Transcript Falls in Older Adults - Emory University Department of Medicine

Falls in Older Adults
Joseph G. Ouslander, MD
Professor of Medicine and Nursing
Director, Division of Geriatric
Medicine and Gerontology
Chief Medical Officer
Wesley Woods Center of Emory University
Director, Emory Center for Health in Aging
Research Scientist, Birmingham/Atlanta GRECC
Prepared for the Department of Otolaryngology
Emory University School of Medicine
Supported by the John A. Hartford Foundation
and the Donald W. Reynolds Foundation
Falls in Older Adults
Learning Objectives
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Review the epidemiology and
consequences of falls in the elderly
Understand common causes of falls
in this population
Determine the appropriate diagnostic
of older people who fall
Identify targeted management
strategies for common causes of falls
Falls in Older Adults
Definition
An event which results in a person
unintentionally coming to rest on
the ground or some other lower
level, and not being due to
syncope, stroke, or sustaining a
violent blow
Falls in Older Adults
Epidemiology
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Community dwelling: 1 in 3 fall in
a year
Nursing home: 50% fall in a year
Falls in Older Adults
Consequences of Falls
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Fractures
Soft-tissue injuries
Closed head injuries/subdural hematomas
Prolonged lying on the ground (rhabdomyolysis)
Fear of falling/restriction in activity
Use of restraints
Institutionalization
Death
Falls in Older Adults
Falls Affect Prognosis
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Falls occur in both frail and healthy older
persons
Single falls are not necessarily an
indicator of poor prognosis
Multiple falls are associated with
disability and poor health outcomes
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Multiple falls are a marker for other
underlying conditions that put older persons
at increased risk for adverse health outcomes
Falls in Older Adults
A Typical Case (1)
Mr. C. is an 89 year old man who is
referred to you for the evaluation of
vertigo. His daughter says that he
has fallen 3 times in the past month
after discharge from the hospital for
a “small heart attack and heart
failure”.
Falls in Older Adults
A Typical Case (2)
Mr. C. has no prior history of falls.
His chronic medical problems include:
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Coronary artery disease
Hypertension
Congestive heart failure
Degenerative joint disease mainly of the right
hip and knee
Insomnia related to pain in his knee
Falls in Older Adults
A Typical Case (3)
Mr. C’s medications include:
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Furosemide and postassium
supplement
Enalapril
Nitroglycerin patch 12 hours per day
Propoxephene as needed for pain
Zolpidem as needed for sleep
Falls in Older Adults
A Typical Case (4)
Further history reveals that each fall
occurred in the morning after
breakfast. He gets up, and when he
starts walking he feels “dizzy”. He
has not to his knowledge passed
out or sustained any severe injury
with these falls. There is no history
suggestive of a seizure.
Falls in Older Adults
A Typical Case (5)
Physical Exam reveals:
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Mr. C. appears well and has no signs of trauma
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Sitting BP and P are 102/58 and 66; standing BP and P
after 1 minute are 88/52 and 72
 Heart rhythm and sounds are normal
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Lungs have bilateral crackles at both lung bases
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Musculoskeletal exam shows very limited range of motion
of the right hip with pain on internal rotation, and
crepitus and pain with flexion of the right knee
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Neurological exam is non-focal without evidence of
peripheral neuropathy, but rapid movement of his head
reproduces his vertigo
Falls in Older Adults
A Typical Case (6)
Get Up and Go observation reveals:
 Difficulty arising without physical
assistance
 Negative Romberg test
 Abnormal gait due to guarding his right
side
 Difficulty and imbalance when turning
Falls in Older Adults
A Typical Case (7)
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What do you think is contributing to
Mr. C’s falls?
What diagnostic tests would you
order?
What interventions would you
implement?
Falls in Older Adults
Causes of Falls
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Intrinsic Factors
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Extrinsic factors
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Acute Conditions
Chronic Conditions
Medications used to treat acute and
chronic conditions
Activity/Behavior
Environment
Often Multi-factorial
Falls in Older Adults
Classifications of Falls
Community-Dwelling:
41% environment related
13% weakness, balance or gait disorder
8% dizziness or vertigo
Nursing Home:
16% environment related
26% weakness, balance or gait disorder
25% dizziness or vertigo
Rubenstein, et al. Ann Intern Med 1994;121;442 – 451
Falls in Older Adults
Causes of Falls – Acute Intrinsic Factors
 Any acute illness
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Infection, MI, stroke, CHF, etc
Postural hypotension
Medications
Falls in Older Adults
Causes of Falls – Postural Hypotension
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Volume depletion
Deconditioing
Post-prandial
Autonomic dysfunction
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Parkinson’s disease, diabetes, other
Medications
Falls in Older Adults
Causes of Falls – Medications
 Decreased mental alertness
 Impaired cognitive function and/or
judgment
 Hypotension
 Postural hypotension
Falls in Older Adults
Causes of Falls – Medications
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Antipsychotics
Sedatives, hypnotics, anxiolytics
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Antihypertensives
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Especially benzodiazepines
Diuretics
Nitrates
Others
Antidepressants
Antiarrythmics
Anticonvulsants
Falls in Older Adults
Intrinsic Factors: Age-related Changes
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Reduced strength
Decreased postural stability
Prolonged reaction time
Decreased visual acuity and depth
perception
Changes in gait
Less ability to dual task (e.g. rushing to the toilet
concentrating on urinary urgency)
Falls in Older Adults
Neurological Components for Intact
Balance and Gait
 Senory Input
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Visual
Proprioceptive
 Motor Output
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Pyramidal
Extrapyramidal
Cerebellar
 Central Integration
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Postural reflexes
Cognitive
Affective
Falls in Older Adults
Intrinsic Factors
Neurological
 Cardiovascular
 Musculoskeletal
 Foot Disorders
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Falls in Older Adults
Neurological Disorders
Contributing to Falls
 Impaired Sensory Input
 Visual (e.g. macular degeneration)
 Vestibular (e.g. benign positional vertigo)
 Proprioceptive (e.g. diabetic peripheral neuropathy)
 Motor Weakness or Control
Disease)
(e.g. stroke, Parkinson’s
 Cerebellar Disorders (e.g. ataxia)
 Cognitive Disorders (e.g. Alzheimer’s Disease)
Falls in Older Adults
Cardiovascular Disorders
Contributing to Falls
 Arryhthmias
 Aortic Stenosis
 Severe peripheral edema
Falls in Older Adults
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Musculoskeletal Factors
Contributing to Falls
Joint Pain
Previous Fractures
Skeletal or Joint Deformities
Unstable Joints
Spine osteoarthritis with
neurological involvement
Falls in Older Adults
Foot Disorders Contributing
to Falls
 Painful conditions
 Joint deformities
 Improperly fitted or risky shoes
(e.g. slippery soles, high spiked heels)
Falls in Older Adults
Activity and Behavioral Factors
 Excess alcohol intake
 Unsafe activities
 Poor judgment in patients
with dementia
Falls in Older Adults
Extrinsic Factors
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Over 70% of falls occur at home
Environmental factors may be present in
50% of falls
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Most commonly these are objects that cause a
trip or a slip
Environmental difficulties depend on the
individual’s disabilities and susceptibilities
Falls in Older Adults
Extrinsic Factors
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Ill-fitting clothes or footwear
Furniture, rugs, lamp cords
Physical features – stairs, tight areas,
clutter
Poor lighting, visual distortions or
distractions
Slippery or wet surfaces
Yard obstacles
Pets that get under foot
Falls in Older Adults
Evaluation
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Falls in the elderly are generally multi-factorial
Risk of falling increases with the number of
predisposing conditions
Identify all potential contributing problems by
systematic clinical evaluation
Evaluation forms the basis for specific treatments
and preventive strategies
Goals are to identify:
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Reversible conditions and environmental factors
Modifiable impairments
Fixed disabilities requiring compensation
Falls in Older Adults
Evaluation - Falls History
“SPLATT”
S ymptoms
P revious falls
L ocation
A ctivity
T ime
T rauma
Falls in Older Adults
Evaluation - Falls History
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Detailed history of the fall
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What, When, Where, Why
Activity
Environmental factors
Associated symptoms, e.g.
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Postural lightheadedness
Vertigo
Syncope or near syncope
Seizure (tongue biting, incontinence)
Circumstances of any previous falls
History of any intrinsic risk factors
Medication review
Alcohol intake
Assessment for acute illness (e.g. dehydration, infection,
acute cardiac or neurological symptoms)
Falls in Older Adults
Evaluation – Physical Exam
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Postural vital signs
Vision
Cardiovascular (CHF, edema, arrhythmias)
Musculoskeletal (pain, deformity)
Feet and footwear
Neurological (focal signs, peripheral neuropathy)
Mental status (cognition, judgment)
Balance and Gait (with assistive device if used)
Watch the patient get up and walk!
(“Get Up and Go” Test)
Falls in Older Adults
Evaluation – “Get Up and Go” Test
Task
Observations
Sit in a chair at a comfortable
height
Sitting balance
Stand without using arms to
help if possible
Balance when standing
Proximal leg muscle strength
Judgment (to lock wheelchair if applicable)
Close eyes at rest
Romberg test
Sternal nudge (eyes closed)
Standing stability
Walk
Step height and length, sway, unsteadiness
Turn around
Stability, number of steps (> 4 increases risk)
Walk back to chair and sit down Balance when sitting down
Falls in Older Adults
Evaluation – Diagnostic Tests
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Routine testing has limited value in the
assessment of falls
Extensive diagnostic work-up generally not
required
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Helpful in evaluating acute problems
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Should be guided by history and physical exam
Dehydration, infection, anemia, trauma
EKG and event monitoring not necessary as
part of routine evaluation after a fall
Falls in Older Adults
Interventions
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Goals are to:
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Minimize risk of falling
Preserve mobility and independence
Multi-component interventions should
be based on the evaluation
Preventive strategies should address
intrinsic and environmental factors
Falls in Older Adults
Interventions
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Medical
Rehabilitative
Environmental /Behavioral
Surgical
Falls in Older Adults
Examples of Medical Interventions
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Manage acute medical problems that may have
contributed to the fall (s)
Assess and treat postural hypotension
Adjust medication (s) if indicated
Reduce alcohol intake if indicated
Optimize management of chronic medical conditions
that increase fall risk
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Parkinson’s disease
Cardiovascular disease
Musculoskeletal disorders
Anemia
Diabetes
Ophthalmology assessment for visual problems
Evaluate for treatable causes of neuropathy if present
Assess and treat osteoporosis in those at risk
Falls in Older Adults
Examples of Rehabilitative Interventions
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Gait and balance training
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Physical Therapy
Tai Chi
Strengthening exercises for muscular weakness
Physical therapy modalities for pain (e.g. heat, cold,
ultrasound, massage, etc.)
Balance exercises for vestibular and proprioceptive problems
Habituation exercises for benign positional vertigo
Ensure patient has correct walking aid and uses it
appropriately
Training in safe performance of daily activities
Braces – e.g. ankle-foot orthotic (AFO) for foot drop
Shoe orthotic for painful foot problems and leg length
discrepancy
Falls in Older Adults
Examples of Environmental and Behavioral
Interventions
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Bathroom modifications: grab bars, raised toilet seat,
rubber mat in tub or shower
Improve lighting, use of night light
Nonskid throw rugs
Remove obstacles from walking paths
Stair safety
Proper storage of items
Bed and chairs at appropriate height
Proper footwear and clothing
Hip protectors for those at high risk
Falls in Older Adults
Examples of Surgical Interventions
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Joint surgery or replacement for
painful arthritis
Neural decompression for neuropathic
pain
Cataract extraction for vision
impairment
Treatment of calluses, bunions, and
foot deformities by podiatrist
Falls in Older Adults
Summary
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Falls are common in both community and
institutionalized older persons
They are associated with significant morbidity and can
cause mortality
Most falls are multi-factorial, involving an interaction
between intrinsic risk factors, activity, and
environment
The evaluation of the elderly faller should be directed
towards identifying multiple risk factors that can
contribute to falls
Medical, rehabilitative, environmental/behavioral, and
targeted surgical interventions may decrease the
incidence of falls and fall-related injuries
Falls in Older Adults
A Typical Case (1)
Mr. C. is an 89 year old man who is
referred to you for the evaluation of
vertigo. His daughter says that he
has fallen 3 times in the past month
after discharge from the hospital for
a “small heart attack and heart
failure”.
Falls in Older Adults
A Typical Case (2)
Mr. C. has no prior history of falls.
His chronic medical problems include:





Coronary artery disease
Hypertension
Congestive heart failure
Degenerative joint disease mainly of the right
hip and knee
Insomnia related to pain in his knee
Falls in Older Adults
A Typical Case (3)
Mr. C’s medications include:





Furosemide and postassium
supplement
Enalapril
Nitroglycerin patch 12 hours per day
Propoxephene as needed for pain
Zolpidem as needed for sleep
Falls in Older Adults
A Typical Case (4)
Further history reveals that each fall
occurred in the morning after
breakfast. He gets up, and when he
starts walking he feels “dizzy”. He
has not to his knowledge passed
out or sustained any severe injury
with these falls. There is no history
suggestive of a seizure.
Falls in Older Adults
A Typical Case (5)
Physical Exam reveals:

Mr. C. appears well and has no signs of trauma

Sitting BP and P are 102/58 and 66; standing BP and P
after 1 minute are 88/52 and 72
 Heart rhythm and sounds are normal

Lungs have bilateral crackles at both lung bases

Musculoskeletal exam shows very limited range of motion
of the right hip with pain on internal rotation, and
crepitus and pain with flexion of the right knee

Neurological exam is non-focal without evidence of
peripheral neuropathy, but rapid movement of his head
reproduces his vertigo
Falls in Older Adults
A Typical Case (6)
Get Up and Go observation reveals:
 Difficulty arising without physical
assistance
 Negative Romberg test
 Abnormal gait due to guarding his right
side
 Difficulty and imbalance when turning
Falls in Older Adults
A Typical Case (7)



What do you think is contributing to
Mr. C’s falls?
What diagnostic tests would you
order?
What interventions would you
implement?
Falls in Older Adults
A Typical Case

What do you think is contributing to Mr. C’s
falls?

Postural hypotension
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Volume depletion
Drug-induced
Post-prandial
Painful poorly managed arthritis
Proximal leg muscle weakness
Benign positional vertigo
Medications – propxyphene, zolpidem
Need to exclude acute problem, e.g. worsening CHF
Falls in Older Adults
A Typical Case (7)
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What diagnostic tests would you order?
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Chemistry panel (BUN/Cr ratio)
Chest xray (for CHF)
Consider a brain natriuretic peptide level
and/or echocardiogram to further evaluate
for CHF
EKG (to exclude new MI worsening CHF)
Falls in Older Adults
A Typical Case (7)
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What interventions would you implement?
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Modification of cardiovascular medications depending
on results of chemistry panel and evaluation of CHF
Discontinue the propoxyphene and zolpidem
Improve pain management, initially trying routine
acetominophen - 1000 mg tid
Physical therapy for leg strengthening and habituation
exercises for positional vertigo
Use of a cane in the left hand to unload painful joints
Education on getting up too quickly after meals