6 - FALL PREVENTION & MANAGEMENT Flashcards
What’s elderly?
- WHO defines person as old from age of 60
- Forecast between 2015 & 2050:
- Proportion of elderly people will double (12 to 22%)
- By 2050, 80% of elderly will live in low- & middle-income countries
- Aging of population is much faster than in past
What’s aging?
- Accumulation of molecular & cellular damage over time
- No difference between process of aging & degenerative processes
- Age is poor indicator of changes
- Associated with life transitions:
- Retirement
- Housing adaptations
- Death of relatives
Changes related to aging
- Reduced reaction time
- Gait impairment
- Reduced adaptive strategies
- Difficulties in double tasks
- Reduced perception of obstacles & adaptation to light
- Balance impairment
- Sarcopenia
- Hormonal changes: sleep, growth factor, osteoporosis…
=> Each problem individually is not same as each problem at same time
Sarcopenia: def + proportion + precipitated by
= Loss of muscle mass, quality & strength lying with aging
- 4 to 6% per decade
- Women starting 40 y.o, men starting 60 y.o
—> Strictly correlate with physical impairment, quality of life & death
Precipitated by:
- Poor diet
- Physical inactivity
- Co-morbidities (more than 2 diseases at same time) - Genetics
- Hormones
- Neuromuscular dysfunction
- Trauma
Frailty: description + 4 major components + operational def using 5 areas
- Risk of failing not strictly related to age
- Relates more to frailty
- No consensus
- Conjunction of multiple interacting conditions
- Inescapable process
- Consequences of sub-clinical elements that are difficult to observe on clinical
examination - Assessed by functional scales
4 major components
- Muscle function
- Balance & waling function
- Cognitive function
- Nutritional status
Operational definition using 5 areas
- Mobility
- Physical impairment
- Sensory ability
- Memory
- Energy
- Dependency not only expression of frailty
* < 20% of frail people are dependent
- Not correlated with gender, region of residence, marital status age
- Correlated with sociology-economic level
- Energy most frequently affected area
- No typical elderly
- Inequalities in health
- Stereotypes
- Rapidly changing world
Falling: different types description
- Interior of housing: 67% —> Female > Male (ratio 0,3)
- Outside housing: 11% —> Male > Female (56% of accident)
- Accident on public roads: 15%
- Accounts for 82% of accidents in everyday life in 65+ age group
- 65% amount 65-69 y.o
- 95% from 90 y.o
- Underestimated: recurrence within year > 50%
- Most autonomous fall outside, most fragile at home
Falling: definition & consequences
Definition
= event in which person inadvertently lands on ground or other surface at lower level than previously - Excludes loss of consciousness, stroke, major extrinsic accidents
Consequences
Leads to significant & lasting functional decline even in absence physical trauma
- Mortality exceeds MVA
- Following fracture
* Hip: excess mortality 10 to 20% within 12 months
* Vertebra: excess mortality > 12 months
* Wrist: no excess mortality
- > 9300 people over 65 die each year in France
- Revealing frailty
- Decreased ability to respond to minor external disturbances
* Aggravated frailty process
- Relapses > 50% within year
- Reflects maladjustment to environment
* Can be influenced by multiple factors
- About 20% result in medical intervention
* About 10% result in fracture
* Hip
* Vertebrae
* Wrist
Post fall syndrome: description + schema
- Fear of falling predate fall
- Psychomotor maladjustment
- Spontaneous reduction in activity
- Decreased functional abilities
- Postural disorders
- Gait disorders
- Increased risk of further falls
Schema
Falling: predictive factors: multifactorial, intrinsic factors, extrinsic factors & recurrent factors
Multifactorial
- Aging
- Pathology affecting equilibrium function
- Medication
- Environment
- Behavior
Intrinsic factors
- Do not identify a priori those at high risk of serious injury
Tableau
Extrinsic factors
- Environment (30-50%)
* Object on floor
* Poor lighting
* Slippery or uneven ground
* Steps
* Chair
* Bed height
- Behavior
* Alcohol
* Sedentary lifestyle
* Nutrition
- Activities
- Risk taking
* Vigorous older people 20-40% fall
* 22% (vigorous) vs 6% (frail) of serious injury
=> Risk of falling not generally associated with number of hazards but with relevance of hazard to elder
Recurrence factors
- History of falls > 2
- Time spent on ground > 3h
- Tinetti test score less than 20 points
- Timed up & go test performance greater than 20 sec
- Unipolar hold less than 5 sec
- Impaired postural adaptation reactions
- Stopping walking when examiner asks person to speak
Falling prevention & strategies
Schema
Tableau
Assessment of frailty: name + description + what to assess & how
Fried’s criteria
1) Physical inactivity: less than 150 min of moderate activity per week
2) Low muscle strength: can be measured by grip strength - < 21 kg in men & < 14 kg in women
3) Slow walking speed
1) Less than 0,8 m/s with or without walking aids
2) Predictor of mortality
4) Exhaustion / fatigue: self reported
5) Weight loss: loss of 4,5 kg or more (5% of weight) in 1y
=> Scoring as follows: 0-1: not frail, 1-2: pre-frail, 3+: frail (mild, moderate & severe)
What to assess
1) Muscle function
1) Grip strength
2) Chair lift
2) Balance & walk function
1) Timed up & go
2) 6MWT
3) Tinetti
4) Unipolar balance
3) Cognitive functions
1) Mini mental state
2) CODEX (dementia)
3) Geriatric depression scale
4) Nutritional status
1) Nutritional screening initiative
5) Dependency
1) KATZ: activity of daily living
2) IADL: instrumental activity of daily living
Assessment of dependency: description + name of one & description
- Assessing dependency = constant concern for geriatrician to limit dependence of elderly person, to preserve & restore autonomy
- Functional assessment used to describe performance or ability of elderly person to preform basic activities of daily living
- Term “dependence” refers to need for 3rd party to carry our these basic activities
ADL - KATZ questionnaire
- Most appropriate tool to assess functional status by ensuring patient’s ability to perform activities of daily living independently
- Assesses 6 functions: bathing, dressing, toileting, transferring, continence & feeding
- Score 1 or 0 per question
- Total score out of 6
- Results: full function 6 / moderate function 4 / severe impairment <2
- Strength: can be administered by many allied health in 10 min
- Weakness: not sensitive to small changes in function
Assessment of nutritional status
- Unquestionable consequences of malnutrition
- Questioning allows initial screening
- Inspect contents of refrigerator: reduced supply coupled with large proportion of out-of-date foodstuffs indicates major difficulties in managing diet
- Monitoring weight curve also cost effective approach. 5% weight loss over 1y is individual predictor of increased mortality over 1y
- Biologically, albumin level below 35 g/L is 5,3-fold increase in mortality risk
=> Combination of hypoalbuminemia & hypocholesterolemia constitutes increased risk of either functional decline or mortality
Assessment of cognitive startups: name + description
Mini-mental state examination (MMSE)
- Count 1 point for each correct answer
- Pathological threshold depending on situation
- Score below 24 indicates disorder without prejudging its origin
- Completed by clock test
Image
Assessment of depressive status: name + description
Geriatric depression scale
- 30 item
- Answer yes or no
- One point per yes
- Interpretation:
* 0-9: normal
* 10-19: moderate depression
* 20-30: severe depression
* > 13: existence of depression state
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