Transcript Falls in Older Adults - Emory University Department of Medicine

Joseph G. Ouslander, MD
Director, Boca Institute for Quality Aging
University of Miami Miller School of Medicine at Florida Atlantic University
and
Thomas Price, MD
Division of Geriatric Medicine and Gerontology
Emory University School of Medicine
FALLS IN OLDER ADULTS
2008 UPDATE
Learning Objectives



Review the epidemiology and consequences of falls
in the elderly
Identify common risk factors for falls in this
population
Identify the pros and cons of prevention and
management strategies
Falls Case


Mr. C. is an 89 year old man who is
referred to you for the evaluation
of dizziness. 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”.
Mr. C. has no prior history of falls.
Falls Case
Past Medical History:
 Coronary
artery disease
 Hypertension
 Congestive heart failure (chronic, systolic)
 Degenerative joint disease mainly of the right hip and
knee
 Insomnia
Falls Case
Medications:
 Furosemide
40 mg BID
 K-dur 20 meq daily
 Enalapril 10 mg daily
 Carvedilol 6.25 mg po BID
 Simvastatin 20 mg PO QHS
 Nitroglycerin 0.4 mg/hr patch TOP 12 hours per day
 Propoxyphene/Acetaminophen 1 tab Q4hr PRN pain
 Amitriptyline 50 mg po QHS prn insomnia
Falls Case

Further history reveals that each fall occurred in the
morning after breakfast. He gets up, and when he
starts walking he feels “light-headed”. The
sensation eases when he lies down. 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 Case
Physical Exam:

GEN: No signs of trauma

Vitals: Sitting 102/58;66  Standing 88/52;72 (after 2 minutes)

Heart: RRR +s1,s2 no s3, s4; 2/6 SEM at apex

Lungs: Mild rales bilateral bases


MS: Reduced ROM rt hip with pain on internal rotation; crepitus and
pain with flexion of the rt knee
Neuro: No peripheral proprioceptive/fine touch abnormalities; ear
exam shows minimal cerumen; Dix-Hallpike maneuver to elicit
nystagmus is negative
Falls Case
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 Case

What do you think is contributing to Mr. C’s falls?

What diagnostic tests would you order?

What interventions would you implement?
Falls
Definition
A fall is defined as a sudden, uncontrolled,
unintentional, downward displacement of the body to
the ground or other object, excluding falls resulting
from violent blows or other purposeful actions.
An unwitnessed fall occurs when a patient is found on
the floor and neither the patient nor anyone else
knows how he or she got there.
Epidemiology

Annual incidence in patients >65y
 35-40%
of community dwelling older persons
 Rates increase threefold if in NH or hospital

Injury rate
1
in 20 require hospitalization
 75% of falls-related deaths occur in patients >65y

Falls a major reason for NH admission (40%)
Tinetti NEJM 348:1, 2003
Morbidity of Falls
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
Soft tissue injury
Fractures
Intracranial bleed
Rhabdomyolysis
Reduced Mobility
NH admission
Death
Restraint use
Fear of Falling
Prognosis of Falls



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

Multiple falls are a marker for other underlying conditions
that put older persons at increased risk for adverse health
outcomes
Contributors to Falls
Contributors to 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
Intrinsic Risk Factors for Falls
Risk Factor
Relative Risk (OR)
1. Muscle Weakness
4.4
2. History of falls
3.0
3. Gait deficit
2.9
4. Balance deficit
2.9
5. Use of assistive device (walker, etc)
2.6
6. Visual impairment
2.5
7. Arthritis
2.4
8. Impaired ADL
2.3
9. Depression
2.2
10. Cognitive impairment / dementia
1.8
AGS Panel on falls prevention, JAGS 49(5):2001, 665
Extrinsic Risk Factors for Falls

Environmental hazards
 Loose

rugs, cords, etc
Iatrogenic
 Medications

Behavioral
 Alcohol,

poor judgment, impulsiveness
Clothing
 Poorly
(loose) fitting clothes and footwear
The Morse Fall Risk Assessment Tool

Morse Fall Scale
 High
Risk: 45+
 Med Risk: 25 – 44
 Low Risk: 0 – 24


Everyone may score
high risk in a nursing
home environment
Adjust score based on
your patient
population
Simplified Risk Factors

100% chance of fall in one year for all three of the
following:
 More
than three medications
 Hip weakness
 Unstable balance
Clinical Assessment and Management






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

Falls History
Medication Use
Vision
Postural BP
Balance and Gait
Neurologic exam
Musculoskeletal exam
Cardiovascular exam
Post-discharge home-hazard evaluation
Falls History

SPLATT
Symptoms
Previous falls
Location
Activity
Time
Trauma
Falls History

Detailed history of the fall
Activity, environmental factors
 Symptoms:
Postural lightheadedness Syncope / near syncope
Vertigo
Seizure




Circumstances of any previous falls
Alcohol intake
Assessment for acute illness (e.g. dehydration,
infection, acute cardiac or neurological symptoms)
Medication Use

Assessment
 Evaluate
for high-risk medications
 Four or more medications

Management
 Discontinue
or replace potentially harmful medications
High-Risk Medications

Serotonin-reuptake inhibitors


Tricyclic antidepressants


Alprazolam, clonazepam, lorazepam
Anticonvulsants


Haloperidol, risperidone, quetiapine
Benzodiazepines


Nortriptyline
Neuroleptics


Sertraline, fluoxetine
Phenobarbital, phenytoin
Class IA antiarrhythmics

Procainamide, quinidine
Tinetti NEJM 348:1, 2003
Vision

Assessment
Mid-range and far vision using
Snellen wall chart
 Check peripheral vision/visual fields
 Light reflex (cataracts)


Management
Referral to ophthalmologist
 Avoid bifocals when walking
 Improve lighting in enclosed areas of
home

Postural Blood Pressure




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First 5 minutes SUPINE
Then check BP
Then STAND
Immediately check BP
Wait 2 minutes
Then check BP
Positive test if SBP drops
20% or more either
immediately or after 2
minutes
Postural Blood Pressure

Assessment
 Check
for 20mm Hg (or 20% drop) in systolic pressure
with or without symptoms
 Pulse not as reliable an indicator in older patients

Management
 Check
for acute or chronic causes
 Hydration, compensation strategies (pressure stockings,
etc) if idiopathic
Balance and Gait

Assessment
 Patient’s
report
 Get up and Go test

Management
 Diagnosis
and treatment of underlying cause
 Medications
that cause gait imbalance (see above)
 Environmental obstacles modification
 Referral to physical therapist for gait/progressive balance
training, assist device
Neurologic Examination

Assessment
 Proprioception
 Cognition
 Neuromuscular

(Parkinsonism, etc)
Management
 Diagnose
and treat underlying cause
 Medication adjustment
 Reduction of environmental risk factors
 Physical Therapy Evaluation
Musculoskeletal Examination

Assessment
 Joints
and range of motion (arthritis)
 Foot exam (ulcers, fallen arch, etc)
 Strength testing (Get Up and Go)

Management
 Identify
and treat underlying causes
 Physical therapy referral
 Podiatry referral
The Get Up And Go Test



Time it takes a patient
to get up from a seated
position, walk 8 feet,
then sit back down
Patient must rise from
chair without use of
hands
If takes more than 8
seconds, then patient has
high fall risk
Cardiovascular Exam

Assessment
 Syncope
(Tilt)
 Arrhythmia (ECG)

Management
 Referral
to cardiologist
 Assessment of cardiac anatomic and electrophysiologic
status (echo, signal avg. ECG)
Prevention Strategies



Chang et al. BMJ 2004
Meta-analysis
comparing 40 trials
Effective falls reduction
is achieved only when
assessment is coupled
with aggressive
management
Referral is not sufficient
 When actively managed,
falls were reduced by a
composite 37%

Chang et al. BMJ 328(7441): 2004
Prevention Strategies

New Zealand Falls Intervention (2007)
 Intervention:
At-home nurse evaluation of risk factors
and referral to community interventions and/or PT
 Population: 312 patients with history of falls, avg. age
81, F>M
 No statistical significance between intervention and
control group
Elley et al. JAGS 56(8), 2008
Prevention Strategies

Maastricht GP Cooperative study (Netherlands,
2007)
 Intervention:
Medical/OT eval with recommendations
and referral if needed
 Population: 333 persons >65 yo, F>M with recent fall
 No statistical significance between intervention and
control groups in # new falls, fear of falling, or activity
avoidance
Hendriks et. al JAGS 56(8), 2008
Prevention Strategies


Multifactorial evaluations useless without aggressive
pursuit of treatment
Elements of the multifactorial evaluation:
-- Orthostatic BP
-- Vision testing
-- Balance and gait testing
-- Drug review
-- IADL/ADL assessment
-- Cognitive evaluation
-- Assessment for environmental
hazards
Prevention Strategies

Bang for the buck?
Balance and gait training
reduction
Reduction in home hazards
Stop psychotropics
Multifactorial risk E&M
Balance and strength exercise*
=
14-27%
=
=
=
=
19%
39%
25-39%
29-49%
* Community based
Falls Case


Mr. C. is an 89 year old man who is referred to you
for the evaluation of dizziness. 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”.
Mr. C. has no prior history of falls.
Falls Case
Past Medical History:
 Coronary
artery disease
 Hypertension
 Congestive heart failure (chronic, systolic)
 Degenerative joint disease mainly of the right hip and
knee
 Insomnia
Falls Case
Medications:
 Furosemide
40 mg BID
 K-dur 20 meq daily
 Enalapril 10 mg daily
 Carvedilol 6.25 mg po BID
 Simvastatin 20 mg PO QHS
 Nitroglycerin 0.4 mg/hr patch TOP 12 hours per day
 Propoxyphene/Acetaminophen 1 tab Q4hr PRN pain
 Amitriptyline 50 mg po QHS prn insomnia
Falls Case

Further history reveals that each fall occurred in the
morning after breakfast. He gets up, and when he
starts walking he feels “light-headed”. The
sensation eases when he lies down. 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 Case
Physical Exam:

GEN: No signs of trauma

Vitals: Sitting 102/58;66  Standing 88/52;72 (after 2 minutes)

Heart: RRR +s1,s2 no s3, s4; 2/6 SEM at apex

Lungs: Mild rales bilateral bases


MS: Reduced ROM rt hip with pain on internal rotation; crepitus and
pain with flexion of the rt knee
Neuro: No peripheral proprioceptive/fine touch abnormalities; ear
exam shows minimal cerumen; Dix-Hallpike maneuver to elicit
nystagmus is negative
Falls Case
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 Case



What do you think is contributing to Mr. C’s falls?
What diagnostic tests would you order?
What interventions would you implement?
Falls Case

Contributors
 Arthritis
of hip and knee
 Vasodilators (nitroglycerin)
 Iatrogenic cognitive impairment? (propoxyphene,
amitriptyline)
 Post-prandial orthostasis?
 Postural hypotension (too much BP med?)
 Proximal muscle strength weakness
 Balance disorder
Falls Case

Diagnostics
 Basic
Labs (volume depletion?
Diabetes?)
 Comprehensive
chemistry
 Complete blood count (orthostasis)
 Other
labs
 B12
level abnormal?
 CT of head?
 Assessment of thyroid function?
 Cognitive
performance test (MMSE)
Falls Case

Interventions
 Physical
therapy for gait training and strengthening
 Replace amitriptyline with alternative agent, or
discontinue completely
 Same with propoxyphene
 Home safety assessment
 Adaptive?
Summary

Falls are common in both community and
institutionalized older persons

Associated with significant morbidity and mortality

Most falls are multi-factorial


Evaluation should be directed towards identifying
multiple contributory risk factors
Multi-modal interventions can decrease the
incidence of falls and fall-related injuries