Post on 07-Nov-2014
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Case Discussion for Pharmacy Undergraduates
Geriatric FallsBy,By,
Dr. Lokesh ShettyDr. Lokesh Shetty
MPHARM – PharmacologyMPHARM – Pharmacology
Lecturer - RCsDPLecturer - RCsDP
Falls in Geriatrics
Falls: Mrs. F. Mrs. F. is an 80 year old woman who lives alone. Mrs. F. is an 80 year old woman who lives alone.
She just came in to your office for follow up of a She just came in to your office for follow up of a
fallfall resulting in a resulting in a Colles’ fracture (Colles’ fracture (fracture fracture of the distal radius in the forearm). of the distal radius in the forearm). She has had She has had two other falls over the past year. She is scared two other falls over the past year. She is scared of falling again. She has a history of of falling again. She has a history of
osteoarthritisosteoarthritis and and anxiety/ depressionanxiety/ depression. She is . She is
on on naproxennaproxen 500mg BID and 500mg BID and diazepamdiazepam 5mg 5mg BID when necessary.BID when necessary.
Overview PrevalencePrevalence Clinical ImportanceClinical Importance Risk Factors & EtiologyRisk Factors & Etiology Evaluation Evaluation Prevention & ManagementPrevention & Management Falls & restraint useFalls & restraint use SummarySummary
Prevalence
30% of those over the 30% of those over the age of 65 age of 65 fall annuallyfall annually Half are repeat fallersHalf are repeat fallers Falls go up with each decade of life as inclining Falls go up with each decade of life as inclining
ageage
1% of falls result in hip fracture
Impact of Hip Fractures
25% die within 6 months25% die within 6 months 60% have restricted mobility60% have restricted mobility 25% remain functionally more dependent25% remain functionally more dependent
Falls Causes
Mortality (death)Mortality (death) Fractures: 6% of fallsFractures: 6% of falls Soft tissue injury, head injury etcSoft tissue injury, head injury etc Fear of falling can result in Fear of falling can result in
decreased activity, isolation, and further decreased activity, isolation, and further functional declinefunctional decline
Nursing home placement and loss of Nursing home placement and loss of independenceindependence
Falls are Multifactorial
Intrinsic Factors Extrinsic Factors
FALLS
Medical conditions
Impaired vision and hearing
Age related changes
Medications
Improper use of assistive devices
Environment
Normal Changes with Aging NeurologicNeurologic
Increased reaction timeIncreased reaction time Decreased righting reflexes (Decreased righting reflexes (regain back former regain back former
body position)body position) Vision ChangesVision Changes
Decreased accommodation & dark adaptationDecreased accommodation & dark adaptation Decreased muscle massDecreased muscle mass Old Age Old Age Slower gait Slower gait (manner in which human or (manner in which human or
animal moves using limbs) animal moves using limbs) FallsFalls
Risk Factors for Falls Risk FactorRisk Factor
Sedative useSedative use Cognitive ImpairmentCognitive Impairment Lower extremity problemLower extremity problem Pathologic ReflexPathologic Reflex Foot ProblemsFoot Problems gait problemsgait problems
Common Pathologies associated with Falls Ophthalmologic diseasesOphthalmologic diseases Arthritis Arthritis Foot problems Foot problems Neurologic illnessNeurologic illness
Parkinson’s & related disordersParkinson’s & related disorders StrokesStrokes Peripheral neuropathyPeripheral neuropathy
Dizziness and disequilibriumDizziness and disequilibrium
Medications and Falls Sedative-hypnotics, especially long acting Sedative-hypnotics, especially long acting
benzodiazepines, increase fallsbenzodiazepines, increase falls Small association between most psychotropics Small association between most psychotropics
and fallsand falls SSRIs and TCAs both incrsease fallsSSRIs and TCAs both incrsease falls Weak association between Type 1A Weak association between Type 1A
antiarrythmics, digoxin, diuretics, and fallsantiarrythmics, digoxin, diuretics, and falls
Evaluation of Falls: History Location & circumstances of FallLocation & circumstances of Fall Associated symptomsAssociated symptoms Other falls or near fallsOther falls or near falls Medications (including nonprescription) and Medications (including nonprescription) and
alcoholalcohol Injury & ability to get upInjury & ability to get up
Evaluation of Falls: Physical Examination
Supine and standing BP - alwaysSupine and standing BP - always Routine physical examinationRoutine physical examination
Focus on cardiovascular, MS, neuro, feetFocus on cardiovascular, MS, neuro, feet Vision and hearing evaluationVision and hearing evaluation Consider acute medical illness & deliriumConsider acute medical illness & delirium Formal gait and balance assessmentFormal gait and balance assessment
Evaluation of Falls: Home Evaluation
Can be performed by nurse or othersCan be performed by nurse or others ? Reason for fall? Reason for fall
Evaluation of Falls:Evaluation of Falls: Risk Factors AssessmentRisk Factors Assessment
Common Causes of Abnormal Gait Difficulty arising from chairDifficulty arising from chair WeaknessWeakness ArthritisArthritis Instability on first standingInstability on first standing Hypotension, Hypotension,
Weakness Weakness Instability with eyes closedInstability with eyes closed ProprioceptionProprioception Step height/lengthStep height/length ParkinsonismParkinsonism Frontal lobe Frontal lobe
Fear Fear
Prevention & Treatment
Treat acute injury & underlying medical Treat acute injury & underlying medical conditionsconditions
Remove unnecessary medicationsRemove unnecessary medications Rehabitation, exercises, assistive devicesRehabitation, exercises, assistive devices Correct sensory impairmentsCorrect sensory impairments Environmental modifications & safetyEnvironmental modifications & safety Evaluate for osteoporosis treatmentEvaluate for osteoporosis treatment
Osteoporosis Calcium and vitamin D for most elders at riskCalcium and vitamin D for most elders at risk
Osteoporosis evaluation and treatment Osteoporosis evaluation and treatment Hip protectors appear to protect from hip Hip protectors appear to protect from hip
fractures in those who wear themfractures in those who wear them Thiazides may help slightlyThiazides may help slightly Statins?Statins?
Quit smoking
Treat impaired vision
Stop sedatives
Add 1 Gram Calcium
Hip Protectors
Risk Factor Modifications for Fractures
Falls: Primary Prevention
Intervention: adjustment in medications, Intervention: adjustment in medications, behavioral instructions, exercise programs behavioral instructions, exercise programs aimed at modifying risk factorsaimed at modifying risk factors
One year follow upOne year follow up
Restraint (Restriction to movement) Reduction and Injury
No evidence that restraints reduce fall injuries No evidence that restraints reduce fall injuries Restraints increase morbidity and may cause Restraints increase morbidity and may cause
deathdeath Risk factor for delirium, malnutrition, aspiration Risk factor for delirium, malnutrition, aspiration
pneumoniapneumonia
Alternatives to Restraints for Patients Who Fall or Wander
Accept the risk of fallingAccept the risk of falling Hip protectorsHip protectors Environmental modifications, day rooms, low Environmental modifications, day rooms, low
bedsbeds Least restrictive alternativesLeast restrictive alternatives AlarmsAlarms Sitters or familySitters or family Geriatric consultation team Geriatric consultation team
Summary
Falls are common in the elderly & may lead to Falls are common in the elderly & may lead to injuries and decline in functioninjuries and decline in function
Evaluation should included risk factor Evaluation should included risk factor assessment, gait assessment, and home assessment, gait assessment, and home assessmentassessment
Exercise can improve outcomesExercise can improve outcomes We have no evidence that restraints reduce fall We have no evidence that restraints reduce fall
related injuriesrelated injuries