Falls & Balance: Overview & Assessments PDF

FALLS & BALANCE: OVERVIEW & ASSESSMENTS HESC3592 NEUROMUSCULAR REHABILITATION Dr Jasmine Menant Research Fellow, Falls, Balance and Injury Research Centre , NeuRA Conjoint Senior Lecturer, UNSW Medicine Acknowledgements • Professor Stephen Lord, NeuRA • Dr Daina Sturnieks, NeuRA / UNSW 2 KEY L...

FALLS & BALANCE: OVERVIEW & ASSESSMENTS HESC3592 NEUROMUSCULAR REHABILITATION Dr Jasmine Menant Research Fellow, Falls, Balance and Injury Research Centre , NeuRA Conjoint Senior Lecturer, UNSW Medicine Acknowledgements • Professor Stephen Lord, NeuRA • Dr Daina Sturnieks, NeuRA / UNSW 2 KEY LEARNING OUTCOMES At the end of this lecture you should  Demonstrate knowledge of the neurological changes that occur with aging and their implications for physical function/activity.  Sensorimotor and cognitive changes  Develop an awareness of ‘falls’ as a major indicator and consideration for exercise interventions  Understand the prevalence, risk factors for, and implications of falls in elderly populations.  Multifactorial – exercise interventions form one part of a bigger clinical picture  Effectively differentiate between a ‘screening’ and ‘assessment’ in the context of falls.  Demonstrate knowledge/skills to determine the most relevant/applicable test for particular contexts (i.e. instrument selection, validity, reliability, floor and ceiling effects)  Have a resource for future use to help in the selection of falls related tests. PRIOR KNOWLEDGE  In HESC3504 you have learned about aging with regard to ▫ Aerobic fitness testing and exercise ▫ VO2, VT, Cardiac, pulmonary and vascular changes ▫ Muscular function testing and exercise ▫ Sarcopenia - Skeletal muscle changes in structure and function ▫ Resistance training You haven’t yet learned about the neurological changes that occur with aging. NEUROLOGICAL CHANGES WITH AGING  Sensorimotor changes  Loss of motor units as source of muscle loss  Loss of peripheral sensation  Cognitive changes  Decline in executive function, reaction time, attention Importance of balance  Balance is the ability to maintain the position of the body (its centre of mass) within specific boundaries of space (stability limits)  Poor balance is a significant contributor to falls in people aged 65 years and older  Balance requires the integration of different sensory information (visual, vestibular, proprioceptive) and the ability to generate appropriate motor responses istockphoto.com/ Physiological systems for balance oaktreemobility.co.uk Vision • An important source of information for the control of balance – information about the external environment – feedback about the position and movements of the body • Postural sway increases ~ 30% with eyes closed Age affects • Visual acuity • Contrast sensitivity • Depth perception • Visual field (peripheral vision) • Increased use of spectacles visiontherapy.co.uk Cataracts Macular degeneration  16% of people over the age of 65  9% of older people over 65  Opacity of the lens of the eye, causing clouded vision  Thinning of the macula area (centre) of the retina  Usually a result of denaturation of lens proteins  Causes a loss of central vision and inability to see fine details  Due to advanced age and diseases such as diabetes Sensation / proprioception  Balance relies upon combination of cues from the proprioceptive system  Tactile information from hands and feet  Input from muscles and joints Vestibular sensation  Inner ear structures that detect position and motion of the head  Important for posture and coordination of head, eye and body movements  Reduced sensation with age  Some evidence suggests that impaired vestibular function may contribute to falls in older people Age-related neurological changes  The human brain loses 10% of its weight by the age of 90 years (loss of neurons)  Reduced brain blood flow and metabolism  Declining production of neurotransmitters  Functional problems depend on region of loss/damage  Degeneration of myelin sheaths, axonal degeneration  Reduced nerve conduction velocity: slower responses  Compensatory mechanisms  reorganisation and redistribution of functional networks 87 year old 27 year old Reaction time  25% increase in simple reaction time from age 20-60  Increased simple reaction time is a strong risk factor for falls in older people  Fallers have particularly slower reaction times in more complicated tasks, such as stepping 1. J L. Fozard et alJ Gerontol. 1994 2. Lord SR et al. J Am Geriatr Soc. 1994 Cognitive changes  The basic cognitive functions most affected by age are processing speed, attention and memory.  Balance control requires attentional resources  balance is affected by one’s information-processing ability when performing two or more tasks simultaneously (distracted)  A greater cost of dual tasks in older persons than young, suggests that there is an increase in the cognitive resources required for postural control with age Definition of a fall  “an event which results in a person coming to rest inadvertently on the ground or floor or other lower level” (World Health Organisation, 2007)  “an unexpected event in which the participant comes to rest on the ground, floor or lower level” (Prevention of Falls Network Europe (ProFaNE) collaborators, 2007) • “unintentionally coming to the ground or some lower level and other than as a consequence of sustaining a violent blow, loss of consciousness, sudden onset of paralysis as in stroke or an epileptic seizure” (Kellogg International Working Group on the Prevention of Falls in the Elderly, 1987) Causes of falls  N= 529 older people aged 70+ y living in the community  46% fallers , 20% multiple fallers  85% balance-related falls, 15% of unexplained falls (blackout, dizziness, faint as cause of fall) Falls incidence rate  1 in 3 community dwelling >65years, per annum  10-20% multiple fallers  1 in 2 people living in residential aged care facilities, per annum  “Greying of the population”: 1 in 4 Australians will be over 65 by 2051 Falls in clinical groups  Incidence rate of falls increases to double that of healthy older people  Cognitive impairment  Parkinson’s disease  Multiple sclerosis  Stroke  Other groups at risk of falls  Visual impairment  Peripheral neuropathy: diabetic, chemotherapyinduced Adapted from Taylor et al., International Psychogeriatrics; 2013 Personal costs  Morbidity & mortality  Leading cause of hospitalisation (4%) in older people  Leading cause of injury-related death in older adults  Loss of independence  Institutionalisation  Loss of functional mobility, reduced physical activity  Loss of confidence NSW Health projected costs to 2050 700.0 600.0 falls Cost $millions 500.0 400.0 300.0 road trauma 200.0 100.0 violence self harm 0.0 1994 1996 1997 2001 2006 2011 2021 2031 2051 Moller J: Changing resource demands related to fall injury in an ageing population – unpublished paper (NSW Health, Injury Prevention Policy Unit), 2000. Falls are multifactorial Medical conditions Psychosocial and demographics Medications Falls Environment Sensorimotor function and balance Screening vs. assessment  Screening  Identification of people at risk  Increased surveillance  Referral for further assessment and intervention  Assessment  Identification of risk factors amenable to treatments/correction  Tailoring of intervention strategies Considerations for instrument selection  Reliability – measures consistently each time  Validity – measures what it is supposed to measure  Feasibility – appropriate for population and setting  Diagnostic accuracy  Sensitivity - how well a test correctly identifies the cases in a population with the condition  Specificity - how well a test correctly identifies the cases without the condition Comparison of 8 mobility tests  362 community-dwellers aged 74–98 years; 22% (n=80) had ≥2 falls in one-year follow-up (Tiedemann A. et al. Age Ageing. 2008) Test Validity Reliability Feasibility Total Sit -to-stand 5 ** 10 5 5 20 Alternate step** 10 4 4 18 6m walk** 10 4 3 17 Stair descent** 10 5 0 15 Stair ascent 5 5 0 10 Turn 0 4 5 9 Sit-to-stand 1 0 2 5 7 Pick-up weight 0 1 4 5 ** significantly worse in multiple fallers Different settings  Community  Residential  Hostel  Nursing home  Hospital ward  Emergency department (ED) Screening tools  2 or more falls in past year  Mobility /functional tests Standing balance Tandem stand Check for excessive swaying or falling One-leg stand Maintained for 10 secs Sit to stand Time to stand up and sit down five times from a seated position Complete the task in less than 12 seconds Step tests strength, balance and co-ordination Hill step test – Alternate step test – test one leg at a time alternate left and right step ups 7.5cm or 15cm Average 16 steps in 15 seconds 18cm Complete the task in less than 10 seconds Walking tests 6 min walk 6 metre walk 6 metres • Associated with survival in older people (Studenski et al., JAMA 2011) • When performed with concurrent cognitive task, no better than single task to predict falls (Menant et al., Ageing Res Rev, 2014) • Frail / mobility impaired: 2-min walk Timed up and go • stand up • walk 3m • turn • walk back • sit down Useful to assess functional mobility; for falls risk prediction, better in frail, low functioning older people (Schoene et al., J Am Geriatr Soc, 2013) Berg balance scale 41-56 = low fall risk 21-40 = medium fall risk 0 –20 = high fall risk Berg K, et al. Can. J. Pub. Health, 1992. Berg balance scale • 14-items (0: worst - 4: best) (total score /56) • Designed for frail older people – has ceiling effect in healthy elderly • Has reasonable validity as a screen for falls • Most useful in identifying functional limitations for informing exercise intervention strategies 41-56 = low fall risk 21-40 = medium fall risk 0 –20 = high fall risk Berg K, et al. Can. J. Pub. Health, 1992. Other balance screening tests  FROP – Com https://www.nari.net.au/resources/health-professionals/falls-and-balance  Tinetti Performance Oriented Mobility Assessment (Tinetti ME et al., JAGS. 1986)  Short Physical Performance battery (Guralnik et al., J Gerontol. 1994)  5 sit-to-stand time  Standing with feet together, in semi-tandem and in full tandem for 10s  4-m walk time QuickScreen© Clinical Falls Risk Assessment • A validated and reliable set of measures used to predict the probability of future multiple falls and identify risk factors Tiedemann A et al., J Gerontol; 2010 QuickScreen© Clinical Falls Risk Assessment Sit to stand test 5 repetitions with arms folded, must complete within 12 secs Alternate step test 8 foot taps, must complete within 10 secs Low contrast visual acuity test Read all of the letters on the 3rd line Near tandem stand test 2.5cm 2.5cm Stand for 10 secs with eyes closed Tactile sensitivity test Must feel at least 2 of the 3 trials Clinical Falls Risk Assessment Form Client Name:___________________________ MEASURE Date:_____________ RISK FACTOR PRESENT? (please circle) ACTION Previous Falls One/more in previous year Yes/No Medications Four or more (excluding vitamins) Yes/No Any psychotropic Yes/No Recommendation: Review current medications Vision Visual acuity test Unable to see all of line 16 Yes/No Recommendation: Give vision information sheet. Examine for glaucoma, cataracts and suitability of spectacles. Refer if necessary. Peripheral Sensation Tactile sensitivity test Unable to feel 2 out of 3 trials Yes/No Recommendation: Give sensation loss information sheet. Check for diabetes. Strength/ Reaction Time/ Balance Near tandem stand test Unable to stand for 10 secs Alternate step test Unable to complete in 10 secs Sit to stand test Unable to complete in 12 secs Yes/No Yes/No Yes/No Recommendation: Give strength/balance information sheet. Refer to community exercise class or home exercise program if appropriate to individual level of functioning. Number of risk factors Probability score 0-1 2-3 4-5 6+ 7% 13% 27% 49% Probability score: The patient has a _______% probability of falling in the next 12 months. QuickScreen© Clinical Falls Risk Assessment • A validated and reliable set of measures used to predict the probability of future multiple falls and identify risk factors • 72% accuracy in predicting risk • Proven feasibility for use with older community dwellers by a variety of health professionals • Results guide interventions • Quick and easy to use, minimal equipment, low cost Tiedemann A et al., J Gerontol; 2010 Physiological assessment of fall risk Physiological Profile Assessment (PPA) (Lord SR et al, Physical Therapy 2003)  Physiological, rather than disease-oriented  Involves direct assessment of sensorimotor abilities  Assumes that disease processes will be manifest in impaired performances in one or more tests  Cataracts – poor vision  Neuropathy – poor sensation  Prior-polio – weakness  Stroke – weakness, poor coordination, instability Vision Reaction time Lower limb strength Peripheral sensation Balance Use of a physiological profile to document motor impairment in ageing and in clinical groups The Journal of Physiology, Volume: 594, Issue: 16, Pages: 4513-4523, First published: 25 September 2015, DOI: (10.1113/JP271108) PPA – Composite fall risk score use  Predicting outcomes  Falls  Fall-related injuries, fractures  Disability, need for institutional care  Evaluating interventions  Exercise interventions  Balance and mobility training  Multifaceted interventions Stepping tests A. Choice-stepping reaction time test B. Inhibitory stepping test  Composite measure of balance, strength and processing speed + inhibition B. Stroop stepping test  Predictive of falls in older people  Used as outcome measure of exercise interventions Lord & Fitzpatrick, J Gerontol, 2001; Schoene et al., J Am Dir Assoc, 2017. Gait assessments  Walking speed  Step length  Cadence (step rate)  Step time variability  Rhythm or smoothness  Symmetry  Stability indices  Kinematics  Kinetics Complementary assessments I 8  Cognitive function – executive function and attention 9 4 H 3  Trail making test – executive function  Fear of falling 7 12 1 C G  Environmental conditions  HOME FAST (Mackenzie et al., 2000) 5 J 2 L  Medications  Medical conditions D B  Montreal Cognitive Assessment (Nasreddine et al., 2005)  Falls Efficacy Scale-International (FES-I) (Yardley et al., 2005) 10 A 6 F K E 11 Conclusions  Balance relies on contributions from sensorimotor systems which are progressively affected by age, contributing to the increased risk of falls.  Epidemiological studies have identified demographic, physiological and medical risk factors for falls  The screen or assessment used depends on the resources available and the extent to which the understanding of the causes of falls is required  Tests of vision, sensation, strength, speed and balance can accurately predict older people at risk of falls  Assessments in complementary domains may help refine the approach  Physiological profiles provide information about the causes of falls on an individual basis and provide information about potential intervention strategies  Importance of using right assessment for the participant and setting Resources • NSW Falls Prevention & Healthy Aging Network https://fallsnetwork.neura.edu.au/ • Active & Healthy https://www.activeandhealthy.nsw.gov.au/ References  General knowledge in ageing and clinical groups at risk of falls  Series of articles: Day BL and Lord SR. Balance, Gait, and Falls. Handbook of Clinical Neurology, 2018: 159, pages 2-432.  Fasano A, Canning CG, Hausdorff JM, Lord S, Rochester L. Falls in Parkinson's disease: A complex and evolving picture. Mov Disord. 2017 Nov;32(11):1524-1536. doi: 10.1002/mds.27195.  Gunn HJ, Newell P, Haas B, Marsden JF, Freeman JA. Identification of risk factors for falls in multiple sclerosis: a systematic review and meta-analysis. Phys Ther. 2013 Apr;93(4):504-13. doi: 10.2522/ptj.20120231. Epub 2012 Dec 13. PMID: 23237970.  Assessment tools  Tiedemann A et al. The comparative ability of eight functional mobility tests for predicting falls in community-dwelling older people. Age Ageing. 2008 Jul;37(4):430-5. doi: 10.1093/ageing/afn100.  Perera S, Mody SH, Woodman RC, Studenski SA. Meaningful change and responsiveness in common physical performance measures in older adults. J Am Geriatr Soc. 2006 May;54(5):743-9. doi: 10.1111/j.1532-5415.2006.00701.x. PMID: 16696738.  Freiberger E, de Vreede P, Schoene D, Rydwik E, Mueller V, Frändin K, Hopman-Rock M. Performance-based physical function in older community-dwelling persons: a systematic review of instruments. Age Ageing. 2012 Nov;41(6):712-21. doi: 10.1093/ageing/afs099. Physiological profile assessment  Lord SR, Menz HB, Tiedemann A. A physiological profile approach to falls risk assessment and prevention. Phys Ther. 2003 Mar;83(3):237-52. PMID: 12620088.  Lord SR, Ward JA, Williams P, Anstey KJ. Physiological factors associated with falls in older community-dwelling women. J Am Geriatr Soc. 1994 Oct;42(10):1110-7. doi: 10.1111/j.15325415.1994.tb06218.x. PMID: 7930338.  Lord SR, Delbaere K, Gandevia SC. Use of a physiological profile to document motor impairment in ageing and in clinical groups. J Physiol. 2016 Aug 15;594(16):4513-23. doi: 10.1113/JP271108. Quickscreen  Tiedemann A, Lord SR, Sherrington C. The development and validation of a brief performance-based fall risk assessment tool for use in primary care. J Gerontol A Biol Sci Med Sci. 2010 Aug;65(8):896-903. doi: 10.1093/gerona/glq067. Berg Balance scale  Berg KO, Wood-Dauphinee SL, Williams JI, Maki B. Measuring balance in the elderly: validation of an instrument. Can J Public Health. 1992 Jul-Aug;83 Suppl 2:S7-11. PMID: 1468055. Performance Oriented Mobility Assessment (POMA)  Tinetti ME. Performance-oriented assessment of mobility problems in elderly patients. J Am Geriatr Soc. 1986 Feb;34(2):119-26. doi: 10.1111/j.1532-5415.1986.tb05480.x. PMID: 3944402. Timed up and go  Schoene, D., et al., Discriminative ability and predictive validity of the timed up and go test in identifying older people who fall: systematic review and meta-analysis. Journal of the American Geriatrics Society, 2013. 61(2): p. 202-208. Short Physical Performance Battery (SPPB)  Guralnik JM, Simonsick EM, Ferrucci L, Glynn RJ, Berkman LF, Blazer DG, Scherr PA, Wallace RB. A short physical performance battery assessing lower extremity function: association with selfreported disability and prediction of mortality and nursing home admission. J Gerontol. 1994 Mar;49(2):M85-94. doi: 10.1093/geronj/49.2.m85. PMID: 8126356. FROP-COM  Russell, M.A., et al., Development of the Falls Risk for Older People in the Community (FROP-Com) screening tool. Age and Ageing, 2008. 38(1): p. 40-46.  https://www.nari.net.au/frop-com        References       Stepping tests  Lord SR, Fitzpatrick RC. Choice stepping reaction time: a composite measure of falls risk in older people. J Gerontol A Biol Sci Med Sci. 2001 Oct;56(10):M627-32. doi: 10.1093/gerona/56.10.m627. PMID: 11584035.  Okubo Y, Schoene D, Caetano MJ, Pliner EM, Osuka Y, Toson B, Lord SR. Stepping impairment and falls in older adults: A systematic review and meta-analysis of volitional and reactive step tests. Ageing Res Rev. 2021 Mar;66:101238. doi: 10.1016/j.arr.2020.101238. Gait speed  Hardy SE, Perera S, Roumani YF, Chandler JM, Studenski SA. Improvement in usual gait speed predicts better survival in older adults. J Am Geriatr Soc. 2007 Nov;55(11):1727-34. doi: 10.1111/j.1532-5415.2007.01413.x. Studenski S, Perera S, Patel K, et al. Gait speed and survival in older adults. JAMA. 2011 Jan 5;305(1):50-8. doi: 10.1001/jama.2010.1923. PMID: 21205966; PMCID: PMC3080184.  Menant JC, Schoene D, Sarofim M, Lord SR. Single and dual task tests of gait speed are equivalent in the prediction of falls in older people: a systematic review and meta-analysis. Ageing Res Rev. 2014 Jul;16:83-104. doi: 10.1016/j.arr.2014.06.001. Inertial sensors  Baker N, Gough C, Gordon SJ. Inertial Sensor Reliability and Validity for Static and Dynamic Balance in Healthy Adults: A Systematic Review. Sensors (Basel). 2021 Jul 30;21(15):5167. doi: 10.3390/s21155167. PMID: 34372404; PMCID: PMC8348903.  Kobsar D, Charlton JM, Tse CTF, Esculier JF, Graffos A, Krowchuk NM, Thatcher D, Hunt MA. Validity and reliability of wearable inertial sensors in healthy adult walking: a systematic review and meta-analysis. J Neuroeng Rehabil. 2020 May 11;17(1):62. doi: 10.1186/s12984-020-00685-3. PMID: 32393301; PMCID: PMC7216606. Cognitive function  Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, Cummings JL, Chertkow H. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005 Apr;53(4):695-9. doi: 10.1111/j.1532-5415.2005.53221.x. Erratum in: J Am Geriatr Soc. 2019 Sep;67(9):1991. PMID: 15817019.  Muir, S.W., K. Gopaul, and M.M. Montero Odasso, The role of cognitive impairment in fall risk among older adults: A systematic review and meta-analysis. Age and Ageing, 2012. 41(3): p. 299308.  Brodaty, H., et al., The GPCOG: a new screening test for dementia designed for general practice. Journal of the American College of Cardiology, 2002. 50(3): p. 530-4.  McFadyen BJ, Gagné MÈ, Cossette I, Ouellet MC. Using dual task walking as an aid to assess executive dysfunction ecologically in neurological populations: A narrative review. Neuropsychol Rehabil. 2017 Jul;27(5):722-743. doi: 10.1080/09602011.2015.1100125.  Morris R, Lord S, Bunce J, Burn D, Rochester L. Gait and cognition: Mapping the global and discrete relationships in ageing and neurodegenerative disease. Neurosci Biobehav Rev. 2016 May;64:326-45. doi: 10.1016/j.neubiorev.2016.02.012. Fear of falling  Yardley L, Beyer N, Hauer K, Kempen G, Piot-Ziegler C, Todd C. Development and initial validation of the Falls Efficacy Scale-International (FES-I). Age Ageing. 2005 Nov;34(6):614-9. doi: 10.1093/ageing/afi196. PMID: 16267188.  Delbaere K, Close JC, Mikolaizak AS, Sachdev PS, Brodaty H, Lord SR. The Falls Efficacy Scale International (FES-I). A comprehensive longitudinal validation study. Age Ageing. 2010 Mar;39(2):210-6. doi: 10.1093/ageing/afp225. Epub 2010 Jan 8. PMID: 20061508.  Delbaere, K., S.T. Smith, and S.R. Lord, Development and initial validation of the Iconographical Falls Efficacy Scale. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 2011. 66(6): p. 674-680. Home hazards assessment tool  Mackenzie, L., Byles, J., & Higginbotham, (2000). Designing the Home Falls and Accidents Screening Tool (HOME FAST): Selecting the items. British Journal of Occupational Therapy, 63, (6), 260-269