FP

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Fall_Project_PPT1.pdf

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FALLS

OBJECTIVES

Know and understand:

• The importance of falls in older people

• How to assess and treat falls in an older

person

TOPICS COVERED

• Epidemiology of Falls

• Causes of Falls

• Evaluation and Treatment of Falls

• Clinical Guidelines for Preventing Falls

FALLS

• Definition: coming to rest inadvertently on the

ground or at a lower level

• One of the most common geriatric syndromes

• Most falls are not associated with syncope

• Falls literature usually excludes falls

associated with loss of consciousness

EPIDEMIOLOGY OF FALLS

Each year 30%–40% of community-dwelling

people aged ≥65, and about 50% of residents of

long-term-care facilities, experience falls

Community LT Care

EPIDEMIOLOGY OF FALLS

• Annual incidence of falls is close to 60% among

those with history of falls

• Complications of falls are the leading cause of

death from injury in people aged ≥65

MORBIDITY AND MORTALITY

• Most falls by older adults result in some injury

• 10%–15% of falls by older adults result in

fracture or other serious injury

• The death rate attributable to falls increases

with age

• Mortality highest in white men aged ≥85:

180 deaths/100,000 population

SEQUELAE OF FALLS

• Associated with:

➢ Decline in functional status

➢ Nursing home placement

➢ Increased use of medical services

➢ Fear of falling

• Half of those who fall are unable to get up without help

(“long lie”)

• A “long lie” predicts lasting decline in functional status

COSTS OF FALLS

•  Emergency department visits

•  Hospitalizations

• Indirect cost from fall-related injuries such as

hip fractures is substantial

CAUSES OF FALLS

BY OLDER ADULTS

• Rarely due to a single cause

• May be due to the accumulated effect of impairments in

multiple domains (similar to other geriatric syndromes)

• Complex interaction of:

➢ Intrinsic factors (eg, chronic disease)

➢Challenges to postural control (eg, changing position)

➢Mediating factors (eg, risk taking, underlying mobility

level)

CAUSES: INTRINSIC

• Age-related decline

➢ Changes in visual function

➢ Proprioceptive system, vestibular system

• Chronic disease

➢ Parkinson’s disease

➢ Osteoarthritis

➢ Cognitive impairment

• Acute illness

• Medication use (see next slide)

CAUSES: MEDICATION USE

• Specific classes, for example:

➢ Benzodiazepines

➢ Other sedatives

➢ Antidepressants

➢ Antipsychotic drugs

➢ Cardiac medications

➢ Hypoglycemic agents

• Recent medication dosage adjustments

• Total number of medications

FALLS ASSESSMENT

• Ask all older adults about falls in past year

• Single fall: check for balance or gait disturbance

• Recurrent falls or gait or balance disturbance:

➢ Obtain relevant medical history, physical exam,

cognitive and functional assessment

➢ Determine multifactorial falls risk (see next slide)

FACTORS AFFECTING FALLS RISK

• History of falls

• Medications

• Visual acuity

• Gait, balance, and

mobility

• Muscle strength

• Neurologic

impairments

• Heart rate and rhythm

• Postural hypotension

• Feet and foot wear

• Environmental

hazards

PHYSICAL EXAMINATION

• Blood pressure and pulse, both supine and

standing

• Vision screening

• Cardiovascular exam

• Musculoskeletal exam

• Neurologic exam

GAIT AND BALANCE EVALUATION

• Romberg test

• One-legged stance for 30 seconds, eyes open

• Tandem gait task for 10 feet

• Mental status exam (eg, Mini-Cog)

• Timed Up and Go test

• Berg Balance Test

• Performance Oriented Mobility Assessment (POMA)

• Functional reach

• Appropriateness of footwear

LABORATORY AND

DIAGNOSTIC TESTING

• Tests and procedures should be guided by the history & physical exam: echocardiography, brain imaging, radiographic studies of spine

• Hemoglobin, serum urea nitrogen, creatinine, glucose:

can exclude anemia, dehydration, or hyperglycemia

• Holter monitoring: no proven value for routine

evaluation

• Carotid sinus massage with continuous heart rate and

BP monitoring: can uncover carotid sinus

hypersensitivity

TREATMENT

• Most favorable results with health screening

followed by targeted interventions

• Aim to reduce intrinsic and environmental risk

factors

• Interdisciplinary approach to falls prevention

is most efficacious

AGS FALLS PREVENTION

GUIDELINES

• Assessment of all older adults and anyone with history of falls

• Multifactorial interventions including:

➢ Minimize medications

➢ Initiate individually tailored exercise program

➢ Treat vision impairment

➢ Manage postural hypotension, and heart rate and rhythm abnormalities

➢ Supplement vitamin D

➢ Manage foot and footwear problems

➢ Modify the home environment

SUMMARY

• Falls by older adults are common and usually multifactorial

• Falls predict functional decline

• Screening and targeted preventive interventions

are most effective

• AGS falls prevention guidelines are available

and recommend multifactorial interventions

CASE 1 (1 of 3)

• A 75-year-old woman is brought to the office by her daughter. The mother has been falling, most often when rising from the toilet or attempting to climb stairs.

• History includes sarcopenia and frailty. She has no neurologic or metabolic abnormalities.

• Exercise was recommended at a previous office visit. Despite the daughter’s efforts, the patient is reluctant to spend time and energy on the exercise program.

• The daughter asks for help prioritizing the exercises. In particular, she wants to know which exercises are most important in preventing falls.

CASE 1 (2 of 3)

Which of the following is most effective for preventing falls?

A. Strengthening exercise

B. Aerobic exercise

C. Balance exercise

D. Multicomponent exercise

CASE 1 (3 of 3)

Which of the following is most effective for preventing falls?

A. Strengthening exercise

B. Aerobic exercise

C. Balance exercise

D. Multicomponent exercise

CASE 2 (1 of 3)

• An 85-year-old man comes to the office because he

has fallen 3 times in the past 6 months.

• None of the falls involved dizziness or fainting. One

fall occurred while he was walking in his yard; in the

other instances, he tripped inside his house.

• History includes hypertension without postural

changes, gout, osteoarthritis, and depression.

• He takes 5 medications on a regular basis.

CASE 2 (2 of 3)

Which of his medications is most likely to

contribute to his risk of falls?

A. Acetaminophen

B. Allopurinol

C. Hydrochlorothiazide

D. Lisinopril

E. Paroxetine

CASE 2 (3 of 3)

Which of his medications is most likely to

contribute to his risk of falls?

A. Acetaminophen

B. Allopurinol

C. Hydrochlorothiazide

D. Lisinopril

E. Paroxetine

CASE 3 (1 of 3)

• A 70-year-old woman comes to the office for a routine

visit.

• History includes hypertension and osteoarthritis.

• She mentions that last month she tripped on a high

curb and fell after parking her car.

• She has had no other falls.

CASE 3 (2 of 3)

Which of the following is the most appropriate initial step for evaluating her risk of future falls?

A. Test visual acuity.

B. Measure blood pressure for postural changes.

C. Evaluate gait and balance.

D. Ask about environmental hazards in her home.

E. Examine her feet and footwear.

CASE 3 (3 of 3)

Which of the following is the most appropriate initial step for evaluating her risk of future falls?

A. Test visual acuity.

B. Measure blood pressure for postural changes.

C. Evaluate gait and balance.

D. Ask about environmental hazards in her home.

E. Examine her feet and footwear.

GRS8 Slides Editor: Annette Medina-Walpole, MD, AGSF

GRS8 Chapter Authors: Sarah D. Berry, MD, MPH

Douglas P. Kiel, MD, MPH

GRS8 Question Writer: Mary B. King, MD

Medical Writers: Beverly A. Caley

Faith Reidenbach

Managing Editor: Andrea N. Sherman, MS