2/1/2016
By Dr. D. Charmane Kandt
FHSU Neuromuscular Wellness Center
Fort Hays State University



Although, the CDC reports that 50% of people over the age of 75 will have had at least one fall (defined as a fall to the ground)
Accidents are the 5th leading cause of death in this age group of which 2/3 are from falls
Evidence based fall prevention programs report average improvements in fall rates of around 30% Fall death rates


According to the CDC, adjusted for inflation costs are around 34 billion annually. In 2011, emergency departments treated 2.4 million nonfatal fall injuries among older adults; more than 689,000 of these patients had to be hospitalized. Today, they report 2.5 million injuries and over 700,000 hospitalized. Circumstances
Hit hip/thigh when fall
Hit hand when fall
Hit knee when fall
Fell sideways vs other
directions
Fell forward vs other
directions
Fell backward vs other
directions
Odds Ratio
95% CI
48.6
0.42
0.26
3.17
22.5-105
0.23-0.76
0.14-0.49
1.78-5.66
0.22
0.12-0.38
1.03
0.53-1.99
 Of those hospitalized, 50% will not be alive one year later.
Risk of death is greatest in men following hip fracture, particularly in the first 3 months following surgery. The risk is still around 20% 10 years following the fracture.



Falls backward lying flat resulted in fewer hip injuries if the person then sat down. When they fell back and hit their head, there was greater injury.
Elderly on anticoagulants are at risk for subdural hematoma if they hit their head.
Head injuries and hip injuries are the areas that can cause the greatest morbidity and mortality.
Age adjusted OR; Schwartz et al. 1998
1
2/1/2016



















Frail (muscle weakness) very large predictor. Number one in some studies.
Fear of Falling
Previous falls > 1 with injury in one year
Over the age of 75
Poor cardiovascular health:
Arrhythmias, postural hypotension, peripheral artery disease
Dehydration








Poor visual acuity (macular degeneration, cataracts, and multifocal eye glasses)
Cognitive disorders
Vertigo (vestibular problems)
Orthopedic problems
Neuromuscular disorders (especially undiagnosed)
Depression
Arthritis
Biomechanics such as shuffling and toeing out.
Poor nutrition: low calorie (low muscle strength, low bone mass, lack of alertness) low salt, low potassium, overweight, and diabetes. Poor lighting (especially on stairs inside and out).
Bathroom rugs with no backing, slick or wet floors. Area rugs with raised edge.
Storage of frequently used items in out of reach places.
Bathrooms are the room where the most serious falls occur. Grab bars, shower chairs, mats and shoes can help prevent falls.
Furniture: too much, close to doorways
Uneven flooring or things stored on the floor.
No hand rails. Hand rails should be on both sides of the hall (stroke patients)
Improper use of assistive devices or not using assistive devices all the time. From experience and use of physical principles, I encourage using the devices just for stability not leaning or pushing against. If you push against, the force works best if it is straight down and into the floor. I like the walkers that have a place to sit down to rest.
Poor footwear is a major factor in falls, thick rubbery soles or loose sloppy house shoes.
Clothing that is too loose and long (robes).
Medications: antidepressants, sedatives, benzodiazepines, and neuroleptics. Digoxin, diuretics (electrolyte imbalances)
2
2/1/2016
One reason for the increase in the number of falls may be that the elderly are simply reporting them more. Falls in the elderly tend to go unreported for a variety of reasons:  They may feel they will lose their independence
 Be put on more medication  They may be embarrassed.  Some may not want to bother anyone
 They may simply forget that they fell
 As when they were young, a fall may be no big deal.




It is important to educate your patients that if they do not report their fall, they more than double their risk of having another fall.
Not only that, but fear of falling is, by itself, an independent risk for future falls.
When health providers know, they can find the cause; be it environment, medication, a new disease, or a condition and treat it.
Not only will you need to educate, but you will need to assess, and observe your residents or patients
3
2/1/2016

















Slow speed and fear of speeding up
Increased stride frequency
Stride length decreases at any given speed
Double support time increases
Weight on the balls of the feet
Reaching for support

Timed Get Up and Go Test Measures mobility in people who are able to walk on their own (assistive device permitted) Instructions: The person may wear their usual footwear and can use any assistive device they normally use. 1. Have the person sit in the chair with their back to the chair and their arms resting on the arm rests. 2. Ask the person to stand up from a standard chair and walk a distance of 10 ft. (3m). 3. Have the person turn around, walk back to the chair and sit down again. Timing begins when the person starts to rise from the chair and ends when he or she returns to the chair and sits down. The person should be given 1 practice trial and then 3 actual trials. The times from the three actual trials are averaged. Predictive Results Seconds Rating <10 Freely mobile
<20 Mostly independent 20‐29 Variable mobility >20 Impaired mobility 

Source: Podsiadlo, D., Richardson, S. The timed ‘Up and Go’ Test: a Test of Basic Functional Mobility for Frail Elderly Persons. Journal of American Geriatric Society. 1991; 39:142‐148 
According to the Center for Disease Control 35% of nursing home falls occur in persons who cannot walk

In May 2013, the U.S. National Library of Medicine reported a study that connected the use of nonbenzodiazepine sleep medications with nursing home falls and fractures. The study focused on nonbenzodiazepine hypnotic drugs, such as eszopiclone, zolpidem tartrate, and zaleplon that may be used to help nursing home patients sleep. The study concluded that elderly patients taking nonbenzodiazepine sleep medications were at an increased risk of nursing home falls. This nursing home patient risk was most significant for those who were taking the drug for the first time or suffered from cognitive difficulties.








Visual, notice risk everyday
Talk to patients often about dizziness, lightheadedness, and fear of falling. When you give meds.
Assessment tools annually, Timed get up and Go, OT assessment (of environmental hazards), medication review, ADL assessment, vision screening, cognitive evaluation.
Timed Get up and Go
One Legged Stance Test
30 second Chair Stand Test
Four Stage Balance Test
Dynamic Gait Index
Berg Balance Scale
Textbook definition of body balance is the position of it’s center of mass (or gravity) over it’s base of support with little movement or sway.
4
2/1/2016
Center of Mass
Balance
The point at which the sum of all the mass or weight of a body is equal to 0
A body is balanced when it’s center of mass is centered over it’s base of support. This person is maneuvering his limbs around his center of mass so that he can keep it over that one leg on the rope.
All of our body parts are involved in balance. Sudden shifts of body weight of the upper body will alter balance.
When it is difficult to move your lower body, you may overreach or turn your upper body without moving your feet.
Stroke patients are a good example.

Robinovitch, et. al. reported that 41% of nursing home falls in commons areas were due to improper weight shift. They video taped 227 falls in 130 elderly residents. They hypothesized that video taping was better than relying on patient recall. 
Different weight distributions 
Point out visual cues (nose over toes)

One foot slightly forward

Sit down with a bend forward





C of M over base of support

He has a visual cue of seeing his chest over his knee
Easy to sit No turning
No freezing
Visual
5
2/1/2016





Stand tall, eyes straight ahead
Swing legs in line with hips
Arm swing and leg swing occurs exactly together “Boom”
Foot lands on back of heel
Weight transfers forward








Weight on the up stair
Stay tall
Kick out with the downhill foot until the back of the heel touches the stair
Downhill leg is straight
Practice at parallel bars in front of a mirror.
Stretch – hams, quads, gluts and Achilles
Be certain they can flex their foot
Practice striking with the heel first
CHIN DRIFTING FORWARD


CHIN MORE IN LINE WITH CHEST
Verbal cue:
“Boom”
This is a TUG test.




Whole foot on the stair
Chest over the up stair
Arms lead forward up the rails
Continue to lean forward and walk away at top of stairs
6
2/1/2016
RELAXED
ATTENTION TO POSTURE

Information from the National Institute for Occupational Safety and Health indicates stooped posture is closely associated with a high incidence of low back disorders, including injuries to muscles, nerves, discs, and ligaments of the low back.

Please note that the COM is in front of his toes NOT over his base of support.

This will encourage heel lift (resulting in toe drop) and shuffling.

Many elderly may have the muscle stiffness and short stride/shuffle like Parkinson’s patients
Any person with those characteristics should be evaluated by a physician or neurologist, especially if they have propulsion or retropulsion. Medications for Parkinson’s will greatly reduce falls in those patients. About 15‐20% may have no tremor.

PROPULSION

propulsion /pro∙pul∙sion/ (pro‐pul´shun)1. a tendency to fall forward in walking.2. festination
(an involuntary tendency to take short accelerating steps in walking.)

RETROPULSION

ret∙ro∙pul∙sion (rĕt′rō‐
pŭl′shən)n.1. An involuntary backward walking or running, as seen in Parkinsonism..

The American Heritage® Medical Dictionary Copyright © 2007, 2004 by Houghton Mifflin Company. Published by Houghton Mifflin .
Company. All rights reserved

Notice where the COM is when reaching. If he misses the table, he is down. Handled reachers work well in this case, but it is also good to make that walk over to the table.
Dorland's Medical Dictionary for Health Consumers. © 2007 by Saunders, an imprint of Elsevier, Inc. All rights reserved.
7
2/1/2016























STEADI
STEPPING ON
A Matter of Balance
SAIL
The National Council on Aging offers more information on their website. Locally, Hays Medical Center offers a Fall Prevention Program and the FHSU Neuromuscular Wellness Center can follow that care with strength, conditioning, and practice as long as the patient would like.

These programs include the physician, physical therapist, and occupational therapist along with patient education and education materials.
Stretching – neck, back, shoulders, trunk rotation, glut., hamstrings, quad, ankles, calves. 30 min of low to medium level activity on a recumbent stepper or a treadmill.
Balance activities at parallel bars
Stair climbing (except those with bad knees or hips)
Specific strengthening with weights and coordination activities
Assisted walking (holding a gait belt while they walk) with feedback about performance.










The Primary Care Physician‐ they are invaluable in evaluating, shaping behavior, and supporting your efforts.
The physical therapist
The occupational therapist
The dietician
The more the patient hears from professionals, the more meaning it will have.
Falls are not part of the aging process
They are highly debilitating and expensive
Focus on one’s center of mass and biomechanics can give a visual strategy that compensates for other disabilities
Other preventative strategies and other health professionals can provide a multifaceted approach to fall prevention
Regular exercise and assisted practice can be important facilitators in maintaining gait and balance
Backward disequilibrium in elderly subjects. Manckoundia,Patrick et. al. Clinical Interventions in Aging. 2008 Dec; 3(4): 667–672.
Bhatta, Charya, DO., M.P.H., Department of Family Medicine, PPT presentation, public access, Kansas Reynolds Program in Aging, University of Kansas Medical Center
Center for Disease Control Website http://www.cdc.gov/homeandrecreationalsafety/falls/fallcost.html and http://www.cdc.gov/steadi/videos.html
Characteristics of Falls and Risk of Hip Fracture in Elderly Men. Schwartz, A. V. et. al. Osteoporois International, May 1998, Volume 8, Issue 3, pp 240‐246
Circumstances and outcomes of falls among high risk community‐dwelling older adults. Stevens, Judy A , et. al. Injury Epidemiology 2014 1:5.
Lord SR, Dayhew J, Howland A. Multifocal glasses impair edge‐contrast sensitivity and depth perception and increase the risk of falls in older people. Journal of the American Geriatrics Society 2002:50(11), pp. 1760‐1766. http://www.toyourhealth.com/mpacms/tyh/article.php?id=632
http://www.merckmanuals.com/professional/geriatrics/gait‐disorders‐in‐the‐elderly/gait‐disorders‐in‐the‐
elderly
National Council on Aging http://www.cdc.gov/steadi/videos.html
One legged stance test ,http://physical‐therapy.advanceweb.com/Article/One‐Legged‐Single‐Limb‐Stance‐
Test.aspx
Spiruduso, Waneen, EdD., et.al. The Physical Dimensions of Aging, 2nd ed. Human Kinetics: Champagne, IL., 2005, pp 132,150‐151
Video capture of the circumstances of falls in elderly people residing in long‐term care: an observational study
Stephen N Robinovitch, PhD, et. al. Lancet. 2013 Jan 5; 381(9860): 47–54.
8