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, 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
30% of ambulatory + 50% institutionalized elderly fall each yr1,2
½ falls result in injury
(10-15% in fractures)3
¼ of all fallers limit their activities and lifestyle due to fear of falling4
1. Tinetti, ME et al. NEJM 1988; 319: Thapa, PB, et al. JAGS 1996; 44: Nevitt, MC, et al.J Gerontol 1991; 46:M Tinetti, ME et al. J of Gerontol A bio Sci Med Sci 1998; 53: M 112
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
Sattin RW. Annu Rev Public Health 1992;13:
Runge JW. Med Clin North Am 1993;11:
Sattin RW. Falls among older persons: a
public health perspective. Annu Rev Public
Health 1992;13:
Runge JW. The cost of injury. Emerg
Med Clin North Am 1993;11:

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. Case Part 1

8. Question
What questions do you want to ask Sally Johnson about the fall?

9. 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

10. Details of the Fall Sally Johnson lives alone in her 2 story house
Patient fell 2 days earlier while rushing to answer the phone as she was putting away the groceries
Felt unsteady just prior to the fall as she tripped on kitchen mat. Was wearing shoes. Adequate lighting. Was able to get up right way. Uses no assistive walking devices at baseline
Reports new left arm pain immediately after the fall. Scattered bruising and swelling of Left forearm. Warm compresses and Tylenol prn has been helping
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

11. Details of the Fall
No Head trauma, LOC, syncope or presyncope, vertigo, visual changes, bowel or bladder incontinence, eating and drinking as usual, no medication changes.
Prior fall was 1 year ago while rushing down the stairs. No injury was incurred.
Had many near falls while running barefooted on waxed, wooden floors.
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

12. Details of Chronic Diseases:
DM with peripheral neuropathy
Has had no hypoglycemic episodes
BS running around ’s
Last hbA1c=7%
Last eye exam was 1 year ago. No retinopathy but does wear bifocals
HTNhas been well-controlled recently
Atrial fibrillationhas had no sxs. INR was 2.1 a week ago
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

13. Details of Chronic Diseases:
R hip OA
Has R hip ache with overexertion and with cold, rainy weather
Heating pad and Tylenol prn has been helpful
Depression + insomnia
Controlled with use of citalopram 10 mg and zolpidem 10 mg nightly
Does not drink alcohol
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

14. Case Part 2

15. Question
Are there any other physical exam maneuvers you would want to perform on Sally Johnson?

16. Evaluation of Falls: Physical
Check orthostatics
Perform a visual exam
Evaluate cognition
Gait Assessment:
Motor + Balance + Coordination
Age related: decreased barorecptor sensitivity, vestibular fnc, cataract, NPH

17. 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

18. Evaluation of Falls: Physical
Balance Assessment:
3 Stances
One leg stand
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

19. 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

20. Answer Orthostatics: 135/70 88 sittingstanding 122/70 100
Eye: +cataract. visual acuity: 20/40 L and 20/80 R. Corrected with bifocals
Gait:
-Motor: Bilateral Quad weakness+, 3 chair rise >10 sec
-Balance: semi tandem and tandem stances <10 sec, one leg stand< 10 secs
-Gait: Hesitant at start but walks with normal path, walks with extended arms, no wide based gait, no foot drop, heel clears toes of other foot. Slow turn with outstretched hands
Cognition: 1/3 on 3 item recall
Neuro: No Parkinsonian features or focal weakness

21. Question
What are the possible predisposing ‘intrinsic’ risk factors and ‘extrinsic’ precipitants of Sally Johnson’s fall?

22. Answer Multi-factorial Immutable predisposing factors:
Age, female and prior history of falls
Modifiable predisposing and precipitating factors

23. Modifiable Predisposing and Precipitating Factors:
Mild weakness + moderate balance impairment
Has cataracts + refractive error +wears bifocals
Takes 4+ medications, including high risk meds bp meds, digoxin, citalopram and zolpidem
Borderline orthostasis
?Cognitive impairment, depression
?Unsafe environment and behaviors
(kitchen matt, waxed floor. barefoot, rushing)

24. Question
What evidenced-based interventions can you recommend to prevent future falls for this patient?

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

26. 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

27. 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

28. 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

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

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

31. 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+

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. Clinical Pearls Screen all pts >70 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

41. Thanks to Dr. Helen Fernandez
Acknowledgment
Thanks to Dr. Helen Fernandez