Case study Irene is an 85-year-old woman who lives with her 87-year-old husband, Dwight, in a retirement community. Irene is referred to home health physical therapy due to multiple falls. Irene and Dwight have lived in their own apartment on the third floor for 7 years, where they must negotiate 300 feet to the elevator, a 20-foot ramp from their apartment building to their car, and an occasional curb or threshold, depending on how close they can park to the entrance. Irene uses a cane crafted out of PVC pipe by her home health physical therapist, who treated her after her first fall 2 years ago. Irene spends most of her time sitting in her favorite chair, reading, watching some TV, or sleeping. She has difficulty with community ambulation due to unsteady gait, poor endurance, and fear of falling (ABC score 55/100). Irene’s past medical history includes: ● Hypertension for 25 years controlled by medication. ● Corrected vision. ● Type 2 diabetes mellitus diagnosed 15 years ago, also requiring medication. ● CABG x 3 10 years ago. ● Osteoporosis for an undetermined length of time. ● A recurring case of horizontal canal benign paroxysmal positional vertigo (BPPV). ● Five medications (Lipitor, Metformin, Anti-vert, Xanax, and Fosamax). Irene has had multiple falls over a 2-year period, mostly in the bathroom or bedroom, but none resulting in more than a bruise or scrape. The local emergency medical system must assist Irene from the floor each time she falls, as her husband is unable to transfer her from the floor. Irene is referred to physical therapy secondary to a fall 3 days ago in her bathroom while being assisted into the shower by her husband. She spent 1 day in the hospital and was released to home 2 days ago with a sprained right wrist and bruised right hip. Irene’s personal history includes being retired for 20 years from bookkeeping, being a mom to four grown children (none of whom live nearby), and attending church semiregularly until she started falling. She enjoys reading and playing cards. Irene’s goal: Be as independent as possible, stop falling, accompany her husband into the community as much as possible. Functional status ● Self-care: ○ Dresses while sitting at edge of bed, minimal assist for bathing, reaching in standing. ○ Husband does all laundry, cooking, bills, driving. ○ Verbal cues for consistent and thorough hygiene. ● Mobility: ○ Independent for bed mobility and short sitting balance. ○ Independent sit-to-stand transfers using upper extremities and needing multiple attempts, unable to get up from floor. ○ Independent static standing balance with feet together; increased sway with eyes closed. ● Locomotion: ○ Independent gait indoors using furniture for assist or cane. ○ Slow gait speed (2.3 ft/s), which declines even further during dual tasking, and while walking on uneven surfaces. ○ Very slow negotiation of steps; needs a rail; avoids steps when possible. ● Cognition: Mild cognitive decline typical for her age. ● Communication: Alert and oriented, occasionally despondent when homebound. ● Psychosocial: Anxious about falls, loss of independence Motor control ROM/Posture: moderate kyphosis, neutral hip/knee extension and ankle dorsiflexion, limited cervical ROM secondary to peripheral vestibular hypofunction and BPPV confirmed by semicircular canal testing.
Sensation: minimal peripheral neuropathy in bilateral feet, loss of protective sensation on soles of both feet with monofilament score of 5/10; vision corrected with bifocals. Muscle Strength: Functional Manual Muscle Testing and Observation Joint/Area Bilateral Comments Neck flexion/extension 4 Head control: Good. Upper trunk/Scapular 4 Trunk control: Good.
Lower trunk/ Abdominals
3+ Irene is 20 lbs overweight.
Shoulder
4-
Elbow
4
Wrist
4- 4-
Hand/Fingers
Hip
3+
Knee
3+ Complains of mild knee pain during testing.
Ankle
4-
Mild edema noted.
Foot/Toes
4-
Mild edema noted.
Outcome measures ● ABC score 55/100. ● TUG score 15 seconds. ● TUG cognitive 20 seconds. ● Four-Stage Balance Test: could not maintain tandem stance more than 5 seconds. ● 30-Second Chair Stand at five attempts. ● Dynamic Gait Index (DGI) 5/24 due to assistance needed with most tasks on exam. ● mCTSIB results were 30 seconds, 30 seconds, 15 seconds, and 5 seconds in positions 1 to 4. Questions 1. Which risk factor for falls is the best predictor for future falls? 2. Which fall risk outcome measure would be the most appropriate for Irene? 3. Which sensory system does Irene rely on for balance? 4. Which fall prevention exercise program would be the most effective approach for Irene? 5. Which combination of fall risk factors should be addressed initially in order to have the most effect on future fall risk? Responses 1. Irene has several risk factors for falls. Her recent injurious fall is the best predictor of future falls, but she has additional risk factors, including being female, her advanced age, her slow gait speed, her poor balance as evidenced by sitting at the bedside to dress, decreased lower extremity strength as evidenced by manual muscle testing and chair-stand test, history of vestibular hypofunction that could cause dizziness, polypharmacy, and cognitive decline. Irene also scored as being at risk for falls on every one of her outcome measures (all STEADI tests, ABC, mCTSIB, and DGI). 2. The TUG fall risk screening measure would be a good choice for Irene as it best matches her physical abilities out of the outcome measures listed. The Functional Reach exam would require assistance for Irene as she needed help while reaching in standing, and thus be too difficult. The Functional Gait Assessment would also be too difficult for Irene as it incorporates several high level balance activities. The DGI might be a consideration, but when it was performed, Irene’s score was only 5/24, indicating that it was also too
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