Fall Prevention: Screening Older Adults from the Bedside ... · FPTA Annual Conference -- Orlando...

FPTA Annual Conference -- Orlando 8/17/2014

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Fall Prevention: Screening Older Adults from the Bedside to the

CommunityJacqueline Osborne PT, DPT, GCS, CEEAA

September 14, 2014

1. Recognize the content of evidence-based falls screening tools for older adults in different settings:

a) Community

b) Home Health Care

c) Skilled Nursing Facility

d) Sub-acute/Inpatient Rehabilitation

e) Acute Care

Session Objectives

2. Recognize the steps necessary to implement a falls screen event for community dwelling older adults.

3. Identify how to use the information collected at a falls screening event for community dwelling older adults.

Session Objectives



Many falls are preventable through risk identification and

targeted intervention!

Beattie 2014

Fall Prevention

Starts with a Screen



• High risk = Further assessment

–Reports frequent falls in the last year

–Reports 1 fall with high-risk circumstances

–Presents for medical attention due to a fall

–Report difficulties with walking or balance

Risk Stratification

Beattie 2014

• Moderate Risk = Referral to community-based programs or to a health care provider

–Reports only a single fall

–Reports or demonstrates no difficulty with walking or balance

Risk Stratification

Beattie 2014

• Low Risk = Referral to community-based programs

–No reported falls

–No demonstrate gait and balance difficulties

Risk Stratification

Beattie 2014



• Private Residences

• Assisted Living Facilities

• Senior Center Members

• Outpatients

Community Dwelling Older Adults

• American Geriatric Society/British Geriatric Society Clinical Practice Guidelines for Fall Prevention

• Performance-Based Measures

• STEADI Toolkit

• Risk Stratification Tool

Evidence-Based Screening Tools

“All older people should be given a short screen for fall risk and, if at

risk referred on to further detailed assessment and intervention.”

(AGS, BGS, AAOS 2001;2010)



Screen

• Require little time

• Require minimal to no specialized training

• Inexpensive

• Valid in general older adult populations

Assessment

• Increased time commitment

• Requires specialized training to administer and interpret

• May be costly to obtain and use

• Non-generalizable to all older adult populations

Screen vs Assessment (Fabre 2010)

Sidebar: Screening for Fall(s) Questions

1. Two or more falls in prior 12 months?

2. Presents with acute fall?

3. Difficulty with walking or balance?

AGS/BGS Clinical Practice Guidelines for Fall Prevention

Refer to provider to obtain a multifactorial

assessment:

1. Physical Therapy

2. Physician




Standardized

tests:

1. TUG

2. BBS

3. POMA


Standardized

tests:

1. OLS

2. Gait Speed

• Berg Balance Scale (Neuls 2011; Muir & Berg 2008; Daubney 1999)

– Predictive of falls ONLY in frail older adult populations

– Has a ceiling effect in more active community dwelling older adults

– Recommended that the BBS be used as a balance test in older adults in conjunction with other tests not as a fall risk tool

– 58% is related to ankle DF and subtalar evertorstrength

The Berg Balance Test

• Can be used as screens for falls:

– Timed Up & Go

– One Legged Stand

– 10 Meter Walk Test

Performance-Based Tests



• Stand from sitting in a chair 46 cm in height w/o armrests, walk at usual walking pace 3 m, turn around and sit back down in the chair

• Score:-- >14 sec = high risk for falls; community dwelling older adultSn = 87%; Sp = 87% (Shumway-Cook 2000)

-- < 12 sec = normal mobility; community dwelling older adultSn & Sp not reported (Bischoff 2003)

Timed Up & Go (TUG)

3 meters Remember to consider

chair height

TUG (seconds) – Normative data in community dwelling older adults

Males n Females n

60-69a 7.30 1 8.10 5

71-75b 8.60 73 10.70 64

76-80b 9.42 53 10.71 35

81-85b 10.34 29 12.36 25

86-99b 11.13 16 13.15 13

(Lusardi 2003a; Pondal & del Ser 2008b)

One Legged Stand (OLS)

• Stand on preferred leg w/ EO

arms across chest, barefoot for 30 s

• Assistance to assume the starting position or to maintain the position for 30 sec = impairment

• Statistically significant ↑ in fall risk in community dwelling older adults who are unable to hold OLS for at least 10 seconds (Muir 2010)

• Consider taking an average of 3 trials



OLS (Franchignoni 1998)

• Can predict fall risk

– Sn = 0.95; Sp = 0.58 (cutoff time of 30 sec)

– +LR = 20; -LR = -0.08

Age Seconds (Mean)

20-59 29.4 – 30.0 (Bohannon 1984)

60 -69 27.0

70-79 17.2

80-99 7.5

Gait Speed: 10MWT

Acceleration : 2 meters Acceleration : 2 meters

10 meters: Timed

Gait speed =

meters x

seconds

Gait Speed: The 6th Vital Sign (Fritz & Lusardi 2009)



Gait Speed (m/s)Normative data

(Oh-Park 2010)

Age Males (n = 116) Females (n = 188)

70-74 1.12 1.10

75-79 1.12 1.02

80-84 1.08 1.00

> 85 1.02 1.01

Calculated via GAITRite mat = 21 feet (15 feet measured)

Preferred Speed

Gait Speed m/sNormative data (Chui 2010)

Age Males n Females n

70-79 1.55 4 1.34 15

80-89 1.30 26 1.05 51

90-99 1.09 5 0.78 17

Fast Speed

Age Males n Females n

70-79 2.19 4 1.69 15

80-89 1.74 26 1.44 51

90-99 1.55 5 1.05 17

Calculated via GAITRite mat = 21 feet (15 ft measured)

Self-Selected Speed

Gait Speed (m/s)Normative data (Lusardi 2003)

Age Group N Mean

60-69 M 1 1.26

F 5 1.24

All 6 1.24

70-79 M 9 1.25

F 10 1.25

All 19 1.25

80-89 M 10 0.88

F 24 0.80

No Device 24 0.91

Device 10 0.63

All 34 0.82

90-101 M 2 0.72

F 15 0.71

No Device 7 0.88

Device 10 0.59

All 17 0.71

Calculated via GAITRitemat = 12 ft

Comfortable Fast Age Group N Mean

60-69 M 1 1.96

F 5 1.81

All 6 1.84

70-79 M 9 1.94

F 10 1.80

All 19 1.86

80-89 M 10 1.29

F 24 1.20

No Device 24 1.38

Device 10 0.88

All 34 1.23

90-101 M 2 1.27

F 15 1.05

No Device 7 1.29

Device 10 0.93

All 17 1.08




• American Geriatric Society/British Geriatric Society Clinical Practice Guidelines for Fall Prevention

• Performance-Based Measures

• STEADI Toolkit

• Risk Stratification Tool

Evidence-Based Screening Tools

• Developed by the CDC to assist primary care providers to incorporate fall risk assessment and individualized interventions into their clinical practice

• Launched in 2011 to pilot in 3 states over 5 years (Oregon, New York and Colorado)

• Based on the Clinical Practice Guidelines for Fall Prevention developed by the AGS and the BGS

http://www.cdc.gov/homeandrecreationalsafety/Falls/steadi/index.html



• Algorithm for Fall Risk Assessment & Interventions

– Stay Independent Brochure

– Score ≥ 4 points = may be at risk for falling

– Fell in the past year

– Feels unsteady when standing or walking

– Worries about falling

http://www.cdc.gov/HomeandRecreationalSafety/pdf/steadi/algorithm_fall_risk_assessment.pdf

http://www.cdc.gov/HomeandRecreationalSafety/pdf/steadi/stay_independent.pdf



• Performance-based gait strength and balance assessment:

– Timed Up & Go

– 30 Second Chair Stand Test

– 4-Stage Balance Test

• Test of LE functional strength

– Select a standard height chair (45-46cm;17-18in height) place against a wall

– Arms across chest; sit in middle of chair

– Stand fully then return to sit

– Repeat as many times as possible in 30s

30 Second Chair Stand Test



Age Men Women

60-64 < 14 < 12

65-69 < 12 < 11

70-74 < 12 < 10

75-79 < 11 < 10

80-84 < 10 < 9

85-89 < 8 < 8

90-94 < 7 < 4

30s Chair Stand Below Average Scores

Rikli R& Jones J. Senior Fitness Test Manual. 2001, Champaign, IL: Human Kinetics

• Test of Static Balance– EO

– No AD

– 4 positions• Feet side-by-side

• Semi-tandem

• Tandem

• One leg stand

4-Stage Balance Test

The 10 s cutoff may not be sensitive enough to capture

higher functioning older adults with a balance

impairment (Hile 2012)

If individual can hold a position

for 10 sec w/o moving feet or

needing support, go on to next

position. If not, stop the test.



• 4 determinants for recurrent falls:– History of falls -- 8

– Living alone -- 3

– Taking ≥ 4 medications/day -- 3

– Being female – 2

Low risk = 0-4; moderate risk = 5-10; high risk = 11-16

• Perform an in-depth multifactorial assessment for those in high risk category and moderate risk who fail the FTSS (>15 sec)

Fall Risk Stratification Tool (Buatois 2010)

• Multifactorial tool developed:

– For community dwelling older adults ≥ 65

– To be administered by minimally trained staff with a follow up interpretation by a trained primary care provider

Contains previously validated measures

• TUG

• Modified Falls Efficacy Scale

• Home Safety Checklist

• Mood Scale (GDS – short)

– Score : ≥ 5/30 = PCP review

Fall Risk Assessment and Screening Tool: FRAST (Renfro 2011)

FRAST



FRAST

Modified Falls Efficacy Scale

Geriatric Depression Scale -- Short



• Community dwelling older adults

• Non-institutionalized

• Home-bound

Home Health Care

• 10 core elements

• ≥ 4 = at risk for falls; < 4 = not at risk for falls

• Cutoff score of 4: Sn = 96.9%; Sp = 13.3%

• Cutoff score of 6: Sn = 68.7%; Sp = 46.9%

Missouri Alliance for Home Care Fall Risk Assessment Tool (MAHC-10)

Calys 2012

Calys 2012



• 15 sec = cut-point that discriminates those @ low risk & high risk for falls; frail older adults in LTC facilities; Sn = 81%, Sp = 39% (J Whitney 2005)

• > 35 sec = rule-in high fall risk; but < 35 sec did not rule it out; frail older adults in LTC facilities; Sn = 36%, Sp = 86% (Nordin 2008)

• Value of TUG lies in ability or inability to complete the test rather than time to complete the test; older adult in acute settings; Sn and Sp not reported (Large 2006)

TUG

• TUG may be more appropriate for screening or assessing fall risk in frail community dwelling older adults or those using an AD (Lin 2004) rather than in healthy community dwelling older adults even if they have a fall history

• Consider chair height

TUG Take Home Message

• Institutionalized

• Lower functioning than those living in ALF or private home

• May be similar in function to an older adult who is home bound

Skilled Nursing or Sub-acute Setting



St. Thomas Risk Assessment Tool in Falling Elderly Patients (STRATIFY)

Oliver 1997

STRATIFY: Setting Matters

• Oliver 1997: risk score ≥ 2 local: Sn= 93%, Sp= 88%; +LR= 7.75, -LR=0.08remote: Sn= 92%, Sp= 68%; +LR=2.87, -LR=0.12

• Coker 2003: Predictive value for fall risk in older adults not as applicable in a GRU in Ontario, Canada:Sn= 66%; Sp= 47%; +LR=1.24, -LR=0.72

• Wijnia 2006: STRATIFY was disappointing when used in a nursing home in the Netherlands:Sn = 50%, Sp= 76%; +LR=2.10, -LR=0.66

STRATIFY: Population Matters

• STRATIFY ≥ 2 = was a poor predictor of falls post-stroke in 3 rehab facilities in North England: (Smith 2006)

– After first 28 days of admission -• Sn = 11.3%; Sp = 89.5%; +LR=1.07, -LR=0.99

– At discharge -• Sn = 16.3%; Sp = 86.4%; +LR=1.20, -LR=0.97

• What is the take home message? –– It is doubtful that this tool can accurately identify potential fallers for preventative interventions when used in isolation



4-item Peninsula Health Fall Risk Assessment Tool (PH-FRAT)

(Stapleton 2009)

> 14 = fallers

• Administered by nurses

• Based on PMH, medication list, patient/caregiver consultation, observation

• n = 291

• Cutoff @ 14: Sn = 68.8%; Sp = 70.2%

FRAT (Stapleton 2009)

• # readmitted to acute care after SNF D/C– 22.1%: within 30 days

– 12%: within 10 days

• 10.3% ER visit w/o hospitalization – 5,800 people

• 14.7% ED visit w/ hospitalization• 8,300 additional people

Acute Care Use After SNF D/C(Toles 2014)



• Easily identifiable high risk population of older adults (Close 2012)

• Demographics & medical history

Acute Care Setting

Hendrich II Fall Risk Model (HIIFRM) (Hendrich 1995)

Available at www.hartfordign.organd/or www.ConsultGeriRN.org

E-mail notification of usage to: [email protected]

Cutoff = 5Sn = 74.9%Sp = 73.9%

Morse Falls Scale (MFS) (Morse 1989)

No risk = 0-24Low Risk = 25 - 50High Risk = ≥ 51

Cutoff = 25Sn = 88%

Sp = 48.3% Kim 2007

http://www.hartfordign.org/

http://www.consultgerirn.org/

mailto:[email protected]



• Variables associated with falls were interventions (Titler 2011)

–Medical and nursing treatments

• Iatrogenic factors (Memtsoudis 2014)

• Patient’s perspectives (Carroll 2010)

– Need to toilet

– Unexpected weakness and imbalance

Acute Care Setting

Falls Risk Screen

• If the purpose of the screen is to determine fall risk, the literature does not recommend that screens include measures of:

– Orthostatic Hypotension

– Visual Impairment

– Medication Review

– ADLs

– Cognitive Impairment

– Tandem Stand

– Observational Gait Analysis

Ganz 2007

Muir 2010

• Audience

• Venue

• Timing

• Incentives

• Marketing

• Data Collection

• Staffing and Logistics

• Consent

• Outcomes

Screen Event Details



• Gather information

– Current activity levels

– Recent need for physical therapy services

– Fall history

Audience

• Ample space

• Low noise

• Provide a snack

Venue

• Consider time of day

• Avoid holding event at the same time as competing programming

Timing



• Consider giveaways

– T-shirts

– Water bottles

– Night lights

– Educational Materials (handouts; CDC, APTA)

Incentives

• Avoid advertising a “fall” screening event

• Consider alternative wording:

– Wellness Screen

– Health Check

– Activity Screen

Marketing

• Can start with questions (history & demographics)

– Have you fallen at least 1 time in the last year?

– Do you perceive that you have any problems with your balance or walking?

– Do you take more than 4 medications?

Data Collection



• Should have a performance-based section:– 30 second chair stand– 4-stage balance test

• Feet side-by-side• Semi-tandem• Tandem• One leg stand

– Timed Up & Go

– 10 Meter Walk Test

Data Collection

• Provide synopsis of findings in a written, brief easy to understand format

• Provide comparisons

• Develop a plan for recommendations that an individual can take to a physician

• Provide your contact information

Data Collection

Screening Form

Example



• Determine the flow of the event

• Set up stations with necessary equipment

• Ensure adequate seating for participant and guest

Logistics

• Staff the screening event with volunteer health care providers, students

• Consider training your staff

Staffing



Consent

• Survey staff/volunteers

– Were there any issues/problems during the event?

– Is there anything you would change should a similar event be offered in the future?

– Did you find this event beneficial?

Outcomes

• Survey senior center members

– Did anyone seek services from a physical therapist or physician?

• If not, what were the barriers?

• If so, what was the recommendation?

– Would you attend a future similar event?

• Why or why not?

– Are there any aspects of the event you would change, omit, or add?

Outcomes



[email protected]

Thank You!

1. American Geriatrics Society, British Geriatrics Society, American Academy of Orthopaedic Surgeons Panel on Falls Prevention. Guideline for the prevention of falls in older persons. J Am Geriatr Soc. 2001;49:664–672.

2. Beattie BL. Effective fall-prevention demands a community approach. J Geriatr PhysTher. 2014;37:31-34.

3. Bischoff HA et al. Identifying a cutoff point for normal mobility: a comparison of the Timed Up & Go test in community dwelling and institutionalized elderly women. Age Ageing 2003; 32:315-320.

4. Bohannon RW et al. Decrease in timed balance test scores with aging. Phys Ther. 1984; 64(7):1067-1070.

5. Buatois S et al. A Simple Clinical Scale to Stratify Risk of Recurrent Falls in Community Dwelling Adults Aged 65 Years and Older. Phys Ther. 2010;90:550-560.

6. Calys, M et al. A validation study of the Missouri Alliance for Home Care Fall Risk Assessment Tool. Home Health Care Management & Practice 2012; 1-6

7. Carroll DL et al. Patient’s perspective of falling in an acute care hospital and suggestions for prevention. Appl Nurs Res 2010; 23(4):238-241.

8. Chu LW et al. Incidence and predictors of falls in the Chinese elderly. Am Acad Med Singapore. 2005; 34:60-72.

9. Chui K et al. Spatial and temporal parameters of self-selected and fast walking speeds in healthy community-living adults aged 72-98 years. J Geriatr Phys Ther.2010;33:173-183.

References

10. Close JC et al. Older people presenting to the emergency department after a fall: a population with substantial recurrent health care use. Emerg Med J 2012; 29(9):742-747.

11. Coker E, Oliver D. Evaluation of the STRATIFY falls prediction tool on a geriatric unit. Outcomes Management. 2003;7(1):8-14.

12. Daubney M et al. lower extremity muscle force and balance performance in adults aged 65 and older. Phys Ther. 1999;79:1177-1185.

13. Fabre, J et al. Falls riks factors and a compenduim of falls risk screening instruments. J Geriatr Phys Ther. 2010;33:184-197.

14. Franchignoni F et al. Reliability of four simple, quantitative test of balance and mobility in healthy elderly females. Aging. 1998; 10(1):26-31.

15. Fritz S & Lusardi M. White Paper: “Walking speed: the sixth vital sign.” J Geriatr PhysTher. 2009;32(2):2-5.

16. Ganz D et al Will My Patient Fall? JAMA. 2007;297:77-86

17. Hendrich A et al. Hosptial falls: development of a predictive model for clnical practice. Appl Nurs Res. 1995;8(3):129-139.

18. Moreland J et al. Muscle Weakness and Falls in Older Adults: A Systematic Review and Meta-Analysis. JAGS 52:1121–1129, 2004

References



19. Hile E et al. Interpreting the need for initial support to perform tandem stance tests of balance. Phys Ther. 2012; 92(10):1316-13218.

20. Kalyani R. Vitamin D Treatment for the Prevention of Falls in Older Adults: Systematic Review and Meta-analysis. JAGS 2010;58:1299-1310.

21. Kim EA et al. Evaluation of three fall-risk assessment tools in an acute care setting. J Adv Nurs 2007;60(4):427-435.

22. Large J et al. Using the Timed Up and Go Test to stratify elderly inpatients at risk of falls. Clinical Rehabilitation 2006; 20: 421-428.

23. Lamb S. et al. The Optimal Sequence and Selection of Screening Test Items to Predict Fall Risk in Older Disabled Women: The Women’s Health and Aging Study. Journal of Gerontology: MEDICAL SCIENCES. 2008, 63A(10):1082–1088.

24. Lin MR et al. Psychometric comparisons of the timed up and go, one leg stand, functional reach and Tinetti balance measures in community dwelling older people. J Am Geriatr Soc. 2004;52:1343-1348

25. Memtsoudis S et al. Inpatient falls after total knee arthroplasty: the role of anesthesia type and peripheral nerve blocks. Anesthesiology 2014; 120(3):551-563.

26. Milisen K et al. Use of Fall Prevention Practice Guidelines for Community-Dwelling Older Persons at Risk for Falling: A Feasibility Study. Gerontology 2009;55:169-178.

References

27. Muir S et al. Use of the Berg Balance Scale for predicting multiple falls in community dwelling elderly people: a prospective study. Phys Ther. 2008;88(4):449-461.

28. Muir SW, Berg K, Chesworth B, et al. Balance impairment as a risk factor for falls in community dwelling older adults who are high functioning: a prospective study. Phys Ther. 2010;90:338–347.

29. Morse JM et al. Development of a scale to identify the fall-prone patient. Can J Aging. 1989;8(4):366-377.

30. Neuls PD et al. Usefulness of the Berg Balnce Scale to predict falls in the elderly. J Geriatr Phys Ther. 2011;34:3-10

31. Oh-Park M et al. Conventional and Robust Quantitative Gait Norms in Community Dwelling older adults. J Am Geriatric Soc. 2010;58:1512-1518.

32. Oliver D et al. Development and evaluation of an evidence-based risk assessment tool (STRATIFY) to predict which elderly inpatients will fall: case-control and coort studies. BMJ 1997;315:1049-53.

33. Renfro, M and Fehrer S. Multifactorial screening for fall risk in community dwelling older adults in the primary care office: development of the Fall Risk Assessment & Screening Tool. J Geriatr Phys Ther 2011;34:174-183.

34. Rikli R& Jones J. Senior Fitness Test Manual. 2001, Champaign, IL: Human Kinetics

References

35. Rosendahl E et al. Prediction of falls among older people in residential care facilities by the Downton index. Aging Clin Exp Res 2003; 15:142-147.

36. Shumway-Cook A et al. Predicting the probability for falls in community-dwelling older adults using the Timed Up and Go Test. Phys Ther 2000; 80 (9): 896-902.

37. Smith J, Forster A, Young J. Use of the 'STRATIFY' falls risk assessment in patients recovering from acute stroke. Age And Ageing . 2006;35(2):138-143.

38. Tilson JK et al. Characterizing and identifying risk for falls in the LEAPS Study: A randomized clinical trial of interventions to improve walking poststroke. Stroke. 2012;43:446-452.

39. Titler MG et al. Factors associated with falls during hospitalization in an older adult population. Res Theory Nurs Pract 2011; 25(2):127-148.

40. Toles M et al. Restarting the cycle: incidence and predictors of first acute care use after nursing home discharge. J Am Geriatr Soc 2014; 62:79-85.

41. Whitney J et al. Streamlining assessment and intervention in a falls clinic using the Timed Up and Go Test and Physiological Profile Assessments. Age and Ageing 2005; 34: 567–571.

42. Wijnia J, Ooms M, van Balen R. Validity of the STRATIFY risk score of falls in nursing homes. Preventive Medicine. 2006;42(2):154-157

References

Fall Prevention: Screening Older Adults from the Bedside ... · FPTA Annual Conference -- Orlando...

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