Geriatric Falls for the Inpatient Physician Translating Knowledge into Action Ethan Cumbler M.D. Associate Professor of Medicine Director UCH Acute Care For Elderly Services University of Colorado Anshcutz Medical Campus

IMPACT  30-40% of people over age 65 will have a fall each year  The percentage higher for patients who reside in nursing homes  In an elderly patient who has fallen, the risk of having a second fall within a year rises to 60%  8% of all people over age 70 will present to the ER each year after a fall. 1/3 will be admitted  Think about how many ED visits that creates….

Consequences  Many falls cause minor or no injury. Skin tears and lacerations may require ED treatment but generally cause no lasting harm.  Between 5 and 10% of community dwelling elderly patients who fall (up to 20-30% of elderly patients overall) will suffer a serious injury  What injuries are particularly problematic?

Injuries  Hip Fractures-1% of falls in the elderly lead to hip fx  20-30% mortality in the year after hip fx  ¼ to ¾ of patients do not recover prior level of ADLs

Injuries  Prolonged lie- 1/2 of elderly are unable to get back up 2 o rhabdo, dehydration/ARF, pressure ulcers 2 o rhabdo, dehydration/ARF, pressure ulcers What duration of unrelieved pressure does it take to create skin damage? What duration of unrelieved pressure does it take to create skin damage?  Subdural Hematoma  What changes to the structure of the brain as patients age increase the risk of SDH? increase the risk of SDH?  Rib Fractures- Mortality 12% with 1-2 rib fx. Mortality 12% with 1-2 rib fx. Rising to 40% in patients with 7 or more fx Rising to 40% in patients with 7 or more fx

Post Fall Anxiety Syndrome  Picture the Geriatric Fall as a node on a decline spiral  Probably not the first step in the decline Fall as symptom of underlying frailty Fall as symptom of underlying frailty  Frequently will create a marked acceleration of decline Self-limiting activity, worsening deconditioning, social isolation photoeverywhere.com

Risk Factors  Prototypical Geriatric Syndrome  Multifactoral  More than 20 separate risk factors for falls have been identified.  Very quickly how many can you think of?

Risk Factors  The factors interact in a dynamic and exponential fashion. 27% of patients with 0-1 risk factors will have a fall compared to 78% with >4 risk factors  Unfortunately creating a list is not a particularly helpful exercise in practical patient care.  Some of these risk factors are non-modifiable (female gender) and for others effective treatment seems limited (peripheral neuropathy).  There are so many that it takes significant time just to recall them all. We are likely to always miss a few. We are likely to always miss a few.

A Brief Diversion… Jam  In Malcolm Gladwell’s book on cognition “Blink”, he describes a fascinating psychology experiment.  A sample table is set up at two grocery stores for customers to try a sample of jam.  One table has 6 varieties of jams, the other has 24 selections.  Which table do you think sold more jam?

 The table with only 6 varieties sold far more jam.  This might seem counter-intuitive but the reason lies in the human psyche.  Faced by too many choices, customers freeze up and make no decision at all.

Why are you telling me about jam?  “Multiple Alternatives Bias” Physicians faced with multiple possibilities unconsciously ignore some of them in order to make a list which, while incomplete, is at least more mentally manageable. Physicians faced with multiple possibilities unconsciously ignore some of them in order to make a list which, while incomplete, is at least more mentally manageable.  In multi-factoral geriatric syndromes such as falls, physicians frequently treat only the sequelae of the fall Missing opportunity to intervene to prevent future injury Missing opportunity to intervene to prevent future injury  The multiplicity of contributors seems overwhelming- “possibility paralysis”

A New Conceptual Framework  We are going to break down the fall into its component parts  Latent risk for fall Physiologic changes of aging Physiologic changes of aging Disease and medications Disease and medications Behavioral traits Behavioral traits  Environmental trigger- the “accident”  Underlying frailty/vulnerability- the injury  Each step will lead to concrete actions to reduce the risk of future injury!

Postural Challenges Of Aging Medications And Comorbidities Behavioral Contributors ↓Baroreceptor Sensitivity ↓Balancefrom vestibular and proprioception ↓vision (esp night) ↓reflex speed for correction ↑impulsivity (esp in dementia) Dehydration/diuretics Bp meds causing orthostasis Benzodiazepines Psychotrophics Anticholinergics Alpha antagonists Parkinsons Neuropathy Arthritis podiatry problems Fall Risk Environmental Trigger “Accident” Fall INJURY Frailty Osteoporosis Decreased muscle speed to deflect injury OPPORTUNITY FOR INTERVENTION 1)Physical therapy 2)Sensory Aids (glasses) 3)Ambulation/Gait Aids (4 prong cane, walker) 4)Review Medication list- (remove problematic meds) 5)Behavioral Measures (in supervised environment) Bed Alarms for dementia with impulsivity Scheduled toileting 5) OT Home Safety Eval -rugs-cords -lighting-rails 6) Calcium+Vitamin D/Bisphosphonate Bisphosphonate for prior frailty fx or known O/P Vitamin D level 7) Hip protectors? (uncertain benefit)

Prevention of Future Injury  Evidence suggests that for at-risk elders a multi-pronged targeted prevention strategy such as this can reduce the risk of future falls

What about Tests?  No specific laboratory or imaging testing is indicated in the absence of clinical correlation Vitamin D levels are recommended by some authors Vitamin D levels are recommended by some authors Deficiency associated with falls as well as fracturesDeficiency associated with falls as well as fractures  If anemia or dehydration suspected, CBC and Chem7 reasonable  Similarly, urinalysis, B12 levels and TSH are reasonable if driven by other clinical cues.  Echo is only indicated if exam suggests valvular disease.  In the absence of syncope, chest pain, or palpitations, EKG is low yield and holter monitoring not proven to be of benefit.  Spinal or brain imaging is indicated only if neurologic findings on exam suggest lesion (or significant head injury from the fall)

Inpatient Falls  Falls with injury in the hospital are a JCAHO mandated reportable event  How do you reduce the risk of an event which rarely occurs in the presence of the physician?

Risk Assessment- Physicians  How do we as physicians assess a patient’s risk for inpatient falls?  For the most part, physicians pay little or no attention to this issue on a general medical ward.  Reliable solutions require systems change.  You can standardize a simple physician assessment for fall risk in elderly patients. Two- question falls screen: Have you fallen in the last month? Have you fallen in the last month? Are you afraid of falling? Are you afraid of falling?  You can perform a witnessed Get-Up-And-Go test Pay attention and you learn a lot of information about strength, balance, and gait in 30 seconds. Pay attention and you learn a lot of information about strength, balance, and gait in 30 seconds.

WORKSHOP  Using the example of a patient you have admitted in the last 48 hours, would you rate their risk of inpatient fall as low, moderate, or high?  How do you think the nursing staff rated this patient’s fall risk?  Where would you find the nursing assessment?  What changes does the hospital system put in place for patients at moderate or high risk?  What changes can we as physicians institute to reduce the risk of falls?

SAMPLE CASE Risk Assessment-Nursing

Hospital Fall Prevention Measures Triggered By A High Risk Patient

What Changes Can You Make For The Patient Identified In Your Case

Physician Measures to Reduce Hospital Falls  Recognition of patients at increased risk should cause us to critically examine the orders we are writing which influence chance of inpatient falls.  Review med list to determine if some medications should not be continued For instance, be more hesitant to allow zolpidem for sleep in the unstable patient with nocturia. For instance, be more hesitant to allow zolpidem for sleep in the unstable patient with nocturia.  Minimize Patient Tethers Heparin/LMWH instead of SCDs for DVT prophylaxis Heparin/LMWH instead of SCDs for DVT prophylaxis Early elimination of IV drips Early elimination of IV drips Early removal of urinary catheters Early removal of urinary catheters  Involve PT/OT/Assisted ambulation rather than independent ambulation for moderate+high risk patients  Schedule toileting

Thought Experiment  If you were in charge of the hospital what systems changes would you put in place to reduce the risk of hospital falls or resultant injury?