Falls risk assessment in the satellite dialysis population.

Falls Risk Assessment in the
Satellite Dialysis Population
Marlena Esposito
Physiotherapist, Falls Prevention Team
April Falls Forum 2011

Introduction

Chronic Kidney Disease
> 1 in 7 Australians over 25 years have some degree of CKD
> Contributed to 10% of deaths in Australia 2006
Description
GFR*mL/min/1.73m2
Stage 1
Slight kidney damage with normal or
increased filtration
Stage 2 Mild decrease in kidney function 60-89
More than 90
Stage 3 Moderate decrease in kidney function 30-59
Stage 4 Severe decrease in kidney function 15-29
Stage 5
Kidney failure requiring dialysis or
transplantation
Less than 15

End Stage Chronic Kidney
Disease ESKD (Renal Failure)
"stage in chronic
renal impairment
that appears
irreversible and
permanent, and
requires a regular
course of dialysis
or kidney
transplantation to
maintain life.”
Medicare Australia 2009

End Stage Kidney Disease -
Causes of New Cases
> Diabetes 31%
> Nephritis or inflammation of the
kidney 25%
> High blood pressure 16%
ANZDATA 2008

Dialysis Units in Adelaide
Public Hospitals:
> Flinders
> RAH
> TQEH
> WCH
Satellite Centres:
> LMHS
> HRC
> Wayville
> Noarlunga
Usually involves:
3- 5 hours per session
2- 3 sessions per week
Private:
> Payneham
> Brighton
> Modbury

New Patients, Australia
New Patients, NZ
New Patients 1960 - 2010
Australia and New Zealand
2500
500
2000
400
1500
300
1000
200
500
100
0
0
1960 1970 1980 1990 2000 2010
Year
Australia NZ
ANZDATA 2010

Age of New Haemodialysis Patients 2006
Number (Total=2030)
Australia
0.6%
2% 4% 9% 14% 22% 26% 20%
2%
0-14 15-24 25-34 35-44 45-54 55-64 65-74 75-84 >=85
No.
Pats. 13 33 77 188 292 452 526 404 45
© ANZDATA Registry
ANZDATA 2008

Dialysis and Falls Risk
> Previously received little attention
> Recent literature: greater risk of
falling then the age equivalent
general population
> Rates of falling in literature as
high as 47%
Cook et al 2006; Li et al 2008; Roberts et al 2007; Cook & Jassal 2005;
Desmet et al 2005; Roberts et al 2003

Hip Fracture
Mortality
Older Person
Older Person on Dialysis
1.5% of
all falls
6% of
all falls
27% deceased
within the first
year
50% deceased
within the first
year
Health SA 2009 Coco and Rush 2000

Dialysis Falls Risk Factors:
1. Co-morbidities
High prevalence of:
> Diabetes
> Sleep disorders
> Bone disease
> Depression
> Cardiovascular disease
> Peripheral and autonomic
neuropathies
Cook et al 2006, Jassal et al 2006

Dialysis Falls Risk Factors:
2. Medications
> Average of 9
medications
> More likely to be
prescribed
antidepressants,
narcotics and
hypnotics
Elder et al 2004

Dialysis Falls Risk Factors:
3. The Dialysis Process
Rapid fluid and electrolyte shifts
during dialysis pre-dispose to
dialysis-related hypotension and
self-limited arrthymias.

Gaps in the
Literature
To date no published studies of
physiological risk factors such as vision,
proprioception, strength, vision and
balance.
No published studies of effect of falls
prevention interventions with this group.
Collaborative study (CPAA, HDC, WDC, Deakin
University & CaNAHS Falls Prevention Team)
to investigate Falls Risk Factors of satellite Dialysis
Patients

Aim of the Study

Study Aims
1. To determine the falls risk of patients
from two South Australian satellite
dialysis units.
2. To determine the impact of
proprioception, contrast sensitivity,
balance, strength and reaction time
on falls risk.
3. To determine the difference between
pre and post dialysis falls risk scores.

Methods

92 satellite dialysis patients
were assessed pre and
post dialysis (i.e. same
day) using the
Physiological Profile
Assessment (PPA).
The FROP-Com Screen
was also undertaken.

The Physiological Profile
Assessment (Short Form PPA)
The PPA is a falls risk calculator tool comprised of 5 tests:
Scores are loaded into a computer software program to
calculate performance in relation to the normative database
complied from large population studies.
Lord et al 2003

Individual test
component z-score
Age-matched
individual scores
Normal range across
age groups
Falls Risk Score and
Category

Results

Patient Demographics
84 patients completed the test.
‣Age: Mean = 65.53
Range 29 -87 yrs
‣Gender: Female = 28 (33.3%)
Male = 56 (66.7%)
‣ATSI: n = 8 (9.5%)
Mean age 56.25

1. Aged Matched Falls Risk Score
68 % performed worse than age and
gender matched normal non-dialysis population

2. Falls Risk Category
23%
2%
11%
17%
17%
very low
low
mild
moderate
marked
very marked
30%

3. Individual Test Results

a) Contrast Sensitivity
83 % worse than
average aged
matched nondialysis
population
53% significantly
worse

) Postural Sway
47% worse than
average aged
matched nondialysis
population
37% significantly
worse

c) Proprioception
37% worse
than average
aged matched
non-dialysis
population
21%
significantly
worse

d) Muscle Strength
81% worse
than average
aged matched
non-dialysis
population
32%
significantly
worse

e) Reaction Time
62% worse than average aged
matched non-dialysis population
42% significantly worse

Other Significant Findings
Significant correlations between:
‣Reaction time and lower limb strength
‣Reaction time and postural sway
‣Individuals > 60 yrs performed significantly worse in
all tests than < 60 yr group.
‣ATSI patients performed better with vision but
significantly worse on all other tests and higher overall
falls risk scores.

Falls History
‣Significant negative correlation between self-reported
12 month fall history and postural sway.
‣Indicates that a lower number of falls is associated with
higher (i.e. better) postural sway scores.
‣There were no statistically significant correlations
between history of falls and the other four variables.
Mean Score
Multiple Falls
Single Fall
No Falls
-1.2 -1 -0.8 -0.6 -0.4 -0.2 0

Number of patients
Pre and Post Dialysis Falls Risk Scores
40
38
35
30
25
20
15
18
17
10
5
0
7
3
1
Increase by 3 Increase by 2 Increase by 1 No change Decrease by 1 Decrease by 2
Pre-post change in falls risk

Where to from here?

Strength and Balance Intervention

Conclusions

Preliminary data confirms the high
prevalence of falls risk in people
receiving haemodialysis in satellite
dialysis units.
This group perform below average in
PPA test components compared to the
age and gender equivalent general
population.
Same day pre and post dialysis falls risk
scores did not significantly change.

PPA is a practical method of
differentiating dialysis patients are at risk
for falls from those who are not at risk
for falls.
Identifying at risk patients can assist
exercise physiologists, physiotherapists,
occupational therapists, dialysis nursing
staff and other health professionals to
provide falls prevention interventions to
prevent falls in the high risk groups.

Acknowledgments
> Dr Paul Bennett, RN (Renal) MHSM PhD,
Deakin University Melbourne
> Danwin Chan, Exercise Physiologist,
Centre for Physical Aging and Activity
> Dee Parkhurst, Clinical Service
Coordinator, Wayville Dialysis Unit
> Leo Breugelmans, Clinical Services
Coordinator, Hampstead Dialysis
> Bob Barnard, Chief Exercise Physiologist,
Centre for Physical Activity in Ageing

References
> Leinau L and Perazella M. Hip fractures in end-stage renal disease patients:
incidence, risk factors and prevention. Seminars in Dialysis 2006:19:1;75-79.
> Cook, WL & Jassal, SV 2005, Prevalence of falls among seniors maintained on
hemodialysis, International Urology and Nephrology, vol. 37, pp. 649-652.
> Cook, WL, Tomlinson, G, Donaldson, M, Markowitz, SN, Naglie, G, Sobolev, B &
Jassal, SV 2006, Falls and Fall-Related Injuries in Older Dialysis Patients, Clin J Am
Soc Nephrol, vol. 1, pp. 1197-1204.
> Desmet, C, Beguin, C, Swine, C, & Jadoul, M 2005, Falls in Hemodialysis Patients:
Prospective Study of Incidence, Risk Factors, and Complications, American Journal
of Kidney Diseases, vol. 45, no. 1, pp. 148-153.
> Elder, SJ, Pisoni, RL, Akizawa, T, Fissell, R, Andreucci, VE, Fukuhara, S, Kurokawa,
K, Rayner, HC, Furniss, AL, Port, FK & Saran, R 2008, Sleep quality predicts quality
of life and mortality risk in haemodialysis patients: Results from the Dialysis
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pp. 998-1004.
> Johansen, KL 2005, Exercise and Chronic Kidney Disease: Current
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290-300.
> Kutner, NG, Zhang, R, Huang, Y & Bliwise, DL 2008, Patient-reported sleep difficulty
and cognitive function during the first year of dialysis, Int Urol Nephrol, vol. 40, pp.
203-210.
> Roberts, R, Jeffrey, C, Carlisle, G & Brierley, E 2007, Prospective investigation of
the incidence of falls, dizziness, and syncope in dialysis patients, Int Urol Nephrol,
2007, vol. 39, pp. 275-279.
> Roberts, RG, Kenny, RA, & Brierley, EJ 2003, Are elderly haemodialysis patients at
risk of falls and postural hypotension?, International Urology
> Marottoli R, Berkman L et al. Decline in physical function following hip fracture. J Am
Geriatr Society. 1992;40:861-866
> Moller J(Commonwealth Department of Health and Aging).Projected costs of fall
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