Download Evidence Based Approach To Falls 2008

Evidence Based
Approach To Falls
Dr Larry Dian
Division Of Geriatric Medicine
U.B.C.
Evidence Based
Approach
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Epidemiology
 Falls are common; 50% for those 80
years and older fall yearly
 60 % of those with a history of a fall in
the previous year will have a subsequent
fall
 Most falls result in an injury of some type
 10% major injury, 5 % lead to
hospitalization, >70% fear of falling
Scenario 1
 You receive a call from the emergency
physician regarding your 86 year old
patient who is being sent home after
receiving sutures for a scalp laceration
that occurred after a fall. CT head
“normal”.
Acute Fall
Why did the person Fall?
5 Step Assessment
 Question 1: Did the fall result as a loss
of consciousness?
If yes: Sz. or Stokes- Adams
attack
EEG, 24 hour holter, echocardiogram
Micro burst of LOC likely not significant
Confusion or drowsiness after fall
somewhat supportive
Collateral history very helpful
If No Loss of Consciousness
 Was Fall preceded by dizziness?
Type 1: VertigoCentral/peripheral
BPV commonest
Type 2
Lightheadedness/ transient cerebral
hypo-perfusion/orthostatic hypotension
Type 3: “Dizziness of legs”/unsteadiness
Type 4: De-afferentation /psychological
If No Dizziness
 Was the fall associated with an acute
medical illness?
Atypical presentation
Delirium
“Round up all the usual suspects”
If No Acute Illness
 What was the mechanism of the fall?
Be as precise as possible recreating
actions before and after the fall
Avoid leading questions; patients
may not remember
Collateral history very useful
If No Mechanism For Fall
 Falls are either multi-factorial or lower
limb weakness
 “Just Fall” fall –eccentric weakness of
quadriceps muscle
5 Step Algorhythm
 Provides a rational strategy for
mechanistic determination of the fall
 Provides a strategy for fall risk reduction
Scenario 2
 The family of your 89 year old patient
wants your opinion about moving their
reluctant mother in a nursing home
because of the concern that she might
fall and “hurt herself”
Risk Factors
 Past history of a fall
 Psychotropic drug
use
 Lower extremity
 Arthritis
weakness
 History of stroke
 Age
 Orthostatic
 Female gender
hypotension
 Cognitive impairment
 Dizziness
 Balance problems
 Anemia
Chronic Diseases
 Parkinson's disease
 Osteoarthritis of the knee, feet ankle
 Cognitive impairment (mmse 18-23) 2x
increased risk of falls
 Risk increases with increasing number of
chronic diseases
 Number and type of medications
 Alcohol use
Targeted Physical Exam
 Cardiovascular system
 Central nervous system
 Musculoskeletal system; lower limbs
Targeted Physical Exam
 Postural blood pressure
 Heart failure, Atrial fib, Aortic stenosis
 Mental status, Parkinson’s disease, stroke
peripheral neuropathy, visual acuity
 Arthritis of knees feet, podiatric problems
 Strength of hip flexors, ankle dorsi-flexors
 Environmental factors, footwear, mobility aids
Supplemental Tests
 Get Up and Go Test
 Functional reach test
 Sternal nudge test; unipedal and tandem stance
Get Up and Go Test
 Have the patient sit in a straight-backed
high-seat chair
 Instructions for patient: Get up (without
use of armrests, if possible)
 Stand still momentarily
 Walk forward 10 ft (3 m)
 Turn around and walk back to chair
 Turn and be seated
Get Up and Go Test
Factors to note:
 Sitting balance
 Transfers from sitting to standing
 Pace and stability of walking
 Ability to turn without staggering
Diagram of functional reach test to
assess balance in elderly persons
e-mail this to a colleague
Therapy
 Address medical issues
 Review home environment
 Provide appropriate walking aid
 Gait and balance exercise training
 Falls are not random events
 Falls are common and are associated
with significant morbidity and mortality
 Standardized assessment tools exist
 A coherent mechanism can be
developed in most cases
 Consider referral to falls clinic in complex
cases