FALLS in THE ELDERLY

1. FALLS inTHE ELDERLY Vania L. Yu, MD

2. INCIDENCE • 25% at 70 years of age • 35% after 75 years of age • 40% after 80 years of age Women fall twice as much as men until the age of 75; after which the frequency equalizes. • Institutionalized elderly fall more often than community elderly.

3. One third of elderly who live at home have at least one fall a year. Falls and its sequela are the fifth most common cause of death among the aged. • The most-feared consequence of a fall is a broken hip. Less than 5% of falls among older adults lead to a bone fracture.

4. Common Types Of Fracture From A Fall • Hip • Wrist • Upper arm • Pelvis

5. Definition A fall is an event which leads to the conscious subject coming to rest inadvertently on the ground.(J. Miller) …regardless of whether an injury was sustained.(J. Jensen)

6. Classification of Injuries:( Abbreviated Injury Scale ) • MINOR - superficial wounds and bruises • MODERATE - intermediate injuries such as vertebral and wrist fractures • SERIOUS - major fractures such as hip and femur

7. 3 Stages of Falling:( WC Hayes ) • Fall initiation • Fall descent • Fall impact

8. Main Reasons forHigh Incidence of Falls in The Elderly:( J. Sheldon ) • Increased liability to trip over trivial objects • Difficulty in maintaining erect posture once balance is disturbed • Susceptibility to a sudden collapse of the postural controlling mechanism leading to a “drop attack”

9. DROP ATTACK: Sudden loss of muscular tone without loss of consciousness. (Kremer, Sheldon, Clark) Pressure exerted on the soles of the feet appears to restore neurologic integrity. (Sheldon)

10. Sensory Systems that Control Posture • Vestibular • Visual • Somatosensory

11. Risk Factors For Falls: • Extrinsic (environment) • Physical environment • Visual environment • Intrinsic (individual) • Age • Cardiovascular disorders (orthostatic hypotension) • Neurologic disorders (dementia, stroke, parkinson’s • Metabolic derangements (hyponatremia, hypoglycemia) • Musculoskeletal deficits (gait abnormalities) • Medication (sedatives, psychotropic drugs, alcohol intake)

12. Most Important Intrinsic Predictors for Falls:(AM Tromp) • Decreased mobility • Cognitive impairment • Medication use • Depression • Urinary incontinence • Stroke • Postural hypotension • Dizziness • Fear of falling • Impaired vision • History of previous falls

13. Predictors Significantly Associated with Recurrent Falls:(AM Tromp) • Previous falls • Urinary incontinence • Visual impairment • Functional limitation

14. Types Of Falls:(H Wieman) • Slips and trips • Falls while attempting a difficult maneuver • Syncope – LOC precedes falls • Seizure – LOC accompanies falls • Drop attack – no LOC • Vertigo • Sliding off furniture

15. Psychosocial Manifestations of Fall: • Anxiety • Loss of consciousness • Social withdrawal • Restrictions in ADLs • Postfall syndrome • Fallaphobia • Loss of independence and control • Depression • Feelings of vulnerability and fragility • Concerns regarding death and dying

16. POSTFALL SYNDROME: Inability to stand or walk unsupported in the absence of any neurological or orthopedic abnormalities that would influence gait and balance (clutch and grab). FALLAPHOBIA: Fearful anticipation of a fall.

17. Common Environmental Hazards: • Poorly designed or unstable furniture • Floor surfaces • Inadequate lighting • General clutter • Pets in the house • Electrical cords • Loose or uneven stair treads

18. General Management of Falls in The Elderly: • Primary prevention minimize the risk of falling among elderly people and prevent a fall. • Secondary prevention prevent the elderly person from having another fall.

19. Complications of Fall Related to Immobility: • Dehydration • Bronchial pneumonia • Contractures • Constipation • Decubitus ulcers • Hypothermia • Iatrogenic complications • Disability • Institutionalization • Loss of independence

20. Assessment: • Fall History • Medication History • Mental Status • Cardiovascular and neurological functions • Mobility and balance

21. Position change or balance maneuver Position Changes, Balance Maneuvers and Gait Components in Functional Mobility Assessment (ME Tinetti and SF Ginter)

22. Gait component or maneuver

23. Feasibility & Measurement Properties of the Functional Reach & the Timed Up & Go Tests in the Canadian Study of Health & AgingK Rockwood et alJ of Gerontology Feb 2000 Problems in gait and balance may lead to an individual’s inability to meet the daily requirements of life. Physical performance measures was seen to meet problems inherent in self report, such as errors in memory or judgment.

24. The Functional Reach (FR) is a simple measure of standing balance, which correlates well with traditional measures of balance and is a predictor of falls in elderly people. (PW Duncan) The Timed Up and Go (TUG) is a measure of self-selected gait speed, balance and function, and is predictive of nursing home placement. (T Nikolaus)

25. The TUG is conducted using a standard kitchen chair with no armrests. The interviewer stands 3 meters away (10 feet) and times the subject (secs) as they rose from the chair, walked the 3 meters to the interviewer, turned, walked back and sat down again. Three trials are allowed with the shortest timed trial (best performance) as the final score.

26. For the FR, a leveled measuring device is mounted on the wall at shoulder height. The subject holds his arm out straight at shoulder height to establish normal reach, and then asked to reach as far as possible without taking a step, in a plane parallel with the measuring device. The reach distance is recorded. Three trials are allowed, with the farthest reach recorded as the final score.

27. Methodology: 2,305 community-dwelling elderly people of Canada were surveyed for cognitive impairment, followed by the TUG and FR during the clinical examination. Comparative measures were used to validate the results (Frailty Scale, Cumulative Illness Rating Scale, Activities of Daily Living and Older Americans Resources and Services Instrumental ADLs).

28. RESULTS: • The TUG and FR tests are not feasible in a survey setting. • The tests are more feasible when administered to a cognitively intact subject. • Moderate correlation of FR and TUG with ADLs and IADLs. • There is still a role for self-reported measures.

29. Validity of the Multi-Directional Reach Test: A Practical Measure for Limits of Stability in Older AdultsR Newton et alJ of Gerontology Apr 2001 Daily activities require shifting the center of gravity (COG) within the base of support (BOS). Once the COG moves outside the BOS, the limits of stability (LOS) are exceeded. Falls occur not only in the forward direction, but also to the side and backward. The Multi-Directional Reach Test (MDRT) measures the LOS in four directions.

30. MDRT: A yardstick affixed to a telescoping tripod is placed at the subject’s acromion process level. Subject lifts an outstretched arm to shoulder height and an initial reading is done. He then reaches as far forward as possible without moving his feet. For the backward direction, subject leans as far back as possible. The start and end positions of the index finger is recorded and the difference represents the total reach for that direction. Left and right reaches were recorded using the respective arm. Two trials were recorded in each direction.

31. Methodology: 254 community-dwelling older persons were administered the Berg Balance Test (BBT), TUG and MDRT. BBT assesses performance on 14 routinely performed activities. A 0-4 point rating system is used for each task with a maximum score of 56. Customary assistive device was permitted during the TUG test. Pearson correlation statistics were used to compare scores on the MDRT to scores of the BBT and TUG.

32. Sitting to standing Standing unsupported Sitting unsupported Standing to sitting Transfers Standing with eyes closed Standing with feet together Reaching forward with outstretched arm Retrieving object from floor Turning to look behind Turning 360 degrees Placing alternate foot on stool Standing with one foot in front Standing on one foot BERG’S BALANCE TEST:

33. RESULTS: • MDRT scores demonstrated a positive relationship with BBT scores. • MDRT scores demonstrated an inverse relationship with TUG scores. • MDRT is a valid and reliable clinical measure for limits of stability.

34. Long-term Home Exercise Program: Effect in Women atHigh Risk of FractureK Kerschan-Schindl et alArch Phys Med Rehab Mar 2000 Falling is a manifestation of failure of the neuromuscular system in the elderly. Measurements of balance are strong predictors of falling in the elderly, while poor performance on neuromuscular function testing was associated with an increased risk of hip fracture. Neuromuscular deficits are associate with an increased likelihood of falling.

35. Neuromuscular Tests: • One leg stance standing on one leg with eyes open, repeated three times for each leg, alternating from left to right. Test is timed, stopped after 30 secs. • Chair rise arms folded across chest, stand up and sit down five times in a row, from a straight-backed chair as quickly as possible. Time is recorded. • Tandem walk 2 meter line, 5 cm wide walk. In addition to time, number of errors are also counted.

36. Body sway 40 cm rod extending anteriorly is attached to subject’s waist level. A pen is fixed at end of this rod. Subject stands in front of table where a paper with a convoluted track is placed. Subjects are to trace the track with the pen. Number of errors are recorded. • Tapping test Tests coordination of the upper extremities. Two electrostatic contact sensors are fixed, 50 cm from each other. Subject asked to tap the sensors alternately as quickly as possible. Time needed for 20 tap cycles is registered.

37. Interventions: • Correct causes of fall • Exercise • Education on home safety

38. Fall and Injury Preventionin Older PeopleLiving in Residential Care FacilitiesJ Jensen et alAnnals of Internal Medicine May 2002 An intervention program that targeted multiple risk factors for falls in older people living in residential care facilities would reduce falls and fall related injuries. 439 subjects, 65 years and older, living in 9 residential care facilities in Sweden. Study design is cluster randomized, controlled, nonblinded trial. Subjects divided into control and intervention groups.

39. METHODOLOGY: 11 week multidisciplinary program that targeted general and resident-specific risk factors for falling. 34 weeks follow-up of residents. STRATEGIES: • Staff education on risk factors for falls and intervention strategies. • Environmental modification. • Exercise for strength, balance, gait and safe transfer.

40. Supply or repair of mobility aids, including walkers, wheelchairs and footwear. • Change in medication • Provision of hip protectors • Post-fall problem-solving conferences • Staff guidance

41. PRIMARY OUTCOMES: • Number of residents sustaining a fall • Number of falls • Time of occurrence of the first fall SECONDARY OUTCOME: • Number of injuries resulting from falls

42. RESULTS: • 44% of intervention group had a fall vs 56% of control group. • 26% of intervention group sustained more than one fall vs 33% in the control group. • Incidence of falls was 6.7 / 1000 person days in the intervention group vs 8.3 / 1000 days in the control group. • Time to first fall was longer for the intervention group than the control group. • 1.6% of the intervention group had a femoral fracture vs 6.1% in the control group.

43. CONCLUSION: An interdisciplinary, multifactorial fall prevention program that avoids the use of physical restraints and that targets older people, staff and residential care environment may reduce the number of residents who fall, the total number of falls and femoral fractures.

44. Randomized Factorial Trial of Falls Prevention among Older People Living in their Own HomesL Day et alBMJ July 2002 1,090 Australians, aged 70 and over were divided into three intervention groups (group based exercise, home hazard management and vision improvement). Design is randomized controlled with full factorial trial. Main outcome measure is time to first fall ascertained by an 18 month falls calendar. Participants reported falls using a monthly postcard calendar system.

45. Interventions: • Group based exercises weekly one hour exercise class for 15 weeks • Home hazards home hazards removed or modified by participants or a professional home maintenance group • Vision participants’ vision were tested then treatment provided

46. RESULTS: • Group based exercise was the most potent single intervention tested, with a reduction in falls. • Effects of the interventions were additive.

47. Exercise Training for Rehabilitation & Secondary Prevention of Falls in Geriatric Patients with a History of Injurious FallsK Hauer et alJ Am Geriatric Society Jan 2001 57 female geriatric patients admitted in acute care or inpatient rehabilitation with history of fall. Intervention included ambulatory strength training, functional performance and balance training 3x/week for 3 months. Patients were measured for strength, functional ability, motor function, psychological parameters and fall rates at the start, end, and 3 months post intervention

48. Strength training resistance at 70-90% of maximum workload. Load is increased at each training session. Each session lasting 1.5 hours. • Progressive functional-balance training performed in static and dynamic positions. (Ball throwing and catching, group games, basic dance, tai chi). Each session lasting 45 minutes.

49. Physical Function Measurements: • Maximal gait speed over 15 meter course • Stair climbing performance • Ability to rise from a standard chair • Maximal step height with a stepping platform • Timed up and go test • Functional Reach test • Balance performance in 5 positions (feet apart, feet parallel side by side, semi-tandem, tandem, one leg stance left and right under different conditions – eyes open with and without front outstretched hands; eyes closed with and without front outstretched hands).

50. RESULTS: Patients in the intervention group increased strength, functional motor performance and balance significantly. Fall related behavioral and emotional restrictions were also reduced significantly.