1. C. Bree Johnston, MD MPH Copyright May 2001
Falls in the Elderly
C. Bree Johnston, MD MPH
Copyright May 2001
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

2. UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Overview
Prevalence
Clinical Importance
Risk Factors & Etiology
Evaluation
Prevention & Management
Falls & restraint use
Summary
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

3. UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Falls: Mrs. F.
Mrs. F. is an 80 year old woman who lives alone. She just came in to your office for follow up of a fall resulting in a Colles’ fracture. She has had two other falls over the past year and a half. She is scared of falling again. She has a history of osteoarthritis and anxiety/depressison. She is on naproxen 500mg BID and diazepam 5mg BID prn
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

4. UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Falls in the Elderly
Prevalence
Clinical Importance
Risk Factors & Etiology
Evaluation
Prevention & Management
Falls & restraint use
Summary
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

5. UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Prevalence
30% of those over 65 fall annually
Half are repeat fallers
Falls go up with each decade of life
Over half of those in nursing homes and hospitals will fall each year
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

6. UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Falls in the Elderly
Prevalence
Clinical Importance
Risk Factors & Etiology
Evaluation
Prevention & Management
Falls & restraint use
Summary
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

7. Impact of Hip Fractures
1% of falls result in hip fracture
$2 billion + in medical costs annually
25% die within 6 months
60% have restricted mobility
25% remain functionally more dependent
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

8. Falls Cause Morbidity and Mortality
Mortality: found down syndrome, indirect effects
Fractures: 6% of falls
Soft tissue injury, head injury, subdural hematoma
Fear of falling can result in decreased activity, isolation, and further functional decline
Nursing home placement and loss of independence
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

9. UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Falls in the Elderly
Prevalence
Clinical Importance
Risk Factors & Etiology
Evaluation
Prevention & Management
Falls & restraint use
Summary
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

10. UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Falls are Multifactorial
Intrinsic Factors
Extrinsic Factors
Medical conditions
Impaired vision and hearing
Age related changes
Medications
Improper use of assistive devices
Environment
FALLS
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

11. Normal Changes with Aging
Neurologic
Increased reaction time
Decreased righting reflexes
Decreased proprioception
Vision Changes
Decreased accommodation & dark adaptation
Decreased muscle mass
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

12. UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Normal changes of Gait
Slower gait
Decreased stride length and arm swing
Forward flexion at head and torso
Increased flexion at shoulders and knees
Increased lateral sway
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

13. UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Dysmobility
Dysmobility and falling closely related
15% of those over 65 have trouble walking
1/4 men and 1/3 women over age 85 have difficulty with walking
2/3 of people in hospital or NH unable to ambulate without assistance
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

14. UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Risk Factors for Falls
Risk Factor OR
Sedative use
Cognitive Impairment 5
Lower extremity problem 4
Pathologic Reflex 3
Foot Problems 2
> 3 balance/gait problems
>5 balance/gait problems
Tinetti NEJM 1988
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

15. Common Pathologies associated with Falls
Ophthalmologic diseases
Arthritis
Foot problems
Neurologic illness
Parkinson’s & related disorders
Strokes
Peripheral neuropathy
Dizziness and dysequilibrium
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

16. Dizziness: A Multifactorial Syndrome
Vertigo: BPV, Posterior CVA/TIA, Cervical
Presyncope: Orthostatic, Dysrythmia, Anemia
Dysequilibrium: Peripheral neuropathy, Visual
Other: Anxiety, depression
In older people, usually multifactorial
Tinetti, Annals of Internal Med 2000
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

17. UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Falls in the Community
Accidents/environment 37%
Weakness, balance, gait 12%
Drop attack %
Dizziness or vertigo 8%
Orthostatic hypotension 5%
Acute illness, confusion, drugs, decreased vision 18%
Unknown %
Discussing the etiology of falls is a little misleading because almost all falls result from the combination of environmental + physiologic factors. For example, I was recently skiing with my husband.....
Rubenstein JAGS 1988
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

18. Falls in Residential Care
Generalized weakness 31%
Environmental hazard 27%
Orthostatic hypotension 16%
Acute illness 5%
Gait or balance disorder 4%
Drugs %
Other or unknown 10%
Rubenstein Ann Int Med 1990
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

19. UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Medications and Falls
Sedative-hypnotics, especially long acting benzodiazepines, increase falls
Small association between most psychotropics and falls
SSRIs and TCAs both incrsease falls
Weak association between Type 1A antiarrythmics, digoxin, diuretics, and falls
Leipzig JAGS 1999
Thapa NEJM 1998
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

20. UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Falls in the Elderly
Prevalence
Clinical Importance
Risk Factors & Etiology
Evaluation
Prevention & Management
Falls & restraint use
Summary
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

21. Evaluation of Falls: History
Location & circumstances of Fall
Associated symptoms
Other falls or near falls
Medications (including nonprescription) and alcohol
Injury & ability to get up
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

22. Evaluation of Falls: Physical Examination
Supine and standing BP - always
Routine physical examination
Focus on cardiovascular, MS, neuro, feet
Vision and hearing evaluation
Consider acute medical illness & delirium
Formal gait and balance assessment
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

23. Evaluation of Falls: Home Evaluation
Can be performed by nurse, OT, PT, others
Stairs
Lighting
Clutter
Bathroom
Specific hazards: cords, throw rugs
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

24. Evaluation of Falls: Risk Factors for Injury
Osteoporosis assessment
Anticoagulation: Usual benefits outweigh risks unless repeat or high risk faller
Can the person get up from fall?
Is there a way to notify others in case of falling?
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

25. UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Mrs. F.
History reveals that she fell at home in the bathroom at night, tripping over a bathmat. Both other falls have been in similar circumstances. She was able to get up.
On PE, she has visual acuity of 20/100 with bilateral cataracts. She has mild OA of the knees, with bunyon deformities of her feet and poor fitting shoes.
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

26. UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Mrs. F.
Her gait assessment shoes that she is unable to get up out of the chair without help. Her gait is hesitant and slightly wide based.
Home evaluation reveals poor lighting in all rooms, multiple throw rugs in every room, and no grab bars or safety equipment in the bathroom.
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

27. UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Mrs. F.
She is weaned off of her diazepam over 3 months
T-score on dexa is –3.0, and she is begun on alendronate, vitamin D, and calcium
She goes to ophthalmology and podiatry
PT begins exercises, followed by weight lifting and exercise 3X a week at a Senior Center
She gets home safety equipment, improved lighting, and gives away her throw rugs
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

28. Formal Gait Evaluation
Get up and Go Test
Tinetti Gait and Balance Evaluation (POMA)
Tinetti JAGS 1986
Podsiallo jAGS 1991
Mathias Arch Phys Med 1986
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

29. POMA: Balance Component
Sitting (in hard, armless chair)
Arising
Standing balance (immediate and delayed)
Balance with Nudge
Balance with Eyes closed
Balance with 360 degree turn Tinetti JAGS 1986
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

30. UCSF Division of Geriatrics Primary Care Lecture Series May 2001
POMA: Gait Component
Initiation
Step length and height
Step symmetry & continuity
Path
Stance
Ability to pick up speed Tinetti JAGS 1986
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

31. Common Causes of Abnormal Gait
Difficulty arising from chair Weakness Arthritis
Instability on first standing Hypotension, Weakness
Instability with eyes closed Proprioception
Step height/length Parkinsonism Frontal lobe Fear
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

32. UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Falls in the Elderly
Prevalence
Clinical Importance
Risk Factors & Etiology
Evaluation
Prevention & Management
Falls & restraint use
Summary
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

33. Prevention & Treatment
Treat acute injury & underlying medical conditions
Remove unnecessary medications
Rehab, exercises, assistive devices
Correct sensory impairments
Environmental modifications & safety
Evaluate for osteoporosis treatment
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

34. UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Osteoporosis
Calcium and vitamin D for most elders at risk
Dawson-Hughes, NEJM, 1997
Osteoporosis evaluation and treatment
Hip protectors appear to protect from hip fractures in those who wear them
Kannus, NEJM, 2000
Thiazides may help slightly
Statins?
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

35. Risk Factor Modifications for Fractures
Change Estimated Change in Risk
Quit smoking 38%
Treat impaired vision 50%
Stop sedatives 40%
Add 1 Gram Calcium 24%
Hip Protectors 50%?
Adapted from Stteve Cummings
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

36. Hip pads to prevent hip fracture
“RCT” of 1801 frail subjects in Finland
Nursing home or frail community patients
Mean age 81
78% women
63% assisted walking
Kannus. NEJM;2000;343;
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

37. UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Fractures with Hip Protectors
2.1% per year vs. 4.6% per year (p<.01)
40 patients needed to be treated with hip protector for 1 year to prevent one fracture
2.4% of falls resulted in hip fracture when not wearing protector
0.4% resulted in hip fracture when wearing protector (80% risk reduction)
But patient acceptance low
Kannus. NEJM;2000;343;
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

38. UCSF Division of Geriatrics Primary Care Lecture Series May 2001
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

39. UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Prevention of “Found Down” Syndrome
Lifelines
Accessible telephones
Teach in getting up off floor
Friendly phone calls or visitors for isolated elderly
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

40. Falls: Primary Prevention
301 community dwelling elders with 1+ risk factors for falling
Intervention: adjustment in medications, behavioral instructions, exercise programs aimed at modifying risk factors
One year follow up
Risk factors
Postural hypotension
Use of 4 or more Rx meds
Impairment in arm or leg strength, ROM, balance, ability to transfer, or gait
Tinetti et al NEJM
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

41. Multifactorial Intervention
Tinetti et al 1994 NEJM
Wagner and his group found that a one time intervention in a group of HMO enrollees age 65 and older also reduced the incidence of falls. Benefits at one year, not sustained. AJPH 1994
P = .04
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

42. Exercise Training & Nutrition
Although this study did not look at falls (the numbers were too low at baseline), it does allow a look at an exercise intervention on a skilled nursing home population to look at the intermediate outcomes of strength, gait velocity, stair climbing, muscle strength, and spontaneous physical activity.
Progressive high intensity hip and knee extensors resistance training
Mean study age 87 years, 100 patients
Shown here is muscle strength. Other outcomes included gait velocity, stair climbing and spontaneous Pe.
Fiatarone et al NEJM 1994
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

43. UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Tai Chi and Falling
Atlanta FICSIT Trial
200 community dwelling elders 70+
Intervention: 15 weeks of education, balance training, or Tai Chi
Outcomes at 4 months: Strength, flexibility, CV endurance, composition, IADL, well being, falls
Falls reduced by 47% in Tai Chi group Wolf JAGS 1996
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

44. Exercise, Falls, and Frailty
FICSIT Trials
8 independent prospective RCTs
Goal: reduction in falls and frailty
Pre-planned Meta-analysis
Intervention RR CI
Any Exercise ( )
Balance Component ( )
Province JAMA 1995
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

45. Training frail older persons: The New Zealand Study of Women
223 women >80 years
Intervention: PT tailored to individual needs, with resistance and balance training
Results:
Clinical balance, chair rise improved
RR for falls .47 (CI )
RR for injurious falls .61 ( )
Campbell BMJ 1997
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

46. UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Falls in the Elderly
Prevalence
Clinical Importance
Risk Factors & Etiology
Evaluation
Prevention & Management
Falls & restraint use
Summary
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

47. Restraint Reduction and Injury
No evidence that restraints reduce fall injuries
Restraints increase morbidity and may cause death
Reported strangulation deaths from restraints every year
Risk factor for delirium, decubitus ulcers, malnutrition, aspiration pneumonia
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

48. Restraint Reduction Decreases Injuries
816 bed Jewish Home for the Aged
- Restraints decreased from 39% to 4% over 3 years
- No change in falls, injuries, psychotropic use
2 year educational intervention covering beds
- Restraint reduction 41% to 4%
- Decrease in serious injuries from 7.5% to 4.4%
Tinetti 1992, Capezuti, Neufeld 1999, Evans 1997
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

49. Alternatives to Restraints For Patients with Lines and Tubes
Sedation (especially in ICU)
Reducing delirium risk factors (drugs, dehydration)
Does the benefit of tubes and lines (or hospitalization) outweigh the risks of restraints?
Geriatric Consultation Team
Sometimes restraints may be unavoidable in this setting
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

50. Alternatives to Restraints for Patients Who Fall or Wander
Accept the risk of falling
Hip protectors
Environmental modifications, day rooms, low beds
Least restrictive alternatives
Alarms
Sitters or family
Geriatric consultation team
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

51. UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Summary
Falls are common in the elderly & may lead to injuries and decline in function
Evaluation should included risk factor assessment, gait assessment, and home assessment
Exercise can improve outcomes
We have no evidence that restraints reduce fall related injuries
UCSF Division of Geriatrics Primary Care Lecture Series May 2001