OL 215 Southern New Hampshire University Do You Embrace Change Essay

Chapter 9Functional
Performance in
Later Life:
Basic Sensory,
Perceptual, and
Physical Changes
Associated with
Aging
Objectives (1 of 3)
1. List at least four recommendations for
healthcare professionals who work with
people who have diminished visual skills.
2. Define perception and describe how
perceptual skills may change as one ages.
3. Describe compensatory measures related
to decreased perceptual functioning.
4. Describe how sensory systems tend to
change over the course of aging, impacting
function.
Objectives (2 of 3)
5. List compensatory measures for each of
the sensory changes related to aging.
6. List at least four recommendations for
healthcare professionals who work with
people who are hard of hearing.
7. Describe the basic physical changes of
aging related to range of motion, strength,
motor control, and endurance.
Objectives (3 of 3)
8. Discuss how physical changes affect
performance in various life skills,
including self-care and work.
9. Describe how sleep patterns change with
age.
10.Describe the components of interventions
related to sleep disorders, including
cognitive behavioral therapy.
Vision (1 of 8)
• Begins to deteriorate around age 30
– Older adults can maintain near 20/20 vision
with corrective lenses until about age 88
• Aging eye is vulnerable to diseases that
can permanently damage the ability to
see
Vision (2 of 8)
Vision (3 of 8)
• Other visual skills that decline with age:
–
–
–
–
–
–
Visual processing speed
Sensitivity to light
Ability to see well in dim light
Near vision
Upward gaze without moving head
Contrast sensitivity
Vision (4 of 8)
• Other visual skills that decline with age
(continued):
– Color sensitivity
– Dynamic vision, which includes
•
•
Smooth visual pursuits of a moving target
Visual tracking or saccades
Vision (5 of 8)
• Visual skills preserved with age:
– Basic color vision
– Ability to maintain fixation on a target
• The healthcare professional can offer
several simple compensatory measures
for older persons with decreased
eyesight
Vision (6 of 8)
Vision (7 of 8)
• Visual perception
– Brain’s ability to make sense of visual data
– Does not uniformly decline with age
– Older adults may:
•
•
•
•
Become more proficient at inferring meanings
from less sensory input
Have difficulty distinguishing novel items
Be slower at processing the information
Take in less visual information per unit of time
Vision (8 of 8)
• Decreases in perceptual skills are not
usually associated with typical aging
– Problems are usually related to a disease
process or psychiatric disorder
• Rehabilitation specialists can work with
individuals with perceptual difficulties in
adapting the environment and daily tasks
to promote functional performance
Hearing (1 of 5)
• Presbycusis (hearing loss)
– Occurs in both genders
• Older adults tend to:
– Have more difficulty distinguishing higherpitched consonant sounds
– Not be able to recall earlier conversations
when the number of words spoken per
minute is high
Hearing (2 of 5)
• Older women are more likely to:
– Report hearing loss
– Compensate by searching for nonverbal
cues
– Seek treatment
• Older men are more likely to:
– Have hearing loss
– Deny a problem and not seek treatment
Hearing (3 of 5)
• Mild hearing loss
– Doubles for every decade past the age of 50
– Worsened by repeated or ongoing exposure
to high-intensity sound
• Older adults have more difficulty tuning
out background noise in noisy social
gatherings
– May lead to social isolation
Hearing (4 of 5)
• Older adults with hearing loss report:
– Feelings of loneliness and anxiety due to
social isolation
– Fewer friends in their social network
• Social isolation can lead to mental
decline
– Hearing loss is associated with a higher risk
for being diagnosed with dementia
Hearing (5 of 5)
• Recommendations for working with older
adults with hearing loss:
–
–
–
–
–
–
Speak in a tone that can be heard
Face people so they can see you speak
Speak at an appropriate rate of speed
Avoid elderspeak
Keep background noise to a minimum
Do not verbally jump between ideas quickly
Smell
• Ability to detect smells and correctly identify
differing odors decreases with age
– High prevalence of hyposmia and anosmia
• Sense of smell declines insidiously with age
– Can constitute a serious safety issue
– Compensatory strategies are recommended
• Decreased sense of smell can contribute to
decreased pleasure in eating
Taste (1 of 2)
• Ability to detect salty, bitter, and sour
tastes decreases with age
– Threshold of salty flavor needed for
detection increases
– Ability to taste sweets does not change
• Thirst sensation declines with age
– Increased risk of dehydration
Taste (2 of 2)
• Inadequate dietary intake can cause a
loss of taste perception
– Number of taste buds can be reduced due to
malnutrition or as side effects of medication
• Appetite can decrease due to the sense
of fullness and early satiation from age or
disease-related changes in the GI tract
Physical Changes (1 of 11)
• Range of motion (ROM)
– Ability of a joint to move through its natural
pattern of movement
– Every joint has a typical range
– Declines in joint ROM in the shoulder, hip,
and wrist occur with age
– Some age-related conditions can restrict
smooth movements and limit maximum
range of motion
Physical Changes (2 of 11)
• Non-resistive, repetitive ROM exercises
may:
– Be able to maintain or improve current range
– Slow down the progression of disease
processes such as osteoarthritis
• Regular movement is important if the
individual is able
Physical Changes (3 of 11)
• Joint contractures
– Stiff muscles and tendons leading to joint
rigidity
– Being sedentary or immobile puts an
individual at a higher risk for contractures
– Joints typically affected include the hips,
shoulders, fingers, and knees
– Prevention is the best treatment
– Remedial treatment should involve a passive,
active-assisted, or active ROM program
Physical Changes (4 of 11)
• Strength
– Slight decline in middle age
– 15% loss per decade after age 50
– Some individuals may not get progressively
weaker with age
– If physically capable, older adults can still be
involved in, and improve in, sports requiring
practice
Physical Changes (5 of 11)
• Older adults who exercise can:
–
–
–
–
–
Reduce pain caused by arthritis
Restore balance to reduce fall potential
Strengthen bones
Maintain ideal weight
Improve glucose control for diabetes
management
– Improve heart health
Physical Changes (6 of 11)
• Encouraging physical activity is almost
always appropriate, although:
– The level of exertion and duration of activity
need to be determined by the primary
healthcare provider(s)
– Goals related to physical fitness need to be
clearly discussed with the older client
Physical Changes (7 of 11)
• Endurance
– Ability to sustain involvement in a physical
activity
– Lack of physical reserve and ability to resist
stressors can lead to frailty
– As muscle power decreases, frailty level
increases
Physical Changes (8 of 11)
• Combination of endurance and strength
training has been found to:
– Have a positive impact on heart and
pulmonary function
– Improve muscle function
– Increase functional capacity
– Improve cognition
Physical Changes (9 of 11)
• Physical exercise
– Long-term aerobic exercise training
programs for older adults are associated
with improved physical endurance
– Can improve:
•
•
•
Range of motion
Strength
Endurance
– May slow the course of physiologic aging
Physical Changes (10 of 11)
• Praxis
– Ability to carry out purposeful motor actions
– Dyspraxia
•
Decreased ability to plan and/or execute
purposeful movements
– Apraxia
•
Complete inability to carry out motor plans
Physical Changes (11 of 11)
• Frequent repetition of routine goaldirected activities throughout the day
enables the conversion of once novel
actions into established habits and
routines
• When there is a decline in function, an
overarching rehabilitation goal is often to:
– Help people regain lost skills
– Learn to work with their remaining abilities
Physical Performance (1 of 5)
• Age-related performance can be
measured in several domains:
–
–
–
–
–
Reaction time
Gross motor coordination
Strength
Endurance
Work-related performance
Physical Performance (2 of 5)
• Reaction time
– Older people are not able to react as quickly
as they were able to in their younger years
– Particularly important in regard to driving
– Other factors relevant to driver safety:
•
•
•
•
Physical strength
Mobility
Cognition
Perception
Physical Performance (3 of 5)
• Motor coordination
– Falls affect the older population more than
any other age group
•
•
Falling once increases the risk of falling again
Repeated falls are often associated with declines
in balance, coordination, and/or strength
– Impaired ambulation may be cause for a
referral to a physical therapist
Physical Performance (4 of 5)
• Fine motor coordination
– Hand-based skills such as writing, selffeeding, buttoning, and working with tools
– Often impaired in old age due to arthritis,
stroke, or other skill-robbing disease
– Older adults aging typically without
limitations from disease are just as capable
as their younger counterparts in completing
fine motor tasks
Physical Performance (5 of 5)
• Important to address significant
decreases in level of functioning
occurring either suddenly or over the
course of a few weeks or months
• Abrupt behavioral changes may warrant
a call and visit to the primary care
provider
Work Performance (1 of 3)
• General work performance of older
adults is not inferior to that of younger
counterparts
• Older adults are:
–
–
–
–
Considered more dependable
Less likely to be absent from work
Less frequently injured in the workplace
Less likely to demonstrate workplace
aggression and substance abuse
Work Performance (2 of 3)
• Changes in cognition, sensation,
perception, and physical performance do
not make a substantial impact on older
adults’ comprehensive work performance
or essential daily living skills
• Most older adults can do very well in the
workplace with minimal modifications
Work Performance (3 of 3)
• Healthcare professionals need to help
older workers remain on the job, even
after the onset of disabilities
– Can support older workers to return to, or
remain at, work by encouraging
accommodations and partial absences
instead of permanent withdrawal from the
workplace
Sleep (1 of 17)
• Essential part of everyday life
• Plays a central role in promoting good
health and a high quality of life
• Changes in sleep patterns can occur with
age due to difficulty falling and staying
asleep
• Lack of sleep contributes to how one
feels and acts during the day
Sleep (2 of 17)
• Normal sleep
– Circadian rhythm
•
Sleep-wake cycle
– Light stimulates wakefulness
– Melatonin is released with the fall of
darkness
– Many fall asleep between 9 and 11 at night
– States of sleep include non-rapid eye
movement (NREM) and rapid eye
movement (REM)
Sleep (3 of 17)
• Non-rapid eye movement (NREM)
– N1—link between consciousness and
unconsciousness; some awareness of
surroundings
– N2—loss of consciousness; light sleep
– N3—deep sleep
Sleep (4 of 17)
• Rapid eye movement (REM)
– Sleep in which we dream
– Brain is more active than when awake
– Experience muscle atonia and loss of a
degree of autonomic control
• Sleep cycle consists of four to five
periods of non-REM and REM sleep
– Each lasts about 90 minutes
Sleep (5 of 17)
• Impact of sleep on older adults
– Adults need about 8 hours per day
– Getting enough refreshing sleep may
become more difficult with age
•
•
•
More time spent in lighter sleep stages
Many medications interfere with sleep
Depression, menopause, frequent urination,
heart disease, and stress also lead to insomnia
Sleep (6 of 17)
• Circadian rhythms change as people age
– Melatonin released earlier in the evening
– Leads to earlier sleep and wake-up times
– Easiest way to delay the hour of sleep is
exposure to bright light later in the day
Sleep (7 of 17)
• Sleep disorders
– Sleep-onset insomnia
– Waking up often during the night
– Waking up too early and not being able to
get back to sleep
– Waking up not feeling refreshed
– Snoring (may be related to sleep apnea)
– Unpleasant feelings in the legs
Sleep (8 of 17)
• Insomnia
– Most common symptom of more than 30
different sleep disorders
– Acute insomnia lasts fewer than 30 days
– Chronic insomnia lasts longer than a month
– Onset may begin with an emotional event
•
•
New cycle becomes the norm
Can be difficult to resume the previous sleep
routine
Sleep (9 of 17)
• Sleeping pills
– May be a good short-term solution
– Other techniques preferable in the long run:
•
•
•
•
Sleep restriction
Stimulus control
Sleep hygiene
Cognitive behavioral therapy
– Underlying health issues should be
addressed
Sleep (10 of 17)
• Obstructive sleep apnea (OSA)
– Signs and symptoms:
•
•
•
Snoring
Witnessed apnea during sleep
Complaints of excessive sleepiness during the day
– Caused by total or partial tracheal obstruction
– Disruption of sleep pattern can occur up to 60
times per hour
Sleep (11 of 17)
• Health conditions attributed to the
presence of OSA:
–
–
–
–
–
High blood pressure
Heart disease
Stroke
Diabetes
Poor brain oxygenation
Sleep (12 of 17)
• Addressing OSA
– Repositioning to side-lying may help
•
Back-lying seems to exacerbate the problem
– Leading therapy is the use of a CPAP
device
•
Often prescribed after a sleep study is completed
by a sleep specialist
Sleep (13 of 17)
• Aspects evaluated during a sleep study:
–
–
–
–
–
–
–
Sleep state
Eye movement
Muscle activity
Heart rate
Respiratory effort
Airflow
Blood oxygen levels
Sleep (14 of 17)
• Restless leg syndrome (RLS)/periodic
leg movements of sleep (PLMS)
– RLS is a neurologic disorder including:
•
•
Unpleasant sensations in the legs
Irresistible urge to move the legs while in bed
– Symptoms of RLS lead to PLMS
•
•
May occur every 10 to 60 seconds
May last the entire night
Sleep (15 of 17)
• Medications that have been able to offer
some relief to PLMS sufferers:
–
–
–
–
Parkinsonian-type medications
Anticonvulsants
Benzodiazepines
Narcotics
Sleep (16 of 17)
• Other strategies for addressing PLMS:
–
–
–
–
–
Avoid stimulants
Exercise
Leg massages
Warm packs
Leg compression devices
Sleep (17 of 17)
• Treatment of sleep disorders
– Effective strategies:
•
•
•
•
•
Sleep restriction
Stimulus control
Sleep hygiene
CBT
Relaxation techniques
Case Study #1: Physical Therapy/Fall Preventions
Directions:
Read the assigned chapters in the course textbooks (for the week’s covered by this case study).
Read the following information (statement and scenario). Answer the questions at the end of the
Scenario for F.P. using your textbooks, the supplemental readings and other sources that you find
to support your statements. This case study should use the APA guidelines (title page (with
author notes), body (with your specific headings/subheadings), citations/references,
graphs/tables/charts as appropriate). Please spell and grammar check your submission prior to
submitting via Blackboard – Communications – Course Messages. No other forms of submission
will be accepted or graded.
A primary concern for Older Adults is in preventing falls (National Council on Aging, 2016, Nov 30).
Given the anatomical and physiological changes that may occur, due to changing health status, there is
an increased risk for falls among Older Adults (American Physical Therapy Association, 2010; Robnett &
Chop, 2015; p. 158). Efforts to prevent these adverse events require coordinated and managed
healthcare interventions (Patient Safety and Quality Healthcare, 2015, Mar/Apr).
References
American Physical Therapy Association. (2010). Physical Therapy and Falls Prevention. Retrieved from
http://www.nhsportandspine.com/docs/FallsPrevention.pdf
National Council on Aging. (2016, Nov 30). 6 steps to protect your Older loved one from a fall. Retrieved
from https://www.ncoa.org/healthy-aging/falls-prevention/preventing-falls-tips-for-older-adultsand-caregivers/6-steps-to-protect-your-older-loved-one-from-a-fall/
Patient Safety and Quality Healthcare. (2015, Mar/Apr). Providers in the loop: Preventing falls across the
continuum of care. Retrieved from http://psqh.com/march-april-2015/providers-in-the-looppreventing-falls-across-the-continuum-of-care
Robnett, R.H. & Chop, W. (2015). Gerontology for the Health Professional. Burlington: MA: Jones &
Bartlett.
Scenario
•
•
F.P. is an 85 year old male who has the following health conditions:
o
Diabetes – Type II (diagnosed when he was 70 years old)
o
Hypertension (aka High Blood Pressure)
o
Cardiopulmonary Disease (COPD)
o
Asthma
The following medications have been prescribed:
o
Symbicort – AER 160-4.5 – 10.2gm Inhaler – Refill 1x per month
o
Advair Diskus – AER 250/50 – blister pack 60 aerosols – Refill 1x per month.
o
Hydrochlorothorizide (HCTZ) – generic Lisinopril – TAB 20-12.5 mg – Refill 1x per month.
o
Metformin HCL – 500 mg – twice a day – Refill 1x per month
o
Sometimes F.P. forgets to take one or more of his medications.
•
F.P. is a former smoker who occasionally “sneaks” a cigarette from a friend.
•
F.P. drinks beer and tries to have only 2-3 drinks per day.
•
F.P. is living in his own home, alone, after his wife’s death last year.
•
F.P. has Medicare and Medicaid for his insurances.
•
F.P. has Meals on Wheels delivered each week since he is unable to cook nutritiously for himself.
•
When possible, F.P.’s son visits him to check on him, but often his work schedule allows only
several times per month.
•
F.P. is average weight for his height (170 lbs. for 5’10”)
Questions for Case Study
1. What concerns do you have for F.P. regarding fall prevention? (Note: Explain what
conditions may lead to a fall.)
2. What individuals/agencies should be involved in addressing these concerns? (Note: Who
should be included in the discussion or be consulted regarding fall prevention?)
3. How would you develop an intervention/care strategy of reducing the potential risks for
F.P. having a falling incident? (Note: What steps should be taken to reduce fall risks).
4. What can F.P. do to reduce the potential for a fall? (Note: What physical or behavioral
changes may be necessary to reduce fall risks?)
5. What other agencies can assist with improving the quality of F.P.’s home to minimize fall
risks? (Note: Think about what types of devices or tools are available to fall proof a home
or improve mobility within the home.)
6. What processes or procedures are necessary to safeguard F.P. from falling?
SPECIAL ARTICLE
Exercise and Fall Prevention: Narrowing the
Research-to-Practice Gap and Enhancing Integration
of Clinical and Community Practice
Fuzhong Li, PhD,* Elizabeth Eckstrom, MD, MPH, † Peter Harmer, PhD, MPH,‡
Kathleen Fitzgerald, MD,§ Jan Voit, PT,¶ and Kathleen A. Cameron, MPH**
Falls in older adults are a global public health crisis, but
mounting evidence from randomized controlled trials
shows that falls can be reduced through exercise. Public
health authorities and healthcare professionals endorse the
use of evidence-based, exercise-focused fall interventions,
but there are major obstacles to translating and disseminating research findings into healthcare practice, including
lack of evidence of the transferability of efficacy trial
results to clinical and community settings, insufficient local
expertise to roll out community exercise programs, and
inadequate infrastructure to integrate evidence-based programs into clinical and community practice. The practical
solutions highlighted in this article can be used to address
these evidence-to-practice challenges. Falls and their associated healthcare costs can be reduced by better integrating
research on exercise intervention into clinical practice and
community programs. J Am Geriatr Soc 64:425–431,
2016.
Key words: falls; older adults; evidence-based; exercise
very year, one in three community-dwelling adults aged
65 and older falls. Many of these falls lead to moderate
to severe injuries, resulting in emergency department visits
and hospital admissions, and the death rate from falls has
risen sharply over the past decade.1 Falls present a considerable financial challenge to the nation’s healthcare services.
In 2013, the direct medical costs for fall-related incidents,
E
From the *Oregon Research Institute, Eugene; †Division of General
Internal Medicine and Geriatrics, Oregon Health & Science University,
Portland; ‡Willamette University, Salem; §Oregon Medical Group, Eugene,
Oregon; ¶Harborview Medical Center, Seattle, Washington; and
**National Council on Aging, Arlington, Virginia.
Address Correspondence to Fuzhong Li, 1776 Millrace Dr., Eugene,
OR 97403. E-mail: fuzhongl@ori.org
DOI: 10.1111/jgs.13925
adjusted for inflation, was $34 billion, mostly covered by
Medicare.1,2 These medical costs will rise as baby boomers
age and fall-related injuries increase.2
Falls are preventable with risk assessment and exercise. Exercise has been shown to reduce the incidence of
falls by 13%3 to 40%,4,5 which has led to a broad consensus among experts that community-dwelling older adults,
especially those at risk of falling, should be offered exercises that incorporate elements of balance, gait, and
strength training.6,7 Organizations including the American
Geriatrics Society and British Geriatrics Society,6 Academy
of Geriatric Physical Therapy of the American Physical
Therapy Assocation,7 National Institute for Health and
Care Excellence,8 U.S. Preventive Services Task Force,9
and National Council on Aging have issued guidelines, recommendations, and action plans to assist practitioners
working with those at risk for falls.
The Centers for Disease Control and Prevention
(CDC) Injury Center has created the CDC Compendium
of Effective Fall Interventions: What Works for Community-Dwelling Older Adults,10 which identifies 14 exercisebased interventions supported by randomized controlled
trials (RCTs). Table 1 provides summary information of
these interventions, their outcomes in reducing falls, and
on-line resources.
However, few of these evidence-based interventions
have been adopted in clinical or community practice 25,26
because of a lack of research-to-practice data and gaps in
the current guidelines regarding how to prescribe appropriate interventions or implement and integrate them into
routine clinical and community practice. In this article we
highlight current challenges to delivering these CDC-compiled interventions and offer solutions to enhance their
potential to serve clients through community programs
and medical practice.
CHALLENGES
Efficacy Versus Effectiveness Research
Most of the CDC Compendium exercise interventions are
efficacy (explanatory) trials conducted under controlled
JAGS 64:425–431, 2016
© 2016 The Authors.
The Journal of the American Geriatrics Society published by Wiley Periodicals, Inc. on behalf of The American Geriatrics Society.
0002-8614/16/$15.00
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and
distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
426
Program
Reduction in
Fall Rates or
Risk
Setting and Delivery
Method
Time Required for
Implementation
Online Program
Resources
1-hour class session (37 sessions
total) once per week over 1-year
period
30-minute individual session 3
times per week plus outdoor walk
≥2 times per week
www.cdc.gov/
HomeandRecreationalSafety/
Falls/compendium.html
www.med.unc.edu/aging/cgec/
exercise-program
www.acc.co.nz/
PRD_EXT_CSMP/groups/
external_providers/documents/
publications_promotion/
prd_ctrb118334.pdf
www.cdc.gov/
HomeandRecreationalSafety/
Falls/compendium.html
tjqmbb.org/program.html
Control and
Current Implementation
Status
Training
Opportunities
Unavailable
Unavailable
www.med.unc.edu/aging/
cgec/exercise-program
www.ncoa.org/healthyaging/falls-prevention/fallsprevention-programs-forolder-adults/
www.med.unc.
edu/aging/cgec/
exercise-program
Unavailable
Unavailable
tjqmbb.org
www.ncoa.org/healthyaging/falls-prevention/fallsprevention-programs-forolder-adults/
Unavailable
tjqmbb.org
Stay Safe, Stay
Active11
40%
Community setting, delivered by
accredited exercise instructors
The Otago
Exercise
Programme12
35%
Home setting, delivered by physical
therapists or nurses
Erlangen Fitness
Program 13
23%
Home setting, delivered by physical
therapists or nurses
Tai Chi: Moving
for Better
Balance14a
55% risk of
multiple falls
Local senior centers and adult activity
centers, delivered by a tai chi grand
master
Australian Group
Exercise
Program 15
22% for the
whole study
sample; 31% for
a subsample
who had fallen in
previous year
6 falls per
1,000 hours of
activity
31%
Residential care community centers
and senior centers, delivered by
trained exercise instructors
1-hour class session (96 sessions
total) twice weekly for 12 months
www.cdc.gov/
HomeandRecreationalSafety/
Falls/compendium.html
Clinical settings, delivered by trained
exercise physiology graduate students
90-minute class session (36
sessions total) 3 times weekly for
12 weeks
1-hour class session (36 sessions
total) weekly plus 30-minute,
twice-weekly home exercise
session for 36 weeks
1-hour class session (16 sessions
total) weekly for 16 weeks
www.cdc.gov/
HomeandRecreationalSafety/
Falls/compendium.html
www.laterlifetraining.co.uk/
Unavailable
Unavailable
www.cdc.gov/Homeand
RecreationalSafety/
Falls/compendium.html
Unavailable
www.cdc.gov/
HomeandRecreationalSafety/
Falls/compendium.html
Unavailable
Unavailable
25-minute class session (30
sessions total) twice weekly, with
an encouragement of 15 minute
practice daily, for 15 weeks
www.cdc.gov/
HomeandRecreationalSafety/
Falls/compendium.html
Unavailable
Unavailable
Simplified Tai
Chi19
35%
47% risk of
multiple falls
Community leisure centers and
homes, delivered by trained exercise
instructors, physical therapists, and
occupational therapists
General community settings (e.g.,
town halls, senior centers), delivered
by experienced tai chi instructors or
instructors experienced in teaching
physical activity to older people
Facilities in a residential retirement
community, delivered by tai chi grand
master
Unavailable
JAGS
(Continued)
FEBRUARY 2016–VOL. 64, NO. 2
Veterans Affairs
Group Exercise
Program 16
Falls
Management
Exercise
Intervention17
Central Sydney
Tai Chi Trial 18
1-hour class session (32 sessions
total) twice weekly for 16 weeks
plus selected daily home exercises
1-hour class session (48 sessions
total) twice weekly for 24 weeks
LI ET AL.
Table 1. Summary Information on Exercise-Focused Evidence-Based Fall Prevention Interventions Compiled by the Centers for Disease
Prevention
JAGS
Program
Reduction in
Fall Rates or
Risk
Setting and Delivery
Method
Time Required for
Implementation
Online Program
Resources
Lifestyle
Approach to
Reducing Falls
Through
Exercise20
Senior Fitness
and Prevention21
31%
Home settings, delivered by a
physical therapist, occupational
therapist, or exercise physiologist
Weekly 40–90 minute sessions for
5 weeks with 2 booster visits
46%
Community gymnasiums, delivered by
certified exercise instructors
Adapted Physical
Activity
Program 22
Music-Based
Multitask
Exercise
Program 23
Multitarget
Stepping
Program 24
60%
A local community sport center,
delivered by a physical therapist and
a physical therapy student assistant
Common areas of residential
retirement
Communities, delivered by certified
Jaques-Dalcroze instructors
A community health center, delivered
by a physical therapist or an exercise
trainer
Twice-weekly 60-minute classes
plus two 20-minute home exercise
sessions for 18 months
1-hour class session (48 sessions
total) twice weekly for 25 weeks
65%
The program has been renamed Tai Ji Quan: Moving for Better Balance. 31,36
1-hour weekly classes (25
sessions total) for 25 weeks
Twice weekly 5- to 7-minute
multitask stepping exercises plus
30-minute physical exercise
(including mild strength training,
aerobic, balance, flexibility
exercises) sessions (48 sessions
total) for 24 weeks
Training
Opportunities
www.cdc.gov/
HomeandRecreationalSafety/
Falls/compendium.html
ses.library.usyd.edu.au/handle/
2123/10627
www.cdc.gov/
HomeandRecreationalSafety/
Falls/compendium.html
www.cdc.gov/
HomeandRecreationalSafety/
Falls/compendium.html
www.cdc.gov/
HomeandRecreationalSafety/
Falls/compendium.html
Unavailable
Unavailable
Unavailable
Unavailable
Unavailable
Unavailable
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www.cdc.gov/
HomeandRecreationalSafety/
Falls/compendium.html
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EVIDENCE AND PRACTICE
a
54%
Current Implementation
Status
FEBRUARY 2016–VOL. 64, NO. 2
Table 1 (Cont.)
427
428
FEBRUARY 2016–VOL. 64, NO. 2
LI ET AL.
“research conditions” (e.g., adhering to stringent eligibility
criteria to exclude individuals with comorbidities, poor
compliance, medication complications, or limited English
language ability) to answer the question “Does this exercise reduce falls?” However, they do not answer the subsequent question “Will this intervention be effective outside
of the constraints of the efficacy research model?” Effectiveness trials for fall prevention are rare but necessary to
determine whether it makes clinical and financial sense to
implement a program in real-world settings (e.g., outpatient rehabilitation clinics) and community facilities (e.g.,
senior centers or meal sites) by linking or referring clinical
populations at risk for falling per established guidelines 6 to
primary care settings (i.e., community facilities). Thus, the
extent to which these programs are effective in practical
settings where healthcare or preventive services are routinely delivered remains to be determined.
Lack of Specific Utilization Directions
Current clinical guidelines6–8 and recommendations9 do
not translate into specific exercise prescriptions for older
adults with varying risks of falling, nor are there sufficient
resources for making specific referrals to community-based
exercise programs. These deficiencies create obstacles for
prescribing fall-prevention exercise interventions, especially
for primary care physicians who are often overburdened
with competing healthcare priorities.25
Adoption of Guidelines by Healthcare Providers Is
Limited
Adoption of guidelines in clinical practice has been limited
and slow.26 Jones and colleagues showed that only 8% of
primary care physicians based their fall prevention practices on guidelines from any recognized organization. 27
Commonly cited barriers to adoption include the lack of
time, training opportunities, financial incentives, and coordination among healthcare providers, and the need for
simpler and more easily disseminated materials and referral resources.25–27 In rehabilitation settings, Peel et al.
reported that although home physical therapists were
knowledgeable in identifying fall risk factors, they had difficulty linking them to prescribed interventions or identifying available interventions. 28
Few Comprehensive Community Programs Are
Available
Although community service providers may wish to sponsor fall prevention programs, they often do not have adequate knowledge of best practices in fall prevention 29 nor
do they have the expertise to support program implementation (e.g., determining the cost and financing for the
intervention, training instructors, and monitoring fidelity
of intervention delivery). In addition, most CDC-compiled
interventions do not provide an implementation plan with
details on program installation, instructor training requirements, class conduct, or program fidelity and adaptation.
Consequently, the majority of the interventions are not
easily accessible, readily available, or widely disseminated
to local communities (Table 1).
JAGS
Clinicians and Community Providers Do Not Connect
Although it seems obvious that maximizing the impact of
any intervention relies primarily on clinicians referring
patients to existing community-based programs, little
effort has been made to bridge the communication gap
between clinicians and community service providers. Most
communities have no coordinated system that allows clinicians to determine what specific interventions are available, which would be the best fit for a particular patient,
or whether a patient has enrolled in and completed a program. Similarly, community providers have no standard
means to gauge potential demand for specific interventions
and generally have offered programs using an “if you build
it, they will come” approach rather than responding to a
clear need identified by healthcare professionals. These
gaps have made implementation of any proven intervention challenging for clinicians and community service providers.
SOLUTIONS
Conducting More Translation/Effectiveness Research
Once efficacy has been established, RCTs that have an
effectiveness focus need to be implemented in settings
where the targeted populations reside and sustainable programs are to be established. Additional research into the
optimal training modes (i.e., strength, balance, gait), specificity (duration, intensity, frequency), and delivery methods
(e.g., referrals, covered services) in practical settings is necessary. Findings from these studies would improve translation of research into practice and policy.
Studies must include successful public health models,
such as RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance),30 to evaluate translation and
dissemination of interventions. For example, when utilizing
the RE-AIM model, Li et al.31 found that a customized Tai
Ji Quan program was successfully adopted by healthcare
providers (i.e., patients were referred to the program), had
excellent reach into the target population (referred patients
enrolled in the program), was delivered with high fidelity,
and produced significant improvements in physical performance and reductions in falls among participants. This type
of data provides critical practice-based information related
to program dissemination and implementation.
Increasing Clinician Awareness and Adoption of Proven
Exercise Interventions
To integrate American Geriatrics Society and British Geriatrics Society guidelines into clinical practice, the CDC has
developed the toolkit Stopping Elderly Accidents, Deaths,
and Injuries,32 which provides clinicians with tools to
assess and reduce fall risks among older adults. The materials include recommendations for participation in evidence-based exercise programs. For example, in the section
Integrating Fall Prevention into Practice, providers are
encouraged to identify community exercise fall prevention
programs for their patients, but as noted previously, clinicians are often unaware of available resources in their
community. Links to local community resources
that
JAGS
FEBRUARY 2016–VOL. 64, NO. 2
provide details of community fall-prevention programs
must be created so that clinicians can use available
resources. Another useful example is the National Council
on Aging, which provides excellent resources for professionals, including a checklist for assessing the quality of
fall prevention programs, a guide to state coalition building, and a compendium of initiatives from state coalitions.
Professional organizations and the public health sector
must actively campaign for, and sponsor, in-service and
continuing education opportunities for healthcare providers to expose them to specific fall prevention interventions and bring available resources (e.g., referral
procedures, ready-to-use pamphlets, referral pads) directly
to their attention. Research shows that offering providers
opportunities to undertake training programs as part of
their continuing education increases referrals to fall
prevention programs.31
Increasing Support for Community Intervention
Programs
Two keys to broadening availability of evidence-based
exercise fall prevention programs are enhancing the expertise of community providers and securing financial support. Although interested community providers can
improve their understanding of operational challenges
associated with fall prevention programs by attending
workshops or inviting in experts, substantial progress will
require an increase in the availability of turnkey packages
derived from translational research that provide specific
directions for all aspects of a program (e.g., advertising,
recruitment, instructor training, class teaching procedures,
program adaption, outcome assessment). To increase the
EVIDENCE AND PRACTICE
429
number of these packages, research funding agencies must
extend support for research that focuses on the transition
of efficacy research findings into effectiveness studies in
clinical and community service delivery settings. In the
meantime, program developers and physical therapists
(who are already directly involved in managing patients
with falls and balance deficits) 7 might be contracted on an
ad hoc basis to assist community implementers in translating efficacy-based training protocols into practical programs and provide ongoing training and technical support
to ensure implementation integrity and intervention fidelity.
Although local community organizations (e.g., Archstone Foundation) fully sponsor a few fall prevention programs, the majority are self-supported, fee-based
enterprises, which may limit their reach to populations
with limited financial resources. Fall prevention exercise
programs require financial support through Medicare,
Medicaid, and private health insurers to make33them truly
accessible to all older adults at risk of falls.
The current
model of coverage for screening for fall risk but not for
exercise interventions, especially for noninstitutionalized
individuals, is shortsighted. This should be a policy priority for national organizations with elder care or public
health mandates. Cost-effectiveness data exist for public
policymakers and insurers to underwrite these programs.
For example, several of the CDC-identified programs are
shown to deliver excellent returns on investment, with Tai
Ji Quan programs returning 509% per dollar invested and
the Otago program returning 127% per dollar invested for
persons aged 80 and older.34 Funds that support health
promotion and disease prevention programs (including
falls) sponsored by the Administration on Community
Healthcare Providers
– Conduct risk assessment (e.g., using STEADI tool)
– Refer patients to a Health Coach
– Review outcome data and modify risk assessment as necessary
Health Coaches
– Locate local community service provider that offers evidence-based fall prevention
programs
– Process paperwork (referral, medical records, insurance coverage)
– Connect the patient to the community service provider
– Liaise between clinician and provider
Community Providers
– Enroll patient in program delivered by an accredited exercise instructor
– Supervise class participation and collect class attendance information
– Conduct basic clinical assessment (e.g., Timed Up&Go) and record monthly falls
– Provide health information gathered during a program to Health Coach when patient
completes participation
Figure 1. Proposed model to incorporate evidence-based fall prevention interventions into integrated practice by healthcare professionals and community service providers. STEADI = stopping elderly accidents, deaths, and injuries
430
FEBRUARY 2016–VOL. 64, NO. 2
LI ET AL.
JAGS
Table 2. Translation of Efficacy-Based Fall Prevention Interventions into Clinical and Community Practice: Summary of Challenges and Possible Solutions
Challenges
The limited number of exercise-based fall prevention
interventions, which limits broad dissemination to at-risk
older adults
Current clinical guidelines and public health
recommendations lack:
provision of specific exercises appropriate for people at
various levels of risk for falling
guidance on linking older adults with known fall risk
factors to the optimal evidence-based exercise specific
interventions
community resources where targeted older adults can be
referred and receive an appropriate intervention
Limited adoption of guidelines by healthcare providers
(lack of time, training opportunities, financial incentives,
clinical coordination)
Limited number of comprehensive community-based fall
prevention programs currently available
Lack of communication between healthcare providers and
community service providers
Lack of integrated fall prevention healthcare systems that
link clinical referrals to evidence-based community
interventions
Solutions
Funding support for effectiveness trials that focus on translating and disseminating
evidence-based interventions, with specific attention to population at risk, mode of
intervention, delivery methods, outcome evaluation, and settings where healthcare or
preventive services are routinely delivered
Develop selective preventive interventions that target individuals at higher risk of
falling
Increase clinical and community awareness of available tools (e.g., Centers for Disease
Control and Prevention STEADI) that facilitate adoption of evidence-based fall
prevention interventions; increase access to national and local resources (e.g., National
Council on Aging) designed to increase fall prevention efforts
Develop streamlined systems that link referrals of at-risk individuals directly into
community-based interventions delivered by reliable community service providers
Increased promotion of STEADI-type tools that integrate the American Geriatrics
Society/British Geriatrics Society guideline and are easy to use in clinical practice
Provide fall prevention training opportunities for clinicians
Provide resources for implementing evidence-based interventions available to clinicians
Establish a reward system that provides incentives to clinicians to conduct fall risk
assessment and link patients to local community-based interventions
Provide staff training on fall prevention interventions; encourage integration of
evidence-based programs into fall prevention services
Provide sufficient funds to establish community infrastructure to implement evidencebased interventions
Develop turnkey packages for community stakeholders
Engage partnerships and relationships between clinicians, health insurers, and
community service providers to fill gaps in converting evidence-based fall prevention
interventions into practice
Establish a clinical-community linkage system (Figure 1)
STEADI = Stopping Elderly Accidents, Deaths, and Injuries.
Living (ACL),35 in collaboration with National Council on
Aging, have helped build a necessary infrastructure that
promotes national implementation and dissemination of
evidence-based fall prevention programs through community projects. The ACL effort in conjunction with other
public health agencies such as the CDC and community
stakeholders is likely to increase participation and assist in
the integration and sustainability of these programs.
Improving Communication and Collaboration Between
Clinicians and Providers
Given the numerous responsibilities that clinicians already
have, it is unlikely they will also be able to remain current
on available community fall prevention exercise programs.25 Similarly, community providers often do not
know which clinicians have patients requiring their programs. Healthcare systems need to embed intermediaries
responsible for connecting clinicians with service providers
in their networks to streamline clinical referrals to evidence-based community interventions.
INTEGRATED CLINICAL AND COMMUNITY
PRACTICE
In the proposed model of clinical and community practice
integration (Figure 1), healthcare providers (e.g., physi-
cians, physical therapists) perform a risk assessment
according to existing guidelines 6–8 and then simply refer
patients to a “health coach,” who is accountable for identifying and facilitating an appropriate fall-prevention class
referral. Community providers are then responsible for
enrolling and instructing clients and collecting participation information, which is passed back to the clinician
through the health coach to monitor progress. This system
requires a collaborative effort and coordination involving
multiple providers across different professions in clinical
and public health practice but represents an innovative
and practical step toward accelerating the transition
between clinical practice and community-based interventions.
CONCLUDING REMARKS
The current challenges and possible solutions to disseminating evidence-based exercise fall prevention interventions
have been presented (Table 2). The results of efficacy studies on fall prevention provide a strong foundation on
which to build a more-cohesive and more-comprehensive
approach to this persistent healthcare dilemma. CDC-compiled interventions provide healthcare practitioners and
community-based organizations with clear directions for
linking those at risk of falling to specific evidence-based
programs in the community as part of their care plans, but
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FEBRUARY 2016–VOL. 64, NO. 2
translational research and uptake of the exercise interventions that the CDC cites have been limited in the community. Unless the challenges to providing exercise-based
options for fall prevention to millions of older adults currently at risk of falling are recognized and overcome, the
personal, social, and fiscal costs related to falls will continue to rise. The solutions articulated in this article could
bridge evidence-to-practice gaps and facilitate clinical and
community integration of proven fall-prevention exercise
interventions.
ACKNOWLEDGMENTS
The authors would like to thank Dorothy Baker and David
Fink for their valuable comments on early versions of this
manuscript.
Conflict of Interest: The editor in chief has reviewed
the conflict of interest checklist provided by the authors
and has determined that the authors have no financial or
any other kind of personal conflicts with this paper. Fuzhong Li is paid by a National Institutes of Health,
National Intistute on Aging Grants AG034956 and
AG045094.
Author Contributions: Fuzhong Li conceived the idea
for the paper. All authors contributed to the intellectual
content of the paper and participated in writing.
Sponsor’s Role: There was no sponsor involvement in
writing the paper or in the decision to submit it for publication.
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CARE OF THE AGING PATIENT
FROM EVIDENCE TO ACTION
The Patient Who Falls
“It’s Always a Trade-off”
Mary E. Tinetti, MD
Chandrika Kumar, MD
The Patient’s Story
Mr Y, an 89-year-old retired salesman, lived independently
until 3 years ago. He had a right humeral fracture in 2006
and a left hip fracture 3 months later. After hip fracture repair and rehabilitation, he moved in with his daughter, a
physical therapist.
Mr Y’s medical history includes coronary artery bypass grafting and porcine aortic valve replacement in 2003; dementia;
hypertension; gout; peptic ulcer disease; macular degeneration;
and bilateral hearing aids. In 1992, Mr Y fractured his right hip
in a bar brawl; he used alcohol heavily until a few years ago.
On arrival at his daughter’s home, Mr Y reported left hip pain
and an unsteady gait. He became delirious when taking oxycodone ER, 10 mg every 12 hours. In June 2007, his daughter
brought Mr Y to see Dr C, a geriatrician, who noted pruritus,
chronic rhinorrhea, and weight loss. Mr Y scored 28 of 30 on
the Folstein Mini-Mental State Examination1; he missed the date
and recalled 2 of 3 objects at 5 minutes.1 Mr Y’s recall of 2 words,
plus his abnormal clock drawing (eFigure, available at http:
//www.jama.com), indicated a positive screen for dementia.2,3 Mr Y denied depressed mood or loss of interest with the
2-item depression screen.4 He was independent in his basic
activities of daily living (ADL) but dependent in his instrumental ADL (TABLE 1, footnote f ).5,6 His medications included aspirin, 81 mg; metoprolol XR, 100 mg; lisinopril, 40
mg; hydrochlorothiazide, 12.5 mg; simvastatin, 20 mg; omeprazole, 20 mg twice a day; allopurinol, 100 mg; acetaminophen/
hydrocodone, 1 tablet as needed; docusate, 250 mg twice a
day; and nitroglycerin, 0.4 mg sublingually for chest pain.
Mr Y’s blood pressure was 148/61 mm Hg without orthostatic changes. He weighed 158 lb. A grade 3/6 systolic ejection murmur was present without signs of heart failure. Mr
Y’s strength and sensation were normal except for left hip and
knee weakness. There was tenderness to palpation over the
left greater trochanteric region; the hardware from his hip surgery was palpable. The Romberg test result was negative. A
mobility screen (with Mr Y’s results) is shown in the BOX.7
Results of urinalysis, complete blood cell count, and routine serum chemistries were normal. A left hip radiograph
revealed nonunion and bony collapse. A magnetic resonance imaging scan of the brain revealed multiple infarcts.
See also p 273 and Patient Page.
Falls are common health events that cause discomfort and
disability for older adults and stress for caregivers. Using
the case of an older man who has experienced multiple falls
and a hip fracture, this article, which focuses on communityliving older adults, addresses the consequences and etiology of falls; summarizes the evidence on predisposing factors and effective interventions; and discusses how to
translate this evidence into patient care. Previous falls;
strength, gait, and balance impairments; and medications
are the strongest risk factors for falling. Effective single interventions include exercise and physical therapy, cataract surgery, and medication reduction. Evidence suggests that the most effective strategy for reducing the
rate of falling in community-living older adults may be intervening on multiple risk factors. Vitamin D has the
strongest clinical trial evidence of benefit for preventing
fractures among older men at risk. Issues involved in incorporating these evidence-based fall prevention interventions into outpatient practice are discussed, as are the tradeoffs inherent in managing older patients at risk of falling.
While challenges and barriers exist, fall prevention strategies can be incorporated into clinical practice.
JAMA. 2010;303(3):258-266
www.jama.com
Dr C changed Mr Y’s acetaminophen/hydrocodone to
round-the-clock dosing, not to exceed 8 tablets daily, and
prescribed vitamin D, 400 IU daily. In September 2007, an
orthopedist injected corticosteroids in the area of the left
greater trochanteric bursa. The pain decreased.
Mr Y completed 20 outpatient physical therapy (PT) sessions between October 2007 and June 2008. He was discharged from PT when he was no longer making progress.
He used a 4-wheel walker.
Over the next few months, he continued to fall. One fall
occurred after he took a cold medication containing diphenAuthor Affiliations: Departments of Medicine (Drs Tinetti and Kumar) and Epidemiology and Public Health (Dr Tinetti), Yale University School of Medicine, New
Haven, Connecticut.
Corresponding Author: Mary E. Tinetti, MD, Department of Internal Medicine,
Yale University School of Medicine/Section of Geriatrics, 333 Cedar St, PO Box
208025, New Haven, CT 06520 (mary.tinetti@yale.edu).
Care of the Aging Patient: From Evidence to Action is produced and edited at the
University of California, San Francisco, by Seth Landefeld, MD, Louise Walter, MD,
and Helen Chen, MD; Amy J. Markowitz, JD, is managing editor.
Care of the Aging Patient Section Editor: Margaret A. Winker, MD, Deputy Editor.
258
JAMA, January 20, 2010—Vol 303, No. 3 (Reprinted)
©2010 American Medical Association. All rights reserved.
Downloaded from jama.ama-assn.org at Virginia Commonwealth University on February 13, 2012
CARE OF THE AGING PATIENT: FROM EVIDENCE TO ACTION
hydramine. Another fall occurred in July 2008 after he inadvertently took several sublingual nitroglycerin tablets and developed dizziness and headache. In the emergency department,
his initial blood pressure reading while sitting was 130/60
mm Hg, with a pulse rate of 67/min; the corresponding values while standing were 90/50 mm Hg and 58/min. An echocardiogram showed an ejection fraction of 65% and an aortic
valve area of 1.7 cm2. Results of computed tomography of the
head were unremarkable. Mr Y was sent home but continued
to feel dizzy. Dr C subsequently stopped the lisinopril and reduced the dose of metoprolol. The dizziness resolved.
The fall in July 2008 exacerbated Mr Y’s left hip pain. In
November he underwent removal of his left hip fixation plate
and screws and restarted PT. The dose of vitamin D was increased to 800 IU daily. He had no further falls.
Mr Y denied that his falls were a significant problem. He
declined a paid attendant or referral to adult day care but
Falls are major contributors to functional decline and health
care utilization. Falling without a serious injury increases the
risk of skilled nursing facility placement by 3-fold after accounting for cognitive, psychological, social, functional, and medical factors; a serious fall injury increases the risk 10-fold.16 Falls
and fall injuries are among the most common causes of decline
in the ability to care for oneself and to participate in social and
physical activities.17,18 Diminished self-confidence may partially
explain functional loss following falls without serious injury.
As with other conditions affecting older adults, such as delirium and urinary incontinence, falling is classified as a geriatric syndrome. Defining features of geriatric syndromes include the contribution of multiple factors and the interaction
between chronic predisposing diseases and impairments and
Table 1. Independent Risk Factors for Falling Among
Community-Living Older Adultsa,b
agreed to a personal emergency response system when it was
explained that this would give his daughter peace of mind.
A Care of the Aging Patient series editor interviewed Mr Y;
Ms Y, his daughter; and Dr C in early 2009.
Studies in Which Factor
Was Significantc
Ranges of
Adjusted Valuesd
References (Listed
Risk Factor
No.
in eAppendix)
RR
OR
1, 2, 5, 6, 7, 9, 10,
11, 15, 17, 18, 19,
21, 25, 26, 29
1, 4, 5, 7, 9, 12, 13,
17, 18, 19, 22, 24,
28, 30, 31
1.9-6.6
1.5-6.7
1.2-2.4
1.8-3.5
Previous falls
16
PERSPECTIVES
Mr Y: I’ll be 90 this year… [my daughter] invited me to live
with her…. I’ve fallen a couple of times. When you get old,
Balance impairmente
15
your equilibrium doesn’t work as good …. It was a big worry
of my daughter and my doctors.
Dr C: He was on a lot of different medications and was hav-
Decreased muscle
strength (upper or lower
extremity)e
9
4, 6, 9, 18, 19, 21,
24, 25, 26
2.2-2.6
1.2-1.9
Visual impairment
8
8, 11, 15, 16, 13, 22,
29, 30
1.5-2.3
1.7-2.3
Ms Y: He was in a skilled nursing facility recuperating from
his hip fracture when they diagnosed him with dementia and
Medications (>4 or psychoactive medication use)
8
4, 11, 17, 23, 28, 29,
30, 33
1.1-2.4
1.7-2.7
told him he couldn’t live alone. We had meetings with the doc-
Gait and impairment or
walking difficultye
7
6, 7, 8, 9, 10, 12, 20
1.2-2.2
2.7
tors, social workers, and therapists. He wanted to go back and
live alone, but I said, ‘I’m a very good gait therapist and I can
help you walk better’….I told him that it would be more of a
burden… to be too far away….
Depression
Dizziness or orthostasis
Functional limitations, ADL
disabilitiesf
6
5
5
2, 11, 17, 25, 32, 33 1.5-2.8 1.4-2.2
4, 10, 20, 21, 30
2.0
1.6-2.6
2, 9, 13, 21, 23
1.5-6.2
1.3
inga lot of pain…a lot of medical issues….
Falling can cause lasting discomfort and decreased function, imposing family and societal care burdens. While evidence indicates that assessment and intervention can reduce the risk of falls and injuries, often these interventions
require trade-offs between health conditions and between
the patient’s desire for independence and safety concerns.
matic brain injuries.13,14 Inability to rise without help, experienced by half of older persons after at least 1 fall, may result
PREVALENCE, CONSEQUENCES, AND ETIOLOGY
OF FALLS
More than one-third of community-living adults older than
65 years fall each year.9-11 Approximately 10% of falls result
in a major injury such as a fracture, serious soft tissue injury,
or traumatic brain injury.9-13 Injury rates are similar for elderly men and women and for African Americans and whites,
although women are more likely to experience fractures, and
men and African Americans are more likely to experience trauDownloaded from jama.ama-assn.org at Virginia Commonwealth University on February 13, 2012
Age >80 y
Female
Low body mass index
Urinary incontinence
Cognitive impairment
Arthritis
Diabetes
Pain
4
3
3
3
3
2
2
2
5, 18, 23, 30
1, 27, 30
8, 21, 27
3, 29, 30
18, 27, 28
1, 26
13, 22
14, 19
1.1-1.3
2.1-3.9
1.5-1.8
2.8
1.2-1.9
3.8
1.1
2.3
3.1
1.3-1.8
1.9-2.1
2.8
1.7
Abbreviations: ADL, activities of daily living; OR, odds ratio; RR, relative risk.
a A total of 33 studies met search criteria. The complete search strategy is available at http:
//www.jama.com.
in dehydration, pressure ulcers, and rhabdomyolysis.15
©2010 American Medical Association. All rights reserved.
b Identified as an independent risk factor in multivariate analyses in at least 2 of the 33 pro-
spective cohort studies. Study sizes ranged from 152 to 9249 participants. Risk factors
identified in a single study include white race, Parkinson disease, peripheral neuropathy,
and multifocal lens.
c It is not possible to determine the number of studies in which each factor was considered,
because many studies did not list all the potential factors included in the models.
d Odds ratios are presented separately because they may overestimate the risk of the factor
with a common outcome such as falling. The RRs and ORs are results of multivariate analyses reported in individual studies. Only results in which the 95% confidence intervals did
not include 1 are included.
e Some studies assessed balance, gait, strength, and transfer impairments separately and
others at various combinations.
f Basic ADL comprise bathing, dressing, eating, grooming, transferring, and walking across
room; instrumental ADL comprise taking medications, using the telephone, handling finances,
housekeeping, cooking, shopping, and using transportation.
(Reprinted) JAMA, January 20, 2010—Vol 303, No. 3
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259
CARE OF THE AGING PATIENT: FROM EVIDENCE TO ACTION
Box. Mobility Screen and Balance and Gait Evaluation
Get Up and Go Test.7 The most frequently recommended screen- height, and symmetry; path deviation; walk stance (how far feet ing
test for mobility, this test takes less than 1 minute. Have the are apart while walking); steadiness on turning; arm swing; neck, patient
get up from a chair, walk 10 feet, turn, return to the chair,
trunk, hip, and knee flexion.
and sit down. Any unsafe or ineffective movement suggests balIn addition to determining if the patient is at risk of falling,
ance or gait impairment and increased risk of falling, and the pa- the POMA can be used to ascertain if there are balance and gait
tient should be referred to physical therapy for complete evalua- impairments that require intervention (eg, cane or walker) and
tion and treatment.
to assess for the presence of possible neurological or muscu(Mr Y was very slow and unsteady getting out of the chair; loskeletal disorders. For example, difficulty getting up withhe had flexed posture and a slow, shuffling gait.)
out arms suggests proximal muscle weakness; difficulty with
A person who fails this quick mobility screen should have a gait initiation suggests fronto-subcortical disorders such as Parmore complete balance or gait evaluation by a physician or a kinson disease or normal-pressure hydrocephalus; worse perphysical or occupational therapist. An example:
formance with eyes closed than open suggests peripheral neuPerformance-Oriented Mobility Assessment (POMA).8,9 The ropathy or vestibular problem; wide-based gait that worsens
POMA involves assessing the quality of transfer, balance, and gait with eyes closed and improves with handheld assist suggests
maneuvers used during daily activities and takes about 5 to 10 peripheral neuropathy; leg crossing the midline suggests cenminutes to complete. The POMA is not appropriate for very func- tral nervous system disorder such as stroke or normaltional patients or patients with a single disabling disease such as pressure hydrocephalus; shorter step with one leg suggests a
Parkinson disease or stroke. While there are several versions of muscle, joint, or nervous system problem on the opposite side.
the POMA, one feasible in a busy ambulatory setting includes obA version of the POMA, with scoring, can be found at http:
serving these transfer and balance maneuvers: get up from chair; //www.geriatricsatyourfingertips.org/ebook/gayf_36
perform side-by-side, 1-leg, and tandem (one foot in front of the .asp#c36s7_PERFORMANCE-ORIENTED_MOBILITY
other) stands (5-10 seconds each); turn in circle; sit down; and _ASSESSMENT_POMA.
assessment of these gait components while the patient walks 10 Copies of the assessment with instructions and scoring can
feet and turns: gait initiation; heel-toe sequencing; step length, also be obtained from the author.
acute precipitating insults.19 The ability to transfer and walk
safely depends on coordination among sensory (vision, vestibular, proprioception), central and peripheral nervous, cardiopulmonary, musculoskeletal, and other systems. Falls that
occur during usual daily activities generally result from diseases or impairments affecting 1 or more systems.
THE EVIDENCE: RISK FACTORS AND PREVENTION
Methods
We conducted 3 systematic reviews, focused on communityliving older adults, to identify (1) multiple impairments and
conditions predisposing to falls; (2) effective physical therapy
and exercise interventions; and (3) effective multifactorial
interventions. The search strategies, search results, and publications resulting from each search are presented in the
eAppendix, available at http://www.jama.com.
Risk Factors for Falling
The factors identified in the systematic review as contributing independently to risk of falling or experiencing a fall injury in at least 2 of the 33 studies appear in Table 1. The strongest risk factors for falling include previous falls; strength, gait,
and balance impairments; and use of specific medications. Of
note, falls and fractures share many risk factors.20
The risk of falling increases with the number of risk factors.
In 1 study, the 1-year risk of falling increased from 8% to 19%
to32% to60% to78%(x2 fororderinproportions,62.7;P3) Fall Prevention Strategies in Community-Living Older Adults Without Known
Cognitive Impairmenta
Participants
Sourceb
Setting
Clemson,
2004
Close, 1999
Community
Davison, 2005
ED
Day, 2002d
Community
Hogan, 2001
ED
Persons Who Fell
No./Total (%)
Mean
Age, y Female, % Intervention
Eligibility Criteria
No.
Control
Investigators Carried Out or Ensured Completion of at Least 1 Component
Self-reported fall or
310
78.4
74
82/157 (52)
89/153 (58)
fear of falling
Presented with a fall
397
78.2
Not
59/184 (32) 111/213 (52)
reported
Cognitively intact
313
77
73
94/144 (65) 102/149 (68)
No recent exercise
program; physician
approval
Recent fall
272
76.1
60
65/135 (48)
87/137 (64)
P Value
Risk Reduction
(95% CI) c
NS
RR, 0.69 (0.50-0.96)
NR
OR, 0.39 (0.23-0.66)
NS
RR, 0.95 (0.81-1.12)
IRR, 0.64 (0.46-0.90)
RR, 0.67 (0.51-0.88)
NR
Self-referred or by
163
77.6
Not
54/75 (72)
61/77 (79)
NS
RR, 0.74 (0.62-0.88)
health professional
reported
ShumwayCommunity
Complete Get Up and
453
75.6
77
124/226 (55) 130/227 (57)
.61
RR, 0.96 (0.82-1.13)
Cook, 2007
Go Test in 75)
79
NR
NR
NR
HR, 0.70 (0.48-1.01)
2000
senior association
>50 years
intervention
groups; 1
control group)
Tinetti, 1994
General medicine At least 1 fall risk factor
301
78
69
52/147 (35)
68/144 (47)
.04
RR, 0.76 (0.58-0.98)
practices
IRR, 0.69 (0.52-0.90)
Vind, 2009
ED
Presentation after fall
392
72
74
110/196 (56) 101/196 (52)
NS
RR, 1.21 (0.81-1.79)
Wagner, 1994 Random selection
Volunteers who
1242
72.5
60
175/635 (28) 223/607 (37)
70
NA
95/240 (40)
65/210 (30) Difference,
practices
9 (95% CI,
−5 to 21)
Whitehead,
ED
Presentation after a fall
140
NA
NA
NA
NA
NA
OR, 1.7 (0.7-4.4)
2003
(6 mo)
Abbreviations: AOR, adjusted odds ratio; CG, control group; CI, confidence interval; ED, emergency department; HMO, health maintenance organization; HR, hazard ratio; IRR,
incident rate ratio; NA, not available; NR, not reported; NS, not significant; OR, odds ratio; RR, relative risk.
a Includes only trials that evaluated at least 3 risk factors identified in the first search (Table 1) and that enrolled only community-living participants without known cognitive impairment. Follow-up was 12 months unless stated otherwise.
b References are included in the eAppendix.
c All results are for the intervention group relative to the control group.
d Used a factorial design with 7 intervention groups. Only the full multifactorial intervention and control groups are included here. Total N = 1107 in all groups.
e Additional primary care group (risk factor assessment plus referral back to primary care physicians) was not effective (primary care referral relative to control: OR, 1.17; 95% CI, 0.57-2.37).
f Community sites and physicians may not have had the training or ability to complete the interventions; there was no assurance that participant or physician followed up on recommendations.
262
JAMA, January 20, 2010—Vol 303, No. 3 (Reprinted)
©2010 American Medical Association. All rights reserved.
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CARE OF THE AGING PATIENT: FROM EVIDENCE TO ACTION
Table 3. Recommended Assessment and Management of Predisposing and Precipitating Factors for Falls Among Community-Living Older
Adults Based on Observational and Trial Evidence
Level of
Evidencea
Predisposing factors
Cardiovascular (carotid sinus
Ib
hypersensitivity, bradyarrhythmias,
tachyarrhythmias)
Screen/Assessment
Management
Cardiac evaluation, including heart rate and blood
pressure responses to carotid sinus stimulation
if indicated
Medication management as indicated; consider
dual chamber cardiac pacing
Postural hypotension
Ia
Check blood pressure and pulse after >5 min
supine, then on standing. Abnormal is defined
as >20 mm Hg (or >20%) decrease in systolic
blood pressure with or without symptoms
immediately or after 1 or 2 min of standing
Reduce or eliminate medications likely to contribute
(eg, antihypertensive medications, alpha
agonists, tricyclic antidepressants); elevate head
of bed; dorsiflexion and hand clench exercises
before arising; compression stockings;
Other chronic conditions
(especially arthritis, neurological
diseases)
III
Musculoskeletal and neurological examination (joint
range of motion, muscle strength, proprioception, tone, rapid alternating movements)
medication (eg, midrinone, fludrocortisone)
Treat the underlying disease(s) and managethe
identified musculoskeletal and neurological
impairments
Cognitive impairment or dementia III
Balance or gait impairment
Ia
Vision problems
Ib
III
Psychoactive medications
Ia
Other medications
Ia
Functional disabilities (activities
of daily living limitations)
Precipitating factors
Ia
See eFigure for example
See Box
Refer to physical or occupational therapy for
progressive strength, balance, and gait training;
appropriate assistive device (eg, cane, walker)
Check for cataracts
Refer for single cataract extraction
Check acuity (eg, Snellen and Jaeger charts,
Refer to occupational therapy or low vision clinic if
although Snellen test results are poorly corresevere impairment interferes with mobility or
lated with daily visual function); have patient read
functioning
headline and sentence from a newspaper (central visual loss due to cataracts, macular degeneration, or glaucoma may become apparent)
Medication review; because patients are unlikely to
volunteer such information, clinicians also
should inquire about common medicationrelated adverse effects such as confusion,
impaired alertness, fatigue, insomnia, dizziness,
unsteadiness, or decreased appetite
Medication review, including both prescription and
Eliminate or reduce dose of as many other medicanonprescription medications, especially if taking
tions as possible, particularly medications that
>4 or a high-risk medication; assess for
cause (1) orthostasis (eg, antihypertensives, alpossible adverse medication-associated effects
pha blockers, nitrates); (2) confusion or impaired
(see above)
alertness (eg, opioids, antihistamines, anticonvulsants); (3) parkinsonism (eg, antipsychotics,
metoclopramide); or (4) other (eg, digitalis)
Assessment tools in references 4 and 5
Physical and occupational therapy (see text); home
safety modifications
Home hazards
Ia
Home visit (by occupational therapist, physical
therapist, nurse); self-administered checklist
Footwear and foot problems
III
Ask about foot pain; check for bunions, toe
deformities, ulcers or deformed nails, and
peripheral neuropathy
III
Check footwear
Multifocal eyeglasses
II
New eyeglass prescription
following refraction; Ib
Ib
Alcohol
IV
Eliminate or reduce dose of as many of the following
as possible (all types increase fall risk):
sedatives, antidepressants; anxiolytics;
antipsychotics
Physical and/or occupational therapy: adaptive
devices (eg, reaching device; sock aid and long
shoe horn; grab bars in the bathtub; shower
chairs; raised toilet seats). Remove tripping
hazards; ensure adequate lighting; other safety
measures (keep a telephone at floor level or a
cell phone in pocket at all times; enroll in
personal emergency response system such
as “Lifeline”)
Refer to orthotist, podiatrist, or other relevant expert
Advise patients that walking with well-fitting shoes of
low heel height and high surface contact area
may reduce falls
Avoid multifocal lenses while walking, particularly
on stairs
Caution that there may be an increased risk of falling
after new lenses are placed
Use nonjudgmental general screen such as, “Please Alcohol counseling or treatment
tell me about your drinking,” followed by screening tools such as by the 4-item CAGE questionnaire47 or 10-item AUDIT test48 if indicated
Abbreviation: AUDIT, Alcohol Use Disorders Identification Test.
Downloaded from jama.ama-assn.org at Virginia Commonwealth University on February 13, 2012
a Level of evidence based on the results of authors’ 3 systematic reviews (eAppendix): class Ia, evidence from at least 2 randomized controlled trials; Ib, evidence from 1 randomized
controlled trial or meta-analysis of randomized controlled trials; II, evidence from at least 1 nonrandomized controlled trial or quasi-experimental study; III, evidence from prospective
cohort study (risk factor for falls); IV, based on expert committee opinion or clinical experience in absence of other evidence. All management recommendations also meet the criteria
of ease of implementation and clinical importance.
©2010 American Medical Association. All rights reserved.
(Reprinted) JAMA, January 20, 2010—Vol 303, No. 3
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263
CARE OF THE AGING PATIENT: FROM EVIDENCE TO ACTION
appropriate assistive devices… [we did] a home safety evaluation…. We started him on calcium and vitaminD… .
The multifactorial nature of fall prevention means that care
must be coordinated among physicians, nurses, physical therapists, and occupational therapists. A primary care clinician can
coordinate care by assessing and managing the medical components and referring patients to home care or outpatient rehabilitation. Alternatively, interdisciplinary fall teams or clinics are available at many geriatric or rehabilitation centers.
Regardless of location or disciplines involved, effective fall prevention requires assessing potential risk factors, managing the
risk factors identified, and ensuring that the interventions are
completed. Potential trade-offs must be considered in formulating the assessment and management strategy.
Assessing the Risk Factors
Assessment should focus on determining the circumstances
of previous falls and on identifying risk factors or factors known
to be the target of effective interventions (Table 1 and TABLE 3).
The assessments of fall risk listed in Table 3 should be completed in all older patients at risk. Factors increasing Mr Y’s
risk of recurrent falls include past falls; cognitive, strength,
gait, and balance impairments; ADL limitations; macular degeneration; pain; postural hypotension; mild aortic stenosis;
alcohol (in his earlier falls); and several of his medications,
specifically metoprolol, lisinopril, hydrochlorothiazide,
nitroglycerin, hydrocodone, and diphenhydramine (Table 3).
A decreased vitamin D level (17.9 ng/mL), which should be
suspected with muscle pain or weakness, fractures, or decreased sun exposure, could also have contributed.
The examination should include cognitive evaluation, postural blood pressure measurement, cardiac rhythm and rate,
muscle strength, joint range of motion, and examination of
the feet and proprioception (Table 3). A balance and gait
screen or evaluation should also be performed (Box).
Mr Y’s abnormal clock drawing (eFigure) indicates executive dysfunction that can occur with intact memory, as with
Mr Y.49 Like Mr Y, individuals with executive dysfunction may
have difficulty with instrumental ADL (Table 1) and may manifest slow gait and other gait impairments. 50 This combination of cognitive and gait impairments can be seen in subcortical degenerative disorders such as normal-pressure
hydrocephalus (not evident on Mr Y’s magnetic resonance
imaging scan) or subcortical vascular dementias.51
MANAGING THE RISK FACTORS IDENTIFIED
The evidence suggests that improving as many of the factors listed in Table 3 as possible is the most effective way to
reduce the risk of falling. Medication reduction, physical
therapy, and home safety modifications have the strongest
evidence of benefit for fall prevention in clinical practice.
Dr C: I took off a lot of blood pressure medications because he
was feeling dizzy and his pressure was low. . . . We need to make
surethatwecontrolthepain,becauseifyouhaveseverepain… you
get deconditioned and you fall. On the other hand, the more medi264
JAMA, January 20, 2010—Vol 303, No. 3 (Reprinted)
cations you take, you run the risk of getting more confused… it
increases the risk that… he might fall….
Medications
Dizziness or lightheadedness on standing or the use of 4 or
more medications should prompt the measurement of postural blood pressure and reduction in the number and dosages of medications. Particular attention should be given to
the possible elimination or dose reduction of medications
known to increase orthostasis or fall risk (Table 3).
The presence of multiple health conditions necessitatesa consideration of trade-offs between benefits vs risks of medications,
particularly when the treatment of one condition may worsen
another.52 Antihypertensive, anticoagulant, and antidepressant
medications commonly pose such trade-offs for patients at risk
for falling. Few data currently exist to guide decision-making
for these trade-offs. The clinician must consider which condition presents the greatest threat to the outcome priority of greatest importance to the patient.53,54 By eliminating unnecessary
medications and reducing the dose of necessary medications,
it is often possible to treat coexisting conditions while minimizing risk of medication-related fall or injury.
Dr C articulated well the trade-off between pain management and fall risk for Mr Y. Because pain is a risk factor for
falling,55 appropriate treatment may reduce fall risk. Pain
assessments result in improved detection and treatment. The
American Geriatrics Society pain management guideline provides strategies for older adults (Resources, available at
http://www.jama.com).
Adding vitamin D, 800 IU and probably without calcium,
is indicated in patients such as Mr Y, who are deficient.45
PHYSICAL THERAPY AND HOME SAFETY
MODIFICATION
Mr Y: My doctor and my daughter… decided [an emergency
alert necklace] would be g o od … and it is. It’s a 24-hour-aday watchdog. It’s very simple to u s e . . . I have a fixture in the
bathtub with handrails and seats. . . . I haven’t had any misstep s… since I started it.
Ms Y: When he had the [hip] hardware removed, I requested [physical] therapy again….
Home safety evaluations and modifications, as described in
Table 3, can be self-conducted (Resources) or performed by
a nurse, physical therapist, or occupational therapist. Patients with reported or observed balance or walking problems should be referred for PT. If homebound, a patient is eligible for treatment by a Medicare-certified home care agency
if progress is documented. Treatment at home allows assessment and management of mobility in the patient’s own environment. If not homebound, then the patient must be referred to outpatient rehabilitation, and the therapist must rely
on self- or family-report of home safety issues. Available evidence suggests that, for fall prevention, PT should consist of
progressive standing balance and strength exercises; transfer
practice; gait interventions, including evaluation for an assis©2010 American Medical Association. All rights reserved.
Downloaded from jama.ama-assn.org at Virginia Commonwealth University on February 13, 2012
CARE OF THE AGING PATIENT: FROM EVIDENCE TO ACTION
tive device (cane or walker); and instructions in techniques
for arising after a fall. Referral should be made to therapists
skilled in evidence-based progressive balance training for older
patients (Resources). Endurance training, such as walking,
should be added when safe. A challenge is that ongoing exercise is needed to maintain improvements after therapy ends.
In addition to recommending walking, referral to community programs targeting older adults should be considered (Area
Agencies of Aging may have this information). There is
insufficient evidence to determine if PT is beneficial for
patients with dementia.56 Strategies used by therapists with
patients with dementia include simple, repetitive routines; removal of environmental hazards; easy-to-read instructions with
pictures; and caregiver involvement.
Occupational therapy for community-dwelling at-risk older
adults focuses on safe ADL functioning; upper-extremity function; activity tolerance; and mobility.57 Occupational therapists
provide patient and family education and prescribe adaptive
devices(Table3).Forpatientswithdementia,occupationaltherapists counsel caregivers about strategies for safe functioning.
SAFETY VS INDEPENDENCE
Ms Y: I’m a physical therapist, so safety is my job. He does everything the least safe, worst way possible! I’m trying to learn
to choose my battles… .
Persons at risk for falling face trade-offs between safety
and functional independence. To reduce fall risk, they may
have to avoid desired activities or rely on help. Conversely,
patients may have to accept risk of serious injury if they wish
to continue performing activities beyond their balance capability. For individuals who are cognitively intact, the clinician’s responsibility is to present the evidence, attempt to
minimize risk through proven assessment and manage- ment
strategies, and ensure an informed decision. If there is any
question, the clinician must ascertain whether the in- dividual
has the capacity to make informed decisions, either by
interviewing the patient and family or by referring the patient
to a psychiatrist or geriatrician.
For the individual with reduced decisional capacity, the
clinician must work with the family or caretakers, as did Dr
C and Mr Y’s daughter. As she has done, Mr Y’s daughter
needs to take the initiative. As was evident with Mr Y and
his daughter, the family may prioritize safety while the patient values independence and mobility. Negotiations are
often needed to get the family to agree, and the patient to
assent, to a balance between safety and independence.
Support for Caregivers
Ms Y: Living with someone with dementia—is tremendously
stressful. I had no idea that I would be this impatient sometimes. I have a group of women I know from taking a class on
caregiving, and we try to support each other. It’s been rough,
but it’s been a real gift in terms of getting to know my dad.
Dr C: I wanted to know what would help her [daughter] not
get burnt out and to try to provideher with more services… we’ve
©2010 American Medical Association. All rights reserved.
talked about respite programs. . . . We’ve offered home health
aides and other kinds of home support.
Cognitively intact older adults who fall may handle their own
health and functional needs. Among community-dwelling frail
or cognitively impaired older adults, however, falls further increase caregiver burden.58 As Dr C elicited from Ms Y, primary
caregivers of cognitively and functionally impaired elders often experience stress, which can be uncovered through a brief
private interview withthecaregiver orby use of self-administered
instruments.59 Caregivers with high levels of stress should be
referred to social agen…

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