PT, doc team up to cut fall risk
If you took a young athlete and put him on bed rest, he would lose between 2% and 4% of his muscle strength each day. Imagine what happens when an elderly person remains sedentary for long periods due to a fear of falling. "For older people, that compounds because they just don’t move as much anymore," says Richard Brunader, MD, a geriatrician with the University of California (UC), Davis Health System, and associate professor of family and community medicine at UC Davis Medical Center. "Their joints become stiff; their muscles become weaker; the systems in place to keep the blood pressure up when standing weakens. The very act of cutting back increases the risk of falling," he points out.
But cut back they do. Between 20% and 25% of elderly patients who have fallen have a severe fear of falling that often rules their lives. "People realize they can injure themselves. It’s often a fear of nursing home placement. If the family becomes concerned, they might say Dad, you need to slow down. You shouldn’t be doing this stuff anymore,’" Brunader says. "Most falls happen, not with a person on a ladder, but in ordinary everyday activities like walking around the house, getting into the shower, going out to the back yard," he says. "Because of that, people really cut back. As you cut back, further deconditioning occurs."
To help break this vicious cycle in elderly patients, Brunader recently started a Geriatric Falls Evaluation and Management Clinic at UC Davis Medical Center. Brunader and Janet Retke, PT, a physical therapy supervisor with the hospital’s outpatient therapy clinic, see patients every Wednesday from 8:30 a.m. to noon. The goal is to look for patients older than 65 who have had a fall that required medical attention or who have had more than two falls in six months. Other candidates for the clinic are patients who have a high likelihood of fall injury due to underlying conditions such as osteoporosis, arthritis, hypertension, and dizziness.
The medical literature shows that about one-third of people older than 65 fall every year, and that a multifactorial assessment intervention can reduce those falls from 20% to 50%. "It’s a widespread problem," Brunader says. "It’s something that is not easily addressed in a regular office visit."
At the initial visit, Brunader reviews potential causes for falling and injury, including medications, circulatory problems, vision, balance, depression, dementia, and osteoporosis. "If you approach it as I’m going to look at why the person fell,’ you’re not going to find it," he says. "Most people fall for multiple reasons. It might have been one final thing, but there’s a host of imbalances as one ages. It’s a genetic part of aging, the deterioration of organ systems. Your nervous system slows down; your receptors slow down; but there’s also disease: arthritis, hypertension, diabetes. The other part is deconditioning. You have arthritis in your knee, so you don’t move as much and your muscles begin to atrophy."
Brunader performs a physical exam, complete with fall history, orthostatic vital signs, and depression screen. One of his early findings from this clinic is that more patients are depressed — and more intensely depressed — than the geriatric population he normally sees. He cautions that he has not seen enough patients yet to have numbers he can bank on, but the early sample shows that 70% to 80% are significantly depressed.
"When they are depressed, they lack the motivation to help themselves," he says. "If you are depressed, it accentuates your pain, it hinders your ability to work with us. If you’re not improving, that makes you more depressed."
Care team sets course
The other component of the clinic — and the thing that sets it apart from other clinics for elderly patients — is the fact that the physical therapist and the clinician work together and see the patients at the same visit. Retke gives patients a series of tests, including a balance-gait assessment, a modified clinical test of sensory integration and balance, and a dynamic gait index.
At the second visit, the care team discusses medical management and recommendations for physical therapy, ongoing exercise routines, or perhaps participation in a community-based exercise program. Brunader says he is exploring ways to make home visits to assess environmental hazards financially feasible. Patients will return for follow-up appointments at six months and one year or more often as necessary.
He says he feels a sense of urgency to help this population. If a patient is hospitalized with a hip fracture, there is a 50% one-year mortality rate. "The population is aging. The fastest-growing segment of the population in the United States today is those [older than] 85, and those are the people who fall," Brunader says. "Anything that can be reasonably done to better their lives that is cost-effective is going to be very valuable. There is a large number of patients coming down the road that we’re going to have to address this with."
One benefit of the thorough exam and the approximately 1½ hours each patient spends with the care team at the initial visit is the detection of previously unknown disorders. "I’ll end up finding related diseases such as vascular disease or undetected diabetes or cardiac causes or a stroke they were unaware of," Brunader stresses. "Some of these things may not show up in a regular office visit. They are gradually progressive, and maybe nobody noticed Mom seemed different until after the fall. The fall is a symptom but also a marker for underlying conditions."
Retke helps Brunader determine the best course of rehab action for each patient. If it’s appropriate, Retke will set up one-on-one therapy with her or with a physical therapist close to the patient’s home. She and Brunader also have been traveling to community exercise locations such as the YMCA to observe and assess their ability to work with elderly patients. That way they can recommend a program for patients who don’t need or qualify for individual therapy.
Elderly patients and their families may resist the idea of exercise. But Retke emphasizes the benefits of exercise, even if all the patient can manage is simple tasks such as stretches, short walks, or chair aerobics. "The results can be dramatic," Retke says. "I’ve seen patients who can get to the point where they can walk without being considered a fall risk. They can live a more active and independent lifestyle, to be able to go out and about instead of being restricted to the home."
The exercise has another benefit: increasing patients’ self-confidence. "Their anxiety around the possibility of falling decreases their normal body movement and perpetuates the problem," she adds. "If you show them what they can do, they reinforce it themselves by being successful at doing it."
Need more information?
- Richard Brunader, MD, Associate Professor, UC Davis Medical Center, Department of Family and Community Medicine, 4860 Y St., Sacramento, CA 95817. Phone: (916) 734-3922.
- Janet Retke, PT, Supervisor, Physical Medicine and Rehabilitation Therapies Clinic, UC Davis Medical Center. Phone: (916) 734-9040.