Transcript Falls in the Elderly

Falls in the Elderly
C. Bree Johnston, MD MPH
Copyright May 2001
UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Overview
Prevalence
 Clinical Importance
 Risk Factors & Etiology
 Evaluation
 Prevention & Management
 Falls & restraint use
 Summary

UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Falls: Mrs. F.

Mrs. F. is an 80 year old woman who lives
alone. She just came in to your office for
follow up of a fall resulting in a Colles’
fracture. She has had two other falls over the
past year and a half. She is scared of falling
again. She has a history of osteoarthritis and
anxiety/depressison. She is on naproxen
500mg BID and diazepam 5mg BID prn
UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Falls in the Elderly
 Prevalence
Clinical Importance
 Risk Factors & Etiology
 Evaluation
 Prevention & Management
 Falls & restraint use
 Summary

UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Prevalence
30% of those over 65 fall annually
 Half are repeat fallers
 Falls go up with each decade of life
 Over half of those in nursing homes and hospitals
will fall each year
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UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Falls in the Elderly

Prevalence
 Clinical
Importance
Risk Factors & Etiology
 Evaluation
 Prevention & Management
 Falls & restraint use
 Summary

UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Impact of Hip Fractures
1% of falls result in hip fracture
 $2 billion + in medical costs annually
 25% die within 6 months
 60% have restricted mobility
 25% remain functionally more dependent
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UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Falls Cause Morbidity and Mortality
Mortality: found down syndrome, indirect effects
 Fractures: 6% of falls
 Soft tissue injury, head injury, subdural
hematoma
 Fear of falling can result in decreased activity,
isolation, and further functional decline
 Nursing home placement and loss of
independence
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UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Falls in the Elderly
Prevalence
 Clinical Importance

 Risk
Factors & Etiology
Evaluation
 Prevention & Management
 Falls & restraint use
 Summary

UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Falls are Multifactorial
Intrinsic Factors
Medical
conditions
Impaired vision
and hearing
Age related
changes
Extrinsic Factors
Medications
FALLS
Improper use of
assistive devices
Environment
UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Normal Changes with Aging
Neurologic
 Increased reaction time
 Decreased righting reflexes
 Decreased proprioception
 Vision Changes
 Decreased accommodation & dark adaptation
 Decreased muscle mass
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UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Normal changes of Gait
Slower gait
 Decreased stride length and arm swing
 Forward flexion at head and torso
 Increased flexion at shoulders and knees
 Increased lateral sway
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UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Dysmobility
Dysmobility and falling closely related
 15% of those over 65 have trouble walking
 1/4 men and 1/3 women over age 85 have
difficulty with walking
 2/3 of people in hospital or NH unable to
ambulate without assistance
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UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Risk Factors for Falls

Risk Factor
 Sedative use
 Cognitive Impairment
 Lower extremity problem
 Pathologic Reflex
 Foot Problems
 > 3 balance/gait problems
 >5 balance/gait problems
OR
28
5
4
3
2
1.4
1.9
Tinetti NEJM 1988
UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Common Pathologies associated with Falls
Ophthalmologic diseases
 Arthritis
 Foot problems
 Neurologic illness
 Parkinson’s & related disorders
 Strokes
 Peripheral neuropathy
 Dizziness and dysequilibrium
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UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Dizziness:
A Multifactorial Syndrome
Vertigo: BPV, Posterior CVA/TIA, Cervical
 Presyncope: Orthostatic, Dysrythmia, Anemia
 Dysequilibrium: Peripheral neuropathy, Visual
 Other: Anxiety, depression
 In older people, usually multifactorial

Tinetti, Annals of Internal Med 2000
UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Falls in the Community
Accidents/environment
 Weakness, balance, gait
 Drop attack
 Dizziness or vertigo
 Orthostatic hypotension
 Acute illness, confusion, drugs,
decreased vision
 Unknown

37%
12%
11%
8%
5%
18%
8%
Rubenstein JAGS 1988
UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Falls in Residential Care
Generalized weakness
 Environmental hazard
 Orthostatic hypotension
 Acute illness
 Gait or balance disorder
 Drugs
 Other or unknown
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31%
27%
16%
5%
4%
5%
10%
Rubenstein Ann Int Med 1990
UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Medications and Falls
Sedative-hypnotics, especially long acting
benzodiazepines, increase falls
 Small association between most psychotropics
and falls
 SSRIs and TCAs both incrsease falls
 Weak association between Type 1A
antiarrythmics, digoxin, diuretics, and falls

Leipzig JAGS 1999
Thapa NEJM 1998
UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Falls in the Elderly
Prevalence
 Clinical Importance
 Risk Factors & Etiology

 Evaluation
Prevention & Management
 Falls & restraint use
 Summary

UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Evaluation of Falls: History
Location & circumstances of Fall
 Associated symptoms
 Other falls or near falls
 Medications (including nonprescription) and
alcohol
 Injury & ability to get up
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UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Evaluation of Falls: Physical Examination
Supine and standing BP - always
 Routine physical examination
 Focus on cardiovascular, MS, neuro, feet
 Vision and hearing evaluation
 Consider acute medical illness & delirium
 Formal gait and balance assessment
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UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Evaluation of Falls: Home
Evaluation
Can be performed by nurse, OT, PT, others
 Stairs
 Lighting
 Clutter
 Bathroom
 Specific hazards: cords, throw rugs
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UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Evaluation of Falls: Risk Factors for Injury
Osteoporosis assessment
 Anticoagulation: Usual benefits outweigh risks
unless repeat or high risk faller
 Can the person get up from fall?
 Is there a way to notify others in case of falling?

UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Mrs. F.
History reveals that she fell at home in the
bathroom at night, tripping over a bathmat.
Both other falls have been in similar
circumstances. She was able to get up.
 On PE, she has visual acuity of 20/100 with
bilateral cataracts. She has mild OA of the
knees, with bunyon deformities of her feet and
poor fitting shoes.
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UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Mrs. F.
Her gait assessment shoes that she is unable to
get up out of the chair without help. Her gait
is hesitant and slightly wide based.
 Home evaluation reveals poor lighting in all
rooms, multiple throw rugs in every room,
and no grab bars or safety equipment in the
bathroom.
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UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Mrs. F.
She is weaned off of her diazepam over 3 months
 T-score on dexa is –3.0, and she is begun on
alendronate, vitamin D, and calcium
 She goes to ophthalmology and podiatry
 PT begins exercises, followed by weight lifting
and exercise 3X a week at a Senior Center
 She gets home safety equipment, improved
lighting, and gives away her throw rugs
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UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Formal Gait Evaluation
Get up and Go Test
 Tinetti Gait and Balance Evaluation (POMA)

Tinetti JAGS 1986
Podsiallo jAGS 1991
Mathias Arch Phys Med 1986
UCSF Division of Geriatrics Primary Care Lecture Series May 2001
POMA: Balance Component
Sitting (in hard, armless chair)
Arising
Standing balance (immediate and delayed)
Balance with Nudge
Balance with Eyes closed
Balance with 360 degree turn
Tinetti JAGS 1986
UCSF Division of Geriatrics Primary Care Lecture Series May 2001
POMA: Gait Component
Initiation
Step length and height
Step symmetry & continuity
Path
Stance
Ability to pick up speed
Tinetti JAGS 1986
UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Common Causes of Abnormal Gait

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
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Difficulty arising from chair Weakness
Arthritis
Instability on first standing Hypotension,
Weakness
Instability with eyes closed Proprioception
Step height/length
Parkinsonism
Frontal lobe
Fear
UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Falls in the Elderly
Prevalence
 Clinical Importance
 Risk Factors & Etiology
 Evaluation

 Prevention
& Management
Falls & restraint use
 Summary

UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Prevention & Treatment
Treat acute injury & underlying medical
conditions
 Remove unnecessary medications
 Rehab, exercises, assistive devices
 Correct sensory impairments
 Environmental modifications & safety
 Evaluate for osteoporosis treatment
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UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Osteoporosis

Calcium and vitamin D for most elders at risk

Dawson-Hughes, NEJM, 1997
Osteoporosis evaluation and treatment
 Hip protectors appear to protect from hip
fractures in those who wear them


Kannus, NEJM, 2000
Thiazides may help slightly
 Statins?
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UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Risk Factor Modifications for Fractures
Change
Estimated Change in Risk
Quit smoking
38%
Treat impaired vision
50%
Stop sedatives
40%
Add 1 Gram Calcium
24%
Hip Protectors
50%?
Adapted from Stteve Cummings
UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Hip pads to prevent hip fracture

“RCT” of 1801 frail subjects in Finland
 Nursing home or frail community patients
 Mean age 81
 78% women
 63% assisted walking

Kannus. NEJM;2000;343;1506-1513.
UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Fractures with Hip Protectors
 2.1% per year vs. 4.6% per year (p<.01)
 40 patients needed to be treated with hip
protector for 1 year to prevent one
fracture
 2.4% of falls resulted in hip fracture when
not wearing protector
 0.4% resulted in hip fracture when
wearing protector (80% risk reduction)
 But patient acceptance low
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Kannus. NEJM;2000;343;1506-1513
UCSF Division of Geriatrics Primary Care Lecture Series May 2001
www.hipsavers.com
UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Prevention of “Found Down”
Syndrome
Lifelines
Accessible telephones
Teach in getting up off floor
Friendly phone calls or visitors for isolated
elderly
UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Falls: Primary Prevention
 301
community dwelling elders with 1+
risk factors for falling
 Intervention: adjustment in medications,
behavioral instructions, exercise programs
aimed at modifying risk factors
 One year follow up
Tinetti et al. 1994 NEJM
UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Multifactorial Intervention
%
Falling
Tinetti et al 1994 NEJM
50
40
30
20
Control
Intervent
i
Mo
10
P = .04
0
0
3
6
9
12
Months
UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Exercise Training & Nutrition
140
120
100
%
80
Change
60
Muscle
strength 40
20
0
-20
Exer
Exer + Su
Sup
Control
Exer
Exer +
Sup
Su
STUDY GROUP
Control
Fiatarone et al NEJM 1994
UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Tai Chi and Falling

Atlanta FICSIT Trial
200 community dwelling elders 70+
 Intervention: 15 weeks of education, balance training,
or Tai Chi
 Outcomes at 4 months: Strength, flexibility, CV
endurance, composition, IADL, well being, falls


Falls reduced by 47% in Tai Chi group
Wolf JAGS 1996
UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Exercise, Falls, and Frailty
FICSIT Trials
8 independent prospective RCTs
Goal: reduction in falls and frailty
Pre-planned Meta-analysis
Intervention
RR
Any Exercise
Balance Component
.90
.83
CI
(.81-.99)
(.70-.98)
Province JAMA 1995
UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Training frail older persons:
The New Zealand Study of Women
223 women >80 years
Intervention: PT tailored to individual needs, with
resistance and balance training
Results:
Clinical balance, chair rise improved
RR for falls .47 (CI .04-.90)
RR for injurious falls .61 (.39-.97)
Campbell BMJ 1997
UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Falls in the Elderly
Prevalence
 Clinical Importance
 Risk Factors & Etiology
 Evaluation
 Prevention & Management

 Falls

& restraint use
Summary
UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Restraint Reduction and Injury
No evidence that restraints reduce fall injuries
 Restraints increase morbidity and may cause
death
 Reported strangulation deaths from restraints
every year
 Risk factor for delirium, decubitus ulcers,
malnutrition, aspiration pneumonia

UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Restraint Reduction Decreases Injuries
816 bed Jewish Home for the Aged
- Restraints decreased from 39% to 4% over 3 years
- No change in falls, injuries, psychotropic use
2 year educational intervention covering 2000+
beds
- Restraint reduction 41% to 4%
- Decrease in serious injuries from 7.5% to 4.4%
Tinetti 1992, Capezuti, Neufeld 1999, Evans 1997
UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Alternatives to Restraints For Patients
with Lines and Tubes
Sedation (especially in ICU)
 Reducing delirium risk factors (drugs,
dehydration)
 Does the benefit of tubes and lines (or
hospitalization) outweigh the risks of restraints?
 Geriatric Consultation Team
 Sometimes restraints may be unavoidable in this
setting

UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Alternatives to Restraints for Patients
Who Fall or Wander
Accept the risk of falling
 Hip protectors
 Environmental modifications, day rooms,
low beds
 Least restrictive alternatives
 Alarms
 Sitters or family
 Geriatric consultation team

UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Summary
Falls are common in the elderly & may lead to
injuries and decline in function
 Evaluation should included risk factor
assessment, gait assessment, and home
assessment
 Exercise can improve outcomes
 We have no evidence that restraints reduce fall
related injuries

UCSF Division of Geriatrics Primary Care Lecture Series May 2001