Transcript Falls - Department of Family Medicine, University of Ottawa

Falls
Sydnee Burgess PGY1
Geriatric Medicine
October 26th 2015
objectives
• Falls in the elderly in Canada
• What to do when a patient falls
• Prevention of falls in the elderly
Falls among the elderly in Canada
• Leading cause of injury-related hospitalizations among Canadian seniors
• Self-reported injuries due to falls increased by 43% between 2003 and 2009/2010
• Number of deaths due to falls increased by 65% from 2003 to 2008.
• Majority lead to bone # and 1/3 to hip #
• 20-30% of seniors fall each year
• Cost to patient, caregivers and health care system (~$2billion annually, 3.7 greater
than for younger adults)
• Can lead to
• Negative mental health outcomes (fear of falling), loss of autonomy, greater
isolation, immobilization, depression
89 yo F, admitted to A1 for UTI tx, PMHx:
dementia, osteoporosis…
• FALLS!
• What do you do?
Over the phone
• Ask
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Reason for admission?
fall witnessed?
obvious injury?
VS?
Change in LOC?
Is patient receiving
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ACO
Antineoplastic
Any Rx affecting coagulation
Antiseizure meds?
YES to Any of these questions requires
immediate assessment
On your way over, as yourself:
1)Why does a patient fall
CARDIO
Vasovagal attack
Dysrythmia
MI
Orthostasis
Volume depletion, drugs,
autonomic failure
NEURO
Confusion and cognitive
impairment (↓ safety
awareness)
Rx: Narcotics, sedatives,
antidepressants,
tranquilizers,
antihypertensives
Metabolic: E+ abnormality,
kidney/liver failure
Gait and balance disorders
TIA, stroke
seizure
ENVIRONMENTAL
Restraints
Improper bed height
Wet floors
Unsafe clothing (tractionless
slippers, long hospital gowns
or pyjamas)
Obstacles (bed rails, IV poles,
clutter around bed)
Poor vision
2)rule out Head Injury
• as it is a major threat to life
• r/o acute epidural or subdural bleed.
• Any suspicion of head trauma requires full neuro exam
• Any new onset neuro problem requires immediate CT scan of head
At bedside
• Quick look
• Airway and VS
• Selective hx
Selective history
• Circumstances of fall
• Associated symptoms
• Relevant comorbid conditions
• ↓ decrease foot sensitivity/mobility, ↑ weakness, ↑ pretest prob% of #
• Medication review
P/E
• Postural pulse and BP lying and 3min after standing, temperature
• Vision: acuity (w/aids), visual fields, cataracts
• Motion induced nystagmus
• Arthritic changes, ↓ ROM, Romberg, gait, deformities, hip flexor
weakness, tremor, rigidity
• Heart arrhythmia, valve dysfunction, pedal pulses
• Balance, gait and mobility
• Get Up and Go test / POMA
investigations
• CBC, E+, BUN, Cr, glucose, B12, TSH, 25OH-vitD
• BMD in all women >65 yo
• Cardiac workup if symptoms of syncope or pre-syncope
• Neuroimaing if
• head injury or r/o cervical spondylosis
• new focal neuro findings on P/E
• lumbar stenosis + abnormal gait, neuro exam, or LE spasticity or hyperreflexia
• Drug concentrations for anticonvulsants, antiarrhythmics, TCAs and
high-dose ASA
Search for cause
• Treat the cause
• Treat reversible factors:
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Volume depletion
Inapproprite drug therapy
Iatrogenic nocturia
Environmental access
• Poseys and bed rails may actually contribute to falls and should be discouraged
Prevention
Focus on most common RFs
History of falls
Fear of falling
Gait deficit
Balance deficit
• Other risk factors
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Visual deficit, particularly unilateral visual loss, Use of assistive devices
Arthritis
Impaired iADLs
Depression
Cognitive impairment
>80 yo
>2 pain locations
Higher pain severity
Pain interference with activities
Inadequate diet (34% of Canadian seniors in private households are at risk)  fraily,
weakness (lack of vitD linked to muscle strength)
• At risk behaviour (walking without a mobility aid when one is needed, climbind ladders or
unsteady chairs)
• 50% of falls that result in hospitalisation happen in a home setting
• Therefore, important to plan for safety (educate in the elderly)
Screen!
As proposed by the
AGS…
No falls does not
mean not at risk!
P/E at periodic
exam:
- Get up and go
- Romerg
Assessing fall risk in 10 minutes:
 POMA
 Cane,
walker
fitting
Preventive home
visits = 37%
reduction in fate of
falls with>80yo….
But cost.
Medications associated with falls
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Antipsychotics
Sedatives, hypnotics
MAOIs, SSRIs, TCAs,
Antiarrhythmics
Anticonvulsants
Anxiolytics (benzos)
Antihypertensives
Diuretics
Systemic glucorticoids
Skeletal muscle relaxants
Consider agents with less risk of
falls
Taper and d/c Rx as possible
Address sleep problems with non
pharmaco interventions
Multifactorial interventions
• Educate
• PHAC has developed a number of pamphlets for seniors and their families
• Treat/correct
• Cardiovascular disorders
• Hypotension
• Visual problems
• OT consult for home adaptation
• Rails
• Low stiffness flooring can reduce impact of falls up to 50% w/o impairing balance
• Exercise programs
• Balance training ± strength training
• Eg: tai chi. Evidence in reducing falls is mixed, but studies supporting effectiveness were generally of higher quality
• Only 11% of Canadians between 60-79 yo are meeting Canada’s physical activity guidelines
• Gait and balance deficits
• Anti-slip shoes for ice ↓ falls
• Good on some surfaces, not others. Not cleated shoes
Multifactorial interventions
• Visual referral and correction
• Nutrition and supplements
• AGS recommends vitamin D for older adults at risk of falls or with
known/suspectd vitamin D deficiency
• Vit D + Ca+ reduces risk of falls… impact most profound when an older person
is deificent in vitamin D
Tailor to your patient
• Thank you!
References
• Reuben DB, Herr KA, Pacala JT, et al. Geriatrics At Your Fingertips:
2014, 16th Edition. New York: The American Geriatrics Society; 2014.
• Seniors’ Falls in Canada, Second Report: Protecting Canadiaans From
Illness. Public Health Agency of Canada. 2014
• Marshall SA, Ruedy J. On Call: Principles & Protocols, 4th Edition.
Elsevier Saunders. 2004