Page 3
Caídas
Son comunes y son los principales factores que
amenazan su independencia
El individuo cae usualmente ocurren cuando
las deficiencias en varios dominios ponen en peligro la capacidad de
compensación del individuo
JAMA. 1995;273(17):1348.
Page 5
““80 percent of older women 80 percent of older women preferred death to a "bad" hip preferred death to a "bad" hip
fracture fracture that would result inthat would result in
nursing home admission”nursing home admission”
““80 percent of older women 80 percent of older women preferred death to a "bad" hip preferred death to a "bad" hip
fracture fracture that would result inthat would result in
nursing home admission”nursing home admission”
BMJ. 2000;320(7231):341
Page 6
Epidemiología12.6 billones de dolares (1995)
30 – 40% > 65 años (comunidad) se caen cada año (50% para mayores de 80ª)
En una encuesta de EE.UU. de más de 90.000 personas > 65 años, las caídas se registraron
en los tres meses anteriores en un 16%
N Engl J Med. 2003;348(1):42
Page 7
EpidemiologíaEstudio en mujeres mayores de 70 a (2 años)
41 % trauma menor41 % trauma menor
6% trauma mayor6% trauma mayor
Pacientes institucionalizados tienen más trauma mayor
5% serán hospitalizados
N Engl J Med. 2003;348(1):42
Page 8
““In an Australian study, 9.5 percent of patients hospitalized for falls became first-time residents of a
long-term care facility at discharge””
““In an Australian study, 9.5 percent of patients hospitalized for falls became first-time residents of a
long-term care facility at discharge””
Emerg Med J. 2012 Sep;29(9):742-7.
Page 10
““ In a large study of elderly persons In a large study of elderly persons seeking emergency care after a fall, seeking emergency care after a fall, 2.2 percent of injurious falls resulted 2.2 percent of injurious falls resulted
in deathin death””
““ In a large study of elderly persons In a large study of elderly persons seeking emergency care after a fall, seeking emergency care after a fall, 2.2 percent of injurious falls resulted 2.2 percent of injurious falls resulted
in deathin death””
Am J Epidemiol. 1990;131(6):1028
Page 11
Miedo a caerDespués de una caída…
60% restricción moderada60% restricción moderada
15% restricción marcada15% restricción marcada
50% después de una fx de cadera50% después de una fx de cadera
J Am Geriatr Soc. 2010;58(9):1739
Page 14
Órganos de los sentidos
Lentes multifocales aumentan el riesgoLentes multifocales aumentan el riesgo
Agudeza visual, percepción de profundidad, Agudeza visual, percepción de profundidad, adaptación a la oscuridadadaptación a la oscuridad
Propiocepción alteradaPropiocepción alterada
Sistema vestibular alteradoSistema vestibular alterado
J Am Geriatr Soc. 2002;50(11):1760
Page 16
Activación y composición muscular
Activación muscular proximalActivación muscular proximal
Mayor activación de músculos antagónicosMayor activación de músculos antagónicos
Recuperación alteradaRecuperación alterada
Infiltración grasa y riesgo de Fx caderaInfiltración grasa y riesgo de Fx cadera
J Am Geriatr Soc. 2002;50(11):1760
Page 17
Historia de caídas
Riesgo de segunda Fx de caderaRiesgo de segunda Fx de cadera
““Framingham Study”: 14.8% Framingham Study”: 14.8% tuvieron una segunda fractura en tuvieron una segunda fractura en
los siguientes 4 años los siguientes 4 años
J Am Geriatr Soc. 2002;50(11):1760
Page 19
Presión arterial
Hipotensión ortostáticaHipotensión ortostática
Menos % agua, diuréticos, climas Menos % agua, diuréticos, climas cálidoscálidos
J Am Geriatr Soc. 2002;50(11):1760
Page 20
Enfermedades crónicas
Enfermedad de ParkinsonEnfermedad de Parkinson
Dolor musculo-esquelético crónicoDolor musculo-esquelético crónico
OsteoartritisOsteoartritis
DiabetesDiabetes
J Am Geriatr Soc. 2002;50(11):1760
Page 21
Deterioro cognitivo
J Am Geriatr Soc. 2002;50(11):1760
““ In one study of 1600 persons aged 75 years and In one study of 1600 persons aged 75 years and above, the risk of hip fracture over six year follow-up above, the risk of hip fracture over six year follow-up
was twice as high when the score on the mini-was twice as high when the score on the mini-mental status examination was suggestive of mild mental status examination was suggestive of mild impairment (score 18 to 23) compared with those impairment (score 18 to 23) compared with those
with no impairmentwith no impairment””
““ In one study of 1600 persons aged 75 years and In one study of 1600 persons aged 75 years and above, the risk of hip fracture over six year follow-up above, the risk of hip fracture over six year follow-up
was twice as high when the score on the mini-was twice as high when the score on the mini-mental status examination was suggestive of mild mental status examination was suggestive of mild impairment (score 18 to 23) compared with those impairment (score 18 to 23) compared with those
with no impairmentwith no impairment””
Page 22
Medicamentos
Arch Intern Med. 2009;169(21):1952
“ “ In a meta-analysis of 22 studies involving multiple In a meta-analysis of 22 studies involving multiple classes of drugs, the likelihood of falling was increased classes of drugs, the likelihood of falling was increased with the use of with the use of sedatives and hypnotics sedatives and hypnotics (odds ratio [OR] (odds ratio [OR] 1.47, 95% credible interval (CrI) 1.35-1.62), 1.47, 95% credible interval (CrI) 1.35-1.62), neurolepticsneuroleptics
and and antipsychoticsantipsychotics (OR 1.59, 95% CrI 1.37-1.83), (OR 1.59, 95% CrI 1.37-1.83), antidepressantsantidepressants (OR 1.68, 95% CrI 1.47-1.91), and (OR 1.68, 95% CrI 1.47-1.91), and
benzodiazepinesbenzodiazepines (OR 1.57, 95% CrI 1.43-1.72)” (OR 1.57, 95% CrI 1.43-1.72)”
“ “ In a meta-analysis of 22 studies involving multiple In a meta-analysis of 22 studies involving multiple classes of drugs, the likelihood of falling was increased classes of drugs, the likelihood of falling was increased with the use of with the use of sedatives and hypnotics sedatives and hypnotics (odds ratio [OR] (odds ratio [OR] 1.47, 95% credible interval (CrI) 1.35-1.62), 1.47, 95% credible interval (CrI) 1.35-1.62), neurolepticsneuroleptics
and and antipsychoticsantipsychotics (OR 1.59, 95% CrI 1.37-1.83), (OR 1.59, 95% CrI 1.37-1.83), antidepressantsantidepressants (OR 1.68, 95% CrI 1.47-1.91), and (OR 1.68, 95% CrI 1.47-1.91), and
benzodiazepinesbenzodiazepines (OR 1.57, 95% CrI 1.43-1.72)” (OR 1.57, 95% CrI 1.43-1.72)”
Page 23
Alcohol, calzado, factores medio-ambientales
A mayor consumo de alcohol, mayor riesgoA mayor consumo de alcohol, mayor riesgo
Suelas, taconesSuelas, tacones
Ayudas especialesAyudas especiales
Pacientes institucionalizadosPacientes institucionalizados
J Am Geriatr Soc. 2002;50(11):1760
Page 24
Reportar caídas recurrentes
Reportar alteración en la marcha o el balance
Buscar atención médica ó presentarse al departamento de urgencias cuando haya una
caída
Page 25
Historia clínica completa, valoración funcional y cognitiva
Función musculo-esquelética
Examen físico
Laboratorios e imágenes
Page 26
1. Repeated Chair Stands
2. Balance Testing
a. Semitandem Standb. Side-by-Side stand
c. Tandem Stand
3. 8’ Walk (2.44 meters)
Short Physical Performance Battery (SPPB)
Page 27Fleming KC, Evand JM, Weber DC, Chutka DS. Practical Functional Assessment of Elderly Persons: A Primary-Care Approach [Symposium on Geriatrics-Part III]. Mayo Clinic Proceedings 1995; 70:890. Copyright © 1995 Mayo Foundation.
The "Get up and go" test for gait assessment in elderly patients
The "Get up and go" test for gait assessment in elderly patients
Page 29Tinetti ME. Performance-oriented assessment of mobility problems in
elderly patients. JAGS 1986; 34: 119-126. (Scoring description: PT Bulletin Feb. 10, 1993)
Tinetti Performance Oriented Mobility Assessment (POMA)*
Tinetti Performance Oriented Mobility Assessment (POMA)*
Page 30Tinetti ME. Performance-oriented assessment of mobility problems in
elderly patients. JAGS 1986; 34: 119-126. (Scoring description: PT Bulletin Feb. 10, 1993)
Tinetti Performance Oriented Mobility Assessment (POMA)
Tinetti Performance Oriented Mobility Assessment (POMA)
Balance
Page 31Tinetti ME. Performance-oriented assessment of mobility problems in
elderly patients. JAGS 1986; 34: 119-126. (Scoring description: PT Bulletin Feb. 10, 1993)
Tinetti Performance Oriented Mobility Assessment (POMA)
Tinetti Performance Oriented Mobility Assessment (POMA)
Marcha
Page 32Fleming KC, Evand JM, Weber DC, Chutka DS. Practical Functional Assessment of Elderly
Persons: A Primary-Care Approach [Symposium on Geriatrics-Part III]. Mayo Clinic Proceedings 1995; 70:890. Copyright © 1995 Mayo Foundation.
Diagram of functional reach test to assess balance in elderly persons
Page 34The Prevention of Falls in Older Persons: Clinical Practice Guideline
(http://www.medcats.com/FALLS/frameset.htm) from the American Geriatrics Society. For more information visit the AGS online at www.americangeriatrics.org.
Page 35The Prevention of Falls in Older Persons: Clinical Practice Guideline
(http://www.medcats.com/FALLS/frameset.htm) from the American Geriatrics Society. For more information visit the AGS online at www.americangeriatrics.org.
Page 37
• Marcha y balance
• Fuerza
• Flexibilidad
• Movimientos (TaiChi o baile)
• Actividad física general
• Resistencia
Ejercicio
Page 39
Otras intervencionesOtras intervencionesHipersensibilidad seno carotídeo y marcapasos (RaR 0.42, 95% CI 0.23-0.75)
Cataratas (RaR 0.66, 0.45-0.95)
Suplemento nutricional
Hipotensión ortostática: medias elásticas, líquidos, fludrocortisona,
Intervención en podiatría
Protectores de cadera
Caminador ó bastón
Page 40
Tiempo en el suelo
JAMA. 1993;269(1):65
“ A study of 1100 individuals over age 72 found that 47 percent of the 313 who
experienced non-injurious falls were unable to get up for at least one hour after falling”
“ A study of 1100 individuals over age 72 found that 47 percent of the 313 who
experienced non-injurious falls were unable to get up for at least one hour after falling”
Page 41
Anticoagulación
“ “ A decision analysis has concluded that a A decision analysis has concluded that a predisposition to falls, with potential head predisposition to falls, with potential head
trauma, is trauma, is rarelyrarely a contraindication to the use a contraindication to the use of anticoagulants in older adult patients with of anticoagulants in older adult patients with
atrial fibrillation (AF)”atrial fibrillation (AF)”
“ “ A decision analysis has concluded that a A decision analysis has concluded that a predisposition to falls, with potential head predisposition to falls, with potential head
trauma, is trauma, is rarelyrarely a contraindication to the use a contraindication to the use of anticoagulants in older adult patients with of anticoagulants in older adult patients with
atrial fibrillation (AF)”atrial fibrillation (AF)”
Page 43
Recommended Components of Clinical Assessment and Management for Older Persons Living in the Community Who Are at Risk for Falling
N Engl J Med. 2003;348(1):42
Page 44
Recommended Components of Clinical Assessment and Management for Older Persons Living in the Community Who Are at Risk for Falling
N Engl J Med. 2003;348(1):42