The Dual-Task Condition: Attention-Related Fall Risk in Older Adults

By Megan Christiansen, SPT

 

The crucial task of old age is balance: keeping just well enough, just brave enough, just gay and interested and starkly honest enough to remain a sentient human being. 

– Florida Scott-Maxwell

 

Overview

As members of the Baby Boomer generation begin to join the “65 & older” demographic, there can be little doubt that our Nation’s older adult population is rapidly expanding.  Simultaneously, there has been a steady increase in the number of geriatric falls reported each year, and a corresponding rise in the billions of federal dollars used to cover fall-related healthcare expenses.  Because the risk of falling increases substantially between the ages of 65 and 80, fall prevention is a growing focus among today’s healthcare providers.  Physical therapists who work with older patients/clients on a regular basis are uniquely suited to combat the (often complex) issue of fall risk.

Factors contributing to an individual’s fall risk can be many and diverse, and this is particularly true of older adults.  Muscle weakness in the core and lower extremities, and gait deviations are common offenders, as well as age-related declines in sensory abilities, flexibility, and balance.  Polypharmacy is common among aging individuals, and may increase symptoms of dizziness, fatigue, or lower mental function.  Vestibular impairment, cognitive decline, diabetic neuropathy, environmental components, deconditioning due to reduced activity levels… the list goes on.

In addition to the physical factors, many researchers now consider attentional ability to play a significant role in geriatric fall risk, particularly when attention must be divided between two simultaneous actions. This form of multi-tasking, known as a “dual-task condition,” most often involves concurrent performance of a motor and cognitive task (i.e. walking and talking).  As the aging process continues, basic functions including balance and postural control, ability to navigate obstacles, and ambulation often become increasingly difficult under dual-task conditions.

 

Let’s Start at the Very Beginning…

Last Fall, I completed a research paper to explore the therapeutic potential of dual-task vs. single-task training for reducing geriatric fall risk.  Encouraged by my findings, I began to think back to past clinical experiences, and to realize how seldom I had encountered dual-task related intervention.  For that matter, I found that I could identify only one dual-task outcome measure (and had never seen it used with a patient).  Instruments such as the Berg, TUG, or Modified CTSIB had always been my go-to means for inspecting balance and fall risk, yet none of these actually addresses the factor of attentional divide.

Given the importance (and quantity) of multi-tasking in everyday life, it is essential that clinicians who work with older adults be able to recognize, measure, and address attention-related fall risk.  To help increase awareness, I decided to create a dual-task continuing education module outlining current evidence-based theory, outcome measures, and guidelines to inform best practice for training.  My ultimate goal was two-fold: First, to provide information along the entire continuum of the problem, beginning with an explanation of the cause at a functional level (intro), then progressing to clarification of how to “find and interpret” (assessment), and finally, providing instruction for what to do about the issue once detected (intervention).  Second, I wanted to review and present the current dual-task literature in a manner that would make it more accessible and clinically relevant to working therapists, thus increasing translation of evidence-based concepts into practice with older adults.

 

My Project

After months of reading, writing, designing, questioning, e-mailing, interviewing, phone-calling, pondering, discarding this feature completely, and adding considerably more to that one… “The Dual-Task Condition: An Evidence-Based Guide to Assessment and Intervention for Attention-Related Fall Risk in Older Adults” is ready for a trial run.

 

The project consists of several visual and auditory components: two voicethread lectures describing dual-task assessment and intervention, a supplemental handout based on the two voicethread lectures, and a feedback evaluation.  The entire module is designed as a complete package, but deliberately organized so that each viewer may choose to focus more specifically on aspects of the dual-task condition that fit his or her educational needs and interests (for example: Assessment vs. Intervention, or the explanation of a particular assessment measure).  PDF files containing the voicethread slides have been made available for those who would like hardcopy notes (or a quick summary of content to guide the listening experience).  A complete list of the sources for this project has also been included.  You will find all of these components below, accompanied by a brief description:

 

A. Voicethread Lectures: A 2-Part Series

A short intro to “using voicethread” is available in the narration of Part 1’s title slide

Part 1: Intro & Assessment

An overview of attention and how it relates to fall-risk in older adults, followed by an introduction to the concept of dual-task costs, and a summary of select assessment tools used to evaluate fall risk under dual-task conditions.  Click here for printable slides.

Part 2: Intervention

An introduction to dual-task intervention, including guidelines for task selection, progression, and methods to enhance treatment effectiveness.  Detailed reviews of 4 alternative dual-task interventions (and the corresponding studies) are also included.  Click here for printable slides.

 

 B. Supplemental Resources

Dual-Task Assessment & Intervention Handout

A supplemental resource based on the information presented in both voicethread lectures.  Contains: definitions for common terminology; Dual-Task FAQ; the protocols for administration and interpretation of all assessment measures discussed in Part 1; the chart of possible interventions discussed in Part 2; guidelines for progressing dual-task intervention.  Please feel free to print!

List of Project Sources

A complete list of the journal articles and resources used in the making of this project.

 

C. Feedback

My goal is for this module to be as user-friendly, complete, and helpful to clinical practice as possible.  Please take a moment to fill out the Evaluation Form  -OR-  use the evaluation form as a guide to provide commentary via the “Comments” feature at the bottom of this page.  Please be honest – your comments will help me identify what is working well, and ways to improve the module for future use!

 

 

Special Thanks…

Mountains of appreciation go out to my wonderful committee members:

Dietra Buxton – for allowing me to use your Capstone project as a starting point for this endeavor, for your consistently fantastic constructive comments, and for the unflagging support you’ve given, even in the midst of adjusting to your own new surroundings (true dual-tasking!).

Laura Terry – for finding time to squeeze me in despite your busy schedule, for your continual encouragement (and yoga) along the way, and for representing geriatric PT with all the excellence, compassion, and creativity that remind me of why I can’t wait to start practicing.

Karen McCulloch – for facilitating the connections that made this project possible, for enduring the early stages (and changes) of my planning with great patience, and for all the ways you’ve helped to give my vague ideas substance.

Without your support and expertise, this project could not have come to be 🙂

  And thank YOU so much for visiting my Capstone site!