Falls and the Elderly: Case Presentation

Falls Risk Factors

• One in every three adults age 65 and older will fall each year. 
• Falling is the leading cause of injury-related death and the 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 the declining function of several physiological systems that support balance. These systems include the Visual system (detail and contrast of objects), the Muscular system, the Kinesthetic or Sensory system, and the Vestibular or Balance system. An accurate measure and detection of fall risk should assess the status of all physiologically related factors. 
• Clinical examination utilising force platform tests (such as the Computerised Dynamic Posturography (CDP) Test of Balance—in particular, Limits of Stability (LOS) is a modern approach to quantitatively assessing balance problems.

How Can We Help Prevent Falls? 

Accurate identification of the balance disorder is paramount in preventing falls. Balance function testing determines the site and degree of damage, gathers information regarding general functional abilities, and evaluates the level of compensation. 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 essential 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. Adverse effects from prescription and over-the-counter drugs are a common cause of dizziness. 
• Have their eyes checked by an eye doctor at least once a year and update their eyeglasses to maximise their vision. 
• They can 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 from Dementia. 

On inspection, this lady found it difficult to maneuver 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 more significant than 30 degrees at 5 steps;
• Visio-motor response was hypokinetic; 
• Vestibular-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 and 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 fall 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). 

Therapy was performed twice daily for 30 minutes, with supervision three times per week. Sessions were modified and progressed through the program. In the last three weeks of the program, virtual reality vestibular training was implemented. 

Clinical Outcomes 

A full evaluation was completed at weeks two, four and eight. At week two, the patient had improved MFES to 59 and a TOB confidence scale of 42. At week eight, the patient further improved on the MFES 21 and TOB confidence scales 35. The patient completed 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 that she is now taking vacations and excursions away.