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Don't Let a Fall Be Your Last Trip: Who's At Risk? H2U - Health, Happiness, You April 15, 2009 Brian Werner, MPT President – Werner Institute Question? • How many of you in the • audience know that for injury related deaths, the number one (1) reason in people over 70 is due to a serious fall? – Why is Fall Prevention Programs not a primary focus in medicine? How many of you have been formally assessed in your doctors office for FALL RISK? – If so, what did they do to determine your risk? Brian K. Werner, PT, MPT • Master’s Degree in Physical Therapy – Northern Arizona University – Flagstaff, AZ • National Certification of Competency – Vestibular Assessment and Treatment – Miami School of Medicine: Physical Therapy Department – Miami, Fl (2000) • Service – Director and Lead Clinician of Balance Centers of America: Las Vegas and Henderson (2001-2005) • Service – Lead Clinician and Owner of the Werner Institute of Balance and Dizziness, Inc. (11/05 to present) Scenario • Dorothy, an energetic 68-year old, had an active life that involved family, church, community volunteer work and lots of social time with friends. That is, until she broke her hip from a fall she took in her own home. Her daughter found Dorothy one morning lying helplessly on the kitchen floor unable to call for help. Learning Objectives for Presentation • • • • • • • • • • • • You should really be aware of your risks Is this really a big problem or this really just an age issue Why Seniors Don’t Tell Their Doctors What is a fall How can falls be reduced The Tipping Point What is balance and is it really something that can be treated Dizziness Defined How Do You Treat Dizziness Most Common Form of Dizziness - BPPV Does the therapy actually work What can you do to prevent a fall Should You Be Aware… • On average, a person • loses about one-half a percent of their overall balance every year starting from about the age of 20 mostly due to decreasing levels of activity, not aging. Inactivity causes the balance system to weaken much like a muscle that isn't used. Is This Really a Big Problem… • 1 in 4 Americans over 40 have a • balance disorder developing! Falls are the leading cause of fatal and nonfatal injuries to older people in the U.S. – Treatment of the injuries and complications associated with these falls costs the U.S. approx. $20.2 billion annually. • A serious national problem now, falls could reach epidemic levels as the population ages in the future. • The total cost for all fall injuries in older Americans was $27.3 billion in 1994, and is expected to reach $43.8 billion by 2020. Why Seniors Don’t Tell Their Physician About Their Balance Issues • They DON’T KNOW they have a problem! – Loss of balance can be insidious over decades… – By the age of 40, 40% of the population has a balance disorder developing or developed – By the age of 65, the 3rd leading physician visit is a balance disorder • By 75 it is the leading physician visit • They DON’T KNOW there is anything that can be done for balance despite having a problem! – How many of you have been in a formal balance therapy program? • They DON’T WANT anyone to know! – Why? • Could mean losing their home or driving (Loss of independence) • Embarrassed because a sign of aging or weakness What Constitutes a Fall… • Most people think they have to hit the ground to “count” that as a fall. – A fall can be as simple as a loss of balance, hitting the walls at home, grabbing furniture or a rail going up stairs – A Serious Fall (defined by NIH): • an unexpected event in which the participant comes to rest on the ground, floor, or lower level " and accompanied by a fracture or another serious injury – – – – head injuries requiring hospitalization, joint dislocations, severe sprains, other non-specified serious joint injuries, and lacerations requiring suturing. • It is recommended that you “count” all your falls. – More than two falls in six months is a sign of a balance disorder developing. The Tipping Point • The point where you must make a change • Average cost per hip fracture = $50K – total hip fractures (2006) ≈ 400K – What if we could prevent 12 a year…save Medicare $90 million annually in Nevada • Medicare Cap – – – Started in 1999 for Balance Budget Act of 1996 Repealed by congress 3 times Re-implemented 2006 • Medicare Cap - $1,810 for PT and Speech – Ex. Stroke Do you want to talk or walk • The Trend Towards Concierge Services with Physicians Recent Reviews on Falls…Physical Therapists • Many elderly people who have fallen don’t want to tell anyone, she said. “I saw a patient recently. She told me she’d fallen in the bathtub, but said, ‘Don’t tell my daughter.’ She was so afraid her daughter would put her in a nursing home,” Martin said. • Your thoughts on this… Recent Reviews on Falls…MD Perspective • A Family Physician recently stated it was impractical to treat all patients with dizziness or imbalance… – Is this fair to you the patient who may need help? • Shouldn’t you expect best care – 12 patients a year proposal per Werner Institute (handout for your MD) – Is this really a problem – why aren’t we expecting our physicians to protect us or at least ID or problem • Gait disorders in the elderly are common and in most cases cannot be treated medically or surgically. – What about physically treating with therapy versus putting people on canes or walkers alone...? • Would you be happy about going on a cane or Front-wheeled walker…? What is Your Balance System • Composed of three systems – Sensory • Visual • Vestibular (inner ear) • Touch, pressure, pain (somatosensory) – Integration • Brainstem/Brain • Past memories – Motor • Muscles • Nerves What Happens When The Balance System Becomes Injured • Dizziness is primary symptom: – Vertigo – Illusion of movement – Lightheadedness – Impending passing out – Motion Sickness – Genetic weakness of balance – Dysequilibrium Unsteadiness – Fear, Anxiety – Combination – Other Issues: • Fatigue • Loss of Strength • Dizziness is not a natural What Can We Do For Dizziness? What Can We Do For Dizziness? • Nothing – Do no harm – patients get better over time • Yardley study found 40 % of patients with vertigo/dizziness continue to complain of symptoms in 2 year follow-up – Most patients believe not moving improves symptoms but in fact prolongs the symptoms – Waiting for grandma to get her balance back at home may be too late • 35% of hip fractures occur at home What Can We Do For Dizziness? • Medicate – PROS – may need medication (PRN) • Meniere’s disease • Acute vestibular disorders • Severe intolerance to motion – CONS – may retard the natural compensation process of the brain • Over 70% of all patients diagnosed with dizziness get a prescription of Meclizine • Meclizine reduces reaction times equal to a blood alcohol level of 0.04 to 0.06 – Would you put a senior on this medication at risk for falls? What Can We Do For Dizziness? • Surgery – Used in very rare cases • Ex. Meniere’s Disease – Ablative surgery • Ex. Perilyphatic Fistula – Repairs a hole in the oval and/or round window • Ex. Acoustic Neuroma – Evacuation of the tumor from the inner ear nerve. What Can We Do For Dizziness? • Therapies – Naturopathy - Uses an herb or natural remedy – Homeopathy – Uses a micro dosage of irritative remedy that helps the body develop a tolerance to the symptoms – Chiropractor – Manipulation of the spine – Chinese Medicine – Herbal remedies and acupuncture – Allopathic – treat the symptoms with drugs or surgery – ***EBM – Evidence Based Medicine uses objective testing and treatments to identify the cause and treat the disorder Who’s At Increased Risk for Falling? • Fallen Previously • Age (> 65 years old) • Loss of Cognition • Lots of Obstacles • Spills and pills Where Do Falls Occur the Most? • 60 percent: home • 30 percent: in the community • 10 percent: in institutions, such as nursing homes Forty percent of nursing home admissions are due to falls. KEY: We want you to stay in your homes. Why Do People Fall? • Some of the reasons people fall are: – Tripping or slipping due to loss of footing or traction – Slow reflexes, which make it hard to keep your balance or move out of the way of a hazard – Balance problems – Reduced muscle strength – Poor vision – Illness – Taking medicines – Drinking alcohol. What Can You Do…Get Balance Tested • Its Just Like a Blood Pressure Test • to R/O Hypertension… Get assessed for your fall risk annually – This is no different than getting a test for blood pressure or diabetes • A Fall and subsequent hip fracture could cause death quicker than BP or DM • Why are we not getting balance tested more regularly? – Cost – Free… – Ease – 2 Minute10 minutes – Not knowing balance should be test (ignorance is bliss until you break your hip) – Fear of unknown – Problem: Another test… is this really that important? • Remember, the leading cause of injury death over the age of 70 is a balance problem. What Can you Do to Prevent Falls …Footwear • Koepsell, 2005 (American Journal of Gerentology) – The study found that people not wearing shoes (i.e. barefoot or in stockings) had an 8to 11-fold greater risk of falling than those wearing athletic or canvas shoes. What Can You Do to Prevent Falls… • Balance Retraining Therapy – Form of physical therapy – Challenging the imbalance improves your function • Similar to learning to hit a golf ball – Over 400 peer review articles currently support its effectiveness – Covered by your insurance in most cases • Tai Chi Craze!!! – Great for those with existing “good” balance – can be challenging for those with balance problems Falls are not natural occurrences. Many falls can be prevented. • Eliminate tripping hazards in your home • Install handrails, grab bars and other safety devices. • Engage in regular, moderate amounts of physical activity to maintain – Your strength, coordination, agility and balance. • Get an eye examination and physical each year. • Check with your PCP about side effects of all your prescription and • • • over-the-counter medications. Wear properly-fitting shoes with nonskid soles. Obtain adequate intake of calcium and vitamin D. Avoid excessive alcohol intake. What Exercises Can I Do To Prevent Falls Now? • AARP study (2003) • • • found lower extremity strength key to balance. Tai Chi or Yoga for coordination/balance Swiss Ball Courses Flexibility (stretching) – Hips – Ankles Most Common Diagnosis We Find Causing Falls - BPPV • Loose calcium particles in the inner ear – Crystals/Rocks • Creates an illusion of vertigo when changing head position – Causes dysequilibrium and off-balance • Sign of a diseased or • injured inner ear Patients can have for years and not know it – By 60 - #1 cause of vertigo is BPPV Treatment of BPPV at Werner Institute • OMNIAX – Designed by John Epley, MD • Epley maneuver (1983) • Only 8 systems in the world – Takes the place of the table maneuver • Safer – Patient is safely secure in 5-point harness • More Reliable • Easier to perform – Patient – Treating clinician • Treat difficult cases – With less stimulus on patient Does the Therapy Really Work? • We are not going to get you back to a 20 year old. • Therapy reduces fall risk – does not eliminate it • Therapy for vertigo commonly eliminates it • All the patients improve with the program to some degree – Really up to the individual What Are Your RESULTS!!! Number of Return to ADL Patients (2008) equivalent BPPV (99%) 2,545 patients BPPV+ (90%) 1,234 patients Dysequilibrium (80%) 2,457 patients 2,539 patients return to prior ADL (Age/Ht) 1,111 patients return to ADL (Age/Ht) 1,969 patients return to prior ADL (Age/Ht) How do I get to See You… • Referral from MD is needed in most cases • Most insurances pay for the therapy and testing – Medicare, etc. • Free Balance Assessment • available annually. You can come as a direct patient without referral – Cash basis – runs around $2,000 for 8 weeks of concentrated therapy. Questions and Answers