To prevent falls, physical therapists and occupational therapists can recommend assistive devices and help patients improve strength, range of motion, and balance. So what can a speech-language pathologist do?
An SLP’s role in fall avoidance varies. If we start by assessing a patient’s cognitive function, we can better grasp our role in prevention.
Assessment of Cognitive Function
Many of my patients have been walking for more than 80 years (and love to remind me of this fact). Even with significant experience, walking requires thinking. Older adults with cognitive impairment are twice as likely to fall than older adults with normal cognition.1 SLPs can help detect cognitive impairment to identify older adults who are at higher risk for falling.
SLPs can diagnose cognitive impairment via both standardized assessment and structured observation and interviews in the patient’s natural setting. As SLPs, we’re particularly good at identifying cognitive deficits, even when people cleverly disguise them. My goal in identifying these deficits isn’t to persuade the patient they have cognitive impairment, it’s to design interventions so the patient can successfully reduce their fall risk.
It’s not unusual for an SLP to collaborate with a PT and OT to help a patient improve safety and sequencing after a fall. We can provide similar intervention for patients who are at risk for falling. Through the use of tools like errorless learning, spaced retrieval therapy, and vanishing cues, we can teach patients safety strategies and sequences to reduce their risk of falling.2
- Errorless learning helps people with cognitive impairment learn by providing cues in such a way to minimize errors rather than relying on trial and error learning.
- Spaced retrieval therapy allows people with memory impairment to learn specific information by gradually increasing the time before having the person recall.
- Vanishing cues promote independence with task completion by systematically reducing cues.
Reorder the steps
Many of us have worksheets that ask patients to reorder the 4-5 step task by placing 1-5 in the blanks. I usually avoid these when the primary goal is sequencing of walker and safe ambulation. If I aim to reduce falls, I try to be specific with my treatment tasks.
I still have patients reorder steps (in addition to many other functional tasks). Instead of worksheets, I’ll write down the steps for their individualized task sequence on index cards. I consult with a PT and OT to make sure I’m targeting each patient’s specific sequence. I also make sure that I write down and use steps in my patient’s words.
Once I’ve got the steps, I have patients rearrange them in the correct order. I may start by putting them all in order except one, and then have the patient tell me where that one goes in the sequence. Later, I’ll ask them to reorder the steps with all the cards mixed up.
I love using errorless learning and vanishing cues to address fall risk in patients who have cognitive impairment. I combine these tools by having patients teach me a correct transfer sequence.
This technique of gradually fading cues may look like this:
- Give the patient step-by-step written instructions
- Instruct them to tell you what to do as you complete the sequencing task. Often people will use gestures in addition to words.
- Provide verbal cues such as, “Look at number 1, what should I do first?”
- Use visual cues as well as the verbal.
- Figure out which steps they are close to mastering, and, before that step, have them tell you it without looking at the instructions. Continue to aid with verbal and visual cues.
- Use verbal and visual cues only, as the need for written instructions fades.
- Phase the verbal and visual cues out until you’re just saying, “and then…” to cue to the next instruction.
Eventually, they will no longer need cues to tell you how to complete the task.
A Varied Approach
An SLP’s role in fall prevention is multifaceted. To prevent a fall, it’s imperative that we identify cognitive impairment in patients and work to teach patients safety strategies and sequences. We can take advantage of learning tools such as errorless learning, spaced retrieval therapy, or vanishing cues in order to improve cognitive function and prevent falls.
- Blackwood, J., Shubert, T., Fogarty, K., Chase, C. (2015). Relationships between performance on assessments of executive function and fall risk screening measures in community-dwelling older adults. Journal of Geriatric Physical Therapy, 00, 1-8. DOI: 10.1519/JPT.0000000000000056Res
- Ehlhardt, L., Sohlberg, M., et al. (2008). Evidence-based practice guidelines for instructing individuals with neurogenic memory impairments: What have we learned in the past 20 years?. Neuropsychological Rehabilitation: An International Journal, DOI:10.1080/0960201070173319