Ger 8 Falls Flashcards
What is a common devastating problem among older people?
Falls
What do falls result in?
Morbidity, mortality, and the use of health care services such as premature nursing home admission
What are falls associated with?
One or more risk factors: Weakness, unsteady gait, confusion, medication
What can significantly reduce the number of falls?
Attention to these risk factors
What is the most cost-effective and overall effectiveness in fall reduction?
A risk factor assessment with targeted intervention, exercise programs, and environmental hazards assessment and changes
Why is medical assessment of fall risks and providing appropriate intervention challenging?
Because of the complex nature of falls
What are 2 serious clinical problems in older patients?
Falls and unstable balance
What do falls cause and increased rate in? (4)
- Morbidity
- Mortality
- Immobility
- Premature nursing home placement
What is the 5th leading cause of death in older adults?
Unintentional injuries (after CV disease, cancer, stroke, pulmonary disorders)
What causes 2/3 of unintentional injuries?
Falls
In the US what 3/4 of deaths due to falls occur in what % of the population over 65?
13%
-This is a geriatric syndrome
What % of 65+ living at home fall at least once each year?
40%
Of the 40% of 65+ living at home that fall at least once each year, how many will be hospitalized?
1/40
Of the people who are admitted to the hospital after a fall, how many will be alive a year later?
1/2
What are the majority of the reasons why people end up at nursing homes?
Repeated falls and instability
Where is the lowest rate (0.3-1.6/person annually) of falls for older people?
Community living (generally healthy elderly people over 65)
In falls in healthy older people living in the community, what % can induce fractures or require hospitalization?
5% (most don’t result in serious injuries)
What happens to the rates of falls and associated complications with age?
They steadily rise and are 2X the previous number in over 75 years
Where is the highest rate (0.6-3.6/bed annually) of falls in older people?
Those living in long term care institutions
Of people in institutions, what % of falls results in fracture or lacerations?
10-25%
What fractures are more common between ages 65-75?
Wrist fractures
What fractures are more common in ages after 75?
Hip fractures
What are complications of falls due to? (3)
Combination of high incidence and high susceptibility to injury
*This is due to high prevalence of clinical diseases (osteoporosis) and age-related changes (reflexes)
What is a risk factor for subsequent falls?
Delayed recovery from falls that results in deconditioning
What is it called when a patient down-regulates activity because of fear of falling leading to deconditioning, weakness, and abnormal gait, leading to and increase in a fall in the future?
Post-fall anxiety syndrome
What are falls the largest cause of according to the National Health Interview Survey?
Restricted activity days (18%)
What % of medical expenditures are for fall-related injuries in people over 65?
6%
What proportion of deaths due to falls are preventable based on retrospective assessment of causes and circumstance according to the US Public Health Services
2/3
What is the most frequently cited cause of falls accounting for 30-50%?
Accidental or environmental
What are many of the accidents leading to falls an interaction between?
Environmental hazards and increased susceptibility to hazards because of age and disease
What 3 things result in an impaired ability to avoid a fall after tripping or slipping?
- Stiffer bodies
- Less coordination and dangerous gaits (compared to young)
- Decline in postural control, reflexes, muscle strength and tone, and height of stepping
What happens to balance as a person ages?
They start to change their strategy for maintaining balance
What is the shift in strategy for maintaining balance in older adults?
Rapid correcting hip strategy to step strategy to total loss of ability to correct in time
What is hip strategy?
Avoiding fall by shifting weight at the hips
What is step strategy?
Avoiding fall via rapid step
What are 3 other things that increase the number of trips and stumbles due to old age?
Vision, hearing, and memory impairment
What is the second most common cause of falls accounting for 10-25%?
Gait problems and weakness
What 3 bio-mechanical components affect the ability to walk normally?
- Free mobility of joints (especially in legs)
- Appropriate timing and intensity of muscle action
- Normal sensory input such as vision proprioception, and vestibular system
Gait problems adversely affect what % of function in people over 65
20-40%
Of the gait problems adversely affecting 20-40% of function in people over 65, how many are considered severe?
1/2
Gait problems adversely affect what % of function in people over 85?
40-50%
What are 8 potential causes of falls in elderly adults?
- Accident or environmental related
- Gait/balance disorders or weakness
- Dizziness or vertigo
- Drop attack
- Confusion
- Postural hypotension
- Visual disorder
- Syncope
In people over 75, what % need assistance to walk across a room?
10%
In people over 75, what % can’t climb stairs without help?
20%
In people over 75, what % can’t walk half a mile?
40%
What are 3 things gait problems can arise from?
- Age-related changes in gait and balance
- Dysfunction of the nervous, muscular, skeletal, circulatory, and respiratory systems
- Deconditioning following a period of inactivity
What is a common non-specific symptom among older persons?
Dizziness
What is dizziness associated with?
- Cardio disorders
- Hyperventilation
- Orthostasis
- Drug side-effect
- Anxiety
- Depression
What is a related problem to dizziness?
Orthostatic hypotension
What is orthostatic hypotension?
Drop of 20mmHg of systolic BP between lying and standing
Why is orthostatic hypotension a less common cause of falls?
Because most people have become accustomed to it and are able to find a seat or adjust before falling
When is orthostatic drop more pronounced?
In the morning (there is a decrease in baroreceptor response after lying down for so long
What is the % of orthostatic hypotension among normal elderly people living at home?
10-30%
What are 5 factors for orthostatic hypotension?
- Autonomic dysfunction: Related to age, diabetes, or brain damage
- Hypovolemia, low CO
- Parkinsonism
- Metabolic and endocrine disorders
- Medications: Sedatives, anti-HTN, anti-depressants
What is a sudden fall without LOC or dizziness?
Drop attacks
What % of falls are caused by drop attacks?1
1-10%
What do patients experience in a drop attack?
Sudden leg weakness precipitated by head movement
What are drop attacks attributed to?
Transient vertebrobasilar insufficiency
What plays a bigger role than transient vertebrobasilar insufficiency?
Mechanics (leg weakness and knee instability)
What was used as a “waste basket” category for unexplained falls in the past, but is now reported less often and uncommon?
Drop attacks
What does syncope or sudden LOC result from?
Decreased cerebral blood flow or metabolic factors
What % of falls are caused by syncope or sudden LOC?
2-10% of falls
Why is syncope/sudden LOC excluded from many study series?
Either because definition (not a typical type of fall) or because many elderly with syncope are acutely hospitalized and treated differently
What are 7 other specific causes of falls?
- CNS disorders/cognitive deficits
- Poor vision
- Drug side-effects, alcohol intake
- Anemia
- Hypothyroidism
- Unstable joints/foot problems
- Severe osteoporosis with spontaneous fracture and acute illness
Why is it difficult to determine the exact cause of falls in elderly patients?
Because the have multiple identifiable risk factors predisposing to falls
True or False: Most falls are multifactorial in origin
TRUE
What is more useful than trying to classify specific causes of falls?
Identifying risk factors
What are most common and most important risks for falls?
- Muscle weakness
2. Problems with gait
What is a common finding in the aged population that stems more from disease and inactivity rather than actually aging?
Muscle weakness
What are 2 screening tests for gait and balance that are useful in determining risk and correct treatment plan?
- Time up and go
2. Tinetti’s gait and balance test
What is the relative risk of falls due to medications (especially psychoactive meds)?
1.5-1.7 range
What are 9 risk factors for falls in order of highest relative risk to lowest?
- Weakness
- Balance deficit
- Gait deficit
- Visual deficit
- Mobility limitation
- Cognitive impairment
- Impaired functional status
- Postural hypotension
- Medications: Psychoactive
What can be done by identifying risk factors early?
Effective preventative strategies can be devised and instituted
What do risk factor reduction strategies involve?
Regular exercise (to improve strength, gait, and balance)
What is crucial when assessing a fall patient?
A full H&P
What is important in evaluation of a fall patient because many patients may have a fuzzy recollection of what happened?
Reports from witnesses
What can point to specific etiology and narrow-down the differential diagnosis?
Circumstances
What circumstance for fall might point to orthostatic hypotension?
Sudden rise from a lying to sitting position
What circumstance for fall might point to gait, balance, vision disturbance, or environmental hazard?
Trip or slip
What circumstance for fall might point to vertebrobasilar insufficiency?
Drop attack
What circumstance for fall might point to arterial or carotid sinus compression?
Looking up or sideways
What circumstance for fall might point to syncope or seizure?
Loss of consciousness
What else can be helpful to narrow down the cause of fall?
Symptoms experienced near the time of the fall
What symptoms can point to orthostatic hypotension, vestibular problem, hypoglycemia, arrhythmia, and drug side-effects?
Dizziness or giddiness
What symptoms can point to arrhythmia?
Palpitations
What symptoms can point to seizure?
Incontinence or tongue biting
What symptoms can point to cerebrovascular disease?
Asymmetric weakness
What symptoms can point to MI or coronary insufficiency?
Chest pain
What else can play a significant role in falls?
Medication and associated medical conditions
What is it important to look for in post-fall PE?
Findings that directly contributed to the fall
What are some examples of findings that directly contributed to the fall?
- Orthostatic changes in pulse and BP
- Presence of arrhythmias, carotid bruits
- Nystagmus, focal neurological signs, weakness, and other MSK abnormalities
- Visual loss, gait disturbances, and cognitive dysfunction
What can be useful under careful monitoring to identify cause of fall?
Reproduce the circumstances (positional changes, head turning, or carotid pressure)
What are two tests that are helpful for gait and stability that should be assessed by close observation?
Tinietti balance and gait test
What are 3 things that should have a special note taken on them in regards to gait and stability?
- Gait velocity and rhythm, stride length, height of stepping, degree of sway
- Double support time (time spent with both feet on the floor)
- Use of devices
Are laboratory tests helpful for determining cause of fall?
No, but they can tell you of contributory abnormalities
Who should receive expensive tests like Holter monitoring or gait laboratory evaluations?
Those with suggestive signs and symptoms
When should specific therapy be started?
After cause/risk factors are determined
What should cardiac dysrhythmia related to falls be treated with?
Antiarrhythmics, pacemaker, or both
What should hypovolemia due to hemorrhage or dehydration be treated with?
Restoring hemodynamic stability
What should Parkinsonism be treated with?
Specific treatment
What should be done for walking in people with advanced PD
Extensive assistance
What type of medications should be discontinued that might contribute to fall?
Ones that cause postural hypotension or undue sedation
What can be done for patients with gait or balance problems?
Give them devices like walkers, canes, shoe modifications or gait training with PT
What can be done for orthostatic hypotension?
- Sleep in bed with head raised
- Wear elastic stockings (minimize venous pooling in legs)
- Getting up slowly
- Avoiding heavy meals
- Avoiding intense activity in hot weather
What can be done for orthostatic hypotension is conservative mechanical measures aren’t effective?
Increase blood volume with intake of dietary salts
If increasing blood volume with intake of dietary salts to treat orthostatic hypotension isn’t effective then what do you do?
- Mineralocorticoid therapy (fludrocortisone 0.1mg/day, increasing gradually)
- Alpha-1 agonist (midodrine, 2.5mg tid)- To maintain BP
When can you use increased blood volume with intake of dietary salts or mineralocorticoid therapy for orthostatic hypotension?
As long as side-effects of supine HTN and fluid accumulation doesn’t occur
When is treatment for falls considered difficult treatments?
When you are managing and preventing recurrent falls in those where a specific cause is unknown or have multiple or irreversible causes
For people who have disabilities that don’t get better with treatment of the underlying disease, what can be done?
Treat them short term rehab
What can short term rehab do?
Rehab long term disability and improve safety
What can be done for irreversible problems?
Treat with coping methods and supportive care
What are 2 other methods to reduce falls?
- Eliminate home hazards
2. Create specific environmental improvements
What are some home hazards that can be eliminated?
Frayed rugs, electrical cords, unstable furniture
What are specific environmental improvements that can be done?
Adequate lighting, bathroom grab rails, raised toilet seats, secure banisters, bed height
What is the AGS/BGS/AAOS approved combination for effective fall-prevention?
A multidimensional risk factor assessment with
- Targeted intervention
- Exercise programs
- Environmental assessment and changes
What can find conditions and risk factors that were otherwise undetectable any other way?
Post-fall evaluations
What can exercise programs do?
Improve strength, endurance, and body mechanics to help prevent falls
What shows a dramatic reduction in hip fractures from a European trial?
Hip protector pads (mostly in nursing homes)
-But compliance was an issue
What also shows benefits on balance and fall reduction?
Vitamin D
Why does the future look bright in the area of elderly management?
Due to the availability of fall-prevention assessment and approaches
Falls occur in what % of older adults each year?
30-60%
What % of falls result in injury, hospitalization, and/or death?
10-20%
True or False: Most falls are associated with identifiable risk factors
True: Examples include weakness, unsteady gait, confusion, and psychoactive medications
What does research show that can significantly reduce the rate of future falls?
Detection and amelioration of risk factors
What are 2 other evidence-based fall reduction methods?
- Systematic exercise programs
2. Environmental inspection and improvement programs
What have international groups developed for reducing the risk of falls?
Useful clinical guidelines
