Download Falls Clinic Medical Introduction Learning Objectives

FALLS PREVENTION PROGRAM
SENIORS WELLNESS CLINIC
TORONTO WESTERN HOSPITAL
Preceptor:
Robert Lam MD, CCFP (Care of the Elderly)
Certificate of Added Qualifications in Geriatric Medicine (American Board)
Location:
8 East, Toronto Western Hospital, 399 Bathurst Street, Toronto
Time:
Monday afternoons
Introduction: This out-patient interdisciplinary consultation service receives referrals
from the Family Health Centre @ TWH, community family physicians, UHN specialty
clinics (eg. Neurology - movement disorders clinic, memory clinic). Patients are usually
over the age of 65 years and live in their own homes but due to multiple medical
problems, deconditioning and overall “frailty’, they are at high risk for falling. Four
patients will be assessed by an interdisciplinary team consisting of OT, PT, SW, nursing,
dietary and medicine to optimize each patient’s physical and cognitive function. Safety
issues in the home are also addressed and CCAC services can be arranged.
One third of community-dwelling seniors fall each year. Many of these are unreported
for fear of institutionalization. The majority (80%) of trauma admissions to hospital in
the elderly are due to falls (www.cihi.ca). Hospitalists certainly treat medical issues such
as fractures and dehydration but the issue of future falls prevention is not as easily
addressed by medicine. This is where the falls clinic is helpful. It is proven that an
interdisciplinary approach including optimization of medications by pharmacy, gait
assessment and training by physical therapy and home hazard assessment by occupation
therapy is helpful (Cochrane review of falls).
Learning Objectives:
1. Assessment of falls (sensory, cerebral processing, motor/skeletal)
2. Assessment of cognitive impairment (cognitive aging, MCI or dementia).
3. Assessment of depression and anxiety in the elderly. Optimization of insomnia.
4. Management of common medical issues with presentation in the elderly (eg.
Systolic hypertension, stroke, subdural hematomas, atrial fibrillation, coronary
artery disease, congestive heart failure.
5. Management of osteoarthritic pain.
Particulars: You will be responsible for reviewing the patients falls history. Nursing
also contributes to the history of present illness but try to focus on the details of the fall.
Usually patients presenting to our clinic do not have symptoms of lightheadedness or
vertigo but rather say that they “lost their balance” and ended up on the floor. Review
their medications to see if there are any sedating medications. Social history should
include possible alcohol intake. A review of systems pertaining to falls is also important
and should include any memory complaints, visual or hearing disturbance, palpitations,
chest pain, urinary incontinence or painful joints.
Physical exam should include postural vitals (done by nursing) and any abnormalities in
heart rhythm. A complete exam is expected including cardiac and pulmonary systems
but a neurologic exam is often an area of focus. Check coordination for rapid rhythmic
alternating movements. Finger point-to-point cerebellar testing. Check sensory systems
including proprioception and vibration sense. A Rhomberg test is helpful. Also check
reflexes and muscular strength (done by physiotherapist) looking for any focal
neurologic deficits. A helpful test is whether a patient can rise from a chair without using
his/her arms. Finally assess the patients gait using their walking aids. Heel to toe
walking often reveals balance deficits even in the most stable looking patients.
After taking the history and completing a physical exam, try to formulate an impression
that postulates an etiology to the patient’s falls. Does the patient have sensory, cocordination or motor deficits? Painful joints? Extrinsic factors may also play a role such
as unsafe home surroundings (eg. lighting, stairs, ice outside). A multifactorial etiology
is usually present.
Our medical assessment is important but surprisingly not usually helpful in preventing
future falls. It is the ongoing falls program that makes the biggest impact. We will
present our findings at the end of the day during interdisciplinary rounds and try to come
up with practical recommendations for the referring physician. There is a summary sheet
of recommendations that we will fill out together as an interdisciplinary team.
Residents will also be responsible for dictation a note to the referring physician with a
copy to the family physician. Please dictate the history including the medication list and
relevant review of systems. Also dictate the physical examination and include the FES,
Berg balance, TUG scores. It would also be helpful to include the normal values in your
letter. Finish the dictation with the interdisciplinary team’s summary of
recommendations.
The charts can be left in the RGP room on 8 East for Carol Banez, Clinical Nurse
Specialist.