Fall risk reduction for the elderly adult: screen, intervene and redeem. An 8-module course for physical therapy students and new clinicians.

Fall risk reduction for the elderly adult: screen, intervene and redeem.  An 8-module course for physical therapy students and new clinicians.

Prepared by:  Deborah Constantine, PT, GCS

Background

I met Gloria* (not her real name) at an Assisted Living Facility that was her new home.  Unfortunately she was not accepting of the relocation from her sister’s house to a facility, however, her sister was at her wits’ end.  After suffering a CVA weeks prior, Gloria experienced multiple falls and was not adhering to the safety suggestions of the rehabilitation team after her discharge home.  The initial assessment verified Gloria’s fall risk status in addition to depression, weakness, forgetfulness, and peripheral neuropathy secondary to diabetes.  As I completed my assessment it became apparent that the primary reasons for Gloria’s non-adherence were her forgetfulness and her opinion that “old ladies” use walkers.  Neither she nor her sister wanted her in the facility, but for safety reasons, they felt that there were no other options.  At the conclusion of my initial visit, I challenged the family with a bold option.  If Gloria could reduce her fall risk, improve her memory and adhere to my instructions, we might consider advancing her from the rolling walker to a single point cane.  We all agreed on the plan of care.  Gloria was referred to a speech therapist for cognitive re-training and she worked with me on strength, balance and functional mobility tasks.  Using functional outcome measures as markers of progress and incentives to continue making progress, Gloria advanced in her functional level until her TUG was 10 seconds and she ambulated without an assistive device except with a cane on uneven terrain.  The best news of all was that her sister took her back home as a result of her progress.

I wish I can say that every older adult at risk for falls accomplishes what Gloria did, or that I work as hard with every older adult patient as I worked with Gloria.  It just doesn’t happen like that all the time in the clinic.  What it taught me, however, was that with the proper intervention, commitment from both patient and therapist, a patient can make significant functional gains and reduce their risk of falls. I shared this story with a group of physical therapy students who requested details about my treatment sessions with Gloria.  I began to investigate the evidenced-based nature of fall risk reduction interventions and wondered how comfortable students and new clinicians feel when faced with treating similar patients at risk for falls.

What follows is an overview, in an audiovisual format, of the risk factors for falls along with evidence based/best practice screening, assessment and intervention techniques that serve to reduce the risk of falls in the elderly population.  The goal is to equip the learner with basic knowledge and skills needed to promote maximum function older patients at risk for falls.

Overview and purpose

The statistics regarding falls are alarming.  One out of three adults over 65 years old fall each year while nearly one-half of those over 80 years old fall.  One in five falls results in serious injuries including fractures and head injury.  700,000 older adults require hospitalization due to injuries related to falls. More than 95% of hip fractures are caused by falling. Hip fractures are of major concern because of the impact on mobility and ADL function.  Post hip fracture, elderly individuals are more likely to use an assistive device for walking and need assistance with gait and transfers, require assistance with tasks such as bathing, dressing, meal preparation and participation in leisure and community activities.  Finally, it costs $34 billion dollars annually to treat fall-related injuries.

Physical therapists are in a unique position to intervene, provide effective techniques to reduce the risk of falls in the elderly and return them to maximum function.  Our skill set includes screening every older adult at the first patient encounter, performing a multifactorial assessment of all contributing factors for fall risk, designing an individualized fall risk reduction program that addresses all deficits and instructing in safety measures and home exercises.

Successful evidence-based/best practice interventions that reduce fall risk involve utilizing a multicomponent approach directed at modifiable risk factors of weakness, balance deficits and gait instability.  A Cochrane review examined fall prevention literature and found the strongest evidence for the following approaches:  group exercise classes, individually tailored home based exercise programs and group Tai Chi exercises.  The audiovisual presentation discusses evidence based/best practice fall reduction interventions for a wide variety of adults using varied techniques and approaches.  As a result of viewing the presentation, students and new clinicians can be prepared to screen, intervene and redeem elderly adults, like Gloria, who are at risk for falls, and return them to their maximally productive lifestyle.

Products

1. In order to assess knowledge of fall risk reduction content, I developed a pre and post audiovisual viewing evaluation tool. Use the tool to measure any change in information gained as a result of the presentation.  Fall risk reduction. Pre-post Evaluation component
2. The 8-module audiovisual tool (45 minutes) serves as an overview of falls and the major body systems involved in falls along with the screening process, assessment procedure, and intervention techniques.   http://screencast-o-matic.com/watch/cDf2bl1gPU.
3. For those interested in a summary of the presentation material, there is a single page summary sheet available for printing. Fall risk reduction. Summary sheet

Evaluation

The committee members’ input directed me to incorporate case scenarios into the presentation to deliver a product which enhanced the learning process for easier clinical application.  Additionally, because of the audiovisual format, they encouraged me to broaden my use of the PowerPoint applications to provide visual variety to sustain interest and to reinforce selected content. Lastly, the committee members helped make a clear distinction between an initial screen and the assessment that follows, thus the addition of STEADI tools as examples.  An evaluation of the final product by one of the committee members is provided.  Fall risk reduction. Feedback chart_2

Acknowledgements

I would like to express my deepest gratitude to my committee members for their detailed input and constructive critique of my presentation.  Each member, Dr. Catherine Noonan, Dr. Heidi Shearin and Dr. Tiffany Shubert, contributed a different aspect to the development of the presentation creating a seamless interconnection with each others’ input.   Without their professional expertise, guidance, encouragement and feedback, the final product would be a shadow of the presentation published here.  I think that I learned even more about fall risk reduction following their feedback.  Dr. Mike Gross, my advisor shared input, oversaw the details and provided overall evaluation of the final product.

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