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Falls Sara Bradley and Christine Chang, MD

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1 Falls Sara Bradley and Christine Chang, MD
Brookdale Dept of Geriatrics and Adult Development March 10:00-10:40 We are very excited to talk to you about falls. It is a very common geriatric syndrome that we see in our practice; however, most residents and practicing physicians do not feel comfortable evaluating it (outside of ruling out syncope), let alone teach it to other learners.

2 Objectives By the conclusion of the talk, learner will be able to:
List 5 potentially modifiable risk factors for falls in older community dwelling adults. Conduct a physical exam specific to falls, including a gait assessment. Discuss 5 evidenced-based interventions that can reduce future falls. Learn how to teach and evaluate falls in ambulatory practice -Take a patient history and perform a physical exam specific to falls -Formulate an evidenced-based treatment plan for falls

3 Falls Definition: Unintentional change in position, coming to rest at a lower position Not due to an overwhelming intrinsic or environmental cause No loss of consciousness

4 Epidemiology of Falls 1/3 of ambulatory and ½ institutionalized elderly fall each year ½ falls result in injury (10-15 % in fractures) ¼ of all fallers limit their activities and lifestyle due to fear of falling 1. Tinetti, ME, Speechly, M, Ginter, SF. Risk factors for falls among elderly persons living in th community. NEJM 1988; 319:1701. 2. Thapa, PB, Brockman, KG, Gideon P et al. Injurious falls in nonambulatory nursing home residents; a comparative study of circumstances, incidence, and risk factors. JAGS 1996; 44: 273. 3. Nevitt, MC, Cummings, SR, Hudes ES. Risak factors for injurious falls: A prospective study. J Gerontol 1991; 46:M164. 4. Tinetti, ME, Williams, CS. The effect of falls and fall injuries on functioning in community-dwelling older persons. J of Gerontol A bio Sci Med Sci 1998; 53: M 112.

5 Cost of Falls 6% of Medicare costs 15% of ED visits for 65+ years
Extra $24,000/person/year health costs Totals $19 billion/year

6 Theory of Why People Fall
Falls occur when: Older adults who are predisposed because of accumulated effect of diseases / impairments (intrinsic) Are exposed to precipitating challenges (extrinsic)

7 Evaluation of Falls: History
Describe fall Ask questions to R/O syncope Use systematic method to look into etiology of falls Describe fall-tripped/stumbled, unable to get up within 5 minutes, needed assistance to get up Ask questions to R/O syncope-?LOC, LH/palp, sz Use systematic method to look into etiology of falls: Intrinsic vs extrinsic contributors to falls ?psychotropic meds ie neuroleptics, benzo, antipressants ?2+etoh drinks/d ?use mobility devices ?predisposoing conditions: Parkinsons, CVA, dementia, delirium, Cardiac, neuropathic, autonomic insuff, severe OA+weakness, vision problems

8 Evaluation of Falls: History
Immutable Predisposing Factors Age Female Variable for falls Risk injury Past fall Who falls and why is Based on 80 cohort studies that have identified over 25 RF (similar at home, hospital and NH)-modiable/immutable Use systematic method to look into etiology of falls: Intrinsic vs extrinsic contributors to falls ?psychotropic meds ie neuroleptics, benzo, antipressants ?2+etoh drinks/d ?use mobility devices ?predisposoing conditions: Parkinsons, CVA, dementia, delirium, Cardiac, neuropathic, autonomic insuff, severe OA+weakness, vision problems

9 Evaluation of Falls: History
Modifiable Predisposing Factors (Intrinsic) Decreased strength ( fall risk 4 X) Impaired balance, gait ( fall risk 3 X) Visual Depth perception ( fall risk 2.5 X) Contrast sensitivity Who falls and why is Based on 80 cohort studies that have identified over 25 RF (similar at home, hospital and NH)-modiable/immutable >2 studies

10 Evaluation of Falls: History
Modifiable Predisposing Factors (Intrinsic) Disease management Stroke Parkinsonism Orthostasis ( fall risk 2 X) Cognitive impairment ( fall risk 2X) Depressive symptoms ( fall risk 1.5X) Foot problems ( fall risk 2X) + Arthritis Who falls and why is Based on 80 cohort studies that have identified over 25 RF (similar at home, hospital and NH)-modiable/immutable >2 studies

11 Evaluation of Falls: History
Modifiable Precipitators of Falls (extrinsic) 1. Medications 4+ Medications High risk medications: Psychotropics (e.g. sedatives, antidepressants-SSRI & TCA) Antihypertensives Digoxin Anticholinergics Who falls and why is Based on 80 cohort studies that have identified over 25 RF (similar at home, hospital and NH)-modiable/immutable >2 studies

12 Evaluation of Falls: History
Modifiable Precipitators of Falls (extrinsic) Acute illness Multi-focal lens Footwear Environment: Stairs; tripping hazards Unsafe behaviors Who falls and why is Based on 80 cohort studies that have identified over 25 RF (similar at home, hospital and NH)-modiable/immutable >2 studies

13 Evaluation of Falls: Physical
Check orthostatics Perform a visual exam if once has not been done in the last year Look for cataracts Test visual acuity with glasses Evaluate cognition with the 3 Item Recall Age related: decreased barorecptor sensitivity, vestibular fnc, cataract, NPH

14 Evaluation of Falls: Physical
Gait Assessment: Motor + Balance + Coordination

15 Evaluation of Falls: Physical
Motor Assessment: Quad strength: Can rise from chair without using arms Functional assessment. Many other tests including motor strength exam but does not correlate with gait ability

16 Evaluation of Falls: Physical
Balance Assessment: 3 Stances (abnl if < 10 secs each) Consider Resistance to nudge or picking a penny off the floor One leg stand (abnl if < 10 secs) Many other screens: Rhomberg: One-leg stand Functional reach test Tinetti balance assessment tool: sitting, immediate balance (1st 5 secs), standing balance, nudged, eyes closed, turning balance, sitting down balance

17 Evaluation of Falls: Physical
Coordination Assessment: Abnormal if: Hesitant start Broad-based gait Path deviates Heels do not clear toes of other foot Extended arms Tinetti Gait assessment: step length and ht, foot clearance, step symmetry, step continuity, path, trunk , walking time

18 Diagnostic Testing Routine: Cbc, comprehensive chem, B12, Tsh
Drug levels, INR As indicated: EKG/Holter & other cardiac tests Imaging EEG Vestibular testing

19 Fall Prevention Evidenced-based single intervention strategies
Interventions of unknown effectiveness Multi-factorial assessment with targeted interventions Gillespie L, et al. Cochrane Database Syst Rev. 2003; 4: 2005 update

20 Effective Single Interventions
Professionally supervised strength & balance training, ↓falls ~20% (3 trials) Tai Chi group exercise ↓falls 49% (1 trial) Home modification in patients with h/o falls, ↓falls ~34% (3 trials) Withdrawal of psychotropics ↓falls by 63% (1 trial) Cardiac pacing in pts w/ carotid sinus hypersensitivity ↓falls by 58% (1 trial) Gillespie L, et al. Cochrane Database Syst Rev. 2003; 4: 2005 update

21 Interventions That May Be Effective
Expedited Cataract Surgery Decreased the risk of recurrent falls by 40% & all falls by 34% with decreased disability & improved QOL1 Vitamin D & Calcium Meta-analysis found vitamin D supplementation reduced the odds of falling by 22%, NNT 152 1. Harwood RH, et al. Br J Optalmol Bischoff-Gerrari HA, et al. JAMA 2004

22 Not Proven Effective Non-specific group exercise
Targeted leg strengthening Nutritional supplements Cognitive behavioral approach Hormonal therapy Home hazard modification in non-fallers

23 Multifactorial Assessment With Targeted Intervention
Most commonly studied & consistently effective 20+ trials showing 27% (2-37%) fall risk reduction for community dwelling older adults

24 Multifactorial Assessment With Targeted Intervention
Effective components: Balance training: 7/7 trials+ Gait, assistive device: 4/4 trials+ Environmental Modification: 9/11 trials+ ↓Psychoactive meds: 4/4 trials+

25 Multifactorial Assessment With Targeted Intervention (cont)
Effective components: ↓Other meds: 4/4 trials + Manage orthostasis: 2/2 trials + Manage other CV & medical conditions: 2/3 trial + Cardiac pacing: 1+ trial

26 Fall Prevention in Practice
Identify Patients At Risk 70+ with h/o 2 or more falls or 1 injurious fall OR self-reported or observed difficulty with mobility Ask at least annually about falls Assess & manage the health problems that increase fall risk

27 Therapeutic Approach Identify & treat immediate underlying causes & predisposing risk factors Review & reduce meds Manage postural hypotension PT/OT evaluation for strength, balance, & gait training Environmental modification

28 Medication Review Decrease meds, esp psychotropics (benzos, sedatives, anti-depressants) Taper to lowest effective dose or stop Consider need for all meds before adding new one Prescribe non-pharmacologic treatments Advise pt to carry up-to-date med list

29 Postural Hypotension Frequently unrecognized Adequate hydration
½ c. water every ½ hr for first 8 hrs of day Liberalize salt in diet Reduce meds that contribute Teach patients to change position slowly

30 PT/OT Evaluation Gait & strength assessment & training
Balance training Exercises that challenge stability yet are safe Tai chi Assistive devices Recommendations for & regular inspection Appropriate footwear High box, low heel, thin sole

31 Environmental Modification
Home safety assessment By pt or caregiver using checklist, MD at home visit, or visiting nurse Hazards include: Clutter Electric cords Slippery throw rugs & loose carpet Poor lighting

32 Optimize Disease Management
Vision Test acuity, eval for cataracts, ophthalmology referral Patient education Allow time for eyes to accommodate to changing level of light Do not walk using bifocals or reading glasses Osteoporosis Consider vitamin D, bisphosphonates

33 Clinical Pearls Screen all pts >75 yrs for falls at least yearly
Evaluate the circumstances of the fall Systematically evaluate for modifiable predisposing factors and precipitants Motor/balance/gait Environment Medications Vision Disease management, including cognition

34 Acknowledgment Thanks to Dr. Helen Fernandez for her mentorship


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