Falls and older people

Consequences of falls Mortality Injury Psychological sequelae Loss of independence

Why do older people fall?

Staying upright Muscles and joints Eyes: –Acuity –Contrast –Depth perception –Field- range of vision Ears –Semicircular canals in 3 planes –Utricle and saccule

Staying upright Proprioception –Receptors in skin and joints Vasoactive responses –Blood pressure and heart rate correct for changes in position against gravity Neural processing –Needed to put it all together

Healthy ageing Reduced muscle strength and power Reduced reaction times Reduced proprioception Changes in vision Reduced bone strength Reduced neural processing power

Falls in individuals Identify those at greatest risk Previous history of falling High number of risk factors Fear of falling Functional tests

Effects of illness Stroke: Parkinson's disease Arthritis Diabetes Weakness, balance, sensation Neural processing Strength power and proprioception Sensory loss, muscle weakness

Effects of illness Cardiac problems Dementia Bladder problems Changes in blood pressure and heart rhythm Reduced processing need to move fast

Falls risk factors Visual problems History of eye disease: may cause difficulty with contrast and depth even if acuity ok Bifocal glasses Cognitive impairment Evidence of delirium in hospital Inability to walk and talk at same time is subtle clue to loss of processing

Medications Psychotropics Analgesics Anticonvulsants Antihypertensive Antimuscarinics/ anticholinergics Diuretics

FRAT Falls risk assessment tool Any history of fall in the last year On > 4 medications History of Parkinson's disease or stroke Self reported problems with gait and balance Unable to rise from chair at knee height without use of arms

Functional tests of falls risk Sit to stand 5 Six meter walk test 180 degree turn test Stalk test

Functional test of falls Tinetti gait and balance score –Assesses falls risk as high, medium or low Elderly mobility score –Assesses likelihood of independence with functional daily tasks

Syncope and postural hypotension Neurocardiogenic syncope Carotid sinus syndrome Orthostatic hypotension

Neurogenic –Primary autonomic failure –Secondary autonomic failure Non- neurogenic –Reduced intravascular volume –Vasodilatation –Cardiac impairment –Drugs –hypertension

Evidence of loss of consciousness causing fall No recollection of cause Fall with injury particularly facial Symptoms of faint Confusion after event Syncope and seizures

Epilepsy/ syncope VasovagalCardiacEpilepsy TriggerCommonRare ProdromeAlmost alwaysUncommon/ briefCommon/ aura OnsetGradualSuddenSudden usually Duration1-30 secsVariable1-3 mins ColourPale Cyanosed JerksBrief Common Lat tongue biteRareOccasionalCommon BreathingQuiet apnoeic InjuryRareOccasionalCommon RecoverySleepy- mins – hours RapidSlow-often with confusion

Syncope investigations Ambulatory ECG R wave recordings Head up tilt test + carotid sinus massage –Two or more episodes of blackout –One blackout with injury

Syncope invests Contraindications for tests –Atrial fibrillation –Carotid bruit –Dementia

Can falls be prevented?

Interventions Single versus multifactorial inteventions

Falls interventions There have been effective falls interventions using single and multiple components Reduced falls order of % Single interventions are effective if targeted to people where high proportion of falls risk is attributable to risk factor and is modifiable

Modifiable single risk factors Reductions in psychotropic drugs ( Campbell 1999) Treatment of syncope ( Kenny 2001 ) Reductions of home hazards ( Cummings 1999 ) Cataract surgery ( Foss 2006)

Gait and balance training Targeted gait and balance training is part of successful multi-factorial and single interventions Exception is for patients with dementia

Medical falls clinic Examination for new or undiagnosed medical problems Investigation of blackouts and postural hypotension Review of medications especially sedatives or multiple cardiac medicines Screen for osteoporosis Recommendation for exercise/ rehabilitation if frail or high fear of falling

Treatment of syncope Cardiac pacing- cardioinhibitory and mixed carotid sinus syndromes Midodrine –hypotensive carotid sinus syndrome

Orthostatic hypotension- general measures Hot weather Post prandial Drugs Leg crossing Diurnal Raised intrathoracic pressure Increase fluid intake Increase caffeine Isotonic exercises Bed head raise

Orthostatic hypotension- medications Anaemia- erythropoietin Parkinson's disease- domperidone Fludrocortisone Midodrine

Exercise One to one or group Targeted to individual Strength and balance Progressive Prolongued intervention

Home hazards Stair design Maintenance of stairs Footwear Lighting Distracting events

Health promotion in falls Reasons people don’t exercise: Health problems Associations with frailty Increased pain Other priorities Reasons people do: Feeling better Less dizzy Able to do more Looking good!

Summary: Maintaining upright posture and mobility involves complex processes Therefore there maybe many contributors to falls risk including illness but also general ageing and lack of conditioning Assessment of new onset problems or deteriorating mobility is worthwhile

Summary Interventions to reverse weakness and balance problems take time and effort and are not possible for all If a person is unable or unwilling to engage in rehabilitation and exercise then reducing the risk of falls with assisstive devices and environmental checks and aids is the best option

Falls risk assessment Previous history of falls High number of risk factors Fear of falling Functional tests