1) The document provides an overview of falls prevention and treatment for older adults. It discusses epidemiology facts about falls and examines assessment strategies across four domains: medical, cognitive, functional, and environmental. 2) Key points covered include that 25% of community-dwelling older adults fall each year, with 5-10% of falls causing serious injuries like fractures. Falls are also the most common cause of traumatic brain injury in the elderly. 3) The document emphasizes the importance of assessing multiple risk factors across different domains to identify potentially treatable diagnoses. It provides examples of medical, cognitive, functional, and environmental risk factors and stresses that etiologies of falls are usually multifactorial.

1. 1
Falls Prevention and Treatment
Hilary C. Siebens MD
Siebens Patient Care Communications
Consultant, PM&RS Long Beach
VA Health System
2nd
Annual UCSD Clinical Geriatrics Interprofessional
Symposium
San Diego
October 25, 2015

2. 2
Objective Practical
• Appreciate a few key epidemiology facts.
• Learn overarching assessment strategies.
• Explain 3 or more factors contributing to falls in each
of 4-domains: medical, cognitive, functional, and
environmental realms.
• Identify 2 practical interventions to improve your care
of patients with fall risk factors for those who
1) haven’t fallen yet are at high risk and
2) those who have fallen.

3. 3
Disclosures
A model used in consulting with health care
organizations will be mentioned.

4. 4
Epidemiology
 1. What % of community residing older adults
fall each year?
 2. What percentage of falls cause serious
injury?
 3. What are the most frequent causes of TBI
in the elderly – pedestrian vs car accidents,
driving car accidents, muggings, falls, or other?

5. 5
Epidemiology
Answers
1. 25%
2. 5-10%, causing lacerations, traumatic brain
injury (TBI), fractures (most frequent one is of
the hip)
3. Falls are THE MOST frequent cause of
traumatic brain injury (TBI) in the elderly

6. 6Preparing a 21st
Century Work Force: The Challenge of Chronic Conditions, WHO 2005

7. 7
Overarching Concepts in
Assessment of Fall Risk
 4. What is the single most
important
topic to ask your patients?

8. 8
4. Answer
- About falls!
Three questions to ask:
• Have you fallen in the past year?
• Do you feel unsteady when standing or walking?
• Do you worry about falling?
Odds ratio for another fall if a fall – 2.8
See cdc.gov/steadi/; Michael Y et al. Ann Intern Med 2010.

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Understanding Balance
Self-insight and Reflection
 5. Do you have a balance problem?

10. 10
5. Answer
It depends!
• Dynamic balance and falls – falls occur when activities
overpower individuals’ ability to keep upright
dynamically
See cdc.gov/steadi/ for information on screening tests for
fall risks – Timed Up & Go, 30 sec chair stand, 4-stage
balance test.

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A practical model for assessing falls
INDIVIDUAL
Cognition
3 sensory system inputs brain/CNS processing
neuromusculoskeletal output
ACTIVITY CHOSEN*
What/how/when an individual is doing it
* Occupational Therapy – The PEO Model : person,
environment, occupation

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Overarching Concepts in Assessment and
Management
• Many patients don’t understand balance, don’t know they have a
“balance” problem
Dizziness/unsteadiness
Taking extra steps, shorter steps
More trouble in dark, on grass or uneven surfaces
Losing balance with turning, reaching, sit to stand
Furniture surfing required
Free falling into a chair
Feeling that “I walk like I’m drunk”
• Patients often believe “nothing can be done” or believe “I don’t
have a problem but my friend does” (see cdc.gov/steadi/ for
brochure, how to talk to patients)

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Overarching Concepts in Assessments
and Management
• Critical to focus on screening for risk of INJURY
• Several key factors:
Older age
Medical - Oseoporosis, anti-coagulation,
polypharmacy, etc.
Cognition - Impaired judgment
Function - High risk activity for the individual
Environment - Living alone

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Overarching Concepts in Assessments
and Management
• Etiologies of falls usually multifactorial
• Strategy is to address identified risk factors
• Most all treatment strategies involve exercise of
some sort (community-based or physical therapy)
• Strategies limited to date in fall prevention in
setting of cognitive impairment in community-
dwelling individuals (projects underway in nursing
facilities, etc)

15. 15
Identifying Treatable Diagnoses/Risk Factors
Medical
• Cardiac - relative hypotension (overtreated HTN)
BP systolic goals for seniors now <140 mm Hg if under 80 yrs old,
140-150 if over 80 yrs old - go by pt symptoms
- terazosin for treatment of BPH
• Neurological – CNS (subdural, stroke, traumatic brain injury…)
vestibular (BPPV, acoustic neuroma…)
peripheral neuropathy
• Musculoskeletal – deformities back, knees, ankles, feet, pain
• Polypharmacy
• Nutrition - Vitamin D deficiency

16. 16
Identifying Treatable Diagnoses/Risk Factors
Mental, Functional, Environmental
• Cognitive, Emotional (depression, anxiety - fear of
falling)
• Function – abnormalities of gait; unsafe ADLs
• Environment – physical hazards, social supports,
financial resources

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Assessing A Patient – History 1
• Have them describe balance problem (what feels
like, how long present, rate of progression)
• Describe most recent fall (circumstances, then perhaps
one, or two prior falls)(visualize the scene…)
• Describe mobility/devices used (easier to walk when
pushing shopping cart – early sign rollator might help, for
physical activity at least)
• Focused ROS for cardiovascular, neurological,
orthopedic contributors, pain, vision, alcohol

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Assessing Patient – History 2
• Function (other than walking) – showering, on/off toilet (and
whether grab bars, etc); general physical activity habits
• Consider Kemp QOL screen – “Taking everything in your life
into account, please rate your overall Quality of Life on the
following 7-point scale…”
1 life is very distressing, 7 life is great, 4 life is so-so
CAVEATS for KQOL – Please read reference(s) before using.
Siebens H et al Correlates of a single-item quality of life measure in
people aging with disabilities. Am J Phys Med Rehabil 2015 (open access for anyone)

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Assessing Patient – History 3
• Social
- who living with (to help, support)
- any pets (trip hazzard)
- finances - “In terms of your finances, are
you comfortable, making do, or is it a
struggle?”
• ROS – quick screen of sleep, appetite, other

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Physical Exam - Seated
• Cognition screen – IF suspect problems
Mini-cog – recall of 5 words, clock drawing
• Health Literacy – special considerations
• HEENT – depending on suspected dx (re cranial nerves or
visual neglect)
active neck lateral range of motion

21. 21
Clock drawing “Please draw a clock for me. Make it big. Set the time to
10 after 11.” see Borson S et al Int J Geriatr Psychiatry 2000;15:1021-1027
on Mini-cog – 3-item recall and clock drawing as cognitive screen.

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Physical Exam - Seated
• Motor tone (cogwheeling at elbow, clonus -? myelopathy)
• Muscle strength screen
upper extremity (pronator drift)
lower extremity
• Joint exam as indicated (hip, knee)
• FEET KEY – watch taking off socks (one foot if time
short)
check hygiene (clue to cognition problem, etc)
sensation (to identify peripheral neuropathy)

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Physical Exam - Standing
• Sit to stand - with or without arms?
• Romberg
• Sternal push
• Watch walking pattern, watch number of steps to
turn (normal is 3 steps) and if touch wall for balance
• Special physical exam – if suspect vestibular
component, Dix-Hallpike and Epley
See You Tube (Kim et al. Benign paroxysmal positional
vertigo. NEJM;2014;370:12 – excellent review.)

24. 24
Labs and Therapy
• Be sure general internal medicine/family medicine
recent evaluation (thyroid, lytes, CBC, etc to screen for
systemic disease/infections as contributor to balance problems)
• If peripheral neuropathy, consider Vit B12, folate levels, A1C
if not done already, consider referral for work up
• Vitamin D – 25-hydroxy level
• Balance testing/gait assessment by Physical Therapy
• ADLs review for safety, devices by Occupational
Therapy

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Assessment/Plans
• If unclear what’s causing problem, refer to
specialist to help (ENT for vestibular, neurology for ?
Parkinson’s, degenerative process, etc)
• If multifactorial (deconditioning, prior stroke, superimposed
on aging, OA of knees, kyphosis, etc):
1. treat individual identified risk factors
2. focus on compensatory strategies
3. encourage community exercise program or PT if
more severe impairment
4. recommend assistive device (“have cane at home just in
case…”); - if bilateral balance support, consider
rollator for exercise and/or all the time

26. 26
Clinical Case – 75 yo Man

27. 27
Current Status
• Adaptive bicycle on retail market – pedal-forward
• Quality of Life –
KQOL 5.5 - Good!

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In Summary
• Balance, fall problems complex
• Good assessments key:
team of physician/NP, other specialties, rehab
therapies
• Treatments – in health care & community over time
• From single factor(s) to multiple “treatable” factors
to late-life disability (keep patient as safe as possible)

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Observations, Questions?
THANK YOU.
www.siebenspcc.com

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Supplemental Slides

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Activities-specific Balance Confidence (ABC) Scale
• “How confident are you that you will not lose your balance or
become unsteady when you….”
• Response scale from 0% (no confidence) to 100% (completely
confident)
• 16 self-report functional items – walk around the house, walk up
or down stairs… sweep the floor… walk across a parking lot to
the mall…
• Can indicate early balance problems for patients who feel they
don’t have a problem
Powell, LE & Myers AM. The Activities-specific Balance
Confidence (ABC) Scale J Gerontol Med Sci 1995;50:M28-34.

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Assessment/Plan – a Standardized Synthesis
I. Medical/Surgical Issues1
Contributing diagnoses to balance problem (peripheral neuropathy,
severe knee OA, Vit D deficiency, etc) and plan for w/u, tx.
II. Mental Status/Emotions/Coping
- Comment on safety judgment, evidence of good coping or not
(changing behaviors to be safer), Preferences
- Suggest education classes on balance if available, give CDC
brochure on fall prevention
(Patients need to understand how balance works, so
can choose safer ways of doing things)
- Suggest patients keep health information organized, take to all
appointments
1 Using the Siebens Domain Management Model domain headings;
Siebens H. Top Stroke Rehabil 2011; see guidelines for use at
www.siebenspcc.com; © Hilary C. Siebens 2005

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Assessment/Plan – a Standardized Synthesis
III. Physical Function1
Mobility - assistive device?
- 1:1 Physical Therapy? or exercise class in community?
ADLs – safe or unsafe? Occupational Therapy assessment? (toileting,
showering, foot care, meal prep, etc)
Physical Activity – coaching/motivational interviewing, encourage
walking program with safe assistive device, 30 min 5 times a week!
IV. Living Environment
A. Physical – grab bars in shower? rails by front steps?
B. Social – involve/educate of family members?
C. Financial/Community Resources – financial needs? Community
education programs for fall prevention?
1 Using the Siebens Domain Management Model domain headings; Siebens H. Top
Stroke Rehabil 2011; see guidelines for use at www.siebenspcc.com;
© Hilary C. Siebens 2005