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Darcy Grabenstein: Hello from SmartLinx Solutions! In today’s podcast, we’ll discuss fall prevention. Our guests are Gloria Bachmann, MD, Professor of Obstetrics and Gynecology in Medicine, Associate Dean for Women’s Health, and Director of the Women’s Health Institute at the Rutgers Robert Wood Johnson Medical School; and Jacklyn Joki, MD, Clinical Assistant Professor in the Department of Physical Medicine and Rehabilitation at Rutgers Robert Wood Johnson Medical School, who also works for the JFK Johnson Rehabilitation Institute. They recently published a study, along with Dr. Sara Cuccurullo and Kavisha Khanuja, titled “Gait and balance in the aging population: Fall prevention using innovation and technology.” The study is featured in a Maturitas special issue of Modern Medicine for Healthy Aging. Welcome, Gloria and Jackie.
The abstract for your study has some interesting statistics on falls in the aging population:
- On a global basis, adults 65 and older experience falls more frequently than younger individuals, and these often result in severe injuries as well as increased healthcare costs.
- In addition, falls are the second leading cause of unintentional injury-related deaths globally and pose a major health public issue, especially for older individuals.
- Approximately one-third of elderly individuals over the age of 65 and one-half of persons living in community care institutions experience falls annually.
- And your abstract also states that gait and balance disorders in this population are among the most common causes of falls.
- Abnormalities in gait and balance are found in about 35% of adults over the age of 70, and in 61% of adults over the age of 80.
Your paper presents a three-tier model to help prevent falls in this segment of the population. The first tier is assessment. Jackie, could you give us some details about how an assessment is conducted?
Jacklyn Joki: Individualized assessments are important in understanding fall risk and implementing fall prevention plans. Previous falls are the strongest risk factor for future falls. Assessment should begin by finding out about any past falls or near falls and understanding the circumstances or events around those falls. Any injuries or unwanted consequences after these events should also be discussed. It is important to review the older adult’s medical history and medications, and pay close attention to whether the current medications he or she is taking can affect alertness and balance, and cause visual disturbances. Finding out if the older adult is experiencing any side effects from his or her medications is also important.
Reviewing whether the older adult uses an assistive device, what assistive devices, and under what circumstances they use those devices is also important. Understanding whether they require assistance with activities of daily living or ambulation, and who provides that assistance, is also useful. A physical examination should be performed with a focus on the neurologic, musculoskeletal, and cardiovascular systems. Vision should also be assessed.
In patients who have not experienced falls, the modified 30-second sit-to-stand test can be used to differentiate between likely fallers and non-fallers. Currently, precise and effective measurements of gait and balance are difficult to attain from a single office-based encounter. However, new technology is being developed with wearable devices and monitors that could provide more detailed assessments of postural control, balance, and mobility in a variety of settings over a period of time. Gloria, would you like to add anything?
Gloria Bachmann: Actually Jackie, I would like to add to what you’ve already noted. And that is, assessment is key, but also making sure that one assesses family members and friends. Because if an older adult has gait and balance issues, and is with a family member or friend who also has these issues, that if they ambulate together there is going to be a greater risk of fall in the person that we’ve already identified as having issues. They are going to be increasing their risk of not having the stability that we would hope they would have, especially when they’re climbing up and down stairs, or they’re walking in an area that they’re unfamiliar with. So that should also be assessed in terms of not only the patient, but also who is with the patient to be sure that, number one, they get proper assessment, but number two, that their interfacing with the patient will be a positive and not be a negative distraction in the sense that they will make the patient more likely to fall than actually help them.
DG: Oh, I didn’t think about that. That’s a very good point. Thank you. So the second tier is prevention. And you mentioned that guidelines do exist from the US Preventive Services Task Force, and the American Geriatric Society. But they basically recommend exercise and physical therapy. Gloria, could you shed some light on this for us?
GB: Darcy, basically what it’s saying is what we already know as average persons living in society, and that is exercise is important, not only for cardiovascular health, but also for overall health, that there is lots of data now that are suggesting that exercise is important for our cognitive ability. And obviously our cognitive ability will also affect our stability and how we navigate when we walk, when we’re sitting up and down from a chair, and basically lifestyle activities that we engage in.
Exercise is clearly important, and I emphasize to all my patients that, obviously, we think of walking as the best exercise, but for those who cannot walk even sitting in a chair and doing some stretching and yoga-type exercises or in a water environment such as a pool is important. Not only is the cardiovascular important in terms of walking or getting the heart rate up, but I also emphasize the flexibility and weight bearing, because that too will have a bearing on one’s stability when they walk.
So that if they’re able to be more flexible, with yoga, with just stretching activities, again even if it’s in a seated position, they’ll be less likely to lose their balance. And, of course, weight bearing is critically important for the ability to bear weight and walk in a stable manner, rather than if one falls, there is not strength in the muscle to prevent the fall. And without good muscle, we know that they’re also at increased risk for bone fracture. Jackie, what about the actual physical therapy? Where does that fit in?
JJ: Well, physical therapy programs are tailored around each individual’s needs. Therapeutic interventions and exercise will be used to improve strength, joint range of motion, and balance. The objectives of treatment include increasing independence with activities of daily living, increasing independence with functional mobility, decreasing fall risk, and preventing future falls while increasing safety. Some older adults may benefit from use of an assistive device, such as a cane or a walker. A therapist can trial the device with the patient and train them on how to properly use the device and to ensure safety and benefit with use of the device.
Frequently I see some patients may use a cane, but were never trained on how to use a cane, and at times that cane can actually be increasing their risk for fall rather than deterring it. Physical therapists may also be able to observe the older adults in a variety of functional tasks and can provide education to the patient and their caregivers regarding the best way to remain active safely. Development and education regarding a home exercise program to be continued beyond formal therapy is also an important component of physical therapy. Utilizing and continuing an appropriate home exercise program helps maintain the benefits achieved with physical therapy.
As Gloria mentioned, cognitive issues also impair patient safety, and when there are cognitive issues, patients may have poor awareness of their safety. And when working with a physical therapist, it’s a way to identify their decreased safety awareness and alert caregivers to these issues so that measures can be put in place to prevent injuries related to this.
DG: Great, thank you. Gloria, what role can exercise such as tai chi, yoga, or — and I’m curious — even modified boxing play in prevention for older adults?
GB: I’m going to let Jackie answer the modified boxing, but I am thrilled to answer the yoga and tai chi because I myself have started to do yoga over the past two years, and I can honestly tell you that it is one of the best interventions that I have done for gait and balance and would recommend it to everyone.
Basically, my feeling is that the best way to approach yoga and tai chi or to approach it in that it’s very individualized program, and that the person does what he or she can do so that there are no standards to how flexible one has to be or how long one has to engage in it, but rather listening to your own body. That’s why I really recommend group yoga and group tai chi, because everyone in a group can feel comfortable in going at their own pace and not having someone directly say to them, “Well, you’re not doing enough flexibility work” or “You’re not doing enough of the balance work,” but rather doing that at your own pace.
There are lots of studies that are showing that both yoga and tai chi do decrease many of the falls, many of the problems that older individuals have, because they both do enhance not only the flexibility of the individual and the overall cardiovascular benefits, but they also improve balance. And balance is key to remaining stable as one gets older. So these are really ways to maximize stability, to maximize the ability to be flexible as we get older without having to engage in anything more that the older individual may not be able to participate in. And there are classes with chair yoga for those who can’t get on the floor or can’t get up and down, that these are just as effective. And many times, what I’ve seen is that many individuals who start with chair yoga over time get to a point where they can get down on the floor on a mat and do many of the exercises on the floor. But I don’t have a lot of information on modified boxing, so I’m going to ask Jackie to answer that question.
JJ: Modified boxing is a form of exercise that can improve strength, balance, and gait. It can also improve confidence. It utilizes multi-tasking and is a form of functional exercise. It incorporates upper and lower extremity movements while requiring postural balance and flexibility, all of which are essential for functional mobility. Restoring and maintaining functional mobility is important in fall prevention.
DG: So we won’t be seeing any boxing matches at the long-term care facilities, right?
JJ: Probably not! Although it could be of benefit, because it works on that action and reaction so, you know, when you’re moving forward, can you respond appropriately.
GB: What would one need to have boxing in a long-term care facility? What equipment does one need?
JJ: Honestly, they could have just sneakers, because you could be working and doing motions and movements, small steps with the hands and the feet without any other additional equipment.
DG: Thank you, that’s great. So Gloria, you also talk about technology in terms of prevention. You know, at SmartLinx, we’re all about technology. So I’m curious, are seniors typically accepting of the use of technology in this context, or do you get some resistance? And how is technology incorporated into prevention?
GB: Well, Darcy, let me begin by saying that I am most impressed with the number of individuals who are over the age of 60 who are signing on to the medical portal that their medical records are on. And I’m finding that they really aren’t giving too much resistance to participating in a lot of the technological advances that medicine is offering them. And the portal for access to their patient records, the medical records, is one. But I also see many individuals in my ambulatory practice who are taking advantage of many of the “fit” phones and the “fit” wristbands that monitor their sleeping, that monitor the number of steps that they’re doing every day. So I really don’t see a lot of resistance in the older population. I don’t know, Jackie, if you do in your specialty.
JJ: I find that seniors are willing to utilize useful and affordable technology. They’re already using cell phones, they’re using email, and they’re even using social media, perhaps to see pictures of grandchildren and friends. So I think in this setting, technology for incorporation into fall prevention is still in development, but wearable devices and sensors can be used to provide vibratory and visual feedback to the older adults regarding fall risk and could additionally provide an alert to caregivers to increase awareness of fall risk, and allow for them to apply appropriate measures to be taken to prevent the fall from occurring.
DG: Great, thanks. So the third tier is intervention, and you reference the matter of balance. It’s a program developed at Boston University’s Roybal Center for Enhancement of Late-Life Function, and it’s designed to reduce the fear of falling and increased activity levels in older adults. To me this sounds like a great concept. Jackie, could you tell us more about it? And how could long-term care facilities incorporate it into their programming?
JJ: So many older adults experience a fear of falling, and many respond to this concern by reducing their activity. The program’s goal is to stop the fear-of-falling cycle and to increase activity levels among community dwellers and older adults. The program acknowledges the risk of falling, but it emphasizes practical coping strategies to reduce this fear. The program is a workshop consisting of eight sessions, two hours per session, and the program consists of group discussion, problem solving, skill building, alertness training, exercise training, sharing practical solutions, and cognitive restructuring where they learn to shift from negative to positive thinking patterns or thinking about something in a different way. The program attempts to promote a view of falls and fear of falling as controllable and tries to set realistic goals for increasing activity. They try to change the environment around the individual to reduce fall risk. And they try to promote exercise to increase strength and balance.
The program was designed for community-dwelling older adults. However, the goals and intended outcomes of the program would be applicable to long-term care facilities and residents. Perhaps a modified program could be developed for long-term care facilities. The long-term care facility staff could likely benefit from the education and training provided from this program to facilitate incorporation into the long-term care facility’s programming. Gloria, do you have anything else to add about this?
GB: Jackie, I would again emphasize that long-term care facilities should consider this type of program. But what I would add is that, many times, it’s family and friends’ encouragement that will really motivate the individual to join one of these programs. So when one of these programs is offered to someone who would benefit from it, I think getting the family involved, getting the significant other involved is a critical part of that individual really taking it seriously and being an active participant.
DG: Sure, that makes sense. Jackie, what are some specific things that long-term care facilities can implement to assess risk, to prevent incidence of falls, and to improve rehabilitation of residents who have fall-related injuries?
JJ: Implementing programs for ongoing assessment and prevention is key. Encouraging safe and supportive mobility and activity with tailored programs towards each individual’s needs is important. The goal should be to preserve and restore current function and continue efforts to deter further functional decline or immobility. Group-based therapy and individualized therapy and exercise programs should be used whenever appropriate to maintain and encourage continued mobility and activity. This can help decrease complications secondary to immobility, including pneumonia, pressure ulcers, and deep-vein thrombosis. Rehabilitation is best when utilized early and continued long term by incorporating it into one’s daily routine to maximize and sustain its benefits and promote a healthy lifestyle. Gloria, would you add to this, please?
GB: I think that’s pretty comprehensive, Jackie. The only thing I would add — and again this sounds like a broken record — but it really is important for the family to know that when these types of programs are available at a long-term care facility that, number one, they should be aware of it, because it’s definitely a great benefit to the individual who is in the long-term care facility. But it also is a very nice way for the family to bond with the individual by asking, “How has your physical therapy been going?” “How has your gait been improving?” So it’s a great way for the family to get involved with the individual’s care at the long-term care facility.
DG: Thank you, Gloria and Jackie, for sharing this important research for us. And to all our listeners, thank you for tuning in. For more information on Rutgers University Robert Wood Johnson Medical School, visit RWJMS.Rutgers.edu. And if you’d like to learn more about SmartLinx and our fully integrated suite of workforce management solutions, visit us online at SmartLinxSolutions.com.
