1. Fall Risk Reduction Program Patient Assessment Module #2 of 6 Shelley Thomas, MPT, MBA Dara Coburn, M.S., CCC-SLP Shelley Thomas, MPT, MBA Dara Coburn, M.S., CCC-SLP

2. AGENDA  Patient assessment  Choosing the most appropriate assessment protocol  Choosing the top systems of balance impacting falls  Q & A  Patient assessment  Choosing the most appropriate assessment protocol  Choosing the top systems of balance impacting falls  Q & A

3. Patient Selection  Patient and family goals and expectations  History of falling? Fear of falling?  Weight bearing status  Able to weight bear as tolerated? Or partial weight bearing?  Cognitive and communicative status  Attend to task for at least 60 seconds to 2 minutes?  Able to communicate basic wants and needs?  Follow simple directions?  Inpatient vs. outpatient  Intensity of treatment  Patient and family goals and expectations  History of falling? Fear of falling?  Weight bearing status  Able to weight bear as tolerated? Or partial weight bearing?  Cognitive and communicative status  Attend to task for at least 60 seconds to 2 minutes?  Able to communicate basic wants and needs?  Follow simple directions?  Inpatient vs. outpatient  Intensity of treatment

4. Patient Selection  Discharge Disposition  Home with help?  Home alone?  Ongoing treatment?  Concomitant diagnosis  Tolerance to exercise?  Medications?  Vision and Hearing Status  Does the patient have adaptive equipment?  Is the equipment available for their use?  Discharge Disposition  Home with help?  Home alone?  Ongoing treatment?  Concomitant diagnosis  Tolerance to exercise?  Medications?  Vision and Hearing Status  Does the patient have adaptive equipment?  Is the equipment available for their use?

5. Patient Selection, cont. Candidates for this program should have goals that include ambulation and/or lower extremity weight bearing transfers  Standing pivot/squat pivot transfers  Modified depression transfers  Ambulation with or without a device Patients that are dependent with transfers or unable to walk or have severe to profound cognitive and/or communication deficits  May require therapy for other reasons, but focus is less likely on decreasing falls. Often focus is on caregiver training, wheelchair mobility, compensatory strategies etc. Candidates for this program should have goals that include ambulation and/or lower extremity weight bearing transfers  Standing pivot/squat pivot transfers  Modified depression transfers  Ambulation with or without a device Patients that are dependent with transfers or unable to walk or have severe to profound cognitive and/or communication deficits  May require therapy for other reasons, but focus is less likely on decreasing falls. Often focus is on caregiver training, wheelchair mobility, compensatory strategies etc.

6. Long Term Goals Functional LimitationSample Goal Fall or loss of balance at home in past month = 6 Patient will only experience two falls or loss of balance in home per month to decrease risk of injurywithin 8 weeks. Falls or loss of balance in community, on uneven surfaces, in last month = 8 Patient will only experience three falls or loss of balance in the community per month to decrease risk of injurywithin 8 weeks. Unable to safely ascend or descend stairs without physical assistance due to fear of falling Patient will ascend and descend 12 steps with a hand rail independently within 6 weeks. Increasing risk of falling when reaching for objects secondary to poor balance reactions Patient will safely be able to reach for objects outside of base of support and demonstrate appropriate balance reactions (ankle, hip, stepping strategies) to prevent loss of balance within 6 weeks.

7. Long Term Goals Functional LimitationSample Goal Unable to transfer on/off toilet or chair without use of a walker Patient will transfer independently on/off chair or toilet within 6 weeks. Demonstrates increased fall risk while cooking because difficulty with balance, carrying objects, and focusing on cooking task Patient will demonstrate improved dual-tasking ability by being able to prepare a basic meal without loss of balance within 4 weeks. Unable to maintain attention and focus to safely complete ADL’s Patient will demonstrate sustained & accurate visual attention and processing in order to complete a task with 70% accuracy over 3 minutes. Unable to self-regulate Patient will demonstrate sustained attention to task, self-monitoring, & self-correction during a cognitive- motor task with fewer than 3 errors in a 3 minute time period. Unable to follow moderately complex directions Patient will demonstrate improved receptive language and auditory comprehension skills by following a 2 step cognitive/motor task with 50% accuracy and moderate cues.

8. Short Term Goals  Patient will perform both toes for 2 minutes with while holding onto walker for balance and achieve <200 ms task average with difficulty level set at 300, tempo set at 54 bpm, and guide sounds on.  Patient will attend to task during a synchronized cognitive/motor activity for 2 minutes with moderate cues and/or redirection, achieving a temporal processing score within 150 ms of the reference beat in order to persist in daily activities and complete them without constant prompting  Patient will perform both toes for 2 minutes with while holding onto walker for balance and achieve <200 ms task average with difficulty level set at 300, tempo set at 54 bpm, and guide sounds on.  Patient will attend to task during a synchronized cognitive/motor activity for 2 minutes with moderate cues and/or redirection, achieving a temporal processing score within 150 ms of the reference beat in order to persist in daily activities and complete them without constant prompting

9. Documentation Documentation should include:  IM task to be completed  Task average to be achieved  IM settings (i.e. tempo, if guide sounds are on/off, difficulty level, etc.)  Assistance to be provided (i.e. verbal cues, hands on cues, modeling, etc.)  Relationship to functional outcome Documentation should include:  IM task to be completed  Task average to be achieved  IM settings (i.e. tempo, if guide sounds are on/off, difficulty level, etc.)  Assistance to be provided (i.e. verbal cues, hands on cues, modeling, etc.)  Relationship to functional outcome

10. Narrative Note Example Soap Note Example:  S – Patient seen for skilled speech therapy. He was alert and oriented. He participated well in treatment and had no complaints of pain.  O – Patient will follow a 2-step direction  A – Performed a cognitive/motor task direction in the presence of auditory cues and repetitive task practice with hand over hand assistance. Required more assistance from clinician as complexity of auditory cue and feedback was added. Has difficulty in distraction. Required moderate assistance to persist.  P – Increase complexity of feedback, reduce amount of clinical assistance require. Alternate between two different sets of directions as tolerated. Soap Note Example:  S – Patient seen for skilled speech therapy. He was alert and oriented. He participated well in treatment and had no complaints of pain.  O – Patient will follow a 2-step direction  A – Performed a cognitive/motor task direction in the presence of auditory cues and repetitive task practice with hand over hand assistance. Required more assistance from clinician as complexity of auditory cue and feedback was added. Has difficulty in distraction. Required moderate assistance to persist.  P – Increase complexity of feedback, reduce amount of clinical assistance require. Alternate between two different sets of directions as tolerated. Slide 10

11. Determining Patient Baseline Use both IM assessments and standardized evaluation tools to determine baseline prior to starting Fall Risk Reduction Program

12. IM Assessments  Short Form Test (SFT)  Patient performs two 1-minutes task  One without guide sounds, the other with guide sounds  Provides baseline task average for ability to pair auditory information with motor sequencing task  Long Form Assessment (LFA)  14 tasks, evaluates coordination and sequencing with different motor tasks  Takes approximately 20-25 minutes to administer  Modify to meet the patient’s current level  Document any modifications provided  Should administer one of these assessments when evaluating patient  Short Form Test (SFT)  Patient performs two 1-minutes task  One without guide sounds, the other with guide sounds  Provides baseline task average for ability to pair auditory information with motor sequencing task  Long Form Assessment (LFA)  14 tasks, evaluates coordination and sequencing with different motor tasks  Takes approximately 20-25 minutes to administer  Modify to meet the patient’s current level  Document any modifications provided  Should administer one of these assessments when evaluating patient

13. Standardized Assessments  Multitude of standardized assessments that can be used to assess fall risk, ability to perform activities of daily living, cognitive status  Important to assess dual-tasking impact on balance  It's good a person can walk. But can they walk and talk? Walk and carry a glass of water? Be safe when distracted?  Multitude of standardized assessments that can be used to assess fall risk, ability to perform activities of daily living, cognitive status  Important to assess dual-tasking impact on balance  It's good a person can walk. But can they walk and talk? Walk and carry a glass of water? Be safe when distracted?

14. Motor Assessments  Motor/Balance Assessment:  TUG  Tinetti Scale  Functional Reach  Dynamic Gait Index  6-Minute Walk Test  Motor/Balance Assessment:  TUG  Tinetti Scale  Functional Reach  Dynamic Gait Index  6-Minute Walk Test

15. Cognitive Assessments  RIPA  SCATBI  Test of Variables of Attention  Stroop Affect  Trail Making  Delis-Kaplan Executive Functioning Scale (D-KEFS)  Mesulam and Weintraub Cancellation Test (MWCT)  Mini Mental State Examination (MMSE)  Wisconsin Card Sorting Test (WCST)  Woodcock- Johnson, 3rd Edition (WCJ-III)  RIPA  SCATBI  Test of Variables of Attention  Stroop Affect  Trail Making  Delis-Kaplan Executive Functioning Scale (D-KEFS)  Mesulam and Weintraub Cancellation Test (MWCT)  Mini Mental State Examination (MMSE)  Wisconsin Card Sorting Test (WCST)  Woodcock- Johnson, 3rd Edition (WCJ-III)

16. Confidence Assessments  Activities-Specific Balance Confidence (ABC) Scale  Modified Falls Efficacy Scale Including a confidence assessment helps determine if the patient has less concerns about falling and is perceiving improvements in physical abilities.  Activities-Specific Balance Confidence (ABC) Scale  Modified Falls Efficacy Scale Including a confidence assessment helps determine if the patient has less concerns about falling and is perceiving improvements in physical abilities.

17. Other Useful Tools and Assessments  Functional Assessment Tool (Developed by Amy Vega)  Stroke Impact Scale  Canadian Occupational Performance Measure  Functional Assessment Tool (Developed by Amy Vega)  Stroke Impact Scale  Canadian Occupational Performance Measure

18. Timed Up & Go Modification to Assess Dual Tasking  Can modify the TUG to incorporate a cognitive and physical task  Administer TUG under following conditions:  Traditional conditions  While carrying a glass of water  While counting backwards from 100 in serial 7's  Can modify the TUG to incorporate a cognitive and physical task  Administer TUG under following conditions:  Traditional conditions  While carrying a glass of water  While counting backwards from 100 in serial 7's

19. Normative Values TUG ConditionHigh Risk for Falling: TUG Alone> 13.5 seconds TUG Manual (carry full glass of water) > 14.5 seconds TUG Cognitive (count backwards)> 15 seconds Shumway-Cook, A., Brauer, S., & Woollacott, M. (2000, September). Predicting the probability for falls in community-dwelling older adults using the timed up & go test. Physical Therapy, 80(9), 896-903.

20. Create a Dual Task Condition with Short Form Test Compare traditional SFT score with a dual-task condition (document how you create dual-task so it can be replicated). Perform SFT while:  Counting aloud  Marching in place  Transfering sit to/from stand  Walking (use in-motion triggers)  Naming objects Compare traditional SFT score with a dual-task condition (document how you create dual-task so it can be replicated). Perform SFT while:  Counting aloud  Marching in place  Transfering sit to/from stand  Walking (use in-motion triggers)  Naming objects

21. Summary of Patient Selection & Assessment 1.Patient should have goals that include ambulation and/or transfers (that involve lower extremity weight bearing) 2.Use standardized assessment tools to evaluation motor and cognitive performance 3.Use IM assessments to get a baseline on ability to pair auditory information with motor sequencing. 4.Assess performance under dual-task conditions 1.Patient should have goals that include ambulation and/or transfers (that involve lower extremity weight bearing) 2.Use standardized assessment tools to evaluation motor and cognitive performance 3.Use IM assessments to get a baseline on ability to pair auditory information with motor sequencing. 4.Assess performance under dual-task conditions

22. "Homework"  Complete following worksheet to select and assess your patient

25. Post-test  Complete post-test to receive link for Module # 3 of 6

26. Materials Page  This video  PowerPoint  Patient Selection Worksheet  www.interactivemetronome.com/inde x.php/fall-risk-coaching www.interactivemetronome.com/inde x.php/fall-risk-coaching  This video  PowerPoint  Patient Selection Worksheet  www.interactivemetronome.com/inde x.php/fall-risk-coaching www.interactivemetronome.com/inde x.php/fall-risk-coaching

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