individual presentation and clinician decision making. Regarding fall risk assessment, additional questions should be asked by the assessing clinician or primary caregiver related to other fall
risk factors such as osteoporosis, incontinence, alcohol use, depression, and vitamin D insufficiency, as described earlier in Table 1 (Phelan, Mahoney, Voit, & Stevens, 2015).
DESIGNING INTERVENTIONS TO PREVENT FALLS
This section will address fall prevention programs that have been proven to work and are supported by research, existing Evidence-based components of a fall prevention intervention Successful fall prevention interventions include multifactorial components, are salient to the older adults, and result in good compliance with attendance to exercise or educational sessions as well as exercise at home on the recommended schedule (Avin et al., 2015). According to the Academy of Geriatric Physical Therapy CGS, fall prevention programs should include gait, balance, home safety, and attention to foot problems and safe footwear, and should include educational information on fall risk factors specific to the individual (Avin et al., 2015). For an older adult with a history of falls, understanding the need to prevent future falls may be fairly easy. For adults without a fall history, convincing them that they may be at risk requires more objective evidence and education. Getting buy-in from the older adult who considers their fall history to be a one-time only accident also may be challenging. In a study by Porter, Matsuda, and Lindbloom (2010), women who had fallen in their home tied any future intentions of preventing falls to the situation that “caused” the original fall. They failed to generalize risk for falling again to any other situations other than the specific fall situation. These researchers suggest that clinicians ask older adults about their intentions to prevent future falls, so that they can address the need to generalize fall risk factors to multiple settings and challenges. Many fall risk factors potentially
guidelines for fall prevention programs, and recommendations for key actions that can prevent future falls.
balance training that challenges vision (low lighting or eyes closed) or vestibular (head turning) input can improve overall balance performance. Depending on the assessment selected, many of the dynamic balance tasks can be used also as an intervention activity. For example, when using a Dynamic Gait Index, if the older adult has difficulty with gait during head-turning activities they should be instructed to safely practice this at home or with supervision during therapy sessions. Balance training that includes perturbations has been shown to decrease fall frequency in older adults at risk for falls (Mansfield, Wong, Bryce, Knorrs, & Patterson, 2015). Perturbation-balance training is defined in the Mansfield literature review as “the intentional application of repeated postural perturbations that cause loss of balance over the course of a training program with the goal of improving whole-body reactive balance control” (Mansfield et al., 2015). They found positive effects in programs that produced perturbations by using either equipment (moving platform), or manual nudges with losses of balance while standing on unstable surfaces. Another successful approach to balance training is called step training . A meta-analysis of step training found a 52% reduction in falls using reactive and volitional step training that employ stepping tasks that are specific to functional activities required in day-to-day movement (stepping over obstacles, side-stepping to regain balance, etc.; Okubo, Schoene, & Lord, 2017). The most effective intensity and duration of these programs has yet to be determined, but in general, it is believed that longer duration is beneficial (at least 10 weeks; Nnodim & Alexander, 2005). Whatever the balance exercise strategy, it should be individualized and at a difficulty level that challenges the older adult without being unsafe. Balance is one of the three main exercise components in the Otago Exercise Program, which is described in more detail later in this section. The Otago program is one of the few fall prevention programs that has been proven to reduce falls in homebound older adults. It includes several options for both static and dynamic balance activities that are recommended to be performed at least three times per week. Examples of balance exercises included in Otago that progress in level of difficulty include: ● Knee bends while standing with upper extremity (UE) support, then progressed to no UE support. ● Backward walking with hand support, then progressed to no support. ● Walking and turning in a figure-eight pattern. ● Walking sideways. ● Heel toe (tandem) standing with UE support, then progressed to no support. ● Tandem walking with UE support, then progressed to no support. ● Single-leg stance with UE support, then progressed to no support. ● Heel walking with support, then without support. ● Toe walking with support, then without support. ● Tandem walking backward. ● Sit to stand with two hands, then one-hand support, then no UE support. ● Stair walking using a rail. The clinician should observe performance of each prescribed exercise and provide feedback and physical assist as needed before instructing the older adult to perform these at home. Safety is key when performing balance exercises in the home
influence the chance of falling in multiple settings, not just in the adult’s home on a certain carpet or particular set of stairs. Adults who have developed avoidance behaviors because of lack of balance confidence or fear of falling may be more compliant with the suggested program if they understand that completing the entire program will get them back into the community and social activities, driving, or being generally more independent (Yeom, Keller, & Fleury, 2009). Fall prevention education should include examples salient, or important and specific, to that person. Salience is a key to improved exercise compliance with older adults (Robinson, Newton, & Jones, 2014; Shumway-Cook & Woollacott, 2007). Some programs also use exercise logs, fall diaries, and/or phone call check-ins to encourage compliance with the prescribed program. For older adults, the social aspects of a group exercise class also can increase compliance and enjoyment in the fall prevention program (Garmendia et al., 2013). No matter what the approach or the risk factors leading to falls, strongly supported, evidenced-based components of a fall prevention intervention should include balance, strengthening exercises, gait training, correction of environmental hazards, and correction of footwear or foot problems that affect mobility (CGS, Alvin et al, 2015). Other additional interventions that fall into the scope of a primary care provider include vitamin D supplementation (one of the few single interventions that can reduce fall risk; AGS/BGS, 2015, adjusting medications, and managing postural hypotension if present. Balance training Balance training is widely accepted as important in a fall prevention intervention. Both static and dynamic balance abilities should be assessed, as described earlier, by using a mCTSIB exam for static balance in different sensory positions, and by selecting a dynamic balance assessment that matches the older adult’s physical abilities (see Table 6). The mCTSIB can be used to identify specific deficits that should be targeted in the sensory systems used for balance and in planning an intervention that uses multisensory integration, which can be helpful in fall prevention (Whitney, Marchetti, Ellis, & Otis, 2013). For example, if an older adult has impaired integration of somatosensation,
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