Evidence Based Approach To Falls 2008
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Transcript Evidence Based Approach To Falls 2008
Evidence Based
Approach To Falls
Dr Larry Dian
Division Of Geriatric Medicine
U.B.C.
Evidence Based
Approach
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Epidemiology
Falls are common; 50% for those 80
years and older fall yearly
60 % of those with a history of a fall in
the previous year will have a subsequent
fall
Most falls result in an injury of some type
10% major injury, 5 % lead to
hospitalization, >70% fear of falling
Scenario 1
You receive a call from the emergency
physician regarding your 86 year old
patient who is being sent home after
receiving sutures for a scalp laceration
that occurred after a fall. CT head
“normal”.
Acute Fall
Why did the person Fall?
5 Step Assessment
Question 1: Did the fall result as a loss
of consciousness?
If yes: Sz. or Stokes- Adams
attack
EEG, 24 hour holter, echocardiogram
Micro burst of LOC likely not significant
Confusion or drowsiness after fall
somewhat supportive
Collateral history very helpful
If No Loss of Consciousness
Was Fall preceded by dizziness?
Type 1: VertigoCentral/peripheral
BPV commonest
Type 2
Lightheadedness/ transient cerebral
hypo-perfusion/orthostatic hypotension
Type 3: “Dizziness of legs”/unsteadiness
Type 4: De-afferentation /psychological
If No Dizziness
Was the fall associated with an acute
medical illness?
Atypical presentation
Delirium
“Round up all the usual suspects”
If No Acute Illness
What was the mechanism of the fall?
Be as precise as possible recreating
actions before and after the fall
Avoid leading questions; patients
may not remember
Collateral history very useful
If No Mechanism For Fall
Falls are either multi-factorial or lower
limb weakness
“Just Fall” fall –eccentric weakness of
quadriceps muscle
5 Step Algorhythm
Provides a rational strategy for
mechanistic determination of the fall
Provides a strategy for fall risk reduction
Scenario 2
The family of your 89 year old patient
wants your opinion about moving their
reluctant mother in a nursing home
because of the concern that she might
fall and “hurt herself”
Risk Factors
Past history of a fall
Psychotropic drug
use
Lower extremity
Arthritis
weakness
History of stroke
Age
Orthostatic
Female gender
hypotension
Cognitive impairment
Dizziness
Balance problems
Anemia
Chronic Diseases
Parkinson's disease
Osteoarthritis of the knee, feet ankle
Cognitive impairment (mmse 18-23) 2x
increased risk of falls
Risk increases with increasing number of
chronic diseases
Number and type of medications
Alcohol use
Targeted Physical Exam
Cardiovascular system
Central nervous system
Musculoskeletal system; lower limbs
Targeted Physical Exam
Postural blood pressure
Heart failure, Atrial fib, Aortic stenosis
Mental status, Parkinson’s disease, stroke
peripheral neuropathy, visual acuity
Arthritis of knees feet, podiatric problems
Strength of hip flexors, ankle dorsi-flexors
Environmental factors, footwear, mobility aids
Supplemental Tests
Get Up and Go Test
Functional reach test
Sternal nudge test; unipedal and tandem stance
Get Up and Go Test
Have the patient sit in a straight-backed
high-seat chair
Instructions for patient: Get up (without
use of armrests, if possible)
Stand still momentarily
Walk forward 10 ft (3 m)
Turn around and walk back to chair
Turn and be seated
Get Up and Go Test
Factors to note:
Sitting balance
Transfers from sitting to standing
Pace and stability of walking
Ability to turn without staggering
Diagram of functional reach test to
assess balance in elderly persons
e-mail this to a colleague
Therapy
Address medical issues
Review home environment
Provide appropriate walking aid
Gait and balance exercise training
Falls are not random events
Falls are common and are associated
with significant morbidity and mortality
Standardized assessment tools exist
A coherent mechanism can be
developed in most cases
Consider referral to falls clinic in complex
cases