Transcript Falls - Johns Hopkins Medicine

Jessica L. Colburn, MD
Johns Hopkins School of Medicine
Division of Geriatric Medicine & Gerontology
April 15, 2015



Discuss prevalence of falls in older adults
Develop an approach for fall risk screening
and post-fall assessment in older adults
Discuss interventions that reduce fall risk in
older adults
Prevalence
 Outcomes
 Risk Factors

◦ Common Medical
Conditions
◦ Changes with
Aging
Screening
 Evaluation
 Risk Reduction
 Community
Resources
 Take Home Points


One-third of older
adults in the
community fall each
year

One-half of older
adults in long term
care fall each year



Falls are the leading cause of traumatic
injuries in adults over the age of 65
Increased mortality secondary to falls with
each decade of life
Estimated direct medical costs for injuries in
older adults due to falls was $32 billion in
the year 2013
www.cdc.gov/HomeandRecreationalSafety/Fal
ls/fallcost.html
20% need medical
attention
5% fractures
5-10% other serious injuries
(lacerations, head injuries,
dislocations, bleeding)
Kannus et al, Lancet 2005

Hip fracture
◦ Increased risk of dying within the 3-6 months
following a hip fracture
◦ Functional impairment – 20-30% of older adults do
not return to baseline function
◦ Pain, difficult recovery


Found down – risk of injury due to delay to
medical care, can lead to functional
impairment
Fear of falling – leads to social withdrawal,
admission to long term care facilities
Sterling et al, Journal of Trauma 2001



Patients who have fallen in the past year are
more likely to fall again
Most consistent predictor of future falls is
abnormal gait or balance
Think about conditions that your patient has
that contribute to abnormal gait
Ganz et al, JAMA 2007
Patient (Intrinsic) Factors
External Factors
Medical
conditions
Medications
Age-related
changes
Alcohol use
Cognitive
impairment
Vision and hearing
impairment
Falls
Using an assistive
device improperly
Environmental
hazards
Kannus et al, Lancet 2005
Medical Conditions











Parkinson’s disease
Stroke
Seizures
Dementia
Depression
Dizziness
Orthostatic hypotension
Arrhythmia
Osteoarthritis
Diabetes
Peripheral neuropathy
Age-related changes



Changes in balance
Vision changes
Loss of muscle


Cell death in substantia
nigra -> reduction in
brain dopamine levels
Clinical features:
◦
◦
◦
◦
◦

Tremor at rest (pill-rolling)
Cogwheeling rigidity
Masked facies
Bradykinesia
Shuffling gait
Treatment:
◦ Symptomatic relief only
◦ Dopaminergic agents
Image: careplanning.blogspot.com


Early stage – Same fall risk as other
community-dwelling older adults
Middle stage - patients may forget that they
need an assistive device or have knee pain
until they get up and start to walk
◦ Lose fine motor skills, forget how to navigate
environment

Late stage– patients forget how to perform
motor tasks like walking or even swallowing
◦ Muscle wasting, weight loss


Change in blood pressure with position
changes
Reflex mechanisms needed to counteract
gravity are less effective with age
◦ Vasoconstriction
◦ Elevated heart rate



Comorbid medical conditions
Medications – beta blockers,
diuretics, antihypertensives
Volume depletion
Image: nlm.nih.gov


Very common in older adults
Major contributor to gait and balance
problems
◦ Joint pain is commonly reported in primary care
◦ Balance changes due to joint abnormalities
◦ Fear of falling

Pain control: Acetaminophen is safe
◦ NSAIDs (ibuprofen, naproxen) are less safe due to
renal and GI effects
◦ Opiates increase risk of falls and confusion
◦ Physical therapy very useful



Tight control in older adults has been shown
to increase severe hypoglycemic events and
mortality
Oral hypoglycemics (except for metformin)
and insulin are associated with high rates of
hospitalization in older adults
Peripheral neuropathy also
contributes to falls
MEDICATIONS!





Antidepressants
Sedatives/Pain Meds
 Benzodiazepines
 Opiates
Antipsychotics
Dementia agents
(acetylcholinesterase
inhibitors)
Dopaminergic agents

Antihypertensives
Diuretics
Digoxin
Anticholinergics
 Benadryl
 Ditropan
(incontinence)

Polypharmacy



Environmental hazards





Loose rugs
Cords
Clutter
Low lighting
Hand rails
Improper use of assist
devices



Cane
Walker
Wheelchair/scooter

Medications that could increase risk of injury
◦ Blood thinners (benefit may outweigh risk but
important to think about)

Improper use of assistive devices
◦ Hand-me-down devices

Osteoporosis
◦ Increased risk of fracture with a fall
Acute fall?
Two or more falls in
the past year?
Difficulty with
walking or balance?
YES
FALL ASSESSMENT
YES
NO
Fall in the
past year?
NO
YES
Gait and
balance
assessment
Abnormal
?
NO
Reassess periodically
Adapted from AGS Guideline for Prevention of
Falls in Older Persons, 2010


Obtain relevant medical history, physical
exam, cognitive and functional assessment
Determine multifactorial fall risk:
◦
◦
◦
◦
◦
◦
◦
◦
History of falls
Feet/footwear
Medications
Environmental hazards
Gait, balance, mobility
Visual acuity
Other neurologic impairments
Muscle strength
Heart rate and rhythm
Orthostatic hypotension
Adapted from AGS Guideline for Prevention of
Falls in Older Persons, 2010








How did the fall happen?
Did the patient have any symptoms?
Was there an injury?
Patient risk factors for falls (medical
problems, gait imbalance, footwear)
Patient risk factors for injury (anticoagulants,
osteoporosis)
Where there any environmental hazards?
Are there any new or problem medications?
Any change in mental status or functioning?
Moncada LV. Am Fam Phys 2011

Vital signs (orthostatics)
Vision exam
Cognitive assessment
Other neurologic impairments
Muscle strength
Heart rate and rhythm
Gait and balance assessment

Watch your patient walk!










Drop in systolic blood pressure of 20 mm Hg
with position change (sitting to standing)
within 3 minutes
Five minutes of rest before first blood
pressure
Drop may be delayed so typically I check
immediately with standing and again at 2-3
minutes later
Assess for lightheadedness, but not all
patients who are orthostatic get lightheaded






Snellen chart
Pocket card okay
Wearing glasses?
Glasses appropriate?
Reading vs. distance
Bifocals may increase
fall risk


3 word recall + Clock Draw Test
Sensitivity/specificity comparable to using a
cutpoint of 25 on the MMSE
◦ Sensitivity 76% (vs 79% MMSE)
◦ Specificity 89% (vs 88% MMSE)

Shorter to administer in practice than the
MMSE
Borson et al, JAGS, 2003
Borson et al, Int Jnl Geri Psych, 2011

Mini-Cog
◦ Give the patient 3 words to remember
 Banana, chair, sunrise
◦ Administer the Clock Drawing Test – “ten past
eleven” or “two forty-five” or “eight twenty”
◦ 3 word recall

Scoring:
◦ 1 point for each word recalled (0-3 points)
◦ Clock draw test = 2 points normal, 0 points
abnormal
◦ 0-2 = positive screen (“possibly impaired”)
◦ 3-5 = negative screen (“probably normal”)
Borson et al, Int Jnl Geri Psych, 2011





Neurologic exam to assess for causes of falls
Parkinsonian features
Muscle strength
Sensation
Gait/balance


Cardiac examination
Evaluation for abnormalities that would affect
balance or positioning

Irregular heart rhythm

Bradycardia or tachycardia

Timed Up and Go
◦ Start with patient seated in a chair
◦ Instruct patient to stand, walk 3 meters (10 feet),
turn around, come back, and sit down in the chair
◦ Time from when you say go until when patient is
re-seated in the chair
◦ Patient may use his or her assistive device

Scoring:
◦ >/= 12 seconds associated with increased risk of
falls
 87% sensitivity & specificity
Shumway-Cook et al, PT, 2000

Assess home
environment for risks
for falling
◦ Rugs, clutter, cords,
lighting

Consider ways to
improve safety in the
home environment
with assistive devices

Initiate multifactorial intervention to address
identified risks:
Minimize/adjust medications
Recommend appropriate exercise program
Treat vision impairment (consider cataracts, bifocals)
Manage orthostatic hypotension
Manage heart rate and rhythm abnormalities
Supplement vitamin D
Manage foot/footwear problems
Modify the home environment
Consider risks for injury (osteoporosis, blood
thinners)
◦ Provide education and information
◦
◦
◦
◦
◦
◦
◦
◦
◦
Adapted from AGS Guideline for Prevention of
Falls in Older Persons, 2010

Check orthostatics (some patients do not
report dizziness)
◦ Goal BP based on JNC 8 guidelines is 140 – 150
systolic, reduce antihypertensives if appropriate
◦ Encourage fluid intake

Vision screening

Home safety evaluation
◦ Cautious use of bifocals, can increase fall risk
especially with navigating curbs and steps
◦ Medicare no longer reimburses for home safety
evaluation unless it is done as part of home physical
therapy treatment
◦ Can provide instructions for patient/caregiver to
assess home environment


Vitamin D therapy (Grade B evidence) - 800 IU daily
for at least 12 months, regardless of serum level
Physical therapy or exercise referral (Grade B
evidence)
◦ PT for gait & balance training
◦ Assessment of appropriate assistive device and
training to use assistive device
◦ Many types of exercise will reduce falls – Tai Chi, low
to high intensity, group or in home, many are
effective

Multifactorial risk assessment not needed for every
patient, tailor interventions to individual needs
Moyer, Ann Int Med, 2012

Department of Aging –> Resources for
Fitness and Fall Prevention/Risk Reduction
◦ Baltimore County Department of Aging –> Maryland
Access Point: 410-887-2594
◦ Baltimore City Department of Aging -> Maryland
Access Point: 410-396-2273
◦ Senior Centers, exercise programs, fall prevention
programs (ie. Stepping On)
◦ Online tools to help patients/caregivers do their
own home safety assessments




Falls are a common problem for older
adults
Falls are dangerous – increased risk of
functional impairment and death
Risk can be modified with screening,
assessment, and intervention
You can prevent an older adult from falling!

Email:
◦ Jessica Colburn, MD
◦ [email protected]
Thank you!