FALLS IN OLDER ADULTS2008 UPDATE

Joseph G. Ouslander, MD Director, Boca Institute for Quality Aging

University of Miami Miller School of Medicine at Florida Atlantic University

and

Thomas Price, MDDivision of Geriatric Medicine and Gerontology

Emory University School of Medicine

Learning Objectives

Review the epidemiology and consequences of falls in the elderly

Identify common risk factors for falls in this population

Identify the pros and cons of prevention and management strategies

Falls Case

Mr. C. is an 89 year old man who is referred to you for the evaluation of dizziness. His daughter says that he has fallen 3 times in the past month after discharge from the hospital for a “small heart attack and heart failure”.

Mr. C. has no prior history of falls.

Falls Case

Past Medical History: Coronary artery disease Hypertension Congestive heart failure (chronic, systolic) Degenerative joint disease mainly of the

right hip and knee Insomnia

Falls Case

Medications: Furosemide 40 mg BID K-dur 20 meq daily Enalapril 10 mg daily Carvedilol 6.25 mg po BID Simvastatin 20 mg PO QHS Nitroglycerin 0.4 mg/hr patch TOP 12 hours

per day Propoxyphene/Acetaminophen 1 tab Q4hr

PRN pain Amitriptyline 50 mg po QHS prn insomnia

Falls Case

Further history reveals that each fall occurred in the morning after breakfast. He gets up, and when he starts walking he feels “light-headed”. The sensation eases when he lies down. He has not to his knowledge passed out or sustained any severe injury with these falls. There is no history suggestive of a seizure.

Falls Case

Physical Exam: GEN: No signs of trauma Vitals: Sitting 102/58;66 Standing 88/52;72 (after 2

minutes) Heart: RRR +s1,s2 no s3, s4; 2/6 SEM at apex Lungs: Mild rales bilateral bases MS: Reduced ROM rt hip with pain on internal rotation;

crepitus and pain with flexion of the rt knee Neuro: No peripheral proprioceptive/fine touch

abnormalities; ear exam shows minimal cerumen; Dix-Hallpike maneuver to elicit nystagmus is negative

Falls Case

Get Up and Go observation reveals: Difficulty arising without physical

assistance Negative Romberg test Abnormal gait due to guarding his right

side Difficulty and imbalance when turning

Falls Case

What do you think is contributing to Mr. C’s falls?

What diagnostic tests would you order?

What interventions would you implement?

Falls

Definition

A fall is defined as a sudden, uncontrolled, unintentional, downward displacement of the body to the ground or other object, excluding falls resulting from violent blows or other purposeful actions.

An unwitnessed fall occurs when a patient is found on the floor and neither the patient nor anyone else knows how he or she got there.

Epidemiology

Annual incidence in patients >65y 35-40% of community dwelling older

persons Rates increase threefold if in NH or hospital

Injury rate 1 in 20 require hospitalization 75% of falls-related deaths occur in

patients >65y Falls a major reason for NH admission

(40%)

Tinetti NEJM 348:1, 2003

Morbidity of Falls

Soft tissue injury Fractures Intracranial bleed Rhabdomyolysis Reduced Mobility NH admission Death Restraint use Fear of Falling

Prognosis of Falls

Falls occur in both frail and healthy older persons

Single falls are not necessarily an indicator of poor prognosis

Multiple falls are associated with disability and poor health outcomes Multiple falls are a marker for other underlying

conditions that put older persons at increased risk for adverse health outcomes

Contributors to Falls

Contributors to Falls

Community-Dwelling: 41% environment related 13% weakness, balance or gait disorder 8% dizziness or vertigo

Nursing Home:16% environment related26% weakness, balance or gait disorder25% dizziness or vertigo

Rubenstein, et al. Ann Intern Med 1994;121;442 – 451

Intrinsic Risk Factors for Falls

Risk Factor Relative Risk (OR)

1. Muscle Weakness 4.4

2. History of falls 3.0

3. Gait deficit 2.9

4. Balance deficit 2.9

5. Use of assistive device (walker, etc) 2.6

6. Visual impairment 2.5

7. Arthritis 2.4

8. Impaired ADL 2.3

9. Depression 2.2

10. Cognitive impairment / dementia 1.8

AGS Panel on falls prevention, JAGS 49(5):2001, 665

Extrinsic Risk Factors for Falls

Environmental hazards Loose rugs, cords, etc

Iatrogenic Medications

Behavioral Alcohol, poor judgment, impulsiveness

Clothing Poorly (loose) fitting clothes and footwear

The Morse Fall Risk Assessment Tool

Morse Fall Scale High Risk: 45+ Med Risk: 25 – 44 Low Risk: 0 – 24

Everyone may score high risk in a nursing home environment

Adjust score based on your patient population

Simplified Risk Factors

100% chance of fall in one year for all three of the following: More than three medications Hip weakness Unstable balance

Clinical Assessment and Management

Falls History Medication Use Vision Postural BP Balance and Gait Neurologic exam Musculoskeletal exam Cardiovascular exam Post-discharge home-hazard evaluation

Falls History

S P L A T TSymptomsPrevious fallsLocationActivityTimeTrauma

Falls History

Detailed history of the fall Activity, environmental factors Symptoms:

Postural lightheadedness Syncope / near syncope

Vertigo Seizure

Circumstances of any previous falls Alcohol intake Assessment for acute illness (e.g. dehydration,

infection, acute cardiac or neurological symptoms)

Medication Use

Assessment Evaluate for high-risk medications Four or more medications

Management Discontinue or replace potentially harmful

medications

High-Risk Medications

Serotonin-reuptake inhibitors Sertraline, fluoxetine

Tricyclic antidepressants Nortriptyline

Neuroleptics Haloperidol, risperidone, quetiapine

Benzodiazepines Alprazolam, clonazepam, lorazepam

Anticonvulsants Phenobarbital, phenytoin

Class IA antiarrhythmics Procainamide, quinidine

Tinetti NEJM 348:1, 2003

Vision

Assessment Mid-range and far vision using

Snellen wall chart Check peripheral vision/visual

fields Light reflex (cataracts)

Management Referral to ophthalmologist Avoid bifocals when walking Improve lighting in enclosed

areas of home

Postural Blood Pressure

First 5 minutes SUPINE Then check BP Then STAND Immediately check BP Wait 2 minutes Then check BP Positive test if SBP

drops 20% or more either immediately or after 2 minutes

Postural Blood Pressure

Assessment Check for 20mm Hg (or 20% drop) in

systolic pressure with or without symptoms Pulse not as reliable an indicator in older

patients Management

Check for acute or chronic causes Hydration, compensation strategies

(pressure stockings, etc) if idiopathic

Balance and Gait

Assessment Patient’s report Get up and Go test

Management Diagnosis and treatment of underlying

cause Medications that cause gait imbalance (see

above) Environmental obstacles modification Referral to physical therapist for

gait/progressive balance training, assist device

Neurologic Examination

Assessment Proprioception Cognition Neuromuscular (Parkinsonism, etc)

Management Diagnose and treat underlying cause Medication adjustment Reduction of environmental risk factors Physical Therapy Evaluation

Musculoskeletal Examination

Assessment Joints and range of motion (arthritis) Foot exam (ulcers, fallen arch, etc) Strength testing (Get Up and Go)

Management Identify and treat underlying causes Physical therapy referral Podiatry referral

The Get Up And Go Test

Time it takes a patient to get up from a seated position, walk 8 feet, then sit back down

Patient must rise from chair without use of hands

If takes more than 8 seconds, then patient has high fall risk

Cardiovascular Exam

Assessment Syncope (Tilt) Arrhythmia (ECG)

Management Referral to cardiologist Assessment of cardiac anatomic and

electrophysiologic status (echo, signal avg. ECG)

Prevention Strategies

Chang et al. BMJ 2004 Meta-analysis

comparing 40 trials Effective falls reduction

is achieved only when assessment is coupled with aggressive management Referral is not sufficient When actively

managed, falls were reduced by a composite 37%

Chang et al. BMJ 328(7441): 2004

Prevention Strategies

New Zealand Falls Intervention (2007) Intervention: At-home nurse evaluation of

risk factors and referral to community interventions and/or PT

Population: 312 patients with history of falls, avg. age 81, F>M

No statistical significance between intervention and control group

Elley et al. JAGS 56(8), 2008

Prevention Strategies

Maastricht GP Cooperative study (Netherlands, 2007) Intervention: Medical/OT eval with

recommendations and referral if needed Population: 333 persons >65 yo, F>M with

recent fall No statistical significance between

intervention and control groups in # new falls, fear of falling, or activity avoidance

Hendriks et. al JAGS 56(8), 2008

Prevention Strategies

Multifactorial evaluations useless without aggressive pursuit of treatment

Elements of the multifactorial evaluation:

-- Orthostatic BP-- Vision testing-- Balance and gait testing-- Drug review

-- IADL/ADL assessment-- Cognitive evaluation-- Assessment for environmental hazards

Prevention Strategies

Bang for the buck?Balance and gait training = 14-

27% reductionReduction in home hazards = 19%Stop psychotropics = 39%Multifactorial risk E&M = 25-

39%Balance and strength exercise* =

29-49%

* Community based

Falls Case

Mr. C. is an 89 year old man who is referred to you for the evaluation of dizziness. His daughter says that he has fallen 3 times in the past month after discharge from the hospital for a “small heart attack and heart failure”.

Mr. C. has no prior history of falls.

Falls Case

Past Medical History: Coronary artery disease Hypertension Congestive heart failure (chronic, systolic) Degenerative joint disease mainly of the

right hip and knee Insomnia

Falls Case

Medications: Furosemide 40 mg BID K-dur 20 meq daily Enalapril 10 mg daily Carvedilol 6.25 mg po BID Simvastatin 20 mg PO QHS Nitroglycerin 0.4 mg/hr patch TOP 12 hours

per day Propoxyphene/Acetaminophen 1 tab Q4hr

PRN pain Amitriptyline 50 mg po QHS prn insomnia

Falls Case

Further history reveals that each fall occurred in the morning after breakfast. He gets up, and when he starts walking he feels “light-headed”. The sensation eases when he lies down. He has not to his knowledge passed out or sustained any severe injury with these falls. There is no history suggestive of a seizure.

Falls Case

Physical Exam: GEN: No signs of trauma Vitals: Sitting 102/58;66 Standing 88/52;72 (after 2

minutes) Heart: RRR +s1,s2 no s3, s4; 2/6 SEM at apex Lungs: Mild rales bilateral bases MS: Reduced ROM rt hip with pain on internal rotation;

crepitus and pain with flexion of the rt knee Neuro: No peripheral proprioceptive/fine touch

abnormalities; ear exam shows minimal cerumen; Dix-Hallpike maneuver to elicit nystagmus is negative

Falls Case

Get Up and Go observation reveals: Difficulty arising without physical

assistance Negative Romberg test Abnormal gait due to guarding his right

side Difficulty and imbalance when turning

Falls Case

What do you think is contributing to Mr. C’s falls?

What diagnostic tests would you order? What interventions would you

implement?

Falls Case

Contributors Arthritis of hip and knee Vasodilators (nitroglycerin) Iatrogenic cognitive impairment?

(propoxyphene, amitriptyline) Post-prandial orthostasis? Postural hypotension (too much BP med?) Proximal muscle strength weakness Balance disorder

Falls Case

Diagnostics Basic Labs (volume depletion?

Diabetes?) Comprehensive chemistry Complete blood count (orthostasis)

Other labs B12 level abnormal? CT of head? Assessment of thyroid function?

Cognitive performance test (MMSE)

Falls Case

Interventions Physical therapy for gait training and

strengthening Replace amitriptyline with alternative

agent, or discontinue completely Same with propoxyphene Home safety assessment Adaptive?

Summary

Falls are common in both community and institutionalized older persons

Associated with significant morbidity and mortality

Most falls are multi-factorial Evaluation should be directed towards

identifying multiple contributory risk factors Multi-modal interventions can decrease the

incidence of falls and fall-related injuries