Falls and Immobility Flashcards
One major risk factor for falls includes _____. The risk for developing a mobility disorder increases with age.
problems with mobility
- Mobility disorders range from subclinical to obvious, and within this range, fall risk is elevated.
- b/c the risk for mobility disorders and falls is increased in older persons, clinicians should be particularly aware of how to prevent and treat both
Over 50% of people over the age of what fall?
80 y/o
- 60% have hx of falling will have a subsequent fall
50% of falls result in some type of injury, the most serious of which includes ?
hip fractures, head trauma, and cervical spine fractures
Falls in older adults typically are not d/t a single cause, but occur when there is _____
This makes an older person unable to compensate as well as a younger person, and thus more likely to fall.
additional stress - acute illness, new meds, or an environmental hazard,
Fall RF varies – Depending on Source:
name some RF for falls - not including strongest risk factors
● Past history of a fall
● Lower-extremity weakness
● Age
● Cognitive impairment
● Balance problems
● Psychotropic drug use
● Arthritis
● History of stroke
● Orthostatic hypotension
● Dizziness
● Anemia
Multiple studies have shown that the strongest risk factors for falling include: (4)
- previous falls;
- decreased muscle strength;
- gait and balance impairment
- specific medication use.
examples of intrinstic RF for falls
- Advanced age
- Previous falls
- Muscle weakness
- Gait & balance problems
- Poor vision
- Postural hypotension
- Chronic conditions including arthritis, stroke, incontinence, DM, Parkinson’s, dementia
- Fear of falling
extrinsic RF for falls
- Lack of stair handrails
- Poor stair design
- Lack of bathroom grab bars
- Dim lighting or glare
- Obstacles & tripping hazards
- Slippery or uneven surfaces
- Psychoactive medications; improper Rx
- Improper use of assistive
- device
Mobility disorders refer to ____
any deviation from normal walking
what components are necessary to walk normally
control of balance and posture both at rest and with movement
- normal gait requires complex integration of adequate strength, sensation, and coordination.
- For a normal healthy adult, walking is almost automatic.
- control of gait and posture is both complex and multifactorial
complications of falls
- injuries
- soft tissue trauma: hematomas, lacerations, infections
- fractures
- closed head injuries (CHI): concussion, SDH
Lacerations and skin tears can lead to severe blood loss especially in those on what meds?
antiplatelet therapy or anticoagulation
with soft tissue trauma, what must you consider about the patient?
if patient will be able to care for wounds at home
what fractures are MC from falls?
Hip, wrist, humerus, and ribs
1/3 of pts >65 who suffer a hip fracture will die within ?
one year
what type of fracture is among the most common and costly of fall-related injuries in older adults.
hip fracture
> 90% of all hip fractures occur as a result of a fall, often from what type of fall?
falling sideways
what type of closed head injury should have low threshold to admit for serial neuro exams
concussion
SDH is a big risk for those on what type of medication
antiplatelet/anticoag
approach to pt with potential SDH after a fall?
- May have delayed onset of bleeding
- Hematoma may be chronic
- Should be admitted with Neuro coverage
- traumatic subdural hematomas may not return to pre-injury level of function
for closed head injuries, never forget to look for other injuries especially ____
c-spine
The single most important question to ask an elderly patient after they have suffered a fall.
Why did you fall?
Close to half of all falls can be classified as ____
accidental
True trip or slip
Usually precipitated by an environmental hazard
Common Environmental Hazards
- Old, unstable, and low-lying furniture
- Beds and toilets of inappropriate height
- Unavailability of grab bars
- Uneven or poorly demarcated stairs and inadequate railing
- Throw rugs, frayed carpets, cords, wires
- Slippery floors and bathtubs
- Inadequate lighting, glare
- Cracked and uneven sidewalks
- Pets
what medications specifically should you be aware of for potential cause of falls
antihypertensives
psychotropic agents
Qs to ask for Patient’s thoughts on the cause of the fall
- Was patient aware of impending fall?
- Was it totally unexpected?
- Can the patient recall the exact events of the fall w/o family help
circumstances surrounding the fall
- Location and time of day
- Activity
- Situation: alone or not alone at the time of the fall
- Witnesses
- Relationship to changes in posture, turning of head, cough, urination, a meal, medication intake
associated sx of falls
- Lightheadedness, dizziness, vertigo
- Cardiac? Palpitations, CP, SOB
- Sudden focal neurological sx (weakness, sensory disturbance, dysarthria, ataxia, confusion, aphasia)
- Aura
- **Incontinence of urine/stool **
if the patient lost consciousness after the falls, what Qs should be asked?
- What is remembered immediately after the fall?
- Could the patient get up, and if so, how long did it take? - “Help I’ve fallen and can’t get up”!
* Can loss of consciousness be verified by a witness?
PE for falls
- VS - orthostasis (lying, sitting, standing) evaluated for any injuries prior to evaluation
- Skin - Turgor (over the chest; other areas unreliable), Pallor, Trauma
- Eyes - Visual acuity, Pupils, eye movement
- CV - Arrhythmias, Carotid bruits, Signs of aortic stenosis
- Extremities - Degenerative joint disease, ROM, Deformities, Fractures, Podiatric problems (calluses; bunions; ulcerations; poorly fitted, inappropriate, or worn-out shoes)
- Neurological - Mental status, Focal signs, Muscles (weakness, rigidity, spasticity), Peripheral innervation (especially position sense), Cerebellar (especially heel-to-shin testing), Resting tremor, bradykinesia, other involuntary movements, Observation of gait and balance
- Eval assistive devices for hazards - missing tips on canes and walkers, impaired locking devices, or broken footrests on wheelchairs
- feet & footwear
what is The Functional Reach test
- requires using a yardstick mounted on a wall at shoulder height.
- Pt asked to stand close to the wall at a comfortable stance with an outstretched arms-with the shoulders perpendicular to yardstick.
- Pt instructed to extend arm forward as far as possible without taking a step or losing balance;
- the functional reach is measured along the yardstick in inches
- 6-10 inches - moderate fall risk
- <6 inches - severe fall risk
what type of footwear can predispose ppl to trip and fall
- heels, floppy slippers, shoes with slick soles
- Ill-fitting footwear that is too big, without sufficient grip or too much friction, and/or without proper fixation (untied or loosely tied shoes) will also contribute to increasing someone’s fall risk.
what type of shoe is less likely to trips and falls?
- Upper shoe should be soft and flexible with smooth lining.
- The toe box should be deep enough to allow for toe wiggle room.
- The sole should be strong and flexible for a good grip.
- The heel should provide a broad base for stability and be no higher than 4 cm.
- Finally, the fastening should provide a stable fit with some flexibility to allow for unusually shaped feet or swelling.
potentially modifiable risk factors of falls
- muscle strength, gait and balance, and medication
- visual impairment, depression, pain, and dizziness.
General info for Fall Prevention
- Provide PT and education: Gait and balance retraining, Muscle strengthening, Aids to ambulation, Properly fitted shoes, Adaptive behaviors, Rising slowing, using rails, etc
- Alter the environment: Safe and proper-size furniture, Elimination of obstacles (loose rugs, etc.), Proper lighting, Rails (stairs, bathroom)
- Tx Fx Pain, but do not ignore the side effects of treatment
what are the best ways to prevent falls?
medication reduction, physical therapy, and home safety modifications
how to dx fall and immobility?
there is no standard diagnostic evaluation
- Labs: CBC, BMP, UA, or chest radiograph might be appropriate depending on the clinical scenario, especially if significant cognitive impairment or dementia.
- hemoglobin, chemistry panel, TSH, vit B12 (deficiency linked to proprioceptive problems)
- possibly underlying UTI or pneumonia caused the fall
- imaging: CT/MRI - new or unexplained neurologic findings; r/o stroke, mass, nml pressure hydrocephalus, other structural abnormality.
State in which an individual has a limitation in independent, purposeful physical movement of the body or of one or more lower extremities
immobility
Goal of all members of the health-care team working with older adults?
optimizing mobility
small improvements in mobility can:
- decrease the incidence and severity of complications,
- improve the patient’s well-being, and
- decrease the cost and burden of caregiving
Causes of Immobility
MSK - Arthritis, Osteoporosis, Fractures (esp hip and femur), Podiatric problems
Neurologic - Stroke, Parkinson disease, Neuropathies, Normal-pressure hydrocephalus, Dementias
CV - CHF, CAD (frequent angina), PVD (frequent claudication)
Pulm - COPD (severe)
Sensory factors - Impairment of vision, Decreased peripheral sensation
Environmental - Forced immobility (in hospitals and nursing homes), Inadequate aids for mobility
Other - Deconditioning (after prolonged bed rest from acute illness), Malnutrition, Severe systemic illness (eg, widespread malignancy), Depression, Drug SE (eg,antipsychotic-induced rigidity), Fear of falling
- Acute inflammatory response limited to epidermis
- Presents as irregular area of erythema, induration, edema;- may be firm or boggy
- Pressure areas do not blanch when pressed
- May be different with different skin pigments
- Redness with pressure persists after 30 min; in dark skin the color may be red, blue, or a purple hue
- Often over a bony prominence
- Skin is unbroken
what stage is this pressure ulcer?
Stage I
- Extension of acute inflammatory response through dermis to the junction of subcutaneous fat
- Appears as a blister, abrasion, or shallow ulcer with more distinct edges
- Early fibrosis and pigment changes occur
- May look like an abrasion or a blister
what stage is this pressure ulcer
Stage II
- Full-thickness skin ulcer extending through subcutaneous fat. This may extend down to but not through the underlying fascia
- The skin may have undermining
- Base of ulcer infected, often with necrotic, foul-smelling tissue
- This presents like a crater and may have undermining of the adjacent tissue
what stage is this pressure ulcer?
stage III
- Extension of ulcer through deep fascia, so that bone is visible at base of ulcer
- Osteomyelitis and septic arthritis can be present
- Undermining is even more common and there may be sinus tracts
what stage is this pressure ulcer?
stage IV
preventing pressure ulcers
- Identify patients at risk
- Decrease pressure, friction, and skin folding
- Keep skin clean and dry
- Avoid excessive bed rest: optimize and encourage function
- Avoid over-sedation
- Provide adequate nutrition and hydration
tx stage I & II presssure ulcers
- Clean wounds with warm,normal saline or water
- Avoid pressure and moisture
- Cover open wounds with dressing
- Prevent further injury and infection- abx if needed (Stage II)
- Manage associated pain
tx for stage III
- Debride necrotic tissue: autolytic, chemical, mechanical, sharp, or surgical options
- Cleanse and dress wound
- Cx wound
- Abx
- Manage associated pain
tx for Stage IV
- tissue bx for cx
- Abx (likely IV)
- Cleanse and dress wound
- Have surgical consultation to consider surgical repair
- Manage associated pain
