Falls in Older Adults

1. Falls in Older Adults Joseph G. Ouslander, MD Professor of Medicine and NursingDirector, Division of Geriatric Medicine and GerontologyChief Medical OfficerWesley Woods Center of Emory UniversityDirector, Emory Center for Health in AgingResearch Scientist, Birmingham/Atlanta GRECC Prepared for the Department of Otolaryngology Emory University School of Medicine Supported by the John A. Hartford Foundation and the Donald W. Reynolds Foundation

2. Falls in Older Adults Learning Objectives • Review the epidemiology and consequences of falls in the elderly • Understand common causes of falls in this population • Determine the appropriate diagnostic of older people who fall • Identify targeted management strategies for common causes of falls

3. Falls in Older Adults Definition An event which results in a person unintentionally coming to rest on the ground or some other lower level, and not being due to syncope, stroke, or sustaining a violent blow

4. Falls in Older Adults Epidemiology • Community dwelling: 1 in 3 fall in a year • Nursing home: 50% fall in a year

5. Falls in Older Adults Consequences of Falls • Fractures • Soft-tissue injuries • Closed head injuries/subdural hematomas • Prolonged lying on the ground (rhabdomyolysis) • Fear of falling/restriction in activity • Use of restraints • Institutionalization • Death

6. Falls in Older Adults Falls Affect Prognosis • Falls occur in both frail and healthy older persons • Single falls are not necessarily an indicator of poor prognosis • Multiple falls are associated with disability and poor health outcomes • Multiple falls are a marker for other underlying conditions that put older persons at increased risk for adverse health outcomes

7. Falls in Older Adults A Typical Case (1) Mr. C. is an 89 year old man who is referred to you for the evaluation of vertigo. His daughter says that he has fallen 3 times in the past month after discharge from the hospital for a “small heart attack and heart failure”.

8. Falls in Older Adults A Typical Case (2) Mr. C. has no prior history of falls. His chronic medical problems include: • Coronary artery disease • Hypertension • Congestive heart failure • Degenerative joint disease mainly of the right hip and knee • Insomnia related to pain in his knee

9. Falls in Older Adults A Typical Case (3) Mr. C’s medications include: • Furosemide and postassium supplement • Enalapril • Nitroglycerin patch 12 hours per day • Propoxephene as needed for pain • Zolpidem as needed for sleep

10. Falls in Older Adults A Typical Case (4) Further history reveals that each fall occurred in the morning after breakfast. He gets up, and when he starts walking he feels “dizzy”. He has not to his knowledge passed out or sustained any severe injury with these falls. There is no history suggestive of a seizure.

11. Falls in Older Adults A Typical Case (5) Physical Exam reveals: • Mr. C. appears well and has no signs of trauma • Sitting BP and P are 102/58 and 66; standing BP and P after 1 minute are 88/52 and 72 • Heart rhythm and sounds are normal • Lungs have bilateral crackles at both lung bases • Musculoskeletal exam shows very limited range of motion of the right hip with pain on internal rotation, and crepitus and pain with flexion of the right knee • Neurological exam is non-focal without evidence of peripheral neuropathy, but rapid movement of his head reproduces his vertigo

12. Falls in Older Adults A Typical Case (6) Get Up and Go observation reveals: • Difficulty arising without physical assistance • Negative Romberg test • Abnormal gait due to guarding his right side • Difficulty and imbalance when turning

13. Falls in Older Adults A Typical Case (7) • What do you think is contributing to Mr. C’s falls? • What diagnostic tests would you order? • What interventions would you implement?

14. Falls in Older Adults Causes of Falls • Intrinsic Factors • Acute Conditions • Chronic Conditions • Medications used to treat acute and chronic conditions • Activity/Behavior • Extrinsic factors • Environment • Often Multi-factorial

15. Falls in Older Adults Classifications of Falls Community-Dwelling: 41% environment related 13% weakness, balance or gait disorder 8% dizziness or vertigo Nursing Home: 16% environment related 26% weakness, balance or gait disorder 25% dizziness or vertigo Rubenstein, et al. Ann Intern Med 1994;121;442 – 451

16. Falls in Older Adults Causes of Falls – Acute Intrinsic Factors • Any acute illness • Infection, MI, stroke, CHF, etc • Postural hypotension • Medications

17. Falls in Older Adults Causes of Falls – Postural Hypotension • Volume depletion • Deconditioing • Post-prandial • Autonomic dysfunction • Parkinson’s disease, diabetes, other • Medications

18. Falls in Older Adults Causes of Falls – Medications • Decreased mental alertness • Impaired cognitive function and/or judgment • Hypotension • Postural hypotension

19. Falls in Older Adults Causes of Falls – Medications • Antipsychotics • Sedatives, hypnotics, anxiolytics • Especially benzodiazepines • Antihypertensives • Diuretics • Nitrates • Others • Antidepressants • Antiarrythmics • Anticonvulsants

20. Falls in Older Adults Intrinsic Factors: Age-related Changes • Reduced strength • Decreased postural stability • Prolonged reaction time • Decreased visual acuity and depth perception • Changes in gait • Less ability to dual task (e.g. rushing to the toilet concentrating on urinary urgency)

21. Falls in Older Adults Neurological Components for Intact Balance and Gait • Senory Input • Visual • Proprioceptive • Motor Output • Pyramidal • Extrapyramidal • Cerebellar • Central Integration • Postural reflexes • Cognitive • Affective

22. Falls in Older Adults Intrinsic Factors • Neurological • Cardiovascular • Musculoskeletal • Foot Disorders

23. Falls in Older Adults Neurological Disorders Contributing to Falls • Impaired Sensory Input • Visual (e.g. macular degeneration) • Vestibular (e.g. benign positional vertigo) • Proprioceptive (e.g. diabetic peripheral neuropathy) • Motor Weakness or Control (e.g. stroke, Parkinson’s Disease) • Cerebellar Disorders (e.g. ataxia) • Cognitive Disorders (e.g. Alzheimer’s Disease)

24. Falls in Older Adults Cardiovascular Disorders Contributing to Falls • Arryhthmias • Aortic Stenosis • Severe peripheral edema

25. Falls in Older Adults Musculoskeletal Factors Contributing to Falls • Joint Pain • Previous Fractures • Skeletal or Joint Deformities • Unstable Joints • Spine osteoarthritis with neurological involvement

26. Falls in Older Adults Foot Disorders Contributing to Falls • Painful conditions • Joint deformities • Improperly fitted or risky shoes (e.g. slippery soles, high spiked heels)

27. Falls in Older Adults Activity and Behavioral Factors • Excess alcohol intake • Unsafe activities • Poor judgment in patients with dementia

28. Falls in Older Adults Extrinsic Factors • Over 70% of falls occur at home • Environmental factors may be present in 50% of falls • Most commonly these are objects that cause a trip or a slip • Environmental difficulties depend on the individual’s disabilities and susceptibilities

29. Falls in Older Adults Extrinsic Factors • Ill-fitting clothes or footwear • Furniture, rugs, lamp cords • Physical features – stairs, tight areas, clutter • Poor lighting, visual distortions or distractions • Slippery or wet surfaces • Yard obstacles • Pets that get under foot

30. Falls in Older Adults Evaluation • Falls in the elderly are generally multi-factorial • Risk of falling increases with the number of predisposing conditions • Identify all potential contributing problems by systematic clinical evaluation • Evaluation forms the basis for specific treatments and preventive strategies • Goals are to identify: • Reversible conditions and environmental factors • Modifiable impairments • Fixed disabilities requiring compensation

31. Falls in Older Adults Evaluation - Falls History “SPLATT” Symptoms Previous falls Location Activity Time Trauma

32. Falls in Older Adults Evaluation - Falls History • Detailed history of the fall • What, When, Where, Why • Activity • Environmental factors • Associated symptoms, e.g. • Postural lightheadedness • Vertigo • Syncope or near syncope • Seizure (tongue biting, incontinence) • Circumstances of any previous falls • History of any intrinsic risk factors • Medication review • Alcohol intake • Assessment for acute illness (e.g. dehydration, infection, acute cardiac or neurological symptoms)

33. Falls in Older Adults Evaluation – Physical Exam • Postural vital signs • Vision • Cardiovascular (CHF, edema, arrhythmias) • Musculoskeletal (pain, deformity) • Feet and footwear • Neurological (focal signs, peripheral neuropathy) • Mental status (cognition, judgment) • Balance and Gait (with assistive device if used) Watch the patient get up and walk! (“Get Up and Go” Test)

34. Falls in Older Adults Evaluation – “Get Up and Go” Test

35. Falls in Older Adults Evaluation – Diagnostic Tests • Routine testing has limited value in the assessment of falls • Extensive diagnostic work-up generally not required • Should be guided by history and physical exam • Helpful in evaluating acute problems • Dehydration, infection, anemia, trauma • EKG and event monitoring not necessary as part of routine evaluation after a fall

36. Falls in Older Adults Interventions • Goals are to: • Minimize risk of falling • Preserve mobility and independence • Multi-component interventions should be based on the evaluation • Preventive strategies should address intrinsic and environmental factors

37. Falls in Older Adults Interventions • Medical • Rehabilitative • Environmental /Behavioral • Surgical

38. Falls in Older Adults Examples of Medical Interventions • Manage acute medical problems that may have contributed to the fall (s) • Assess and treat postural hypotension • Adjust medication (s) if indicated • Reduce alcohol intake if indicated • Optimize management of chronic medical conditions that increase fall risk • Parkinson’s disease • Cardiovascular disease • Musculoskeletal disorders • Anemia • Diabetes • Ophthalmology assessment for visual problems • Evaluate for treatable causes of neuropathy if present • Assess and treat osteoporosis in those at risk

39. Falls in Older Adults Examples of Rehabilitative Interventions • Gait and balance training • Physical Therapy • Tai Chi • Strengthening exercises for muscular weakness • Physical therapy modalities for pain (e.g. heat, cold, ultrasound, massage, etc.) • Balance exercises for vestibular and proprioceptive problems • Habituation exercises for benign positional vertigo • Ensure patient has correct walking aid and uses it appropriately • Training in safe performance of daily activities • Braces – e.g. ankle-foot orthotic (AFO) for foot drop • Shoe orthotic for painful foot problems and leg length discrepancy

40. Falls in Older Adults Examples of Environmental and Behavioral Interventions • Bathroom modifications: grab bars, raised toilet seat, rubber mat in tub or shower • Improve lighting, use of night light • Nonskid throw rugs • Remove obstacles from walking paths • Stair safety • Proper storage of items • Bed and chairs at appropriate height • Proper footwear and clothing • Hip protectors for those at high risk

41. Falls in Older Adults Examples of Surgical Interventions • Joint surgery or replacement for painful arthritis • Neural decompression for neuropathic pain • Cataract extraction for vision impairment • Treatment of calluses, bunions, and foot deformities by podiatrist

42. Falls in Older Adults Summary • Falls are common in both community and institutionalized older persons • They are associated with significant morbidity and can cause mortality • Most falls are multi-factorial, involving an interaction between intrinsic risk factors, activity, and environment • The evaluation of the elderly faller should be directed towards identifying multiple risk factors that can contribute to falls • Medical, rehabilitative, environmental/behavioral, and targeted surgical interventions may decrease the incidence of falls and fall-related injuries

43. Falls in Older Adults A Typical Case (1) Mr. C. is an 89 year old man who is referred to you for the evaluation of vertigo. His daughter says that he has fallen 3 times in the past month after discharge from the hospital for a “small heart attack and heart failure”.

44. Falls in Older Adults A Typical Case (2) Mr. C. has no prior history of falls. His chronic medical problems include: • Coronary artery disease • Hypertension • Congestive heart failure • Degenerative joint disease mainly of the right hip and knee • Insomnia related to pain in his knee

45. Falls in Older Adults A Typical Case (3) Mr. C’s medications include: • Furosemide and postassium supplement • Enalapril • Nitroglycerin patch 12 hours per day • Propoxephene as needed for pain • Zolpidem as needed for sleep

46. Falls in Older Adults A Typical Case (4) Further history reveals that each fall occurred in the morning after breakfast. He gets up, and when he starts walking he feels “dizzy”. He has not to his knowledge passed out or sustained any severe injury with these falls. There is no history suggestive of a seizure.

47. Falls in Older Adults A Typical Case (5) Physical Exam reveals: • Mr. C. appears well and has no signs of trauma • Sitting BP and P are 102/58 and 66; standing BP and P after 1 minute are 88/52 and 72 • Heart rhythm and sounds are normal • Lungs have bilateral crackles at both lung bases • Musculoskeletal exam shows very limited range of motion of the right hip with pain on internal rotation, and crepitus and pain with flexion of the right knee • Neurological exam is non-focal without evidence of peripheral neuropathy, but rapid movement of his head reproduces his vertigo

48. Falls in Older Adults A Typical Case (6) Get Up and Go observation reveals: • Difficulty arising without physical assistance • Negative Romberg test • Abnormal gait due to guarding his right side • Difficulty and imbalance when turning

49. Falls in Older Adults A Typical Case (7) • What do you think is contributing to Mr. C’s falls? • What diagnostic tests would you order? • What interventions would you implement?

50. Falls in Older Adults A Typical Case • What do you think is contributing to Mr. C’s falls? • Postural hypotension • Volume depletion • Drug-induced • Post-prandial • Painful poorly managed arthritis • Proximal leg muscle weakness • Benign positional vertigo • Medications – propxyphene, zolpidem • Need to exclude acute problem, e.g. worsening CHF