Treatment Strategies for the Falling Older Adult

 Purpose 

To discuss how to screen for older adults at risk for falls, to assess what the major balance impairments are for those older adults, and how to effectively treat those impairments with exercises to decrease fall risk.

 Objective 

1) Screen for falls in older adults.

2) Assess fall risk in the older adult using STEADI algorithm.

3) Introduction to the BESTest to identify balance impairments in older adults.

4) Present balance exercises to address three major balance system components.

 Introduction 

Every 11 seconds an older adult is treated in the emergency room for a fall and every 19 minutes an older adult dies from a fall.1 These stats illustrate why it is important to address fall risk in the older adult. There are many negative consequences that follow an older adult that has fallen which have widespread effects on the patient, their family, and the overall healthcare system. Older adults that have fallen can experience an increased fear of falling, decreased physical activity and social isolation, all of which leads to increased mortality.2

 Screening for Fall Risk 

The most widely used screen for fall risk is the STEADI (Stopping Elderly Accidents, Deaths, and Injuries).3 This tool is meant to be a quick screen that physicians can use to stratify older adults at risk for falls. This tool is especially valuable for a PT to use because the PT can transition directly into highly skilled and effective interventions for falling if warranted after this quick screen. The Steadi uses an algorithm to determine those at low, moderate, and high risk of falls.

Here is a quick summary of the process to conduct the STEADI:

Begin by asking 3 simple questions:

1) Have you fallen in the past year?

2) Do you feel unsteady while walking or standing?

3) Do you worry about falling?

If yes to any of these questions then further assessment is warranted which is includes:

1) Timed up-and-go

2) 30 sec Chair Stand

3) 4 Stage Balance Test

Follow the algorithm for evaluation of these test and to classify the individual as low, moderate, or high fall risk.

 Assessment of Specific Balance Impairments 

After initial screening using the STEADI, The BESTest can be used to identify which aspects of balance needs targeted intervention.4 The BESTest is split into 6 categories which include:

1) Biomechanical Constraints

2) Stability Limits/Verticality

3) Transitions/Anticipatory

4) Reactive

5)Sensory Orientation

6) Stability in Gait

Administration of the BESTest can take anywhere from 30 to 45 minutes.

 Interventions 

Once administering the BESTest, the clinician must now determine which system to address. Three systems involved with the balance of the older adult include the visual, vestibular, and somatosensory system. Physical activity and balance exercises has been shown to decrease the fall risk in older adults.5 Listed below are some specific exercises for each system:

1) Exercises that compromise the visual system: 2) Exercises that compromise the somatosensory system: 3) Exercise that must rely on the proper functioning of the vestibular system (any balance activity where your vision and sensory feedback is compromised):
 * Standing on stable surfaced with eyes closed.
 * Tandem on stable surface with eyes closed.
 * Standing on stable surface while reading words on wall (dual task).
 * Tandem on stable surface while reading words on wall (dual task.
 * Balance on foam or BOSU ball.
 * Tandem stance on foam or BOSU ball.
 * Single leg balance on foam or BOSU ball.
 * Stepping in place on foam pad or BOSU ball.
 * Standing on foam pad with eyes closed.
 * Tandem stance on Foam pad with eyes closed.
 * Tandem stance on foam while catching ball from various directions (dual task).
 * Single leg stance on foam with eyes closed.

Be sure to use exercises that are salient to your patient so you can take these general balance exercises and tailor them specifically to your patient to obtain the most benefit.

 References 

1) Falls Prevention Facts. NCOA. https://www.ncoa.org/news/resources-for-reporters/get-the-facts/falls-prevention-facts/. Published June 4, 2018. Accessed July 12, 2018.

2) Renfro M, Maring J, Bainbridge D, Blair M. Fall Risk Among Older Adult High-Risk Populations: a Review of Current Screening and Assessment Tools. Current Geriatrics Reports. 2016;5(3):160-171.

3) STEADI - Older Adult Fall Prevention. Centers for Disease Control and Prevention. https://www.cdc.gov/steadi/materials.html. Published March 24, 2017. Accessed July 12, 2018.

4) Horak FB. BESTest Balance Evaluation Systems Test. BESTest :: Test Forms. http://www.bestest.us/test_copies/. Accessed July 12, 2018.

5) Guirguis-Blake JM, Michael YL, Perdue LA, Coppola EL, Beil TL. Interventions to Prevent Falls in Older Adults. Jama. 2018;319(16):1705. doi:10.1001/jama.2017.21962.