Falls: A Case Close to Home Geriatrics Interclerkship April 30, 2012 Gary Blanchard, M.D.

“Gait deferred”

Why are we so concerned about falls?

Patient H.B. 86 years old, independently living on Cape Cod with her husband x 65+ years. 86 years old, independently living on Cape Cod with her husband x 65+ years. She is largely independent with her ADLs – but requires IADL assistance. Inconsistently uses her walker. She is largely independent with her ADLs – but requires IADL assistance. Inconsistently uses her walker. She has frequent falls (16) – some of which have resulted in hospitalization – in the past 18 months. She has frequent falls (16) – some of which have resulted in hospitalization – in the past 18 months.

Patient PMHx Type 2 diabetes – oral medications Type 2 diabetes – oral medications Cataracts, visual impairment Cataracts, visual impairment Mild cognitive impairment, anxiety features Mild cognitive impairment, anxiety features Delirium episodes (hospitalizations) Delirium episodes (hospitalizations) Hypertension Hypertension Meds: lisinopril 20 mg once daily, carbamazepine 200 mg twice daily, lorezapam 0.5 mg nightly, metformin 500 mg twice daily, ASA 81 mg daily Meds: lisinopril 20 mg once daily, carbamazepine 200 mg twice daily, lorezapam 0.5 mg nightly, metformin 500 mg twice daily, ASA 81 mg daily

Her perspective: She wants to remain at home, where she has always been. She steadfastly wants to maintain her independence. She wants to remain at home, where she has always been. She steadfastly wants to maintain her independence. She acknowledges inherent risk of current living situation – and that her husband is also declining functionally. She acknowledges inherent risk of current living situation – and that her husband is also declining functionally.

Her grandson geriatrician’s perspective:

Underappreciated “Can cause lasting discomfort and decreased function … cause discomfort and disability for older adults and stress for caregivers.” (JAMA, 2010) “Can cause lasting discomfort and decreased function … cause discomfort and disability for older adults and stress for caregivers.” (JAMA, 2010) Major contributor to functional decline and health care utilization. Major contributor to functional decline and health care utilization. Increased likelihood of nursing home placement. Increased likelihood of nursing home placement. Fear of falling – debilitating. Fear of falling – debilitating.

Pearls Not a normal part of aging Not a normal part of aging Red flag – a sentinel event for illness, functional decline, frailty Red flag – a sentinel event for illness, functional decline, frailty Consider: presentation of acute illness Consider: presentation of acute illness

Not normal, but common More than 1/3 of community-living adults >65 fall each year. At least half recur. More than 1/3 of community-living adults >65 fall each year. At least half recur. Roughly 1 in 4 fallers limit their lifestyle/activities due to fear of falling. Roughly 1 in 4 fallers limit their lifestyle/activities due to fear of falling. Roughly 10% of falls result in major injury (fracture, etc.). Also: inability to rise without help (rhabdomyolysis, pressure ulcers, dehydration) Roughly 10% of falls result in major injury (fracture, etc.). Also: inability to rise without help (rhabdomyolysis, pressure ulcers, dehydration)

Mortality Accidents (commonly falls) are the 6 th leading cause of death Accidents (commonly falls) are the 6 th leading cause of death Clustering of falls is associated with a high 6 month mortality Clustering of falls is associated with a high 6 month mortality Falling increases the mortality rate of patients with Alzheimer's Disease Falling increases the mortality rate of patients with Alzheimer's Disease

Morbidity 4-6 % of falls result in a fracture 4-6 % of falls result in a fracture 1-2% of falls result in a hip fracture 1-2% of falls result in a hip fracture >50% of older adults with a fall-related hospitalization are discharged to a nursing home >50% of older adults with a fall-related hospitalization are discharged to a nursing home Falls account for 10% of ER visits and 6% of urgent hospitalizations for older adults Falls account for 10% of ER visits and 6% of urgent hospitalizations for older adults

Why do people fall?: Vulnerable host, wrong environment Vulnerable host, wrong environment Requires coordination among sensory (vision, vestibular, proprioception), CNS, peripheral nervous system, cardiopulmonary, musculoskeletal, and other systems. Requires coordination among sensory (vision, vestibular, proprioception), CNS, peripheral nervous system, cardiopulmonary, musculoskeletal, and other systems. Need >1 systems affected. Need >1 systems affected.

Risk factors (cumulative): 1) Previous falls 2) Balance impairment 3) Decreased muscle strength 4) Visual impairment 5) Medications (but chronic diseases can increase fall risk, too) 6) Gait impairment 7) Dizziness/orthostasis 8) Functional limitations

Systematic Approach Decreased muscle strength Neuropathy Orthostasis Vestibular, cerebellar

How do you evaluate the faller? History, exam? History, exam? Why might my grandmother fall? Why might my grandmother fall? What workup would you do for my grandmother? What workup would you do for my grandmother?

History

Patient PMHx Type 2 diabetes – oral medications Type 2 diabetes – oral medications Cataracts, visual impairment Cataracts, visual impairment Mild cognitive impairment, anxiety features Mild cognitive impairment, anxiety features Delirium episodes (hospitalizations) Delirium episodes (hospitalizations) Meds: lisinopril 20 mg once daily, carbamazepine 200 mg twice daily, lorezapam 0.5 mg nightly, metformin 500 mg twice daily, ASA 81 mg daily Meds: lisinopril 20 mg once daily, carbamazepine 200 mg twice daily, lorezapam 0.5 mg nightly, metformin 500 mg twice daily, ASA 81 mg daily

Patient PMHx Type 2 diabetes – oral medications Type 2 diabetes – oral medications Cataracts, visual impairment Cataracts, visual impairment Mild cognitive impairment, anxiety features Mild cognitive impairment, anxiety features Delirium episodes (hospitalizations) Delirium episodes (hospitalizations) Meds: lisinopril 20 mg once daily, carbamazepine 200 mg twice daily, lorezapam 0.5 mg nightly, metformin 500 mg twice daily, ASA 81 mg daily Meds: lisinopril 20 mg once daily, carbamazepine 200 mg twice daily, lorezapam 0.5 mg nightly, metformin 500 mg twice daily, ASA 81 mg daily

Physical Examination Gait, balance, mobility, muscle stregth, lower extremity joints Gait, balance, mobility, muscle stregth, lower extremity joints Neurological: Cognition, peripheral nerves, cerebellar, proprioception, extrapyramidal Neurological: Cognition, peripheral nerves, cerebellar, proprioception, extrapyramidal Cardiovascular: orthostatics, rate/rhythm Cardiovascular: orthostatics, rate/rhythm Visual acuity Visual acuity Examine feet and footwear Examine feet and footwear

Watch ‘em walk Observation is critical Observation is critical Demonstrate: Timed ‘Get up and Go’ Timed ‘Get up and Go’ ADL performance screen ADL performance screen

Functional assessment Assess ADL skills (mobility aids) Assess ADL skills (mobility aids) Assess perceived functional abilities and fear of falling Assess perceived functional abilities and fear of falling Environmental: home safety assessment (PT, OT, VNA) Environmental: home safety assessment (PT, OT, VNA)

Workup/Management Plan

Effective Interventions Best when customized, multidisciplinary Best when customized, multidisciplinary Best single: PT, exercise, cataract surgery, medication reduction. Best single: PT, exercise, cataract surgery, medication reduction. Vitamin D strongest evidence for preventing fractures among older men at risk. Vitamin D strongest evidence for preventing fractures among older men at risk.

2010 AGS Guidelines Multifactorial assessment: feet and footwear, functional assessment, an environmental assessment (home safety), and ask about their perceived functional ability and fear of falling. Multifactorial assessment: feet and footwear, functional assessment, an environmental assessment (home safety), and ask about their perceived functional ability and fear of falling. Medications, particularly antipsychotics and psychoactive medications, should be minimized or withdrawn. Medications, particularly antipsychotics and psychoactive medications, should be minimized or withdrawn. Postural hypotension assessment. Postural hypotension assessment.

2010 AGS Guidelines An 800-IU supplement of vitamin D. An 800-IU supplement of vitamin D. An exercise regimen that focuses on balance, gait, and strength training, such as tai chi or physical therapy. An exercise regimen that focuses on balance, gait, and strength training, such as tai chi or physical therapy. For older patients who need cataract surgery, the intervention should be expedited. For older patients who need cataract surgery, the intervention should be expedited.

Effective Multi-factorial Interventions for Fall Prevention Gait training/assistive device training Gait training/assistive device training Review and modify medications Review and modify medications Critically evaluate need for psychotropic medication Critically evaluate need for psychotropic medication Exercise programs (strength and balance) Exercise programs (strength and balance) Treat orthostatic hypotension Treat orthostatic hypotension Modify environmental hazards and activities Modify environmental hazards and activities Treat cardiovascular disorders Treat cardiovascular disorders

Our patient: H.B.

Safety v. independence Safety v. independence ASK!!! (Annual screen >70) ASK!!! (Annual screen >70) Targeted, multi-factorial interventions have been shown to be effective at reducing falls in the home. Targeted, multi-factorial interventions have been shown to be effective at reducing falls in the home.

Reference Tinetti, M.; Kumar, C. “The Patient Who Falls: It’s Always a Trade-Off.” JAMA. 2010; 303(3): doi: Tinetti, M.; Kumar, C. “The Patient Who Falls: It’s Always a Trade-Off.” JAMA. 2010; 303(3): doi: AGS Clinical Practice Guideline : Prevention of Falls in Older Persons (2010) AGS Clinical Practice Guideline : Prevention of Falls in Older Persons (2010) McGee, Sarah, MD, MPH. “Mobility and Functional Assessment.” UMMS Geriatrics Interclerkship, March 28, McGee, Sarah, MD, MPH. “Mobility and Functional Assessment.” UMMS Geriatrics Interclerkship, March 28, Bradley, S.; Chang, C. “Falls,” POGOe. Mount Sinai School of Medicine. Brookdale Dept of Geriatrics and Adult Development. March 4, Bradley, S.; Chang, C. “Falls,” POGOe. Mount Sinai School of Medicine. Brookdale Dept of Geriatrics and Adult Development. March 4, 2008.