Transcript CHAMP A Geriatric Syndrome in the Hospital: The Case of Falls

CHAMP
A Geriatric Syndrome in the Hospital:
The Case of Falls
William Dale, MD, PhD
University of Chicago
Overview
• What is a “geriatric syndrome”?
• How does one think about, and teach about, syndromes
like falls?
• Why worry about falls?
• What are the causes of falls?
• Differential diagnosis and falls: teaching to medicine
housestaff
• Restraints and falls: teaching housestaff about the
dangers of restraints
• Preventing and treating patients who fall
• What should be done at discharge?
• U of C Nursing initiative and pilot project
Falls As a “Geriatric Syndrome”
• A sudden, unexpected descent from a
standing sitting, or horizontal position.
• When a person comes to rest
inadvertently on the ground or a lower
level
– Excludes syncope and overwhelming trauma
– A classic Geriatric Syndrome
• When the nurse calls to report “an event”
What is a Geriatric Syndrome?
• Manifestations of disturbances in complex
systems, usually with more that one organ
system involved
• Examples
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Functional Dependence
Delirium
Incontinence
Falls
Geriatric Syndrome Vs. Traditional Syndrome
How do complex systems, like older
adults, “fail” in causing syndromes?
• Key Concepts
– Physiologic reserve lower across multiple
domains
– Adaptive/redundant systems reduced
• Possible Pathways to Failure
– Major hit to one component (E.g. CVA)
– Dominant deficit with exacerbations (E.g. MI
 CHF/COPD)
– Multiple modest deficits (Geriatric Syndrome)
Yearly Incidence of Falls
• Community-dwelling persons over 65: 3040%
– 20% of falls require medical attention
• History of fall in last year: 60%
• Falls in our hospital: Data not currently
available
Sources: Tinetti, 1988; Tinetti,
1994
Complications
• “Leading cause” fact: death from injury in older
adults
• Fracture risk: 10-15%
– About 8% of 70+ y.o. go to ED yearly for fall-related
injury
• Other common complications
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Decline in functional status
Increased likelihood of nursing home placement
Increased use of medical services
Developing fear of falling  Loss of function
Source: Sattin, 1992.
Causes of Falls
• Rarely due to a single cause
– At least 25 risk factors identified across 5 large
cohort studies
• Interaction across multiple domains: more
risk-factors, increased likelihood to fall
– Intrinsic to individual
– Environmental challenges to postural control
– Mediating factors
Causes: Intrinsic Patient Factors
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Age
Female gender
Cognitive impairment
Chronic diseases
– Arthritis
– Parkinson’s
• Use of certain medications
– Psychotropics
– Diuretics
• History of falls
History of Falls as a Risk Factor
• One year risk of hospitalization by baseline
self reported fall status (n=444)
History of falls
Hospitalized over 12 months
none
61/316 (19%)
one
18/79 (23%)
two or more
19/49 (39%)
Causality: Pathophysiology of Aging and
Postural Control
• Postural control differences in older adults
– Respond to balance perturbations using
proximal muscles first, then distal
– More slowly develop joint torque when
disturbed
– More likely to have decreased baroreflex
sensitivity to hypotensive stimuli
– More likely to have microvascular cerebral
perfusion defects
– Reduction in total body water
Causes: Postural Control Challenges
• Weakness, esp. lower extremity
• Balance difficulties
• Dangerous environment
Causes: Mediating Factors
• Risk-taking behaviors
• Underlying mobility level/inclination
• Principle: Mismatch of risk-taking
behavior with mobility
Probability
of Fall
Mobility
Skills
Source: Studenski, 1991
Causality: Pathophysiology of Aging
• Three sensory input systems involved in
maintaining upright posture
– Visual
– Proprioceptive
– Vestibular
• All of these systems decline with aging
Differential Diagnosis and Falls
• Traditional DDx:
– Multiple symptoms  Possible single causes (I.e.
diagnoses)
– Causes prioritized by probability and severity
– Search for underlying or unifying cause
• Geriatric Syndromes DDx:
– Event/Condition  Possible multiple causes
– Causes prioritzed by probability and contribution to
causing event/condition
– Search for web of interacting causes
History and physical based on the
components of postural control
• Sensory:
– Vision
– Vestibular
– Somatosensation
• Central Processing:
– Global level of consciousness/perfusion
– Attention/response time
– Automatic postural responses
• Effector:
– muscle strength
– range of motion
– endurance
Getting “The Story”
• At time a fall occurs, get good history
– Do this on cross-cover
– Best history at time of fall
– Earlier intervention important
• Activity at time of fall (walking, transferring,
sitting at bedside, going to bathroom, etc)
• Prodromal symptoms
– Lightheadedness?
– Loss of balance?
– Dizziness?
• Location/Timing
Getting the Story
• Observe environment/context of fall
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Lighting
Flooring and footwear
Restraints (both formal and informal)
Furniture
• Past History: Has this happened before?
– Strongest predictor of fall: past fall
– Context of last event
• Review Medications
– Recent Changes in Medications (Check MAR)
– Biggest culprits
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Vasodilators
Diuretics
Sedatives
Hypnotics
The Role of Medications
• Specific meds in observational studies
associated with hip fracture risk
– Benzodiazepines
– Antidepressants
– Antipsychotics
• Medication features associated with falls
– Recent changes in dose
– Total number of meds
Physical Exam
• Orthostatics: Do this yourself if you have time.
• Cardiovascular System
• Sensory Examination
– Special senses
– Proprioception
• Musculoskeletal Exam
– Proximal muscle weakness
– Joint pain/swelling
• Cognition: brief assessment of mental status: Orientation
• Footwear/Floor combination
– Socks on tile; bare feet and wet floor
Physical Exam: Special Tests
• Gait Speed – “Get up and Go” Test
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Rise from (hard-backed) chair, walk 10 feet,
turn, return to chair, sit down
Threshold greater than 10 seconds is
abnormal
• One foot balance
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Threshold: < 30 seconds
• Observe PT/OT evaluations for these
patients—arrange time for team to meet
with PT/OT
Laboratory Testing
• No “standard” battery of tests
• Instead, targeted to specific concerns
Number of Restraints?
Falls and Restraints
• Restraints increasingly recognized as a
cause of falls and increasing serious falls
Mechanical Restraint Use and
Fall-related injuries
• Prospective study, SNFs, n=397
• Outcome: falls after restraints placed
• Logistic regression used to control for
large number of confounders
• Odds ratio for fall-related injury
– Full cohort: 10.2 (CI 2.8 – 36.9)
– High-risk subgroup: 6.2 (CI 1.7 – 22.2)
Source: Tinetti ME, et al, 1992
Mechanical Restraints
• Increases risk of falls and other complications in
hospitalized patients on a medicine service:
Complication
Fall
Restraine
d
(n = 35)
Unrestrained P - value
(n= 243)
17%
1%
0.001
Immobilityrelated
9%
2%
0.045
Nosocomial
infection
23%
5%
0.001
Source: Mion LC, Et al, 1989.
Restraints: Formal and Informal
• Formal
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Mittens
Wrist/Ankle Soft Restraints
4-point “Leathers”
Full Side Rails
Posey Vests
• Informal
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IV Lines
O2 nasal canulas
NG tubes to suction or for feeds
Pulse oximetry
SCDs
Foley catheters
Risks/Benefits of Bedrails
• Potential benefits
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Aiding in repositioning
Hand-hold for support in getting in/out of bed
Reduce fall risk during transport
Enhance access to bed controls
• Potential risks
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Entrapment
Worse falls injuries from climbing
Skin trauma/bruising/scraping
Exacerbation of delerium when used as a restraint
Restricts activities (toileting, personal item retrieval)
Bed Rails and Entrapment
• Incidence of “entrapment” by bed rails
reported to FDA, 1985-1999: 371
– # of beds in U.S. hospitals and LTC facilities:
2.5 million
– Outcomes from entrapment
• Death 61%
• Non-fatal injury 23%
• No injury 15%
Safety Improvement Alternatives
to Bed Rails
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Lower bed for patient, raise for providers
Keep wheels of bed locked
Use transfer and mobility aids
Monitor patient frequently
– Move patient closer to nursing station
– Enlist others: family, medical students
• Identify and meet patient needs that lead to falls
– Toileting: available bedpans/urinal; scheduled
toileting
– Pain: adequate pain relief
Improving Safety of Bedrails
When Used
• Close monitoring
• Lower at least one of rails
– Not considered a restraint when used this
way
– Allows access to and from bed
• Properly sized mattress to reduce gap
between mattress and bedrail
Treatment and Prevention
• No proven benefit in reducing falls
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Untargeted exercise intervention alone
Untargeted health education alone
Untargeted exercise and health education
Assistive devices alone
Outpatient Prevention
• Possible Benefit
– Long-term exercise and balance training
• Includes gait training and proper use of assistive
devices
– Tai Chi: body “consciousness”, balance
– Medication review for possible
discontinuation
• Esp. for those with 4+ medications
• Esp those on psychotropics
In Hospital Treatment and
Prevention
• Impact Protection
– Lower beds and lock wheels
– Hip Protectors
• Significant protection against fracture
• Adherence difficulties substantial
– Diagnose and treat osteoporosis
• Increased Vigilance
– Enroll help of patient, family, nursing
– Re-evaluate often
– Visit yourself if possible
After Discharge
• Proven benefit to reduce falls
– Health screening with followup TARGETED
intervention (OR = 0.79; CI = 0.65-0.95)
• Primarily a balance issue?
• Primarily a strength issue?
– Home safety evaluation by OT (19% reduction
of falls versus control; decreased falls 36% in
those with previous history of falls)
Intervention: Targeted PT
• Three pooled studies, n = 566
– Intervention: individually tailored program of
progressive muscle strengthening, balance
retraining exercises, and a walking plan
• One-year:
– Fall RR 0.80, CI 0.66-0.98;
– Serious injury: RR 0.67, CI 0.51-0.89
• Two-year (69% intervention, 74% controls):
– Falls RR 0.69, CI 0.47-0.97
– Moderate-Serious injury RR 0.63, CI 0.42-0.95
Home Safety Intervention
• Home safety evaluation by OT
• 1 well-designed study
– n = 530, outcome: # of falls
– Stratified by falls history
• Overall RR 0.81, CI 0.66-1.00
• One or more falls, previous year, RR 0.64 (CI 0.49 – 0.84)
• No falls, previous year, RR 1.03 (CI 0.75-1.41)
Other Discharge Considerations
• If sending for rehab/PT, be sure information
about in-house fall is clearly communicated
– Rehab a common location for falls: people
having mobility challenges with mobility
difficulties
– Previous fallers benefit most from
intervention
• Note fall in discharge summary to be added to
patient “problem list”
• Possibility of the development of fearfulness
leading to disability and increased risk of falls
Summary
• Falls as a geriatric syndrome:
– Multiple contributing causes with common final
pathway
• Most likely contributing causes:
– #1 – History of falls
– Patient factors: balance difficulties, LE weakness,
incontinence, medications, cognitive impairment
– Environmental factors: restraints (formal and informal),
bed height, toileting needs, lighting, furniture
– Mitigating factors: mismatch of mobility with
compensatory mechanisms  patient, nursing, family
education
Summary of Teaching Points
• Exercises
– “Get up and Go” Test
– Bedside restraints “memory” test
• Dangers of Restraints
• Discharge Considerations
– Targeted interventions: observe PT evaluation
– OT Home safety evaluation
– Falls added to problem list
U. Of C. Nursing Initiative
• Performance Improvement Initiative to
Reduce Falls in the Hospital
• Protocol based on University of Iowa
Gerontological Nursing Interventions
Research Center
• Adapted from LTC setting to hospital
• Pilot to be initiated on 4SE and 4NW
floors