1. EVALUATION OF FALLs IN THE ELDERLY.
DR. SHU’AIBU ABDULLAHI
FAMILY MEDICINE DEPARTMENT, AKTH.

4. OUTLINE INTRODUCTION/ DEFINITIONS EPIDEMIOLOGY CLINICAL IMPORTANCE
RISK FACTORS/ AETIOLOGY
EVALUATION
History
Physical examination
Investigations
PREVENTION
INTERVENTION/ TREATMENT
SUMMARY

5. Introduction
Falling present a clinical challenge b/c of its frequency of occurrence, associated morbidity & mortality, multifactoral nature.
Falls are the leading cause of injury related visits to emergency dept in the US.
The primary etiology of accidental deaths in persons >65yrs.
Mortality rate of falls increases with age in both sexes & in all racial & ethnic groups
Markers of poor health and declining function.

6. Definitions
A fall is a sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor or the ground .
Elderly
WHO- 65yrs and above
UN- 60yrs and above
Developed countries- 65yrs and above
Developing countries- 60yrs and above due to differences in life expectancies & proportions of older persons within the population

7. Epidemiology
About one third of community-dwelling elderly persons & 60% of nursing home residents fall each year
Falls where the leading cause of external injury, accounting for 24% of these visits
Women fall more frequent than men but men tend to have greater mortality.
From 1992 through 1995, 147 million injury related visits were made to emergency dept in the US

8. Epidemiology Contd 30% of those over 65yrs fall annually
Half of them are repeat fallers
A community based survey conducted in 8 states of Yoruba speaking areas of Nigeria shows 23% incidence of fall among elderly persons aged 65yrs & above
Another community survey on incidence & outcome of falls among elderly persons in Ibadan shows 21.4% incidence

9. Clinical Importance Falls causes morbidity and mortality
Elderly who represent 12% of the population, account for 75% of death from falls
Most elderly persons who survive a fall experience a significant morbidity
Injuries ass with fall include head injury, soft tissue injury, fractures and dislocation which occurs in 5 to 15% of falls in any given year .
Fracture account for 75% of serious injuries with Hip fracture occurring in 1 to 2 percent of fall

10. Impact Of Hip Fracture
Hip fracture is the leading fall related injury that result in hospitalization
1-2% of fall results in hip fracture.
25% die within 6month.
60% have restricted mobility.
25% remain functionally dependent.
Fear of falling can result in decreased activity, isolation and further functional decline.

11. Risk Factors Demographic factors Older age(esply>=75) White race
Female gender
House bound status
Living alone
Historical factors
Use of cane or walker
Previous falls

12. Risk Factors Contd Acute illness
Chronic conditions, esp. neuromuscular diseases
Medications, esp. use of 4 or more drugs
Physical deficits
Cognitive impairment
Reduced vision
Difficulty in rising from the chair
Foot problems

13. Risk Factors Contd Neuromuscular changes Decrease hearing Others
Environmental hazards
Risky behaviors
Risk factors could also be categorized into:-
Intrinsic factors:- present within a patient & are specific to that patient e.g. medical conditions, age related changes like impaired vision & hearing

14. Risk Factors Contd
Extrinsic factors:- act on the patient from outside & are potentially modifiable e.g. improper use of assistive device, environmental obstacles

15. Common Causes of Falls in Elderly
Accident/environmental hazards
Gait disturbance, balance disorders or weakness, pain related to arthritis
Dizziness/Vertigo
Medications or alcohol
Acute illness
Confusion & cognitive impairment
Postural hypotension

16. Common Causes of Fall in Elderly
Visual disorder
CNS disorder, syncope, drop attacks, epilepsy

17. Evaluation
ELDERLY WHO HAVE FALLEN SHOULD UNDERGO A THOROUGH EVALUATION.
HISTORY
1st step in evaluating the faller is to identify the problem
Determine the mechanism of fall
Ask about risk factors for fall such as env hazards, visual & hearing impairment, medical condns, medications etc.
Prodromal symptoms such as light headedness, dizziness
Ask about activity the patient was engaged in just b/4 & at the time of the fall, esp. if the activity involved a positional changes

18. Evaluation Contd Loss of consciousness
The location of the fall should be ascertained
Ask if any one witnessed the fall
The patient & if applicable , the witnesses or caregivers should be asked in detail about previous falls & whether the falls were the same or different in character
The physician also need to determine who is available to assist the patient

19. Evaluation Contd Home visit for assessing modifiable risk factors
Home safety checklist
Particularly important to assess caregiver & housing arrangement, environmental hazards

20. Evaluation Contd Home safety checklist
All living spaces _____ Remove throw rugs. _____ Secure carpet edges. _____ Remove low furniture and objects on the floor. _____ Reduce clutter. _____ Remove cords and wires on the floor. _____ Check lighting for adequate illumination at night (especially in the pathway to the bathroom). _____ Secure carpet or treads on stairs. _____ Install handrails on staircases. _____ Eliminate chairs that are too low to sit in and get out of easily. _____ Avoid floor wax (or use nonskid wax). _____ Ensure that the telephone can be reached from the floor.
Bathrooms _____ Install grab bars in the bathtub or shower and by the toilet. _____ Use rubber mats in the bathtub or shower. _____ Take up floor mats when the bathtub or shower is not in use. _____ Install a raised toilet seat.
Outdoors _____ Repair cracked sidewalks. _____ Install handrails on stairs and steps. _____ Trim shrubbery along the pathway to the home. _____ Install adequate lighting by doorways and along walkways leading to doors.

21. Evaluation Contd PHYSICAL EXAMINATION Routine physical examination
Supine & standing BP always
Focus on cardiovascular, MS, neurological, feet
Vision and hearing evaluation
Consider acute medical illness & delirium
Formal gait and balance assessment
PHYSICAL EXAMINATION

22. Mnemonic
For key physical finding in the elderly pt who falls or nearly falls
I HATE FALLING
I - Inflammation of joints(or joint deformity)
H -Hypotension(orthostatic BP changes)
A -Auditory and visual abnormalities
T -Tremors(parkinson’s dx or other causes)
E -Equilibrium(balance problem)

23. F -Foot problems
A -Arrhythmias, heart block or valvular dx
L -Leg length discrepancy
L -Lack of conditioning(generalized)
I -Illness
N -Nutrition(poor, wt loss)
G -Gait disturbances

24. This mnemonic focuses the physician attention on common problems that are likely to respond to RX.
Only rarely are all of the causes fully reversible

25. Evaluation Contd INVESTIGATIONS
Diagnostic studies – none is required routinely
If indicated in the appropriate patient: CBC, U&E, CR, TFT, X-ray and glucose can be done

26. Formal Gait Evaluation
Timed “UP & GO” test
Pt gets up out of standard armchair(seat ht of ~46cm(18.4in).
Walk a distance of 3m(10ft), turns, walk back to the chair & Sit down again
Pt wears regular foot wear and if applicable uses any customary walking aid(e.g. cane or walker).
No physical assistance is given.

27. Formal Gait Evaluation Contd
Watch is used to time activity in seconds
A score of 30s or greater indicates impaired mobility and required assistance(inc risk of falling).
predictive values
Seconds Rating
< freely mobile
mostly independent
variable mobility
> impaired mobility

28. Formal Gait Evaluation Contd
A simpler alternative is the “ Get up & Go” test
The patient is seated at armless chair placed 3m(10ft) from a wall
The patient stands, walks towards the wall, turns without touching the wall
Returns to the chair, turns & sit down
This activity does not need to be timed
Instead, the physician observes the patient & makes note of any balance or gait problems

29. Prevention There are no cures for faller but falls can be prevented
Physician goal is to identify the faller & implement intervention to prevent future falls
Treat acute injury & underlying medical conditions
Remove unnecessary medications
Rehab, exercises, assistive devices
Correct sensory impairments
Environmental modifications & safety
Evaluate for osteoporosis treatment

30. Prevention Contd
Modify restraints
Involve family
Provide follow up

31. Intervention
Expert-based guidelines & evidence based medicine agree that a multi displinary & multi factorial evaluation with targeted intervention is likely to reduce the risk of subsequent fall
Orthostatic hypotension:
Instruct pt to rise carefully &
ensure balance before ambulating
Ankle pumps or hard clenching
Elevation of the head of the bed
Dec dose of medication or discontinue if necessary

32. Intervention Contd Liberalization of salt
Fludrocortisones 0.1mg bid or tds
Uses of medications
Education about appropriate use
Non pharmacologic RX of sleep problems
Tapering & discontinuation of medications
The use of four or more prescription drugs
also need to be reviewed.

33. Intervention Contd Environmental hazards: Home safety assessment with
appropriate changes such
as removal of hazards
Selection of safer furniture
Installation of structures e.g. grab bars in bathrooms, handrails on staircases
Any impairment in gait
Gait training
Assistive device
Balance exercise

34. Intervention Contd Reduce fracture complication of falls:
Pt with osteoporosis:- biphosphates, calcium, vitamin D
Some studies done have shown a remarkable reduce in falls in pt taking supplemental vitamin D
Use of Hip protectors prevent hip fractures

36. Intervention Contd Restraints reduction
No evidence that restraints reduce fall injuries
Restraints increase morbidity and may cause death
Reported cases of strangulation deaths from restraints every year
A risk factor for delirium, decubitus ulcers, malnutrition, aspiration pneumonia.

37. Summary
Falls are common in the elderly & may lead to injuries and decline in function
Evaluation should include:- risk factor assessment, gait assessment, and home assessment
Exercise can improve outcomes
No evidence that restraints reduce fall related injuries.

38. References Rekel text book of family medine-7th edition
C.Bree Johnson –UCSF Division of geriatrics primary care lecture series-May 2001
George F Fuller col,mc USA-American Academy of Family Physicians
Bischoff etal 2003
American Geriatrics society 2001
Meck Manual
Geriatric medicine book.

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