3: Geriatrics 2 Flashcards
What is a FALL?
Definition: coming to rest inadvertently on the ground or at a lower level
Falls is one of the most common geriatric syndromes. Most falls are not associated with syncope. Falls literature usually excludes falls associated with loss of consciousness
Facts on Falls:
- Leading cause of death in adults over ____ years of age
- Marker of ______ health and declining function
- ______ with age in both males and females
- Highest rate of injury occurs in those _____ years of age
- Leading cause of death in adults over 65 years of age
- Marker of poor health and declining function
- Increase with age in both males and females
- Highest rate of injury occurs in those 85+ years of age
What are some Risk Factors for Falls.
- Age - especially over 75 yrs.
- Female
- Low mobility - use of cane or walker • Low body weight
- Impaired gait and balance
- Limited activities of daily living
- Acute illness
- Chronic illness
Discuss the MORBIDITY AND MORTALITY of falls
- Most falls by older adults result in some injury
- 10%–15% of falls by older adults result in fracture or other serious injury
- The death rate attributable to falls increases with age
- Mortality highest in white men aged ≥85: 180 deaths/100,000 population
What are the SEQUELAE OF FALLS
• Associated with: Decline in functional status Nursing home placement Increased use of medical services Fear of falling
- Half of those who fall are unable to get up without help (“long lie”)
- A “long lie” predicts lasting decline in functional status
What consists of the evaluation of risk factors of FALLS
• Review individual susceptibility and environmental hazards
• Most falls are due to a complex combination of risk factors:
– Intrinsic factors
– Extrinsic factors
– Age related changes
What are some Age Related Changes with respect to falls?
- Broad-based gait
- Flexion of cervical spine, hips and knees
- Decreased arm swing
- Smaller steps
- Poor gait initiation
- Stiff turns
- Dec. baroreceptor sensitivity
- Postural hypotension
- Vision changes
- Decrease total body water
- Decreased proprioception
What are some Intrinsic vs. Extrinsic factors with respect to falls?
Intrinsic:
• Slower reflexes
• Decrease reaction
time
- Increased postural sway
- Decreased vision
- Cognitive impairment
- Alcohol use
- Medications
Extrinsic:
- 4 or more meds
- Poor lighting
- Unsafe stairways
- Clutter
- Irregular walking surface
- Pets
- No grab bars or handrails
- Improper footwear
What are some Medical Conditions Associated with Falls?
• Hypertension
- CVA/stroke
- Myocardial infarction
- Arthritis
- Alzheimer’s disease
- Depression
- Diabetes
- Parkinson’s disease
- Vision/hearing deficits
- Urinary tract infection
- Pneumonia
- Seizures
- Chronic pain
- Dizziness
- Osteoporosis
- Poor nutrition
- Arrhythmia
- Foot problems
List Medications Associated with Falls
• ANY MED THAT CAUSES SIDE EFFECTS:
• Benzodiazepines
- Antidepressants
- Anithypertensives
- Cardiac meds
- Corticosteroids
- Diuretics
- NSAIDs
- Hypoglycemic meds
- Antihistamines
- Sleeping meds
- Narcotics
- Caffeine
- Seizure meds
- Anticholinergic meds
What are the Evaluation of Risk Factors for FALLS?
• Review
– Medical problems
– Medications
– Functional Status – IADLs, ADLs
- Evaluate environmental hazards – Home safety check
- “Get Up and Go” Test
What are some activities of daily living (personal ADL’s)?
– Toileting
– Feeding
– Dressing
– Grooming
– Walking
– Bathing
What are some Instrumental activities of daily living (IADL)?
– Finances
– Shopping
– Cooking
– Hobby
– Current events, appts., reading
– Medications
– Travel
What are some components of a home safety security check?
- Secure carpets
- Remove throw rugs
- Reduce clutter
- Remove wires, cords
- Check lighting
- Handrails/grab bars
- Eliminate low chairs
- Access to phone
- Rubber mats in bathtub
- Raised toilet seat
- No floor wax
- Remove low furniture
- Secure stairs
- Shelves? Step stools?
What does a FALLS assessment consist of?
- Ask all older adults about falls in past year
- Single fall: check for balance or gait disturbance
• Recurrent falls or gait or balance disturbance:
Obtain relevant medical history, physical exam, cognitive and functional assessment
Determine multifactorial falls risk
List FACTORS AFFECTING FALLS RISK
- History of falls
- Medications
- Visual acuity
- Gait, balance, and mobility
- Muscle strength
- Neurologic impairments
- Heart rate and rhythm
- Postural hypotension
- Feet and foot wear
- Environmental hazards
What are important physical examinations of the elderly?
- Blood pressure and pulse, both supine and standing
- Vision screening
- Cardiovascular exam
- Musculoskeletal exam
- Neurologic exam
What is important LABORATORY AND DIAGNOSTIC TESTING for the elderly?
- Tests and procedures should be guided by the history & physical exam: echocardiography, brain imaging, radiographic studies of spine
- Hemoglobin, serum urea nitrogen, creatinine, glucose: can exclude anemia, dehydration, or hyperglycemia
- Holter monitoring: no proven value for routine evaluation
- Carotid sinus massage with continuous heart rate and BP monitoring: can uncover carotid sinus hypersensitivity. In the carotid sinus massage, the sympathetic stimulus to heart is inhibited, which decreases the heart rate as well as causing reduced firing rate of SA node as well as increased block of conduction thru AV node.
Describe the 3 steps of the mini cognitive assesment.
- Repeat three unrelated words.
- The patient is then asked to draw a clock.
- The patient is then asked to recall the three words.
Scoring:
- Recall of 3 words = perfect = no dimentia
- Cannot recall (1 or 2) = maybe dimentia–if cannot draw clock then demented or impaired. If CAN draw, then NOT impaired
- Recall of 0 = impaired or demented
This is not a diagnostic test, it is used as an indication to proceed further.
What are the components of the GAIT AND BALANCE EVALUATION
- Romberg test – In the Romberg test, the standing patient is asked to close his or her eyes. A loss of balance is interpreted as a positive Romberg’s test.
- One-legged stance for ≥30 seconds, eyes open
- Tandem gait task for 10 feet
- Mental status exam (eg, Mini-Cog)
- Timed Up and Go test
- Berg Balance Test–The test takes 15–20 minutes and comprises a set of 14 simple balance related tasks, ranging from standing up from a sitting position, to standing on one foot. It tests static & dynamic balance abilities.
- Performance Oriented Mobility Assessment (POMA)
- Functional reach
- Appropriateness of footwear
What is the get up and go test?
- Time person as they rise from a standard chair
- Walk 10 ft, turn, walk back to the chair and sit down again
- OK to use walker or cane
- Do one practice trial and then three actual trials. Average the times from the three actual trials to get the score.
Scoring:
• < 10 seconds: freely mobile
<20 = mostly independent
20-29 = variable mobility
• 30 seconds: impaired mobility
How do we treat for FALLS?
- Most favorable results with health screening followed by targeted interventions
- Aim to reduce intrinsic (innate) and environmental risk factors
- Interdisciplinary approach to falls prevention is most efficacious
List the American Geriatrics Society FALLS PREVENTION GUIDELINES
- Assessment of all older adults and anyone with history of falls
- Multifactorial interventions including:
Minimize medications
Initiate individually tailored exercise program
Treat vision impairment
Manage postural hypotension, and heart rate and rhythm abnormalities
Supplement vitamin D
Manage foot and footwear problems
Modify the home environment
- Falls by older adults are common and usually ______
- Falls predict functional ______
• Screening and targeted preventive
interventions are most ______
• American Geriatrics Society falls prevention guidelines are available and recommend _______ interventions
- Falls by older adults are common and usually multifactorial
- Falls predict functional decline
• Screening and targeted preventive
interventions are most effective
• AGS falls prevention guidelines are available and recommend multifactorial interventions
