FALLS IN OLDER ADULTS2008 UPDATE
Joseph G. Ouslander, MD Director, Boca Institute for Quality Aging
University of Miami Miller School of Medicine at Florida Atlantic University
and
Thomas Price, MDDivision of Geriatric Medicine and Gerontology
Emory University School of Medicine
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
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 related26% weakness, balance or gait disorder25% 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
Falls History Medication Use Vision Postural BP Balance and Gait Neurologic exam Musculoskeletal exam Cardiovascular exam Post-discharge home-hazard evaluation
Falls History
S P L A T TSymptomsPrevious fallsLocationActivityTimeTrauma
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 Sertraline, fluoxetine
Tricyclic antidepressants Nortriptyline
Neuroleptics Haloperidol, risperidone, quetiapine
Benzodiazepines Alprazolam, clonazepam, lorazepam
Anticonvulsants 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
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 = 14-
27% reductionReduction in home hazards = 19%Stop psychotropics = 39%Multifactorial risk E&M = 25-
39%Balance and strength exercise* =
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
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