1 Rehabilitation Approach to Falls in the ElderlyJames G. Beegan, M.D. Dayton Center for Neurological Disorders 1975 Miamisburg-Centerville Road Centerville OH 45459 Rehabilitation Approach to Falls in the Elderly

2 Goals: Review causes of falls in the ElderlyOutline a practical diagnostic approach to patients at risk for falls Consider treatment protocols for patients at risk for falls in terms of efficacy, safety, compliance and cost “Goals dictate tools, tools dictate actions” -Machowicz (2000) Adapted from Machowicz RJ. “Unleash the Warrior Within”. Marlowe and Company, The correct quote: “Target dictates weapon, weapon dictates movement” Adapted from Machowicz RJ. “Unleash the Warrior Within”. Marlowe and Company, The correct quote: “Target dictates weapon, weapon dictates movement”

3 Tools: Pre-test Lecture with discussion Questions and commentary Post-test

4 Pre-Test: 1. Regarding falls in the elderly,which is true:Not much research exists about falls in the elderly; recommendations are based primarily on common sense interventions The cause of most falls in the elderly can be isolated to one main problem in each patient With appropriate interventions, almost all falls in the elderly can be avoided Despite body composition changes, exercise is a useful intervention for fall risk reduction in the elderly* 10

5 Pre-Test: 2. Regarding falls in the elderly, which is true:According to the CDC, fall risk in nursing home residents increases 3 times in the two days following medication changes* Approximately 1 out of 4 nursing home residents fall each year 5% of patients who sustain a hip fracture die within one year Educational lectures provided by experts are helpful for preventing falls in the elderly 10

6 A Rehabilitation Perspective on Life“Independent, ambulatory adulthood is a temporary state of being” Impairment/Disability/Handicap; these things are not equal!

7 Why Don’t We all Fall Constantly?Vision Somatosensory system Vestibular system Motor control and feedback Muscular power and joint stability Cognition Safe environment

8 Epidemiology of Falls in the Elderly

9 Epidemiology of Falls among Older Adults 1: How many?More than 1/3 of American adults 65 and older fall each year (Hausdorff, 2001) 1.8 million Americans 65 and older received emergency department treatment for non-fatal injuries from falls in ,800 died immediately from fall-related injuries (CDC 2005) Risk of falls for those 85 and older roughly double that of those (Evans, 1988) 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): Evans JG. Falls and Fractures. Age Ageing 1988;17: 361-4 Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) 2005: 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): Evans JG. Falls and Fractures. Age Ageing 1988;17: 361-4 Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) 2005:

10 Epidemiology 2: How Costly?20 to 30% of the elderly who fall suffer moderate to severe injuries, with injury severity worse than in young people and disproportionate to the fall mechanism (Sterling, 2001) Direct medical costs of fall related injuries was over 19 billion in (Stevens, 2006) Direct and Indirect cost of fall injuries expected to reach 54.9 billion by 2020 (Stevens, 2006) Many suffer long-term psychological harm from falls; falls harm quality of life Sterling, DA, O’Connor JA, Bonadies J. Geriatric falls: injury severity is high and disproportionate to mechanism. Journal of Trauma-Injury, Infection and Critical Care 2001; 50(1): Stevens, JA. Fatalities and injuries from falls among older adults. MMWR 2006;55 (45) Sterling, DA, O’Connor JA, Bonadies J. Geriatric falls: injury severity is high and disproportionate to mechanism. Journal of Trauma-Injury, Infection and Critical Care 2001; 50(1): Stevens, JA. Fatalities and injuries from falls among older adults. MMWR 2006;55 (45)

11 Epidemiology 3:Injuries from fallsMost common non-fatal injury: fracture, accounting for 1/3 (and 61% of costs). Hip fractures were the most common type. (Stevens, 2006) Most common fatal injuries: traumatic brain injury, and injuries to the lower limbs, accounting for 78% of fatalities and 79% of costs. (Stevens, 2006)

12 Epidemiology 4: Hip Fractures320,000 hospital admissions for hip fracture in (CDC, 2008) 20% of hip fracture patients die within one year of the injury (Leibson 2002) 25% of those who lived independently prior to the hip fracture require nursing home placement for at least one year (Leibson 2002) 76% of hip fractures occur in women (CDC 2008) National Center for Health Statistics, Trends in Health and Aging. Leibson, et al. Mortality, disability, and nursing home use for persons with and without hip fracture: a population based study. Journal of the American Geriatrics Society 2002;50: National Center for Health Statistics, Trends in Health and Aging. Leibson, et al. Mortality, disability, and nursing home use for persons with and without hip fracture: a population based study. Journal of the American Geriatrics Society 2002;50:

13 Epidemiology 5: Nursing Homes5% of those 65 or older reside in nursing homes, but this group accounts for 20% of deaths from falls (Rubenstein 1997) A typical nursing home with 100 beds reports falls per year; about 3 out of 4 residents fall per year (Rubenstein 1997) Rubenstein LZ. Preventing falls in the nursing home. Journal of the American Medical Association 1997;278(7):595-6 Rubenstein LZ. Preventing falls in the nursing home. Journal of the American Medical Association 1997;278(7):595-6

14 Goal (Target): Prevent Falls in the ElderlyTools (weapons): education, exercise, medical interventions, therapeutic interventions, alteration of environment Actions (movement): group meetings and group exercise, individual instruction and training, family training, physician and pharmacist consultations, physical and occupational therapy, living environment evaluation and modification. “Improve what can be improved, adapt the rest as much as possible” – Earnest Johnson M.D. (1995) personal correspondence

15 Now for the Bad News

16 Conclusions regarding Fall Prevention in the Elderly:Optimal interventions, which are relatively costly and labor-intensive, reduce falls % in the best studies

17 “You can’t be afraid to fail”-Lebron James

18 Risk Factors

19 Causes of Falls in the ElderlyFalls in those over 65 are almost always multi- factorial, and represent a “final common pathway” for multiple impairments Many of the factors causing falls in the elderly are not completely treatable Falls are symptoms of the problem(s) in this population, not the problem itself

20 Risk Factors for Falls Demographic Historical Impairment-relatedMedication-related Environmental Psychological Adapted from Fuller, GF. Falls in the elderly. Adapted from Fuller, GF. Falls in the elderly.

21 Risk Factors: DemographicRate of falls causing injuries is 4 to 5 times higher in those over 85 than those (Stevens, 2005). Advanced age (“the old old”) is the biggest demographic risk factor Other demographic risk factors for fall- induced injuries include white race, female sex (although males have higher risk of fatal falls), and living alone Stevens JA, Sogolow ED. Gender differences for non-fatal unintentional fall related injuries among older adults. Injury Prevention 2005;11:115-9. Stevens JA, Sogolow ED. Gender differences for non-fatal unintentional fall related injuries among older adults. Injury Prevention 2005;11:115-9.

22 Risk Factors:Patient HistoryPrevious Fall, especially recurrent (more than 2 in a 6 month period) (Fuller, 2000) The best predictor of future behavior is past behavior

23 Risk Factors:Impairments (PMHx)Cognitive Visual Vestibular Somatosensory Central motor control impairments Cardiopulmonary Musculoskeletal

24 Risk Factors: MedicationsUse of 4 or more prescription medications triggers medication review Physician and/or pharmacist medication review as a fall-prevention technique not well-studied yet The short-term risk of falls is 3 times higher in the two days following a medication change in nursing home residents (CDC 2008)

25 Risk Factors: Environmental

26 Risk Factors: PsychologicalThose elderly people living alone are at higher risk for falls Depression is an independent risk factor for falls Fear of falls imposes additional impairments

27 Risk Factors: ConclusionPractitioners can impact, but not completely eliminate many risk factors The best opportunities for positive intervention are in the realms of medical impairments, medications, and environmental adaptations

28 Medical Impairments

29 Impairments: CognitiveApproximately 50% of adults meet the criteria for dementia by age 85 (Pugar, 2010) Dementia alone is a minor risk factor for falls, but is a “risk multiplier” in combination with other risk factors Pugar, Ken D.O., personal correspondence Pugar, Ken D.O., private conversation

30 Impairments: Visual,Vestibular, Somatosensory SystemsThe “Big 3” of sensory feedback for fall prevention Impairments in any of these realms can lead to symptoms of dizziness, a very frustrating complaint to evaluate and treat Sensory feedback is more important for gait function than strength; for example a person with sensory ataxia is much more prone to falls than one with isolated, severe weakness due to remote polio. Johnson, personal correspondence

31 “Dizziness” and the elderly“Dizziness” is a common symptom in people of all ages and has multiple etiologies Morbidity and mortality greatly increased in elderly with chief complaint of dizziness

32 Mechanisms of DizzinesHundreds of potential causes Limited number of physiological mechanisms Nature of patient symptoms helps define most likely mechanism, which clarifies possible causes and guides diagnostic evaluation Determining the most likely specific causes leads to best treatment approaches and outcomes

33 Prevention of “Dizziness”The “Big 3” provide feedback for postural orientation and posture: Vestibular system, visual system, and somatosensory system “Dizziness” type symptoms may result from dysfunction in any of these systems The three systems overlap enough to provide at least partial compensation for problems in any one of them

34

35 “Dizziness” Symptom SubtypesPre-syncope, syncope: “lightheadedness”, “passing out” Ataxia: disequilibrium, “unsteadiness” Weakness: Collapsing, buckling, “legs give out” Vertigo: illusory sense that the environment or one’s own body is moving; “swaying and rocking” as if on a ship (mal de debarquement), motion sickness, nausea and vomiting, feelings of rotation or linear movement, disequilibrium and oscillopsia (oscillating vision-objects seem to jerk), diploplia. Commonly d/t vestibular dysfunction.

36 Dizziness: Physician perspective“There can be few physicians so dedicated to their art that they do not experience a slight decline in spirits when they learn that their patient’s complaint is dizziness. This frequently means that after exhaustive enquiry it will not be entirely clear what it is that the patient feels is wrong and even less so why he feels it.” Matthews, (1963)

37 Vertigo Definition: an illusory sense that either the environment or one’s own body is moving Mechanisms: Multiple, often over-lapping and difficult to differentiate Often described as vestibular dysfunction or vestibulopathy, but vertigo is a symptom with multiple etiologies, whereas vestibulopathy is a diagnosis that usually causes vertigo

38 Vestibular System Anatomy

39 Physiologic Vertigo Represents normal function of the three systems (visual, somatosensory, and vestibular). Multiple types: Mismatch between systems (chase scenes at the movies, especially imax; height vertigo) Vestibular exposure to unusual stimuli to which it has not had time to adapt (sea- sickness) Vestibular stimulation due to unusual head positioning (protracted cervical extension)

40 Vestibular System Three semicircular canals, and the otolithic apparatus consisting of the utricle and saccule, all housed within the inner ear, collectively called the vestibular organs Eighth cranial nerve carries neural projections from the vestibular organs to the vestibular nuclei in the brainstem Vestibular nuclei project (mainly) to the nuclei of cranial nerves III, IV, and VI (vision), the spinal cord, the cerebral cortex via the pons (the source of nystagmus), and the cerebellum

41 Vestibular function The three semicircular canals transmit indications of angular acceleration The otolithic apparatus transmits indications of linear acceleration and gravity/head position in space. The utricle for horizontal and saccule for vertical orientation Together, these organs stabilize gaze (vestibulo-ocular reflexes or VOR), maintain posture, and stabilize head posture

42 Vestibular Disorders Generally divided into Central and Peripheral Vestibular disorders Central Vestibular Disorders: Caused by dysfunction to the central vestibular nuclei in the brainstem and the pathways and other organs which project from these nuclei Peripheral Vestibular Disorders: Caused by dysfunction of the semicircular canals and otolithic apparatus

43 Peripheral Vestibular DisordersSymptoms: Vertigo, severe nausea and vomiting, usually mild oscillopsia, tinnitus, hearing loss, feeling of fullness in the ears, mixed vertical and torsional nystagmus Signs: Fixation and suppression of nystagmus with habituation, smooth visual pursuit Causes: Displacement of otoconia (Benign, Paroxysmal Positional Vertigo or BPPV); Hypofunction of vestibular function due to inflammation of vestibular nerve or labyrinth organs (Vestibular neuritis, Labyrinthitis); Abnormal fluid pressure in inner ear (Meniere’s Disease), Trauma to vestibular organs, or toxins/drugs

44 Benign Paroxysmal Positional Vertigo (BPPV)Peripheral vestibular dysfunction caused by displacement of otoconia in the semicircular canals Symptoms: brief (usually less than one minute) episodes of vertigo associated with changes in head position with nausea and nystagmus Signs: Torsional nystagmus, brought on by changes in head position, with distinctive eye movements

45 Vestibular Function TestingIf Central cause is suspected, MRI of brain Posturography to measure somatosensory function: moving platform measures balance Dynamic and static visual acuity tests, visual vertical testing Autonomic nervous system testing Electronystamography: cold and warm water or air applied to tympanic membrane, which induces nystagmus. The type and direction of nystagmus distinguishes the type (peripheral vs. central) and side of vestibular pathology Vestibular evoked myogenic potentials (VEMP) help measure function of the otolithic apparatus Rotary chair: induced nystagmus measurements

46 Otoconia repositioning: Diagnostic and Therapeutic

47 Vestibular RehabilitationProvided by certified PT’s and OT’s. National certification course is competency based Applicable to Central and Peripheral Vestibular disorders Goals: decrease dizziness, improve visual and balance functions, improve activity level, promote compensation for vestibular deficits

48 Vestibular Rehabilitation: General ApproachClarify diagnosis as much as possible: Central vs. peripheral, unilateral vs. bilateral, BPPV vs. loss of vestibular function due to Meniere’s, inflammation, trauma, etc. and treat accordingly (antihistamines, antibiotics, meclizine, valium). Surgical intervention if others fail Find specific diagnosis of central vestibulopathy Identify associated conditions (such as peripheral neuropathy) Rule out cervical pathology prior to performing repositioning type manuevers

49 BPPV: Treatment Otoconia repositioning manuevers: Several types, designated by eponyms (Eply, Semont, Liberatory, Brandt-Daroff, Appiani, Casani) Effective, but require specialized hands-on training One to three visits usually required Prognosis is good, symptoms usually subside in weeks

50 Central Motor Control Impairments: AtaxiaDefinition: failure of muscular coordination Patient descriptions: dizziness, impaired balance, poor motor control and poor accuracy Mechanisms: Impairments of motor control feedback (somatosensory system) at any level (peripheral sensation, transmission of peripheral sensation to brainstem, brainstem or brain, dysfunction of cerebellum) Multiple causes

51 Causes of Ataxia Central Nervous System dysfunction: Brain: cerebrovascular disease (especially brainstem/cerebellar), vertebral artery compromise, tumors, frontal lobe (Brun’s frontal ataxia) Central Nervous System dysfunction: Spinal cord conditions: tabes dorsalis, dorsal column dysfunction due to stenosis, masses, alcohol abuse, others Peripheral Nervous System dysfunction: Peripheral neuropathies (over 100 recognized types) Psychiatric (conversion disorder) Vestibular disorders (central or peripheral): often described as ataxia, but can usually be distinguished by physical exam and other testing

52 Central Motor Control Impairments: Movement DisordersParkinson’s disease is most common and well researched, but many others exist (multi- system atrophy, dystonias, tremor disorders, cerebral palsy, etc.) Most are idiopathic and incurable Severity of disability often reduced by medical and therapy interventions Generally a minor fall risk until late stage

53 Parkinson’s Disease

54 Cardiopulmonary Impairments: Presyncope and SyncopePatient descriptions: lightheadedness, passing out Mechanism: Decreased flow of blood, oxygen and nutrients to the brain Multiple causes , all of which affect the somatosensory system at its end-organ (the brain)

55 Causes of Presyncope Cardiopulmonary: autonomic neuropathy, carotid sinus hypersensitivity, heart valvular disorders (mitral valve prolapse, others), heart failure, dysrhythmias, COPD, hyperventilation, multiple medications Metabolic: Anemia, hyperviscosity syndromes, hypoglycemia, thyroid disease, carbon monoxide Psychiatric: anxiety disorders, panic, depression, noxious stimuli Neurological (Rare): cerebrovascular disease affecting brainstem or both cerebral hemispheres

56 Medications that can cause PresyncopeDiuretics Anti-hypertensives Beta-blockers Anti-arrhythmic Vasodilators (viagra, others)

57 Impairments: MusculoskeletalWeakness: Failure of muscle activation; patients sometimes describe weakness of the trunk or lower limb in terms of dizziness, especially when associated with sudden falls Mechanisms: Impaired control mechanisms (diseases of the central or peripheral nervous system, psychiatric disorders, pain inhibition), muscle dysfunction (myopathies, deconditioning, sarcopenia, obesity), joint dysfunction, vitamin D deficiency

58 Physical composition and Function changes with Age

59 Muscular weakness Isolated muscular weakness is a minor risk factor for falls in younger people Muscular weakness is a major risk factor for falls in the elderly

60 Vitamin D deficiency (?)Vitamin D deficiency causes postural sway and weakness due to myopathy, as well as Osteomalacia. Approximately 50% of disabled, elderly women have moderate to severe Vitamin D deficiency (decreased skin synthesis in elderly implicated) Vitamin D 800 IU qd (not 400) reduced falls in the elderly to significant degrees (Bischoff, 2003) Bischoff HA, et al. Effects of vitamin D and calcium supplements on falls: a randomised controlled trial. J Bone Minter Res 2003;18: Bischoff HA, et al. Effects of vitamin D and calcium supplements on falls: a randomised controlled trial. J Bone Minter Res 2003;18:

61 Vitamin D Supplementation!A 2009 meta-analysis by Dr. H.A. Bischoff- Ferrari of 8 RCT’s found: 1. Supplemental Vitamin D in dose ranges iu’s/day reduced fall risk in those over 65 by 19%. 2. Doses less than 700 iu’s/day may not reduce the risk of falling. HA Bischoff-Ferrari, et al. Fall Prevention with Supplemental and active forms of Vitamin D: a Meta-Analysis of Randomised Controlled Trials. BMJ 2009; 339:b 3692.

62 Vitamin D Supplementation?Cochrane review 2012: meta-analysis of 34 trials, 13,617 participants, found vitamin D did not reduce the risk of falling. “Overall, vitamin Did not reduce rate of falls…but may do so in people with lower vitamin D levels before treatment.” Gillespie, LD et al. Interventions for Preventing Falls in Older People Living in the Community. The Cochrane Library, published online 12 Sep 2012.

63 Diagnostic Approach to the Falling Elderly Patient1. Screening elderly patients with risk factors; undertake investigation for treatable causes if more than two falls in a 6 month period (?) (Fuller, 2000) 2. Investigation: History, review of meds, social history with emphasis on social support/living environment, physical exam. 3. Additional investigations if indicated 4. Highest yield medical investigations: visual acuity, postural hypotension, balance, cognition, depression, medication problems (Close, 1986) Close J, et al. Prevention of falls in the elderly trial (PROFET): a randomized controlled trial. Lancet Jan 9;353(9147):93-7 Close J, et al. Prevention of falls in the elderly trial (PROFET): a randomized controlled trial. Lancet Jan 9;353(9147):93-7

64 Hospital Admission post FallsCMS publishes no specific guidelines Clinically, isolated fall without injury meeting guidelines for admission are discharged home from ED Multiple falls from multiple chronic co- morbidities without injury often meet criteria for observation status from ED (Williams, 2010) Beverly Williams M. D., personal correspondence Williams BA, personal correspondence

65 History Nature of the fallsAssociated symptoms: cognitive impairments, visual disturbances, vertigo, ataxia, syncope, tinnitus, hearing loss, sensory abnormalities, weakness, spasticity, tremor, stiffness, joint abnormalities, other medical impairments Medication review including compliance Functional review: ADL’s to include mobility, toileting, continence, bathing, dressing, skin integrity, home management, previous interventions

66 Social History Alcohol and drugs Support systemsLiving environment (s) Adaptive equipment Patient and caregiver goals

67 Physical exam Vital signs with Emphasis on orthostatic blood pressureGait analysis, timed “get up and go” test, walking up on toes and back on heels, walking heel-to-toe, postural sway Somatosensory evaluation: vision, vestibular system, peripheral sensation (vibration with tuning fork, proprioception if able, pinprick) Musculoskeletal exam Neurologic exam, especially screening for upper motor neuron signs and peripheral neuropathy Cognitive screen

68 Additional Investigations: CognitiveNeuropsychological testing (especially helpful if psychogenic overlay suspected) Separate family and caregiver input, especially re: short-term memory

69 Additional Investigations: Visual, vestibular and somatosensoryVisual specialist consultation ENT specialist consultation Vestibular Rehab specialty center referral CNS imaging studies (especially if Upper motor neuron signs present) Electrodiagnosis if sensory loss identified

70 Additional Investigations: MusculoskeletalVitamin D levels CPK Electrodiagnosis

71 Additional Investigations: CardiopulmonaryPhysical exam including orthostatic BP Cardiology specialist consultation Syncope evaluation (carotid doppler studies, EKG, cardiac monitor studies, echocardiogram, cardiac stress test, tilt table, autonomic testing)

72 Impairments Conclusions: Medical History and Physical are Critical for Optimal Outcomes

73 Finally, the Good Stuff: What Works?

74 What Works: The Big 6: 1. Education 2. Medical review and treatment3. Visual compensation 4. Living environment modification 5. Correct exercise 6. Multi-disciplinary team interventions

75 What works: Education Home based individualized health assessment with education about risk factors and follow-up changes in meds, environment and social support is, by itself, ineffective in decreasing falls (CDC 2008) Medication review and modification not well- studied, but periods of medication change recognized as high-risk period for falls, and a CDC study is underway in North Carolina

76 What works: Exercise An individualized exercise program, combined with education regarding risk factors, referral for medical management when applicable, and home hazard assessment reduces falls 25% in community elderly (CDC 2008) Physical therapist guided group exercise including modified Tai Chi programs for at-risk elderly can reduce falls by 40% (Barnett, 2003) Exercise participants 80 years and older who had fallen in the previous year show the greatest benefit (Campbell 2003) Tai Chi programs seem especially effective, reducing falls up to 55% in those 70 or older (Li, 2005) Barnett A., et al. Community-based group exercise improves balance and reduces falls in at-risk older people: a randomized controlled trial. Age and Ageing Jul;32 (4):407-14 Campbell et al at: -prevention/home-safety/older-adults/otago- exercise-programme/index.htm Li F, et al. Tai Chi and fall reduction in older adults: a randomized controlled trial. Journal of Gerontology Feb;60A(2):187-94 Barnett A., et al. Community-based group exercise improves balance and reduces falls in at-risk older people: a randomized controlled trial. Age and Ageing Jul;32 (4):407-14 Campbell et al at: -prevention/home-safety/older-adults/otago-exercise-programme/index.htm Li F, et al. Tai Chi and fall reduction in older adults: a randomized controlled trial. Journal of Gerontology Feb;60A(2):187-94

77 Exercise: more evidenceIn addition to reducing the risk of falls, exercise programs designed to prevent falls in older adults also: 1. Decrease the number of injuries caused by falls 2. Reduce the rate of falls leading to medical care Fabienne El-Khoury, et al. BMJ 2013; 347:f6234

78 What works: Living environment modificationHome evaluation with specific modification recommendations by OT practitioners decreases falls by one-third to 37% in those who had fallen in the previous year (Cumming, 1999) (Nikolaus, 2003) General education programs regarding proper home modifications are ineffective (CDC 2008) Cumming, et al. Home visits by an occupational therapist for assessment and modification of environmental hazards: a randomized trial of falls prevention. Journal of the American Geriatric Society Dec;47(12): Nikolaus T, Bach M. Preventing falls in community-dwelling frail older people using a home intervention team. Journal of the American Geriatrics Society Mar;51 (3):300-5 Cumming, et al. Home visits by an occupational therapist for assessment and modification of environmental hazards: a randomized trial of falls prevention. Journal of the American Geriatric Society Dec;47(12): Nikolaus T, Bach M. Preventing falls in community-dwelling frail older people using a home intervention team. Journal of the American Geriatrics Society Mar;51 (3):300-5

79 Home Modifications 1 Reduce clutter and furniture, clear walkwaysRemove easily tipped furniture such as floor lamps, non-sturdy chairs, foot stools Low pile carpet or clean, dry smooth surfaces Minimize electrical cords, move them out of the way Maximize light, minimize glare, use nightlights Contrast thresholds such as the top of stairs

80 Home Modifications 2 Ramps with 1 inch rise to 1 foot runHandrails in stairways, bathrooms Non-skid surfaces inside and outside tubs Secure raised toilet seats or bedside commodes Portable phones kept close Carts for moving food or other items Walker baskets Avoid throw rugs

81 Home Modifications 3: Better, more expensive“Aging in Place” Consultation: Comprehensive home modification plans individually designed by a team of certified therapists and architects Contact: Rachelle (“Shelly”) Janning, MS, OTR/L, care of The NeuroRehab and Balance Center 7677 Yankee Street, Centerville OH (937)

82 What works: multi-disciplinary team interventionsIn those over 65 treated in the emergency room for a fall, medical assessments with interventions as indicated in combination with OT home evaluations and modifications result in a 60% reduction in falls(Close, 1986) Close J, et al. Prevention of fall in the elderly trial (PROFET): a randomised controlled trial. Lancet Jan 9;353(9147) 93-7 Tinetti ME, et al. FICSIT: Risk factor abatement strategy for fall prevention. Journal of American Geriatric Society Mar;41(3):315-20 Close J, et al. Prevention of fall in the elderly trial (PROFET): a randomized controlled trial. Lancet Jan 9;353(9147) 93-7

83 What works: Multidisciplinary InterventionsIn community-dwelling people age 70 and older (enrolled in a single HMO), individual medical and/or nursing assessment and interventions, with home health therapy, education and environmental modification decreased the risk of falls 30% (Tinetti, 1993) Tinetti ME, et al. FICSIT: Risk factor abatement strategy for fall prevention. Journal of American Geriatric Society Mar;41(3):315-20

84 What Works: Local ResourcesThe NeuroRehab and Balance Center Yankee Street, Centerville OH (937) Area Agency on Aging: (937) Kettering Home Care: (937) Dynamic Senior Solutions: (937) , Dynamicseniorsolutions.com

85 What works: ConclusionsFalls in the elderly are usually multi-factorial in origin. The most successful approaches use the strength of multi-disciplinary team interventions

86 Post-Test: 1. Regarding falls in the elderly,which is true:Not much research exists about falls in the elderly; recommendations are based primarily on common sense interventions The cause of most falls in the elderly can be isolated to one main problem in each patient With appropriate interventions, almost all falls in the elderly can be avoided Despite body composition changes, exercise is a useful intervention for fall risk reduction in the elderly* 10

87

88 Post-Test: 2. Regarding falls in the elderly, which is true:According to the CDC, fall risk in nursing home residents increases 3 times in the two days following medication changes* Approximately 1 out of 4 nursing home residents fall each year 5% of patients who sustain a hip fracture die within one year Educational lectures provided by experts are helpful for preventing falls in the elderly 10

89