Transcript Falls Powerpoint Presentation

Falls
Kathleen Pace Murphy, PhD, MD, GNP-BC
The University of Texas Health Science Center at Houston
Assistant Professor, Division of Geriatric and Palliative Medicine,
Department of Internal Medicine
Acknowledgement
• The Houston Geriatric Education Center is
funded by the United States Department of
Health Resources and Services
Administration (HRSA) Grant Number
UB4HP19058.
• The Baby Boomer Imperative Project was
possible because of this funding.
Learning Objectives
Successful students will be able to :
• Identify aging changes and risk factors for falls
in older adults.
• Develop an approach to assessment of an
older adult with falls, balance and gait disorder.
• Describe the role of intrinsic and extrinsic
factors in the prevention and management of
falls.
• Develop practical, effective management
strategies for falls in ambulatory practice and
develop practice protocols for fallers.
Definition
• An event that results
in a person’s
inadvertently coming
to rest on the ground
or lower level with or
without loss of
consciousness or
injury.
Excludes falls from
major intrinsic
event (seizure,
stroke, syncope) or
overwhelming
environmental
hazard
Prevalence
•~ 33% of community
dwelling persons over
the age of 65 years fall
annually
•~50% of community
dwelling persons over
the age of 85 years fall
annually
•~50% of Nursing home
residents fall annually
(Flaherty and Resnick, 2014)
Prevalence and Morbidity
• 33% of people who fall need medical
attention
• Only 50% of people who fall can get
themselves up (long lie phenomena)
• Falls are associated with
– Functional status decline
– Increased likelihood of NHP
– Increased use of medical services
Flaherty & Resnick (2014)
Impact of falls
•Leading cause of accidental death in older adults
•Risk of dying from a fall increases with age
•White males aged 85 and older - highest death rate
•2.2 Million non-fatal falls treated in U.S. ER – 26% required
hospitalization (2009)
RISK FACTORS
Intrinsic or Extrinsic
Intrinsic
•Age and age-related physiologic changes
•Acute/chronic illness
•Mobility factors
•Medications*
Extrinsic
•Environmental Factors
•Foot ware
•Use of ambulatory assistive devices
•Mechanical Restraints
Falls are multi-factorial
• Highest RF from prospective studies:
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Increasing age
Cognitive impairment
Females
Past Fall history
Mobility problems
Balance Problems
Low vitamin D level
Psychotropic medication use
PD
Stroke
Arthritis
Risk Factors
Medications
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Polypharmacy
Diuretics
Hypnotics and Sedatives
Antidepressants
(TCA/SSRI)
Antipsychotics
Cardiac medications
Anticholinergic drugs
Hypoglycemic agents
Antiparkinson
medications
Topical eye medications
Case Study
• Joe is an 82-year-old patient in your
ambulatory outpatient clinic.
• Recently widowed and living alone
• One daughter who lives 50 miles away
and works fulltime
• Chief Complaint: urinary frequency and
boredom
• Past Medical History: HPTN, DM,
intermittent nausea with gastroparesis,
BPH, bilateral OA of the knees
• Medications - Joe forgot to bring his
medications or medication list with him
• Physical Exam: Bent eyeglass frames,
abrasions on his forehead, left cheek, left
forearm. Bruises on left arm.
• After questioning he admits he fell a few
days ago. He insists you not tell his
family.
Is it a heart attack??
• Elders have nonspecific
disease presentations
• Acute illnesses
• Multiple diseases
increases the risk of falls
• Diseases that affect your
vision, neuro and MSK
system increase your risk
• Depression is an
independent risk factor
• Dementia
Falling is a Red Flag
Exclude acute illness or
underlying systemic or
• metabolic process
• Infection
• electrolyte imbalance
as indicated by history,
examination, and
laboratory studies
Differential Diagnosis
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Accident
Environmental hazard
Gait or balance disorder
Dizziness
Vertigo
Syncope
Hypotension
Dementia
Visual disorders
Loss of consciousness??
FALLS
Screening
• Under-reported
• Ask all the time at
LEAST once a year
• Memory impairment
may decrease self
report- ask CGs,
family or friends
• Reluctant to tell you
Fall History
• Tell me about your falls.
• ID circumstances
surrounding the fall
• Acute illness vs. syncope
• Other RF explored
• Drug
• Abnormal motor
• Cognitive Impairment
• Dizziness
• Impaired vision
• Environmental hazards
History
How do you ask the right ??
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Fall with standing
Fall with reaching
Carpet edge
Flexion of the neck
After a meal
Day or night
Where are the injuries
Depression
Incontinence
Falls
Baseline Functional Level
• Change in functional
activity level
• Change in cognitive
status
• Recent changes
(confusion,
worsening memory
loss)
Is there a
recent
change?
How do you go about this?
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Falls Y or N
Recurring Falls Y or N
Fall evaluation
Assess
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History
Medications
Vision
Gait and balance
Lower limb joints
Neurological
cardiovascular
American
Gerontological
Society
Physical
Skin
Cardiac
Neuro
MSK
Cognitive
Vital signs
Physical Exam
Functional Assessment
•Functional gait and balance
•Timed-Up-and-Go
•Mobility
•Ask about person’s ability to complete activities of
daily living: bathing, dressing, transferring,
continence.
Examiner asks the patient to:
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Stand up from a chair
Walk 3 meters
Turn around
Walk back
Sit down
(observe and time patient)
10 seconds or less – low risk
11-19 low-moderate risk
20-29 moderate – high risk
30 seconds or more indicates that the
patient has impaired mobility and is at
high risk of falling
Laboratory and Radiologic Studies
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CBC
Thyroid function test
Electrolytes
Glucose
Calcium
Vitamin B
u/a (Sp gravity, infection)
Drug levels and urine
toxicology (anticonvulsants,
illicit)
• Brain imaging or cardiac
evaluation
No specific
guidelines
Depends..
Prevention
• Target interventions to risk
factors
• Prioritize fall prevention
programs
• Establish tailored exercise
• Tai Chi classes/PT
• Offer hip protectors to all
persons at very high risk of
falling, particularly if risks are
not modifiable.
• (Available via
http://www.hipprotector.com
or http://www.hipsaver.com)
Goal is to
minimize risk of
falling without
compromising
mobility and
functional
independence
CD Older adult
• Exercise/PT
• Tai Chi exercise (15
wks)
• IDT home evaluation
• Medication review and
modification
• Pacemaker for carotid
sinus syndrome
• Vitamin D
Prevention
Strategies
Postural hypotension:
drop in SBP  20 mm Hg
or to < 90 mm Hg on
standing
•Behavioral recommendations, such as
ankle pumps or hand clenching and
elevation of head of bed
•Decrease in dosage, discontinuation,
or substitution of medication that may
contribute to hypotension
•Pressure stockings (e.g., Jobst)
•Fludrocortisone (Florinef) 0.1 mg qd—
tid [0.1] if indicated
Midodrine (ProAmatine) 2.5-5 mg tid
[2.5, 5]
•Caffeinated coffee (1 cup) or caffeine
100 mg with meals
Risk Factor
Intervention
Use of any benzodiazepine
or other sedative-hypnotic
agent
Education about the
appropriate use of
sedative-hypnotic agents
Nonpharmacologic
treatment of sleep
problems (i.e., sleep
restriction)
Tapering and
discontinuation of
medications
Use of  4 prescription
medications
Review and modification
of medications, if
appropriate
Risk Factor
Intervention
Environmental hazards for falls
or tripping
Environment assessment with
appropriate changes:
 removal of hazards
 safer furniture (e.g., correct
height, more stable)
 installation of structures (e.g.,
grab bars, handrails)
 improved lighting
 reduced use of active
restraints (e.g., wheelchair
adaptations, removable belts,
wedge seating)
 protective hip padding
Risk Factors
Intervention
Any impairment in gait
Gait training
Use of an appropriate
assistive device
Balance or strengthening
exercises, if indicated
Any impairment in balance or
transfer skills
Balance exercises; training
in transfer skills, if indicated
Environmental alterations
(e.g., grab bars, raised toilet
seats)
Risk Factor
Impairment in leg or
arm muscle strength or
range of motion (hip,
ankle, knee, shoulder,
hand, elbow)
Intervention
•Exercises with resistive
rubber bands and putty
•Resistance training 2-3
x/wk: increase resistance
when able to complete 10
repetitions through the full
range of motion
•Tai Chi
Summary
Thank you for your kind attention
Credits
Content credits
Content provided by:
• Dr. Kathleen Pace Murphy
• Please see reference list
Images:
Houston GEC would like to thank:
• Google images
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References
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Chou WC, Tinetti ME, King MB, Irwin K, Fortinsky RH. Perceptions of physicians on the barriers and
facilitators to integrating fall risk evaluation and management into practice. J. Gen Intern Med.
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