Falls & falls risk

Question 1

What are the risk factors for the fall? (3 categories)

Answer 1

Medical conditions impairing mobility: stroke, PD, arthritis, spinal disease

Medications: anti-PD, anti-hypertensives, alpha-1-blockers (prostatism), sedatives, sedatives, alcohol.

Geriatrism (!): previous falls, dementia, polypharmacy

Question 2

Falls Hx?

Answer 2

P: how many falls, what were the circumstances? prodromal symptoms? syncopal or neurologic?

R: previous falls, dementia, stroke, PD, polypharmacy, visual impairment. Medications: ETOH, opioids, sedatives, alpha-blockers, PD drugs, anticholinergic.

I: have the patient have a comprehensive geriatric assessment (or seen geriatrician)

C: fractures, other serious injuries, loss of independence

M: OT/PT assessment? Hip protectors, OP management?

C: how is the patient coping with falls? (sensible or not!?) _lack of confidence/fear of falls, impact on driving, shop, AD_Ls. Is the rest of the family affected? Is the patient using the sticks/WF? is the patient doing anything risky (e.g. clearing gutters, climbing ladders…etc)

P: is patient adherence to falls precautions, walking aids…etc? otherwise suspect adherence issues/cognitive impairment.

Question 3

Falls examination? (MOST SALIENT = 6)

Answer 3

Visual Acuity

Postural BP

Features of Cardiovascular disease: arrythmia, VHD

MSK deformities: spine, knees, hips

Neuro: strength, cerebellar, PN

Get-up-and-go test (get up from chair, walk 3m, turn around, walk-back and sit down) - abnormal if >10 seconds.

Question 4

How would you manage this patient’s falls risk?

Answer 4

Goals: prevent falls, optimise bone health, improve strength&balance, slow progression of frailty

Confirm dx: dedicated history to assess situations around each falls episodes (review previous admissions…etc)

A: investigate & treat secondary causes & contributing factors

• Anaemia, B12, folate deficiency, hypoglycemia, electrolyte abnormalities, infection
• Arrythmia, valvular heart disease
• Postural hypotension: rationalise medications (anti-hypertensives & centrally acting drugs)
• Correct visual impairment: treat cataracts, avoid confocal lenses, appropriate glasses
• ETOH excess, malnutrition

Screen for complications: CTB (chronic subdural), spine/pelvic #, DEXA, depression.

T: Non-pharm

• Educate: falls precautions, avoiding risky behaviours, importance of using walking aids,
• Enroll patient on Falls prevention programs: “Stepping on” - an excellent resource for education, exercise, home hazards, safety wear and how to cope.
• OT: home modifications - shower, stair rails, vital calls, remove rugs, night lights
• PT: balance & strength training, graded exercise programs
• Podiatry review: orthotics and appropriate footwear (risk of falling increases with narrow heel, loose fitting, poor fastening)
• Hip protectors
• Vitamin D (reduce risk of falls by 14%) & calcium supplements
• Life-style: smoking cessation (risk factor for OP), ETOH moderation, balanced/healthy diet & exercise promotes general well being
• Nutritional supplements
• Infection prophylaxis, vaccinations…etc.

T: Pharm

• Need to rationalise meds.
• Osteoporosis management to reduce # risk

Involve: SW (more services at home), OT/PT, dietician, refer to comprehensive geriatric assessment (CGA): strong evidence base

CE: 2 yearly DEXA, spine/pelvic XR, CTB (chronic subdural)

Question 5

When you suggest ‘exercise’ for falls prevention, what evidence-based format should this take? (4 features)

Answer 5

• Home or group-based
• At least 2 hours per week
• Focus on balance (primarily)
• Strength training yields additional benefits, esp in frail elders

Question 6

What balance exercises have good evidence for falls prevention? (2)

Answer 6

• Tai chi (37% reduction in falls)
• Otago exercise program (32% reduction)

Question 7

How would you interpret Up and Go test?

Answer 7

= Time taken from get up from the chair, walk 3m, turn around, walk-back and sit down.

Abnormal if >10s (suggestive of frailty or disability)

>15s suggests high falls risk

>20s supervision outside home is required.

Question 8

What is a reasonable, 10-step approach to addressing frailty?

Answer 8

1. Optimise known comorbidities: especially MSK complaints, cardiorespiratory.
2. Identify & treat undiagnosed comorbidities that can exacerbate frailty: anaemia, thyroid, malnutrition, cognitive/psychiatric impairment
3. Rationalise medications, especially Surgical interventions
4. Engage family + external supports (e.g. geriatrician, PT/OT)
5. Increase protein & caloric intake + supplementation, involve dietician
6. Vitamin D replacement (14% risk reduction in fall)
7. Prescribe directed exercise therapy (resistance/balance exercise)
8. OT & home assessments
9. Consider Rehabilitation
10. Advanced Care Directive

Question 9

How would you manage this frail patient’s falls risk? - remember to approach this as any other medical issues.

Answer 9

Investigate & Manage Patient factors (top-down) and Environmental factors

Patient factors

• Rule out infection, hypothyroid (proximal myopathy)
• Vision - poor acuity, appropriate glass wear, cataracts → correct these, address e.g. cataracts (Local, not general anaesthesia). No bifocal lenses (impairs clear vision of the ground)
• Cardiovascular - postural hypotension → educate patient to wait then go. Rationalise medications.
• Examine for muscle strength & balance - up and go test (>10s fallers) → group exercises, home physiotherapy, integrative exercise like Tai-Chi (balance, strengh, movement)
• Examine feet and footwear - loose fitting, poor fastening, non-slipperey shoes, heels >5cm or narrow heels have higher risk of falls. 10 degree heel level has minimal risk of fall.
• Address malnutrition
• Osteoporosis Mx
• Manage pain

Environmental factors

• Assess home environment: trip hazards, loose rugs, clutters, slippery surfaces
• Install stair rails, bathroom rails, lightening, slip-resistant deck surfacing, non-slip bath mats, viral calls