Elderly Fall Risk Assessment

Assessment and Exercise Prescription for Geriatric Population

• This topic focuses on assessment and exercise prescription for elderly patients.

Lecture Outline

• Challenges and consequences of falls in the elderly
• Physiological reminders of aging
• Risk factors for falls
• Intrinsic factors
• Extrinsic factors
• Strategies for preventing falls
• Scientific validity of prevention strategies
• Lifestyle advice
• Exercise therapy

Introduction

• When are we considered "old"?
• What is aging?

What is Aging?

• Accumulation of molecular and cellular damage over time
• No difference between the process of "aging" and degenerative processes
• Age is a poor indicator of the changes
• Associated with life transitions (retirement, housing adaptations, death of relatives)

Additional Aspects of Aging

• Reduced reaction time
• Gait impairment
• Reduced adaptive strategies
• Difficulties in double tasks
• Reduced perception of obstacles and light adaptation
• Balance impairment
• Sarcopenia
• Hormonal changes (sleep, growth factor, osteoporosis)

Sarcopenia

• Loss of muscle mass, quality, and strength linked with aging
• Measured at 4-6% per decade(women starting ~40, men ~60)
• Correlates with physical impairment, quality of life, and death
• Precipitated by poor diet, physical inactivity, comorbidities (more than two diseases at a same time), genetic factors, hormones, neuromuscular dysfunction, & trauma

Frailty

• Risk of falling not strictly related to age; relates to frailty
• Conjunction of multiple interacting conditions
• It's an unavoidable process
• Difficult subclinical elements unobservable during clinical exam
• Assessed via functional scales
• Four major components: muscle function, balance and walking function, cognitive function, and nutritional status
• Operational definition via 5 areas: mobility, physical impairment, sensory ability, memory, energy
• Dependency is not the only expression of frailty: less than 20% of frail individuals are dependent
• Not correlated with gender, region of residence, marital status, or age; correlated with socioeconomic level
• Energy is the most commonly affected area
• No typical elderly: health inequalities and stereotypes
• Rapidly changing world

What is Falling?

• Event where a person unintentionally lands on a lower level
• Excludes loss of consciousness, stroke, and significant external events

Consequences of Falling

• Leads to significant and lasting functional deterioration, even without severe trauma
• Reveals frailty
• Decreases ability to respond to external disturbances
• Increases frailty process
• Relapse is more than 50% within a year
• Reflects maladjustment to the environment; influenced by many factors
• Approximately 20% result in medical interventions
• Approximately 10% result in fractures (hip, vertebra, wrist)

Post-Falls Syndrome

• Fear of falling comes before the fall
• Psychomotor maladjustment
• Spontaneous reduction in activity
• Decreased functional abilities
• Postural or gait disorders
• Increased risk of further falls

Predictive Factors

• Multifactorial
• Aging
• Pathology affecting equilibrium function
• Medication
• Environment
• Behaviour (Intrinsic factors)
• Do not prioritize individuals at high risk of serious injury
• Extrinsic factors: environment, behaviour, activities

Extrinsic Factors

• Behavioural: alcohol, sedentary lifestyle, nutrition
• Risk-taking: vigorous older people (20-40%) fall (22% vs 6% frail)
• Environmental: objects on ground, poor lighting, slippery/uneven ground, steps, chairs, bed height; relevance of hazards is important, not just number

Example of Fall Prevention Strategies

• Illustration showing adjustments to a living space to prevent falls

Intrinsic Factors

• Demographics: age > 80 correlates with reduction in ADL, reduced mobility
• Pathology: Parkinson's, dementia, incontinence
• Musculoskeletal factors: reduction in knee/hip/ankle/grip strength; gait dysfunction, reduced walking speed; altered dynamic balance; sit-to-stand difficulty
• Sensory factors: reduced visual acuity
• Cognitive factors: Mini Mental State; Depression
• Medication: sedative, hypnotic, anxiolytic, >4 medications

Recurrence Factors

• History of falls > 2
• Time spent on ground > 3 hours
• Tinetti test score <20 points
• Timed up & go test >20 seconds
• Unipodal hold <5 seconds
• Impaired postural adaptation reactions
• Stopping walking when asked

Prevention

• Medical appointment for fall history
• Risk factor assessment (history, previous falls, intrinsic/extrinsic risk factors, gait/balance quick test, neurological assessment, cardiovascular assessment)
• Personalized multifactorial intervention
• Exercise prescription (gait, balance)
• Medication adaptation
• Environmental adaptation

Strategies

• Different phases of health and living situations (good health, frail, dependent living) with corresponding assessment and specific/common strategies, detailed in a table format

Assessing Frailty

• Fried's criteria:
• Physical inactivity (less than 150 minutes moderate activity per week)
• Low muscle strength (grip strength <21 kgf for men, <14 kg for women)
• Slow walking speed (less than 0.8 m/s)
• Exhaustion/fatigue
• Weight loss (4.5kg, or 5% of body weight)
• Scoring: 0-1 = not frail; 1-2 = pre-frail; 3+ = frail (mild, moderate, severe)

Assessing Frailty - What to Assess

• Muscle function (grip strength, chair lift)
• Balance and walk function (Timed Up & Go, 6-minute walk test, Tinetti, unipodal balance)
• Cognitive functions (Mini Mental State, CODEX, Geriatric Depression Scale)
• Nutritional status (Nutritional Screening Initiative)
• Dependency (Katz: Activity of Daily Living, IADL: Instrumental Activity of Daily Living)

Assessing Dependency

• Assessing dependency is a constant concern for geriatricians
• Functional assessment is used to describe the elderly person's performance in basic activities of daily living (ADLs)
• Dependency refers to the need for a third party to assist in these activities
• ADL - Katz Questionnaire for measuring functional status; assesses 6 functions (bathing, dressing, toileting, transferring, continence, feeding)
• Score 1 or 0 per question

Assessing Nutritional Status

• Malnutrition has consequences.
• Questioning allows initial screening
• Refrigerator inspection for out-of-date items indicates difficulties managing the diet
• 5% weight loss over 1 year is a predictor of increased mortality
• Low albumin levels (<35g/L) increased mortality (5.3 times higher)
• Hypoalbuminemia and hypocholesterolemia increase risk of decline/mortality

Assessing Cognitive Status

• Detailed information on the Mini Mental State Examination (MMSE) including questions asked and scoring

Exercise Prescription for Osteoporosis

• Weight-bearing exercises (walking, dancing, stair climbing, hiking)
• Resistance training (squats, lunges, seated rows)
• Balance exercises (one-leg stands, tandem walking, heel-to-toe walking)
• Postural exercises (to address kyphosis and vertebral fractures)
• Gradual increase in exercises' intensity, duration, and complexity

Exercise Prescription for Sarcopenia

• Resistance training (rows, leg presses, chest presses, bicep curls)
• Aerobic exercises (walking, cycling, swimming)
• Balance and functional exercises (single-leg stances, tandem walking, chair stands, step-ups)
• Flexibility exercises (stretching)
• Gradual increase in intensity, duration, and complexity

Exergames

• Project promoting fall risk prevention in seniors in Luxembourg
• Video game use for improving balance
• Participants report high satisfaction with the physical enjoyment component, some uncertainty about independent use at home

Otago Home Exercise Program

• Study specifically designed for falls prevention, with strengthening, balance, and walking exercises
• Moderate intensity exercise

Community Exercises

• Exercises for improving balance and flexibility focused on many activities (dancing, gym sessions, group exercises, home exercise programs, lawn bowling/boules/pétanque, Pilates, Tai Chi, yoga, hydrotherapy).

Fall Management - Rehab Plan Reasoning

• Uni-factorial interventions(strength training, balance exercises) are effective reducing falls in home-living people.
• Multiple factors (multi-factorial interventions) are needed in high-risk or frail individuals
• Important key muscles for balance include dorsal flexors of feet, triceps surae, quads, hamstrings
• Balance training is essential
• Physical activity maintains the elderly person's autonomy, preferably individual, targeted, and adapted to the person

Fall Management - Balance

• Sensory input (vestibular, visual, proprioceptive input) is integrated.
• This integrated input leads to motor output to control body adjustments
• Key organs for balance include the vestibular system, cerebellum, cerebral cortex, and brainstem.

Fall Management - Strengthening

• Account for fatigue
• Focus on key muscles (ankle, dorsiflexors, triceps, quads, hamstrings)
• Use 60-80% of 1RM
• Use closed chain exercises
• Aim for lower energy cost and functional movements.

Fall Management - Foot

• Important sensory input
• Gait (ROM: Ankle, feet, muscle length, triceps surae)
• External sensory stimulation
• Weight-bearing proprioceptive exercises

Fall Management - Addressing Fear

• Progressive exposure to feared situations is used; gradual increase in difficulty
• Individualised exercise program is designed for the specific circumstances (desensitization)

Fall Management - Optimizing Sensory Afferents

• Exercises on foam cushions or mats/seated exercises with balls/unstable trays.
• Progression in difficulty for sensory training (reducing support, oscillations, eye closure etc)

Fall Management - Optokinetic Examples

• Exercises that focus on cervical spine ROM/eye-head dissociation/egocentric and exocentric targets/walking + eye-head dissociation

Fall Management - Exocentric

• Focus is on external objects/targets.
• Visual and spatial information is used to interact with external environment.
• Examples include ball sports, target-based activities, and interactive activities (partner/opponent interaction)

Fall Management - Egocentric

• Focus is on body movements, positioning, and spatial orientation.
• Proprioceptive and kinesthetic information is important for maintaining balance and coordination.

Fall Management - Walking Rehabilitation

• Footwear modifications
• Adapting aids
• Speed changes/walking phases
• Walking on uneven surfaces
• Positional changes/standing balance
• Obstacle negotiation

Fall Management - Getting Up After Falling

• Detailed steps and instructions (visual aids provided) are presented

Exercise Prescription for Osteoporosis Exercise Prescription for Sarcopenia

• Details on specific exercises, and targeting muscles, for better posture, strength, balance, and function

References

• A comprehensive list of publications and web resources related to the topic.

This quiz assesses your understanding of the risk factors associated with falls in the elderly population and the implications of mobility impairment. Explore key physiological changes, intrinsic factors, and prevention strategies that can help mitigate these risks. Test your knowledge about falls and aging in this comprehensive quiz!