Transcript Title goes in here - Pennsylvania Academy of Family

Falls: Preventing a
Downward Course
Thru Assessment of the
Geriatric Patient
Paula Bordelon, DO
Disclosure
• No conflicts of interest
• No financial relationships with
pharmaceuticals to disclosure
Objectives
• Teach a systematic approach to
assessment of gait and balance
• Highlight abnormalities commonly seen
in elderly
• Increase knowledge STEADI toolkit
• Review AGS’s fall guidelines
Case History
• 78-year old female scheduled with you to
establish care.
• Presents with her daughter.
• Lives alone and uses no assistive
devices.
• Dtr reports 1 fall “mom slipped”
• Dtr reports occasional dizziness and
balance issues. Patient states “I’m fine”
Case History (cont)
• Meds: HCTZ, glyburide, ASA,
temazepam prn
• DEXA: osteoporosis of femoral neck
• Did your new patient fall?
• Does your new patient need specific
intervention to prevent falls?
Falls Affect Morbidity and Mortality
• Falls should not be viewed as normal aging!
• Overall nonfatal fall injury rate was 43/100,000
falls (based on those seeking care)
• 1 out of 3 seniors fall but < 50% report this
• Among seniors falls are leading cause of fatal
and nonfatal injuries
• 1 in 5 falls cause serious injury
Falls: the Facts
• Falls are common:
– About 35% of community-dwelling ages 65-69 fall
– > 50% of community-dwelling > age 80 fall
• 95% of hip fractures are caused by falls
• FALLS CAUSE POOR OUTCOMES!
• Death rate from falls has risen sharply over
past decade (64% men; 84% women)
Fall Prevention is Paramount
• Falls are a MAJOR health hazard, up to 30%
who fall suffer injuries, lacerations, hip fractures,
head trauma
• Functional deterioration after falls is common
and often leads to institutionalization
• Of those who fall, only 50% can arise without
assist
• Falls are the most common cause of traumatic
brain injuries in seniors
• 75% of fall-related deaths occur in those > age
65
The Most Costly Fall: Hip Fractures
• Hip fractures are the most costly injuries in
terms of mortality, health, reduced quality of
life, and admission into nursing home
• Recover more slowly
• More adverse consequences post-op
• 33% of hip fracture survivors spend at least
one year in SNF
• 20% of seniors hospitalized for hip fracture die
within 1 year
What is a fall?
• Any incident that involves unintentionally
coming to some lower level (or to the
ground) is a fall.
• Older adults frequently have incidents
that meet the definition of a fall, but deny
falling
• Slipping, tripping, stumbling or tumbling.
Who is at Risk?
• Intrinsic Factors
– Advanced age
– Cognitive
Impairment
– Sensory Impairment
(e.g. decreased
vision)
– LE weakness
– Poor mobility
• Extrinsic Factor
– Medications
• Polypharmacy (> 4)
• Psychoactive
– Inactivity
– Environmental
Who Should Be Screened?
• Anyone age 65 and over should be
screened (that is, asked if they have
fallen IN THE PAST YEAR!)
• Alternative: Have patient answer CDC’s
risk factor (12 question) screening
Screening (cont)
• Anyone senior who has fallen, feels
unsteady, or a fear of falling, should be
evaluated for gait and balance
• If senior performs poorly on evaluation,
should undergo multifactorial fall risk
assessment
How Do You Screen?
• Simply use questionnaire from STEADI
toolkit or
• Inquire about history of falls:
– Have you slipped, tripped, stumbled, or
fallen in the last 6 weeks? In the last 12
months?
– Do you feel unsteady when standing or
walking?
– Are you fearful about falling?
How Do You Screen? (cont.)
• For “yes” responses, inquire as to
frequency, circumstances, and if have
difficulty with balance. Getting an
accurate history gives you info to
prescribe the best plan
How Do We Balance?
• Balance via dynamic input:
– Vision
– Inner Ear (vestibular)
– Proprioceptive Sensing
– Strength and flexibility
How Does Aging Affect Balance?
• Successful fall prevention begins with
knowledge of age-related changes
• Vision - reduction in glare tolerance,
nocturnal acuity, contrast sensitivity,
reduction in peripheral vision and poor
depth perception
How Does Aging Affect Balance?
• Vestibular - peripheral vestibular excitability
declines with age while vestibular dysfunction
(e.g. BPPV, Meniere’s) increases, with loss of
hair cells and ganglion cells, contributing to
falling
• Proprioception - reduced function occurs in
many d/o (e.g. DM, Etoh, malnutrition, cervical
spondylosis)
Centers for Disease Control &
American Geriatrics Society
• CDC
www.CDC.gov/homeandrecreationalsafety/falls/STEA
DI
• AGS
www.americangeriatrics.org/health_care_professional
s/clinical_practice/clinical_guidelines_recommendation
s/prevention_of_falls_summary_of_recommendations
Key Components of Fall HISTORY
• Get History: Get description of the
circumstances of the fall: frequency,
symptoms at time of fall, injuries (TARGET
INTERVENTIONS)
• Review Meds: All prescribed and over-thecounter medications with dosages
• Obtain History of relevant risk factors: Acute or
chronic medical problems, (e.g., osteoporosis,
urinary incontinence)
Key Components of PHYSICAL
Evaluation
• 1. Lower Extremity Muscle Strength
• 2. Exam feet & footwear
• 3. Neurologic (cognitive eval,
proprioception, peripheral nerves,
reflexes, cerebellar function)
• 4. Visual acuity (when to consider
monocular)
• 5. HR, rhythm, BP, check orthostatics
Components of FUNCTIONAL
ASSESSMENT
• Assess ADL, including ability to use
assistive devices and adaptive
equipment
• Assess for fear of falling and perceived
functional abilities and health
Post-fall Syndrome
• Is a phobic response to the discordant and
inaccurate sensory inputs
• Creates a self-perpetuating cycle of increasing
weakness and instability via joint mobility
reductions, physical deconditioning, and poor
balance
• Loss of self-confidence to ambulate can result
in self-imposed limitations
Source: Journal of Rehabilitation Research and Development: 40
(1); January/February 2003: 49-58.
Exam of Lower Extremities
• Search for mechanical problemsorthopaedic, vascular, podiatric,
rheumatic
• Examine ROM at hip, knee, ankle
• Palpate for pulses at femoral, popliteal,
dorsalis pedis, posterior tibial
Exam of Lower Extremity (cont)
• Muscle Tone (resistance of
extension)– if increased and feet are
“stuck to the floor” , consider NPH or
frontal lobe dysfunction
Neurologic Dysfunction
• Cerebellar Ataxia – Cerebellum processes
input from brain, spinal cord, and sensory
receptors to provide timing of precise,
coordinated movements of skeletal muscle
system (e.g. limb position). With ataxia, have
dizziness, imbalance, and difficulty
coordinating movements
Neurologic Considerations
• Dizziness and Vestibular Ataxia– use
inner ear (vestibular) and sensory to
balance; consider an etiology for
vascular, vestibular, brain stem, trauma,
or medication problems
Neurologic Considerations
• Romberg’s (standing balance with eyes
closed) – presence means sensory deficit
(abnormality of proprioception) in peripheral vestibular,
peripheral neuropathy, decreased position sense
(dorsal column) ; if due to neuropathy, ankle jerks will
be absent; if a spinal cord issue, Babinski will be
present
• Treatment – improve lighting, use assistive devices,
good footwear
Neurologic Considerations
• Cerebellar signs – presents with
incoordination, ataxia, unsteadiness with eyes
open. If positive, determine rapidity of onset.
Acute: posterior fossa stroke; Subacute:
mass, demyelinating or degenerative
processes, metabolic disorder, or drug effect
• Treatment – assistive devices, reduce
clutter, gait training
Neurologic Considerations
• Sternal nudge – with staggering or
becoming unstable, consider neurologic
or back disease
• Treatment – remove clutter, prescribe
assistive devices, avoid slippers or
loose-fitting shoes
Neurologic Considerations
• Unstable with turns – with instability,
consider cerebellar, reduced
proprioception, hemiparesis, or visual
field cut
• Treatment – gait training, prescribe
assistive devices, proper fitting shoes,
reducing obstacles
Functional Examination
• Evaluate patient’s gait. Note symmetry,
speed, and ability to walk in a straight line/path
undeviating.
• Is center of gravity altered? (Wide-based?)
• Look for hesitation with turns when pivoting.
• Note if good arm swing and if there is sound
distance between floor and soles of feet.
Functional Evaluation of Gait: “Timed Up
and Go” (TUG): per STEADI
• “TUG” should be able to execute in < 13
seconds
• Difficulty of arising from chair suggests
proximal muscle weakness, arthritis, or
neurologic disease
• Treatment: portable seat lift, muscle
strengthening exercises, increase functional
mobility, treat specific illness
Functional Examination: 4-Stage
Balance Test: per STEADI
• Test stance: Side-by-side, semi-tandem,
tandem stances, and balancing one foot.
• If cannot perform side-by-side, semitandem, or tandem stances, senior is at
increased risk
Functional Exam: One Opinion*
• Failing
– Side-by-side: if “fail”, need walker and PT
– Semi-tandem: if break early, need walker
and PT; mid-break, need cane; late break,
order balance (e.g. Tai Chi) and exercise
classes
– Tandem: balance and exercise classes
• *my personal opinion
Functional Examination: 30-second
Chair Stand: per STEADI
• Results are based on sex and age and
grid that details “Below Average Scores”
• If patient scores are below average, he is
at risk for falling and needs intervention
Other Aspects of Examination
• Psychiatric
– Brief screen for cognitive functioning
– Brief screen for mood (depression)
– Assess for fear of falling: Do you have a
fear of falling? If yes, does your fear
decrease your activity level?
Appliances Recommended to Reduce
Morbidity and Mortality
•
•
•
•
Reachers
Portable seat lift
Special step stools
Hip protectors
(controversial,
falling in and out of
favor)
Interventions for Community Dwellers:
According to AGS
• Adaptation/modification of home environment [A]
• Withdrawal/minimization of psychoactive medications
[B]
• Withdrawal/minimization other medications [C]
• Management of postural hypotension [C]
• Management of foot problems and footwear [C]
• Exercise, particularly balance, strength, and gait
training [A]
Strength of Recommendation Rating
System
• [ A ] A strong recommendation that the clinicians provide the
intervention to eligible patients.
•
Good evidence was found that the intervention improves health outcomes and the
conclusion is that benefits substantially outweigh harm.
• [ B ] A recommendation that clinicians provide this intervention to
eligible patients.
•
At least fair evidence was found that the intervention improves health outcomes
and the conclusion is that benefits outweigh harm.
• [ C ] No recommendation for or against the routine provision of
the intervention is made.
•
At least fair evidence was found that the intervention can improve health
outcomes, but the balance of benefits and harms is too close to justify a general
recommendation.
Strength of Recommendation
Rating System
• [ D ]Recommendation is made against routinely
providing the intervention to asymptomatic patients.
•
At least fair evidence was found that the intervention is ineffective or that
harm outweighs benefits.
• [ I ] Evidence is insufficient to recommend for or
against routinely providing the intervention.
•
Evidence that the intervention is lacking, or of poor quality, or conflicting,
and the balance of benefits and harms cannot be determined.
Quick Tips
• Studies demonstrate that Vitamin D
supplementation (800 IU/day) reduces
falls
• Patients using monocular (single vision)
vision glasses when performing activities
and walking are less likely to fall
The Bottom Line
• Falls are treatable geriatric syndrome
• Screening for falls begins with one
question
• Falls can be reduced by up to 40% with
intervention
• Medicare typically covers services
needed to treat patient’s risk factors
Conclusion
• Falls are complex and multifactorial
• Marker of frailty
• What predisposes persons to falling often
produces observable disturbances in gait and
balance—so assess in office
• Interventions most likely to prevent injury are
exercise and environmental modification