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This article discusses the prevalence of falls in the geriatric population, the potential injuries that can result from falls, and a new conceptual framework for reducing the risk of future injury. It also provides practical interventions for healthcare professionals to consider in their care of elderly patients.
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Geriatric Falls for the Inpatient PhysicianTranslating Knowledge into Action Ethan Cumbler M.D. Associate Professor of Medicine Director UCH Acute Care For Elderly Services University of Colorado Anshcutz Medical Campus
IMPACT • 30-40% of people over age 65 will have a fall each year • The percentage higher for patients who reside in nursing homes • In an elderly patient who has fallen, the risk of having a second fall within a year rises to 60% • 8% of all people over age 70 will present to the ER each year after a fall. 1/3 will be admitted • Think about how many ED visits that creates….
Consequences • Many falls cause minor or no injury. Skin tears and lacerations may require ED treatment but generally cause no lasting harm. • Between 5 and 10% of community dwelling elderly patients who fall (up to 20-30% of elderly patients overall) will suffer a serious injury • What injuries are particularly problematic?
Injuries • Hip Fractures-1% of falls in the elderly lead to hip fx • 20-30% mortality in the year after hip fx • ¼ to ¾ of patients do not recover prior level of ADLs
Injuries • Prolonged lie- 1/2 of elderly are unable to get back up • 2o rhabdo, dehydration/ARF, pressure ulcers • What duration of unrelieved pressure does it take to create skin damage? • Subdural Hematoma • What changes to the structure of the brain as patients age increase the risk of SDH? • Rib Fractures- • Mortality 12% with 1-2 rib fx. • Rising to 40% in patients with 7 or more fx
Post Fall Anxiety Syndrome Self-limiting activity, worsening deconditioning, social isolation • Picture the Geriatric Fall as a node on a decline spiral • Probably not the first step in the decline • Fall as symptom of underlying frailty • Frequently will create a marked acceleration of decline photoeverywhere.com
Risk Factors • Prototypical Geriatric Syndrome • Multifactoral • More than 20 separate risk factors for falls have been identified. • Very quickly how many can you think of?
Risk Factors • The factors interact in a dynamic and exponential fashion. 27% of patients with 0-1 risk factors will have a fall compared to 78% with >4 risk factors • Unfortunately creating a list is not a particularly helpful exercise in practical patient care. • Some of these risk factors are non-modifiable (female gender) and for others effective treatment seems limited (peripheral neuropathy). • There are so many that it takes significant time just to recall them all. • We are likely to always miss a few.
A Brief Diversion…Jam • In Malcolm Gladwell’s book on cognition “Blink”, he describes a fascinating psychology experiment. • A sample table is set up at two grocery stores for customers to try a sample of jam. • One table has 6 varieties of jams, the other has 24 selections. • Which table do you think sold more jam?
The table with only 6 varieties sold far more jam. • This might seem counter-intuitive but the reason lies in the human psyche. • Faced by too many choices, customers freeze up and make no decision at all.
Why are you telling me about jam? • “Multiple Alternatives Bias” • Physicians faced with multiple possibilities unconsciously ignore some of them in order to make a list which, while incomplete, is at least more mentally manageable. • In multi-factoral geriatric syndromes such as falls, physicians frequently treat only the sequelae of the fall • Missing opportunity to intervene to prevent future injury • The multiplicity of contributors seems overwhelming- “possibility paralysis”
A New Conceptual Framework • We are going to break down the fall into its component parts • Latent risk for fall • Physiologic changes of aging • Disease and medications • Behavioral traits • Environmental trigger- the “accident” • Underlying frailty/vulnerability- the injury • Each step will lead to concrete actions to reduce the risk of future injury!
OPPORTUNITY FOR INTERVENTION • Physical therapy • Sensory Aids • (glasses) • Ambulation/Gait Aids • (4 prong cane, walker) • Review Medication list- • (remove problematic meds) • 5) Behavioral Measures (in supervised environment) • Bed Alarms for dementia with impulsivity • Scheduled toileting ↓Baroreceptor Sensitivity ↓Balancefrom vestibular and proprioception ↓vision (esp night) ↓reflex speed for correction Fall Risk Dehydration/diuretics Bp meds causing orthostasis Benzodiazepines Psychotrophics Anticholinergics Alpha antagonists Parkinsons Neuropathy Arthritis podiatry problems ↑impulsivity (esp in dementia) Environmental Trigger “Accident” 5) OT Home Safety Eval -rugs -cords -lighting -rails Fall 6) Calcium+Vitamin D/Bisphosphonate Bisphosphonate for prior frailty fx or known O/P Vitamin D level 7) Hip protectors? (uncertain benefit) Frailty Osteoporosis Decreased muscle speed to deflect injury INJURY
Prevention of Future Injury • Evidence suggests that for at-risk elders a multi-pronged targeted prevention strategy such as this can reduce the risk of future falls
What about Tests? • No specific laboratory or imaging testing is indicated in the absence of clinical correlation • Vitamin D levels are recommended by some authors • Deficiency associated with falls as well as fractures • If anemia or dehydration suspected, CBC and Chem7 reasonable • Similarly, urinalysis, B12 levels and TSH are reasonable if driven by other clinical cues. • Echo is only indicated if exam suggests valvular disease. • In the absence of syncope, chest pain, or palpitations, EKG is low yield and holter monitoring not proven to be of benefit. • Spinal or brain imaging is indicated only if neurologic findings on exam suggest lesion (or significant head injury from the fall)
Inpatient Falls • Falls with injury in the hospital are a JCAHO mandated reportable event • How do you reduce the risk of an event which rarely occurs in the presence of the physician?
Risk Assessment- Physicians • How do we as physicians assess a patient’s risk for inpatient falls? • For the most part, physicians pay little or no attention to this issue on a general medical ward. • Reliable solutions require systems change. • You can standardize a simple physician assessment for fall risk in elderly patients. Two- question falls screen: • Have you fallen in the last month? • Are you afraid of falling? • You can perform a witnessed Get-Up-And-Go test • Pay attention and you learn a lot of information about strength, balance, and gait in 30 seconds.
WORKSHOP • Using the example of a patient you have admitted in the last 48 hours, would you rate their risk of inpatient fall as low, moderate, or high? • How do you think the nursing staff rated this patient’s fall risk? • Where would you find the nursing assessment? • What changes does the hospital system put in place for patients at moderate or high risk? • What changes can we as physicians institute to reduce the risk of falls?
Hospital Fall Prevention Measures Triggered By A High Risk Patient
What Changes Can You Make For The Patient Identified In Your Case
Physician Measures to Reduce Hospital Falls • Recognition of patients at increased risk should cause us to critically examine the orders we are writing which influence chance of inpatient falls. • Review med list to determine if some medications should not be continued • For instance, be more hesitant to allow zolpidem for sleep in the unstable patient with nocturia. • Minimize Patient Tethers • Heparin/LMWH instead of SCDs for DVT prophylaxis • Early elimination of IV drips • Early removal of urinary catheters • Involve PT/OT/Assisted ambulation rather than independent ambulation for moderate+high risk patients • Schedule toileting
Thought Experiment • If you were in charge of the hospital what systems changes would you put in place to reduce the risk of hospital falls or resultant injury?