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Beyond Balance: Evidence Based Practice Enhancing Quality of Life in the Geriatric Patient

Beyond Balance: Evidence Based Practice Enhancing Quality of Life in the Geriatric Patient. Jenny Zimney, MPT, GCS jenny@northwestrehab.com Northwest Rehabilitation Associates 1380 Liberty St. SE Salem, OR 97302 (503) 371-0779. Beyond Balance: . What factors create safety and balance?

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Beyond Balance: Evidence Based Practice Enhancing Quality of Life in the Geriatric Patient

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  1. Beyond Balance:Evidence Based Practice Enhancing Quality of Life in the Geriatric Patient Jenny Zimney, MPT, GCS jenny@northwestrehab.com Northwest Rehabilitation Associates 1380 Liberty St. SE Salem, OR 97302 (503) 371-0779 J Zimney MPT, GCS

  2. Beyond Balance: • What factors create safety and balance? • Can I really impact the frequent faller? • Can fear of falling be overcome? J Zimney MPT, GCS

  3. Course Objectives: Following today’s session you will be able to: • Choose and implement the appropriate functional scale for their patient status and setting. • Develop objective measurable treatment interventions and goals based on the functional scales used. • Discuss the rationale and purpose for each functional scale presented. J Zimney MPT, GCS

  4. Course Objectives cont’d: • Quantify a geriatric patients balance, fear of falling and fall risk using the functional scales presented. • Identify reliable reimbursement and marketing options for fall prevention programs in your community. • Make a greater impact on reducing falls in your community! J Zimney MPT, GCS

  5. Systems of Balance J Zimney MPT, GCS

  6. Balance and Motor Planning: • What is my plan/objective? • What am I feeling? • What am I going to do about it? • Was this successful last time? • What is my plan this time? • Can my body do this (or) do this in time? J Zimney MPT, GCS

  7. Allum et al 2002 J Phys Changes in Postural Control with Age Results: With perturbation on sway board Younger = Trunk rolls toward from perturbation (uphill) Older = Trunk rolls away from perturbation (downhill) J Zimney MPT, GCS

  8. Sensory Systems Vision Somatosensory Vestibular J Zimney MPT, GCS

  9. Age Related Changes: Vision • ↓visual acuity • Impaired dark adaptation • ↓ response to peripheral field visual stimuli • ↓ contrast sensitivity • Difficulties with accommodation • Abnormal visual perception J Zimney MPT, GCS

  10. Age Related Changes: Vestibular • Loss of hair cells in semicircular canals • Calcification in cupula • “Thinning” of vestibular afferent axons J Zimney MPT, GCS

  11. Age-Related Changes: Somatosensory • 10-15% ↓ nerve conduction velocity • ↑ Sensory detection thresholds • ↑ Central processing time • ↑ latency of automatic postural responses J Zimney MPT, GCS

  12. Age related changes: Efferent System • ↑ Active muscle stiffness • ↓ Muscle force and power generation capacity • ↑ Variability of contraction amplitudes for proximal/distal muscles of a synergy • ↑ of trials to adapt strategy for perturbation J Zimney MPT, GCS

  13. Age Related Changes: Etiology • Normal changes associated w/ aging • Decrease in physical activity/stimulation • Disease states: Diabetes, PVD, CVA, vestibular dysfunctions, macular degeneration OR Learned non-use J Zimney MPT, GCS

  14. J Zimney MPT, GCS

  15. Common medications related to falls: • Benzodiazapines (Valium, Ativan) • Sedatives (Benadryl, Buspar) • Hypnotics (Xanax) • Antipsychotics (Thorazine, Haldol) • Antidepressants (Elavil) • Antihypertensives (Lopressor, Catapress) • Antianxiety (Librium) • Diuretics (Lasix, Diuril) J Zimney MPT, GCS

  16. Balance Review: More thoughts… • Environmental Demands • Cognition/Attentional Demands • Self-Efficacy/Fear of Falling J Zimney MPT, GCS

  17. Environmental Demands and Balance/Mobility 36 older adults self reported trip log and videotaped weekly (tracking 8 environ dimensions) Results: Temporal (speed), physical load, terrain and postural transitions (head mvmt) distinguished those w/ disabilities, 1/2 as many activities and had to be accompanied. (Shumway-Cook A, et al. Phys Ther. 2002;82:670-681) J Zimney MPT, GCS

  18. Attentional Demands: Static vs. Dynamic Equilibrium 6 healthy young subjects (20-30 yo) Tested reaction time to auditory cue with sitting, standing upright (broad and narrow base, walking (SLS and DLS) Standing > sitting; Walking > sit or stand; SLS > DLS Conclusion: Balance control w/in gait is not automatic. Lojoie, Teasdale, Bard, Fleury. Exp Brain Res. 1993;97:139-144. J Zimney MPT, GCS

  19. Attentional Demands of Obstacle Negotitation • 15 older adults vs. 15 younger adults • Testing reaction time to auditory cue with walking level and over foam block when in SLS Results: Pre-crossing and Crossing were = in older adults Brown, McKenzie, Doan. J Geron. 2005;60A(7):924-927 J Zimney MPT, GCS

  20. Attentional Demands: Dual-task Methodology: • Limited Central Processing Capacity • Task performance requires part the limited capacity within the CNS • If performing 2 tasks and that capacity is exceeded, 1 or both tasks can be disturbed. J Zimney MPT, GCS

  21. Voluntary Step and Cognitive Task • 66 healthy elderly vs. healthy young adults • Tested voluntary stepping on force plate single task and w/ modified Stroop test Results: Older adults with Single task: 42-52% slower step initiation Dual task: 190-256% slower, 41% no reaction Melzer, Oddsson. JAGS. 2004;58(8):1255-1262 J Zimney MPT, GCS

  22. Fear of Falling Influences Gait • 95 com-dwell older adults • Gait parameters: speed, stride length, step width, double limb support time • In fearful group, speed was slower, stride shorter, step width larger and double limb support time was 6% longer. Chamberlin ME, Fulwider BD, Sanders SL, Medeiros JM. J Geron: Med Sci. 2005;60A:9:1163-1167 J Zimney MPT, GCS

  23. Fear of Falling: Predisposing Factors 6. No Emotional Support 5. Sedentary Lifestyle 4. Chronic Dizziness 3. Fall history w/ in previous year 2. Vision > 50% impaired 1: Age > 80 Anxiety Trait Murphy, Dubin, Gill. J Geron 2003;58A(10):M943-947. J Zimney MPT, GCS

  24. Assessing Balance: Falls History • How often do you lose your balance, i.e. slip, trip or stumble? • When was your most recent fall? • Did the fall occur inside or outside? • How did the fall occur? • Were you injured? • Were you dizzy when you fell? J Zimney MPT, GCS

  25. Why use Functional Testing? • Evidence-based • Demonstrate skill • Establish Goals • Guide to treatment • Objective measure of progress • Prediction of future events J Zimney MPT, GCS

  26. Types of Reporting • Self-Report** • Clinician observation and rating** • Equipment-based testing **Focus of Functional Test presented J Zimney MPT, GCS

  27. Which is best? Self-Report Clinical Observation Proxy-Report J Zimney MPT, GCS

  28. The Activities-specific Balance Confidence Scale (ABC) Developed by Powell and Myers with input from 15 clinicians and 12 older outpatients to quantify fear of falling • Type of Information: Self Report • Components: 16 items of varying difficulty rated on 0-100% scale • Equipment needed: Paper and pencil • Time to Complete Test: 5-10 minutes J Zimney MPT, GCS

  29. The Activities-specific Balance Confidence Scale (ABC) Scoring: • > 80 = high functioning older adult (I com. Dwelling) • 50-80 = moderate level of functioning (Chronic Health Conditions or ALF) • < 50 = low physical functioning (Home care) Myers AM et al, J of Gerontol:Medical Sci, 1998 J Zimney MPT, GCS

  30. Strengths: Inexpensive Self Testing Examines community mobility Variety of situations and environments assists in treatment and goal setting Weaknesses: Cannot use w/ significant cognitive impairment Imagination needed if not regularly performed Very high ceiling Nearly no floor effects The Activities-specific Balance Confidence Scale (ABC) J Zimney MPT, GCS

  31. Modified Falls Efficacy Scale (mFES) Adapted from Tinetti’s FES to quantify fear of falling • Type of Information: Self Report • Components: 16 items of varying difficulty rated on 0-100% scale • Equipment needed: Paper and pencil • Time to Complete Test: 5-10 minutes J Zimney MPT, GCS

  32. Modified Falls Efficacy Scale (mFES) Scoring: • Items are scored from 0 to 10. • Total the ratings (possible range = 0 – 140) and divide by 14 to get each subject’s mFES score. • Scores of < 8 indicate fear of falling, 8 or greater indicate lack of fear. J Zimney MPT, GCS

  33. Modified Falls Efficacy Scale (mFES) • Weaknesses: • Cannot be used w/ significant cognitive impairment Strengths: • Inexpensive • Self Testing • Assesses indoor and outdoor situations • More realistic activities then ABC J Zimney MPT, GCS

  34. ABC mFES VS J Zimney MPT, GCS

  35. Timed “Up and Go” Developed by Richardson and Podsiadlo to assess basic mobility skills in older adults • Type of Information: Clinician Observation and rating • Components: One Item- stand, walk 10 ft, turn come back and sit down. • Equipment needed: Stopwatch, Chair (46cm)w/ arms (65 cm) • Time to Complete Test: 1-2 minutes J Zimney MPT, GCS

  36. Timed “Up and Go” Scoring: • >30 sec people that are more dependent, unable to climb stairs, require AD, help with transfers, dependent in most activities • <10 sec freely independent • <20 sec( I) transfers, I toilet, able to climb most stairs, go out alone J Zimney MPT, GCS

  37. Strengths: Can use assistive device Quick, easy, inexpensive Incorporates most aspects of mobility Sensitive to change Not diagnosis dependent Weaknesses: Not usable for non-ambulatory patients Ceiling – not challenging for community dwellers Must be able to follow directions Only a few aspects of balance are challenged Timed “Up and Go” J Zimney MPT, GCS

  38. Normal Values of Balance Tests in Women Aged 20-80 456 women in 6 age cohorts Tests: TUG, Step, FR, LR Results: Linear change with Step and TUG FR started to decline in 40’s LR started to decline in 30’s!!!!! Isles, Choy, Steer, Nitz JAGS 2004;52(8):1367-1372. J Zimney MPT, GCS

  39. Berg Balance Scale Developed to measure balance of the older adult in a clinical setting • Type of Information: Clinician observation • Components: 14 items of everyday tasks rated on 0-4 scale • Equipment needed: Ruler, Watch, 2 standard chairs, footstool or step, object • Time to Complete Test: 15-20 minutes J Zimney MPT, GCS

  40. Berg Balance Scale Specifics of testing: • No assistive device can be used • Must be able to stand unsupported • Forward reach w/ fingers outstretched (36% cannot do this) J Zimney MPT, GCS

  41. Berg Balance Scale Scoring: • 41-56 low fall risk • 21-40 medium fall risk • 0-20 high fall risk Additionally • > 45 safe, independent ambulator • < 36 fall risk near 100% J Zimney MPT, GCS

  42. Strengths: Challenging for healthy, Com. Dweller Wide range of difficulty and patients Reliable for PD or CVA Weaknesses: Cannot use assistive device Ceiling effect for high level functioning Berg Balance Scale J Zimney MPT, GCS

  43. Physical Performance Test Developed to assess function in community dwelling older adults • Type of Information:Clinician observation and rating • Components:3 Versions (7,8,9 item tests) rated on 0-4 scale • Equipment needed: Stopwatch, paper & pen, bowl and 5 kidney beans, spoon, coffee can, heavy book, jacket or sweater, penny, 25-foot walkway, flight of stairs • Time to Complete Test: 15-20 minutes Reuben, Siu. JAGS 1990;38(10):1105-1112 J Zimney MPT, GCS

  44. Physical Performance Test Specifics of testing: • Timing is from the word “Go” • Incorporates stair climbing J Zimney MPT, GCS

  45. Physical Performance Test Scoring: • < 15 predictor of recurrent falls **Treatments, goals and other referrals can be designed from each item. J Zimney MPT, GCS

  46. Strengths: Can use assistive device High ceiling Measure multiple areas of function Responsive to change w/ functional training Weaknesses: Requires equipment Scale is ordinal- decreased sensitivity to change May fail to challenge multiple facets of balance Physical Performance Test J Zimney MPT, GCS

  47. Physical Performance Test • Schmidt et al: • Predictive of frail elderly dropout rates in exercise program (JAGS 2000;48(8):952-960) • Brown et al: • Differentiates Mild to Moderate Frailty (J Geron 2000;55A(6):M350-355.) J Zimney MPT, GCS

  48. Dynamic Gait Index Developed by Shumway-Cook and Wollacott to assess likelihood of falling in older adults • Type of Information:Clinician observation and rating • Components: 8 facets of gait, 0-3 scale • Equipment needed: box, 2 cones, stairs, at least 25 ft walkway • Time to Complete Test: 15 minutes Shumway-Cook A, Woollacott A, Motor Control Theory and Practical Applications. Williams & Wilkins, 1995 J Zimney MPT, GCS

  49. Dynamic Gait Index Specifics of the test: • Test gait at different speeds • Stepping over and around obstacles • Gait w/ head turns (horizontal and vertical) J Zimney MPT, GCS

  50. Dynamic Gait Index Scoring: < 19 related to falls • > 22 safe J Zimney MPT, GCS

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