Fall Risk Assessment in an Older Adult with Parkinson's Disease
A 75-year-old man with Parkinson's disease (Hoehn and Yahr stage 3) is referred to PT due to two falls in the past 6 months. He lives with his wife in a two-story house. He reports freezing of gait when turning or passing through doorways, and occasional festination. He uses a cane for ambulation. His medications include levodopa/carbidopa (Sinemet) and a recent addition of a dopamine agonist. He complains of dizziness upon standing. Physical exam: Berg Balance Scale 40/56, Timed Up and Go (TUG) 18 seconds, 10-meter walk test 12 seconds, and 5-times sit-to-stand 20 seconds. He has mild cogwheel rigidity and bradykinesia. He denies fear of falling but his wife expresses concern.
1. What are the key examination findings that indicate fall risk, and what additional assessments would you perform?
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Key findings indicating fall risk: 1) History of falls: Two falls in 6 months. 2) Berg Balance Scale: 40/56 indicates moderate fall risk (score <45 predicts falls). 3) **TUG**: 18 seconds (>13.5 seconds indicates fall risk). 4) Freezing and festination: Increase fall risk, especially during turns. 5) Dizziness on standing: Possible orthostatic hypotension, which can cause falls. 6) Parkinsonian symptoms: Rigidity and bradykinesia affect postural responses. Additional assessments: 1) Orthostatic vital signs: BP and HR supine and after 1-3 minutes of standing to rule out orthostatic hypotension. 2) Freezing of gait questionnaire. 3) Fear of falling: Falls Efficacy Scale-International (FES-I) even though he denies fear, wife's concern warrants assessment. 4) Home safety evaluation: Especially stairs and bathroom. 5) Cognitive screen: MoCA to assess executive function, which affects gait and dual-tasking. 6) Medication review: Dopamine agonists can cause orthostasis and impulse control disorders; levodopa timing affects mobility. 7) Dual-task gait assessment: To evaluate cognitive-motor interference.
2. What would be your prioritized intervention plan to reduce fall risk, and how would you address the freezing of gait?
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Prioritized intervention plan: 1) Address orthostatic hypotension: Educate on slow position changes, hydration, and compression stockings; collaborate with physician regarding medication adjustment. 2) Gait and balance training: Focus on turning strategies, weight shifting, and stepping over obstacles. Use external cues (auditory, visual) to overcome freezing. 3) Freezing of gait: Teach cueing strategies (e.g., marching to a rhythm, laser pointer, stepping over imaginary lines), and practice turning in wide arcs. 4) Strength and flexibility: Strengthen hip and ankle musculature, stretch especially flexors. 5) Home modifications: Remove throw rugs, improve lighting, install grab bars, and consider stairlift if needed. 6) Education: Fall prevention strategies, use of assistive device (cane may be insufficient; consider walker with laser for freezing), and emergency plan. 7) Dual-task training: Practice walking while talking or carrying objects to improve automaticity. 8) Medication timing: Schedule PT sessions when levodopa is most effective (on periods). Monitor for orthostatic hypotension during sessions.