C. Bree Johnston, MD MPH Copyright May 2001 Falls in the Elderly C. Bree Johnston, MD MPH Copyright May 2001 UCSF Division of Geriatrics Primary Care Lecture Series May 2001

UCSF Division of Geriatrics Primary Care Lecture Series May 2001 Overview Prevalence Clinical Importance Risk Factors & Etiology Evaluation Prevention & Management Falls & restraint use Summary UCSF Division of Geriatrics Primary Care Lecture Series May 2001

UCSF Division of Geriatrics Primary Care Lecture Series May 2001 Falls: Mrs. F. Mrs. F. is an 80 year old woman who lives alone. She just came in to your office for follow up of a fall resulting in a Colles’ fracture. She has had two other falls over the past year and a half. She is scared of falling again. She has a history of osteoarthritis and anxiety/depressison. She is on naproxen 500mg BID and diazepam 5mg BID prn UCSF Division of Geriatrics Primary Care Lecture Series May 2001

UCSF Division of Geriatrics Primary Care Lecture Series May 2001 Falls in the Elderly Prevalence Clinical Importance Risk Factors & Etiology Evaluation Prevention & Management Falls & restraint use Summary UCSF Division of Geriatrics Primary Care Lecture Series May 2001

UCSF Division of Geriatrics Primary Care Lecture Series May 2001 Prevalence 30% of those over 65 fall annually Half are repeat fallers Falls go up with each decade of life Over half of those in nursing homes and hospitals will fall each year UCSF Division of Geriatrics Primary Care Lecture Series May 2001

UCSF Division of Geriatrics Primary Care Lecture Series May 2001 Falls in the Elderly Prevalence Clinical Importance Risk Factors & Etiology Evaluation Prevention & Management Falls & restraint use Summary UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Impact of Hip Fractures 1% of falls result in hip fracture $2 billion + in medical costs annually 25% die within 6 months 60% have restricted mobility 25% remain functionally more dependent UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Falls Cause Morbidity and Mortality Mortality: found down syndrome, indirect effects Fractures: 6% of falls Soft tissue injury, head injury, subdural hematoma Fear of falling can result in decreased activity, isolation, and further functional decline Nursing home placement and loss of independence UCSF Division of Geriatrics Primary Care Lecture Series May 2001

UCSF Division of Geriatrics Primary Care Lecture Series May 2001 Falls in the Elderly Prevalence Clinical Importance Risk Factors & Etiology Evaluation Prevention & Management Falls & restraint use Summary UCSF Division of Geriatrics Primary Care Lecture Series May 2001

UCSF Division of Geriatrics Primary Care Lecture Series May 2001 Falls are Multifactorial Intrinsic Factors Extrinsic Factors Medical conditions Impaired vision and hearing Age related changes Medications Improper use of assistive devices Environment FALLS UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Normal Changes with Aging Neurologic Increased reaction time Decreased righting reflexes Decreased proprioception Vision Changes Decreased accommodation & dark adaptation Decreased muscle mass UCSF Division of Geriatrics Primary Care Lecture Series May 2001

UCSF Division of Geriatrics Primary Care Lecture Series May 2001 Normal changes of Gait Slower gait Decreased stride length and arm swing Forward flexion at head and torso Increased flexion at shoulders and knees Increased lateral sway UCSF Division of Geriatrics Primary Care Lecture Series May 2001

UCSF Division of Geriatrics Primary Care Lecture Series May 2001 Dysmobility Dysmobility and falling closely related 15% of those over 65 have trouble walking 1/4 men and 1/3 women over age 85 have difficulty with walking 2/3 of people in hospital or NH unable to ambulate without assistance UCSF Division of Geriatrics Primary Care Lecture Series May 2001

UCSF Division of Geriatrics Primary Care Lecture Series May 2001 Risk Factors for Falls Risk Factor OR Sedative use 28 Cognitive Impairment 5 Lower extremity problem 4 Pathologic Reflex 3 Foot Problems 2 > 3 balance/gait problems 1.4 >5 balance/gait problems 1.9 Tinetti NEJM 1988 UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Common Pathologies associated with Falls Ophthalmologic diseases Arthritis Foot problems Neurologic illness Parkinson’s & related disorders Strokes Peripheral neuropathy Dizziness and dysequilibrium UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Dizziness: A Multifactorial Syndrome Vertigo: BPV, Posterior CVA/TIA, Cervical Presyncope: Orthostatic, Dysrythmia, Anemia Dysequilibrium: Peripheral neuropathy, Visual Other: Anxiety, depression In older people, usually multifactorial Tinetti, Annals of Internal Med 2000 UCSF Division of Geriatrics Primary Care Lecture Series May 2001

UCSF Division of Geriatrics Primary Care Lecture Series May 2001 Falls in the Community Accidents/environment 37% Weakness, balance, gait 12% Drop attack 11% Dizziness or vertigo 8% Orthostatic hypotension 5% Acute illness, confusion, drugs, decreased vision 18% Unknown 8% Discussing the etiology of falls is a little misleading because almost all falls result from the combination of environmental + physiologic factors. For example, I was recently skiing with my husband..... Rubenstein JAGS 1988 UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Falls in Residential Care Generalized weakness 31% Environmental hazard 27% Orthostatic hypotension 16% Acute illness 5% Gait or balance disorder 4% Drugs 5% Other or unknown 10% Rubenstein Ann Int Med 1990 UCSF Division of Geriatrics Primary Care Lecture Series May 2001

UCSF Division of Geriatrics Primary Care Lecture Series May 2001 Medications and Falls Sedative-hypnotics, especially long acting benzodiazepines, increase falls Small association between most psychotropics and falls SSRIs and TCAs both incrsease falls Weak association between Type 1A antiarrythmics, digoxin, diuretics, and falls Leipzig JAGS 1999 Thapa NEJM 1998 UCSF Division of Geriatrics Primary Care Lecture Series May 2001

UCSF Division of Geriatrics Primary Care Lecture Series May 2001 Falls in the Elderly Prevalence Clinical Importance Risk Factors & Etiology Evaluation Prevention & Management Falls & restraint use Summary UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Evaluation of Falls: History Location & circumstances of Fall Associated symptoms Other falls or near falls Medications (including nonprescription) and alcohol Injury & ability to get up UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Evaluation of Falls: Physical Examination Supine and standing BP - always Routine physical examination Focus on cardiovascular, MS, neuro, feet Vision and hearing evaluation Consider acute medical illness & delirium Formal gait and balance assessment UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Evaluation of Falls: Home Evaluation Can be performed by nurse, OT, PT, others Stairs Lighting Clutter Bathroom Specific hazards: cords, throw rugs UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Evaluation of Falls: Risk Factors for Injury Osteoporosis assessment Anticoagulation: Usual benefits outweigh risks unless repeat or high risk faller Can the person get up from fall? Is there a way to notify others in case of falling? UCSF Division of Geriatrics Primary Care Lecture Series May 2001

UCSF Division of Geriatrics Primary Care Lecture Series May 2001 Mrs. F. History reveals that she fell at home in the bathroom at night, tripping over a bathmat. Both other falls have been in similar circumstances. She was able to get up. On PE, she has visual acuity of 20/100 with bilateral cataracts. She has mild OA of the knees, with bunyon deformities of her feet and poor fitting shoes. UCSF Division of Geriatrics Primary Care Lecture Series May 2001

UCSF Division of Geriatrics Primary Care Lecture Series May 2001 Mrs. F. Her gait assessment shoes that she is unable to get up out of the chair without help. Her gait is hesitant and slightly wide based. Home evaluation reveals poor lighting in all rooms, multiple throw rugs in every room, and no grab bars or safety equipment in the bathroom. UCSF Division of Geriatrics Primary Care Lecture Series May 2001

UCSF Division of Geriatrics Primary Care Lecture Series May 2001 Mrs. F. She is weaned off of her diazepam over 3 months T-score on dexa is –3.0, and she is begun on alendronate, vitamin D, and calcium She goes to ophthalmology and podiatry PT begins exercises, followed by weight lifting and exercise 3X a week at a Senior Center She gets home safety equipment, improved lighting, and gives away her throw rugs UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Formal Gait Evaluation Get up and Go Test Tinetti Gait and Balance Evaluation (POMA) Tinetti JAGS 1986 Podsiallo jAGS 1991 Mathias Arch Phys Med 1986 UCSF Division of Geriatrics Primary Care Lecture Series May 2001

POMA: Balance Component Sitting (in hard, armless chair) Arising Standing balance (immediate and delayed) Balance with Nudge Balance with Eyes closed Balance with 360 degree turn Tinetti JAGS 1986 UCSF Division of Geriatrics Primary Care Lecture Series May 2001

UCSF Division of Geriatrics Primary Care Lecture Series May 2001 POMA: Gait Component Initiation Step length and height Step symmetry & continuity Path Stance Ability to pick up speed Tinetti JAGS 1986 UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Common Causes of Abnormal Gait Difficulty arising from chair Weakness Arthritis Instability on first standing Hypotension, Weakness Instability with eyes closed Proprioception Step height/length Parkinsonism Frontal lobe Fear UCSF Division of Geriatrics Primary Care Lecture Series May 2001

UCSF Division of Geriatrics Primary Care Lecture Series May 2001 Falls in the Elderly Prevalence Clinical Importance Risk Factors & Etiology Evaluation Prevention & Management Falls & restraint use Summary UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Prevention & Treatment Treat acute injury & underlying medical conditions Remove unnecessary medications Rehab, exercises, assistive devices Correct sensory impairments Environmental modifications & safety Evaluate for osteoporosis treatment UCSF Division of Geriatrics Primary Care Lecture Series May 2001

UCSF Division of Geriatrics Primary Care Lecture Series May 2001 Osteoporosis Calcium and vitamin D for most elders at risk Dawson-Hughes, NEJM, 1997 Osteoporosis evaluation and treatment Hip protectors appear to protect from hip fractures in those who wear them Kannus, NEJM, 2000 Thiazides may help slightly Statins? UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Risk Factor Modifications for Fractures Change Estimated Change in Risk Quit smoking 38% Treat impaired vision 50% Stop sedatives 40% Add 1 Gram Calcium 24% Hip Protectors 50%? Adapted from Stteve Cummings UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Hip pads to prevent hip fracture “RCT” of 1801 frail subjects in Finland Nursing home or frail community patients Mean age 81 78% women 63% assisted walking Kannus. NEJM;2000;343;1506-1513. UCSF Division of Geriatrics Primary Care Lecture Series May 2001

UCSF Division of Geriatrics Primary Care Lecture Series May 2001 Fractures with Hip Protectors 2.1% per year vs. 4.6% per year (p<.01) 40 patients needed to be treated with hip protector for 1 year to prevent one fracture 2.4% of falls resulted in hip fracture when not wearing protector 0.4% resulted in hip fracture when wearing protector (80% risk reduction) But patient acceptance low Kannus. NEJM;2000;343;1506-1513 UCSF Division of Geriatrics Primary Care Lecture Series May 2001

UCSF Division of Geriatrics Primary Care Lecture Series May 2001 www.hipsavers.com UCSF Division of Geriatrics Primary Care Lecture Series May 2001

UCSF Division of Geriatrics Primary Care Lecture Series May 2001 Prevention of “Found Down” Syndrome Lifelines Accessible telephones Teach in getting up off floor Friendly phone calls or visitors for isolated elderly UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Falls: Primary Prevention 301 community dwelling elders with 1+ risk factors for falling Intervention: adjustment in medications, behavioral instructions, exercise programs aimed at modifying risk factors One year follow up Risk factors Postural hypotension Use of 4 or more Rx meds Impairment in arm or leg strength, ROM, balance, ability to transfer, or gait Tinetti et al. 1994 NEJM UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Multifactorial Intervention Tinetti et al 1994 NEJM Wagner and his group found that a one time intervention in a group of HMO enrollees age 65 and older also reduced the incidence of falls. Benefits at one year, not sustained. AJPH 1994 P = .04 UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Exercise Training & Nutrition Although this study did not look at falls (the numbers were too low at baseline), it does allow a look at an exercise intervention on a skilled nursing home population to look at the intermediate outcomes of strength, gait velocity, stair climbing, muscle strength, and spontaneous physical activity. Progressive high intensity hip and knee extensors resistance training Mean study age 87 years, 100 patients Shown here is muscle strength. Other outcomes included gait velocity, stair climbing and spontaneous Pe. Fiatarone et al NEJM 1994 UCSF Division of Geriatrics Primary Care Lecture Series May 2001

UCSF Division of Geriatrics Primary Care Lecture Series May 2001 Tai Chi and Falling Atlanta FICSIT Trial 200 community dwelling elders 70+ Intervention: 15 weeks of education, balance training, or Tai Chi Outcomes at 4 months: Strength, flexibility, CV endurance, composition, IADL, well being, falls Falls reduced by 47% in Tai Chi group Wolf JAGS 1996 UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Exercise, Falls, and Frailty FICSIT Trials 8 independent prospective RCTs Goal: reduction in falls and frailty Pre-planned Meta-analysis Intervention RR CI Any Exercise .90 (.81-.99) Balance Component .83 (.70-.98) Province JAMA 1995 UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Training frail older persons: The New Zealand Study of Women 223 women >80 years Intervention: PT tailored to individual needs, with resistance and balance training Results: Clinical balance, chair rise improved RR for falls .47 (CI .04-.90) RR for injurious falls .61 (.39-.97) Campbell BMJ 1997 UCSF Division of Geriatrics Primary Care Lecture Series May 2001

UCSF Division of Geriatrics Primary Care Lecture Series May 2001 Falls in the Elderly Prevalence Clinical Importance Risk Factors & Etiology Evaluation Prevention & Management Falls & restraint use Summary UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Restraint Reduction and Injury No evidence that restraints reduce fall injuries Restraints increase morbidity and may cause death Reported strangulation deaths from restraints every year Risk factor for delirium, decubitus ulcers, malnutrition, aspiration pneumonia UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Restraint Reduction Decreases Injuries 816 bed Jewish Home for the Aged - Restraints decreased from 39% to 4% over 3 years - No change in falls, injuries, psychotropic use 2 year educational intervention covering 2000+ beds - Restraint reduction 41% to 4% - Decrease in serious injuries from 7.5% to 4.4% Tinetti 1992, Capezuti, Neufeld 1999, Evans 1997 UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Alternatives to Restraints For Patients with Lines and Tubes Sedation (especially in ICU) Reducing delirium risk factors (drugs, dehydration) Does the benefit of tubes and lines (or hospitalization) outweigh the risks of restraints? Geriatric Consultation Team Sometimes restraints may be unavoidable in this setting UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Alternatives to Restraints for Patients Who Fall or Wander Accept the risk of falling Hip protectors Environmental modifications, day rooms, low beds Least restrictive alternatives Alarms Sitters or family Geriatric consultation team UCSF Division of Geriatrics Primary Care Lecture Series May 2001

UCSF Division of Geriatrics Primary Care Lecture Series May 2001 Summary Falls are common in the elderly & may lead to injuries and decline in function Evaluation should included risk factor assessment, gait assessment, and home assessment Exercise can improve outcomes We have no evidence that restraints reduce fall related injuries UCSF Division of Geriatrics Primary Care Lecture Series May 2001