ED Management of Falls in the Geriatric Population

1. ED Management of Falls in the Geriatric Population Jennifer Oman, MD, MBA Clinical Professor of Emergency Medicine UC Irvine School of Medicine

2. Non-elderly patients Inouye SK, Studenski S, et al. Geriatric Syndromes: Clinical, research, and policy implications of a core geriatric concept. Jam Geriatr Soc. 2007.55:780-791.

3. Geriatric Syndromes • Elderly do not have single disease category • Significant impact on quality of life • Multiple underlying factors and multiple organ systems Inouye SK, Studenski S, et al. Geriatric Syndromes: Clinical, research, and policy implications of a core geriatric concept. Jam Geriatr Soc. 2007.55:780-791.

4. Geriatric Disease

5. Geriatric Syndromes • Delirium • Falls • Frailty • Syncope • Dizziness • Urinary incontinence

6. Did you know? • Roughly one third of older individuals over the age of 65 fall every year • More than half of older adults living in institutions fall every year • Half of the older individuals who fall have repeated falls Kannus P, Parkkari J et al. Fall induced injuries and deaths among older adults. JAMA. 1999; 281: 1895-1899.

7. Did you also know? • The fall may represent the initial event in an elder adults life • Beginning of serious decline • New or worsening medical illness • More than 2/3 of those that fall will fall again in 6 months • If hospitalization, risk of death in the year following the fall is 15%-50% Baraff LJ, Della Penna R et al. Practice guideline for the ED management of falls in community dwelling elderly persons. Ann emerg Med. Oct 1997; 30:480-489.

8. What we will discuss • Evaluation after the fall • Prevention of future falls

9. Evaluation • Some falls result in serious injury • First things first • Stabilize and treat emergent conditions

10. Evaluation • And sometimes the patient’s condition gives you more time to take the history • Cause of the fall • Location of the fall • Long lie • Medications • Functional status • Medical problems

11. And they wouldn’t call us ED Docs if we didn’t consider Was this syncope?

12. Evaluation • Physical Exam specifics • Vital signs • Get-up-and-go-test

13. History in the Elderly • Present with more than one problem • They overestimate their own healthiness: they explain away or minimize symptoms or problems – explain away as normal aging • Under-reporting of symptoms is common • Use ancillary sources of history--- family, caregiver • Develop problem list rather than chief complaint

14. Evaluation • Cause of the fall • 50% will tell you they tripped • Location of the fall • Only the precipitant of the fall • Have they fallen in the previous 3 months? • Don’t overlook underlying etiology • Long lie (>5 minutes) • Ask if they were able to get up unassisted • If needed assistance more likely to sustain decline in ADLs, be hospitalized or die early Kannus P, Parkkari J. fall induced injuries and deaths among older adults. JAMA1999;281:1895-1899

15. Medications • Medications • Use of 4 or more prescription medications • Which drugs? • The usual suspects- neuroleptic agents, benzodiazapines, anticonvulsants, cardiovascular drugs (antihypertensives) • SSRIs • Tricyclics Tinetti, ME. Preventing falls in elderly persons. N Engl J Med. 2003; 348:1. 42-49.

16. Functional Status • Verify functional status • Do they live alone? • Are they able to carry out activities of daily living for themselves? • If in a care facility, what is their baseline transfer and mobility?

17. Medical Problems • Urinary frequency or incontinence • Alcohol use • Special considerations: • Blood thinners

18. Medical problems Baraff LJ, Della Penna R et al. Practice guideline for the ED management of falls in community dwelling elderly persons. Ann emerg Med. Oct 1997; 30:480-489.

19. Syncope? • Tips for eliciting the history of syncope • Ask multiple ways • Is there a period of time you don’t remember • Go through the events for me • Ask multiple times

20. Syncope? • Bystanders…. • Just like on the board exam- don’t let the medics or witnesses leave until you have gotten the information they know! • Make sure you talk to everyone possible even if that means calling the SNF or patient’s home or relative/friend • Only sometimes helpful

21. Caveats to believing the bystander • All shaking is not a seizure • Mild brief tonic-clonic activity can occur with any etiology of syncope • Cerebral hypoperfusion • Orthostatic vital signs in the elderly population are helpful • Found in up to 40% or asymptomatic patients over 70 and 23% of those younger than 60 • Patients will adopt the bystanders interpretation of the event Huff JS, Decker WW et al. Clinical policy; critical issues in the evaluation and management of adult patients presenting to the emergency department with syncope. Ann Emerg Med. 2007;49:431-444.

22. Physical Exam • Vital signs are vital but …. • Remember the elderly may not mount a fever even in the face of significant infection • Heart rate may be artificially low for their status if on beta blockers • Systolic hypertension is common- may not demonstrate hypotension

23. Physical Exam • Orthostatics: maybe yes maybe no • Largely abandoned in the ED • May have asymptomatic orthostasis • Found in up to 40% or asymptomatic patients over 70 and 23% of those younger than 60 • Will still see it recommended but its usefulness in the ED is debatable

24. Physical Exam • Nutritional status: • Subcutaneous fat and temporal wasting • May suggest underlying physical or mental illness • Mental Status: • Determine if change from baseline • May have delirium, dementia or psychiatric illness • Delirium could be a cause of a fall or a result of the fall

25. Dementia vs Delirium • Dementia- a fall in the intellectual ability from a person’s previous level of performance causing an altered pattern of activity in the setting of normal consciousness • Delirium- a disorder of attention • Cognitive impairment with an acute onset or fluctuating course • Inattention or difficulty maintaining focus • Disorganized thinking

26. Rule out Dementia • Mini cog • Three item recall and draw a clock • If the patient is able to recall all 3 items-you are done – likelihood ratio of dementia <0.1 • If the Patient is unable to recall a single item- the likelihood ratio for dementia is 14- also done • If able to recall 1 or 2 items have them draw a clock. If clock normal likelihood ratio for dementia is 0.14. If abnormal the likelihood ration for dementia is 10-14

27. Delirium • VAMPIRE • Vitals • Acute events ( MI, PE, CVA) • Medications (sedative hypnotics, pain medication, drug-drug interactions) • Pain control • Infections (UTI) • Restricted mobility • Environment (sleep deprivation, vision impairment, hearing impairment)

28. Rule in delirium • Confusion assessment method (CAM) • Need • 1. Acute onset symptoms or mental status changes of fluctuating course and • 2. inattention • Also need either • 3. disorganized thinking or • 4. altered consciousness (other than alert) Inouye SK, van Dyck CH, Alessi CA, et al.Clarifying confusion: The confusion assessment method. Ann Intern Med 1990; 113:941–948

29. Rule in delirium • CAM positive- meaning your patient has delirium- if 1 and 2 present and either 3 or 4 • >94% sensitive and 90-95% specific for diagnosing delirium

30. Physical Exam • Specific cardiopulmonary exam • And finally- look for injuries • Multiple old and new injuries should make you think of abuse

31. Get-up-and-go-test • Tests gait, strength and balance • Evaluates for symptomatic orthostasis • Rules out lower extremity, pelvic and spine injury • Lowers suspicion of intracranial pathology

32. Get-up-and-go-test • Have patient get up from gurney • Once sitting must get up without using arms • Walks a few feet and returns • High risk for subsequent falls if unable to perform

33. Prevention of future falls • Some interventions may be done in the ED • Guidance to patients and families as to what to expect/ measures to take to help prevent future falls • Make appropriate referrals

34. ED interventions • Medication assessment • Benzos or sedatives, antihypertensives • Alcohol screening • Discussion about potential risks at home- at least given in discharge instructions • Referral for assessment • More than 4 prescription medications • One previous fall in the preceding 3 months • A long lie or assistance to get up from a fall • Multiple medical problems

35. ED Management of falls in the Elderly- Pearls • The elderly do not have discrete cause and effect illness– multi-factorial • Half of the older individuals who fall have repeated falls- opportunity to affect quality of life as and ED MD • Don’t forget to address not only immediate injuries but the causes of the fall • Remember to evaluate functional status

36. ED Management of falls in the Elderly- Pearls • Beware the bystander/eye witness • Convince yourself the fall wasn’t syncope • Rule out dementia and rule in delirium • CAM, clock assessment • Perform the get-up-and-go-test • Referral for assessment • More than 4 prescription medications • One previous fall in the preceding 3 months • A long lie or assistance to get up from a fall • Multiple medical problems