Transcript What to Expect from Providers - Ohio Public Health Association

Fall Prevention:
What to Expect from Health
Care Providers?
Betsy Baum, M.D. CMD
Associate Professor of Internal Medicine
NEOMED
Geriatric Consultant Aultman Hospital
Medical Director Bethany Nursing Facility
Clinical Faculty, Canton Residency Education
Objectives
 Review the AGS ( American Geriatric
Society) Guidelines of the evidenced based fall risk assessment recommended
to health care providers
 Review effective interventions to prevent
falls and injuries
 Discuss community programs that will
enhance fall prevention
Two Most Important Things
to Know About Falls in the
Elderly
 Falling is a symptom not a
diagnosis
 Most falls in elderly people are
multifactorial
WHY SO DIFFICULT TO
PREVENT FALLS ?
 Complex unless systematic approach
 ID mutifactorial causes or risk factors
 Tailor interventions to that person’s
specific risk factors
 Followup that interventions get done
Most Common Risk Factors for Falls
D rugs Dementia Depression
O ther Falls
Disease
G ait
O rthostasis, old (>80)
S ensory (vision, hearing), surroundings
L ost Balance
O steoarthritis
W eak lower extremity
Most Common Risk Factors for Falls
I ncontinence, Insomnia
D rugs Dementia Depression, D deficiency
O ther Falls
G ait
O rthostasis, old (>80)
S ensory (vision),surroundings, shoes
L ost Balance
O steoarthritis
W eak lower extremity
Which is the Most Predictive
of a Patient’s Fall Risk?
 A) orthostatic hypotension
 B) polypharmacy
 C) history of previous falls
 D) Parkinson’s Disease
AGS Algorithm Suggests Full
Office Fall Assessment if:
 Single Fall in last year with abnormal gait
 No falls, but difficulty with walking or
balance
 Two or more falls in last year even if gait
WNL
 Patient presents after an acute fall
Fall Risk Assessment
I.
Detailed history
II.
Physical exam
III.
Functional Assessment



Observe gait and balance(Get up and go test)
Cognitive assessment
ADLs/ IADLs
IV. Lab only as indicated by I-III
V. Medication review
Timed ‘Get Up and Go’ Test
 Simple test of observing a person stand
up from a chair, walk 10 feet, turn around,
walk back, and sit down again.
 Correlates with ADLs
 Normal person takes <10 seconds to
complete the task
 Persons who take > 30 seconds are at
increased fall risk and likely to have some
dependency in ADLs
JAGS 1991;39: 142-48
Determine Multifactorial Fall
Risk
 History of falls
 Medications
 Gait, balance and mobility
 Visual acuity
 Muscle strength and neurologic exam
 CV exam and orthostatic BP check
 Feet and footwear
 Environmental Hazards
Initiate Multifactorial
Intervention Tailored to
Individual Risks ID
 Minimize medications
 Tailored exercise program
 Treat vision impairment
 Manage postural hypotension
 SUPPLEMENT VITAMIN D
 Manage foot and footwear problems
 Modify home environment
Office Evaluation of Mrs. T.
 Pt: 84 y/o female
 PMH: HTN, spinal stenosis, depression, anxiety
 HPI: Medical conditions stable, difficulty living
alone d/t mild back and knee pain, near falls,
notes some lightheadedness mainly in the AM,
does c/o general weakness.
 Medications: amlodipine 10mg AM; lisinopril 40
mg AM; HCTZ 25mg AM; lorazepam 0.5mg bid;
sertraline 100mg daily
Mrs. T. Physical Exam
 Vitals:
 BP Lying 140/80, HR 64
 BP Standing 110/60, HR 80
 HEENT WNL, Cardiopulmonary WNL
 Extremities: mild swelling rt. knee,
decrease ROM, pulses ¼
 Neurologic: WNL except proximal leg
weakness 4/5 and mild intention tremor
Mrs. T.’s Functional
Assessment
 Gait: flexed, decreased stride and foot
clearance, does not extend rt. knee well,
does not grasp walker well due to tremor
 ADLs: needs help with dressing and bath
 IADLs: daughter had been assisting with
all except for meds and paying bills
 GUG: 35 seconds
 MMSE: 26/30
Mrs. T.’S Problem List
 Diseases: Spinal Stenosis, Depression,
Hypertension
 Orthostatic Hypotension
 Osteoarthritis
 Tremor
 Gait abnormal /Muscle weakness
 Medications: sertraline, lorazepam, BP
medications
Interventions for Mrs. T.
 Medications rearranged:



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Lisinopril 40 mg continued in AM
HCTZ dose decreased to 12.5mg AM
Amlodipine moved to PM
Began to taper lorazepam with AM dose
Sertraline decreased from 100mg to 50mg
 PT/OT muscle strengthening and balance
 Acetaminophen scheduled 650 tid
 Check BMP, CBC and 25 OH vitamin D
AGS Medication
Recommendations
 Psychoactive medications ( including
sedative hypnotics, anxiolytics,
antidepressants, antipsychotics) should be
minimized or withdrawn, with appropriate
tapering if indicated
 Reduce total number of medications or
dose of individual medications should be
pursued
Division of Geria
Vitamin D
 The most common vitamin deficiency in
older adults
 Vitamin D not only strengthens bone, but
also muscles
 A number of studies have demonstrated
Vitamin D supplementation of at least
800IU daily for 1 year can decrease falls
by 20 %
BMJ 2009;339:b3692.
Other Measures to Prevent
Orthostatic Hypotension
 Correct underlying cause i.e adjust
medications, correct anemia or
dehydration
 Drink plenty of fluid
 Rise slowly, ankle pumps, sleep with head
of bed elevated
 Wear support stockings
 Caffeine with meals can help prevent
postprandial hypotension
Community Programs for Fall
Prevention
 Develop more group exercise programs
tailored for different levels of ability
 Develop community walking groups
through senior centers and health clubs
 Educate older adults on what they should
expect from their health care provider for a
full fall assessment risk
 Over the counter meds associated with
falls and confusion TYLENOL/ADVIL PM
Division of Geriatric Medicin, St. Louis Univ.
Reference
 http:www.americangeriatrics.org/health_care_pr
ofessionals/clinical_practice/clinical_guidelines_r
ecommendations/2010/