Falls Sara Bradley and Christine Chang, MD Brookdale Dept of Geriatrics and Adult Development March 4. 2008 10:00-10:40 We are very excited to talk to you about falls. It is a very common geriatric syndrome that we see in our practice; however, most residents and practicing physicians do not feel comfortable evaluating it (outside of ruling out syncope), let alone teach it to other learners.

Objectives By the conclusion of the talk, learner will be able to: List 5 potentially modifiable risk factors for falls in older community dwelling adults. Conduct a physical exam specific to falls, including a gait assessment. Discuss 5 evidenced-based interventions that can reduce future falls. Learn how to teach and evaluate falls in ambulatory practice -Take a patient history and perform a physical exam specific to falls -Formulate an evidenced-based treatment plan for falls

Falls Definition: Unintentional change in position, coming to rest at a lower position Not due to an overwhelming intrinsic or environmental cause No loss of consciousness

Epidemiology of Falls 1/3 of ambulatory and ½ institutionalized elderly fall each year ½ falls result in injury (10-15 % in fractures) ¼ of all fallers limit their activities and lifestyle due to fear of falling 1. Tinetti, ME, Speechly, M, Ginter, SF. Risk factors for falls among elderly persons living in th community. NEJM 1988; 319:1701. 2. Thapa, PB, Brockman, KG, Gideon P et al. Injurious falls in nonambulatory nursing home residents; a comparative study of circumstances, incidence, and risk factors. JAGS 1996; 44: 273. 3. Nevitt, MC, Cummings, SR, Hudes ES. Risak factors for injurious falls: A prospective study. J Gerontol 1991; 46:M164. 4. Tinetti, ME, Williams, CS. The effect of falls and fall injuries on functioning in community-dwelling older persons. J of Gerontol A bio Sci Med Sci 1998; 53: M 112.

Cost of Falls 6% of Medicare costs 15% of ED visits for 65+ years Extra $24,000/person/year health costs Totals $19 billion/year

Theory of Why People Fall Falls occur when: Older adults who are predisposed because of accumulated effect of diseases / impairments (intrinsic) Are exposed to precipitating challenges (extrinsic)

Evaluation of Falls: History Describe fall Ask questions to R/O syncope Use systematic method to look into etiology of falls Describe fall-tripped/stumbled, unable to get up within 5 minutes, needed assistance to get up Ask questions to R/O syncope-?LOC, LH/palp, sz Use systematic method to look into etiology of falls: Intrinsic vs extrinsic contributors to falls ?psychotropic meds ie neuroleptics, benzo, antipressants ?2+etoh drinks/d ?use mobility devices ?predisposoing conditions: Parkinsons, CVA, dementia, delirium, Cardiac, neuropathic, autonomic insuff, severe OA+weakness, vision problems

Evaluation of Falls: History Immutable Predisposing Factors Age Female Variable for falls Risk injury Past fall Who falls and why is Based on 80 cohort studies that have identified over 25 RF (similar at home, hospital and NH)-modiable/immutable Use systematic method to look into etiology of falls: Intrinsic vs extrinsic contributors to falls ?psychotropic meds ie neuroleptics, benzo, antipressants ?2+etoh drinks/d ?use mobility devices ?predisposoing conditions: Parkinsons, CVA, dementia, delirium, Cardiac, neuropathic, autonomic insuff, severe OA+weakness, vision problems

Evaluation of Falls: History Modifiable Predisposing Factors (Intrinsic) Decreased strength ( fall risk 4 X) Impaired balance, gait ( fall risk 3 X) Visual Depth perception ( fall risk 2.5 X) Contrast sensitivity Who falls and why is Based on 80 cohort studies that have identified over 25 RF (similar at home, hospital and NH)-modiable/immutable >2 studies

Evaluation of Falls: History Modifiable Predisposing Factors (Intrinsic) Disease management Stroke Parkinsonism Orthostasis ( fall risk 2 X) Cognitive impairment ( fall risk 2X) Depressive symptoms ( fall risk 1.5X) Foot problems ( fall risk 2X) + Arthritis Who falls and why is Based on 80 cohort studies that have identified over 25 RF (similar at home, hospital and NH)-modiable/immutable >2 studies

Evaluation of Falls: History Modifiable Precipitators of Falls (extrinsic) 1. Medications 4+ Medications High risk medications: Psychotropics (e.g. sedatives, antidepressants-SSRI & TCA) Antihypertensives Digoxin Anticholinergics Who falls and why is Based on 80 cohort studies that have identified over 25 RF (similar at home, hospital and NH)-modiable/immutable >2 studies

Evaluation of Falls: History Modifiable Precipitators of Falls (extrinsic) Acute illness Multi-focal lens Footwear Environment: Stairs; tripping hazards Unsafe behaviors Who falls and why is Based on 80 cohort studies that have identified over 25 RF (similar at home, hospital and NH)-modiable/immutable >2 studies

Evaluation of Falls: Physical Check orthostatics Perform a visual exam if once has not been done in the last year Look for cataracts Test visual acuity with glasses Evaluate cognition with the 3 Item Recall Age related: decreased barorecptor sensitivity, vestibular fnc, cataract, NPH

Evaluation of Falls: Physical Gait Assessment: Motor + Balance + Coordination

Evaluation of Falls: Physical Motor Assessment: Quad strength: Can rise from chair without using arms Functional assessment. Many other tests including motor strength exam but does not correlate with gait ability

Evaluation of Falls: Physical Balance Assessment: 3 Stances (abnl if < 10 secs each) Consider Resistance to nudge or picking a penny off the floor One leg stand (abnl if < 10 secs) Many other screens: Rhomberg: One-leg stand Functional reach test Tinetti balance assessment tool: sitting, immediate balance (1st 5 secs), standing balance, nudged, eyes closed, turning balance, sitting down balance

Evaluation of Falls: Physical Coordination Assessment: Abnormal if: Hesitant start Broad-based gait Path deviates Heels do not clear toes of other foot Extended arms Tinetti Gait assessment: step length and ht, foot clearance, step symmetry, step continuity, path, trunk , walking time

Diagnostic Testing Routine: Cbc, comprehensive chem, B12, Tsh Drug levels, INR As indicated: EKG/Holter & other cardiac tests Imaging EEG Vestibular testing

Fall Prevention Evidenced-based single intervention strategies Interventions of unknown effectiveness Multi-factorial assessment with targeted interventions Gillespie L, et al. Cochrane Database Syst Rev. 2003; 4: 2005 update

Effective Single Interventions Professionally supervised strength & balance training, ↓falls ~20% (3 trials) Tai Chi group exercise ↓falls 49% (1 trial) Home modification in patients with h/o falls, ↓falls ~34% (3 trials) Withdrawal of psychotropics ↓falls by 63% (1 trial) Cardiac pacing in pts w/ carotid sinus hypersensitivity ↓falls by 58% (1 trial) Gillespie L, et al. Cochrane Database Syst Rev. 2003; 4: 2005 update

Interventions That May Be Effective Expedited Cataract Surgery Decreased the risk of recurrent falls by 40% & all falls by 34% with decreased disability & improved QOL1 Vitamin D & Calcium Meta-analysis found vitamin D supplementation reduced the odds of falling by 22%, NNT 152 1. Harwood RH, et al. Br J Optalmol. 2005. 2. Bischoff-Gerrari HA, et al. JAMA 2004

Not Proven Effective Non-specific group exercise Targeted leg strengthening Nutritional supplements Cognitive behavioral approach Hormonal therapy Home hazard modification in non-fallers

Multifactorial Assessment With Targeted Intervention Most commonly studied & consistently effective 20+ trials showing 27% (2-37%) fall risk reduction for community dwelling older adults

Multifactorial Assessment With Targeted Intervention Effective components: Balance training: 7/7 trials+ Gait, assistive device: 4/4 trials+ Environmental Modification: 9/11 trials+ ↓Psychoactive meds: 4/4 trials+

Multifactorial Assessment With Targeted Intervention (cont) Effective components: ↓Other meds: 4/4 trials + Manage orthostasis: 2/2 trials + Manage other CV & medical conditions: 2/3 trial + Cardiac pacing: 1+ trial

Fall Prevention in Practice Identify Patients At Risk 70+ with h/o 2 or more falls or 1 injurious fall OR self-reported or observed difficulty with mobility Ask at least annually about falls Assess & manage the health problems that increase fall risk

Therapeutic Approach Identify & treat immediate underlying causes & predisposing risk factors Review & reduce meds Manage postural hypotension PT/OT evaluation for strength, balance, & gait training Environmental modification

Medication Review Decrease meds, esp psychotropics (benzos, sedatives, anti-depressants) Taper to lowest effective dose or stop Consider need for all meds before adding new one Prescribe non-pharmacologic treatments Advise pt to carry up-to-date med list

Postural Hypotension Frequently unrecognized Adequate hydration ½ c. water every ½ hr for first 8 hrs of day Liberalize salt in diet Reduce meds that contribute Teach patients to change position slowly

PT/OT Evaluation Gait & strength assessment & training Balance training Exercises that challenge stability yet are safe Tai chi Assistive devices Recommendations for & regular inspection Appropriate footwear High box, low heel, thin sole

Environmental Modification Home safety assessment By pt or caregiver using checklist, MD at home visit, or visiting nurse Hazards include: Clutter Electric cords Slippery throw rugs & loose carpet Poor lighting

Optimize Disease Management Vision Test acuity, eval for cataracts, ophthalmology referral Patient education Allow time for eyes to accommodate to changing level of light Do not walk using bifocals or reading glasses Osteoporosis Consider vitamin D, bisphosphonates

Clinical Pearls Screen all pts >75 yrs for falls at least yearly Evaluate the circumstances of the fall Systematically evaluate for modifiable predisposing factors and precipitants Motor/balance/gait Environment Medications Vision Disease management, including cognition

Acknowledgment Thanks to Dr. Helen Fernandez for her mentorship