FallsFalls

By Dr. Cuong Ngo-MinhBy Dr. Cuong Ngo-Minh

Back to Basics Back to Basics April 14th 2010 April 14th 2010

Falls prevalence in the older personFalls prevalence in the older person

• 30% of seniors living in community fall each year.30% of seniors living in community fall each year.

• 50% of nursing home and hospital residents fall 50% of nursing home and hospital residents fall annually each year.annually each year.

• 1 in 10 falls result in serious injury 1 in 10 falls result in serious injury

(6% require hospitalization)(6% require hospitalization)

Risk for fallsRisk for falls

• Usually multiple factors; age >75 is risk factor (screen Usually multiple factors; age >75 is risk factor (screen Hx of falls)Hx of falls)

• only 1/3 falls have a single causeonly 1/3 falls have a single cause

• Risk of falling is highest the month post-dischargeRisk of falling is highest the month post-discharge and w/ acute illness or exacerbation of chronic illnessand w/ acute illness or exacerbation of chronic illness

• Interactions between long term or short term Interactions between long term or short term predisposing factors & short term precipitating predisposing factors & short term precipitating factors in person’s environmentfactors in person’s environment

History Focused data gatheringHistory Focused data gathering

• Thoroughly detailing the fall and preceding Thoroughly detailing the fall and preceding momentsmoments

• Look for contributing factorsLook for contributing factors• 11stst or recurrent fall…..strongest predictor for fall is or recurrent fall…..strongest predictor for fall is

prior fallprior fall• Location and time of fallLocation and time of fall

• Events, activities, & symptoms preceding the fall:Events, activities, & symptoms preceding the fall: -lightheadedness or positional changes-lightheadedness or positional changes - palpitations, chest pain- palpitations, chest pain -following fall: LOC, incontinence, confusion-following fall: LOC, incontinence, confusion

Falls causesFalls causes

• Extrinsic factorsExtrinsic factorsa) Environment:a) Environment: Loose rugs; slippery floors; uneven door thresholds; Loose rugs; slippery floors; uneven door thresholds;

poor lighting; furniture and fixtures of inappropriate poor lighting; furniture and fixtures of inappropriate height, stairs, chairs lacking arm supportheight, stairs, chairs lacking arm support

b) Medications & alcohol:b) Medications & alcohol: 1. polypharmacy (more than 3 prescription meds)1. polypharmacy (more than 3 prescription meds) 2. use of alcohol, leisure drugs2. use of alcohol, leisure drugs 3. psychotropic drugs double risk(also sleeping 3. psychotropic drugs double risk(also sleeping

pills)pills) 4. anticonvulsants & antiarrythmics (class 1A)4. anticonvulsants & antiarrythmics (class 1A)

Intrinsic factors 1Intrinsic factors 1

• Hypotension (orthostatic, post-prandial, or drug-Hypotension (orthostatic, post-prandial, or drug-related)related)

- assoc w/ up to 20% of falls- assoc w/ up to 20% of falls - affects 15% of seniors, 30 % of those treated for - affects 15% of seniors, 30 % of those treated for

hypertensionhypertension

-age-related changes (decreased vascular -age-related changes (decreased vascular compliance, impaired baroreflex sensitivity, compliance, impaired baroreflex sensitivity, predisposition to postprandial hypotension)predisposition to postprandial hypotension)

- Antihypertensives, diuretics, anticholinergics, - Antihypertensives, diuretics, anticholinergics, psychoactive drugs, benzodiazepines, SSRIs, psychoactive drugs, benzodiazepines, SSRIs, tricyclic meds, neurolepticstricyclic meds, neuroleptics

Intrinsic Factors 2Intrinsic Factors 2

• Acute illnessAcute illness

• Visual impairmentVisual impairment

• Gait, balance, and mobility disordersGait, balance, and mobility disorders

• Lower limb weaknessLower limb weakness

• Fear of falling (post-fall syndrome)Fear of falling (post-fall syndrome)

Acute illnessAcute illness

• Falls may be a nonspecific sign of acute illness or Falls may be a nonspecific sign of acute illness or acute exacerbation of chronic conditions (cardiac acute exacerbation of chronic conditions (cardiac arrythmia, valvular heart disease, syncope, arrythmia, valvular heart disease, syncope, lumbar stenosis)lumbar stenosis)

• 10-20% of falls are related to acute illness10-20% of falls are related to acute illness

(think delirium in the elderly)(think delirium in the elderly)

Visual impairmentVisual impairment

• Age-related including visual acuity, decline in Age-related including visual acuity, decline in accommodation, altered depth perceptionaccommodation, altered depth perception

• Cataracts, glare intoleranceCataracts, glare intolerance

• Slowed light-dark adaptationSlowed light-dark adaptation

Gait, balance & mobility disordersGait, balance & mobility disorders

• 3-fold increase in risk3-fold increase in risk

• Age-related changes: postural instability, Age-related changes: postural instability, decreased central integration from all senses, decreased central integration from all senses, slowed reaction timeslowed reaction time

• Associated w/ arthritis, stroke, parkinson’s Associated w/ arthritis, stroke, parkinson’s disease, foot problemsdisease, foot problems

Lower limb weaknessLower limb weakness

• Common, 5 –fold increase in fallsCommon, 5 –fold increase in falls

• Arises from inactivity with arthritis, Arises from inactivity with arthritis, immobilisation syndromeimmobilisation syndrome

Preventing fallsPreventing falls

• Ask all pts> 75 yrs about falls in past yr and gait Ask all pts> 75 yrs about falls in past yr and gait or balance difficultiesor balance difficulties

• 2 or more falls or balance or gait difficulties 2 or more falls or balance or gait difficulties require torequire to

Observe pts getting up and out of chair w/o using Observe pts getting up and out of chair w/o using arms and walking. The “Get up and Go test”arms and walking. The “Get up and Go test”

- Screening test for safe mobility- Screening test for safe mobility

- Observe standing up, walking, turning, stopping - Observe standing up, walking, turning, stopping and sitting down.and sitting down.

Fall evaluationFall evaluation

• AssessmentAssessment

• History (from client and collateral info, witness of History (from client and collateral info, witness of fall)fall)

• Meds (all list with over the counter products)Meds (all list with over the counter products)

• Physical exam, Vitals with orthostatic BPPhysical exam, Vitals with orthostatic BP

• VisionVision

• Gait and BalanceGait and Balance

• Lower limb jointsLower limb joints

• Neuro/ CardiovascularNeuro/ Cardiovascular

Physical examPhysical exam

• Cardio and vitals:Cardio and vitals: - postural changes in BP- postural changes in BP - pulse rate and rhythm- pulse rate and rhythm - increased resp rate? (CHF, pneumonia or early - increased resp rate? (CHF, pneumonia or early

sepsis)sepsis) - recent wt changes ( dehydration or serious illness)- recent wt changes ( dehydration or serious illness)• MSK exam: joint ROM, and muscle strengthMSK exam: joint ROM, and muscle strength• * Gait, Balance, mobility, GET UP AND GO TEST* Gait, Balance, mobility, GET UP AND GO TEST• Common foot problems, check FootwearCommon foot problems, check Footwear• Neuro exam: tone, power, reflexes, proprioception, Neuro exam: tone, power, reflexes, proprioception,

sensation, cerebellar, visual acuity and fields, sensation, cerebellar, visual acuity and fields, hearinghearing

• Mental status: screen for depression or cognitive Mental status: screen for depression or cognitive Impairment.Impairment.

Multifactorial interventionMultifactorial intervention

• Gait, balance, exercise programsGait, balance, exercise programs

• Medication/polypharmacy modificationMedication/polypharmacy modification

• Postural hypotension treatmentPostural hypotension treatment

• Environment hazard modificationEnvironment hazard modification

• Targeted medical and cardiovascular disorder txTargeted medical and cardiovascular disorder tx

Lab tests and imagingLab tests and imaging

• Complete blood countComplete blood count

• Serum, lytes, bun/creatinineSerum, lytes, bun/creatinine

• GlucoseGlucose

• Vit B12, TSHVit B12, TSH

• Neuro imaging-only if head trauma/focal deficitNeuro imaging-only if head trauma/focal deficit

• Rarely EEG, Holter (depending if suspect seizure Rarely EEG, Holter (depending if suspect seizure disorder or arrhytmia) disorder or arrhytmia)

Counsel and educateCounsel and educate

• Educate about falls risk (extrinsic and intrinsic Educate about falls risk (extrinsic and intrinsic factors)factors)

• How to fall safely and get up when fallenHow to fall safely and get up when fallen

• Personal-emergency response teamPersonal-emergency response team

• Community-based exercise programCommunity-based exercise program

• Progressive balance/ strengtheningProgressive balance/ strengthening

• Home hazard reductionHome hazard reduction

• Low bone-density-hip protectors.Low bone-density-hip protectors.

Confidentiality and legal aspect (Cleo 4.2 Confidentiality and legal aspect (Cleo 4.2 and 5.3)and 5.3)

and Medical records (Cleo 6.5)and Medical records (Cleo 6.5)

• By default, not disclose info unless specific consent from clientBy default, not disclose info unless specific consent from client

• Reporting to Ministry of Transportation is a duty if safety of Reporting to Ministry of Transportation is a duty if safety of public is at sakepublic is at sake

• ““patients who have had a fall should be evaluated for ability to patients who have had a fall should be evaluated for ability to drive. If identified as unsafe, authorities in charge of driving drive. If identified as unsafe, authorities in charge of driving may need to be informed for on-the-road evaluation”may need to be informed for on-the-road evaluation”

• Duty to warn threatened individualsDuty to warn threatened individuals

• Duty to maintain adequate records (re SOAP )Duty to maintain adequate records (re SOAP )

RessourcesRessources

• 1) Practice Based Learning Program from 1) Practice Based Learning Program from McMaster University, Module on Falls in the McMaster University, Module on Falls in the Elderly, Vol 11(9), August 2003Elderly, Vol 11(9), August 2003