Falls Risk Assessment Falls Risk Assessment in Older People in Older People Professor Stephen Lord Professor Stephen Lord Prince of Wales Medical Research Prince of Wales Medical Research Institute Institute
Assessing falls risk Assessing falls risk - unrealistic expectations? unrealistic expectations? - � T � The causes of falls are multifactorial he causes of falls are multifactorial in nature in nature � There is a desire for a single test or � There is a desire for a single test or quick assessment of falls risk quick assessment of falls risk
Screening or assessment? Screening or assessment? Screening – – identification of people at risk identification of people at risk Screening � Increased surveillance � Increased surveillance � Referral for further assessment and � Referral for further assessment and intervention intervention Assessment - - identification of risk factors identification of risk factors Assessment amenable to treatments / correction amenable to treatments / correction � Tailoring intervention strategies � Tailoring intervention strategies
Simplest screen Simplest screen � Have you fallen in the past 12 months? � Have you fallen in the past 12 months? � Degree of difficulty � Degree of difficulty – – easy easy � Sensitivity and specificity � Sensitivity and specificity – – reasonable reasonable � Information gained about prevention � Information gained about prevention strategies – – nil nil strategies
Hospitals: STRATI FY (Oliver 1997) Hospitals: STRATI FY (Oliver 1997) � I tems � I tems � falls as a presenting complaint � falls as a presenting complaint � agitation � agitation � frequent toileting � frequent toileting � visual impairment � visual impairment � transfer and mobility score � transfer and mobility score � Sensitivity 93% and specificity of 88% in � Sensitivity 93% and specificity of 88% in development hospital development hospital � Sensitivity 92% and specificity 68% in different � Sensitivity 92% and specificity 68% in different hospital hospital
Timed Up and Go Test Timed Up and Go Test � Recommended by American and British � Recommended by American and British Geriatrics Societies Geriatrics Societies � Surprisingly little validation as a predictor � Surprisingly little validation as a predictor of falls of falls � Varying methods � Varying methods � Usual vs. fast performance � Usual vs. fast performance � Differing walk distances: 3m vs. 8ft � Differing walk distances: 3m vs. 8ft � Differing instructions about turning: walk � Differing instructions about turning: walk to line, walk past line, walk around a cone to line, walk past line, walk around a cone � Varying cut � Varying cut- -points: 10s, 14s, 15s, 22s points: 10s, 14s, 15s, 22s
Timed Up and Go Test - - recommendations recommendations Timed Up and Go Test � Most widely used method � Most widely used method � Perform at usual (own) pace � Perform at usual (own) pace � Chair with seat height of 43cm with � Chair with seat height of 43cm with armrests armrests � Walk distance of 3m � Walk distance of 3m � Walk past line and turn � Walk past line and turn � Cut � Cut- -points points � 10s for community � 10s for community- -dwelling people dwelling people � 15s for frail groups � 15s for frail groups
Assessment batteries Assessment batteries � Berg Balance Scale � Berg Balance Scale http:/ / www.physicaltherapy.utoronto.ca/ assetfactory.asp www.physicaltherapy.utoronto.ca/ assetfactory.asp http:/ / x?did= 126 = 126 x?did � Tinetti Performance Oriented Mobility Assessment (POMA) � Tinetti Performance Oriented Mobility Assessment (POMA) � Physical Performance battery ( � Physical Performance battery ( Guralnik Guralnik et al) et al) - - http:/ / www.coe.uga.edu/ cs- -pfp/ pdfs/ ppt.pdf pfp/ pdfs/ ppt.pdf http:/ / www.coe.uga.edu/ cs � � Elderly Fall Screening Test Elderly Fall Screening Test � Gait Abnormality Rating Scale � Gait Abnormality Rating Scale
Guralnik Physical performance battery Physical performance battery Guralnik � Has been used in very large studies, and � Has been used in very large studies, and normative values have been established normative values have been established � Comprises � Comprises � timed standing balance � timed standing balance � repeated chair stands � repeated chair stands � timed walk � timed walk � Each item scored / 4 with combined � Each item scored / 4 with combined score / 12 score / 12
Guralnik Physical performance battery Physical performance battery Guralnik
Comparison of 8 function tests Comparison of 8 function tests � Sit � Sit- -to to- -stand 1x & 5x stand 1x & 5x � Alternate step test (19cm high step) � Alternate step test (19cm high step) � Turn test (n steps to turn 180 degrees) � Turn test (n steps to turn 180 degrees) � 6m walk � 6m walk – – normal speed normal speed � Pick � Pick- -up 5kg weight test up 5kg weight test � Stair ascent (8 steps � Stair ascent (8 steps - - 5cm high, 27cm deep) 5cm high, 27cm deep) � Stair descent (8 steps � Stair descent (8 steps - - 5cm high, 27cm deep 5cm high, 27cm deep) ) � 362 community � 362 community- -dwelling people aged 75+ dwelling people aged 75+ � Compared � Compared w.r.t w.r.t. validity, reliability and feasibility . validity, reliability and feasibility
Sit- -to to- -stand test an Alternate Step Tests stand test an Alternate Step Tests Sit
Functional tests - - recommendations recommendations Functional tests Test Validity Reliability Feasibility Total Test Validity Reliability Feasibility Total STS- - 5 5 10 5 5 20 STS 10 5 5 20 Alt step 10 4 4 18 Alt step 10 4 4 18 6m walk 10 4 3 17 6m walk 10 4 3 17 Stair des Stair des 10 10 5 5 0 0 15 15 Stair asc asc 5 5 0 10 Stair 5 5 0 10 Turn 0 4 5 9 Turn 0 4 5 9 STS – – 1 1 0 2 5 7 STS 0 2 5 7 Pick- -up up 0 1 4 5 Pick 0 1 4 5
Need for multiple tests for falls Need for multiple tests for falls prediction prediction � Poor performances in � I mpairments Odds Ratio I mpairments Odds Ratio Poor performances in two tests did increase two tests did increase 0 1 0 1 risk risk � Poor performances in � Poor performances in 1 1.9 1 1.9 3+ tests did not 3+ tests did not 2 4.7 2 4.7 increase risk further increase risk further 3 5.0 3 5.0 4 4.7 4 4.7
QuickScreen QuickScreen Assessment Assessment Form Form
Fall Risk Assessment - - PPA PPA Fall Risk Assessment � Physiological, rather than disease � Physiological, rather than disease- -oriented oriented � I nvolves quantitative functional assessment of � I nvolves quantitative functional assessment of sensorimotor abilities sensorimotor abilities � Assumes that � Assumes that most most disease processes will be disease processes will be manifest in impaired performances in one or more manifest in impaired performances in one or more tests tests � Cataracts � Cataracts – – poor vision poor vision � Neuropathy � Neuropathy – – poor sensation poor sensation � Prior � Prior- -polio polio – – weakness weakness � Stroke � Stroke – – weakness, incoordination, instability weakness, incoordination, instability
Contrast sensitivity - - MET MET Contrast sensitivity Melbourne Edge Test
Proprioception Proprioception
Lower Limb Strength Lower Limb Strength
Reaction Time- - Hand & Foot Hand & Foot Reaction Time
Sway on floor and on foam Sway on floor and on foam
PPA Short form PPA Short form � Significant and independent predictors � Significant and independent predictors Coefficients Coefficients � Visual contrast sensitivity � Visual contrast sensitivity -0.33 0.33 - � Proprioception � Proprioception 0.20 0.20 � Quadriceps strength � Quadriceps strength -0.16 0.16 - � Simple reaction time � Simple reaction time 0.47 0.47 � Postural sway on the compliant surface � Postural sway on the compliant surface 0.51 0.51 � Percentage of subjects correctly classified: 75% . � Percentage of subjects correctly classified: 75% .
Falls and Balance Research Group Barker St, Randwick NSW 2031 Ph. (02) 9399 1062 Prince of Wales Medical Research Institute fax. (02) 9399 1005 www.powmri.unsw.edu.au/FBRG
Falls Screening and Assessment Trade- -offs offs Falls Screening and Assessment Trade COMPREHENSIVE Low cost Low cost Short Time SIMPLE Technical Simplicity Understanding Causes Identifying Factors Amenable to Treatment Likelihood of Prevention
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