Geriatric Medicine Principles Falls Robert Kirby, MD, FACP Clinical Professor of Medicine

1. Geriatric MedicinePrinciplesFallsRobert Kirby, MD, FACPClinical Professor of Medicine

2. Geriatric Medicine

3. Geriatric MedicinePrinciples/ Falls Learning Objectives: 1. List two characteristics of the geriatric population. 2. Describe two instruments to assess function. 3. Define geriatric syndrome. Name three. 4. List four risk factors for falls. 5. Outline three interventions to reduce fall risk.

4. Biology of Aging Genetic Oxidative Stress Mitochondrial Dysfunction Hormonal Changes Telomere Shortening (Hayflick Limit) Defective Host Defenses Accumulation of Senescent Cells Harrison on Line

5. Demographics USA 2020 >65 yo 16% Dependency Ratio-Europe 2050 22% to >50% Harrison on Line Merck Manual Geriatrics

6. Demographics Over Age 65 40% of Hospital Resources 24% of Office Visits 25% of Prescription Drug Costs 25% of Medicare expenditure in last year of life- Half of this in last 60 days Residents of Nursing Homes Age 65 1% Age 85 17% Merck Manual of Geriatrics

7. Condition Age 65 % Age 75 % Chronic Disease Burden Merck Manual Geriatrics

8. Life Expectancy Walter LC, Covinsky KE, JAMA 2001

9. Function: Activities of Daily Living Basic Intermediate Dressing Shopping Eating Housework Ambulating Accounting Toileting Food Preparation Hygiene Transportation

10. Function with Aging

11. Principles in a Flash Aging is not a disease. Geriatric conditions are chronic, multiple, multifactorial Reversible conditions are underdiagnosed and undertreated Function and quality of life are critical outcomes Social support and patient preferences are critical aspects Geriatrics is multidisciplinary Cognitive and affective disorders prevalent and undiagnosed at early stages Iatrogenic disease common and often preventable Care is provided in multiple settings Ethical and end of life issues guide practice • www.cha.emory.edu/reynoldsprogram

12. Clinical Approach Notwhat diseasecaused the problem But what combinationof physiologic change, impairments and diseases are contributing And which onescan be modified Modawal

13. Geriatric Syndromes Dementia and Delerium Falls Polypharmacy Pressure Ulcers Urinary Incontinence

14. Mary Anderson This 85 year old widow presents after a fall in the bedroom of the home where she has raised her family and lives independently. She does not know why she fell, was able to ambulate after the fall and presents six hours later with a bruise on her left cheek and an abrasion on the left forearm. Daughter reports occasional confusion and some limitation of activities due to weakness. She reports a fall four months ago. PMH DJD hips and knees with chronic pain Hypertension Macular degeneration Diabetes 2 Urinary urgency and rare incontinence

15. Medications: Hydrochlorothiazide, Fentanyl patch, KCL,Tylenol, MVI Examination: BP supine 160/88; standing 3 minutes 168/92 Vision 20/50 Chest – rare crackles right base Neuro: absent achilles, romberg normal Gait antalgic secondary to right hip pain Get up and go test: 18 seconds. Uses arms to arise from chair Functional Reach test 5 inches Laboratory: Hemoglobin 11 gm/dl K 3.0 meq/L Glucose 212 mg/dl Creatinine 1.4 mg/dl BUN 24 mg/dl Urinalysis wbc 20, nitrite positive

16. Questions about Mary Anderson What is the most important risk factor for her recent fall? What is the most important physical examination finding related to her fall? What additional diagnostic studies will be helpful? What is the most important initial step in managing Mary’s fall? What consultations/referrals would be most useful?

17. Fall “Unintentional coming to rest at a lower position unrelated to obvious intrinsic or environmental factor.” Importance Risk Factors Clinical Assessment History Physical Examination Laboratory Management

18. Importance Prevalence Ambulatory Adults >65 30% per year Consequences Death Injury Fractures 10-15% Hip 1-2% Long Lie Fear of Falling Reduced Activity/Independence (25%)

19. Causes Extrinsic Environment Intrinsic Age Gait/Balance Disorder Sarcopenia Vestibular Orthostatic Hypotension Special Senses –Vision/Hearing Disease Dementia Depression Drugs Foot problems Incontinence

20. Risk Factors Muscle weakness: 4.4 History of falls: 3.0 Gait or balance deficit: 2.9 Use of assistive device: 2.6 Visual deficit: 2.5 Arthritis: 2.4 Depression: 2.2 Cognitive impairment: 1.8 Age over 80 years: 1.7 Mean RR or OR of risk factors for falls from 16 studies Data from AGS Panel on Falls Prevention. Guideline for the prevention of falls in older persons. J Am Geriatr Soc 2001;49(5):664–72.

21. Stride Length Arm Swing Slow Forward Flex Head and Torso Flexion shoulders knees Lateral Sway Gait Normal Gait Video

22. Laboratory CBC CMP EKG History-Physical Injury Details of Fall Inability to Get Up Associated Disease and Disability Drugs General Orthostatic BP Vision Cognition ( MMSE) Gait/Balance/Coordination

23. Get Up and Go Normal Abnormal

24. Modified Single Leg Stance

25. Functional Reach

26. Sharpened Romberg

27. Reducing Fall Risk Fall Risk Next Treatment Year (%) Reduces Risk(%) Fall Past Year 50 30 Gait Problem 30 20 One Risk 20 10 Two Risks 30 20 Three Risks 60 40 Four or More 80 50 Treatable Risks: 1. Problem walking or moving 2. Orthostatic hypotension 3. Four or more meds or one psychoactive 4. Unsafe footwear or foot problems 5. Environmental hazard www.fallprevention.org

28. Guideline for Fall Prevention JAGS 2001. 49:664-672

29. ManagementReduce Fall Risk Environment Exercise and Balance Cardiovascular (orthostasis) Vision Assistive Devices Medication Review Footwear Behavior Education Restraints Rubinstein Med Clin N Am 2006

30. ManagementReduce Fall Risk -47% Exercise MMWR Rep 2004;53(2):25-28 Wolf JAGS 1996

31. Hip Protectors Reduce Fracture Risk Vitamin D/Calcium 400-800IU / 1200-1500 Lauritzen JB, Peterson MM et al Lancet 1993; 341:11-13.

32. Questions about Mary Anderson What is the most important risk factor for her recent fall? a. History of previous falls b. Medications c. Possible urinary infection and/or dementia d. Gait disorder e. Visual impairment

33. Questions about Mary Anderson 2. What is the most important physical examination finding related to her fall? a. Extent of injury and pain b. Result of blood pressure c. Result of “Up and Go Test” d. Visual acuity e. Neurologic findings

34. Questions about Mary Anderson What additional diagnostic studies will be helpful? a. Twenty four hour ambulatory EKG ( Holter) monitor b. Carotid Doppler study c. Brain MRI d. Head-up tilt test e. Radiograph of chest and hips f. Electoroencephalogram (EEG)

35. Questions about Mary Anderson 4. What is the most important initial step in managing Mary’s fall? a. Reduce hydrochlorothiazide and fentanyl b. Hydrate and treat UTI c. Treat injury and pain d. Osteoporosis treatment e. Counsel on “fear of falling” f. Recommend hip protectors

36. Questions about Mary Anderson 5. What consultations/referrals would be most useful? a. Ophthalmology b. Physical Therapy for strengthening exercise c. Home safety evaluation by Occupational Therapy d. Neurology consultation e. Cardiology consultation

37. Geriatric MedicinePrinciples/ Falls Learning Objectives: 1. List two characteristics of the geriatric population. 2. Describe two instruments to assess function. 3. Define geriatric syndrome. Name three. 4. List four risk factors for falls. 5. Outline three interventions to reduce fall risk.