Download Falls - POGOe

Falls
Sara Bradley and Christine Chang, MD
Brookdale Dept of Geriatrics and Adult Development
March 4. 2008
10:00-10:40
Objectives
By the conclusion, learner will be able to:
1. List 5 potentially modifiable risk factors for
falls in older community dwelling adults.
2. Conduct a physical exam specific to falls,
including a gait assessment.
3. Discuss 5 evidenced-based interventions
that can reduce future falls.
Falls
Definition:
•
Unintentional change in position,
coming to rest at a lower position
•
Not due to an overwhelming
intrinsic or environmental cause
•
No loss of consciousness
Epidemiology of Falls
• 30% of ambulatory + 50%
institutionalized elderly fall each yr1,2
• ½ falls result in injury
(10-15% in fractures)3
• ¼ of all fallers limit their activities
and lifestyle due to fear of falling4
1. Tinetti, ME et al. NEJM 1988; 319:1701. 2. Thapa, PB, et al. JAGS 1996; 44: 273. 3. Nevitt, MC, et al.J
Gerontol 1991; 46:M164. 4. Tinetti, ME et al. J of Gerontol A bio Sci Med Sci 1998; 53: M 112
Cost of Falls
• 6% of Medicare costs
• 15% of ED visits for 65+ years
• Extra $24,000/person/year health
costs
• Totals $19 billion/year
Sattin RW. Annu Rev Public Health 1992;13:489-508.
Runge JW. Med Clin North Am 1993;11:241-53.
Theory of Why People Fall
Falls occur when:
• Older adults who are predisposed
because of accumulated effect of
diseases / impairments (intrinsic)
• Are exposed to precipitating
challenges (extrinsic)
Case Part 1
Question
What questions do you want to ask
Sally Johnson about the fall?
Evaluation of Falls: History
• Describe fall
• Ask questions to R/O syncope
• Use systematic method to look
into etiology of falls
Details of the Fall
• Sally Johnson lives alone in her 2 story house
• Patient fell 2 days earlier while rushing to answer the
phone as she was putting away the groceries
• Felt unsteady just prior to the fall as she tripped on
kitchen mat. Was wearing shoes. Adequate lighting.
Was able to get up right way. Uses no assistive walking
devices at baseline
• Reports new left arm pain immediately after the fall.
Scattered bruising and swelling of Left forearm. Warm
compresses and Tylenol prn has been helping
Details of the Fall
• No Head trauma, LOC, syncope or presyncope, vertigo,
visual changes, bowel or bladder incontinence, eating
and drinking as usual, no medication changes.
• Prior fall was 1 year ago while rushing down the stairs.
No injury was incurred.
• Had many near falls while running barefooted on waxed,
wooden floors.
Details of Chronic Diseases:
DM with peripheral neuropathy
• Has had no hypoglycemic episodes
• BS running around 120-180’s
• Last hbA1c=7%
• Last eye exam was 1 year ago. No retinopathy
but does wear bifocals
HTNhas been well-controlled recently
Atrial fibrillationhas had no sxs. INR was 2.1 a
week ago
Details of Chronic Diseases:
R hip OA
• Has R hip ache with overexertion and with cold,
rainy weather
• Heating pad and Tylenol prn has been helpful
Depression + insomnia
• Controlled with use of citalopram 10 mg and
zolpidem 10 mg nightly
• Does not drink alcohol
Case Part 2
Question
Are there any other physical exam
maneuvers you would want to
perform on Sally Johnson?
Evaluation of Falls: Physical
1. Check orthostatics
2. Perform a visual exam
3. Evaluate cognition
4. Gait Assessment:
Motor + Balance + Coordination
Evaluation of Falls: Physical
Motor Assessment:
Quad strength:
Can rise from chair without using arms
Evaluation of Falls: Physical
Balance Assessment:
3 Stances
One leg stand
Evaluation of Falls: Physical
Coordination Assessment:
Abnormal if:
Hesitant start
Broad-based gait
Path deviates
Heels do not clear toes of other foot
Extended arms
Answer
• Orthostatics: 135/70 88 sittingstanding 122/70 100
• Eye: +cataract. visual acuity: 20/40 L and 20/80 R.
Corrected with bifocals
• Gait:
-Motor: Bilateral Quad weakness+, 3 chair rise >10 sec
-Balance: semi tandem and tandem stances <10 sec, one
leg stand< 10 secs
-Gait: Hesitant at start but walks with normal path, walks
with extended arms, no wide based gait, no foot drop, heel
clears toes of other foot. Slow turn with outstretched
hands
• Cognition: 1/3 on 3 item recall
• Neuro: No Parkinsonian features or focal weakness
Question
What are the possible predisposing
‘intrinsic’ risk factors and ‘extrinsic’
precipitants of Sally Johnson’s fall?
Answer
Multi-factorial
1) Immutable predisposing factors:
Age, female and prior history of falls
2) Modifiable predisposing and precipitating
factors
Modifiable Predisposing and
Precipitating Factors:
1.
Mild weakness + moderate balance impairment
2.
Has cataracts + refractive error +wears bifocals
3.
Takes 4+ medications, including high risk
meds bp meds, digoxin, citalopram and
zolpidem
4.
Borderline orthostasis
5.
?Cognitive impairment, depression
6.
?Unsafe environment and behaviors
(kitchen matt, waxed floor. barefoot, rushing)
Question
What evidenced-based interventions
can you recommend to prevent
future falls for this patient?
Diagnostic Testing
Routine:
•
Cbc, comprehensive chem, B12, Tsh
•
Drug levels, INR
As indicated:
•
EKG/Holter & other cardiac tests
•
Imaging
•
EEG
•
Vestibular testing
Fall Prevention
Evidenced-based single intervention
strategies
Interventions of unknown
effectiveness
Multi-factorial assessment with
targeted interventions
Gillespie L, et al. Cochrane Database Syst Rev. 2003; 4: 2005 update
Effective Single Interventions
Professionally supervised strength & balance
training, ↓falls ~20% (3 trials)
Tai Chi group exercise ↓falls 49% (1 trial)
Home modification in patients with h/o falls,
↓falls ~34% (3 trials)
Withdrawal of psychotropics ↓falls by 63% (1 trial)
Cardiac pacing in pts w/ carotid sinus
hypersensitivity ↓falls by 58% (1 trial)
Gillespie L, et al. Cochrane Database Syst Rev. 2003; 4: 2005 update
Interventions That May Be Effective
Expedited Cataract Surgery
Decreased the risk of recurrent falls by 40% & all
falls by 34% with decreased disability &
improved QOL1
Vitamin D & Calcium
Meta-analysis found vitamin D supplementation
reduced the odds of falling by 22%, NNT 152
1. Harwood RH, et al. Br J Optalmol. 2005. 2. Bischoff-Gerrari HA, et al. JAMA 2004
Not Proven Effective
Non-specific group exercise
Targeted leg strengthening
Nutritional supplements
Cognitive behavioral approach
Hormonal therapy
Home hazard modification in non-fallers
Multifactorial Assessment
With Targeted Intervention
Most commonly studied &
consistently effective
20+ trials showing 27% (2-37%) fall
risk reduction for community
dwelling older adults
Multifactorial Assessment
With Targeted Intervention
Effective components:
Balance training: 7/7 trials+
Gait, assistive device: 4/4 trials+
Environmental Modification: 9/11
trials+
↓Psychoactive meds: 4/4 trials+
Multifactorial Assessment
With Targeted Intervention (cont)
Effective components:
↓Other meds: 4/4 trials +
Manage orthostasis: 2/2 trials +
Manage other CV & medical
conditions: 2/3 trial +
Cardiac pacing: 1+ trial
Fall Prevention in Practice
Identify Patients At Risk

70+ with h/o 2 or more falls or 1 injurious fall
OR self-reported or observed difficulty with
mobility

Ask at least annually about falls
Assess & manage the health
problems that increase fall risk
Therapeutic Approach
Identify & treat immediate underlying
causes & predisposing risk factors
Review & reduce meds
Manage postural hypotension
PT/OT evaluation for strength, balance,
& gait training
Environmental modification
Medication Review
Decrease meds, esp psychotropics
(benzos, sedatives, anti-depressants)
Taper to lowest effective dose or stop
Consider need for all meds before
adding new one
Prescribe non-pharmacologic
treatments
Advise pt to carry up-to-date med list
Postural Hypotension
Frequently unrecognized
Adequate hydration
 ½ c. water every ½ hr for first 8 hrs of day
Liberalize salt in diet
Reduce meds that contribute
Teach patients to change position slowly
PT/OT Evaluation
Gait & strength assessment & training
Balance training
Exercises that challenge stability yet are safe
 Tai chi

Assistive devices

Recommendations for & regular inspection
Appropriate footwear

High box, low heel, thin sole
Environmental Modification
Home safety assessment

By pt or caregiver using checklist, MD at home
visit, or visiting nurse
Hazards include:
Clutter
 Electric cords
 Slippery throw rugs & loose carpet
 Poor lighting

Optimize Disease Management
Vision
Test acuity, eval for cataracts, ophthalmology
referral
 Patient education
 Allow time for eyes to accommodate to
changing level of light
 Do not walk using bifocals or reading
glasses

Osteoporosis

Consider vitamin D, bisphosphonates
Clinical Pearls
Screen all pts >70 yrs for falls at least
yearly
Evaluate the circumstances of the fall
Systematically evaluate for modifiable
predisposing factors and precipitants
•
•
•
•
•
Motor/balance/gait
Environment
Medications
Vision
Disease management, including cognition
Acknowledgment
Thanks to Dr. Helen Fernandez