Welcome to My Capstone Site
No Tumbles for Tyrrell!
By: Sarah Yancey, SPT
Background
For a long time, the devastating effects falls can have on community-dwelling older adults have intrigued me. When I was in middle school, my great-grandmother fell and broke her hip while working in her garden. At 96 and after giving birth to four children, the broken hip caused her to spend her first night in a hospital. Despite being very active prior the fall, the fracture proved to be devastating for my great-grandmother. Although she did walk again with a walker, she never regained her previous agility and died in a nursing home three years later. As an undergraduate Exercise and Sport Science major at UNC-CH, I learned more about the negative effects falls can have on the elderly population and the large public health problem they create. I began volunteering my junior year at the Orange County Senior Center in Chapel Hill helping with group balance classes for elderly community-dwellers. Here I witnessed the positive effects group balance classes could have on elderly participants and knew that I wanted to explore more about fall prevention in older adults when I entered PT school.
Research Leading Up to the Project
During the Evidence Based Practice II class in the fall of my third year in the DPT program, I focused on the efficacy of multifactorial group fall prevention programs for improving scores on the Berg Balance Scale (BBS) and preventing falls in community-dwelling elderly patients. This evidence table summarizes my research on the topic. Ultimately, I found that effectively integrating group exercise, falls education, behavioral and environmental risk factor modification, and medication reviews have the potential to improve BBS scores and reduce falls rates in the elderly population. Further, programs that concentrated heavily on exercise and strength training yielded the most optimal results.
Overview of No Tumbles for Tyrrell
While my research in the fall focused on the efficacy of group fall prevention programs, I began to wonder about those elderly individuals who reside in rural areas and do not have access to group programs. What about those older folks who do not live near an amazing facility like the Orange County Senior Center? With guidance from Vicki Mercer, I began to look more into the efficacy of home-based exercise programs for elderly persons, specifically looking at the Otago exercise program. Developed in New Zealand, the Otago program was designed to specifically prevent falls in the elderly population and has been found to reduce both the number of falls and the number of injuries due to falls by 35% .1 I volunteered for the Spring Break Service Learning Trip to Tyrrell County to implement my project. Tyrrell County is a very rural county located in Eastern, NC . The county’s senior center is located in the town of Columbia. Although the Tyrrell Senior Center has several exercise machines, there is no formal balance class or fall prevention program in place. Therefore, Tyrrell County was an ideal place to conduct falls screenings and provide the residents with information on falls prevention.
Falls Screens
On the second day of the five-day trip, Vicki Mercer, our fearless leader, myself, and two other PT students, conducted falls screens at the local senior center for the elderly adults who wanted to participate. Each participant filled out a falls screen form. Next, each participant’s balance was tested using the Five Times Sit to Stand Test, Four-Test Balance Scale, and the Timed “Up and Go” Test. I choose these three tests based on recommendations from the developers of the Otago Exercise Program and on the Centers for Disease Control and Prevention’s STEADI (Stopping Elderly Accidents, Deaths, & Injuries) Tool Kit for health care providers. This word document contains instructions on how to complete the tests and evidence on each measure. After the screening, each participant was then placed into a falls risk category and exercise level based on his or her performance on the tests. During the trip, we were able to screen and provide exercises to eight seniors at the senior center and two additional seniors while conducting home visits.
Home Exercises
The Otago Exercise program consists of individually prescribed exercises to strengthen leg muscles and improve balance.1 Based on this program, I developed specific exercises of increasing difficulty. Each participant received a set of exercises for level I, level II, or level III and the assessors reviewed exercises in a one-on-one manner with each participant.
Multifactorial Handout
Although, the Otago program has been tested as a single factorial intervention, the developers support its use as part of a multifactorial falls prevention program.1 Since the majority of my research during the fall concentrated on multifactorial falls prevention strategies, I created a brochure specifically for Tyrrell County incorporating multifactorial fall prevention strategies. Considering Tyrrell County has a significantly lower percentage of high school graduates compared to the rest of NC and older adults’ reading ability typically atrophy due to disuse, I worked hard to create all materials at an appropriate reading level with large size font. 2,3 For example, the brochure I created was written at a 1.0 Flesch-Kincaid Grade Reading Level with a 97.0 out of 100 Readability Ease Score.
Falls Prevention Presentation
As a part of this interdisciplinary service learning trip, Erin Toomey Hopper, another third year PT student, and I were asked to give a presentation on falls in the elderly population and effective ways to screen older patients at risk for falls. Erin and I created and presented this PowerPoint to the group of PT, nursing, public health, and sociology students who went on the Tyrrell County Trip. Our goal was to give an overview of the public health problem that falls in the elderly create. We also sought to reiterate that all health care professionals who treat older adults are capable and responsible for screening for falls. The references for the presentation can be found in this document.
Many Thanks
I would especially like to thank Vicki Mercer, my Capstone advisor, and Sandy Moore, my Capstone PT committee member, for their guidance and feedback on this project. Also, big thanks to Louise Etchison, Erin Toomey, and Karen McCulloch for their help. I am also very appreciative of the wonderful people I met in Tyrrell County who participated with the project.
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1. Campbell J, Robertson C. Otago exercise programme to prevent falls in older adults. . March 2003.
2. Tyrrell county QuickFacts from the US census bureau. U.S. Department of Commerce Web site. http://quickfacts.census.gov/qfd/states/37/37177.html. Updated December 6, 2012. Accessed January 10, 2013.
3. Doak C, Doak L, Root L. Teaching patients with low literacy skills. 2nd ed. Philadelphia, PA: J.B. Lippincott Company; 1996.
6 Responses to “No Tumbles for Tyrrell”
Sarah Yancey
Thank you so much for the information Vicki! I definitely plan to complete this training soon. My current CI is also interested in the Otago program. I have passed on this information to him as well. Thanks so much again for sharing your valuable insight, clinical experience, and outdoor painting expertise on the trip!
Sarah
Vicki Mercer
Hi Sarah!
Fantastic work on this project! It was great to see you and Erin in action in Tyrrell! I also wanted to let you (and others visiting this site) know about a resource on the Otago program that recently became available. There is now online Otago training for PTs available through AHEConnect. This is a 3-hour online learning module that costs only $25. I have completed this training, and I think it is pretty well done. Check it out by signing up at http://www.aheconnect.com
There is no cost to sign up, and then you have access to a large number of online courses that you can choose from. Some are free, and some have a minimal charge. Scroll down the list to find Otago online training for PTs.
Again, excellent work!
Vicki
Sarah Yancey
Hi Betsy, Erin, and Nick!
First of all, thank you all so much for your interest in my Capstone. As you know, fall prevention in the geriatric population is an area that is very near and dear to my heart and I am so happy to hear feedback from you guys!
Betsy – To answer your question, yes some of the participants were very surprised with the falls risk category they were placed in. I can think of two elderly women in particular. On the falls screen form, which was filled out prior to completing the tests, these two women put that they felt their balance was a 10 out 10 because they had not fallen recently. Both women performed well above the cut-off scores on all three tests even though subjectively they felt like their balance was good! They were surprised when they were given an overview of their performance and put into the “high falls risk category”. However, they both agreed after completing the screen they needed to improve their balance. With more “digging” it seemed that both women used a lot of compensatory strategies to keep from falling such as furniture walking. After hearing about their performance on the tests, they were much more open to learning the simple exercises that could be completed in their home.
I am also so glad you thought educating other health care professionals about their role in falls prevention was important, I totally agree. The CDC advocates for all health care professionals who treat elderly patients to be knowledgeable about their STEADI toolkit as the questions and tests to screen for falls are not complicated. The Otago exercise program used nurses who were supervised by PTs to help successfully deliver the program to participants. The nursing student on our trip agreed that nursing professionals should play a role in screening and preventing falls in the elderly. Similarly, two of the public health students told me separately they learned a lot from the PowerPoint. They were surprised to find that preventing falls typically requires a multifactorial intervention plan that involves health care professionals other than just PTs. For examples, pharmacists are so important for medication review in this population! Thanks again for your comments Betsy!
Erin – Hey there! I too took a lot away from the participants I met in Tyrrell, what an amazing group of people. I also really enjoyed and sincerely thank you for your collaboration with me on this project. I am glad you liked the patient handouts for the specific exercise levels. Please feel free to use these resources for any patients you deem appropriate in the future. I really wanted my Capstone to be geared towards educating and providing services for the geriatric population, so I would love it if my materials helped others in the future. Out of the three phone numbers I got from participants in Tyrrell, I was able to get in touch with one elderly lady in Columbia who participated in the falls screens. She reported no falls since our trip in March, but again reiterated her story about her bad fall six months ago. She said she was still doing her Level I exercises about four times a week. This lady’s previous fall really scared her and she said the resources we gave her helped to get her confidence back. She also mentioned they are looking into starting an exercise program at the Senior Center based off some of the exercises I provided. I tried to contact the director of the center via e-mail to get more information, but as of yet I have not been able to get in touch with her about these new exercises classes. I hope these classes involve safe and controlled exercises as opposed to simply “playing on the Wii” like their previous unstructured classes have involved. Thanks again for your help and comments!
Nick – It is so great to hear from someone who has actual clinical experience with the Otago program! I first heard about the program last fall and was impressed by its ability to reduce falls and the number of injuries from falls by a whopping 35%. However, I too was skeptical at first about a home exercise plan for geriatric patients; I was especially worried about injuries during exercising and compliance. However, looking more into the program, I realized all exercises were very safe. Further, the exercise plan requires minimal equipment; ankle weights for Levels II and III are probably the only item not found in a typical home. As you mentioned, the exercises are also very simple and not difficult to understand. I think safety, minimal equipment, and the less complicated exercises really add to the compliance level for elderly adults in the program. Thanks again for your comments and sharing your experiences!
Please let me know if you all have any additional questions, I would love to discuss anything in more detail. Thanks again!
Sarah
Nick Camilleri
Hi Sarah!
Great job on your capstone project! Geriatrics is one of my clinical interest areas and as such I found your project particularly interesting. I studied a very similar topic in the fall, and like you see the importance in this topic. As you point out, falls can have such devastating effects on the elderly population, and although this topic has been addressed many times before, it is critical that we continue striving to find the best way to prevent falls in this population.
I have experience utilizing the Otago exercise program from my geriatrics clinical rotation, but had not done any formal research into the evidence on this program. As such, I found this part of your project to be particularly interesting. When I first used this program, I remember being skeptical because the program relied so heavily on patient compliance at home. I was surprised to find that the majority of patients for whom we included this program as part of their plan of care were very compliant and seemed to really enjoy working through the program. I think this had to do with the easy to follow and formal way in which their exercises were presented to them in this facility, where it was almost like a book that they could work though.
I really like the powerpoint that you and Erin put together too. There is a lot of good information in there and you present it really well in an easy to follow format. I really like the home/environment modifications tips; really easy to implement and effective tips that a lot of people can benefit from.
Great job overall Sarah, you put a lot of great information together on an extremely important topic.
Nick
etoomey
Hi Sarah!
I really enjoyed being a part of your Capstone implementation in Tyrrell County. Your love for older adults is so evident in your interactions with this population. I took away many good experiences working with such a wonderful group of individuals and feel as though they appreciated our time and expertise as well.
During our partnership in Tyrrell, I benefitted from the opportunity to learn about the Otago Exercise program and look forward to using it to supplement my clinical toolbox! I also really appreciate your resource highlighting the evidence of each measure; it will be nice to have a battery of balance tests available in one document for easy clinical reference. My next clinical rotation will likely involve a large geriatric population and I know that these resources will be put to good use. I especially like the patient handouts you created detailing the exercise levels (plus the pictures are great!), would you mind if I provided these to patients in the future?
Also, did you ever get in touch with the participants to see if they were keeping up with their exercise plans? I would be interested to hear how they have incorporated this program into their lives and get their feedback on the program!
I’m going to miss collaborating with you–perhaps one day we will team up again to make big things happen in the geriatric world!
Erin
bfred36
Sarah,
Your capstone is awesome and very well put together. I think sometimes it is easy to over look falling in the elderly because it happens so often. It is almost expected that an older person will fall. Focusing on this topic for your capstone is really important because we have the tools to help prevent falls whether it be through a home exercise strengthening program, like you put together, education on management of medications, home modifications, assistive devices, etc. Were the participants surprised at the falls risk category they were placed into based off of their scores on the testing components you used? Also, were they motivated to complete the home strength program you made for them?
One other component of your capstone that I thought was important was the education to the other healthcare professionals on the trip. We have learned a lot about falls in the elderly throughout our program which may not be the case for other professions. I think it is equally important for other professions to have the tools for their patients to educate them on the impact of having a fall and ways to prevent it. Did the other health professionals on the trip seem to have learned something from that powerpoint? I had not heard of one of those falls assessment tests nor did I know that 60% of falls occur in the home, so I definitely learned something!
Again, good job with your capstone! I enjoyed looking through it!
Betsy