The Essentials of Preventing Falls in the

Older AdultJessica L. Colburn, MD

Johns Hopkins School of MedicineDivision of Geriatric Medicine & Gerontology

April 15, 2015

Discuss prevalence of falls in older adults

Develop an approach for fall risk screening and post-fall assessment in older adults

Discuss interventions that reduce fall risk in older adults

Objectives

Prevalence Outcomes Risk Factors

◦Common Medical Conditions

◦Changes with Aging

Overview

Screening Evaluation Risk Reduction Community Resources

Take Home Points

Prevalence of Falls

Falls Are A Big Problem

One-third of older adults in the community fall each year

Prevalence One-half of older

adults in long term care fall each year

Falls are the leading cause of traumatic injuries in adults over the age of 65

Increased mortality secondary to falls with each decade of life

Estimated direct medical costs for injuries in older adults due to falls was $32 billion in the year 2013

Prevalence

www.cdc.gov/HomeandRecreationalSafety/Falls/fallcost.html

Fall Outcomes

Kannus et al, Lancet 2005

20% need medical attention

5% fractures

5-10% other serious injuries (lacerations, head injuries, dislocations, bleeding)

Hip fracture◦ Increased risk of dying within the 3-6 months

following a hip fracture◦ Functional impairment – 20-30% of older adults do

not return to baseline function◦ Pain, difficult recovery

Found down – risk of injury due to delay to medical care, can lead to functional impairment

Fear of falling – leads to social withdrawal, admission to long term care facilities

Fall Outcomes

Sterling et al, Journal of Trauma 2001

Risk Factors for Falls

Patients who have fallen in the past year are more likely to fall again

Most consistent predictor of future falls is abnormal gait or balance

Think about conditions that your patient has that contribute to abnormal gait

Risk Factors

Ganz et al, JAMA 2007

Risk Factors for Falls

Falls

External Factors

Medications

Alcohol use

Using an assistive device improperly

Patient (Intrinsic) Factors

Environmental hazards

Medical conditions

Age-related changes

Vision and hearing impairment

Cognitive impairment

Kannus et al, Lancet 2005

Patient Factors

Medical Conditions Age-related changes

Parkinson’s disease Stroke Seizures Dementia Depression Dizziness Orthostatic hypotension Arrhythmia Osteoarthritis Diabetes Peripheral neuropathy

Changes in balance Vision changes Loss of muscle

Cell death in substantia nigra -> reduction in brain dopamine levels

Clinical features:◦ Tremor at rest (pill-rolling) ◦ Cogwheeling rigidity◦ Masked facies◦ Bradykinesia◦ Shuffling gait

Treatment:◦ Symptomatic relief only◦ Dopaminergic agents

Parkinson’s Disease

Image: careplanning.blogspot.com

Early stage – Same fall risk as other community-dwelling older adults

Middle stage - patients may forget that they need an assistive device or have knee pain until they get up and start to walk◦ Lose fine motor skills, forget how to navigate

environment

Late stage– patients forget how to perform motor tasks like walking or even swallowing◦ Muscle wasting, weight loss

Dementia

Change in blood pressure with position changes

Reflex mechanisms needed to counteract gravity are less effective with age◦ Vasoconstriction◦ Elevated heart rate

Comorbid medical conditions Medications – beta blockers,

diuretics, antihypertensives Volume depletion

Orthostatic (Postural) Hypotension

Image: nlm.nih.gov

Very common in older adults Major contributor to gait and balance

problems◦ Joint pain is commonly reported in primary care◦ Balance changes due to joint abnormalities◦ Fear of falling

Pain control: Acetaminophen is safe◦ NSAIDs (ibuprofen, naproxen) are less safe due to

renal and GI effects◦ Opiates increase risk of falls and confusion◦ Physical therapy very useful

Osteoarthritis

Tight control in older adults has been shown to increase severe hypoglycemic events and mortality

Oral hypoglycemics (except for metformin) and insulin are associated with high rates of hospitalization in older adults

Peripheral neuropathy also contributes to falls

Diabetes

External Factors

Antihypertensives Diuretics Digoxin Anticholinergics

Benadryl Ditropan

(incontinence)

Polypharmacy

MEDICATIONS! Antidepressants Sedatives/Pain Meds

Benzodiazepines Opiates

Antipsychotics Dementia agents

(acetylcholinesterase inhibitors)

Dopaminergic agents

External FactorsImproper use of assist devices

Loose rugs Cords Clutter Low lighting Hand rails

Cane Walker Wheelchair/scooter

Environmental hazards

Medications that could increase risk of injury◦ Blood thinners (benefit may outweigh risk but

important to think about)

Improper use of assistive devices◦ Hand-me-down devices

Osteoporosis◦ Increased risk of fracture with a fall

Risk Factors for Injuries

Screening, Evaluation & Fall Risk Reduction

Acute fall?Two or more falls in

the past year?Difficulty with

walking or balance?

Screening for Falls

Adapted from AGS Guideline for Prevention of Falls in Older Persons, 2010

YES

NO

Gait and balance

assessment

Fall in thepast year?

YES

NO

Abnormal?

FALL ASSESSMENT

YES

NOReassess periodically

Obtain relevant medical history, physical exam, cognitive and functional assessment

Determine multifactorial fall risk:◦ History of falls Feet/footwear◦ Medications Environmental hazards◦ Gait, balance, mobility◦ Visual acuity◦ Other neurologic impairments◦ Muscle strength◦ Heart rate and rhythm◦ Orthostatic hypotension

Fall Assessment

Adapted from AGS Guideline for Prevention of Falls in Older Persons, 2010

How did the fall happen? Did the patient have any symptoms? Was there an injury? Patient risk factors for falls (medical

problems, gait imbalance, footwear) Patient risk factors for injury

(anticoagulants, osteoporosis) Where there any environmental hazards? Are there any new or problem medications? Any change in mental status or functioning?

Evaluation - History

Moncada LV. Am Fam Phys 2011

Vital signs (orthostatics) Vision exam Cognitive assessment Other neurologic impairments Muscle strength Heart rate and rhythm Gait and balance assessment

Watch your patient walk!

Evaluation – Physical Exam

Drop in systolic blood pressure of 20 mm Hg with position change (sitting to standing) within 3 minutes

Five minutes of rest before first blood pressure

Drop may be delayed so typically I check immediately with standing and again at 2-3 minutes later

Assess for lightheadedness, but not all patients who are orthostatic get lightheaded

Physical Exam – Orthostatic Hypotension

Snellen chart Pocket card okay

Wearing glasses? Glasses appropriate? Reading vs. distance Bifocals may increase

fall risk

Physical Exam – Visual Acuity

3 word recall + Clock Draw Test

Sensitivity/specificity comparable to using a cutpoint of 25 on the MMSE ◦ Sensitivity 76% (vs 79% MMSE) ◦ Specificity 89% (vs 88% MMSE)

Shorter to administer in practice than the MMSE

Physical Exam - Cognitive Assessment – Mini-Cog

Borson et al, JAGS, 2003Borson et al, Int Jnl Geri Psych, 2011

Physical Exam - Cognitive Assessment – Mini-Cog Mini-Cog

◦ Give the patient 3 words to remember Banana, chair, sunrise

◦ Administer the Clock Drawing Test – “ten past eleven” or “two forty-five” or “eight twenty”

◦ 3 word recall Scoring:

◦ 1 point for each word recalled (0-3 points)◦ Clock draw test = 2 points normal, 0 points

abnormal◦ 0-2 = positive screen (“possibly impaired”)◦ 3-5 = negative screen (“probably normal”)

Borson et al, Int Jnl Geri Psych, 2011

Clock Draw Test Examples

Neurologic exam to assess for causes of falls

Parkinsonian features Muscle strength Sensation Gait/balance

Physical Exam – Neurologic Impairments

Cardiac examination

Evaluation for abnormalities that would affect balance or positioning

Irregular heart rhythm

Bradycardia or tachycardia

Physical Exam – Heart Rate and Rhythm

Timed Up and Go◦ Start with patient seated in a chair◦ Instruct patient to stand, walk 3 meters (10 feet),

turn around, come back, and sit down in the chair◦ Time from when you say go until when patient is

re-seated in the chair◦ Patient may use his or her assistive device

Scoring:◦ >/= 12 seconds associated with increased risk of

falls 87% sensitivity & specificity

Gait & Balance Assessment

Shumway-Cook et al, PT, 2000

Home/Environmental Assessment Assess home

environment for risks for falling◦ Rugs, clutter, cords,

lighting

Consider ways to improve safety in the home environment with assistive devices

Initiate multifactorial intervention to address identified risks:◦ Minimize/adjust medications◦ Recommend appropriate exercise program◦ Treat vision impairment (consider cataracts, bifocals)◦ Manage orthostatic hypotension◦ Manage heart rate and rhythm abnormalities◦ Supplement vitamin D◦ Manage foot/footwear problems◦ Modify the home environment◦ Consider risks for injury (osteoporosis, blood

thinners)◦ Provide education and information

Indication for Intervention?

Adapted from AGS Guideline for Prevention of Falls in Older Persons, 2010

Fall Risk Reduction Check orthostatics (some patients do not report

dizziness)◦ Goal BP based on JNC 8 guidelines is 140 – 150 systolic,

reduce antihypertensives if appropriate◦ Encourage fluid intake

Vision screening ◦ Cautious use of bifocals, can increase fall risk especially with

navigating curbs and steps Home safety evaluation

◦ Medicare no longer reimburses for home safety evaluation unless it is done as part of home physical therapy treatment

◦ Can provide instructions for patient/caregiver to assess home environment

Vitamin D therapy (Grade B evidence) - 800 IU daily for at least 12 months, regardless of serum level

Physical therapy or exercise referral (Grade B evidence)◦ PT for gait & balance training◦ Assessment of appropriate assistive device and

training to use assistive device◦ Many types of exercise will reduce falls – Tai Chi, low

to high intensity, group or in home, many are effective

Multifactorial risk assessment not needed for every patient, tailor interventions to individual needs

Fall Risk Reduction – USPSTF Recommendations

Moyer, Ann Int Med, 2012

Department of Aging –> Resources for Fitness and Fall Prevention/Risk Reduction◦ Baltimore County Department of Aging –>

Maryland Access Point: 410-887-2594◦ Baltimore City Department of Aging -> Maryland

Access Point: 410-396-2273

◦ Senior Centers, exercise programs, fall prevention programs (ie. Stepping On)

◦ Online tools to help patients/caregivers do their own home safety assessments

Community Resources

Falls are a common problem for older adults

Falls are dangerous – increased risk of functional impairment and death

Risk can be modified with screening, assessment, and intervention

You can prevent an older adult from falling!

Take Home Points

Email:◦ Jessica Colburn, MD◦ jcolbur1@jhmi.edu

Thank you!

Questions?