Fall Prevention Program for Older Adults With a Fear of Falling

Department of Otolaryngology Head and Neck Surgery Department of Communication Sciences and Disorders Fall Prevention Program for Older Adults With a Fear of Falling Julie A. Honaker, Ph.D Robert W. Keith, Ph.D. Laura Kretschmer, Ed.D. Daniel Choo, M.D. Patrick Shumrick, DPT

An Aging Society Prediction for the US: By 2010, 40 million 65 years By 2040, 80 million 65 years 1. Girardi, M., Konrad, H.R., Amin, M., Hughes, L.F. (2001)

Boston, Massachusetts Population Estimates 1 : 680,000 Mean age = 32 years 55-59 years = 27,380 60-64 years = 22,160 > 65 years = 76,160 1. http://censtats.census.gov/

Epidemiology of Falls 30% to 50% of people 60 years or older will fall 10-20% repeatedly Elderly in nursing homes (rate rises to 50% will fall twice or more per year) 1. Rubenstein, L.Z. and Josephson, K.R. (2002).

Hip Fractures Major cause of morbidity and mortality In 1999, hip fractures resulted in nearly 338,000 hospital admissions 1 By 2050, hip fractures will exceed 600,000 2 1. 1. Popovic, J.R.(2001). 2. 2. American Academy of Orthopaedic Surgeons (2006)

Risk Factors for Falls Broad range of risk factors identified in the literature (between 130 and 400) 1 Likelihood of falling increases with four or more risk factors 2 Classified as extrinsic or intrinsic 1. McMurdo, M. (2001). 2. Masud, T., Morris, O. (2001) 2. Nevitt, M.C., Cummings, S.R., Kidd, S., & Black, D. (1989).

Risk Factors for Falls Extrinsic Environmental Factors: Poor lighting Unsafe stairways Irregular floor surfaces

Risk Factors for Falls Intrinsic Decline in sensory system: Vestibular, vision and proprioception

Risk Factors for Falls Decline in motor Strength, coordination and endurance Increased age History of Falls Slow walking speed Decline in function and integration (response time/reaction time)

Risk Factors for Falls 1. Steinweg, K.K,, (1997). 50% of falls are due to a medical condition 1 Diabetes, Parkinson s disease, stroke, arthritis, osteoporosis Any acute or chronic disease Visual disorders Cataracts, glaucoma, macular degeneration Medications Type and number CNS disorder Balance disorders and dizziness*

Falls and the Older Adult Unfortunately, some older adults fail to seek help for falls Attribute these to normal aging Many older adults fear falling and do not realize that many falls they associate with aging can be prevented

Fear of Falling (FoF( FoF) Injuries can be treated/fear of another fall is persistent Fear of falling can: Create excessive anxiety Restrict participation in activities of daily living Decrease quality of life Increase dependence on others

Fear of Falling Definitions 1. Unusual variation of agoraphobia 1 2. Ptophobia 2 or post-fall syndrome 3 3. A lasting concern about falling that leads to individuals avoiding activities that he/she remains capable of performing 4 1. Marks, I., & Bebbington, P. (1976). 2. Bhala, R.P., O Donnell, J., & Thoppil, E. (1982). 3. Murphy, S.L., & Isaacs, B. (1982). 4. Tinetti, M.E., & Powell, L. (1993).

Fear of Falling Assessment Instruments Instrument Authors Item Response Scale Yes/No Question Tinetti et al. 1988 1 = yes, 2 = no Falls Efficacy Scale (FES) Tinetti et al. 1990 10 point confidence rating Activities Specific Balance Confidence Scale (ABC) Powell & Myers (1995) 0-100% Scale Survey of Activities and FoF in the Elderly (SAFFE) Lachman et al. (1998) Dichotomous yes/no, 4 point scale

Risk of Falling Programs

Risk of Falling Programs Multidisciplinary care (Fall Clinics) Exercise intervention programs Home hazard assessment/environment modification Studies incorporating these elements have established that falls and fall related injuries can be prevented Not easily replicated in most clinical settings Few have included FoF as an outcome of interest

Article Summary of Research Findings in the Reduction of Falling Concerns in Older Adults FoF assessment FoF Outcomes 8-session intervention = *Tennstedt et al. (1998) Modified FES reduction in FoF/this decayed by 6-month f/u *Taggart (2002) FES Signif icant decrease in FoF *Brouwer et al. (2003) ABC scale significant decrease in FoF for activity program only *Liu-Ambrose et al. (2004) ABC scale *Sattin et al. ABC scale (2005) FES improved balance confidence for resistance and agility groups no improved confidence for stretching group significant decrease in FoF for Tai Chi group * Study design aimed specifically at reducing fear of falling

Summary of Research Findings in the Reduction of Falling Concerns in Older Adults: Majority of studies were group programs Frail elderly (>75 years average age of inclusion) Few studies provided multidisciplinary fall prevention/risk of falling clinics, No audiologist/physical therapist/neurotologist (or otolaryngologist) for the initial evaluation

Summary of Research Findings in the Reduction of Falling Concerns in Older Adults: Few included home hazard assessment Excluded patients with complaints of vertigo, lightheadedness, etc Only 1 study provided qualitative descriptions from the subject;limited to patient satisfaction of the program None of the studies examined the impact of FoF on the patient or caregivers

Purpose of My Research To determine if intervention with a team approach risk of falling assessment and remediation program reduces fear of falling in older independent living individuals with a balance disorder. Evaluate the impact of FoF due to a balance disorder on the patient s activities of daily living Determine the impact of FoF on a selected family member, significant other, or spouse of the patient

Specific Aims 1. Establish/evaluate the impact of FoF due to a balance problem on selected family member, significant other or spouse 2. Verify level of anxiety and depression in the patient, due to FoF 3. Reveal the patient s present attitude toward their balance problem/activity level before FoF 4. Verify the effectiveness of the risk of falling intervention program designed to reduce FoF 5. Determine via the (ABC) Scale if the risk of falling program reduced FoF

Methods Male and female patients were recruited from individuals referred to the Balance Disorder Center (Group 1) Completed a balance disorder questionnaire One family member, significant other, or spouse of the patient was recruited for the study (Group 2)

Methods (Group 1) scheduled for 2 half days of risk of falling assessment Audiology and Physical therapist Testing was performed in 2 clinical settings Medical evaluation with neurotologist Remediation Portion (balance/vestibular rehabilitation with PT) Audiologist observed and interviewed patient/selected family member, spouse, or significant other before and after the remediation portion

Audiology Assessment (Group 1) 1. Reviewed balance questionnaire answers 2. Mini Mental State Exam 3. Geriatric Depression Scale 4. Beck Anxiety Inventory 5. Home Safety Checklist for Detection of Fall Hazards 6. Activities Specific Balance Confidence (ABC) Scale 7. Near vision acuity testing With and w/o corrective lenses Determined date of last eye examination

Audiology Assessment (Group 1) 8. Audiometric exam Tympanometry Acoustic reflexes Pure tone and speech audiometry 9. Balance assessment Platform Posturography Clinical Test of Sensory Integration and Balance (CTSIB) 10. Impaired balance function VNG

Significant Other Assessment (Group 2) 1. Mini-Mental State Examination 2. Home Safety Checklist for Detection of Fall Hazards 3. Modified ABC scale

Physical Therapy Assessment (Group 1) 1. Review of symptoms (fall history etc ) 2. Type and number of medications 3. Dizziness Handicap Inventory 4. Musculoskeletal examination Lower extremity strength, flexibility, reflex and sensation testing 5. Functional Reach Test 6. Timed Up and Go test 7. Examination of gait length and velocity 8. Berg Balance Test 9. Dynamic Gait Index

Neurotologist Assessment (Group 1) 1. Review of all risk of falling assessment results/case History 2. Head and neck examination Cranial nerve function/neurologic exam 3. All results integrated to yield diagnosis 4. Referral to PT for balance disorder remediation

Qualitative Assessment (Group 1 and 2) In home interview/observation 1 st interview scheduled prior to remediation portion of the program Separately interviewed (Group 1) and (Group 2) subjects w/ audiotape recorder Counseled/educated participants on the results of home hazard checklist Addressed home hazard issues

Remediation Program (Group 1) Balance/Vestibular Rehabilitation Designed to incorporate concerns/goals agreed upon by the PT and patient habituation, gaze stability, balance mobility, strength and endurance training Therapy sessions based on assessment results Length of program depended on indiv. objectives (on average 6-10 weeks)

Completion of Risk of Falling Program (Group 1 and 2) 1. Follow-up observation/interview 2. Separate interviews 3. (Group 1) post questionnaires: Geriatric Depression Scale Beck Anxiety Inventory ABC Scale 4. (Group 2) post questionnaire: Modified ABC scale

Results: Subject Characteristics Originally 32 subjects 2 participants & spouses dropped out N = 28 14 from each group Characteristic: Mean SD Range Age 69.14 9.02 (56-82) Education in # of years 12.21 2.19 (9-16) # of co-morbid conditions 8.21 2.39 (5-12) # of medications 6.21 4.47 (2-19) Gender Male Female Race/ethnicity Caucasian Africian American Hispanic Native American Asian Home Type House Apartment Condominium Group 1 Sample Characteristics Group 1 (n = 14) Percentage of Sample 36% 64% 93% 7% 0 0 0 79% 0 21%

Description of Balance Problems 1. Primary symptom Unsteadiness Standing or walking 2. Constant symptoms (57%) 3. Moderate disability (35%) Group 1 (n = 14) Balance Disorder Symptom Lightheaded Unsteady when standing Unsteady when walking Vertigo (spinning sensation) I tend to fall I get nervous/panic when walking Symptom duration intermittent constant Description of Balance Problems Overall Balance Severity no disability slight disability mild disability moderate disability severe disability long term disability Percentage of Sample 71.42 92.86 100 42.86 92.86 64.28 42.86 57.14 0 7.14 21.43 35.71 14.29 21.43

Fall History Fall History Answers Do you need assistance to walk? Can you easily walk up stairs? Fall History Group 1 (n = 14) Percentage of Sample 28.57 85.72 1. FoF, fall, near fall (100%) 2. 78% avoided activities inside the house 3. 92% avoided activities outside the house Can you walk 10-20 meters without assistance? Do you use a walker, cane, or roller walker? Do you hold onto a spouse or loved one while walking? Do you engage in regular physical activity? Have you ever had a near fall experience? Have you ever fallen? Did you have an injury from the fall? Were you hospitalized due to a fall? Are you afraid of falling? Do you think your spouse is afraid that you might fall? 100 21.43 57.14 7.14 100 100 57.14 28.57 100 83.33 Do you think family members or friends are afraid that you might fall? 92.85 Does your fear of falling prevent you from doing activities around the house? 78.57 Does your fear of falling prevent you from doing activities outside of the house? 92.86

Physical therapy assessment results (Pre) n = 14 Subject No. Descriptive information, Physical Therapy Assessment Information for Group 1 Subjects BERG SCORE BERG Description DGI SCORE DGI Description FR (inches) SCORE FR Description TUG (sec) SCORE TUG Description DHI SCORE 1 22 Severe 3 Severe 7 Severe 14 high risk 88 2 40 Moderate 12 Severe 7 Severe 20 high risk 54 5 35 Severe 13 Severe 8 Moderate 17 high risk 84 6 44 Moderate 13 Severe 11 WNL 19 high risk 84 7 38 Moderate 13 Severe 8 Moderate 16 high risk 76 8 40 Moderate 13 Severe 11 WNL 15 high risk 60 BERG9 33 BERG Severe DGI 10 DGI Sever FR (inches) 11 WNL FR TUG 23 (sec) high risk TUG 78 DHI SCORE 10 Description 35 Severe SCORE10 Description Severe SCORE 8 Moderate Description unable SCORE high Description risk 56SCORE 11 40 Moderate 17 Moderate 7 Severe 15 high risk 28 12 40 Moderate 15 Moderate 11 WNL 15 high risk 64 13 48 Mild 14 Moderate 11 WNL 14 high risk 64 14 28 Severe 8 Severe * * 33 high risk 84 15 40 Moderate 11 Severe 6 Severe 17 high risk 56 16 42 Moderate 12 Severe 10 WNL 14 high risk 50 Mean 37.5 11.7143 8.9230769 17.84615 66.142857 SD 6.60711 3.36106 1.9348358 5.289079 16.448435 Key: * Missing Data BERG = Berg Balance Test;DGI = Dynamic Gait Index;FR = Functional Reach;TUG = Timed "Up & Go" DHI = Dizziness Handicap Inventory; WNL = Within Normal Limits; SD = Standard Deviation Descriptive Information, Pre- Physical Therapy Assessment Information for (Group 1) Subjects Mean 37.5 Moderate 11.7 Severe 8.9 Moderate 17.8 High risk 66.1 SD 6.61 risk of falling 3.36 risk of falling 1.93 limitation 5.29 of falling 16.45

Audiology Assessment Results Type of Corrective Lenses Type of Corrective Lenses: Percentage of Sample (n= 14) 42.86 14.29 7.14 21.43 7.14 Bifocals Trifocals Contacts Reading Glasses Bifocals + reading Bifocals + prism 7.14 64% indicated last visual exam > 1 year ago

Audiology Assessment Results 93% sensorineural loss in both ears VNG results: 29% both peripheral and central 29% peripheral only 21% central only 21% normal Platform/CTSIB results 2 = severe dysfunction pattern 1 = visual/vestibular dysfunction pattern 8 = vestibular dysfunction pattern 3 = unable to perform test

Questionnaire results Mini Mental Group 1 (mean = 27.6, SD = 2.21) Group 2 (mean = 28.1, SD = 2.50) Home Hazard Overall scores indicated = good rating Only 3 out of 4 families scored w/in the same range

Questionnaire results (Group 1) ABC, Geriatric Depression, Beck Anxiety Compared pre/post Wilcoxon signed ranks test n = 14 Pre Remediation Mean & (SD) Post Remediation Mean & (SD) *p value for difference (Wilcoxon signed ranks) ABC 50.5, (27.36) 77.9, (18.07) p = 0.02 GD 13.1, (6.89) 12.6, (7.0) p = 0.03 BECK 23.5, (13.38) 9.7, (7.51) p < 0.01 *α =.05

Questionnaire results (Group 2) ABC scale Compared pre/post Wilcoxon signed ranks test n = 14 Pre Remediation Mean & (SD) Post Remediation Mean & (SD) *p value for difference (Wilcoxon signed ranks) ABC 54.8, (24.56) 66.7, (16.29) p < 0.01 *α =.05

Spearman r Correlation Coefficients between ABC scale, Geriatric Depression scale, and Beck Anxiety Inventory (Group 1) 1. Significant negative correlation between change in FoF and depression 2. Significant negative correlation between change in FoF and anxiety (n = 14) ABC Post correlations *p-value ABC- GD -0.64 0.01 ABC- Beck -0.81 <0.001 *α =.05

Spearman r Correlation Coefficients between ABC (Post) Scores and Age and Co-Morbidities for (Group 1) Significant negative correlation between change in ABC scores and age No significant association between number of comorbidities and change in ABC scores (n = 14) Post correlations *p-value Age -0.55 0.04 Co-morbidities 0.13 0.65 *α =.05

Qualitative Research: Example of Open Ended Questions Sample interview questions for patient with fear of falling: 1. Tell me about a typical day at home. 2. How has your life changed since the fear of falling? Sample interview questions for family member/spouse 1. Describe for me some activities your spouse/family member is afraid to perform to due the fear of falling. 2. Describe what activities your spouse/family member depends on you to perform due to his/her fear of falling.

Qualitative Results 1. Phenomenological approach 2. Open ended interview questions 30 40 minutes (Group 1 & 2) 3. Content Analysis Transcribed (350 total pages) Group 1 = 172 pages, Group 2= 178 pages) Coded Coding example: No, I can walk through the house. Then sometimes I can t. It just depends on my day or if I m overly tired. Codes = description of balance problems, fatigue, limiting activities

Qualitative Results Content Analysis of 28 interviews yielded two Main Themes: Impact of a Fear of Falling/Balance Disorder on Daily Living Role of Risk of Falling Program

Data Display: Impact of a Fear of Falling/Balance Disorder on Daily Living Description of Fall/ Near Fall Experience Limiting activities/ lack of confidence Emotional Reaction of Participant since FoF Dependence on family members Family stress due to FoF/Balance problem Anxiety and Depression Problems with Family Members Problems with previous medical care Embarrassment due to FoF Discussion of Assistive Devices

Data Display: Role of Risk of Falling Program Overall Impression of Risk of Falling Program Change in Activity Level Post Program Limitations of the Remediation Program Increased Confidence Post Program Emotional Reaction Post Program Limiting Activities/ Dependence on Others Falls + Balance Problems not eliminated Education on Falls/Risk of Falling and Balance Problems Plans to Keep Up with Program Other Medical Concerns Post Program

Summary of Results: 1. All reported fall, FoF 2. High risk of falling 3. Statistically significant reduction in FoF (group 1 and 2) 4. Significant reduction in depression/anxiety (group 1) 5. Qualitative results

Summary of Results: Evidence of Improvement Post Treatment Descriptive information, Physical Therapy (Post Intervention) results for Group 1 Subjects Subject 1. Patient s BERG BERG advocate DGI DGI No. SCORE Description SCORE Description FR (inches) SCORE FR Description 2. Vestibular/balance rehabilitation component FR TUG (sec) SCORE TUG Description 1 * n/a 17 Moderate * n/a * WNL 2 52 Mild to WNL 16 Moderate >10" WNL 10 WNL Descriptive Information, Post- Physical Therapy Assessment Information for (Group 1) Subjects 3 56 Mild to WNL 22 Mild to WNL >10" WNL 9 WNL 4 52 Mild to WNL 18 Moderate >10" WNL TUG 12 Mild BERG BERG DGI DGI (inches) FR (sec) TUG 5 48 Mild to WNL 18 Moderate 8" Moderate 12 Mild n = 14 SCORE Description SCORE Description SCORE Description SCORE Description 6 51 Mild to WNL 22 Mild to WNL >10" WNL 10 WNL Moderate 7 49 Mild WNL 15 Moderate >10" WNL Mean 51.1 Mild to 18.1 to 9.5 Mild to 10.3 WNL 8 47 Mild to WNL 16 Moderate 8" Moderate 10 WNL SD 6.6 WNL 3.36 Mild 1.93 WNL 5.29 9 * n/a 17 Moderate * n/a 10 WNL 10 52 Mild to WNL 20 Mild to WNL >10" WNL 10 WNL 11 51 Mild to WNL 20 Mild to WNL >10" WNL 10 WNL 12 * n/a 16 Moderate 8" Moderate * n/a 13 52 Mild to WNL 21 Mild to WNL >10" WNL 10 WNL 14 52 Mild to WNL 15 Moderate >10" WNL 11 WNL Mean 51.09091 Mild to WNL 18.07143 Mod to Mild 9.5 Mild to WNL 10.33333 WNL SD 6.607106 3.361057 1.934836 5.289079

Limitations 1. Assessment appointments 2. Short follow-up period

Other Interesting Findings: 1. Depression scores 2. Family member falling concerns post program 66.7 (mean ABC post) Group 2 77.9 (mean ABC post) Group 1

Future Directions: 1. Greater public awareness/education on reducing falls/fear of falling Screening tests for risk of falling 2. Primary Care Physicians Role

Conclusion: Team approach risk of falling program (audiology, PT, neurotology) with vestibular/balance rehab, counseling & education on balance disorders/falls effective way to deal with fears about falling and improve quality of life.