Falls in the Elderly Flashcards
Exam: assessment of cause of falls, get up and go test, meds contributing to falls
Exam: assessment of cause of falls, get up and go test, meds contributing to falls
Falls or Motor Vehicle Crash (MVC) – Which is the most common cause of traumatic brain injury (TBI)
Falls
Exam: assessment of cause of falls, get up and go test, meds contributing to falls
•Fall or MVC – Which is the most common cause of injury-related death in older adults?
Falls
Exam: assessment of cause of falls, get up and go test, meds contributing to falls
Consequences of falls in the elderly
- 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
Exam: assessment of cause of falls, get up and go test, meds contributing to falls
Falls after age 65: Prevalence & Significance
- Prevalence and significance
- 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
CDC: http://www.cdc.gov/HomeandRecreationalSafety/Falls/adultfalls.html
Exam: assessment of cause of falls, get up and go test, meds contributing to falls
Nursing homes: how many older adults, how often do they fall?
- 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
Exam: assessment of cause of falls, get up and go test, meds contributing to falls
How does number of falls relate to number or risk factors?
Exam: assessment of cause of falls, get up and go test, meds contributing to falls
High Risk Time Periods for Falls
- First month after hospital discharge
- During an acute illness
- During an exacerbation of a chronic illness
- Recent eye surgery or procedure
Exam: assessment of cause of falls, get up and go test, meds contributing to falls
Common causes for falls
**exam
- 1/3 - Intrinsic risk factors (medical and age-related factors)
- 1/3 - Medications, alcohol use and OTC products
- 1/3 - Extrinsic risk factors (environmental)
Exam: assessment of cause of falls, get up and go test, meds contributing to falls
Name intrinsic risk factors, extrinsic risk factors, and precipitating causes that lead to falls
**exam
Exam: assessment of cause of falls, get up and go test, meds contributing to falls
Medications associated with falls
**exam
- •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
Exam: assessment of cause of falls, get up and go test, meds contributing to falls
Which of the following CNS medications has been associated with the largest increase in Falls ?
- Benzodiazepines (short and long acting)
- Antidepressants-SSRI
- Antidepressants-Tricyclics
- Anticonvulsants
- Narcotics
- Benzodiazepines (short and long acting)
Exam: assessment of cause of falls, get up and go test, meds contributing to falls
Describe Clinical Approach to Falls
- 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)
Exam: assessment of cause of falls, get up and go test, meds contributing to falls
Fall Mnemonic: SPLATT
assessment of falls
S Symptoms
P Previous falls
L Location
A Activity
T Time: time of day or night
T Trauma
Exam: assessment of cause of falls, get up and go test, meds contributing to falls
Fall Assessment
Important Details of events surrounding the fall:
- 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.
Exam: assessment of cause of falls, get up and go test, meds contributing to falls
Describe the PE for assessing falls
- 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
Exam: assessment of cause of falls, get up and go test, meds contributing to falls
Describe the Timed ‘Up and Go’ test
Sensitivity and Specificity
**exam
- 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 < 10 seconds to complete the task
- Note: use of hands, staggering, unsteadiness
- Sensitivity, 54-87%; Specificity 74-87%
Exam: assessment of cause of falls, get up and go test, meds contributing to falls
Fall: Diagnostic Studies
**exam
- 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
Exam: assessment of cause of falls, get up and go test, meds contributing to falls
Fall Mnemonic: I HATE FALLING
assessment of falls
**exam
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
Exam: assessment of cause of falls, get up and go test, meds contributing to falls
What % of falls can be prevented?
30-40%
Exam: assessment of cause of falls, get up and go test, meds contributing to falls
algorithm for falls screening
Exam: assessment of cause of falls, get up and go test, meds contributing to falls
Falls 2/2 leg extension weakness
what would you see on exam, how to manage risk?
- Impaired Get up & go, stair climbing, slow gait
- MGMT
- Resistance training
- Quadriceps sets
- Environmental Safety + Osteoporosis prevention (calcium & Vitamin D)
Exam: assessment of cause of falls, get up and go test, meds contributing to falls
Falls 2/2 poor balance
what would you see on exam, how to manage risk?
- 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)
Exam: assessment of cause of falls, get up and go test, meds contributing to falls
Falls 2/2 Medication Toxicity
what would you see on exam, how to manage risk?
- 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)
Exam: assessment of cause of falls, get up and go test, meds contributing to falls
Falls 2/2 hypotension
what would you see on exam, how to manage risk?
- 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)
Exam: assessment of cause of falls, get up and go test, meds contributing to falls
Describe the Functional Reach Test
- •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
- –<6 inches related to falls
- –Minimal fall risk if >10 inches of reach
Exam: assessment of cause of falls, get up and go test, meds contributing to falls
What is Romberg’s?
How to use in the elderly?
- Test for proprioception primarily to differentiate sensory ataxia (central and peripheral) from cerebellar ataxia
- Sharpened Romberg’s may be helpful in the elderly
Exam: assessment of cause of falls, get up and go test, meds contributing to falls
What is the single leg stance test?
- Best balance measure for any individual
- If one can stay on one leg for 10 seconds, there are usually no significant balance problems
Exam: assessment of cause of falls, get up and go test, meds contributing to falls
Important steps to Preventing Fractures and Injury
- 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; )
Exam: assessment of cause of falls, get up and go test, meds contributing to falls
Patient Education: reducing falls
- 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
Exam: assessment of cause of falls, get up and go test, meds contributing to falls
Take Home message: “7-steps” to take for elderly fallers
- 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
