Transcript webmedia.unmc.edu

Goals:
 To
reduce the number of falls in the
elderly
 To reduce the degree of injury
from falls in the elderly
Objectives
 The
learner will
 1) recognize the significance of falls
 2) understand the etiologies of falling
 3) list the appropriate evaluation of a
fallen elder
 4) list the appropriate evaluations and
treatments to prevent falls
Why Important ?
 Incidence

Falls per year

1/3 community
1/2 Nursing home
Most frequent cause of
accidental injury for age > 75
50% minor injury
5% fractures (not hip)
2% hip fracture
10% serious (other)


 Morbidity



 Mortality


2% of injurious falls- FATAL
(1/2 of these are hip
fractures)
Why Important ?

FUNCTION
 50% need help to
get up
 3% lie helpless for
for > 20 minutes
 40-73% fear falling
and 1/2 of these
restrict activities
based on fear.

Complications
from falls
 leading cause of
death due to injury
in all > 65 y.o.

Kiel P. Falls , Geriatric Review
Syllabus
Causes: of community dwellers

Accidents (environment related) 41%
 Medical illnesses
17%
 Gait/balance disorders
13%
 Drop attacks
13%
 Dizziness/vertigo
8%
 Unknown
6%
 Confusion
2%
 Postural hypotension
1%
 Visual disorder
0.8%
 Syncope
0.4%
“Grail Quest”
Rule #1:
“It’s never only one thing,
Always look for multiple
factors causing falls”
“Why Granny Goes Down”
Normal Postural Control & Aging

What keeps us up:
 Input: visual,
vestibular, &
proprioceptive

Central processing:
cortical & cerebellar

Output:
neurological &
musculoskeletal
systems
What changes with age:
-visual acuity
-depth perception,
-dark adaptation
-contrast sensitivity
Speed of
processing complex
tasks
Joint ROM, Motor
conduction, Strength
Add:
“ Disease And Medications”


Sedatives
Cognitive impairment
 LE disability
 Foot problems
 Balance/gait d/o
 Postural control dz
 > 2 chronic dz.
 ADL impairment
 > 2 falls per year
 Fear of falling

Application of risk
factors:
 > 3 risk factors: 65100% fell over next 12
months
 No risk factors:
8-12% fell over next
12 months



HIGHEST RISK OF FALLS:
First month after discharge for
those frail enough to require
home care
Mahoney J,JAGS 1994;42:269-74
“Grail Quest”
Rule #2
“Correct any risk
factors while you can”
Risk Modification
“Be proactive”

-“Every falling elderly that gets up, gives us a
chance to learn something to prevent the next
fall”
Eddie,1998
Risk Modification

Study # 1 Tinetti
 Medications review & reduction, environment
& behavior, strength & balance training
 Result: 26-50%  in falls
 Study #2 Close
 6 month exercise Result: 40 % in falls
Risk Modification cont’d










Study # 3-PROFET
Medical & OT evaluation. after fall
Result:
510 falls in controls
183 falls intervention
Study # 4
Exercise, vision improvement and home hazard
management
14% reduction in falls
Treat 7 to prevent 1 fall
Exercise most effective component but all three were
additive
Day L, Fildes B, BMJ Vol 325, 20 July 2002
Review

Increased morbidity, mortality, and
decreased quality of life associated with
falls
 Falls usually have multiple factors of
contribution and causality.
 Risk factors predict falls and guide
prevention
GOALS of FALL Evaluation:
 1)
evaluate injury
 2)
evaluate cause of fall
 3)
prevent future falls
GRAIL QUEST
Rule # 3
“Look for
more than one factor, and
correct even the smallest factor”
“The Initial Steps in the
Fall Evaluation”
The Steps to the Quest
 Step
# 1 Acute
Injury
Evaluation
 Step
#2
SYNCOPAL ?
The Complete Evaluation of
Falls
“The Five Question of the Quest”
(You Must Answer All Five Questions to Complete the
Quest)

Q#1

Q#2
ACUTE
CHRONIC

Plan work-up:

but can be improved

Q#3
MEDICATIONS?
cause or contributory

Q#4 REHABILITATION ?

Q#5 ENVIRONMENT/
BEHAVIORAL factors

To cover acute
factors immediately
Chronic factors
longitudinally
Q# 1
ACUTE
D-E-L-I-R-I-U-M-S + Pain (mnemonic)

D rugs
 E motional
 L ow O2 states
 I nfection
 R etention
 I ctal states
 U ndernutrition/hydration
 M etabolic
 S ubdural
 + Pain
Q#2
CHRONIC
but Can Be Improved
1) Sensory:
Visual
Proprioceptive

Examples

2)Central processor:
Cataracts, refraction
 Neuropathy (e.g B12
def.), cervical stenosis
 Benign positional
vertigo
3) Effector systems:

Vestibular
Muscular

Parkinson’s, NPH,
CVA’s
Dementia, depression
Skeletal


DISUSE ATROPHY,
vit D def., Hypothyroid
Feet deformity, joint
instability
Q#3
MEDICATIONS
Cause and/or Contributory

Suspect centrally
active suppressors:
 Narcotics
 Sedatives
 Hypnotics
 Antipsychotics
 TCA & SSRI’s
 Anticholinergics
 Alcohol
 IA antiarrhythmics

Ensrud KE, JAGS 50 1629-1636
2002

If orthostatic
hypotension or
orthostatic
symptoms present:
 Suspect:
 Antihypertensives
 Diuretics
 Vasodilators
 Antiparkinsonian
GRAIL QUEST
Rule # 4
 “Never miss an
opportunity to perform”:
Medication
debridement
REHABILITATION
Screen With: “Get Up and Go Test”
Q#4

Ask the patient to:
 Stand without arm
assistance
 Walk ten feet

Turn sharply
 Return and sit down

Areas tested
 Hip and knee
extensor strength
 Gait stability and
speed
 Gait and balance
 Vision, LE strength,
coordination
REMEDIES of PROVEN
EFFECTIVENESS
Muscle
strengthening
Balance training
Gait training
REMEDIES of PROVEN
EFFECTIVENESS

Muscle
restrengthening

 used 80% of maximal



effort for training level
q. o. d.
120% increase strength
in community dwellers.
improved strength and
gait velocity and
increase activity level
25% reduction in
falls

Balance training : Tai
Chi > PT guided training
but both very effective
Gait Training: consider
especially for neurologic
disease and msk
dysfunction

e.g. old CVA or knee OA,
, Parkinson’s dz
Q#5
ENVIRONMENTAL/BEHAVIORAL
Factors
 Facts:
 25-50%
of community falls due to
environmental factors
 The healthier the patient, the more likely
the fall is due to the environment
 50% of recurrent falls in healthy
community dwelling--------occur with
same activity
How Do You Improve Home
Safety?
 Home
safety evaluation
 Compliance is questionable

Australians age > 70 y.o. (n = 342 )
 80 % of homes inspected had >1 hazard
 39% had > 5 hazards
 Bathroom is the most hazardous room

(60% had hazards)
 30% of those who rated their home as “VERY
SAFE”---- had > 5 hazards

Carter SE, Age Ageing 1997 May; 26: 195-202
Q#5
ENVIRONMENTAL/BEHAVIORAL
Factors

Most Common recommended modifications:
 What would you guess?
 remove rugs
 safer footwear
 nonslip bath mats
 night lights
 stair rails
 Compliance range from 19 % to 75%
Cumming RG, JAGS 1999;47:1397-402
How Do You Improve Home
Safety?
 Remedy
?
 Quest rule # 5
 Give the crusader a
 That
task
is:
“have someone OTHER THAN PATIENT do
the safety evaluation”
Does Home Safety Evaluation
work?
 San
Francisco Elders
 intervention:
 -home safety evaluation and
modifications
result:
60%
reduction in falls
REVIEW:
Goals of Fall Evaluation
 1)
evaluate injury
 2)
evaluate cause of fall
 3)
prevent future falls
The Initial Steps in the Fall
Evaluation”
Step
# 1 Acute Injury Evaluation
Step # 2 SYNCOPAL ?
The Complete Evaluation of
Falls
ACUTE
 Q#2 CHRONIC but can be improved
 Q#3 MEDICATIONS? Cause &/or
contributory
 Q#4 REHABILITATION ?
 Q#5 ENVIRONMENT/BEHAVIORAL
factors

Q#1

NH
SYNCOPE PATH
May All Your Quests Be Fruitful
Thank you for your kind attention !
Nursing Home Falls

INCIDENCE:

0.6-3.6 falls/resident/yr.




INURY:
 fractures
-4%
 serious injury -12%
Non-Ambulatory
most fall involve
equipment
occur when seated
or with transfer

Ambulatory:

highest risk of fall


non-ambulatory but capable
of independent transfer
ambulatory on
psychotropics
Causes of Falls
community NH resident

Environment/accident
 other causes
 gait/balance/weakness
 drop attack
 dizziness/vertigo
 unknown
 confusion
 postural hypotension
 visual disorder
 syncope

41%
 17%
 13%
 13%
 8%
 6%
 2%
 1%
 0.8%
 0.4%
16%
12%
26%
0.3%
25%
4%
10%
2%
4%
0.2%
Risk Factors for NH Falls

Physical:
rel.
risk
 Weakness
6.2
 Balance def. 4.6
 Gait deficit
3.6
  mobility
3.3
  function
3.1
  vision
2.7




Post. Hypotension 2.1
 cognition
1.5
Medications rel.
risk
 Antidepressants
2.4
 Sedative/hyp 2.0
 NSAID’s
1.6
 Vasodilators
1.4
Diagnoses:
 Arthritis
 Depression
1.6
1.6
Extrinsic factors of Falls in NH
 Environment/extrinsic
factors cause
20% of falls

Most falls:
 Resident

rooms
highest activity associated with falls:
 12%
of all falls exiting bed or bathroom
Environmental safety features

Interior






non-slip surfaces
sufficient lights
glare free lights
low lying objects out of
way
chairs at proper height
and with armrest to assist
transfer
time-delay doors

Bathroom




wide doors
skidproof mats in
shower and stool
grab bars for stool
and shower
elevated toilet seats
Environmental safety features
 Bedroom








bedside or nightlights for nocturnal ambulation
UNOBSTRUCTED WAY TO BATHROOM
height adjusted bed for safe transfers
completely recessible bed rails
sag-resistant edges on mattresses
appropriate shelf height in closet
movement monitoring devices
skid resistant bedside mats
Nursing Home fall
interventions

Individualized
assessment &
 4 area targeting
 1) environment:
( lighting, nonskid
flooring and footwear.)
 2) WC use &
maintenance
 3) psychotropic drug
eval.
 4) facility wide
interventions ( inservice)

Ray 1997 JAMA 278:557-562

19% reduction in
total falls
 31% decrease in
injurious falls
 Similar studies in
hospitals gave 25 %
reduction in falls.

AHRO Making Health care safer #43
Personal safety features
 Hip
protectors

prevents 1 hip fracture for every 41 wearing
 Restraints in NH or Hospital..Help or Hinder?
 HINDER!!
Serious falls
unrestrained
5%
restrained
17%
 Why?

During restraint use: decreased strength
(inactivity), increased delirium and injury form
attempts to escape.
Tinetti M Ann. Intern.
Med. 1992 116: 369-374
syncope case
end
Mr. George Falls
 78
y.o presents to
ER with history of
fall secondary to
syncope:


Unconscious for < 2
min. No seizure activity
per witnesses
PMHx:
 DM II,
Hyperlipidemia
 HTN
 Meds: Glucotrol,
Hytrin

120/80-60-36.5-16
 COR-normal
 CNS-normal
 No injury
 What’s your next
move ?
SYNCOPE EVALUATION
Pathway
INITIAL:
 H & P*
 EKG
 Labs: (CBC, Lytes, BG, BUN/Cr,
Ca+,SaO2, Cardiac enzymes)
SYNCOPE EVALUATION
Pathway
What symptoms, findings
or historical features
should indicate
admission to hospital?
 Structural heart dz. or
 Cardiac sx &/or risk or
 Abn EKG or
 Unsecure home
environment or
 Seizure sx’s or
 Significant injury or
 Neurologic symptoms
Admit orders could
include? :
 R/o MI labs/ EKG’s
Cardiac monitor
 If Cardiac risk &/o sx
or Structural heart dz


If Seizure sx’s:


Echo
EEG
If neuro sx’s/signs or
head trauma:

Neuorimaging
SYNCOPE EVALUATION
Pathway
If work-up Inpatient
NEGATIVE
But
Patient has
Structural heart dz. or
Cardiac sx &/or risk or
Abn EKG order
 Stress testing
 (Exercise stress echo or
pharmacological stress
test)
If work-up Inpatient
NEGATIVE
And NO
Structural heart dz?
or Abn. EKG?
or Cardiac risk or sx?
Q: Still suspicious for
arrhythmia?
YES - EPS
NO - PASS OUT w/u
SYNCOPE EVALUATION
Pathway
continued

If NONE of the
following in ER
 Structural heart dz. or
 Cardiac sx &/or risk or
 Abn EKG or
 Unsecure home
environment or
 Seizure sx’s or
 Significant injury or
 Neurologic symptoms
Outpatient w/u
1) Q: Still suspicious
for arrhythmia?
YES EPS
NO PASS OUT w/u
Review
Definition
List the consequences
Describe the aging
physiology that
predisposes to syncope
List the causes
Describe the evaluation
Sudden LOC
Mortality high in cardiac
Barorecptor,
 B receptors,
Volume
 MM tone
P-A-S-S O-U-T
R/o cardiac first
H &P, EKG, Labs
causes?
“Mnemonics”
 P-A-S-S
O-U-T
The following mnemonic reviews the etiologies of
syncope, and pertinent data on each.
 P ressure (hypotensive causes) O utput
(cardiac)/O2 (hypoxia)
 A rrhythmias
U nusual causes
S eizures
T ransient Ischemic
S ugar (hypo/hyperglycemia)
Attacks &
Strokes,
CNS
dz’s
End
Thank you for your
Attention!!
kind