Transcript Falls in the Elderly

Falls in the Elderly
A Geriatric Giant
Dr Gary Sinoff
Department of Gerontology
University of Haifa
Geriatric Giants
WHAT IS A FALL?
DEFINTION OF A FALL?
“An involuntary event producing a change in
posture resulting in an unplanned change in
position.”
Most falls are multifactorial in origin, resulting
from interaction between the impaired stability
of an individual and the hazards and demands
of the environment.
FALLS DEFINED
ACCORDING TO THE MERCK MANUEL OF
GERIATRICS :
A FALL IS ANY DROP FROM A HIGHER
TO A LOWER POSITION
Outline
 Frightening statistics
 An organized approach
 Intrinsic versus Extrinsic factors
 Physiological versus Pathological
 Preventative strategies
 Specific gait disturbances related to falls
FALLS !!!
 1 in 3 people over age 65 fall each year
 Falls incidence per Cochrane review 2009
 111 trials (55,303 participants)
 30% of older adults fall each year
 Increased to over 40% of elderly over 80
Keeping the hospitals
busy
10% of falls result in injury
5% result in fractures
5th leading cause of death in elderly
Bad prognostic indicator
65% of LTC residents with >6 falls were dead
within 2 years
 5.3% of admissions related to falls.
 8% of >70 will visit ER post fall during year.
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Let us learn from others
Every 18 seconds an
older adult is treated
in an emergency
department for a fall,
and every 35 minutes
someone in this
population dies as a
result of their injuries.
Osteoporosis and Fractures
Epidemiology of falls in elderly
MORTALITY
MORBIDITY
Consequences of falls
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Physical injury
Emotional trauma
Psychological problems – Fear of Falling
Social consequences
Financial impact
50% restrict activities after a fall
Message for you
 Falls rarely associated with single factor
 Intervention often reduces risk factors
without eliminating risk
 “Any condition which decreases ‘well
being’, will increase sway, reduce
stability, decrease judgement &
compensatory mechanisms and will
increase risk of falls”
When do falls occur?
Statistics show that most falls occur in
the daytime when people are more
active, around 11 am and between 4 pm
and 6 pm.
Where do people fall?
 50% of falls take place in and around the
home.
 25% of falls take place in public places
 21% occur in residential care environments.
Fractures due to a Fall by Location, Average
Annual Hospital Cases Ages 65+
400
350
300
250
85+
75-84
65-74
200
150
100
50
0
Home
Res/Inst
Other
Street
ABC’s of Why Older Adults Fall
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Age, ambulatory status, assistive device use
Balance, behavior at time of fall
Chronic conditions, cognitive deficits
Drugs
Exercise level, environment
Footwear & flooring
Which medical conditions
cause falls?
 Stroke/TIA
 Epilepsy
 Faints (syncope)
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postural hypotension
carotid hypersensitivity
syncope unknown cause
cardiac arrythmia
 Infection & sepsis
Multiple factors associated
with falls!
 Intrinsic physiological factors:
 vision
– dark adaptation
– cataracts?
– glare
 hearing??
 postural reflexes
– decreased sensory input
– decreased muscle strength
– changes in vestibular function
A few pathological factors
to consider
Neurological
 Parkinson’s
 Seizures
 Cerebrovascular disease
CVS
 MI
 Arrythmia
 Hypotension
More pathology
Metabolic
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Hypoglycemia
Anemia
Hypokalemia
Hyponatremia
GIT
 Acute bleeding
 Defecation syncope
Further pathology
GUT
 Micturition syncope
 Nocturia
Musculo-Skeletal
 Proximal muscle
weakness
 OA and lower extremity
pain
 Look at their shoes & feet
Shoes
How does psychiatry
interact with falls?
Psychiatric factors
 Dementia & cognitive impairment
 Depression
 “Fear of Falls” & Anxiety
Medicines from one family
This is geriatrics- always
think IATROGENIC
Medications associated with falls:
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diuretics
“antihypertensives”
sedative/hypnotics
antipsychotics
tricyclic antidepressants
others
Extrinsic Factors
Risk Factor for Falls
Visiting “the old folks at
home”
Extrinsic factors:
 Majority of environmental falls happen
during normal activities
 Stairs are #1
 other common spots:
• Bedroom transfers
• Kitchen cupboards
• Bath and toilet transfers
Preventing falls &
fractures
 Intrinsic factor assessment:
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Review medications
Check postural vitals
Optimize visual acuity
Review lower extremity disorders
Screen for psychiatric factors
Multidisciplinary Teamwork
Physician/Nurse Clinician
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Consultation with Family Physician
Comprehensive Assessment
Vision screen
Continent Assessment
Appropriate medical workup
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Screening blood tests
ECG
Syncope evaluation
Osteoporosis screen
Teamwork
 Physiotherapist / Occupational Therapy
 Evaluate motor strength, coordination, stability
 Cognitive evaluation to detect dementia
 Adapt Environment
 Dietician
 Evaluate overall nutritional state
 Review lab results
 Pharmacist
 Reviews all medications for interactions
 Social Worker
 Evaluates social and family situation
 Arranges community resources
Gait disorders in the
elderly: 5 main conditions
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Parkinsonism
Cerebrovascular disease
Frontal lobe gaits
Cervical spondolytic myelopathy
Sensory neuropathy (B12, DM, tabetic)
Goal: Break the Cycle
Fall
Fear of falling
Decrease in activity/
increased isolation
Unsteady gait
Muscle
deconditioning or
increased frailty
Risk Factors
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Female, Age >75
Living alone/housebound
Previous falls
Acute illness
Cognitive Impairment
Environmental Hazards
Risky Behaviors
Multiple medications (3 or more)
Gait problems
Falls history
Medication
review
Gait, balance
and mobility
Visual
impairment
Cognitive
impairment
Functional ability/
fear of falling
Multifactorial
assessment
Neurological
examination
Cardiovascular
examination
Urinary
continence
Osteoporosis risk
NICE guidelines
Risk Factors
Muscle weakness:
History of falls:
Gait or balance deficit:
Use of assistive device:
Visual deficit:
Arthritis:
Depression:
Cognitive impairment:
Age over 80 years:
4.4
3.0
2.9
2.6
2.5
2.4
2.2
1.8
1.7
AGS Panel on Falls Prevention J Am Geriatr Soc 2001
Applying the guidelines to the
individual
Treat any acute illness that precipitated the fall
Treat specific conditions affecting balance
Correct postural hypotension or arrhythmia
Rationalise medication especially psychotropic
agents
Correct visual impairment where possible
Physiotherapy: balance and strength training
OT: environmental hazard check, safety
awareness
Occupational Therapy
considers the physical context
 During Assessment
 Understand obstacles/barriers
 Consider individual, groups, populations who use the
physical space
 During intervention
 Reduce activity demands from the environment
 Insure adequate supports
 Facilitate performance though the use of the
environment
 Avoid further functional decline and excess disability
caused by environmental factors
How to stand up safely
 Sit on the edge of the bed/chair with feet
on the floor for a few minutes before
getting up.
 Stand slowly using both arms to push up
for support.
 Make sure you have good balance and do
not move off if you feel lightheaded or
dizzy.
 Use support when bending down and stand
back up slowly.
I HATE FALLING
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H
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E
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Inflammation of joints
Hypotension
Auditory and visual abnormalities
Tremor (PD)
Equilibrium
I HATE FALLING
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F
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G
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Foot problem
Arrhythmia
Leg-length discrepancy
Lack of Conditioning
Illness
Nutrition
Gait Disturbance
Gait and Balance
Evaluation
 Tinetti’s Gait and Balance Evaluation
 Get-Up-And-Go Test
Assessment of Balance
Test
Purpose
Discipline(s)
Patient Population
Timed Up and
Go (TUG)
Screening
All
Geriatric
MEOW
Evaluation and
Diagnosis
Physician
Geriatric
Berg Balance
Scale
Objective
evaluation
PT, OT
Frail elderly,
neurologically
impaired, low to midfunctioning adults
Vision/VOR
Objective
evaluation
MD, PT, OT
All
“MEOW”
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 Multifactorial
 Medical (Acute)
 Medical (chronic)
 Medicines
 Mental
 Maladaptive assistive devices
 Multifocal lens
 E
 Environmental
 Eyes
 Ethanol
 0
 Orthostatic hypotension
 OUCH! (pain)
 W
 Weakness in the lower extremities
Nnodim et al., Geriatrics 2005
Assessment of Balance
Test
Purpose
Discipline(s) Patient Population
Dynamic Gait Objective
Index (DGI) evaluation
PT, OT
All, medium to higher
functioning adults
Functional
Gait
Assessment
(FGA)
Objective
evaluation
PT
Adults with vestibular
impairment; has a
format that combines
with DGI
Tinneti
(POMA)
Screening
MD, PT, OT
Frail elderly, low to
mid-functioning adults
Multiple Task
Test (MTT)
Objective
evaluation
PT, OT
Parkinson’s Disease
Modern Technology
 An added benefit for preventing falls.
 Prevent fractures
Home Strategies
Hip protectors
Cochrane review 2006
 Meta-analysis of 11 trials in care home settings:
Reduction in incidence of hip fracture (RR 0.77 (95% C.I. 0.62-0.97)
(but weak cluster randomisation methodology in 7 trials)
 Meta-analysis of 3 individually randomised trials in community
settings: No reduction (RR 1.16 (95% C.I. 0.85-1.59)
 Poor acceptance (median 68%) and compliance rates (median 56%)
 Conclusion: hip protectors are ineffective for those living at home and
their effectiveness in an institutional setting is uncertain.
Parker et al. BMJ 2006
PREVENTION IS BETTER
THAN CURE
Next
Incontinence