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Download Falls in Older Adults - Emory University Department of Medicine
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Joseph G. Ouslander, MD Director, Boca Institute for Quality Aging University of Miami Miller School of Medicine at Florida Atlantic University and Thomas Price, MD Division of Geriatric Medicine and Gerontology Emory University School of Medicine FALLS IN OLDER ADULTS 2008 UPDATE Learning Objectives Review the epidemiology and consequences of falls in the elderly Identify common risk factors for falls in this population Identify the pros and cons of prevention and management strategies Falls Case Mr. C. is an 89 year old man who is referred to you for the evaluation of dizziness. His daughter says that he has fallen 3 times in the past month after discharge from the hospital for a “small heart attack and heart failure”. Mr. C. has no prior history of falls. Falls Case Past Medical History: Coronary artery disease Hypertension Congestive heart failure (chronic, systolic) Degenerative joint disease mainly of the right hip and knee Insomnia Falls Case Medications: Furosemide 40 mg BID K-dur 20 meq daily Enalapril 10 mg daily Carvedilol 6.25 mg po BID Simvastatin 20 mg PO QHS Nitroglycerin 0.4 mg/hr patch TOP 12 hours per day Propoxyphene/Acetaminophen 1 tab Q4hr PRN pain Amitriptyline 50 mg po QHS prn insomnia Falls Case Further history reveals that each fall occurred in the morning after breakfast. He gets up, and when he starts walking he feels “light-headed”. The sensation eases when he lies down. He has not to his knowledge passed out or sustained any severe injury with these falls. There is no history suggestive of a seizure. Falls Case Physical Exam: GEN: No signs of trauma Vitals: Sitting 102/58;66 Standing 88/52;72 (after 2 minutes) Heart: RRR +s1,s2 no s3, s4; 2/6 SEM at apex Lungs: Mild rales bilateral bases MS: Reduced ROM rt hip with pain on internal rotation; crepitus and pain with flexion of the rt knee Neuro: No peripheral proprioceptive/fine touch abnormalities; ear exam shows minimal cerumen; Dix-Hallpike maneuver to elicit nystagmus is negative Falls Case Get Up and Go observation reveals: Difficulty arising without physical assistance Negative Romberg test Abnormal gait due to guarding his right side Difficulty and imbalance when turning Falls Case What do you think is contributing to Mr. C’s falls? What diagnostic tests would you order? What interventions would you implement? Falls Definition A fall is defined as a sudden, uncontrolled, unintentional, downward displacement of the body to the ground or other object, excluding falls resulting from violent blows or other purposeful actions. An unwitnessed fall occurs when a patient is found on the floor and neither the patient nor anyone else knows how he or she got there. Epidemiology Annual incidence in patients >65y 35-40% of community dwelling older persons Rates increase threefold if in NH or hospital Injury rate 1 in 20 require hospitalization 75% of falls-related deaths occur in patients >65y Falls a major reason for NH admission (40%) Tinetti NEJM 348:1, 2003 Morbidity of Falls Soft tissue injury Fractures Intracranial bleed Rhabdomyolysis Reduced Mobility NH admission Death Restraint use Fear of Falling Prognosis of Falls Falls occur in both frail and healthy older persons Single falls are not necessarily an indicator of poor prognosis Multiple falls are associated with disability and poor health outcomes Multiple falls are a marker for other underlying conditions that put older persons at increased risk for adverse health outcomes Contributors to Falls Contributors to Falls Community-Dwelling: 41% environment related 13% weakness, balance or gait disorder 8% dizziness or vertigo Nursing Home: 16% environment related 26% weakness, balance or gait disorder 25% dizziness or vertigo Rubenstein, et al. Ann Intern Med 1994;121;442 – 451 Intrinsic Risk Factors for Falls Risk Factor Relative Risk (OR) 1. Muscle Weakness 4.4 2. History of falls 3.0 3. Gait deficit 2.9 4. Balance deficit 2.9 5. Use of assistive device (walker, etc) 2.6 6. Visual impairment 2.5 7. Arthritis 2.4 8. Impaired ADL 2.3 9. Depression 2.2 10. Cognitive impairment / dementia 1.8 AGS Panel on falls prevention, JAGS 49(5):2001, 665 Extrinsic Risk Factors for Falls Environmental hazards Loose rugs, cords, etc Iatrogenic Medications Behavioral Alcohol, poor judgment, impulsiveness Clothing Poorly (loose) fitting clothes and footwear The Morse Fall Risk Assessment Tool Morse Fall Scale High Risk: 45+ Med Risk: 25 – 44 Low Risk: 0 – 24 Everyone may score high risk in a nursing home environment Adjust score based on your patient population Simplified Risk Factors 100% chance of fall in one year for all three of the following: More than three medications Hip weakness Unstable balance Clinical Assessment and Management Falls History Medication Use Vision Postural BP Balance and Gait Neurologic exam Musculoskeletal exam Cardiovascular exam Post-discharge home-hazard evaluation Falls History SPLATT Symptoms Previous falls Location Activity Time Trauma Falls History Detailed history of the fall Activity, environmental factors Symptoms: Postural lightheadedness Syncope / near syncope Vertigo Seizure Circumstances of any previous falls Alcohol intake Assessment for acute illness (e.g. dehydration, infection, acute cardiac or neurological symptoms) Medication Use Assessment Evaluate for high-risk medications Four or more medications Management Discontinue or replace potentially harmful medications High-Risk Medications Serotonin-reuptake inhibitors Tricyclic antidepressants Alprazolam, clonazepam, lorazepam Anticonvulsants Haloperidol, risperidone, quetiapine Benzodiazepines Nortriptyline Neuroleptics Sertraline, fluoxetine Phenobarbital, phenytoin Class IA antiarrhythmics Procainamide, quinidine Tinetti NEJM 348:1, 2003 Vision Assessment Mid-range and far vision using Snellen wall chart Check peripheral vision/visual fields Light reflex (cataracts) Management Referral to ophthalmologist Avoid bifocals when walking Improve lighting in enclosed areas of home Postural Blood Pressure First 5 minutes SUPINE Then check BP Then STAND Immediately check BP Wait 2 minutes Then check BP Positive test if SBP drops 20% or more either immediately or after 2 minutes Postural Blood Pressure Assessment Check for 20mm Hg (or 20% drop) in systolic pressure with or without symptoms Pulse not as reliable an indicator in older patients Management Check for acute or chronic causes Hydration, compensation strategies (pressure stockings, etc) if idiopathic Balance and Gait Assessment Patient’s report Get up and Go test Management Diagnosis and treatment of underlying cause Medications that cause gait imbalance (see above) Environmental obstacles modification Referral to physical therapist for gait/progressive balance training, assist device Neurologic Examination Assessment Proprioception Cognition Neuromuscular (Parkinsonism, etc) Management Diagnose and treat underlying cause Medication adjustment Reduction of environmental risk factors Physical Therapy Evaluation Musculoskeletal Examination Assessment Joints and range of motion (arthritis) Foot exam (ulcers, fallen arch, etc) Strength testing (Get Up and Go) Management Identify and treat underlying causes Physical therapy referral Podiatry referral The Get Up And Go Test Time it takes a patient to get up from a seated position, walk 8 feet, then sit back down Patient must rise from chair without use of hands If takes more than 8 seconds, then patient has high fall risk Cardiovascular Exam Assessment Syncope (Tilt) Arrhythmia (ECG) Management Referral to cardiologist Assessment of cardiac anatomic and electrophysiologic status (echo, signal avg. ECG) Prevention Strategies Chang et al. BMJ 2004 Meta-analysis comparing 40 trials Effective falls reduction is achieved only when assessment is coupled with aggressive management Referral is not sufficient When actively managed, falls were reduced by a composite 37% Chang et al. BMJ 328(7441): 2004 Prevention Strategies New Zealand Falls Intervention (2007) Intervention: At-home nurse evaluation of risk factors and referral to community interventions and/or PT Population: 312 patients with history of falls, avg. age 81, F>M No statistical significance between intervention and control group Elley et al. JAGS 56(8), 2008 Prevention Strategies Maastricht GP Cooperative study (Netherlands, 2007) Intervention: Medical/OT eval with recommendations and referral if needed Population: 333 persons >65 yo, F>M with recent fall No statistical significance between intervention and control groups in # new falls, fear of falling, or activity avoidance Hendriks et. al JAGS 56(8), 2008 Prevention Strategies Multifactorial evaluations useless without aggressive pursuit of treatment Elements of the multifactorial evaluation: -- Orthostatic BP -- Vision testing -- Balance and gait testing -- Drug review -- IADL/ADL assessment -- Cognitive evaluation -- Assessment for environmental hazards Prevention Strategies Bang for the buck? Balance and gait training reduction Reduction in home hazards Stop psychotropics Multifactorial risk E&M Balance and strength exercise* = 14-27% = = = = 19% 39% 25-39% 29-49% * Community based Falls Case Mr. C. is an 89 year old man who is referred to you for the evaluation of dizziness. His daughter says that he has fallen 3 times in the past month after discharge from the hospital for a “small heart attack and heart failure”. Mr. C. has no prior history of falls. Falls Case Past Medical History: Coronary artery disease Hypertension Congestive heart failure (chronic, systolic) Degenerative joint disease mainly of the right hip and knee Insomnia Falls Case Medications: Furosemide 40 mg BID K-dur 20 meq daily Enalapril 10 mg daily Carvedilol 6.25 mg po BID Simvastatin 20 mg PO QHS Nitroglycerin 0.4 mg/hr patch TOP 12 hours per day Propoxyphene/Acetaminophen 1 tab Q4hr PRN pain Amitriptyline 50 mg po QHS prn insomnia Falls Case Further history reveals that each fall occurred in the morning after breakfast. He gets up, and when he starts walking he feels “light-headed”. The sensation eases when he lies down. He has not to his knowledge passed out or sustained any severe injury with these falls. There is no history suggestive of a seizure. Falls Case Physical Exam: GEN: No signs of trauma Vitals: Sitting 102/58;66 Standing 88/52;72 (after 2 minutes) Heart: RRR +s1,s2 no s3, s4; 2/6 SEM at apex Lungs: Mild rales bilateral bases MS: Reduced ROM rt hip with pain on internal rotation; crepitus and pain with flexion of the rt knee Neuro: No peripheral proprioceptive/fine touch abnormalities; ear exam shows minimal cerumen; Dix-Hallpike maneuver to elicit nystagmus is negative Falls Case Get Up and Go observation reveals: Difficulty arising without physical assistance Negative Romberg test Abnormal gait due to guarding his right side Difficulty and imbalance when turning Falls Case What do you think is contributing to Mr. C’s falls? What diagnostic tests would you order? What interventions would you implement? Falls Case Contributors Arthritis of hip and knee Vasodilators (nitroglycerin) Iatrogenic cognitive impairment? (propoxyphene, amitriptyline) Post-prandial orthostasis? Postural hypotension (too much BP med?) Proximal muscle strength weakness Balance disorder Falls Case Diagnostics Basic Labs (volume depletion? Diabetes?) Comprehensive chemistry Complete blood count (orthostasis) Other labs B12 level abnormal? CT of head? Assessment of thyroid function? Cognitive performance test (MMSE) Falls Case Interventions Physical therapy for gait training and strengthening Replace amitriptyline with alternative agent, or discontinue completely Same with propoxyphene Home safety assessment Adaptive? Summary Falls are common in both community and institutionalized older persons Associated with significant morbidity and mortality Most falls are multi-factorial Evaluation should be directed towards identifying multiple contributory risk factors Multi-modal interventions can decrease the incidence of falls and fall-related injuries
