What is a fall and why do we care about it in the elderly?
FALL = event in which pt unintentionally ends up on the ground or a lower level
The issue in the elderly is not just the ↑ likelihood of falling but the ↑ propensity to sustain injuries. This may be both physical and psychological morbidity.
- 30% of people aged > 65 fall annually
- 50% of people aged > 80 fall annually
- 2 to 3 fold increase in falls rates for those in hospital or Residential Aged Care Facilities (RACF)
What should be EXAMINED when assessing for FALLS RISK?
1) General physical examination
- VITALS
- Postural BP & HR (lying & standing & @ 2 min)
2) Musculo skeletal examination (esp feet, ankles, knees and hips), looking for:
- deformity
- range of movement
- leg length discrepancy
- PAIN
3) Neurological assessment
- proximal muscle weakness
- distal vibration/sensation
- joint position sense
- cerebellar signs
(looking for peripheral + central causes of ataxia/weakness/balance disturbance etc)
4) Vision testing
- acuity, peripheral vision
- assess spectacles
5) Gait and Balance Assessment: various bedside assessments - e.g.:
STATIC: Romberg’s test
DYNAMIC: Timed up & go (TUG), Pastor’s, sternal tug, functional reach
6) Assessment of feet and footwear - appropriate?
7) Investigations - syncope needs to be investigated for cardiac + neurological causes
What are the bedside tests for assessing BALANCE/postural stability?
- Romberg’s Test
- Timed Up and Go (TUG)
- Pastor’s Test OR Sternal Push
- Functional reach
- Standing on heels & toes
- Vestibular walking
- Hallpike manœuvre
Warnings
• When doing any balance testing safety is essential.
• Always stay close to the person so if they start to overbalance you can support them.
What is ROMBERG’S TEST + how is it performed?
ROMBERG’s = test of proprioception
- uses the premise that a person needs 2 of the following 3 senses to maintain balance: proprioception, vestibular function, vision.
+ve = when the patient is able to stand with feet together and eyes open without losing his balance but is unable to remain steady with the eyes closed.
- indicates a sensory (proprioceptive) cause of ataxia
- This occurs because patients are using their eyes to compensate for the lack of sensory feedback they are receiving from their lower extremities.
- ve = patient is unsteady when eyes are open, suggests that ataxia is CEREBELLAR in nature
What is TIMED UP AND GO + how is it performed?
= test of INTEGRATED BALANCE + MOTOR CONTROL
MoA:
- The person is tested using his/her usual footwear and gait aid.
- They are seated in a standard chair with arms.
- On the word ‘go’ the person rises from the chair without the use of arm rest if possible, walks 3 meters, turns, returns to the chair and sits down.
A normal score in older people is ≤ 10 seconds.
Factors to note:
• Sitting balance
• Transfers from sitting to standing
• Gait pattern and stability
• Ability to turn without staggering
What is a PASTER’S TEST?
Pastor’s Test
= testing patient’s DYNAMIC BALANCE REACTIONS in response to external perturbation.
MoA:
- the examiner stands behind the person and gives a brief tug backwards on the shoulders.
- The person is warned prior to the tug and is asked to try to stay standing.
- Balance reactions are graded.
+ve = less able to respond to and compensate for sudden and unexpected movements,eg jostled in a crowd.
What is a STERNAL PUSH?
= testing patient’s DYNAMIC BALANCE REACTIONS in response to external perturbation.
MoA:
- This is conducted with the examiner standing to the side of the person with one hand behind them to prevent them falling.
- There should also be a chair or bed placed behind the patient should they overbalance.
- After instructions and warning have been given to the person the examiner gives a brief firm push to the sternum.
- Again balance reactions are graded
How do you grade sternal push or Paster’ test with regards to balance?
Balance reactions after external perturbation
Grading may be conducted using either the following number system or the reactions in the diagram below:
1 - Sways, but takes no step,
2 - Takes one step,
3 - Takes 2 or more steps but stays upright,
4 - Takes 2 or more steps but doesn’t stay upright,
5 - ‘Timber’ reaction
/Users/evadeutscher/Desktop/balance grading.jpg
Note: grade 1 or 2 response is considered normal
What is FUNCTIONAL REACH TEST?
= test of DYNAMIC BALANCE REACTION in response to self-generated perturbation
MoA:
- The person stands with feet comfortably apart and their arms raised to 90° shoulder flexion.
- The person then leans forward as far as possible and the distance is measured in cms.
The mean for healthy older:
- males 33cm
- females 27 cm
A person with an abnormal test would be expected to have difficulties with activities of daily living such as making a bed or putting laundry on a clothes line.
What investigations for someone who is at risk of or has had FALLS?
NO ROUTINE Ix → should be based on Hx + O/E
Often performed
- Vit D
- CMP: Ca/PO4
- FBE
- UEC
- random glucose
PSYCHOSOCIAL/DEMOGRAPHIC + ENVIRONMENTAL risk factors for FALLS
PSYCHOSOCIAL/DEMOGRAPHIC
- ↑ age
- female
- living alone
- Hx of falls
- inactivity/frailty
- ADL limitations
ENVIRONMENTAL
- poor footwear
- inappropriate glasses
NORMAL AGEING/NEUROMUSCULAR risk factors for FALLS
NORMAL AGEING/NEUROMUSCULAR
- ↓ visual acuity
- ↓ peripheral sensation
- muscular weakness
- poor reaction times
BALANCE & MOBILITY risk factors for FALLS
BALANCE + MOBILITY
- impaired gait/mobility
- impaired transfers
- impaired balance reaction
MEDICAL CONDITIONS as RF for falls
MEDICAL CONDITIONS
- impaired cognition
- depression
- neurological signs
- stroke
- Parkinson’s disease
- incontinence
- acute illness
- arthritis
- foot problems
- dizziness
MEDICATION RF for FALLS
MEDICATIONS
- psychoactive medications (esp benzol)
- anti-hypertensives
- polypharmacy (> 4 meds)
- (hypoglycamics)
What factors contribute to falls?
COMBINATION OF FACTORS/MULTIFACTORIAL
INTRINSIC ( factors to do with the pt + their health) • medical conditions affecting: - visual - MSK - neurological - cardiovascular
• medications
- psychoactive
- anti-hypertensive
EXTRINSIC (factors to do with the environment the pt operates in)
• personal: inappropriate footwear, clothing or mobility aids
• domestic: poor lighting, loose rugs, slippery floors, stairs, general clutter
• general: reduced indoor circulating space, lack of rails in strategic locations and uneven or slipper paths outdoors
BEHAVIOURAL (factors to do wit the interaction between the pt + their environment)
• undertaking activities that are inherently risky (complex tasks, energy demanding tasks)
- climbing a ladder
- standing on a chair
- turning quickly
Mx strategies to help PREVENT falls?
1) identify all factors contributing to overall risk of falling
- determine which factors are amenable to intervention
2) REVIEW MEDS
- look @ meds causing drowsiness/anti-HTN/psychotropic
- Reduction/cessation of psychotropic medication
- withdrawal from benzos is associated with ↑ risk of falls + delirium
2) Balance, strength & gait retraining (Physio)
3) Vit D / Ca supplementation (esp those at high risk due to ↓ sun exposure)
4) Reduction/cessation of psychotropic medication
- withdrawal from benzos is associated with ↑ risk of falls + delirium
5) Home hazard assessment & modification + patient education
6) improving transfers and gait +/- gait aids
7)
Mx strategies to help prevent INTRINSIC FACTORS of falls?
1) improve medication conditions contributing to risk
- impaired vision
- postural hypotension
- painful foot or joint condition
2) medication review
- especially those that effect balance, cause drowsiness
3) Ix + Mx of syncope (neuro + CVS)
Mx strategies to help prevent EXTRINSIC + BEHAVIOURAL FACTORS of falls?
1) appropriate foot care & advice regarding safe footwear
2) Assess for need of gait aid
- ensure gait aids are appropriately sized
3) Home hazard assessment of environmental factors (inside + outside)
- loose rugs, poor lighting, lack of rails in strategic places, slippery or uneven pathways
BEHAVIOUR
- advice about appropriate behaviour to reduce falls
- for severe fear of falling, clinical psychology + behavioural modification may be required
