Falls By Dr. Cuong Ngo-Minh Back to Basics April 16th 2009

Falls prevalence in the older person 30% of seniors living in community fall each year. 30% of seniors living in community fall each year. 50% of nursing home and hospital residents fall annually each year. 50% of nursing home and hospital residents fall annually each year. 1 in 10 falls result in serious injury 1 in 10 falls result in serious injury (6% require hospitalization) (6% require hospitalization)

Risk for falls Usually multiple factors; age >75 is risk factor (screen Hx of falls) Usually multiple factors; age >75 is risk factor (screen Hx of falls) only 1/3 falls have a single cause only 1/3 falls have a single cause Risk of falling is highest the month post-discharge Risk of falling is highest the month post-discharge and w/ acute illness or exacerbation of chronic illness and w/ acute illness or exacerbation of chronic illness Interactions between long term or short term predisposing factors & short term precipitating factors in person’s environment Interactions between long term or short term predisposing factors & short term precipitating factors in person’s environment

History Focused data gathering Thoroughly detailing the fall and preceding moments Thoroughly detailing the fall and preceding moments Look for contributing factors Look for contributing factors 1 st or recurrent fall…..strongest predictor for fall is prior fall 1 st or recurrent fall…..strongest predictor for fall is prior fall Location and time of fall Location and time of fall Events, activities, & symptoms preceding the fall: Events, activities, & symptoms preceding the fall: -lightheadedness or positional changes -lightheadedness or positional changes - palpitations, chest pain - palpitations, chest pain -following fall: LOC, incontinence, confusion -following fall: LOC, incontinence, confusion

Falls causes Extrinsic factors Extrinsic factors a) Environment: Loose rugs; slippery floors; uneven door thresholds; poor lighting; furniture and fixtures of inappropriate height, stairs, chairs lacking arm support Loose rugs; slippery floors; uneven door thresholds; poor lighting; furniture and fixtures of inappropriate height, stairs, chairs lacking arm support b) Medications & alcohol: 1. polypharmacy (more than 3 prescription meds) 1. polypharmacy (more than 3 prescription meds) 2. use of alcohol, leisure drugs 2. use of alcohol, leisure drugs 3. psychotropic drugs double risk(also sleeping pills) 3. psychotropic drugs double risk(also sleeping pills) 4. anticonvulsants & antiarrythmics (class 1A) 4. anticonvulsants & antiarrythmics (class 1A)

Intrinsic factors 1 Hypotension (orthostatic, post-prandial, or drug-related) Hypotension (orthostatic, post-prandial, or drug-related) - assoc w/ up to 20% of falls - assoc w/ up to 20% of falls - affects 15% of seniors, 30 % of those treated for hypertension - affects 15% of seniors, 30 % of those treated for hypertension -age-related changes (decreased vascular compliance, impaired baroreflex sensitivity, predisposition to postprandial hypotension) -age-related changes (decreased vascular compliance, impaired baroreflex sensitivity, predisposition to postprandial hypotension) - Antihypertensives, diuretics, anticholinergics, psychoactive drugs, benzodiazepines, SSRIs, tricyclic meds, neuroleptics - Antihypertensives, diuretics, anticholinergics, psychoactive drugs, benzodiazepines, SSRIs, tricyclic meds, neuroleptics

Intrinsic Factors 2 Acute illness Acute illness Visual impairment Visual impairment Gait, balance, and mobility disorders Gait, balance, and mobility disorders Lower limb weakness Lower limb weakness Fear of falling (post-fall syndrome) Fear of falling (post-fall syndrome)

Acute illness Falls may be a nonspecific sign of acute illness or acute exacerbation of chronic conditions (cardiac arrythmia, valvular heart disease, syncope, lumbar stenosis) Falls may be a nonspecific sign of acute illness or acute exacerbation of chronic conditions (cardiac arrythmia, valvular heart disease, syncope, lumbar stenosis) 10-20% of falls are related to acute illness 10-20% of falls are related to acute illness (think delirium in the elderly) (think delirium in the elderly)

Visual impairment Age-related including visual acuity, decline in accommodation, altered depth perception Age-related including visual acuity, decline in accommodation, altered depth perception Cataracts, glare intolerance Cataracts, glare intolerance Slowed light-dark adaptation Slowed light-dark adaptation

Gait, balance & mobility disorders 3-fold increase in risk 3-fold increase in risk Age-related changes: postural instability, decreased central integration from all senses, slowed reaction time Age-related changes: postural instability, decreased central integration from all senses, slowed reaction time Associated w/ arthritis, stroke, parkinson’s disease, foot problems Associated w/ arthritis, stroke, parkinson’s disease, foot problems

Lower limb weakness Common, 5 –fold increase in falls Common, 5 –fold increase in falls Arises from inactivity with arthritis, immobilisation syndrome Arises from inactivity with arthritis, immobilisation syndrome

Preventing falls Ask all pts> 75 yrs about falls in past yr and gait or balance difficulties Ask all pts> 75 yrs about falls in past yr and gait or balance difficulties 2 or more falls or balance or gait difficulties require to 2 or more falls or balance or gait difficulties require to Observe pts getting up and out of chair w/o using arms and walking. The “Get up and Go test” Observe pts getting up and out of chair w/o using arms and walking. The “Get up and Go test” - Screening test for safe mobility - Observe standing up, walking, turning, stopping and sitting down.

Fall evaluation Assessment Assessment History (from client and collateral info, witness of fall) History (from client and collateral info, witness of fall) Meds (all list with over the counter products) Meds (all list with over the counter products) Physical exam, Vitals with orthostatic BP Physical exam, Vitals with orthostatic BP Vision Vision Gait and Balance Gait and Balance Lower limb joints Lower limb joints Neuro/ Cardiovascular Neuro/ Cardiovascular

Physical exam Cardio and vitals: Cardio and vitals: - postural changes in BP - postural changes in BP - pulse rate and rhythm - pulse rate and rhythm - increased resp rate? (CHF, pneumonia or early sepsis) - increased resp rate? (CHF, pneumonia or early sepsis) - recent wt changes ( dehydration or serious illness) - recent wt changes ( dehydration or serious illness) MSK exam: joint ROM, and muscle strength MSK exam: joint ROM, and muscle strength * Gait, Balance, mobility, GET UP AND GO TEST * Gait, Balance, mobility, GET UP AND GO TEST Common foot problems, check Footwear Common foot problems, check Footwear Neuro exam: tone, power, reflexes, proprioception, sensation, cerebellar, visual acuity and fields, hearing Neuro exam: tone, power, reflexes, proprioception, sensation, cerebellar, visual acuity and fields, hearing Mental status: screen for depression or cognitive Impairment. Mental status: screen for depression or cognitive Impairment.

Multifactorial intervention Gait, balance, exercise programs Gait, balance, exercise programs Medication/polypharmacy modification Medication/polypharmacy modification Postural hypotension treatment Postural hypotension treatment Environment hazard modification Environment hazard modification Targeted medical and cardiovascular disorder tx Targeted medical and cardiovascular disorder tx

Lab tests and imaging Complete blood count Complete blood count Serum, lytes, bun/creatinine Serum, lytes, bun/creatinine Glucose Glucose Vit B12, TSH Vit B12, TSH Neuro imaging-only if head trauma/focal deficit Neuro imaging-only if head trauma/focal deficit Rarely EEG, Holter (depending if suspect seizure disorder or arrhytmia) Rarely EEG, Holter (depending if suspect seizure disorder or arrhytmia)

Counsel and educate Educate about falls risk (extrinsic and intrinsic factors) Educate about falls risk (extrinsic and intrinsic factors) How to fall safely and get up when fallen How to fall safely and get up when fallen Personal-emergency response team Personal-emergency response team Community-based exercise program Community-based exercise program Progressive balance/ strengthening Progressive balance/ strengthening Home hazard reduction Home hazard reduction Low bone-density-hip protectors. Low bone-density-hip protectors.

Confidentiality and legal aspect (Cleo 4.2 and 5.3) and Medical records (Cleo 6.5) By default, not disclose info unless specific consent from client By default, not disclose info unless specific consent from client Reporting to Ministry of Transportation is a duty if safety of public is at sake Reporting to Ministry of Transportation is a duty if safety of public is at sake “patients who have had a fall should be evaluated for ability to drive. If identified as unsafe, authorities in charge of driving may need to be informed for on-the-road evaluation” “patients who have had a fall should be evaluated for ability to drive. If identified as unsafe, authorities in charge of driving may need to be informed for on-the-road evaluation” Duty to warn threatened individuals Duty to warn threatened individuals Duty to maintain adequate records (re SOAP ) Duty to maintain adequate records (re SOAP )

Ressources 1) Practice Based Learning Program from McMaster University, Module on Falls in the Elderly, Vol 11(9), August ) Practice Based Learning Program from McMaster University, Module on Falls in the Elderly, Vol 11(9), August 2003