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February 22, 2010

Fall Clinic

I participated in a fall clinic last week. According to the CDC, 1/3 of adults over 65 fall each year in the US and are among the leading cause of injury related deaths. The rate of the deaths has increased significantly in the past decade. As our Veteran population ages (most who participated in Vietnam are now senior citizens), their medical histories become more complicated and their risk of falling increases. Patients who qualify for the VA's fall clinic are assessed by OT, PT and medical doctor.

OT screens for a patient's ability to do activities of daily living such as bathing, dressing, cooking, eating and cleaning. What they are looking for is how the patient's tendency to lose their balance affects these basic functions.

PT assesses strength of the lower extremities, balance, and watches how the patient walks. They ask pertinent questions regarding the number of falls the patient experienced. With this information combined, they can discern a pattern in a patient's fall history and provide devices or advice to assist the patient. For example, a patient who is diabetic and has numbness in their feet may not be able to feel the ground when they are walking. If they walk on an unsteady surface, they are at a higher risk for falling. Using a cane, they are able to get proprioceptive information to their brain subconsciously about the surface they are walking on and reduce their risk for falling.

Then, for patients who are high functioning, we used the Balance Master System, to assess for a patients correction strategy when their balance is interrupted. We test patients with their eyes open, closed and with the environment moving with them as they sway. Then we test the patients using the same criteria, except the platform upon which they stand moves also. This system tests how much a patient relies upon their vision for balance, their proprioception (where they feel they are in space), and their vestibular system (the body's internal balance system in the inner ear).

I was privileged to sit in on the physician's examination of the patient. They too asked questions about sensation and the home environment. They went further to assess hearing and vision, did a neuro examination (including the degree of sensation loss in the feet), screened for drugs, and asked about other medical conditions.

Folks who take multiple medications (called polypharmacy) are at a higher risk for falls. Patient with heart conditions often experience orthostatic hypotension (low blood pressure when you first stand up) which makes them dizzy. As we age, our ability to see in the dark diminishes. Combine that with a diuretic medication and it could mean a patient is up several times in the night making their way to the bathroom in the dark. Getting their feet tangled up in an area rug in a darkened bathroom could lead to a nasty fall onto a hard surface.

One thing I learned that did not occur to me was patients with hearing loss may be at a higher risk for falling. The vestibular system in intimate proximity to the hearing apparatus, and if one is malfunctioning, it is possible the other system is also. Not only that, environmental sounds (dripping water or a refrigerator motor) help orient the brain subconsciously to where we are in a room or how far away an object is. That dripping water may cue someone that the counter top is nearby should they lose their balance and need to reach out and right themselves to prevent a fall.

It was a neat experience. Currently the VA is conducting research to see if a falls clinic is a viable option througout the VA system. The concern is the justification of utilizing so many skilled clinicians for the purpose of falls prevention. The American Geriatrics Society has practical guidelines for Prevention of Falls in Older Persons that the VA program is based upon.

Posted by linda at February 22, 2010 4:22 PM