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Geriatric Falls for the
Inpatient Physician
Translating Knowledge into Action
Ethan Cumbler M.D.
Associate Professor of Medicine
Director UCH Acute Care For Elderly Services
University of Colorado
Anshcutz Medical Campus
IMPACT

30-40% of people over age 65 will have a fall
each year
 The percentage higher for patients who reside in
nursing homes
 In an elderly patient who has fallen, the risk of
having a second fall within a year rises to 60%
 8% of all people over age 70 will present to the
ER each year after a fall. 1/3 will be admitted

Think about how many ED visits that creates….
Consequences
 Many
falls cause minor or no injury. Skin
tears and lacerations may require ED
treatment but generally cause no lasting
harm.
 Between
5 and 10% of community dwelling
elderly patients who fall (up to 20-30% of
elderly patients overall) will suffer a serious
injury
 What
injuries are particularly problematic?
Injuries
 Hip
Fractures-1% of falls in the elderly
lead to hip fx
 20-30%
¼
mortality in the year after hip fx
to ¾ of patients do not recover prior
level of ADLs
Injuries

Prolonged lie- 1/2 of elderly are unable to get back up



Subdural Hematoma


2o rhabdo, dehydration/ARF, pressure ulcers
What duration of unrelieved pressure does it take to
create skin damage?
What changes to the structure
of the brain as patients age
increase the risk of SDH?
Rib Fractures

Mortality 12% with 1-2 rib fx.
Rising to 40% in patients with 7 or more fx
Post Fall Anxiety Syndrome
Self-limiting activity, worsening deconditioning, social isolation

Picture the Geriatric
Fall as a node on a
decline spiral
 Probably not the first
step in the decline


Fall as symptom of
underlying frailty
Frequently will create
a marked acceleration
of decline
photoeverywhere.com
Risk Factors

Prototypical Geriatric Syndrome
 Multifactoral
 More than 20 separate risk factors for falls have
been identified.

Very quickly how many can you think of?
Risk Factors

The factors interact in a dynamic and
exponential fashion. 27% of patients with 0-1
risk factors will have a fall compared to 78% with
>4 risk factors
 Unfortunately creating a list is not a particularly
helpful exercise in practical patient care.
 Some of these risk factors are non-modifiable
(female gender) and for others effective
treatment seems limited (peripheral neuropathy).
 There are so many that it takes significant time
just to recall them all.

We are likely to always miss a few.
A Brief Diversion…
Jam
In Malcolm Gladwell’s book on cognition “Blink”,
he describes a fascinating psychology
experiment.
 A sample table is set up at two grocery stores for
customers to try a sample of jam.
 One table has 6 varieties of jams, the other has
24 selections.


Which table do you think sold more jam?
 The
table with only 6 varieties sold far
more jam.
 This might seem counter-intuitive but the
reason lies in the human psyche.
 Faced
by too many choices, customers
freeze up and make no decision at all.
Why are you telling me about jam?

“Multiple Alternatives Bias”


In multi-factoral geriatric syndromes such as falls,
physicians frequently treat only the sequelae of the fall


Physicians faced with multiple possibilities unconsciously ignore
some of them in order to make a list which, while incomplete, is at
least more mentally manageable.
Missing opportunity to intervene to prevent future injury
The multiplicity of contributors seems overwhelming“possibility paralysis”
A New Conceptual Framework

We are going to break down the fall into its component parts

Latent risk for fall



Physiologic changes of aging
Disease and medications
Behavioral traits

Environmental trigger- the “accident”

Underlying frailty/vulnerability- the injury

Each step will lead to concrete actions to reduce the risk of
future injury!
Postural
Challenges
Of Aging
OPPORTUNITY FOR INTERVENTION
↓Baroreceptor Sensitivity
↓Balancefrom vestibular and proprioception
↓vision (esp night)
↓reflex speed for correction
5) Behavioral Measures (in supervised environment)
Fall Risk
Dehydration/diuretics
Bp meds causing orthostasis
Benzodiazepines
Psychotrophics
Anticholinergics
Alpha antagonists
Parkinsons
Neuropathy
Arthritis
podiatry problems
↑impulsivity
(esp in dementia)
Behavioral
Contributors
1) Physical therapy
2) Sensory Aids
(glasses)
3) Ambulation/Gait Aids
(4 prong cane, walker)
4) Review Medication list(remove problematic meds)
Environmental Trigger
“Accident”
•
•
Bed Alarms for dementia with impulsivity
Scheduled toileting
Medications
And
Comorbidities
5) OT Home Safety Eval
-rugs
-lighting
Fall
Frailty
Osteoporosis
Decreased muscle
speed to deflect injury
INJURY
-cords
-rails
6) Calcium+Vitamin D/Bisphosphonate
Bisphosphonate for prior frailty fx or known O/P
Vitamin D level
7) Hip protectors?
(uncertain benefit)
Prevention of Future Injury

Evidence suggests that for at-risk elders a
multi-pronged targeted prevention strategy
such as this can reduce the risk of future falls
What about Tests?
 No
specific laboratory or imaging testing is
indicated in the absence of clinical
correlation

Vitamin D levels are recommended by some authors
• Deficiency associated with falls as well as fractures





If anemia or dehydration suspected, CBC and Chem7 reasonable
Similarly, urinalysis, B12 levels and TSH are reasonable if driven by other
clinical cues.
Echo is only indicated if exam suggests valvular disease.
In the absence of syncope, chest pain, or palpitations, EKG is low yield and
holter monitoring not proven to be of benefit.
Spinal or brain imaging is indicated only if neurologic findings on exam
suggest lesion (or significant head injury from the fall)
Inpatient Falls

Falls with injury in the hospital are a JCAHO
mandated reportable event
 How do you reduce the risk of an event which
rarely occurs in the presence of the
physician?
Risk Assessment- Physicians




How do we as physicians assess a patient’s risk for
inpatient falls?
For the most part, physicians pay little or no attention to
this issue on a general medical ward.
Reliable solutions require systems change.
You can standardize a simple physician assessment for
fall risk in elderly patients. Two- question falls screen:



Have you fallen in the last month?
Are you afraid of falling?
You can perform a witnessed Get-Up-And-Go test

Pay attention and you learn a lot of information about strength, balance,
and gait in 30 seconds.
WORKSHOP

Using the example of a patient you have admitted
in the last 48 hours, would you rate their risk of
inpatient fall as low, moderate, or high?

How do you think the nursing staff rated this
patient’s fall risk?

Where would you find the nursing assessment?

What changes does the hospital system put in
place for patients at moderate or high risk?

What changes can we as physicians institute to
reduce the risk of falls?
SAMPLE CASE
Risk Assessment-Nursing
Hospital Fall Prevention Measures
Triggered By A High Risk Patient
What Changes Can You Make For
The Patient Identified In Your Case
Physician Measures to Reduce
Hospital Falls





Recognition of patients at increased risk should cause us
to critically examine the orders we are writing which
influence chance of inpatient falls.
Review med list to determine if some medications should
not be continued
 For instance, be more hesitant to allow zolpidem for
sleep in the unstable patient with nocturia.
Minimize Patient Tethers
 Heparin/LMWH instead of SCDs for DVT prophylaxis
 Early elimination of IV drips
 Early removal of urinary catheters
Involve PT/OT/Assisted ambulation rather than
independent ambulation for moderate+high risk patients
Schedule toileting
Thought Experiment

If you were in charge of the hospital what
systems changes would you put in place to
reduce the risk of hospital falls or resultant
injury?