process, in particular, step length shortens, toe out increases, ankle plantar flexion is reduced, pelvic rotation is reduced, and base of support widens, especially in those who fall. Without the presence of pathology, many of these gait deviations are a result of slower self-selected gait speed, as well as reduced fast gait speed and maximal gait speed (Harwood & Conroy, 2009). Gait speed has been studied extensively and is directly correlated with functional status and balance confidence, both of which are important for fall prevention. In an important study by Studenski and colleagues (2011), gait speed was examined in a systematic review of nine studies with more than 34,000 total combined participants, various age groups, both sexes, minority groups, and community-dwelling older adults. A key point of this systematic review was that gait speed predicted survival rates in all nine studies, with 0.8 m/s (2.62 ft/s) gait speed equaling the average life expectancy at most ages for both sexes. In other words, as gait speed increases, survival rates increase and older adults live longer. If an older adult can walk at 1 m/s (3.3 ft/s) or faster, then they would exceed survival rates expected for their age category and sex. Adults who walk slower than 0.6 m/s (or 1.97 ft/s) show increased risk for mortality, poor health, and poor function. Gait speed also has been linked to function, hospitalization, and need for rehabilitation in another key study by Fritz and Lusardi (2009). Table 3, adapted from the Fritz
article, summarizes their findings and is a great educational tool for patients. Table 3: Gait Speed and Links to Function Walking Speed Functional Result
Normal SSWS in meters: 1.2-1.4 m/s (3.3-3.9 ft/s).
Independent community ambulation.
Decline in speed: 0.70 – 1.01 m/s (2.3 – 3.3 ft/s.
Decline in function.
Decline in speed: < 0.61m/s ( 2 ft /s).
Risk for hospitalization, dependent in ADLs.
MCIDa for SSWS older adults in meters: 0.05 m/s (0.33 ft/s). MCID for impaired older adults: 0.1 m/s (0.33 ft/s). ADL = activities of daily living; MCID = minimal clinically important difference; SSWS = self-selected walking speed. a Specific to population age, sex, and diagnoses; amount needed to increase in speed to result in a functionally important difference. Note . From Western Schools, 2019.
ASSESSMENT OF FALL RISK
With so many factors influencing fall risk in older adults, accurate assessment can be complicated and cumbersome. To address the crucial need for practical, effective fall risk screening and more individualized fall risk assessment, several healthcare agencies and organizations have developed guidelines in this area. Four of the more comprehensive approaches will be discussed in this section, including approaches from the National Council on Aging (NCOA), the Centers for Disease Control and Prevention (CDC), Academy of Geriatric Physical Therapy clinical guidance statement (CGS), and the American Geriatrics Society and British Geriatrics Society (AGS/BGS) guidelines. In 2011, the CDC formed a fall prevention task force composed of physicians, nurse practitioners, physician assistants, and nurses. A review of the literature on fall prevention by the task force exposed a large need for healthcare provider education. In 2012, the task force released its product, STEADI, which stands for “Stopping Elderly Accidents, Deaths, and Injuries,” General screening recommendations Fall prevention begins with an accurate and reliable screening process to identify older adults at risk for falls. Many screening processes are designed to be accurately performed by either nonskilled personnel or by a skilled healthcare provider. Screening results may indicate the need for a more in-depth assessment, which should be performed by a clinician with knowledge of fall risk assessments. Screening recommendations for fall risk are generally agreed upon by most clinical guidelines and should identify adults in need of a more in-depth evaluation. The Academy of Geriatric Physical Therapy developed a CGS for community-dwelling older adults, examined multiple existing practice guides, and suggested screening recommendations (Avin et al., 2015). Table 4 summarizes these recommendations. General recommendations include yearly checks/screens that include asking first these two basic questions: If the client answers “yes” to either of these questions, or if the clinician observes gait or mobility impairments, the clinician should perform a balance and mobility screen, such as those in the STEADI toolkit. The general screening tools included in the STEADI toolkit can be used by medical personnel as well as minimally trained staff. Although these physical tests do not identify etiology of falls, they can trigger the need for a more in- 1. Have you fallen in the last year? 2. Do you have difficulty walking?
which was then endorsed by the American Physical Therapy Association. The STEADI tool kit (CDC/STEADI, 2017), available for free online at the CDC website (www.cdc.gov/steadi/index. html), includes fall risk assessment tools, educational information on fall risk for health practitioners and consumers, and helpful guidelines for assessing fall risk in a primary care or in the community setting. Fall risk assessment is a two-step process. First, all older adults should be screened for fall risk. Those who are found to be at risk for falls in the screening process should undergo a full multifactorial assessment by a physical therapist or other qualified healthcare professional in order to design interventions to reduce this risk. In contrast to the quick and simplistic nature of screens, assessments provide a deeper understanding of impairments to help develop targeted rehabilitation strategies. These processes are described in the following sections, beginning with descriptions of screening recommendations. depth evaluation by trained healthcare providers (Renfro et al., 2016). All three tests should be performed on anyone answering “yes” to either of the screening questions on fall risk or with observed gait and/or balance difficulty. STEADI also provides instructions on the performance of these three physical fall risk screening tools, which include the TUG, the 4-Stage Balance Test, and the 30-Second Chair Stand Test, described in more detail below. Timed up and go test To perform the TUG test, the person starts by sitting back in a standard arm chair, then upon the command to “go,” they rise from the chair, walk 10 feet at their normal pace (with or without an assistive device), turn around and return to a seated position in the chair. Timing starts at the “go” command and stops when the individual returns to the seated position. An older adult who takes more than 12 seconds to complete the TUG is at high risk for falls. Four-stage balance test This test of static balance requires the person to stand for at least 10 seconds in four progressively more challenging positions without the use of an assistive device. After demonstration of the four support positions, the tester refrains from assistance and gives a start command for the 10-second timing. Timing stops if the older adult moves their feet or requires assistance to maintain their balance. The four positions start with feet
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