Goals:

1. Goals: • To reduce the number of falls in the elderly • To reduce the degree of injury from falls in the elderly

2. Objectives • The learner will • 1) recognize the significance of falls • 2) understand the etiologies of falling • 3) list the appropriate evaluation of a fallen elder • 4) list the appropriate evaluations and treatments to prevent falls

3. Incidence Morbidity Mortality Falls per year 1/3 community 1/2 Nursing home Most frequent cause of accidental injury for age > 75 50% minor injury 5% fractures (not hip) 2% hip fracture 10% serious (other) 2% of injurious falls- FATAL (1/2 of these are hip fractures) Why Important ?

4. FUNCTION 50% need help to get up 3% lie helpless for for > 20 minutes 40-73% fear falling and 1/2 of these restrict activities based on fear. Complications from falls leading cause of death due to injury in all > 65 y.o. Kiel P. Falls , Geriatric Review Syllabus Why Important ?

5. Causes: of community dwellers • Accidents (environment related) 41% • Medical illnesses 17% • Gait/balance disorders 13% • Drop attacks 13% • Dizziness/vertigo 8% • Unknown 6% • Confusion 2% • Postural hypotension 1% • Visual disorder 0.8% • Syncope 0.4%

6. “Grail Quest”Rule #1: “It’s never only one thing, Always look for multiplefactors causing falls”

7. What keeps us up: Input: visual, vestibular, & proprioceptive Central processing: cortical & cerebellar Output: neurological & musculoskeletal systems What changes with age: -visual acuity -depth perception, -dark adaptation -contrast sensitivity Speed of processing complex tasks Joint ROM, Motor conduction, Strength “Why Granny Goes Down”Normal Postural Control & Aging

8. Sedatives Cognitive impairment LE disability Foot problems Balance/gait d/o Postural control dz > 2 chronic dz. ADL impairment > 2 falls per year Fear of falling Application of risk factors: > 3 risk factors: 65-100% fell over next 12 months No risk factors: 8-12% fell over next 12 months HIGHEST RISK OF FALLS: First month after discharge for those frail enough to require home care Mahoney J,JAGS 1994;42:269-74 Add: “ Disease And Medications”

9. “Grail Quest”Rule #2 “Correct any risk factors while you can”

10. Risk Modification “Be proactive” • -“Every falling elderly that gets up, gives us a chance to learn something to prevent the next fall” Eddie,1998

11. Risk Modification • Study # 1 Tinetti • Medications review & reduction, environment & behavior, strength & balance training • Result: 26-50%  in falls • Study #2 Close • 6 month exercise Result: 40 % in falls

12. Risk Modification cont’d • Study # 3-PROFET • Medical & OT evaluation. after fall • Result: • 510 falls in controls • 183 falls intervention • Study # 4 • Exercise, vision improvement and home hazard management • 14% reduction in falls • Treat 7 to prevent 1 fall • Exercise most effective component but all three were additive Day L, Fildes B, BMJ Vol 325, 20 July 2002

13. Review • Increased morbidity, mortality, and decreased quality of life associated with falls • Falls usually have multiple factors of contribution and causality. • Risk factors predict falls and guide prevention

14. GOALS of FALL Evaluation: • 1)evaluate injury • 2) evaluate cause of fall • 3) prevent future falls

15. GRAIL QUESTRule # 3 • “Look for more than one factor, and correct even the smallest factor”

16. “The Initial Steps in the Fall Evaluation”The Steps to the Quest • Step # 1 Acute Injury Evaluation • Step # 2 SYNCOPAL ?

17. Q#1 ACUTE Q#2CHRONIC but can be improved Q#3MEDICATIONS? cause or contributory Q#4REHABILITATION ? Q#5ENVIRONMENT/ BEHAVIORAL factors Plan work-up: To cover acute factors immediately Chronic factors longitudinally The Complete Evaluation of Falls“The Five Question of the Quest”(You Must Answer All Five Questions to Complete the Quest)

18. Q# 1ACUTED-E-L-I-R-I-U-M-S + Pain (mnemonic) • D rugs • E motional • L ow O2 states • I nfection • R etention • I ctal states • U ndernutrition/hydration • M etabolic • S ubdural • + Pain

19. 1) Sensory: Visual Proprioceptive Vestibular 2)Central processor: 3) Effector systems: Muscular Skeletal Examples Cataracts, refraction Neuropathy (e.g B12 def.), cervical stenosis Benign positional vertigo Parkinson’s, NPH, CVA’s Dementia, depression DISUSE ATROPHY, vit D def., Hypothyroid Feet deformity, joint instability Q#2CHRONICbut Can Be Improved

20. Suspect centrally active suppressors: Narcotics Sedatives Hypnotics Antipsychotics TCA & SSRI’s Anticholinergics Alcohol IA antiarrhythmics Ensrud KE, JAGS 50 1629-1636 2002 If orthostatic hypotension or orthostatic symptoms present: Suspect: Antihypertensives Diuretics Vasodilators Antiparkinsonian Q#3MEDICATIONSCause and/or Contributory

21. GRAIL QUESTRule # 4 • “Never miss an opportunity to perform”: • Medication debridement

22. Ask the patient to: Stand without arm assistance Walk ten feet Turn sharply Return and sit down Areas tested Hip and knee extensor strength Gait stability and speed Gait and balance Vision, LE strength, coordination Q#4REHABILITATIONScreen With:“Get Up and Go Test”

23. REMEDIES of PROVEN EFFECTIVENESS • Muscle strengthening • Balance training • Gait training

24. Muscle restrengthening used 80% of maximal effort for training level q. o. d. 120% increase strength in community dwellers. improved strength and gait velocity and increase activity level 25% reduction in falls Balance training : Tai Chi > PT guided training but both very effective Gait Training: consider especially for neurologic disease and msk dysfunction e.g. old CVA or knee OA, , Parkinson’s dz REMEDIES of PROVEN EFFECTIVENESS

25. Q#5ENVIRONMENTAL/BEHAVIORALFactors • Facts: • 25-50% of community falls due to environmental factors • The healthier the patient, the more likely the fall is due to the environment • 50% of recurrent falls in healthy community dwelling--------occur with same activity

26. How Do You Improve Home Safety? • Home safety evaluation • Compliance is questionable • Australians age > 70 y.o. (n = 342 ) • 80 % of homes inspected had >1 hazard • 39% had > 5 hazards • Bathroom is the most hazardous room • (60% had hazards) • 30% of those who rated their home as“VERY SAFE”---- had > 5 hazards • Carter SE, Age Ageing 1997 May; 26: 195-202

27. Q#5ENVIRONMENTAL/BEHAVIORALFactors • Most Common recommended modifications: • What would you guess? • remove rugs • safer footwear • nonslip bath mats • night lights • stair rails • Compliance range from 19 % to 75% Cumming RG, JAGS 1999;47:1397-402

28. How Do You Improve Home Safety? • Remedy ? • Quest rule # 5 • Give the crusader a task • That is:“have someone OTHER THAN PATIENT do the safety evaluation”

29. Does Home Safety Evaluation work? • San Francisco Elders • intervention: • -home safety evaluation and modifications • result: • 60% reduction in falls

30. REVIEW:Goals of Fall Evaluation • 1)evaluate injury • 2) evaluate cause of fall • 3) prevent future falls

31. The Initial Steps in the Fall Evaluation” • Step # 1 Acute Injury Evaluation • Step # 2 SYNCOPAL ?

32. The Complete Evaluation of Falls • Q#1ACUTE • Q#2 CHRONIC but can be improved • Q#3 MEDICATIONS? Cause &/or contributory • Q#4 REHABILITATION ? • Q#5 ENVIRONMENT/BEHAVIORAL factors • NHSYNCOPE PATH

33. May All Your Quests Be Fruitful Thank you for your kind attention !

34. INCIDENCE: 0.6-3.6 falls/resident/yr. INURY: fractures -4% serious injury -12% Non-Ambulatory most fall involve equipment occur when seated or with transfer Ambulatory: highest risk of fall non-ambulatory but capable of independent transfer ambulatory on psychotropics Nursing Home Falls

35. Environment/accident other causes gait/balance/weakness drop attack dizziness/vertigo unknown confusion postural hypotension visual disorder syncope 41% 16% 17% 12% 13% 26% 13% 0.3% 8% 25% 6% 4% 2% 10% 1% 2% 0.8% 4% 0.4% 0.2% Causes of FallscommunityNH resident

36. Physical: rel. risk Weakness 6.2 Balance def. 4.6 Gait deficit 3.6  mobility 3.3  function 3.1  vision 2.7 Post. Hypotension 2.1  cognition 1.5 Medications rel. risk Antidepressants 2.4 Sedative/hyp 2.0 NSAID’s 1.6 Vasodilators 1.4 Diagnoses: Arthritis 1.6 Depression 1.6 Risk Factors for NH Falls

37. Extrinsic factors of Falls in NH • Environment/extrinsic factors cause 20% of falls • Most falls: • Resident rooms • highest activity associated with falls: • 12% of all fallsexiting bed or bathroom

38. Interior non-slip surfaces sufficient lights glare free lights low lying objects out of way chairs at proper height and with armrest to assist transfer time-delay doors Bathroom wide doors skidproof mats in shower and stool grab bars for stool and shower elevated toilet seats Environmental safety features

39. Environmental safety features • Bedroom • bedside or nightlights for nocturnal ambulation • UNOBSTRUCTED WAY TO BATHROOM • height adjusted bed for safe transfers • completely recessible bed rails • sag-resistant edges on mattresses • appropriate shelf height in closet • movement monitoring devices • skid resistant bedside mats

40. Individualized assessment & 4 area targeting 1) environment: ( lighting, nonskid flooring and footwear.) 2) WC use & maintenance 3) psychotropic drug eval. 4) facility wide interventions ( in-service) Ray 1997 JAMA 278:557-562 19% reduction in total falls 31% decrease in injurious falls Similar studies in hospitals gave 25 % reduction in falls. AHRO Making Health care safer #43 Nursing Home fall interventions

41. Personal safety features • Hip protectors • prevents 1 hip fracture for every 41 wearing • Restraints in NH or Hospital..Help or Hinder? • HINDER!! Serious falls unrestrained 5% restrained 17% • Why? • During restraint use: decreased strength (inactivity), increased delirium and injury form attempts to escape.Tinetti M Ann. Intern. Med. 1992 116: 369-374syncope caseend

42. 78 y.o presents to ER with history of fall secondary to syncope: Unconscious for < 2 min. No seizure activity per witnesses PMHx: DM II, Hyperlipidemia HTN Meds: Glucotrol, Hytrin 120/80-60-36.5-16 COR-normal CNS-normal No injury What’s your next move ? Mr. George Falls

43. INITIAL: H & P* EKG Labs: (CBC, Lytes, BG, BUN/Cr, Ca+,SaO2, Cardiac enzymes) SYNCOPE EVALUATION Pathway

44. What symptoms, findings or historical features should indicate admission to hospital? Structural heart dz. or Cardiac sx &/or riskor Abn EKG or Unsecure home environment or Seizure sx’s or Significant injury or Neurologic symptoms Admit orders could include? : R/o MI labs/ EKG’s Cardiac monitor If Cardiac risk &/o sx or Structural heart dz Echo If Seizure sx’s: EEG If neuro sx’s/signs or head trauma: Neuorimaging SYNCOPE EVALUATION Pathway

45. If work-up Inpatient NEGATIVE But Patient has Structural heart dz. or Cardiac sx &/or riskor Abn EKG order Stress testing (Exercise stress echo or pharmacological stress test) If work-up Inpatient NEGATIVE And NO Structural heart dz? or Abn. EKG? or Cardiac risk or sx? Q: Still suspicious for arrhythmia? YES - EPS NO - PASS OUT w/u SYNCOPE EVALUATION Pathway

46. If NONE of the following in ER Structural heart dz. or Cardiac sx &/or riskor Abn EKG or Unsecure home environment or Seizure sx’s or Significant injury or Neurologic symptoms Outpatient w/u 1) Q: Still suspicious for arrhythmia? YES EPS NO PASS OUT w/u SYNCOPE EVALUATION Pathwaycontinued

48. Definition List the consequences Describe the aging physiology that predisposes to syncope List the causes Describe the evaluation Sudden LOC Mortality high in cardiac Barorecptor,  B receptors, Volume  MM tone P-A-S-S O-U-T R/o cardiac first H &P, EKG, Labs Review

49. How to remember the causes?“Mnemonics” • P-A-S-S O-U-T The following mnemonic reviews the etiologies of syncope, and pertinent data on each. • P ressure (hypotensive causes) O utput (cardiac)/O2 (hypoxia) • A rrhythmiasU nusual causes S eizuresT ransient Ischemic S ugar (hypo/hyperglycemia) Attacks & Strokes, CNS dz’s End

50. Thank you for your kind Attention!!