Evidence Based Approach To Falls

Dr Larry Dian

Division Of Geriatric Medicine

U.B.C.

Evidence Based Approach

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Epidemiology

Falls are common; 50% for those 80 years and older fall yearly

60 % of those with a history of a fall in the previous year will have a subsequent fall

Most falls result in an injury of some type 10% major injury, 5 % lead to

hospitalization, >70% fear of falling

Scenario 1

You receive a call from the emergency physician regarding your 86 year old patient who is being sent home after receiving sutures for a scalp laceration that occurred after a fall. CT head “normal”.

Acute Fall

Why did the person Fall?

5 Step Assessment

Question 1: Did the fall result as a loss of consciousness?

If yes: Sz. or Stokes- Adams attack

EEG, 24 hour holter, echocardiogram Micro burst of LOC likely not significantConfusion or drowsiness after fall

somewhat supportiveCollateral history very helpful

If No Loss of Consciousness

Was Fall preceded by dizziness?Was Fall preceded by dizziness?Type 1: Vertigo- Central/peripheral

BPV commonestType 2 Lightheadedness/

transient cerebral hypo-perfusion/orthostatic hypotension

Type 3: “Dizziness of legs”/unsteadiness Type 4: De-afferentation /psychological

If No Dizziness

Was the fall associated with an acute medical illness?

Atypical presentation Delirium

“Round up all the usual suspects”

If No Acute Illness

What was the mechanism of the fall?Be as precise as possible recreating actions before and after the fall

Avoid leading questions; patients may not remember

Collateral history very useful

If No Mechanism For Fall

Falls are either multi-factorial or lower limb weakness

“Just Fall” fall –eccentric weakness of quadriceps muscle

5 Step Algorhythm

Provides a rational strategy for mechanistic determination of the fall

Provides a strategy for fall risk reduction

Scenario 2

The family of your 89 year old patient wants your opinion about moving their reluctant mother in a nursing home because of the concern that she might fall and “hurt herself”

Risk Factors

Past history of a fall Lower extremity weakness Age Female gender Cognitive impairment Balance problems

Psychotropic drug use

Arthritis History of stroke Orthostatic

hypotension Dizziness Anemia

Chronic Diseases

Parkinson's disease Osteoarthritis of the knee, feet ankle Cognitive impairment  (mmse 18-23) 2x

increased risk of falls Risk increases with increasing number of

chronic diseases Number and type of medications Alcohol use

Targeted Physical Exam

Cardiovascular system Central nervous system Musculoskeletal system; lower limbs

Targeted Physical Exam

Postural blood pressure Heart failure, Atrial fib, Aortic stenosis Mental status, Parkinson’s disease, stroke

peripheral neuropathy, visual acuity Arthritis of knees feet, podiatric problems Strength of hip flexors, ankle dorsi-flexors Environmental factors, footwear, mobility aids

Supplemental Tests

Get Up and Go Test Functional reach test Sternal nudge test; unipedal and tandem stance

Get Up and Go Test

Have the patient sit in a straight-backed high-seat chair

Instructions for patient: Get up (without use of armrests, if possible)

Stand still momentarily Walk forward 10 ft (3 m) Turn around and walk back to chair Turn and be seated

Get Up and Go Test

Factors to note: Sitting balance Transfers from sitting to standing Pace and stability of walking Ability to turn without staggering

Diagram of functional reach test to assess balance in elderly persons

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Algorithm summarizing the assessment and management of falls

                                                                       

Therapy

Address medical issues Review home environment Provide appropriate walking aid Gait and balance exercise training

Falls are not random events Falls are common and are associated

with significant morbidity and mortality Standardized assessment tools exist A coherent mechanism can be

developed in most cases Consider referral to falls clinic in complex

cases