EVALUATION OF FALLs IN THE ELDERLY. DR. SHU’AIBU ABDULLAHI FAMILY MEDICINE DEPARTMENT, AKTH.

OUTLINE INTRODUCTION/ DEFINITIONS EPIDEMIOLOGY CLINICAL IMPORTANCE RISK FACTORS/ AETIOLOGY EVALUATION History Physical examination Investigations PREVENTION INTERVENTION/ TREATMENT SUMMARY

Introduction Falling present a clinical challenge b/c of its frequency of occurrence, associated morbidity & mortality, multifactoral nature. Falls are the leading cause of injury related visits to emergency dept in the US. The primary etiology of accidental deaths in persons >65yrs. Mortality rate of falls increases with age in both sexes & in all racial & ethnic groups Markers of poor health and declining function.

Definitions A fall is a sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor or the ground . Elderly WHO- 65yrs and above UN- 60yrs and above Developed countries- 65yrs and above Developing countries- 60yrs and above due to differences in life expectancies & proportions of older persons within the population

Epidemiology About one third of community-dwelling elderly persons & 60% of nursing home residents fall each year Falls where the leading cause of external injury, accounting for 24% of these visits Women fall more frequent than men but men tend to have greater mortality. From 1992 through 1995, 147 million injury related visits were made to emergency dept in the US

Epidemiology Contd 30% of those over 65yrs fall annually Half of them are repeat fallers A community based survey conducted in 8 states of Yoruba speaking areas of Nigeria shows 23% incidence of fall among elderly persons aged 65yrs & above Another community survey on incidence & outcome of falls among elderly persons in Ibadan shows 21.4% incidence

Clinical Importance Falls causes morbidity and mortality Elderly who represent 12% of the population, account for 75% of death from falls Most elderly persons who survive a fall experience a significant morbidity Injuries ass with fall include head injury, soft tissue injury, fractures and dislocation which occurs in 5 to 15% of falls in any given year . Fracture account for 75% of serious injuries with Hip fracture occurring in 1 to 2 percent of fall

Impact Of Hip Fracture Hip fracture is the leading fall related injury that result in hospitalization 1-2% of fall results in hip fracture. 25% die within 6month. 60% have restricted mobility. 25% remain functionally dependent. Fear of falling can result in decreased activity, isolation and further functional decline.

Risk Factors Demographic factors Older age(esply>=75) White race Female gender House bound status Living alone Historical factors Use of cane or walker Previous falls

Risk Factors Contd Acute illness Chronic conditions, esp. neuromuscular diseases Medications, esp. use of 4 or more drugs Physical deficits Cognitive impairment Reduced vision Difficulty in rising from the chair Foot problems

Risk Factors Contd Neuromuscular changes Decrease hearing Others Environmental hazards Risky behaviors Risk factors could also be categorized into:- Intrinsic factors:- present within a patient & are specific to that patient e.g. medical conditions, age related changes like impaired vision & hearing

Risk Factors Contd Extrinsic factors:- act on the patient from outside & are potentially modifiable e.g. improper use of assistive device, environmental obstacles

Common Causes of Falls in Elderly Accident/environmental hazards Gait disturbance, balance disorders or weakness, pain related to arthritis Dizziness/Vertigo Medications or alcohol Acute illness Confusion & cognitive impairment Postural hypotension

Common Causes of Fall in Elderly Visual disorder CNS disorder, syncope, drop attacks, epilepsy

Evaluation ELDERLY WHO HAVE FALLEN SHOULD UNDERGO A THOROUGH EVALUATION. HISTORY 1st step in evaluating the faller is to identify the problem Determine the mechanism of fall Ask about risk factors for fall such as env hazards, visual & hearing impairment, medical condns, medications etc. Prodromal symptoms such as light headedness, dizziness Ask about activity the patient was engaged in just b/4 & at the time of the fall, esp. if the activity involved a positional changes

Evaluation Contd Loss of consciousness The location of the fall should be ascertained Ask if any one witnessed the fall The patient & if applicable , the witnesses or caregivers should be asked in detail about previous falls & whether the falls were the same or different in character The physician also need to determine who is available to assist the patient

Evaluation Contd Home visit for assessing modifiable risk factors Home safety checklist Particularly important to assess caregiver & housing arrangement, environmental hazards

Evaluation Contd Home safety checklist All living spaces _____ Remove throw rugs. _____ Secure carpet edges. _____ Remove low furniture and objects on the floor. _____ Reduce clutter. _____ Remove cords and wires on the floor. _____ Check lighting for adequate illumination at night (especially in the pathway to the bathroom). _____ Secure carpet or treads on stairs. _____ Install handrails on staircases. _____ Eliminate chairs that are too low to sit in and get out of easily. _____ Avoid floor wax (or use nonskid wax). _____ Ensure that the telephone can be reached from the floor. Bathrooms _____ Install grab bars in the bathtub or shower and by the toilet. _____ Use rubber mats in the bathtub or shower. _____ Take up floor mats when the bathtub or shower is not in use. _____ Install a raised toilet seat. Outdoors _____ Repair cracked sidewalks. _____ Install handrails on stairs and steps. _____ Trim shrubbery along the pathway to the home. _____ Install adequate lighting by doorways and along walkways leading to doors.

Evaluation Contd PHYSICAL EXAMINATION Routine physical examination Supine & standing BP always Focus on cardiovascular, MS, neurological, feet Vision and hearing evaluation Consider acute medical illness & delirium Formal gait and balance assessment PHYSICAL EXAMINATION

Mnemonic For key physical finding in the elderly pt who falls or nearly falls I HATE FALLING I - Inflammation of joints(or joint deformity) H -Hypotension(orthostatic BP changes) A -Auditory and visual abnormalities T -Tremors(parkinson’s dx or other causes) E -Equilibrium(balance problem)

F -Foot problems A -Arrhythmias, heart block or valvular dx L -Leg length discrepancy L -Lack of conditioning(generalized) I -Illness N -Nutrition(poor, wt loss) G -Gait disturbances

This mnemonic focuses the physician attention on common problems that are likely to respond to RX. Only rarely are all of the causes fully reversible

Evaluation Contd INVESTIGATIONS Diagnostic studies – none is required routinely If indicated in the appropriate patient: CBC, U&E, CR, TFT, X-ray and glucose can be done

Formal Gait Evaluation Timed “UP & GO” test Pt gets up out of standard armchair(seat ht of ~46cm(18.4in). Walk a distance of 3m(10ft), turns, walk back to the chair & Sit down again Pt wears regular foot wear and if applicable uses any customary walking aid(e.g. cane or walker). No physical assistance is given.

Formal Gait Evaluation Contd Watch is used to time activity in seconds A score of 30s or greater indicates impaired mobility and required assistance(inc risk of falling). predictive values Seconds Rating <10 freely mobile 10-19 mostly independent 20-29 variable mobility >30 impaired mobility

Formal Gait Evaluation Contd A simpler alternative is the “ Get up & Go” test The patient is seated at armless chair placed 3m(10ft) from a wall The patient stands, walks towards the wall, turns without touching the wall Returns to the chair, turns & sit down This activity does not need to be timed Instead, the physician observes the patient & makes note of any balance or gait problems

Prevention There are no cures for faller but falls can be prevented Physician goal is to identify the faller & implement intervention to prevent future falls Treat acute injury & underlying medical conditions Remove unnecessary medications Rehab, exercises, assistive devices Correct sensory impairments Environmental modifications & safety Evaluate for osteoporosis treatment

Prevention Contd Modify restraints Involve family Provide follow up

Intervention Expert-based guidelines & evidence based medicine agree that a multi displinary & multi factorial evaluation with targeted intervention is likely to reduce the risk of subsequent fall Orthostatic hypotension: Instruct pt to rise carefully & ensure balance before ambulating Ankle pumps or hard clenching Elevation of the head of the bed Dec dose of medication or discontinue if necessary

Intervention Contd Liberalization of salt Fludrocortisones 0.1mg bid or tds Uses of medications Education about appropriate use Non pharmacologic RX of sleep problems Tapering & discontinuation of medications The use of four or more prescription drugs also need to be reviewed.

Intervention Contd Environmental hazards: Home safety assessment with appropriate changes such as removal of hazards Selection of safer furniture Installation of structures e.g. grab bars in bathrooms, handrails on staircases Any impairment in gait Gait training Assistive device Balance exercise

Intervention Contd Reduce fracture complication of falls: Pt with osteoporosis:- biphosphates, calcium, vitamin D Some studies done have shown a remarkable reduce in falls in pt taking supplemental vitamin D Use of Hip protectors prevent hip fractures

Intervention Contd Restraints reduction No evidence that restraints reduce fall injuries Restraints increase morbidity and may cause death Reported cases of strangulation deaths from restraints every year A risk factor for delirium, decubitus ulcers, malnutrition, aspiration pneumonia.

Summary Falls are common in the elderly & may lead to injuries and decline in function Evaluation should include:- risk factor assessment, gait assessment, and home assessment Exercise can improve outcomes No evidence that restraints reduce fall related injuries.

References Rekel text book of family medine-7th edition C.Bree Johnson –UCSF Division of geriatrics primary care lecture series-May 2001 George F Fuller col,mc USA-American Academy of Family Physicians Bischoff etal 2003 American Geriatrics society 2001 Meck Manual Geriatric medicine book.

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