12 Questions When Screening For Falls & Balance Problems

It is not uncommon for a patient in the SNF to experience a fall after having recently been discontinued from skilled Physical Therapy. Discussion often ensues around whether the patient should resume PT and what areas should be addressed. Kris B. Harmony provides the following as a resource for further discussion. Kris B. Harmony notes that it may be necessary for the Rehabilitation Team to look more closely at the cause or contributing factors when screening a patient after a fall or series of falls.

• Changes in vision/vestibular/somatosensory functions alter balance response:  The elderly have reduced information from these systems and lose their balance as a result if one or a combination of these senses is diminished. A patient will often lose their balance when attempting to stand up, or when attempting to pull up clothing after toileting themselves. Poor lighting coupled with impaired vision also puts patients at risk of falls when attempting to toilet themselves during the night.

• Muscle weakness and delay in muscle response:  In the elderly there is a delay in the activation of the ankle dorsiflexion, weak knee flexors and extensors, therefore the hip muscles are often used to give support and balance because the ankle is torque. They also experience decrease muscle mass and strength in the lower extremities and decreased flexibility and elasticity. This all leads to weakness or buckling when standing and trouble initiating sit to stand.

• Medication:  The adverse effects of commonly used drugs often produce pathological manifestations in the elderly which could lead to falls.  For example:  Drugs that can cause increased confusion and disorientation in the elderly, e.g., antidepressants, diuretics, analgesics. Drugs that cause movement disorders; antipsychotics, drugs that cause dizziness, e.g., cardiovascular antilipemic agents (used to decrease cholesterol), antihypertensive, and analgesics. Drugs that cause incontinence such as anticholinergics also cause:

• Cardiac arrhythmias
• Difficulty swallowing
• Confusion
• Hallucinations
• Fatigue
• Ataxia
• Nutrition: There are common nutritional deficiencies in the elderly that may lead to falls and balance problems in the elderly:
• Malnutrition
• Caloric/Energy Intake Deficiency:  Affects physical activity, healing, and energy
• Protein/Energy Malnutrition:  Causes muscle wasting and fatigue
• Calcium/Vitamin D Deficiencies:  For functioning of all the systems
• Iron Deficiency:  Leads to poor oxygenation of the tissues, and anemia leading to weakness
• Vitamin B12 Deficiency:  Results in neurological signs such as dementia and sensory loss in hands and feet
• Vitamin B6 Deficiency:  Causes peripheral neuropathy, fatigue and weakness
• Folic Acid Deficiencies:  Increase red blood cell production (increased clotting) and over oxygenation leads to dizziness
• Vitamin C Deficiencies:  Poor quality of synovial fluid production (increases joint restrictions) can decrease immune system response and cause cognitive impairment. It is also important in preserving central nervous system and circulatory system function.
• Vitamin A Deficiency:  Decrease eye’s ability to adapt to light changes. Toxicity causes malaise and headaches, orthostatic hypotension and dizziness
• Zinc Deficiency:  Causes poor quality of muscle contraction
• Copper Deficiency:  Copper is a catalyst for enhancing stability of collagen and elastin
• Water Intake:  Decreased fluid intake leads to electrolyte disturbances which lead to dehydration, dizziness, confusion muscle weakness, fatigue and poor eyesight. Inadequate water intake results in restricted joint mobility and general tissue integrity.

• Environmental:  Does the patient have problems getting up from the right side of the bed secondary to left Hemiplegia or from a left UE contracture? Would the patient befit from having their bed against the wall on the right side to encourage getting up on the left side to increase independence and safety?
  
  

12 Guiding Questions When Screening for Falls and Balance Problems:

• Flexion of the head backwards and looking up causing dizziness (Vertebral Artery Syndrome)
  • Preventative Measure:  Modify the environment (eye level).
    • Turning head sideways producing dizziness? (Carotid Artery Compression)
      • Preventative Measure:  Avoid tight collars and exaggerated head turning
  • Dizziness while getting up from sitting or supine? (Orthostatic Hypotension)
    • Preventative Measures: Review Medications, Evaluate for diabetic neuropathy, Varicose Veins (support hose), Assess for
      • Dehydration, Teach position changes/strategies, Urinating? (Post Micturition Syncope)
        • Preventative Measure:  Educate the patient to sit while urinating.

• Arrhythmia? Seizure?
  • Preventative Measure: EKG/Holter Monitor, Review Medications

• Ataxic/Analgesic gait - Look for underlying problem. Provide walking aids.
• S/P CVA - Evaluate tone, brace walking aid.
• Decreased proprioception - Rule out B12 deficiency, Diabetes Mellitus.
• Impaired Vision – Illuminate environment, evaluate for glasses.

• Hypotension? Arrhythmia? Sedation and Dizziness?
• Preventative Measure:  Review Medications looking for adverse reactions.

• Deconditioning secondary to inactivity.
• Preventative Measure:   Strengthen lower extremities and trunk emphasizing esxtension, extension, extension. Endurance/Conditioning/Aerobics. Graded exercise programs.

• Decrease in physical ability to preserve balance?
  • Increased postural sway with delayed balance reactions
    • Pathological changes inhibiting function?
    • Preventative Measure:   Thorough evaluation of motor control and balance. Patient education. Assistive devices as warranted 
                               

• Defective wheelchair, walker cane, etc.
• Worn out shoes 
• Preventative Measure:  Repair or replace

Including these areas when dealing with falls could lead to further evaluations and treatments to minimize the risk for future falls.