Striking the Right Balance

Falling on the Right Path: Exploring an Inter-professional Approach to Fall Prevention with Occupational Therapists and Audiologists


In this edition of “Striking the Right Balance,” Andrea Kuntz and Kegan Stephan, Audiology students at the School of Human Communication Disorders at Dalhousie University interview both Ruth Duggan, an occupational therapist and an occupational therapy student at Dalhousie University, Nisha Sandu, about exploring an inter-professional approach to fall prevention between occupational therapists and audiologists.
 
If you are a health care professional and would like to be more involved in all things vestibular, please sign-up for the Vestibular Special Interest Group. Sign-up by emailing JanineAllison.Verge@nshealth.ca to let us know you want to be included. Also, check out our Facebook page for a free list of online vestibular resources at the CAA National Vestibular Special Interest Group page.


Just like peanut butter and jelly, audiologists and ENTs are two professions that seem to go hand-in-hand, but our inter-professionalism can extend far beyond. In this issue, we will explore the role of occupational therapists (OT), and how their skills are an invaluable part of a patient’s recovery. Our names are Andrea and Kegan; as audiology students at Dalhousie University, we have been exposed to a diverse range of patients, many of whose health care requirements transcend amplification. Fall prevention is an important aspect of this care, and requires an inter-professional health care approach in order to provide comprehensive and effective management. In 2004 alone, fall related injuries resulted in 31% of overall injury costs to the health care system.1 Combined with the fact that 20–30% of Canadian senior citizens are likely to fall every year, fall prevention is a service that needs to be addressed.

As audiologists, we can assess a patient’s balance, but the balance system is not just vestibular - there are factors such as confidence, strength, education and assistive devices that can be utilized to help an individual reduce their risk of falls. These aforementioned aspects are where an OT can step in. To learn more about the integral role of this profession we interviewed Ruth Duggan, a practicing OT with Cornerstone Occupational Therapy Consultants, as well as Nisha Sandhu, a student in the Occupational Therapy program at Dalhousie University.

Andrea & Kegan (A&K): Occupational therapists seem uniquely suited to address fall prevention since they evaluate both the person and their environment to help improve independence and reduce the risk of falls. Can you explain the role of OT in evaluating and training clients and their families/caregivers on fall prevention?

Ruth & Nisha (R&N): OTs have a holistic approach in which they not only look at the different personal and environmental risk factors, but also how an individual engages in various occupations within that environment. They investigate any possible physical, cognitive and psychosocial risk factors. There is an emphasis on maximizing a person’s individual functioning within their environment.2 OTs are involved in assertiveness training, physical conditioning exercises, home visits, environmental assessments, adaptations, functional assessments, education regarding the use of assistive devices and reducing risk-taking behaviour.2 We provide education to older adults, family members, the general public and other healthcare professionals. OTs want to reduce the risk of injury and improve safety without compromising mobility and functional independence of the individual so that they can safely engage in various occupations of their choice.2 We also want to increase an individual’s awareness of potential personal and environmental risks since the risk of falling can be decreased by awareness of the problem, modification of the environment and behavioural risk factors.2

A&K: How can fear of falling contribute to fall risk and what is the role of occupational therapy in reducing this risk factor and consequence of falling?

R&N: The fear of falling can lead to reduced occupational engagement which is more related to the fear of falling rather than the actual number of falls. Occupational disengagement also results in reduced physical ability, which increases the risk of a fall and decreases functional independence.2 The inherent anxiety and changes in behaviour patterns seen in individuals with a fear of falling can also induce gait abnormalities, which can ultimately result in a fall.3

An individual’s confidence in their ability to perform daily activities without falling is closely related to their actual performance, which is why assertiveness training is essential for individuals that have a fear of falling.2

A&K: What would you suggest audiologists do to help reduce fear of falling?

R&N:

  • Provide general education on fall prevention.
  • Ensure clients have optimized hearing and auditory processing to eliminate that risk.
  • Screen for inner ear problems, or comorbidities that can increase the risk of falling.
  • Refer to an OT if necessary.

A&K: Where do you work, describe a typical day, and how can clients access occupational therapy services both privately and publicly across Canada?

R&N: It depends! Every day is different because we look at a wide array of things. Occupational therapy itself is very broad and a typical day of an OT depends on the field they work in and where they work. In private practice, where we work, a day usually includes home and work site visits, report writing, education and training. Clients usually get referrals from other professionals and insurance companies in private cases and some cases may be self-referral. In the public system they may be referred from their family doctor, other professionals and even self-referral.

A&K: In your day to day work, which other health professions do you collaborate with most?

R&N: Physiotherapists, physicians, psychologists, SLPs, nurses, audiologists, pharmacists, neuro-optometrists; it depends on the client’s needs!

A&K: What screening tools would you suggest audiologists use to target clients who might benefit from occupational therapy services?

R&N: Two screening tools audiologists could use are:

  1. The Falls Behavioural Scale - looks at different behavioural dimensions during occupations in order to evaluate behavioural factors that could potentially increase the risk of falling within the context of the environment and occupations.4
    • It includes cognitive adaptation, protective mobility, avoidance, awareness, pacing, practical strategies, displacing, being observant, changes in level and getting to the phone.
    • It can assist in increasing an individual’s awareness of their functional abilities and their interaction with their environment.
    • It also helps them recognize how everyday adaptive or maladaptive habits and behaviours may contribute to their fall risk.
      http://sydney.edu.au/health-sciences/staff/docs/lindy_clemson/FaB_manual_2003.pdf
  2. The Home Safety Self-Assessment Tool - was developed to assess the fall risks of older adults in their homes and to help them in improving their home environment.5
    • It is very comprehensive as it covers 64 risk items in nine areas of the home, and also offers solutions and tips for each item on the list.
    • However, it is important to note that the assessment does not provide detailed considerations and solutions for unique situations.
    • Therefore, an OT’s insight into the interaction between an individual and the environment can achieve higher levels of solutions and recommendations for fall risks in a home environment.
      http://www.ongov.net/aging/documents/HSSAT-Updated-2016.pdf

A&K: What case history information would be helpful for audiologists to include in their reports to help occupational therapists prioritize their waitlist?

R&N: Components of a comprehensive assessment include the following6:

  • Medical history, physical examination, cognitive and functional assessment;
  • History of falls; taking multiple medications (particularly psychotropic medications); problems with gait, balance and mobility; impaired vision; other neurological impairments; reduced muscle strength; problems with heart rate and rhythm; postural hypotension; foot problems and incorrect footwear; environmental hazards.

A&K: What educational information would you recommend audiologists share with their clients while they are waiting for occupational therapy services to prevent falls?

R&N: We would recommend audiologists share the screening tools as they include tips and key points which would be beneficial. The screening tools mentioned above can be self-administered and are free to access!

The complementary expertise that occupational therapists and audiologists can provide to patients together is a useful one. Consequently, working collaboratively has been shown to reduce wait times by allowing more appropriate referrals, more specific diagnosis and better outcomes for the patient.7 This multifaceted approach of looking at specific ear related issues, audiology, and creating unique solutions for environmental obstacles, occupational therapy, helps achieve fall prevention. As audiologists we hope to work closely with OTs and other health professions as we try to make a safer environment for our patients.

References

  1. SMARTRISK. The economic burden of injury in Canada. Toronto:
    Author; 2009. Available at:
    http://www.parachutecanada.org/downloads/research/reports/EBI2009-Eng-Final.pdf
  2. Woodland J and Hobson S. (2003). An occupational therapy perspective on falls prevention among community-dwelling older adults. The Canadian Journal of Occupational Therapy, (70)3, 174-182
  3. Harding S and Gardner A. Fear of falling. Aust J Adv Nurs 2009;27(1):94–100.
  4. Tzingounakis A. Falls prevention: Investigating best practice for community occupational therapists. Occupat Ther Now 2012;14(3):9–12.
  5. Tomita MR, Saharan S, Rajendran S, et al. Psychometrics of the Home Safety Self-Assessment Tool (HSSAT) to prevent falls in community-dwelling older adults. Am J Occupat Ther 2014;68(6):711. doi:10.5014/ajot.2014.010801
  6. Public Health Agency of Canada. Seniors Falls in Canada: Second Report (pp. 1-62); 2014. Available at: http://www.phac-aspc.gc.ca/seniors-aines/publications/public/injury-blessure/seniors_falls-chutes_aines/assets/pdf/seniors_falls-chutes_aines-eng.pdf
  7. Rodriguez AI, Zupancic S, Song MM, et al. Importance of an interprofessional team approach in achieving improved management of the dizzy patient. J Am Acad Audiol 2017;28(3):177–86.
About the authors

Ruth Duggan, MSc

Ruth Duggan has over 28 years’ experience working with people of all ages and diagnostic groups in hospital, home, community and employment settings in Canada, Kuwait, and the Caribbean. She earned her Master of Science in Occupational Therapy in May 2002; her post-graduate master's thesis involved using reflective education to foster an increasingly client-centred practice. She has been working exclusively in the private sector since 2000, providing education and consultation to employers and insurers, and community-based rehabilitation for individual clients throughout Nova Scotia. Ruth's occupational therapy interests lie in working with groups and individuals to promote health and prevent disability, including ergonomics, vocational rehabilitation, and life care planning.

Nisha Sandu, BS

Nisha Sandu is currently a second year graduate student at Dalhousie University’s School of Occupational Therapy. She obtained her BS degree at Simon Fraser University with a major in Biomedical Physiology.

Kegan Stephen, BSc, MSc Human Communication Disorders (Candidate)

Kegan Stephen is a third-year audiology student at Dalhousie University from Antigonish, Nova Scotia. He obtained his BSc (Honours in Chemistry) from Dalhousie University in 2014. He is currently a research assistant working in the lab of Dr. Jian Wang.

Andrea Kuntz, BA, MSc Audiology (Candidate)

Andrea Kuntz, is a third year audiology student at Dalhousie University. She obtained her B.A. (Psychology) from Ryerson University in 2015. Having volunteered with Special Olympics Nova Scotia, and interned at the IWK Children’s Hospital, Andrea hopes to work with special populations in her future. She is currently working on a research project examining user satisfaction with BAHDs.

Michael Vekasi, MClSc, RAud, Aud(C)

Michael is a clinical audiologist with Alberta Health Services at the Glenrose Rehabilitation Hospital in Edmonton, AB. His caseload includes vestibular assessments and he is a team-member of a multi-disciplinary Vestibular Clinic. He obtained his Master’s of Clinical Science (Audiology) from Western University and his certificate of Advanced Studies in Vestibular Sciences and Disorders from Salus University. Michael currently serves as Vice President for the Alberta College of Speech Language Pathologists and Audiologists (ACSLPA). He was the recipient of the 2015 ACSLPA Horizon Award. Michael is co-editor of the Striking the Right Balance column in Canadian Audiologist. He is also involved with the Canadian Academy of Audiology as the Chair of the Student Committee and member of the National Vestibular Special Interest Group. Michael is a member of the Audiology Clinical Certification Examination Committee with Speech-Language & Audiology Canada.

Janine Verge, AuD, Aud(C), Clinical Audiologist

Janine Verge has worked as an audiologist at the Nova Scotia Hearing and Speech Centres for the past 18 years. She obtained her BSc (Psychology) at Mount Saint Vincent University, her MSc (Audiology) from Dalhousie University, and her AuD from AT Still University. Janine won the 2009 NSHSC Advocacy Award, the 2013 NSHSC Dr. N. Barrie Coward Continuing Educational Award, and the 2017 NSHSC Outstanding Performance Award. She served as president of the Speech and Hearing Association of Nova Scotia from 2010-2013. Janine is an adjunct professor at Dalhousie University, teaching in the area of vestibular testing and management. She co-created the CAA National Vestibular Special Interest Group and is co-editor of “Striking the Right Balance,” an on-going feature column in the on-line publication Canadian Audiologist. Janine is also co-founder and committee member of the Dalhousie Hearing Aid Assistance Program. Janine is particularly interested in all things vestibular, fall prevention, and mental health advocacy.