Addressing Falls in Older Adults: Part II

As discussed in my last blog post, fall prevention is important to address in older adults, but even more so for individuals who have progressive diseases (diseases which get more severe over time). Multiple Sclerosis is an example of a neurological disease for which fall prevention is critical.

I had the pleasure of working with Vicky, a 60 year old female who had a history of relapsing remitting multiple sclerosis, last Spring. Overall, the progression of Mary’s disease had been slow over the past 15 years until a recent fall down the stairs at her home resulting in a hip fracture. Mary was admitted to inpatient rehabilitation following hip surgery in order to improve her functional status before discharging home.

In speaking with Mary and getting to know her better, I realized that anxiety about falling was a major problem for her:
1) Mary had been restricting how often she would go out of her apartment to once a week because she was afraid of falling in public. [This got my attention! When a person limits their current activities due to fear of falling, it results in deconditioning, decreased strength, and even frailty—which puts a person at higher risk for falling in the future.]
2) Feeling that a cane would label her as “disabled”, Mary refused to utilize an assistive device while walking. [This required significant PT education regarding the benefits of using an assistive device to prevent falls versus not using one and falling—which is exactly what had happened to Mary.]
3) Finally, Mary disclosed that she had a number of falls around her home recently. [Which told me that her condition was progressing and she clearly needed intensive PT intervention.]

Working with Mary involved a multi-dimensional approach to improve her daily function and independence. Firstly, I had to “coach” Mary on her current abilities (how much she could do on her own) and her current functional limitations. I had to help to build her confidence by putting her in challenging situations (ie. practicing flights of stairs, walking on gravel/grass/sand, moving out in the community) to show her how much she could do on her own. We talked at length about the negative effects of another fall—pain, decreased function, decreased independence, etc. By opening her eyes to her actual balance abilities and education about the consequences of decreased balance, I slowly introduced Mary to different potential assistive devices to help her (including cane versus forearm crutch versus walker) and we practiced using them in different environments.

In addition, I utilized standardized “Fall Assessment Measures” to determine her risk for future falls. We commonly use these in physical therapy to objectively show change in our patients over time (from initial evaluation through discharge). Even more importantly, I use these balance assessments to educate my patients about their score and the implications about their score (based on research). For example, the Berg Balance Scale involves 14 items of a person performing different standing balance positions (single limb stance, tandem stance) and functional activities (reaching forward, picking something off the floor, sit to stand). The person is rated from 0-4 on each item depending on their score. A maximum of 56 is possible with scores less than 36 indicating a 100% chance of falling within the next year and scores less than 45 at high risk for falls. Other balance measures I commonly use are: Dynamic Gait Index, Functional Gait Assessment, and the Activities-Specific Balance Confidence Scale (to name a few). You might want to look some of these up online to get more information.

Before Mary discharged from rehab, I made sure that we had evaluated her home to decrease fall hazards: removing throw rugs, decreasing clutter on the floor, placing nightlights in bedroom/bathroom, installing a grab bar and non-stick rug in the tub, and creating more space between furniture so that a clear path for walking was established. Mary also went home with a home exercise program that targeting: strengthening of her hip muscles, balance exercises with a narrow stance, and a daily outdoor walking program with her crutch. Our biggest goal for her home program: No falls for one year! :-) She is checking back in with me every month to tell me how she’s doing.

Addressing Falls in Older Adults (Elise)

You've heard it a million times: falls can be devastating in the elderly population. "Fall Prevention" has a lot of buzz now in the healthcare industry because falls are so costly to the healthcare system. As a physical therapist, I have an important role in helping individuals recover function after falls, but moreso in identifying risk factors of persons who are at high risk for falling in the future.

There can be many different contributors to falls, which makes it a complex and challenging construct to assess in people. Think about it! Falls can be caused by: poor balance, gait deficits (including using an assistive device), muscle weakness, visual changes, polypharmacy (multiple medications), decreased cardiovascular function, neurologic deficits, depression, decreased cognitive capabilities, and fear (to name a few!). By carefully collecting information during the patient interview, as well as taking objective measurements during the PT evaluation, I can develop a treatment strategy to specifically target those areas that place individuals at risk for falls and future falls.

During a subjective interview with older patients, it is important to ask about "fall history" (if the patient has fallen in the past). If they have fallen, one must follow-up with questions:
--How many times they have fallen (one fall suggests an acute medical problem versus several falls suggests slow deterioration of balance ability)
--Where they have fallen (environment)
--What activity they were doing (multi-tasking? one-legged stance? reaching?)
--What time of day (at night when more tired? poor vision in dark?)


Remember-- the interview can help you to form a hypothesis for what can be contributing to falls, but your objective examination will provide you with important information, too. There are many body systems to consider: 1) Sensory systems (vision, vestibular (inner ear), and somatosensation (feet)); 2) Musculoskeletal systems (strength, range of motion, endurance); 3) Cognitive/Affective factors (fear of falling, depression, anxiety, medications)

In addition to these, an environmental assessment is helpful to determine hazards that exist (home/apartment, carpet/wooden floor, stairs, lighting, excess clutter). Also, consider the impact of family support on the person. Are they living alone and forced to be independent with activities that they really should not perform on their own? Or is a family member present to assist or prevent the person from taking "risky" action?

Can you see how much is involved in fall assessment?! In my next post, I will share a patient case with you involving a patient with multiple sclerosis who came to me with a long fall history-- and whose treatment program addressed many of the above issues in order to allow for safe and independent functioning at home and the community.

Being a Manager (Joanna)

As the Manager of my building's Engage Life Department, I must have staff meetings as well as training sessions for staff. My two most recent training sessions for staff included "Back Safety" & "Activities for Residents with Alzheimer's and Dementia" Doing these staff training sessions requires some research, planning, creativity, as well as being comfortable getting up in front of a large group of staff. (No public speaking phobias!) My goal is to always make the training somewhat fun, or at least interesting, after all, I want our staff to get something out of my training sessions!

A challenge I have to deal with on a daily basis is that I'm a young manager. I was promoted to my current manager position at the age of 23. Now I'm 25, no longer rent an apartment (have a house!), currently engaged (wedding this September!), and have four cats (yes...four!!). So, many things have changed for me since I was 23 years old, especially when it comes down to different types of responsibilities. One female resident (in her 90's)always laughs and tells me I look like I'm 12 years old! (Although once in a while there are some days she'll tell me I look like I'm a 14 or 16 year old!) I brought in pictures of when I was 12, 14, and 16 years old so she could see the difference between then and now, but this didn't change her mind of course! Now, it's just an inside joke between her and I. My assistants & I joke around about our ages as well, since my 70 something year old assistant could be my "grandmother", my 50 something year old assistant could be my "mother", which then makes me the "daughter/granddaughter" of the two. All three of us believe that the three different generations truly make us a unique and dynamic Engage Life trio.

Another thing that goes along with being a young yet new manager is constantly learning, and practicing my manager style. I do not like to micro-manage my staff. Instead, I prefer to give my staff space and freedom, while having an understanding that they will give their very best within the rules and expectations of the company. Sometimes I'll give my assistants a to-do list. I like to see and treat my staff as equals, the only difference being that I carry the responsibility for my department. We all share an office, and share doing the activities and other related jobs each day. I make sure that my assistants are aware that I can do and will do everything that they do whether that be moving furniture, driving the 14-seat van, calling Bingo, leading exercise classes, wiping tables down, decorating on theme days, taking pictures, doing trivia, etc. Half the time, my assistants and I ask each other, "which activity would you like to do today at 2:00pm? Bingo or drive residents to the boardwalk downtown to go walking? And then of course we both say, "I don't care, you pick" and this goes on back and forth until we reach a decision. I personally like to give my assistants the option to pick (unless there's a good reason why I must do a particular activity due to any other meetings, conference calls, etc. on my manager schedule for the day that I may need to be at). I do not like being a "bossy" boss. I am also always listening to my staff--I love to hear their ideas, input, and advice. They are a great source of support and creativity.

I can say that it is definitely easier being a manager now compared to when I just started as one two years ago, but this is most likely just due to practice and learning from my experiences. I must not forget to add that I have learned a lot from the other "seasoned" managers at my work. Some of these managers, including my Executive Director, have been working at my building for 10 or more years!

Dementia in the Inpatient Rehab Setting (Elise)

Admission to inpatient rehabilitation involves meeting strict criteria. A person must have certain diagnoses (such as stroke, spinal injury, traumatic brain injury, Multiple Sclerosis, etc.) which have a good prognosis for functional improvement. A person must medically stable and able able to tolerate at least 3 hours of therapy every day from an interdisciplinary team (PT, OT, Speech). Dementia is a common health problem among the aging, but generally is not a qualifying diagnosis for acute inpatient rehabilitation.... unless it is a co-morbid condition occuring along with one of the aforementioned primary diagnoses. Mae is an example of one such patient.

Last fall, Mae was admitted to inpatient rehabilitation following a laminectomy and posterior spinal fusion for lumbar stenosis. She had a 5 year history of progressive dementia and lived with her husband (of 55 years) in a nearby town. Over the course of the past year, Mae had experienced progressive weakness in her legs that eventually required her husband to perform dependent lifts in order to transfer her into bed, onto the toilet, or into the car. She was eventually referred to a neurosurgeon and then became a patient of mine following her surgery.

Mae sticks out in my mind as an especially challenging patient to work with. As a consequence of her dementia, she had frequent "ups" and "downs" in her ability to communicate with me, her ability/desire to participate in therapy, and her tolerance of therapy. Every day, I would walk into her room not knowing if it was a "good day" (where she would be happily smiling in bed eating her breakfast), or a "bad day" (in which she was crying, unsure of where she was, confused of what day it was, and demanding to see her husband or her dog).

My rehab goals for Mae's program significantly differed from other patients on the service. The goal for most patients is to improve their ability to complete daily functional and mobility-related tasks to the level of independence. For Mae, this was not a realistic goal given her cognitive status. My hope was to:
1) Improve her overall function (including lower extremity strength and overall aerobic endurance) for the "good days"
2) Complete family training for her husband and primary caregiver, Jim, who was 80 years old (dependent lifts were not a safe strategy for either of them!!) to determine safe strategies to assist her
3) Prescribe equipment including bath chair, transfer board, and permanent wheelchair to assist her husband during the "bad days"
4) Develop a home exercise program to help maintain her current level of function and prevent secondary impairments (muscle tightness, deconditioning, etc.)

On a day-to-day basis, I asked myself many questions regarding her therapy. She was very different from my other patients. Did I expect Mae to be independent with her exercises like my other patients? Did I expect Mae to remember new techniques for transfers without cueing? Did I expect Mae to independently arrive to the gym at a given time for therapy? Did I expect Mae to demonstrate the ability to walk around and transfer herself no matter what time of day by discharge? The answer to all of these questions was NO.

I had to develop many compensatory techniques to help Mae benefit from rehab. Every day, we worked on therapy in the same environment to establish familiarity. The room was quiet and distraction-free in order to help her to focus. Giving Mae choices in what she wanted to work on was important in engaging her in therapy. Sessions focused on "automatic" tasks to improve her leg strength and overall endurance, such as walking and standing transfers, instead of teaching leg lifts or other exercises requiring multi-step commands. Standardized tests for balance or endurance were not appropriate because the instructions were too complex. One hour sessions were too long for Mae to concentrate and participate in, as she fatigued very quickly and became irritable. Instead, we adjusted her schedule to multiple 30 minute sessions over the course of the rehab day. We continued to work on standing transfers instead of introducing new equipment (such as a transfer board) which was unfamiliar and confusing to her. Repetition was very important to the structure of her therapy-- we had to give her many many opportunities to practice. We provided her with simple, explicit, written instructions (and pictures of her performing them!) for the exercises of her home program.

Finally, it was crucial to address how her husband, Jim, was managing with the changes in his wife and the demands of her care. He was an older man who was deeply concerned about her well-being. More than anything, he wanted to care for the woman he had shared the last 5 decades of his life with, and their bond was inspiring. But, he had to consider if the level of care she required was too much for him. Would it better for her to be in a nursing home? Despite many days of discussing the options with him, performing training, and even doing a home evaluation and home training, Jim decided that he wanted to take Mae home. "We always said that we would love each other and take care of each other for our entire lives," he said.

Aging with a Disability (Elise)

I think it's fair to assume that most people expect their health to decline with aging. Take, for example, the anticipated hip/knee joint problems, hearing or visual loss, osteoporosis, or maybe even a minor neuropathy. Those of us with a family history of more serious diseases like diabetes, cancer, heart disease, or stroke may take proactive steps to prevent or delay the onset of "aging" conditions in the future. Few of us, however, are prepared to age with serious permanent disability, such as a traumatic complete spinal cord injury.

Sam, a 63 year-old hispanic male, was enjoying his life as a husband, construction worker, father of 3 and new grandfather of 1. Last winter, his construction vehicle was rear-ended on the freeway going 50 mph. Immediately upon impact, Sam lost feeling in his legs and the ability to move them. After being emergently transported to the hospital, imaging revealed a thoracic-level complete spinal injury and he underwent spinal stabilization surgery. One week later, he was referred for inpatient rehabilitation. His wife and 3 daughters (and their families) were very supportive of Sam and provided much encouragement as Sam coped with this major life change.

As a PT, there are many things that I must consider when working with an older individual post-SCI:
1) First and foremost, I must consider Sam's desired life roles: What was involved in his role as husband (did he BBQ? fix appliances? do laundry?)? How will he remain intimate with his wife? How will a wheelchair impact his ability to play with his grandchildren? Does he see himself going back to work? What recreational interests does he have?
2) I must consider Sam's body: Does he have a prior injury to his shoulder that would prevent propelling a manual wheelcahir? Does he have a scoliosis, kyphosis, pelvic obliquity, or other postural deformity that requires special seating considerations? Does he have a significant history of diabetes or poor nutrition that may place him at increased risk for skin problems? Does he have heart or lung problems? Did he regularly exercise prior to his injury?
3) I must consider Sam's home: Can he access the kitchen, bedroom, bathrooom, etc? Are the doorways wide enough for his wheelchair? Are there stairs? Can he access his community?
4) I must consider equipment options: A padded bath chair for tub & toilet? A ramp for entering the home? A slide board to transfer into the car? Would a power w/c be more appropriate if it is medically justified?
5) I must consider Sam's ability to learn and desire to prevent long term complications: Will he understand the importance of regular pressure relief to avoid skin ulcers? Will he participate in a regular gym program to promote cardiovascular health and strong shoulder/trunk musculature? Will he understand the importance of a healthy diet to promote healing and avoid weight gain? Will he recognize the need for regular bowel/bladder management to prevent infection?

Many ways that Sam and I work together as patient-therapist are similar to younger patients. I must consider him as a whole person and understand those daily life activities which are most meaningful to him. But the things which are inherently different in working with older adults are: how prior medical history/past injuries impact current presentation; how prior life views on exercise and health will impact response to therapy education; and how cognitive ability to learn new information and movement strategies will promote reintegration to desired activities.