FALLSFALLS

Dr Alastair KerrDr Alastair Kerr

Swindon/Bath DRC April 2006Swindon/Bath DRC April 2006

OutlineOutline

• IncidenceIncidence

• SequelaeSequelae

• Risk factorsRisk factors

• AssessmentAssessment

• InterventionsInterventions

• OsteoporosisOsteoporosis

• NSF/NICENSF/NICE

IncidenceIncidence

• What % >65yrs fall in 1 year ?What % >65yrs fall in 1 year ?

• What % >75yrs fall in 1 year ?What % >75yrs fall in 1 year ?

• What % >85yrs fall in 1 year ?What % >85yrs fall in 1 year ?

• What % elderly institutional care fall in 1 What % elderly institutional care fall in 1 year ?year ?

• What % in previous fallers?What % in previous fallers?

IncidenceIncidence

• What % >65yrs fall in 1 year ?What % >65yrs fall in 1 year ? 3030

• What % >75yrs fall in 1 year ?What % >75yrs fall in 1 year ? 3535

• What % >85yrs fall in 1 year ?What % >85yrs fall in 1 year ? 4040

• What % elderly institutional care fall in 1 year ?What % elderly institutional care fall in 1 year ? >50>50

• What % in previous fallers?What % in previous fallers? 60-7060-70

SequelaeSequelae

• What % people injure themselves What % people injure themselves after a fall ?after a fall ?

• What % people fracture after falling ?What % people fracture after falling ?

SequelaeSequelae

• What % people injure themselves What % people injure themselves after a fall ?after a fall ? 40-6040-60

• What % people fracture after falling ?What % people fracture after falling ?55

SequelaeSequelae

Name 3 common sequelae of falls Name 3 common sequelae of falls

– FractureFracture

– InfectionInfection

– Fear of fallingFear of falling

SequelaeSequelae

• What is What is youryour “life space diameter” ? “life space diameter” ?

• How does a fall affect this ?How does a fall affect this ?

• How else is this known ?How else is this known ?

SequelaeSequelae

• What is What is youryour “life space diameter” ? “life space diameter” ?

A measure of your mobility potential.A measure of your mobility potential.

• How does a fall affect this ?How does a fall affect this ? Reduces Reduces itit

• How else is this known ? Fear of fallingHow else is this known ? Fear of falling

Fear of fallingFear of falling

• What percentage of pts develop this What percentage of pts develop this after a fall?after a fall? 33%33%

• Pts with fear of falling have higher Pts with fear of falling have higher risk of falling, reduced ADL’s, lower risk of falling, reduced ADL’s, lower quality of life scores, and increased quality of life scores, and increased institutionalisation.institutionalisation.

Risk FactorsRisk Factors

• EXTRINSICEXTRINSICEnvironmental Environmental

• INTRINSICINTRINSIC– MedicationMedication– DiseaseDisease

Visual problemsVisual problems NeurologicalNeurological CardiovascularCardiovascular Postural hypotensionPostural hypotension LocomotorLocomotor PsychologicalPsychological NutritionalNutritional Acute illnessAcute illness

Statistical summaries of risk Statistical summaries of risk factors for fallsfactors for falls• RISK FACTORRISK FACTOR Mean RR/ORMean RR/OR

Muscle weaknessMuscle weakness 4.44.4Falls historyFalls history 3.03.0Gait deficitGait deficit 2.92.9Balance deficitBalance deficit 2.92.9Assistive devicesAssistive devices 2.62.6Visual deficitVisual deficit 2.52.5ArthritisArthritis 2.42.4Impaired ADL’sImpaired ADL’s 2.32.3DepressionDepression 2.22.2Cognitive impairmentCognitive impairment 1.81.8Age >80Age >80 1.71.7

Age-related changesAge-related changes

• Increased postural swayIncreased postural sway

• Reduced muscle strength (NB: Hand grip)Reduced muscle strength (NB: Hand grip)

• Reduced proprioception/vibration Reduced proprioception/vibration sense/light touchsense/light touch

• Slower reaction timeSlower reaction time

• Impaired cerebral auto regulationImpaired cerebral auto regulation

• Impaired fluid homeostasisImpaired fluid homeostasis

• Decreased visual acuityDecreased visual acuity

Balance

Musculoskeletal

CNS

Environmental hazards

FALLS

Vision

Vestibular

Proprioception

Tactile sensation

MortalityMortality

• What is mortality rate for #NOF ?What is mortality rate for #NOF ?

At 1 month?At 1 month?

At 1 year?At 1 year?

• What is mortality rate for # pubic What is mortality rate for # pubic ramus ?ramus ?

MortalityMortality

• What is mortality rate for #NOF ?What is mortality rate for #NOF ?

At 1 month?At 1 month? 10%10%

At 1 year?At 1 year? 25%25%

• What is mortality rate for # pubic What is mortality rate for # pubic ramus ?ramus ?

15-20%15-20%

Falls assessmentFalls assessment

• HISTORYHISTORY– Simple fall v collapseSimple fall v collapse– What’s the most useful question to ask What’s the most useful question to ask

in taking the history in pt who has in taking the history in pt who has collapsed?collapsed?

– What factors differentiate between What factors differentiate between cardiac and neurological collapse ?cardiac and neurological collapse ?

– Which drugs are implicated ? Which drugs are implicated ?

Falls assessmentFalls assessment

• HISTORHISTOR– What’s the most useful question to ask in What’s the most useful question to ask in

taking the history in pt who has collapsed?taking the history in pt who has collapsed?• Do you remember fallingDo you remember falling

– What factors differentiate between cardiac and What factors differentiate between cardiac and neurological collapse ?neurological collapse ?• Cardiac-no warning, palpitations, rapid recovery, Cardiac-no warning, palpitations, rapid recovery,

pallor, no tongue bitingpallor, no tongue biting

– Which drugs are implicated ?Which drugs are implicated ?• Many !Many !

ExaminationExamination

• Mental test scoreMental test score• CVS (include postural BP)CVS (include postural BP)• Cranial nerves (incl. vision)Cranial nerves (incl. vision)• Vestibular assessmentVestibular assessment• Peripheral nervous system Peripheral nervous system (NB Neuropathy)(NB Neuropathy)

• Cerebellar functionCerebellar function• MusclesMuscles• JointsJoints• GaitGait(Footwear)(Footwear)

InvestigationInvestigation

• BloodsBloods

• ECG (24 hr tape if ECG abnormal)ECG (24 hr tape if ECG abnormal)

• Tilt table testTilt table test

• Carotid sinus massageCarotid sinus massage

• Dix - HallpikeDix - Hallpike

Interventions to prevent falls – Interventions to prevent falls – the evidencethe evidence

• Multidisciplinary AxMultidisciplinary Ax [FICSIT ;Tinetti 1994][FICSIT ;Tinetti 1994]

[PROFET ;Close 1999][PROFET ;Close 1999]

• Withdrawing centrally acting meds Withdrawing centrally acting meds [Campbell][Campbell]

• Strength & balance training Strength & balance training [Campbell 1997/1999][Campbell 1997/1999]

• Tai ChiTai Chi [Wolf 1996][Wolf 1996]

• CVS Ax & intervention of unexplained CVS Ax & intervention of unexplained fallersfallers [Kenny 2001][Kenny 2001]

• Cataract surgeryCataract surgery [Harwood 2005][Harwood 2005]

• Vitamin DVitamin D

THINK OF FALLSTHINK OF FALLS

THINK OF OSTEOPOROSISTHINK OF OSTEOPOROSIS

Fracture RiskFracture Risk

• Fracture risk = Fracture risk = Risk of fallingRisk of falling

BMDBMD

OsteoporosisOsteoporosis

• ““Time bomb of old ageTime bomb of old age””

• Low bone mass, microarchitectural Low bone mass, microarchitectural deterioration, increased fragility and deterioration, increased fragility and fracture risk.fracture risk.

• 1:3 females ; 1:12 males (>50yrs) will 1:3 females ; 1:12 males (>50yrs) will sustain osteoporotic fracture.sustain osteoporotic fracture.

• <5% on osteoporosis drugs.<5% on osteoporosis drugs.

Bo

ne

Mas

s

Age (years)

Attainment of Peak Bone Mass

Consolidation Age-related Bone Loss

Men

Women

Menopause

0 10 20 30 40 50 60

FractureThreshold

Compston JE. Clin Endocrinol 1990; 33:653–682.

Age Related Changes in Age Related Changes in Bone MassBone Mass

Clinical Impact of Clinical Impact of Osteoporosis Over TimeOsteoporosis Over TimeSignsSigns

• KyphosisKyphosis

• Loss of Loss of heightheight

• Tummy Tummy bulges due bulges due to loss of to loss of space under space under the ribsthe ribs

• Clinically Clinically diagnosed diagnosed fracturefracture

SymptomsSymptoms

• Weak neck and head Weak neck and head falls forwardfalls forward

• Pain in whole or part Pain in whole or part of backof back

• Breathing difficultiesBreathing difficulties

• Indigestion & gastro-Indigestion & gastro-oesophageal refluxoesophageal reflux

• Stress incontinenceStress incontinence

• Difficulty with Difficulty with mobility following #mobility following #

Hip FracturesHip Fractures

• 60,000 /yr in UK60,000 /yr in UK

• Cost : £1.7 billionCost : £1.7 billion

• 25% die at 1 year25% die at 1 year

• 50% do 50% do NOTNOT regain independence regain independence

• Osteoporosis results in more deaths than Ca Osteoporosis results in more deaths than Ca cervix/uterus/ovary combined.cervix/uterus/ovary combined.

• Nos will increase 5-fold in next 50 yrsNos will increase 5-fold in next 50 yrs

DiagnosisDiagnosis

• DEXA :DEXA : Measures B.M.D. at forearm, Measures B.M.D. at forearm, hip and spinehip and spine

• DEXA :DEXA : NormalNormal t> -1t> -1

OsteopeniaOsteopenia t -1 to -2.5t -1 to -2.5

OsteoporosisOsteoporosis t < -2.5t < -2.5

• DEXA - high specificity, low sensitivityDEXA - high specificity, low sensitivity

Risk FactorsRisk Factors

• Hx low trauma fractureHx low trauma fracture

• Steroids (incl inhalers)Steroids (incl inhalers)

• Family Hx of O.P.Family Hx of O.P.

• Premature menopause (<45yrs)Premature menopause (<45yrs)

• Secondary pre-menopausal amenorrheaSecondary pre-menopausal amenorrhea

• Low B.M.I. (<19)Low B.M.I. (<19)

• Smoking, alcoholSmoking, alcohol

• Prolonged immobilizationProlonged immobilization

• XR suggestion of osteopenia/O.P.XR suggestion of osteopenia/O.P.

• Secondary - malabsorption, IBD, hypogonadism, CRF, CLD, Secondary - malabsorption, IBD, hypogonadism, CRF, CLD, RA, primary hyperparathyroidism, Cushing’s, thyrotoxicosis.RA, primary hyperparathyroidism, Cushing’s, thyrotoxicosis.

InvestigationsInvestigations

• FBCFBC - malabsorption- malabsorption

• U and E’sU and E’s - renal failure- renal failure

• TFT’sTFT’s - hyperthyroidism- hyperthyroidism

• LFT’SLFT’S - chronic liver disease- chronic liver disease

• FSHFSH - detect menopause- detect menopause

• PV/ESR/electrophoresisPV/ESR/electrophoresis - myeloma- myeloma

• CalciumCalcium - hyperparathyroidism- hyperparathyroidism

• Testosterone/LH/SHBGTestosterone/LH/SHBG - hypogonadism in males- hypogonadism in males

• (Markers of bone turnover)(Markers of bone turnover)

Prevention of osteoporosis-Prevention of osteoporosis-lifestyle advicelifestyle advice

• Diet Diet

• ExerciseExercise

• AlcoholAlcohol

• SmokingSmoking

Interventions to prevent Interventions to prevent fracturefracture• BisphosphonatesBisphosphonates

• Ca/vitamin DCa/vitamin D

• Selective oestrogen receptor modulators (SERMS)Selective oestrogen receptor modulators (SERMS)

• Hip protectorsHip protectors [Cochrane 2005][Cochrane 2005]

• PTHPTH

• Strontium ranelateStrontium ranelate

Fracture prevention triangleFracture prevention triangle

FRAGILITY

FORCE FALLS

Drugs

Lifestyle

Hip

protectorsFalls prevention measures

Vitamin D

Exercise

Problems with treatmentProblems with treatment

• No immediate benefitNo immediate benefit

• Side effects of medicationSide effects of medication

• Unwillingness to changeUnwillingness to change

N.S.F. – Standard 6 (Falls)N.S.F. – Standard 6 (Falls)

• Prevention – public health strategiesPrevention – public health strategies

• Integrated falls servicesIntegrated falls services

• Prevention & treatment of Prevention & treatment of osteoporosisosteoporosis

N.I.C.E. Clinical guideline – Nov N.I.C.E. Clinical guideline – Nov 20042004

Falls: assessment and prevention of falls in older peopleFalls: assessment and prevention of falls in older people

5 key priorities for implementation:5 key priorities for implementation:

1) 1) Case /risk identificationCase /risk identificationRoutinely ask old people if fallen in past yearRoutinely ask old people if fallen in past yearIf yes, frequency, context & characteristic of fallIf yes, frequency, context & characteristic of fallIf faller or high risk, observe for balance and gait deficitsIf faller or high risk, observe for balance and gait deficits

Refer to multifactorial risk Ax if:Refer to multifactorial risk Ax if:Gait & balance deficitGait & balance deficitRecurrent fallsRecurrent fallsPresent to healthcarePresent to healthcare

N.I.C.E. Clinical guideline – Nov N.I.C.E. Clinical guideline – Nov 20042004

Falls: assessment and prevention of falls in older Falls: assessment and prevention of falls in older peoplepeople

2) Multifactorial falls risk Ax to include Ax of:2) Multifactorial falls risk Ax to include Ax of:

Falls HxFalls Hx

Gait and balanceGait and balance

Mobility & muscle weaknessMobility & muscle weakness

Osteoporosis riskOsteoporosis risk

Fear of fallingFear of falling

Visual impairmentVisual impairment

Urinary incontinenceHome hazardsCognitive impairmentCNS examinationCVS examinationMedication review

N.I.C.E. Clinical guideline – Nov N.I.C.E. Clinical guideline – Nov 20042004

Falls: assessment and prevention of falls in older Falls: assessment and prevention of falls in older peoplepeople

3) 3) Multifactorial interventionsMultifactorial interventions::

All recurrent fallers/high risk should be considered for All recurrent fallers/high risk should be considered for individualised multifactorial intervention.individualised multifactorial intervention.

Including:Including:– Strength and balance trainingStrength and balance training– Home hazard Ax and interventionHome hazard Ax and intervention– Vision Ax and referralVision Ax and referral– Medication review Medication review

N.I.C.E. Clinical guideline – Nov N.I.C.E. Clinical guideline – Nov 20042004

Falls: assessment and prevention of falls in older Falls: assessment and prevention of falls in older peoplepeople

4) 4) Encouraging participation of older people at risk of falling in Encouraging participation of older people at risk of falling in falls prevention programmesfalls prevention programmes

Education and information regarding measures they can Education and information regarding measures they can take to prevent fallstake to prevent falls

Include carers in processInclude carers in process

N.I.C.E. Clinical guideline – Nov N.I.C.E. Clinical guideline – Nov 20042004

Falls: assessment and prevention of falls in older Falls: assessment and prevention of falls in older peoplepeople

5) 5) Professional educationProfessional education

All healthcare professionals dealing with patients known All healthcare professionals dealing with patients known to be at risk of falling should develop and maintain basic to be at risk of falling should develop and maintain basic professional competence in falls assessment and professional competence in falls assessment and prevention.prevention.

SummarySummary

• Very commonVery common

• Can cause fractures and downward spiralCan cause fractures and downward spiral

• History and witness very importantHistory and witness very important

• Thorough examination requiredThorough examination required

• Multidisciplinary approach most effectiveMultidisciplinary approach most effective

• Think falls, think osteoporosisThink falls, think osteoporosis

• Refer to Falls Clinic if not winning!Refer to Falls Clinic if not winning!