FALLS

Slips, trips and fractured hips!

Man Falling, by Giacometti

Falling facts

• 1/3 of people > 65 yo (community dwelling)

• 1/2 of people > 90 yo

• Females > Males

• 1/2 those who fall will have > 2 falls

Further Falling Facts

• 20% need medical attention

• ~10% to A&E

• 6% of all hospital admissions (> 65)

• 2% of all deaths age >65

Fernando Botero: Works on Paper: Woman Falling from Balcony

Falling Freida

• 85-year-old, lives alone with Carl the Cat

• No home services, never married. Former Art Teacher.

• Mobile independently

• several falls recently - bruises only

• worried she’ll hurt herself if she falls again...

Freida’s Falls

– Unexpected visitor when Freida was watching “The Bold and the Beautiful”.

– Felt dizzy on standing, stumbled over coffee table and fell onto box of paints she’d had delivered the day before. - just didn’t see them!

– Out looking for Carl the Cat at dusk. Tripped over loose pavement in backyard. Difficulty gettting up

– now reluctant to leave the house

Falling Frieda’s PMx

• Stroke 40 years ago - affecting L side - minimal weakness now.

• HTN

• Cholecystectomy

• “nerves”

• Macular Degeneration

Examination

• Slightly frail, in high heels!

• BP 140/70, no postural drop

• P=70, reg

• HS dual, no carotid bruits

• Abdo soft and non-tender

• CNS intact - slight decrease proprioception both feet

Harold, the Home visiting nurse• reports that the home is very cluttered, Lounge

dark with curtains drawn.

• morning BP:– 180/100 lying 140/ 70 standing, assoc dizziness.

• Meds:– aspirin

– Perindopril Plus

– nifedipine Oros

– Nitrazepam 5mg nocte

Falling Frieda’s follow-up

• Bloods:– Hb 130, MCV 87

– Na 124, K 3.7, Cr 110, Urea 7.9

– TFT’s, LFT’s, B12 &folate normal

• MSU nad

• ECG - NSR, borderline LVH

Why does Frieda Fall?

Extrinsic:

lives alone visual impairment Poor lighting Loose carpets Badly fitting footwear

Intrinsic:

Hyponatraemia Diuretics Postural Hypotension decreased righting reflexes Sedative Medication

How to help….

• Decrease and aim to stop sedative (controversial after recent article?)

• Stop diuretic.

• Ensure Na normalises

• increase lighting in house

• de clutter

• Improve righting Reflexes

Vaartkapoen, Tom Franzten

Tumbling Thomas

• 87-year-old, former Army Officer

• Anglo-Indian, supportive family

• living in retirement village for last 2 months after his wife died.

• has had several unwitnessed falls in the bathroom, able to use call bell to alert staff.

• Carers concerned as unsteady on walk to dining room

His PMx

• epilepsy - complex partial since childhood

• atrial fibrillation

• ischaemic heart disease

• osteoarthritis

Medications

• sodium valproate 400mg bd

• digoxin 125mcg od

• ISMN 60mg

• aspirin

• diclofenac prn

• frusemide 80mg

Further History

• Feeling generally weaker and more unsteady recently

• Difficulty getting to the bathroom on time - concerned he might become incontinent and need to wear nappies!

• Denied any seizures or post -ictal periods recently. Last~2/12 ago at wife’s funeral.

Examination• Serious, slightly vague

• MMSE 28/30 (-2 recall)

• BP 110/70, no postural drop

• HS dual with ESM, no radiation

• CNS:– marked quadriceps wasting of both legs– decreased reflexes ankles

• osteoarthritis changes +++ of knees.

Investigations• Hb 9.5, MCV 87

• urea 17.5 creatinine 157

• digoxin level 1.2

• ECG shows sinus rhythm with ST/T wave changes consistent with digoxin effect.

Why was Thomas Tumbling?

Extrinsic:

• new environment, not used to bathroom

Intrinsic:

• ?digitoxic

• dehydrated

• deconditioned

• anaemic

• ?aortic stenosis

How to help

• Meds altered

• Echo: aortic sclerosis only

• Physio and hydrotherapy to increase quad strength

• Haematemics: B thalassemia trait and folate deficiency - corrected

But…Thomas was still Tumbling!

• Why?…..

• What should we do next….

CT head

Icarus Falling, Mildred Kaye

Physiology of Falling -Normal Aging Changes

• Decreased height, flattening foot arch, increased hip flexion– change in centre of gravity

• Muscle mass and type II fast Twitch fibres decrease– decreased strength and impaired reaction time

• Cerebellar atrophy– decreased co-ordination

Physiology of Falling II

• Decreased Vision– very important - decreased ability to perceive

obstacles

• Decrease in Peripheral Vestibular Excitation– loss of balance mechanism

• Decrease in Max Heart Rate– decrease exercise tolerance

How to help Falling Frieda and Tumbling Thomas...

Ask, AssessExerciseImprove SurroundingsOsteoporosis reviewUn-medicate

ASK!

• Ask all patients over 65 if they’ve had a fall or near fall in the last year.

Ask about fear of falling Ask about urinary incontinence Ask about Home hazards

Assess Assess vision Assess cognition

MMSE/ IQ code

Assess Cardiology rhythm, rate, evidence failure, murmurs, pulses (and

bruits)

• Assess neurology • Assess gait, balance, mobility and muscle

weakness

Exercise Balance and strength training -community and

institutional settings. Must be structured and tailored to individual

Post #NOF Strengthening muscles around the hip

Teach how to avoid a long lie Improve confidence try Tai Chi

Improve surroundings

Provide appropriate mobility and safety equipment

Adapt the environment

• Educate re potential hazards

Osteoporosis and fracture prevention

• Determine risk– previous fracture?– Family hx– Evidence kyphoscoliosis?

• ?hip protectors in institutional settings

• Vitamin D and Calcium supplementation

• Bisphosphonate as required

Un - Medicate• Stop psychotropic medications

– benzodiazepines, sedatives

• decrease number of medications

• Pay close attention to meds that drop BP:– Anti-Hypertensives– Diuretics– L Dopa– SSRI/TCA’s

Wagner et al. Annals of Int Med. 16/01/07

Benzo’s, Falls and Fractures

• New York state has limited use of Benzodiazepines

• ?did this decrease the number of hip fractures in Elderly

• compared New York (limited use) and New Jersey (still unlimited)

• NY decreased benzo prescribing by 60%• NO reduction in hip fracture change

Oliver et al. BMJ 08/12/06

Falling in Hospitals +High Care Facilities

• Recent meta-analysis

• data often poor - 13 studies found for hospital, 8 for care homes

• Effective:– multifaceted interventions - but only for falls, NOT fractures,

and only in Hospital setting

• Unknown Effectiveness:– Vitamin D (3 smallish trials effective, 1 large trial ineffective)– Hip Protectors (still unproved - studies not enough POWER)– alarms– removing physical restraints

Summary

• Falls are important

• Best improvement seen with multidisciplinary input

• Cause almost always multifactorial

Whenever the horse stopped (which indeed very often), [The Knight] fell off in front; and, whenever it went on again (which it generally did rather suddenly), he fell off behind.

John Tenniel