Falls and the Elderly

Falls Risk Factors

• Each year, one in every three adults age 65 and older will fall. 
• Falling is the leading cause of injury related death and most common cause of nonfatal injuries and hospital admissions for trauma amongst the elderly. 
• Falls are a common cause of Traumatic Brain Injury (TBI) and fractures of the spine, hip, forearm, leg, ankle, pelvis, upper arm, and hand. 
• The aging process involves declining function of a number of physiological systems which support balance. Such systems include Visual system (detail and contrast of objects), Muscular system, Kinaesthetic or Sensory system, and Vestibular or Balance system. An accurate measure and detection of falls risk should assess the status of all physiologically related factors. 
• Clinical examination utilising force platform tests (such as Computerised Dynamic Posturography (CDP) Test of Balance – in particular Limits of Stability LOS) is a modern approach to quantitatively assess balance problems.

How Can We Help Prevent Falls? 

An accurate identification of the balance disorder is paramount with prevention of falls. The purpose of balance function testing is to determine the site and degree of damage, to gather information regarding general functional abilities and evaluate the level of compensations. This permits a specific rehabilitation to be formulated.

Furthermore, to reduce older people from falling, the following has been shown effective: 

• Exercise regularly. It is important that the exercises focus on increasing strength and balance and that they get more challenging over time. Tai Chi and Yoga programs are good. 
• Ask their doctor or pharmacist to review their medicines. A common cause of dizziness is adverse effects from prescription and over-the counter drugs. 
• Have their eyes checked by an eye doctor at least once a year and update their eyeglasses to maximise their vision. 
• Make their homes safer by reducing tripping hazards, adding grab bars inside and outside the tub or shower and next to the toilet, adding stair railings, and improving the lighting in their homes. 
• Get adequate calcium and vitamin D. 
• Do weight bearing exercise.
  

Falls Risk and The Elderly - Case Presentation 

A 65 year old female patient presented with a history of frequent falls and disequilibrium. Her general health was unremarkable otherwise. She was not experiencing vertigo and had no hearing deficiency. She expressed concerns about her increased disequilibrium as she was the primary carer for her husband who suffered Dementia. 

On inspection this lady found it difficult to manoeuvre around the consulting room. In particular, her turn and look gait was ataxic.

• A Sit to Stand (STS) test exceeded 45 seconds. She was not able to complete this test with closed eyes;
• Rhomberg’s test was positive; 
• Fukoda’s test (Marching test on one spot) she turned to left greater than 30 degrees at 5 steps;
• Visio-motor response was hypokinetic; 
• Vestibulo-Occular Reflex (VOR) test reduced to left; 
• Computerised Dynamic Posturography (CDP) confidence for Test of Balance (TOB) at 66 (normal 22); 
• Modified Falls Efficacy Scale (MFES) measured at 82% (highrisk).

Note the plot projection of centre of mass on September 2012 study demonstrates a greater anterior-posterior (A-P) and medial-lateral (M-L) migration, when compared to the November 2012 study. This indicates improved stability confidence while erect.

Treatment and Therapeutic Plan 

From the assessment it appears this lady had a vestibular hypo-function on the left. 

Given this presentation and findings, the Practitioner’s therapeutic goals were: 

1. To improve this lady’s vestibular system and ultimately reduce her Falls Risk 
2. To improve her quality of life 
   

This plan is achieved by supporting her spino-vestibular, olivo-vestibular and ponto-vestibular pathways. 

Over an eight week period the practitioner implemented Vestibular Rehabilitation Therapy (VRT). 

The therapy was performed twice daily for 30 minutes, with supervision three times per week. Sessions were modified and progressed through the program. The use of Virtual Reality vestibular training was implemented in the last three weeks of the program. 

Clinical Outcomes 

A full evaluation was completed at weeks two, four and eight. At week two, the patient had improved MFES to 59 and TOB confidence scale 42. At week eight the patient further improved MFES 21 and TOB confidence scale 35. The patient was able to complete a 10 metre walk test with head turning. She was able to manoeuvre through a tactile organised obstacle course. Her visio-motor activity was full and complete. The patient stated that she was able to walk along the beach without the fear of falling. Her fear of falling is only currently limited to descending stairs – which is improving. 

Overall her neurological health has improved so dramatically, she is now taking vacations and excursions away.