functions that normally Visual functions that normally change in elderly:change in elderly: visual acuity, visual acuity, darkness adaptation, smooth pursuitdarkness adaptation, smooth pursuit

•• Diseases affecting vision:Diseases affecting vision: cataracts, cataracts, glaucoma & macular degenerationglaucoma & macular degeneration

•• Impairments:Impairments: cloudy vision, impaired cloudy vision, impaired peripheral vision and impaired peripheral vision and impaired central visioncentral vision


Simulations of Visual Simulations of Visual ImpairmentsImpairments

Gary P. Jacobson, Ph.D.Gary P. Jacobson, Ph.D.Division of AudiologyDivision of Audiology


NearNear--sighted (myopia)/Farsighted (myopia)/Far--sightedsighted


CataractCataract


Macular DegenerationMacular Degeneration


AstigmatismAstigmatism


Macular DegenerationMacular Degeneration


GlaucomaGlaucoma


Cataract and Cataract and DiplopiaDiplopia


CorneoCorneo--retinal potential retinal potential (Derived indirectly from ENG)(Derived indirectly from ENG)

•• CRP provides CRP provides ““indirectindirect”” information information about the strength of the eye about the strength of the eye ““batterybattery””

•• Direct measure = Direct measure = electroretinographyelectroretinography(ERG)(ERG)


CRP (uV/deg) PercentilesCRP (uV/deg) Percentiles

SexSex 11stst 55thth 1010thth 1515thth 2020thth 5050thth 8080thth 8585thth 9090thth 9595thth 99t99thh

MM 7.17.1 8.28.2 9.29.2 9.59.5 10.410.4 13.813.8 17.317.3 19.119.1 19.919.9 21.821.8 25.825.8

FF 9.09.0 10.810.8 11.411.4 13.013.0 13.213.2 17.217.2 21.721.7 22.222.2 24.524.5 27.327.3 28.228.2


Examples of Patients with Examples of Patients with Reductions in CRPReductions in CRP

•• Top:Top: 80 80 yoyo F with F with dxdx of advanced of advanced glaucoma with glaucoma with hypertensive hypertensive retinopathy (5.3 retinopathy (5.3 uV/deg)uV/deg)

•• Bottom:Bottom: 69 69 yoyo M M patient with patient with diabetic diabetic retinopathy (6.4 retinopathy (6.4 uV/deg)uV/deg)


Assessment of Visual AcuityAssessment of Visual Acuity

•• SnellenSnellen ChartChart•• Patient stands Patient stands

2020’’ awayaway•• Vision tested Vision tested

monocular and monocular and binocular, binocular, uncorrected and uncorrected and ““best correctedbest corrected””


Edge Contrast Sensitivity Edge Contrast Sensitivity (Melbourne Edge Test)(Melbourne Edge Test)


Melbourne Edge TestMelbourne Edge TestScoringScoring

Excellent contrast Excellent contrast vision vision Good contrast vision Good contrast vision 2020Fair contrast vision Fair contrast vision 1616Poor contrast vision Poor contrast vision 11

–– 2424––

--2323––

--1919––

--1515


Effect of Impaired VisionEffect of Impaired Vision

•• Asymmetric acuityAsymmetric acuity (e.g. (e.g. following unilateral cataract following unilateral cataract removal) is associated with removal) is associated with impaired depth perceptionimpaired depth perception

•• Impaired contrast sensitivityImpaired contrast sensitivityresults in difficulty perceiving results in difficulty perceiving edges (steps, tree roots, gutters edges (steps, tree roots, gutters etc)etc)


Gary P. Jacobson, Ph.D.Gary P. Jacobson, Ph.D.Devin L. McCaslin, Ph.D.Devin L. McCaslin, Ph.D.

Vanderbilt Bill Wilkerson CenterVanderbilt Bill Wilkerson Center


Assessment of Falls Risk in a Assessment of Falls Risk in a Cohort of 76 Elderly PatientsCohort of 76 Elderly Patients


Patient Demographics Patient Demographics (N = 76)(N = 76)

•• Mean ageMean age = 75 yrs (sd 10 yrs, = 75 yrs (sd 10 yrs, range 40 yrs range 40 yrs –– 93 yrs)93 yrs)

•• GenderGender = 53 female, 70% of = 53 female, 70% of samplesample

•• History of previous falls (in or History of previous falls (in or outside the home)outside the home) = 61%= 61%


Directed HistoryDirected History

0

10

20

30

40

50

%

Risk Factors

>4 prescriptionsDisequilibriumDiabetesHypertensionCVAOsteoporosisHeart DiseaseOsteoarthritis


Numbers of Risks Per PatientNumbers of Risks Per PatientFrom Results of Risk of Falls AssessmentFrom Results of Risk of Falls Assessment

02468

101214

No. Pts.

1 risk2 risks3 risks4 risks5 risks6 risks7 risks


Cognitive/Psychological Cognitive/Psychological FactorsFactors

•• MMSE:MMSE: Mean = 27 pts. (range = 14Mean = 27 pts. (range = 14--30 30 pts. normal = 23pts. normal = 23--30 pts.)30 pts.)•• Abnormal performance in 11% of Abnormal performance in 11% of

cohort (smaller % than expected)cohort (smaller % than expected)•• Depression:Depression: Mean = 10 pts. (range = Mean = 10 pts. (range =

00--24 pts)24 pts)•• Abnormal performance in 33% of Abnormal performance in 33% of

cohort (approx. proportional to that cohort (approx. proportional to that seen in elderly seeking medical seen in elderly seeking medical care)care)


Orthostatic HypotensionOrthostatic Hypotension•• Defined as decrease in systolic blood Defined as decrease in systolic blood

pressure on standingpressure on standing……•• by by >> 20 mm Hg, or, 20 mm Hg, or, •• to < 90 mm Hgto < 90 mm Hg

•• Postural hypotension was observed Postural hypotension was observed in 18 patients or 24% of the sample. in 18 patients or 24% of the sample. •• Similar to % observed in elderly on Similar to % observed in elderly on

antihypertensive medicationsantihypertensive medications


Timed Timed ““Up and GoUp and Go”” TestTestTestTest Cut off Cut off

score score (sec)(sec)

SensitivSensitiv--ityity (% (% Fallers)Fallers)

SpecificiSpecifici--tyty (% Non (% Non fallers)fallers)

Overall Overall PredicPredic--tiontion (%)(%)

Predicted Predicted ProbabiliProbabili--tyty

TUGTUG >> 13.513.5 8080 100100 9090 .77.77

TUG TUG manualmanual

>> 14.514.5 86.786.7 93.393.3 9090 .5.5

TUG TUG cognitivecognitive

>> 1515 8080 93.393.3 86.786.7 .5.5


GaitGait

•• Mean elapsed time = 13.5 sec.Mean elapsed time = 13.5 sec.•• Range = 6 Range = 6 –– 42 sec.42 sec.

•• 26 patients (34%) demonstrated 26 patients (34%) demonstrated abnormal performanceabnormal performance


Visual AcuityVisual Acuity

•• Effect on postural stability when Effect on postural stability when acuity is 20/50 or poorer (Brandt, acuity is 20/50 or poorer (Brandt, 1985)1985)


Visual AcuityVisual AcuityBest Corrected Binocular VisionBest Corrected Binocular Vision

•• >> 20/50 = 33%20/50 = 33%•• >> 20/70 = 20%20/70 = 20%•• >> 20/100 = 10%20/100 = 10%


VestibuloVestibulo--ocular Reflexocular Reflex•• Unilateral weakness (asymmetry):Unilateral weakness (asymmetry):

mean asymmetry for group = 17% (sd mean asymmetry for group = 17% (sd 17%; range 017%; range 0--88%)88%)•• UW = 23 patients (31%).UW = 23 patients (31%).

•• Rotary Chair abnormalities:Rotary Chair abnormalities:•• 44 patients (64%) 44 patients (64%)

•• Total combined = Total combined = 76% of sample 76% of sample showed evidence of vestibular showed evidence of vestibular system impairmentssystem impairments


Falls in Patients With Falls in Patients With Vestibular DeficitsVestibular Deficits

HerdmanHerdman et al. (2000)et al. (2000)•• Examined frequency of falls for Examined frequency of falls for

patients with unilateral and bilateral patients with unilateral and bilateral peripheral vestibular deficitsperipheral vestibular deficits

•• N = 70 (unilateral) & 45 (bilateral)N = 70 (unilateral) & 45 (bilateral)•• Mean age 63 yrs (Mean age 63 yrs (++ 14 yrs)14 yrs)•• Compared to numbers of falls for Compared to numbers of falls for

communitycommunity--dwelling adultsdwelling adults


Falls in Patients With Falls in Patients With Vestibular DeficitsVestibular Deficits

HerdmanHerdman et al. (2000)et al. (2000)•• Results:Results:

•• Unilateral deficitsUnilateral deficits = incidence of = incidence of falls not different from that of falls not different from that of community dwelling adultscommunity dwelling adults

•• Bilateral deficitsBilateral deficits = significantly > = significantly > incidence of falls re: unilateral incidence of falls re: unilateral deficit patients and community deficit patients and community dwelling adultsdwelling adults


Patients with Normal Caloric Examination Patients with Normal Caloric Examination and Abnormal Rotary Chair Testand Abnormal Rotary Chair Test

-40

0

40

80

120

0.01 0.02 0.04 0.08 0.16 0.32

Normal Upper limit

CohortNormal Lower limit

0

40

80

120

0.01 0.02 0.04 0.08 0.16 0.32

Normal Upper limitCohort

Normal Lower limit

-100

-80

-60-40

-20

0

20

4060

80

100

0.01 0.02 0.04 0.08 0.16 0.32

Normal Upper limit

CohortNormal Lower limit

Phase Gain

Symmetry


Two Subgroups of Patients Two Subgroups of Patients Presented to Risk of Falls ClinicPresented to Risk of Falls Clinic

•• Group 1 Group 1 (control)(control)•• Normal caloric Normal caloric

examinationexamination•• Normal VOR Normal VOR

gain, phase and gain, phase and symmetry symmetry measures on measures on rotational rotational testing

•• Group 2 Group 2 ((experi.experi.--abnabn. VS. VS))•• Normal caloric Normal caloric

examinationexamination•• Normal VOR Normal VOR

gain, symmetry gain, symmetry but but multimulti--frequency phase frequency phase abnormalities on abnormalities on rotational testrotational test(min. 3 adjacent (min. 3 adjacent freq. beginning freq. beginning with 0.01 Hz)

testing

with 0.01 Hz)


Patients Patients –– Group 1Group 1


Patients Patients –– Group 2Group 2


SomesthesiaSomesthesiaL/SEPL/SEP

•• Tibial n. SEP Tibial n. SEP •• abnormalities were observed in abnormalities were observed in

73 patients (89%)73 patients (89%)••abnormalities supported abnormalities supported evidence of peripheral evidence of peripheral neuropathyneuropathy


TibialTibial n. SEPn. SEP

Normal sampleNormal sample PatientPatient


Postural StabilityPostural StabilitySensory Organization TestSensory Organization Test

•• Normal: 15 patients (20%)Normal: 15 patients (20%)•• Abnormal performance: 54 Abnormal performance: 54

patients (71%)patients (71%)•• Too unsteady to test (abnormal): Too unsteady to test (abnormal):

7 patients (9%)7 patients (9%)


SOT ConditionsSOT ConditionsPercent Abnormal on Individual ConditionsPercent Abnormal on Individual Conditions

7% 9% 13%

34% 50% 49%


SOT PatternsSOT PatternsPercent AbnormalPercent Abnormal CombinationsCombinations

0

35

2 3

45

3 5 7

05

1015202530354045

GROUP

VisualVestibularSomatosensoryPreferenceVis + VestSom + VestSom + Vis + VestSom + Vis + Vest + Pref


MultiMulti--modal Abnormalitiesmodal AbnormalitiesSnellenSnellen (acuity)/SEP ((acuity)/SEP (proprioceptionproprioception)/VOR)/VOR

•• Abnormalities in a single modality: Abnormalities in a single modality: 13%13%

•• Abnormalities in multiple modalities:Abnormalities in multiple modalities:•• Visual acuity + Visual acuity + proprioceptionproprioception = =

15%15%•• Visual acuity + Vestibular = Visual acuity + Vestibular = 3%3%•• Vestibular + Vestibular + proprioceptionproprioception == 50%50%•• Visual acuity + Visual acuity + proprioceptionproprioception + +

vestibular =vestibular = 19%19%


““MultisensoryMultisensory System ImpairmentSystem Impairment””

•• DrachmanDrachman and Hart, 1972 and Hart, 1972 –– coined the coined the termterm

•• TinettiTinetti, 2000 , 2000 -- feels that dizziness in feels that dizziness in elderly is a geriatric syndrome (i.e. it is elderly is a geriatric syndrome (i.e. it is multifactorialmultifactorial) like ) like deleriumdelerium and fallingand falling


Summary of N = 76Summary of N = 76•• We were surprised by the number of We were surprised by the number of

patients with unsuspected vestibular and patients with unsuspected vestibular and somestheticsomesthetic system impairments (70% +)system impairments (70% +)•• Of the Of the somatosensessomatosenses impairments of impairments of

proprioceptionproprioception and vibration are most and vibration are most predictive of those who fall (Lord et al. predictive of those who fall (Lord et al. 1991,1994) 1991,1994)

•• Commented on the relationship Commented on the relationship between peripheral neuropathy, loss of between peripheral neuropathy, loss of somesthesiasomesthesia and postural instability and postural instability and falls (Richardson et al. 1992; and falls (Richardson et al. 1992; HorakHorak, , 2001)2001)


Summary of N = 76Summary of N = 76

•• In In absenseabsense of intact of intact somestheticsomestheticinformation elderly rely on the slower information elderly rely on the slower visual sense to remain upright visual sense to remain upright ((PyykoPyyko et al. 1990)et al. 1990)•• CamicioliCamicioli et al. (1997) reported et al. (1997) reported

their elderly were more unstable on their elderly were more unstable on Condition 4 of SOT where vision is Condition 4 of SOT where vision is nonnon--distorted and distorted and somestheticsomestheticinformation is distorted, information is distorted,

•• Same as we observedSame as we observed


Future ConsiderationsFuture Considerations

•• PeriventricularPeriventricular white matter white matter diseasedisease


PeriventricularPeriventricular White Matter White Matter DiseaseDisease

Benson et al. 2002Benson et al. 2002•• Is significant when Is significant when

present present symmetrically in symmetrically in frontal and parietal frontal and parietal areasareas

•• High sensitivity for High sensitivity for identification of identification of patients with patients with reduced mobilityreduced mobility





Fife & Fife & BalohBaloh, 1993, 1993•• Fibers mediating longFibers mediating long--

loop reflexes pass loop reflexes pass through the through the periventricularperiventricular white white matter matter

•• These fibers traverse These fibers traverse great distances great distances connecting remote connecting remote sensory and motor sensory and motor cortical and cortical and subcorticalsubcortical sitessites

•• Lesions in these areas Lesions in these areas would affect would affect sensorimotorsensorimotorprocessing.processing.

Corona Radiata




Case StudyCase Study


Current HistoryCurrent History•• 85 85 yoyo male seen by ENT for an male seen by ENT for an

evaluation of dizziness. evaluation of dizziness.

•• Pt. wPt. w--hearing loss, bilateral tinnitus. hearing loss, bilateral tinnitus.

•• No vertigo, states that he staggers No vertigo, states that he staggers when he walkswhen he walks

•• DysequilibriumDysequilibrium X3 years (worsening X3 years (worsening over the last year)over the last year)


Past Medical HistoryPast Medical History•• HypertensionHypertension•• Degenerative arthritisDegenerative arthritis•• IDDM wIDDM w-- hxhx peripheral neuropathyperipheral neuropathy•• Anxiety disorderAnxiety disorder•• OD enucleated, OS wOD enucleated, OS w--diabetic diabetic

retinopathyretinopathy•• Coronary artery diseaseCoronary artery disease


Tests ConductedTests Conducted

•• MRI:MRI: mild chronic subcortical white mild chronic subcortical white matter ischemic changes.matter ischemic changes.

•• MRA:MRA: demonstrated mild narrowing demonstrated mild narrowing of the right and mildof the right and mild--moderate moderate narrowing of the left proximal narrowing of the left proximal internal carotid arteries, consistent internal carotid arteries, consistent with atherosclerotic with atherosclerotic stenosisstenosis


MedicationsMedications

•• LevoxylLevoxyl-- thyroidthyroid•• PrinivilPrinivil -- hypertensionhypertension•• InsulinInsulin-- diabetesdiabetes•• Assorted vitaminsAssorted vitamins


Risk of Falls AssessmentRisk of Falls Assessment

•• Postural hypotensionPostural hypotension: : Risk Risk existsexists (laying BP 165/65 p 59; (laying BP 165/65 p 59; standing BP 125/61 p60; standing BP 125/61 p60; standing X5 min. 167/73 p66)standing X5 min. 167/73 p66)

•• VisionVision: : Risk existsRisk exists (Uncorrected (Uncorrected OS vision = 20/70; corrected = OS vision = 20/70; corrected = 20/50)20/50)


Risk of Falls AssessmentRisk of Falls Assessment

•• Cognitive Function: Cognitive Function: Unlikely risk Unlikely risk (MMSE = 29/30)(MMSE = 29/30)

•• Depression: Depression: Risk existsRisk exists (GDS = (GDS = 13/30)13/30)

•• Gait:Gait: Unlikely risk (Time Unlikely risk (Time ““Get Up Get Up and Goand Go”” = 13 sec)= 13 sec)


Vestibular Function TestingVestibular Function Testing

•• VFT:VFT: Risk existsRisk exists•• Caloric exam = 27% UWCaloric exam = 27% UW•• Rotary chair examination = Rotary chair examination =

CNT (low CRP)CNT (low CRP)•• CDP = Vestibular + Visual CDP = Vestibular + Visual

patternspatterns


ENGENG


CDPCDP


Automatic Postural ResponsesAutomatic Postural Responses


ProprioceptionProprioception (somesthesia)(somesthesia)

•• Proprioception:Proprioception: Risk existsRisk exists•• LLE & RLE vibration thresholdLLE & RLE vibration threshold

> 40 dB HL> 40 dB HL) ) •• p. tibial n. SEP abs. bilaterallyp. tibial n. SEP abs. bilaterally•• bilateral median n. SEP bilateral median n. SEP

peripheral component abs. peripheral component abs. with delayed subcortical and with delayed subcortical and cortical componentscortical components


TibialTibial n. SEPn. SEP


Normal Tibial n. SEPNormal Tibial n. SEP


Median n. SEPMedian n. SEP


Normal Median n. SEPNormal Median n. SEP


Origins of InstabilityOrigins of Instability•• Postural hypotension (situational)Postural hypotension (situational)•• Visual impairment (low CRP, Visual impairment (low CRP,

monocular vision)monocular vision)•• Unilateral peripheral vestibular Unilateral peripheral vestibular

system disordersystem disorder•• DepressionDepression•• Somesthetic system impairment Somesthetic system impairment

(explains (explains abnabn automatic postural automatic postural responses)responses)


Recommended InterventionsRecommended InterventionsRisk factorRisk factor RecommendationRecommendationPostural hypotensionPostural hypotension Assessment of Assessment of htnhtn med med

by PCPby PCPVisual impairmentVisual impairment Ophthalmology Ophthalmology

assessment to r/o assessment to r/o diabetic retinopathydiabetic retinopathy

Vestibular impairmentVestibular impairment Physical therapy for Physical therapy for vestibular rehabvestibular rehab

DepressionDepression ReccRecc referral by PCP to referral by PCP to psychology/psychiatrypsychology/psychiatry

Somesthesia impairmentSomesthesia impairment Physical therapy for Physical therapy for assistive device/sassistive device/s


InterventionIntervention




Effects of InterventionsEffects of InterventionsLord et al. 2001Lord et al. 2001

StudyStudy FollowFollow--up up period (mo)period (mo)

Event rate Event rate --Control Control GroupGroup

Event rate Event rate --Treatment Treatment GroupGroup

Relative Relative Reduction Reduction in Risk in Risk (CER(CER--ERT/CER)ERT/CER)

Close et al. Close et al. (1999)(1999)

1212 52%52% 32%32% 38%38%

TinettiTinetti et al. et al. (1994)(1994)

1212 47%47% 35%35% 26%26%

Wagner et Wagner et al. (1994)al. (1994)

1212 37%37% 28%28% 24%24%

FabacherFabacher et et al. (1994)al. (1994)

1212 23%23% 14%14% 39%39%

HornbrookHornbrooket al (1994)et al (1994)

2323 44%44% 39%39% 11%11%


Outcomes of Falls InterventionsOutcomes of Falls InterventionsTinettiTinetti et al. (1994)et al. (1994)


Outcomes of InterventionsOutcomes of InterventionsTinettiTinetti et al. (1994)et al. (1994)

•• Followed 301 pts (148 controls, Followed 301 pts (148 controls, 153 in thx group) for 1 year153 in thx group) for 1 year

•• Targeted risk factors =Targeted risk factors =•• Postural hypotensionPostural hypotension•• Use of sedative medsUse of sedative meds•• >> 4 prescription meds4 prescription meds•• Impairment of balanceImpairment of balance


Outcomes of InterventionsOutcomes of InterventionsTinettiTinetti et al. (1994)et al. (1994)

•• Targeted risk factors (contTargeted risk factors (cont’’d) =d) =•• Unsafe transfers (bathroom, Unsafe transfers (bathroom,

bed)bed)•• Gait impairmentGait impairment•• Impaired leg strengthImpaired leg strength•• Impaired arm strength/motionImpaired arm strength/motion


Number of Subjects in Thx Group (N = 153)Number of Subjects in Thx Group (N = 153)

Risk FactorRisk Factor WW--risk risk factorfactor

# receiving # receiving interventionintervention

Postural hypotensionPostural hypotension 7070 6969Use of sedative medsUse of sedative meds 2929 2222Use of > 4 prescription medsUse of > 4 prescription meds 6565 5252Unsafe transfersUnsafe transfers 9898 8080Impaired gaitImpaired gait 9292 8686Impaired balanceImpaired balance 9595 8888Impaired leg strengthImpaired leg strength 5656 3737Impaired arm strength ROMImpaired arm strength ROM 4545 2020


Incidence of Falls at 1 yr F/UIncidence of Falls at 1 yr F/UOutcomeOutcome Treated GroupTreated Group ControlsControls

# pts w# pts w--fallsfalls 5252 6868

# of falls# of falls 9494 164164

# pts w# pts w--falls requiring med falls requiring med carecare

2121 2626

# falls requiring med care# falls requiring med care 2525 3636

# falls resulting in serious # falls resulting in serious injinj..

1313 1818

# hospitalizations (days)# hospitalizations (days) 45 (300)45 (300) 60 (671)60 (671)


CostCost--effectiveness of effectiveness of InterventionsInterventions

TinettiTinetti et al. 1994et al. 1994•• After 1 yr treatment group had mean After 1 yr treatment group had mean

decline of 1.1 risk factorsdecline of 1.1 risk factors•• Cost of interventions were $891/pt.Cost of interventions were $891/pt.•• Cost per fall prevented = $1,947Cost per fall prevented = $1,947•• Cost per fall requiring medical care = Cost per fall requiring medical care =

$12,392$12,392•• In 1994 $In 1994 $’’s = close to s = close to aveave. cost per . cost per

hospitalization of elderly who have hospitalization of elderly who have fallfall--related injuriesrelated injuries


CostCost--effectiveness of effectiveness of InterventionsInterventions

•• Cost savings also include:Cost savings also include:•• Reduction in incidence of falls (and Reduction in incidence of falls (and

fallfall--related hospitalizations)related hospitalizations)•• Improvement in functional Improvement in functional

independenceindependence•• Increase in patientIncrease in patient’’s confidence in s confidence in

performing daily activitiesperforming daily activities


Gary P. Jacobson, Ph.D.Gary P. Jacobson, Ph.D.Devin L. McCaslin, Ph.D.Devin L. McCaslin, Ph.D.

Vanderbilt Bill Wilkerson CenterVanderbilt Bill Wilkerson Center


Development of a Risk of Falls Development of a Risk of Falls Assessment ClinicAssessment Clinic


EndEnd


Assessment of Somesthesia in Assessment of Somesthesia in the Elderlythe Elderly

•• Age results in decreased ability Age results in decreased ability to detect passive movement of to detect passive movement of the foot (direction and position).the foot (direction and position).

•• Associated with disorders Associated with disorders causing distal peripheral causing distal peripheral neuropathiesneuropathies•• e.g. diabetese.g. diabetes


Effects of Impaired SomesthesiaEffects of Impaired SomesthesiaLord et al. (1991)Lord et al. (1991)

•• Somesthesia is the most important Somesthesia is the most important sensory system in maintenance of sensory system in maintenance of staticstatic postural stabilitypostural stability

•• Increased body sway on either firm Increased body sway on either firm or compliant surface with eyes open or compliant surface with eyes open is associated with:is associated with:•• Decreased tactile sensitivityDecreased tactile sensitivity•• Decreased joint position senseDecreased joint position sense•• Decreased vibration senseDecreased vibration sense


Documents

The Assessment of Falls Risk in the Elderlystorage.googleapis.com/wzukusers/user-18795294... · • Bone vibrator is placed at the great toe, ankle, and tibial tuberosity (lower)