CHAMP A Geriatric Syndrome in the Hospital: The Case of Falls

1. CHAMPA Geriatric Syndrome in the Hospital: The Case of Falls William Dale, MD, PhD Katherine Thompson, MD University of Chicago

2. Overview • What is a “geriatric syndrome”? • How does one think about, and teach about, syndromes like falls? • Why worry about falls? • What are the causes of falls? • Differential diagnosis and falls: teaching housestaff • Restraints and falls: teaching housestaff about dangers • Preventing falls and treating patients who fall • What should be done at discharge?

3. Falls: a “Geriatric Syndrome” • A sudden, unexpected descent from a standing sitting, or horizontal position. • When a person comes to rest inadvertently on the ground or a lower level • Excludes syncope and overwhelming trauma • A classic Geriatric Syndrome • When the nurse calls to report “an event”

4. What is a Geriatric Syndrome? • Manifestation of disturbances in complex systems, usually more than one organ system involved • Examples • Functional Dependence • Delirium • Incontinence • Falls

5. Geriatric Syndrome Vs. Traditional Syndrome

6. How do complex systems, like older adults, “fail”, causing syndromes? • Key Concepts • Physiologic reserve lower across multiple domains • Adaptive/redundant systems reduced • Possible Pathways to Failure • Major hit to one component (E.g. CVA) • Dominant deficit with exacerbations (E.g. MI  CHF/COPD) • Multiple modest deficits (Geriatric Syndrome)

7. Yearly Incidence of Falls • Community-dwelling persons over 65: 30-40% • 20% of falls require medical attention • History of fall in last year: 60% • Falls in our hospital: Data not currently available Sources: Tinetti, 1988; Tinetti, 1994

8. Complications • “Leading cause” fact: death from injury in older adults • Fracture risk: 10-15% • About 8% of 70+ y.o. go to ED yearly for fall-related injury • Other common complications • Decline in functional status • Increased likelihood of nursing home placement • Increased use of medical services • Developing fear of falling  Loss of function Source: Sattin, 1992.

9. Causes of Falls • Rarely due to a single cause • At least 25 risk factors identified across 5 large cohort studies • Interaction across multiple domains: more risk factors, increased likelihood to fall • Intrinsic to individual • Mediating factors • Environmental challenges to postural control

10. Risk Factors: Intrinsic to Patient • Age • Female gender • Cognitive impairment • Chronic diseases • Arthritis • Parkinson’s • Use of certain medications • Psychotropics • Diuretics • History of falls

11. History of Falls as a Risk Factor • One year risk of hospitalization by baseline self reported fall status (n=444)

12. Risk Factors: Mediating Factors • Risk-taking behaviors • Underlying mobility level/inclination • Principle: Mismatch of risk-taking behavior with mobility Probability of Fall Mobility Skills Source: Studenski, 1991

13. Risk factors: Postural Control and Environmental Challenges • Postural control differences in older adults • Respond to balance perturbations using proximal muscles first, then distal • More slowly develop joint torque when disturbed • More likely to have decreased baroreflex sensitivity to hypotensive stimuli • More likely to have microvascular cerebral perfusion defects • Reduction in total body water

14. Risk factors: Postural Control and Environmental Challenges • Weakness, esp. lower extremity • Balance difficulties • Dangerous environment • Lighting • Obstacles • Floor surface • Footwear

15. Risk factors: Postural Control and Environmental Challenges • Three sensory input systems involved in maintaining upright posture • Visual • Proprioceptive • Vestibular • All of these systems decline with aging

16. Differential Diagnosis and Falls • Traditional DDx: • Multiple symptoms  Possible single cause (i.e. diagnosis) • Causes prioritized by probability and severity • Search for underlying or unifying cause • Geriatric Syndromes DDx: • Event/Condition  Possible multiple causes • Causes prioritized by probability and contribution to causing event/condition • Search for web of interacting causes

17. History and physical based on the components of postural control • Sensory: • Vision • Vestibular • Somatosensation • Central Processing: • Global level of consciousness/perfusion • Attention/response time • Automatic postural responses • Effector: • muscle strength • range of motion • endurance

18. Getting “The Story” • At time a fall occurs, get good history • Do this on cross-cover • Best history at time of fall • Earlier intervention important • Activity at time of fall (walking, transferring, sitting at bedside, going to bathroom, etc) • Prodromal symptoms • Lightheadedness? • Loss of balance? • Dizziness? • Location/Timing

19. Getting the Story • Observe environment/context of fall • Lighting • Flooring and footwear • Restraints (both formal and informal) • Furniture • Past History: Has this happened before? • Strongest predictor of fall: past fall • Context of last event • Review Medications • Recent Changes in Medications (Check MAR) • Biggest culprits • Vasodilators • Diuretics • Sedatives • Hypnotics

20. The Role of Medications • Specific meds in observational studies associated with hip fracture risk • Benzodiazepines • Antidepressants • Antipsychotics • Medication features associated with falls • Recent changes in dose • Total number of meds

21. Physical Exam • Orthostatics: Do this yourself if you have time. • Cardiovascular System • Sensory Examination • Special senses • Proprioception • Musculoskeletal Exam • Proximal muscle weakness • Joint pain/swelling • Cognition: brief assessment of mental status: Orientation • Footwear/Floor combination • Socks on tile; bare feet and wet floor

22. Physical Exam: Special Tests • Gait Speed – “Get up and Go” Test • Rise from (hard-backed) chair, walk 10 feet, turn, return to chair, sit down • Threshold greater than 10 seconds is abnormal • One foot balance • Threshold: < 30 seconds • Observe PT/OT evaluations for these patients—arrange time for team to meet with PT/OT

23. Laboratory Testing • No “standard” battery of tests • Consider checking vitamin D level • Target to specific concerns

25. Number of Restraints?

26. Falls and Restraints • Restraints increasingly recognized as a cause of falls and increasing serious falls

27. Mechanical Restraint Use and Fall-related injuries • Prospective study, SNFs, n=397 • Outcome: falls after restraints placed • Logistic regression used to control for large number of confounders • Odds ratio for fall-related injury • Full cohort: 10.2 (CI 2.8 – 36.9) • High-risk subgroup: 6.2 (CI 1.7 – 22.2) Source: Tinetti ME, et al, 1992

28. Mechanical Restraints • Increases risk of falls and other complications in hospitalized patients on a medicine service: Source: Mion LC, Et al, 1989.

29. Restraints: Formal and Informal • Formal • Mittens • Wrist/Ankle Soft Restraints • 4-point “Leathers” • Full Side Rails • Posey Vests • Informal • IV Lines • O2 nasal canulas • NG tubes to suction or for feeds • Pulse oximetry • SCDs • Foley catheters

30. Risks/Benefits of Bedrails • Potential benefits • Aiding in repositioning • Hand-hold for support in getting in/out of bed • Reduce fall risk during transport • Enhance access to bed controls • Potential risks • Entrapment • Worse falls injuries from climbing • Skin trauma/bruising/scraping • Exacerbation of delerium when used as a restraint • Restricts activities (toileting, personal item retrieval)

31. Bed Rails and Entrapment • Incidence of “entrapment” by bed rails reported to FDA, 1985-1999: 371 • # of beds in U.S. hospitals and LTC facilities: 2.5 million • Outcomes from entrapment • Death 61% • Non-fatal injury 23% • No injury 15%

32. Safety Improvement Alternatives to Bed Rails • Lower bed for patient, raise for providers • Keep wheels of bed locked • Use transfer and mobility aids • Monitor patient frequently • Move patient closer to nursing station • Enlist others: family, medical students • Identify and meet patient needs that lead to falls • Toileting: available bedpans/urinal; scheduled toileting • Pain: adequate pain relief

33. Improving Safety of Bedrails When Used • Close monitoring • Lower at least one of rails • Not considered a restraint when used this way • Allows access to and from bed • Properly sized mattress to reduce gap between mattress and bedrail

34. Treatment and Prevention • No proven benefit in reducing falls • Untargeted exercise intervention alone • Untargeted health education alone • Untargeted exercise and health education • Assistive devices alone

35. Outpatient Prevention • Possible Benefit • Long-term exercise and balance training • Includes gait training and proper use of assistive devices • Tai Chi: body “consciousness”, balance • Medication review for possible discontinuation • Esp. for those with 4+ medications • Esp those on psychotropics • Vitamin D supplementation

36. In Hospital Treatment and Prevention • Impact Protection • Lower beds and lock wheels • Hip Protectors • Significant protection against fracture • Adherence difficulties substantial • Diagnose and treat osteoporosis • Increased Vigilance • Enroll help of patient, family, nursing • Re-evaluate often • Visit yourself if possible

37. After Discharge • Proven benefit to reduce falls • Health screening with followup TARGETED intervention (OR = 0.79; CI = 0.65-0.95) • Primarily a balance issue? • Primarily a strength issue? • Home safety evaluation by OT (19% reduction of falls versus control; decreased falls 36% in those with previous history of falls)

38. Intervention: Targeted PT • Three pooled studies, n = 566 • Intervention: individually tailored program of progressive muscle strengthening, balance retraining exercises, and a walking plan • One-year: • Fall RR 0.80, CI 0.66-0.98; • Serious injury: RR 0.67, CI 0.51-0.89 • Two-year (69% intervention, 74% controls): • Falls RR 0.69, CI 0.47-0.97 • Moderate-Serious injury RR 0.63, CI 0.42-0.95

39. Home Safety Intervention • Home safety evaluation by OT • 1 well-designed study • n = 530, outcome: # of falls • Stratified by falls history • Overall RR 0.81, CI 0.66-1.00 • One or more falls, previous year, RR 0.64 (CI 0.49 – 0.84) • No falls, previous year, RR 1.03 (CI 0.75-1.41)

40. Other Discharge Considerations • If sending for rehab/PT, be sure information about in-house fall is clearly communicated • Rehab a common location for falls: people having mobility challenges with mobility difficulties • Previous fallers benefit most from intervention • Note fall in discharge summary to be added to patient “problem list” • Possibility of the development of fearfulness leading to disability and increased risk of falls

41. Summary • Falls as a geriatric syndrome: • Multiple contributing causes with common final pathway • Most likely contributing causes: • #1 – History of falls • Patient factors: balance difficulties, LE weakness, incontinence, medications, cognitive impairment • Environmental factors: restraints (formal and informal), bed height, toileting needs, lighting, furniture • Mitigating factors: mismatch of mobility with compensatory mechanisms  patient, nursing, family education

42. Summary of Teaching Points • Exercises • “Get up and Go” Test • Bedside restraints “memory” test • Dangers of Restraints • Discharge Considerations • Targeted interventions: observe PT evaluation • OT Home safety evaluation • Falls added to problem list