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Falls Flashcards

1
Q

Falls or Motor Vehicle Crash (MVC) – Which is the most common cause of traumatic brain injury (TBI)

A

Falls

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2
Q

•Fall or MVC – Which is the most common cause of injury-related death in older adults?

A

Falls

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3
Q

Consequences of falls in the elderly

____% result in serious injuries

_____% cause fracture

_____ residents die each year from falls.

A
  • 10-20% result in serious injuries
  • 2-6% cause fractures
  • 1800 residents die each year from falls
  • Disability and functional decline
  • Reduced quality of life
  • Feelings of helplessness
  • Depression
  • Social isolation
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4
Q

after age 65

_ in _ older adults fall each year

_____ is leading cause of death

_____% moderate to severe injuries

A
    • 1 in 3 older adults falls each year
      • Falls are the leading cause of injury death in older adults
  • 20% -30% - moderate to severe injuries
  • Risk of injury or death ↑s with age
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5
Q

Nursing homes

  • What % of older adults live in nursing home?
  • How many % of fall death occur in this group?
  • How many bed nursing home reports ___ falls?
  • Nursing home has ____x the fall rate of community dwellers
  • Average of ____falls per person per year.
A
  • 4 - 5 % of older adults live in nursing homes
  • 20% of all fall deaths occur in this group
  • Every year: typical 100-bed nursing home reports 100 – 200 falls
    • Many are unreported
  • 2 x the fall rate of community dwellers
  • Average of 2.6 falls per person per year
  • 35% of injuries: persons who cannot walk
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6
Q

How does number of falls relate to number or risk factors?

A

More number of risk - increases falls.

2+ falls in 1 year

0-1 risk = 10% with 2+ falls

4+ risk = 69% with 2+ falls

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7
Q

High Risk Time Periods for Falls

A
  • First month after hospital discharge
  • During an acute illness
  • During an exacerbation of a chronic illness
  • Recent eye surgery or procedure
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8
Q

Common causes for falls

*exam

A
  • 1/3 - Intrinsic risk factors (medical and age-related factors)
  • 1/3 - Medications, alcohol use and OTC products
  • 1/3 - Extrinsic risk factors (environmental)
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9
Q

Name intrinsic risk factors, extrinsic risk factors, and precipitating causes that lead to falls

*exam

A

Extrinsic Factors:

  • Enviromental hazards
  • poor footwear
  • restraints

Precipatiating factors:

trips+slips, drop attack, syncope, dizziness, acute medical issues

Intrinsic risk factors:

  • gait and balance impairment
  • Peripheral neuropathy
  • vestibular dysfunction
  • muscle weakness
  • vision impairment
  • medical illness
  • advanced age
  • impaired ADL
  • orthostatic hypotension
  • dementia
  • drugs
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10
Q

Medications associated with falls

6 categories.

***Exam

A
  • •Anticholinergics – consider total anticholingeric load
  • •Neuropsychiatric – benzodiazepines, neuroleptics, antidepressants, anticonvulsants, antiparkinson, muscle relaxants, analgesics
  • •Cardiovascular – antihypertensives, antiarrythmics (type 1 A), digoxin, nitrates
  • •Alcohol
  • •Histamine (H2) blockers – cimetidine
  • •Over-the-Counter – cough / cold remedies, sedatives, antihistamines
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11
Q

Which of the following CNS medications has been associated with the largest increase in Falls ?

  1. Benzodiazepines (short and long acting)
  2. Antidepressants-SSRI
  3. Antidepressants-Tricyclics
  4. Anticonvulsants
  5. Narcotics
A
  1. Benzodiazepines (short and long acting)
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12
Q

Describe Clinical Approach to Falls

A
  • NOT WHAT DISEASE caused the problem? (Based on one disease/diagnosis model)
  • BUT WHAT COMBINATION of Physiologic changes, impairments and diseases are contributing?
  • AND WHICH ONES can be modified? (Multifactorial Impairment and Intervention Model)
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13
Q

Fall Mnemonic: SPLATT

assessment of falls

A

S Symptoms

P Previous falls

L Location

A Activity

T Time: time of day or night

T Trauma

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14
Q

Fall Assessment

Important Details of events surrounding the fall:

A
  • What was the patient doing when he/she fell?
  • Was there an aura?
  • Was there a loss of vision?
  • Did the patient experience any dizziness?
  • Was there a loss of consciousness?
  • In what direction did the patient fall?
  • Did the patient break the fall?
  • Was he or she using any assistive devices appropriately?
  • Did witnesses notice any seizure activity?

Determine whether falls recurrent or whether they recently increased.

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15
Q

Describe the PE for assessing falls

A
  • Comprehensive with focus on:
    • Orthostatic: BP and pulse
    • CV: arrhythmia, murmurs, carotid bruits
    • Sensory: visual or hearing impairments
    • Musculoskeletal: arthritic changes, limitations in joint motion, deformities, fractures, foot problem, strength of lower extremities
    • Neurologic: nystagmus, neuropathy, tremors, rigidity, focal deficits, weakness
    • Cognitive status: Mini-cog, MMSE
    • Mood: GDS
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16
Q

Describe the Timed ‘Up and Go’ test

Sensitivity and Specificity

*exam

A
  • Simple test of observing a person stand up from a chair, walk 10 feet, turn around, walk back, and sit down again.
  • Correlates with ADLs
  • Normal person takes
  • Note: use of hands, staggering, unsteadiness
  • Sensitivity, 54-87%; Specificity 74-87%
17
Q

Fall: Diagnostic Studies

*exam

A
  • Based on the presenting symptoms and the anticipated benefits for the individual patient.
  • CBC: rules out anemia or infection
  • Urinalysis: rules out infection
  • CMP: rules out electrolyte imbalance
  • TSH
  • Vitamin B12
  • ESR
  • Drug levels as indicated
  • ECG
  • Chest X-ray
  • Holter monitor: if transient arrhythmia is suspected
  • Head CT scan: if mental status or neurologic changes are present
18
Q

Fall Mnemonic: I HATE FALLING

assessment of falls

*Exam

A

I Inflammation of joints (or joint deformity)

H Hypotension (orthostatic blood pressure changes)

A Auditory and visual abnormalities

T Tremor (Parkinson’s disease or other causes of tremor)

E Equilibrium (balance) problem

F Foot problems

A Arrhythmia, heart block or valvular disease

L Leg-length discrepancy

L Lack of conditioning (generalized weakness)

I Illness

N Nutrition (poor; weight loss)

G Gait disturbance

19
Q

What % of falls can be prevented?

A

30-40%

20
Q

algorithm for falls screening

A

initial question

  1. 2+ fall in past year?
  2. presents with acute fall?
  3. diffculty balance or walking?
21
Q

Falls 2/2 leg extension weakness

what would you see on exam, how to manage risk?

A
  • Impaired Get up & go, stair climbing, slow gait
  • MGMT
    • Resistance training
    • Quadriceps sets
    • Environmental Safety + Osteoporosis prevention (calcium & Vitamin D)
22
Q

Falls 2/2 poor balance

what would you see on exam, how to manage risk?

A
  • Exam:
    • +Romberg
    • Poor vision
    • Impaired functional reach
  • MGMT
    • Balance training
    • Widen base of support
    • Shoes
    • Quad cane
    • Walker
    • Correct vision
    • Correct hearing
    • Environmental Safety + Osteoporosis prevention (calcium & Vitamin D)
23
Q

Falls 2/2 Medication Toxicity

what would you see on exam, how to manage risk?

A
  • Exam: Alcohol use, anticonvulsants, digoxin, sedatives/hypnotics anticholinergics, hypotensives, nitrates, antipsychotics, antidepressants
  • MGMT:
    • Drug withdrawal
    • Drug substitution
    • Drug reduction
    • Environmental Safety + Osteoporosis prevention (calcium & Vitamin D)
24
Q

Falls 2/2 hypotension

what would you see on exam, how to manage risk?

A
  • Exam: Orthostatic and postprandial hypotension
  • MGMT:
    • Drug reduction
    • Behavior change
      • Drug/meal separation
      • Posture
      • Meals
      • Exercises
    • Volume
      • Salt
      • Stockings
      • Head of bed elevation
    • Pharmacologic, eg. Fludrocortisone, midodrin
    • Environmental Safety + Osteoporosis prevention (calcium & Vitamin D)
25
Q

Describe the Functional Reach Test

A
  • •Measures forward and lateral balance; Sensitive to change over time
  • •Simple to administer
    • –Arm extension with 90 degrees of shoulder flexion while patient is upright and leaning forward or sideways
  • •Results
    • – less than 6 inches related to falls
    • –Minimal fall risk if over 10 inches of reach
26
Q

What is Romberg’s?

How to use in the elderly?

A
  • Test for proprioception primarily to differentiate sensory ataxia (central and peripheral) from cerebellar ataxia
  • Sharpened Romberg’s may be helpful in the elderly
  • balance test with feet together, semi tandem and tandem for 10 seconds then closed 10 seconds each position

semi tandem feet slightly next to each other

tandem feet- 1 line on top

27
Q

What is the single leg stance test?

A
  • Best balance measure for any individual
  • If one can stay on one leg for 10 seconds, there are usually no significant balance problems
  • stand behind chair while using fingertips for light support on back of chair. stand life one leg for 5 seconds and repeat.
  • PELVIS drop on nonweight bearing side = muscle weakness
28
Q

Important steps to Preventing Fractures and Injury

A
  • Osteoporosis: screen, treat
  • Hip Protectors
  • Use of alarms
  • ‘Breaking a fall’ techniques
  • Environment (indoor/outdoor) modification
  • Shoe-wear
  • Sitter, one-on-one attendance and supervision
  • Professionally supervised gait and balance training and muscle-strengthening exercise
  • Collaborate with patient (and/or proxy), pharmacist, geriatrician and/or psychiatrist for careful taper and d/c of psychotropic meds if possible: including benzodiazepines, antipsychotics, antidepressants (note: involves a risk-benefit analysis; careful documentation and communication related to both risks and benefits is essential; )
29
Q

Patient Education: reducing falls

A
  • —Avoid alcohol consumption
  • —Stay adequately hydrated with fluids
  • —Refer to list of fall prevention strategies (home safety)
  • —Take medications as prescribed and notify your health provider if experiencing unpleasant side effects
  • —Use a walker for extra balance, even if you don’t think you need it
  • —Resources for GNPs:
    • —http://www.fallpreventiontaskforce.org/tools.htm
    • —http://www.mnfallsprevention.org/professional/index.html
    • —Guidelines from American Geriatrics Society
30
Q

Take Home message: “7-steps” to take for elderly fallers

A
  • 1.Falls in the elderly are a marker for ‘acute medical event’, therefore one has to be aware of multifactorial risk factors for falling. Investigate for infections, medication side-effects, and metabolic problems. Falls associated with loss of consciousness (syncope) suggests cardiovascular etiology.
  • 2.Evaluate role of medication adjustment or withdrawal and side-effects in people who fall. (CNS, Cardiovascular, warfarin and INR)
  • 3.Meticulous history with structured assessment of gait and balance, orthostatic hypotension, muscle strength, vision and hearing is essential. Check Romberg’s, Timed ‘get up & Go’ test, Functional reach.
  • 4.Home/Environmental safety assessment should be done with consideration for assistive devices.
  • 5.Interventions for strength and balance training can decrease the risk of falling. Timely Physical and Occupational therapy may help.
  • 6.Osteoporosis prevention and use of protective devices (hip protectors) reduce fractures, particularly hip. Calcium and Vitamin D supplementation for all.
  • 7.Understand the significance of ‘fear of falling’ in the older adults and its impact on mobility and functional status, hence counseling and encouragement of activity and routine exercise is desirable.

Compiled by Arvind Modawal, MD, MPH

University of Cincinanati Medical Center

Falls in the Elderly 2005

Adult Adult (7 decks)

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