Falls

1. Falls Sara Bradley and Christine Chang, MD Brookdale Dept of Geriatrics and Adult Development March 4. 2008 10:00-10:40

2. Objectives By the conclusion of the talk, learner will be able to: • List 5 potentially modifiable risk factors for falls in older community dwelling adults. • Conduct a physical exam specific to falls, including a gait assessment. • Discuss 5 evidenced-based interventions that can reduce future falls.

3. Falls Definition: • Unintentional change in position, coming to rest at a lower position • Not due to an overwhelming intrinsic or environmental cause • No loss of consciousness

4. Epidemiology of Falls • 1/3 of ambulatory and ½ institutionalized elderly fall each year • ½ falls result in injury (10-15 % in fractures) • ¼ of all fallers limit their activities and lifestyle due to fear of falling

5. Cost of Falls • 6% of Medicare costs • 15% of ED visits for 65+ years • Extra $24,000/person/year health costs • Totals $19 billion/year

6. Theory of Why People Fall Falls occur when: • Older adults who are predisposed because of accumulated effect of diseases / impairments (intrinsic) • Are exposed to precipitating challenges (extrinsic)

7. Evaluation of Falls: History • Describe fall • Ask questions to R/O syncope • Use systematic method to look into etiology of falls

8. Evaluation of Falls: History Immutable Predisposing Factors • Age • Female • Variable for falls • Risk injury • Past fall

9. Evaluation of Falls: History Modifiable Predisposing Factors (Intrinsic) • Decreased strength ( fall risk 4 X) • Impaired balance, gait ( fall risk 3 X) • Visual • Depth perception ( fall risk 2.5 X) • Contrast sensitivity

10. Evaluation of Falls: History Modifiable Predisposing Factors (Intrinsic) • Disease management • Stroke • Parkinsonism • Orthostasis ( fall risk 2 X) • Cognitive impairment ( fall risk 2X) • Depressive symptoms ( fall risk 1.5X) • Foot problems ( fall risk 2X) + Arthritis

11. Evaluation of Falls: History Modifiable Precipitators of Falls (extrinsic) 1. Medications • 4+ Medications • High risk medications: • Psychotropics (e.g. sedatives, antidepressants-SSRI & TCA) • Antihypertensives • Digoxin • Anticholinergics

12. Evaluation of Falls: History Modifiable Precipitators of Falls (extrinsic) • Acute illness • Multi-focal lens • Footwear • Environment: Stairs; tripping hazards • Unsafe behaviors

13. Evaluation of Falls: Physical • Check orthostatics • Perform a visual exam if once has not been done in the last year • Look for cataracts • Test visual acuity with glasses • Evaluate cognition with the 3 Item Recall

14. Evaluation of Falls: Physical • Gait Assessment: Motor + Balance + Coordination

15. Evaluation of Falls: Physical Motor Assessment: Quad strength: Can rise from chair without using arms

16. Evaluation of Falls: Physical Balance Assessment: 3 Stances (abnl if < 10 secs each) Consider Resistance to nudge or picking a penny off the floor One leg stand (abnl if < 10 secs)

17. Evaluation of Falls: Physical Coordination Assessment: Abnormal if: Hesitant start Broad-based gait Path deviates Heels do not clear toes of other foot Extended arms

18. Diagnostic Testing Routine: • Cbc, comprehensive chem, B12, Tsh • Drug levels, INR As indicated: • EKG/Holter & other cardiac tests • Imaging • EEG • Vestibular testing

19. Fall Prevention • Evidenced-based single intervention strategies • Interventions of unknown effectiveness • Multi-factorial assessment with targeted interventions • Gillespie L, et al. Cochrane Database Syst Rev. 2003; 4: 2005 update

20. Effective Single Interventions • Professionally supervised strength & balance training, ↓falls ~20% (3 trials) • Tai Chi group exercise ↓falls 49% (1 trial) • Home modificationin patients with h/o falls, ↓falls ~34% (3 trials) • Withdrawal of psychotropics ↓falls by 63% (1 trial) • Cardiac pacing in pts w/ carotid sinus hypersensitivity ↓falls by 58% (1 trial) • Gillespie L, et al. Cochrane Database Syst Rev. 2003; 4: 2005 update

21. Interventions That May Be Effective • Expedited Cataract Surgery Decreased the risk of recurrent falls by 40% & all falls by 34% with decreased disability & improved QOL1 • Vitamin D & Calcium Meta-analysis found vitamin D supplementation reduced the odds of falling by 22%, NNT 152 1. Harwood RH, et al. Br J Optalmol. 2005. 2. Bischoff-Gerrari HA, et al. JAMA 2004

22. Not Proven Effective • Non-specific group exercise • Targeted leg strengthening • Nutritional supplements • Cognitive behavioral approach • Hormonal therapy • Home hazard modification in non-fallers

23. Multifactorial Assessment With Targeted Intervention • Most commonly studied & consistently effective • 20+ trials showing 27% (2-37%) fall risk reduction for community dwelling older adults

24. Multifactorial Assessment With Targeted Intervention Effective components: • Balance training: 7/7 trials+ • Gait, assistive device: 4/4 trials+ • Environmental Modification: 9/11 trials+ • ↓Psychoactive meds: 4/4 trials+

25. Multifactorial Assessment With Targeted Intervention (cont) Effective components: • ↓Other meds: 4/4 trials + • Manage orthostasis: 2/2 trials + • Manage other CV & medical conditions: 2/3 trial + • Cardiac pacing: 1+ trial

26. Fall Prevention in Practice • Identify Patients At Risk • 70+ with h/o 2 or more falls or 1 injurious fall OR self-reported or observed difficulty with mobility • Ask at least annually about falls • Assess & manage the health problems that increase fall risk

27. Therapeutic Approach • Identify & treat immediate underlying causes & predisposing risk factors • Review & reduce meds • Manage postural hypotension • PT/OT evaluation for strength, balance, & gait training • Environmental modification

28. Medication Review • Decrease meds, esp psychotropics (benzos, sedatives, anti-depressants) • Taper to lowest effective dose or stop • Consider need for all meds before adding new one • Prescribe non-pharmacologic treatments • Advise pt to carry up-to-date med list

29. Postural Hypotension • Frequently unrecognized • Adequate hydration • ½ c. water every ½ hr for first 8 hrs of day • Liberalize salt in diet • Reduce meds that contribute • Teach patients to change position slowly

30. PT/OT Evaluation • Gait & strength assessment & training • Balance training • Exercises that challenge stability yet are safe • Tai chi • Assistive devices • Recommendations for & regular inspection • Appropriate footwear • High box, low heel, thin sole

31. Environmental Modification • Home safety assessment • By pt or caregiver using checklist, MD at home visit, or visiting nurse • Hazards include: • Clutter • Electric cords • Slippery throw rugs & loose carpet • Poor lighting

32. Optimize Disease Management • Vision • Test acuity, eval for cataracts, ophthalmology referral • Patient education • Allow time for eyes to accommodate to changing level of light • Do not walk using bifocals or reading glasses • Osteoporosis • Consider vitamin D, bisphosphonates

33. Clinical Pearls • Screen all pts >75 yrs for falls at least yearly • Evaluate the circumstances of the fall • Systematically evaluate for modifiable predisposing factors and precipitants • Motor/balance/gait • Environment • Medications • Vision • Disease management, including cognition

34. Acknowledgment Thanks to Dr. Helen Fernandez for her mentorship