Geriatric Sensory Processing and Fall Prevention

1. Geriatric Sensory Processing and Fall Prevention The link between Fall Risk and Sensory Decline Ana Hernando, OTR, MOT, MBA Please note: material maybe presented that is not printed in this manual. Feel free to use the note pages at the end of the manual

2. Geriatric Sensory Processing and Fall Prevention • Introduction http://www.youtube.com/watch?v=n5w8IfwAlGg • Fall Statistics What’s up with the numbers? • Autonomic Nervous System What’s automatic about falling? • Sensory Processing Getting your 3 senses worth • Factors to Falling • CNS -Illness and Disease • Pharmacology What’s in the fine print • Environmental and Mindset External and Internal Perceptions • Kinesiology- Gift of muscle memory and exercise

3. Fall Assessments • ABCS • Current Trends • Validity and Reliability • Selection Process • Fall Prevention/ Fall Risk Reduction • Therapy Implications • Treatment Plans • Discharge Planning • Multidisciplinary Communication • Medical Team • Family and Caregivers • Documentation

4. Introduction • CMS Definition of Fall- • “Fall” refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (e.g., resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for staff intervention, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred.CMS Manual Department of Health and Human Services Centers for Medicare and Medicaid Services August 17, 2007

5. Introduction • CMS guidelines for fall intervention • Educate staff • Repair equipment • Develop and revise policies and procedures • Resident directed approach • May include implementing specific interventions as part of the POC .

6. Statistics • 1:3 age 65+ fall each year • Leading cause of injury death • Most common cause of hospital admission for trauma for 65+ • Death related to falls is increasing • 30% of falls result in significant injury • Leading cause of fractures in elderly • Fear of falling increases fall risk • Men >women in fall related deaths • Women>men falls resulting in injury • 90% of hip fractures resulted from a fall http://www.cdc.gov/HomeandRecreationalSafety/Falls/adultfalls.html

7. Autonomic Nervous System • Conveys sensory input and impulses • Provides information to the subconscious mind • Parasympathetic Nervous System • Conserves energy, slows down heart rate • Sympathetic Nervous System • Burns energy, fight or flight response to danger Goldberg, 2007

8. Autonomic Nervous System • Dysautonomia- • Fainting • Unexplained loss of consciousness • Orthostatic hypotension ( blood pressure reduction during standing, POTS) • Postprandial hypotension (blood pressure reduction after a meal)

9. Sensory Processing

10. Sensory Processing: Left and Right Hemispheres LEFT RIGHT • Uses Logic and Reason • Thinks in Words • Deals in parts and specifics • Will analyze • Take things apart • Sequential thinking • Time bound • Extroverted • Ordered and controlled • Individualality • Uses intuition and emotions • Thinks in pictures • Deals in wholes and relationships • Will synthesize • Put things together • Holistic thinking • Time free • Introverted • Spontaneous and free • Group mentality

11. Sensory Processing SPACE TIME

12. Visual & Vestibular • Motor Planning & Coordination • Body awareness, proprioceptive input • Walking, sitting, transfers, balance

13. Auditory & Vestibular • Speech & Sequencing • Breathing • Balance

14. Abstract Thought, Reasoning, & Coping Skills Problem solving Humor Visual & Auditory

15. Sensory Processing SPACE TIME

16. CNS Function

17. Quick Review of Cranial Nerves • CN1 Smells • CN2 Sees • CN3, 4, and 6 Moves eyes, constricts pupils, accomodates • CN5 Chews and feels front of head • CN7 Moves the face, tastes, salivates and cries • CN8 Hears and regulates balance • CN9 Tastes, salivates, swallows, monitors carotid body and sinus • CN10 Talks, communication to and from thoraco-abdominal viscera • CN11 Turns head, lifts shoulders • CN12 Moves tongue

18. Factors to Falling • CNS -Illness and Disease • Vertigo-Central vs. peripheral • Tinnitus CN8 • Parkinson’s reduced muscle strength (force) and power (force x velocity) • Shingles is latent in cranial nerve ganglia, dorsal root ganglia and autonomic ganglia along the entire neuraxis. • Neuropathies

19. Factors to Falling • Pharmacology :US geriatrics population : 40% take 5-9 medications and 18 % take 10+ http://www.usatoday.com/news/health/medical/health/medical/treatments/story/2011-11-25/Four-common-meds-send-thousands-of-seniors-to-hospital/51397208/1 • Benzodiazepines • Antipsychotic agents • Non-benzodiazepine sedative-hypnotics • Antidepressants and anticonvulsants • Anti-arrhythmics • Diuretics • Beta-blockers, vasodilators, neuroleptics http://www.ncbi.nlm.nih.gov/pubmed/15972615

20. Side effects of Xanax • Changes in appetite; constipation; decreased sexual desire or ability; diarrhea; dizziness; drowsiness; dry mouth; light-headedness; nausea; tiredness; weight changes. • Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue; unusual hoarseness); behavior changes; blurred vision; burning, numbness, or tingling; chest pain; confusion; dark urine; decreased coordination; decreased urination; fainting; fast or irregular heartbeat; hallucinations; loss of balance or muscle control; memory or attention problems; menstrual changes; muscle twitching; new or worsening mental or mood changes (eg, depression, irritability, anxiety; exaggerated feeling of wellbeing); overstimulation; red, swollen blistered, or peeling skin; severe or persistent dizziness, drowsiness, or light-headedness; shortness of breath or trouble breathing; suicidal thoughts or actions; tremor; trouble speaking; yellowing of the eyes or skin.

21. Side Effects of Coumadin • pain, swelling, hot or cold feeling, skin changes, or discoloration anywhere on your body; • sudden and severe leg or foot pain, foot ulcer, purple toes or fingers; • sudden headache, dizziness, or weakness; • unusual bleeding (nose, mouth, vagina, or rectum), bleeding from wounds or needle injections, any bleeding that will not stop; • easy bruising, purple or red pinpoint spots under your skin; • blood in your urine, black or bloody stools, coughing up blood or vomit that looks like coffee grounds; • pale skin, feeling light-headed or short of breath, rapid heart rate, trouble concentrating; • dark urine, jaundice (yellowing of the skin or eyes); • pain in your stomach, back, or sides; • urinating less than usual or not at all; • numbness or muscle weakness; or • any illness with diarrhea, fever, chills, body aches, or flu symptoms.

22. Vitamin D deficiency • Poor physical performance • Low muscle strength • Cognitive impairments • Falls • Fractures

23. Factors to Falling • Environmental and Mindset http://www.youtube.com/watch?v=5qWpXKhWXcc&feature=related • MOBILIZE 2010 study; • 765 participants • median age 78 • 46.7% fell outside- 23% sidewalks, 14% curbs/streets, 13% outside stairs, 6% parking lots. • Kinesiology http://www.youtube.com/watch?v=hTYDBJ0kP3I&feature=related • Muscle weakness • Limited ROM and poor biomechanics • Reaction time

24. Continuous cycle

25. Fall ABCS • A- Age >85 years old • B- Bone issues • C-Coagulation • S-Surgery

26. Fall Assessments and Screens • Current Trends • Morse Fall Scale • Hendrich II Fall Risk Model • Timed Up and Go (TUG) • Berg Balance • Tinetti Balance Scale • 6 Minute Walk Test • Survey Of Activities and Fear of Falling in the Elderly (SAFE) • Adult Sensory Profile • Validity and Reliability-Case studies and participants vary by setting. • Selection Process- How do you choose?

27. Morse Fall Scale Variables Score History of Falling No (0) Yes (25) Secondary Diagnosis No (0) Yes (15) Ambulatory Aid Bed Rest/ Nurse assist (0) Cruches/cane /walker (15) Furniture (30) IV or IV Access No (0) Yes (20) Gait Normal/bedrest/immobile (0) Weak (10) Impaired (20) Mental Status Knows own limits (0) Overestimates or forgets limits (15)

28. Morse Fall Scale Risk Level MFS Score Action No Risk 0-24 Good basic nursing care Low to Mod risk 25-45 Standard Fall prevention High risk 46+ High fall preventions http://www.patientsafety.gov/SafetyTopics/fallstoolkit/media/morse_falls_pocket_card.pdf

29. Hendrich II Fall Risk Model • http://vimeo.com/4200978 • http://hfhs-formslibrary.org/forms/HFH-59-0749MR-0907%20hendrich%20risk%20form.pdf • To be completed by Nurse

31. Timed Up and Go • http://www.fallpreventiontaskforce.org/pdf/TimedUpandGoTest.pdf

32. Berg Balance • http://www.aahf.info/pdf/Berg_Balance_Scale.pdf

33. Tinetti Balance Scale • http://www.bhps.org.uk/falls/documents/TinettiBalanceAssessment.pdf

34. 6 Minute Walk Test • http://www.rehabmeasures.org/PDF%20Library/6%20Minute%20Walk%20Test%20Instructions.pdf

35. SAFFE-Survey of Activities and Fear of Falling in Adults • http://www.ecu.edu/cs-dhs/encfpc/upload/17-SAFFE.pdf

36. Adult Sensory Profile • Provides insight to life long sensory issues • Gives the individual opportunity to provide input • Helps highlight “learning preference” • AdolescentAdultSampleReport.pdf

37. Adult Sensory Profile • http://www.pearsonassessments.com/NR/rdonlyres/EDCEB5C2-F4BA-435F-B4F7-69C4DF365B3C/0/AdolescentAdultSampleReport.pdf

38. Fall Prevention/ Fall Risk Reduction • Therapy Implications- Immobility is the greatest common denominator. • Screens • Medication changes • UTIs

39. Fall Risk Reduction • Therapy Treatment Plans- Muscle strength Gait Balance Activity tolerance Socialization Home Safety evaluation Community settings

40. Fall Risk Reduction • Discharge Planning • Should be address at beginning of therapy • Forward thinking and problem solving • WHAT HAPPENS NEXT? • Structured, scheduled regular exercise/activity

41. Documentation • S: Pt is 75 yo referred to OT/PT home health after recent fall at dtr’s home in the living room resulting in decreased mobility, increased pain with standing, and decreased independence with bathing. • PLOF: Pt lives with dtr in one story home and approximately 4 inch threshold step for entry. Pt has a pet lap dog that is very friendly and runs around the house. Dtr works approximately 10 hrs a day out of the home. Pt has walker but it was her husband’s, whom is now deceased. Prior to her fall pt was independent with ADLs and CGA for walking. Pt was not driving but does go to Sunday services and to the grocery store with her dtr. She usually goes to the beauty shop every 2 weeks. She is a member of the Rotary Club but reports she is not very active. • PMH: HTN, CHF, UTI, GAD, Depression

42. Documentation • O: ADL’s LB Bathing: Mod A UB Bathing: Min A LB Dressing: Mod A UB Dressing: S Grooming: S Toileting: Mod A Transfers: Min A with RW Balance Sitting s/d fair+/fair, Standing s/d fair/fair-. Pain 5/10 with movement Fear of Falling 7/10 in bathroom. BUE Strength grossly 3/5 • A:Pt is pleasant lady whom states her desire is to get back to what she was doing but states she is afraid to fall again. She demonstrates decreases in her balance for both sitting and standing. Her self reported pain and fear levels are strong indicators for risk of repeat falling. Her history of depression, fall history and fear of falling indicate she is a fall risk. Pt would benefit from skilled OT to increase her participation level for ADLs, increase her overall mobility, decrease her c/o pain and fear to return her to PLOF.

43. Documentation • P: Pt will participate in OT 2 times a week for 4 weeks. • LTG: Pt to perform bathing using AE as needed with less than 2/10 self report of fear of falling. LTG: Pt to increase dynamic standing to good to perform self care tasks with decreased c/o pain to 1/10 to facilitate mobility. LTG: Pt to complete morning ADL routine with Mod I to reduce burden of care. LTG: Pt to complete toilet hygiene with 90% accuracy to increase health and reduce risks of UTI. LTG: Pt will demonstrate understanding of fall recovery plan. STG: Pt to complete 1 set 10 reps of BUE exercises without s/s of fatigue. STG: Pt to perform 30 min of dynamic sitting balance tasks with <5/10 fear of falling. STG: Pt to increase toileting to min A. STG: Pt will verbalize sequencing steps for fall recovery plan with 75% accuracy. STG: Family will verbalized understanding of fall recovery plan with 100% accuracy. STG: pt and family to demonstrate understanding of fall risk reduction recommendations.

44. Multidisciplinary Communication • Medical Team- • What do the therapists need to know? • What do the nurses need to know? • What do the CNA’s need to know? • What do the doctor’s need to know? • How do we share information?

45. Documentation http://www.mnhospitals.org/inc/data/tools/Safe-from-Falls-Toolkit/Post-Fall_Evaluation.pdf

46. Family and Caregivers • What is the patient’s “normal”? Adult Sensory Profile • Empathy and respect • Statistics approach • “What most people do…” • Community class- Matter of Balance

47. Scenarios

48. Notes

49. Notes

50. Notes