FALLS Suggestions for Lecturer -1-hour to 1½-hour lecture -Use GRS slides alone or to supplement your own teaching materials. -Refer to GRS and Geriatrics at Your Fingertips for further content. -Supplement lecture with handouts, eg, “Recommendations from the AGS Guidelines for the Prevention of Falls” and various assessment tools, eg, Romberg, Dix-Hallpike, Mini-Cog, and POMA. -For strength of evidence (SOE) levels, see related chapter text. -See GRS8 questions 11, 41, 132, 148, 238, 240, 281, and 324 for case vignettes.

OBJECTIVES Know and understand: The importance of falls in older people How to assess and treat falls in an older person

TOPICS COVERED Epidemiology of Falls Causes of Falls Evaluation and Treatment of Falls Clinical Guidelines for Preventing Falls

FALLS Definition: coming to rest inadvertently on the ground or at a lower level One of the most common geriatric syndromes Most falls are not associated with syncope Falls literature usually excludes falls associated with loss of consciousness

EPIDEMIOLOGY OF FALLS % Each year 30%–40% of community-dwelling people aged ≥65, and about 50% of residents of long-term-care facilities, experience falls

EPIDEMIOLOGY OF FALLS Annual incidence of falls is close to 60% among those with history of falls Complications of falls are the leading cause of death from injury in people aged ≥65

MORBIDITY AND MORTALITY Most falls by older adults result in some injury 10%–15% of falls by older adults result in fracture or other serious injury The death rate attributable to falls increases with age Mortality highest in white men aged ≥85: 180 deaths/100,000 population

SEQUELAE OF FALLS Associated with: Decline in functional status Nursing home placement Increased use of medical services Fear of falling Half of those who fall are unable to get up without help (“long lie”) A “long lie” predicts lasting decline in functional status

COSTS OF FALLS  Emergency department visits  Hospitalizations Indirect cost from fall-related injuries such as hip fractures is substantial

CAUSES OF FALLS BY OLDER ADULTS Rarely due to a single cause May be due to the accumulated effect of impairments in multiple domains (similar to other geriatric syndromes) Complex interaction of: Intrinsic factors (eg, chronic disease) Challenges to postural control (eg, changing position) Mediating factors (eg, risk taking, underlying mobility level)

CAUSES: INTRINSIC Age-related decline Changes in visual function Proprioceptive system, vestibular system Chronic disease Parkinson’s disease Osteoarthritis Cognitive impairment Acute illness Medication use (see next slide)

CAUSES: MEDICATION USE Specific classes, for example: Benzodiazepines Other sedatives Antidepressants Antipsychotic drugs Cardiac medications Hypoglycemic agents Recent medication dosage adjustments Total number of medications

Ask all older adults about falls in past year FALLS ASSESSMENT Ask all older adults about falls in past year Single fall: check for balance or gait disturbance Recurrent falls or gait or balance disturbance: Obtain relevant medical history, physical exam, cognitive and functional assessment Determine multifactorial falls risk (see next slide)

FACTORS AFFECTING FALLS RISK History of falls Medications Visual acuity Gait, balance, and mobility Muscle strength Neurologic impairments Heart rate and rhythm Postural hypotension Feet and foot wear Environmental hazards

Blood pressure and pulse, both supine and standing PHYSICAL EXAMINATION Blood pressure and pulse, both supine and standing Vision screening Cardiovascular exam Musculoskeletal exam Neurologic exam See GRS8 chapter entitled “Falls” for further content.

GAIT AND BALANCE EVALUATION Romberg test One-legged stance for 30 seconds, eyes open Tandem gait task for 10 feet Mental status exam (eg, Mini-Cog) Timed Up and Go test Berg Balance Test Performance Oriented Mobility Assessment (POMA) Functional reach Appropriateness of footwear A useful test of integrated strength and balance is the Timed Up and Go test, which can be performed with or without timing. It consists of observation of an individual standing up from a chair without using the arms to push against the chair, walking across a room, turning around, walking back, and sitting down without using the arms. This test can demonstrate muscle weakness, balance problems, and gait abnormalities. A test of integrated musculoskeletal function is the Berg Balance Test. The Berg test includes 14 items of balance, including timed tandem stance, semi-tandem stance, and the ability of a person to retrieve an object from the floor. Berg scores <40 have been associated with an increased risk of falls. The POMA tests balance and gait through a number of items, including ability to sit and stand from an armless chair, ability to maintain standing balance when pulled by an examiner, and the ability to walk normally and maneuver obstacles. A reliable cut-point score for predicting falls with the POMA has yet to be established. These and related tests are discussed in GRS8 and Geriatrics At Your Fingertips.

LABORATORY AND DIAGNOSTIC TESTING Tests and procedures should be guided by the history & physical exam: echocardiography, brain imaging, radiographic studies of spine Hemoglobin, serum urea nitrogen, creatinine, glucose: can exclude anemia, dehydration, or hyperglycemia Holter monitoring: no proven value for routine evaluation Carotid sinus massage with continuous heart rate and BP monitoring: can uncover carotid sinus hypersensitivity These and related tests are discussed in GRS8 and Geriatrics At Your Fingertips.

Aim to reduce intrinsic and environmental risk factors TREATMENT Most favorable results with health screening followed by targeted interventions Aim to reduce intrinsic and environmental risk factors Interdisciplinary approach to falls prevention is most efficacious .

AGS FALLS PREVENTION GUIDELINES Assessment of all older adults and anyone with history of falls Multifactorial interventions including: Minimize medications Initiate individually tailored exercise program Treat vision impairment Manage postural hypotension, and heart rate and rhythm abnormalities Supplement vitamin D Manage foot and footwear problems Modify the home environment Cosponsored by the American Geriatrics Society and the British Geriatrics Society. Systematic reviews have concluded that there is no evidence that hip protectors are effective in reducing hip fractures in studies that randomized individual patients within an institution or among older adults living at home. However, adherence to the use of hip protectors was low in these studies, which many argue could explain the lack of efficacy. At least a dozen types of hip protectors are commercially available. Many of these hip protectors have not been tested in either the laboratory or in clinical trials. Despite the lack of evidence to date to support the use of hip protectors, it is not unreasonable to consider their use in patients at high risk of hip fractures who are willing to use them.

SUMMARY Falls by older adults are common and usually multifactorial Falls predict functional decline Screening and targeted preventive interventions are most effective AGS falls prevention guidelines are available and recommend multifactorial interventions

CASE 1 (1 of 3) A 75-year-old woman is brought to the office by her daughter. The mother has been falling, most often when rising from the toilet or attempting to climb stairs. History includes sarcopenia and frailty. She has no neurologic or metabolic abnormalities. Exercise was recommended at a previous office visit. Despite the daughter’s efforts, the patient is reluctant to spend time and energy on the exercise program. The daughter asks for help prioritizing the exercises. In particular, she wants to know which exercises are most important in preventing falls.

CASE 1 (2 of 3) Which of the following is most effective for preventing falls? Strengthening exercise Aerobic exercise Balance exercise Multicomponent exercise

Which of the following is most effective for preventing falls? CASE 1 (3 of 3) Which of the following is most effective for preventing falls? Strengthening exercise Aerobic exercise Balance exercise Multicomponent exercise ANSWER: C Exercise is beneficial in frailty, yet it is difficult for frail individuals to participate in exercise for a host of reasons. Sarcopenia—loss of muscle with aging—results in a loss of reserve capacity and an increased sense of effort for a given exercise intensity. Lactate threshold increases with age, forcing older adults to exercise at a greater percentage of their maximal capacity. As the perception of effort increases, older individuals become more likely to avoid exercise. Graduated exercises could be prescribed so that an individual participates in the exercise that will benefit him or her most. Data from the FICSIT trials (Frailty and Injury: Cooperative Studies on Intervention Techniques), performed in the early 1990s, found that exercise prevented 10% of falls across studies, but prevented 20% of falls if balance training was included. Each type of exercise (strength, aerobic, balance) could be beneficial, and the multicomponent exercise could potentially be the most beneficial, yet the case history indicates that the patient resists multicomponent exercise. For this patient, balance exercises are the priority, because they have been found to prevent falls more often than generalized or strengthening exercise.

CASE 2 (1 of 3) An 85-year-old man comes to the office because he has fallen 3 times in the past 6 months. None of the falls involved dizziness or fainting. One fall occurred while he was walking in his yard; in the other instances, he tripped inside his house. History includes hypertension without postural changes, gout, osteoarthritis, and depression. He takes 5 medications on a regular basis.

CASE 2 (2 of 3) Which of his medications is most likely to contribute to his risk of falls? Acetaminophen Allopurinol Hydrochlorothiazide Lisinopril Paroxetine

CASE 2 (3 of 3) Which of his medications is most likely to contribute to his risk of falls? Acetaminophen Allopurinol Hydrochlorothiazide Lisinopril Paroxetine ANSWER: E Antidepressant agents, including SSRIs, have been shown to increase the risk of falls; thus, paroxetine is most likely to contribute to this patient’s risk. In addition, taking ≥4 medications increases an older adult’s risk of falls; this patient’s drug regimen includes 5 medications. Acetaminophen and allopurinol are unlikely to affect blood pressure, balance, gait, or mental status. Hydrochlorothiazide and lisinopril reduce blood pressure, and hydrochlorothiazide may reduce intravascular volume and lead to postural changes in blood pressure. However, syncope was not a factor in this patient’s falls, and he does not have postural changes in blood pressure. Review of prescription and OTC medications is an important element of reducing the risk of falls. Medication review should be done at each visit to ensure that patients are taking appropriate medications and correct dosages.

CASE 3 (1 of 3) A 70-year-old woman comes to the office for a routine visit. History includes hypertension and osteoarthritis. She mentions that last month she tripped on a high curb and fell after parking her car. She has had no other falls.

CASE 3 (2 of 3) Which of the following is the most appropriate initial step for evaluating her risk of future falls? Test visual acuity. Measure blood pressure for postural changes. Evaluate gait and balance. Ask about environmental hazards in her home. Examine her feet and footwear.

CASE 3 (3 of 3) Which of the following is the most appropriate initial step for evaluating her risk of future falls? Test visual acuity. Measure blood pressure for postural changes. Evaluate gait and balance. Ask about environmental hazards in her home. Examine her feet and footwear. ANSWER: C This patient has fallen once. Her gait and balance should be observed; if no difficulty is seen, formal evaluation of falls risk is not necessary. During routine office visits, patients should be asked about any falls in the past year and should be observed for difficulties with gait and balance. Patients who report no falls do not need formal risk assessment. If the patient has difficulty with gait and balance or has had >1 fall, formal risk assessment should be undertaken. The assessment should include visual acuity testing; measurement of blood pressure for postural changes; evaluation of strength, balance, and gait; examination of feet and footwear; medication review; and home safety evaluation.

Copyright © 2013 American Geriatrics Society GRS8 Slides Editor: Annette Medina-Walpole, MD, AGSF GRS8 Chapter Authors: Sarah D. Berry, MD, MPH Douglas P. Kiel, MD, MPH GRS8 Question Writer: Mary B. King, MD Medical Writers: Beverly A. Caley Faith Reidenbach Managing Editor: Andrea N. Sherman, MS Copyright © 2013 American Geriatrics Society Topic