Gabrielle Herman, SPT November 3, 2015 Outline ◦ Patient demographics ◦ Patient Evaluation, Assessment, Goals, Treatment, Outcome ◦ Clinical Question ◦ 2 Studies ◦ Conclusion ◦ Clinical Application ◦ Future Research To investigate whether the incontinence portion of the Normal Pressure Hydrocephalus triad relates to prognosis of fall risk 84-year-old Caucasian female living in an assisted living facility 3 falls within the past week in her bathroom Patient referred for home health physical therapy Past Medical History: ◦ Hypertension ◦ Incontinence ◦ Dementia ◦ TKA ◦ OA ◦ Idiopathic Normal Pressure Hydrocephalus Cerebral shunt placement 1 month prior Classic triad ◦ Gait impairment ◦ Cognitive decline ◦ Urinary incontinence Ventricular enlargement with MRI: Normal brain absence of elevated CSF pressure Difficult to diagnose ◦ Mimics other neurodegenerative disorders ◦ Aging Typical treatment: shunt placement ◦ Extremely variable improvement rates
MRI: INPH brain Chief complaints: ◦ Frequent loss of balance ◦ Incontinence “I have to go all the time” Have to get up multiple times throughout the night ◦ Unable to safely ambulate to assisted living facility dining room as leaving home requires significant and taxing effort Home situation: Lives alone Prior level of function: completes all ADLS without assistance, but often completed unsafely and without necessary assistive device (rollator) Alert and Oriented x2, showing signs of mild dementia Balance: Poor Transfers: Stand by assistance Decreased coordination Gait deviations: narrow BOS, short step length R and L, impulsive movements, forward leaning posture, and poor/inconsistent rhythm, foot clearance and placement of assistive device Manual Muscle Test: Good overall strength TUG: 20 seconds Fall risk MAHC 10 Fall Risk: 10 Fall risk Berg Balance Test: 31/56 Fall risk ◦ Frequent LOB during testing Short Portable Mental Status Questionnaire (SPMSQ): 4 Mild cognitive impairment Diagnosis: ◦ Lack of coordination ◦ Gait deviations ◦ Poor balance ◦ Fall risk Prognosis: Poor ◦ Lack of insight on deficits ◦ Age ◦ Poor safety awareness Transfers ◦ Sit to stand STG: Modified independent in 3 weeks, LTG MOD I in 5 weeks Get up safely to use the bathroom/perform ADLs around apartment Balance ◦ TUG STG: 18 seconds in 3 weeks, LTG: 15 seconds in 5 weeks To decrease fall risk, to get dressed and use the bathroom safely Gait ◦ STG: level surface distance 500 ft in 3 weeks with MOD I assist, LTG: 600 ft in 5 weeks with MOD I assist ◦ To ambulate to ALF dining room safely with rollator Balance training Gait training Patient education ◦ Safety awareness To decrease fall risk Slow down Never take a step without assistive device Do not reach out far past base-of-support 2 days following initial evaluation, received call from Pt. J First responders on the scene Patient J fell again, also reporting she had fallen the night before Patient received on the floor having soiled herself Patient reported she was trying to get to the bathroom Patient admitted to the hospital later that day Is urinary incontinence a prognostic indicator of increased fall risk in an 80-year-old female patient with the Normal Pressure Hydrocephalus triad? Title: Urinary incontinence is associated with an increase risk of falls in elderly women: A Systematic Review
Chiarelli, Pauline E., Lynette A. Mackenzie, and Peter G. Osmotherly. "Urinary incontinence is associated with an increase in falls: a systematic review."Australian journal of physiotherapy 55.2 (2009): 89-95 Question: Is urinary incontinence associated with falls in community-dwelling older people? Design: Systematic review and meta-analysis of observational studies investigating falls and incontinence Study identification: Database search of MEDLINE, EMBASe, CINAHL, and Cochrane Library from 1985-2008 Total of 9 studies met all inclusion criteria ◦ 5 prospective ◦ 4 cross-sectional Design Participants Outcome Data Measures •Observational •Community- • Falls and •Estimated odds studies dwelling older urinary ratios related to people (>65 yr) incontinence incontinence and measured falls •Not related to any specific clinical • Falls measured •Sufficient data group by self report or to enable odds calendar ratio calculations
•Urinary incontinence defined broadly or more specifically Two investigators independently extracted odds ratio data Comprehensive meta-analysis software ◦ Generated pooled estimate of effect size ◦ Random effects model used Q-test used to identify outliers Influence of different types of UI on effect size estimate explored ◦ Overactive bladder Sx: urinary urgency, leak large sudden volumes, nocturia ◦ Stress incontinence Sx: lose small amounts of urine with coughing, sneezing without sense of urgency to rush to the toilet Association measured: Odds Confidence interval ratio
Falls and incontinence 1.45 95% CI 1.36-1.54
Falls and urge 1.94 95% CI 1.33-2.84 incontinence Falls and Stress 1.11 95% CI 1.00-1.23 incontinence Falls and mixed 1.92 95% CI 1.69-2.18 incontinence A clear association between falls and urinary incontinence More predominately, falls relate to overactive bladder (urgency & nocturia) versus stress incontinence ◦ The need to rush to toilet/commode ◦ Distress and anxiety Effective intervention to manage these symptoms should be included in falls prevention programs Selection of English-language publications only Possibility that association could also be a result of mobility status Not directly related to Normal Pressure Hydrocephalus Title: Urinary incontinence and behavioral symptoms are independent risk factors for recurrent and injurious falls, respectively, among residents in long-term care facilities
Hasegawa, Jun, Masafumi Kuzuya, and Akihisa Iguchi. "Urinary incontinence and behavioral symptoms are independent risk factors for recurrent and injurious falls, respectively, among residents in long-term care facilities." Archives of gerontology and geriatrics 50.1 (2010): 77-81. Design: Cohort study Participants: New residents to 13 randomly selected long-term care facilities ◦ N=1082, 327 male, 755 female ◦ Mean age of 82 Followed up for 6 months or up to D/C or death ◦ All had some physical or mental impairment Fall outcomes collected from long-term care facility charts after 6 months ◦ Falls ◦ Fall related injury ◦ Day fall occurred Participant background data from admission ◦ Physical status of patients ◦ Diagnosed chronic diseases: arthritis, CVD, dementia, HTN, DM, CHF ◦ Prescribed medications ◦ Previous urinary incontinence ◦ Previous behavioral Sx: wandering, resistance to care, agitation Patients assigned to groups: ◦ fall vs. non fall ◦ Injurious falls vs. non-injurious falls ◦ Recurrent falls vs. single falls Chi-squared test to determine if there was a significant association between two variables Cox proportional hazards regression model ◦ Risk of a variable expressed as a hazard ratio (HR) Falls vs. Non-falls ◦ Those who fell had higher rates of Moderate physical function Experiences of incontinence (p<0.001, HR=2.38, 95% CI 1.83-3.09) Behavioral symptoms Higher average number of prescribed medications Injurious falls and recurrent falls ◦ Presence of incontinence increased recurrent falls (p=0.036) ◦ Presence of behavioral Sx increased injurious falls (p<0.001) Urinary incontinence was an independent predictor for recurrent falls, but not for injurious falls In contrast, behavioral Sx were an independent predictor for injurious falls, but not for recurrent falls Urinary incontinence relates to the number of falls among institutionalized older people Treatment/management of these risk factors should be considered to prevent falls in long- term care facilities Due to observational design, significance of incontinence could be due to unmeasured factors ◦ Physical restraints ◦ Visual/balance impairments ◦ Dizziness ◦ Orthostatic Hypotension No information on the circumstances of the fall ◦ Activity being performed before and during fall Changes in medication during the follow-up period were not measured Also not specific to Normal Pressure Hydrocephalus Study participants around same age Mostly female subjects Study 1: A strong association between urinary incontinence and fall risk, especially urge incontinence Study 2: ◦ Patients had some sort of physical/mental impairment ◦ Patients in a long-term care facility ◦ Urinary incontinence strongly associated with recurrent, non-injurious falls Yes ◦ Overactive bladder symptoms ◦ Recurrent falls ◦ Although results are not specific to the NPH diagnosis, they can still be applied to patient J Interventions to decrease Risk assessment is Sx of overactive bladder ◦ the primary Bladder training ◦ intervention Double voiding ◦ Pelvic floor exercises Incontinence may be ◦ Scheduled toilet trips a risk factor not ◦ Fluid/diet management captured by the ◦ Electrical Stimulation current fall risk assessment tools 86% of occupational therapists acknowledged that they should have a Should be part of role in management of incontinence, but routine investigation felt inadequately educated (Supk and Vickerman 2000) Fall risk specifically in Normal Pressure Hydrocephalus Research on misplacement of shunt Dementia, UI, and fall risk for this patient Questions? Chiarelli, Pauline E., Lynette A. Mackenzie, and Peter G. Osmotherly. "Urinary incontinence is associated with an increase in falls: a systematic review."Australian journal of physiotherapy 55.2 (2009): 89-95 Hasegawa, Jun, Masafumi Kuzuya, and Akihisa Iguchi. "Urinary incontinence and behavioral symptoms are independent risk factors for recurrent and injurious falls, respectively, among residents in long-term care facilities." Archives of gerontology and geriatrics 50.1 (2010): 77-81. Verrees, Meg, and WARREN R. Selman. "Management of normal pressure hydrocephalus." American Family Physician 70 (2004): 1071-1090. Vickerman, Supk J. “The hidden role of the occupational therapist in the management of continence.” International Journal of Therapy and Rehabilitation 11 (2000):503-508.