Falls – an over view for GPs Julie Brache Consultant Geriatrician and Falls Lead October, 2014.
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Transcript of Falls – an over view for GPs Julie Brache Consultant Geriatrician and Falls Lead October, 2014.
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Falls – an over view for GPsJulie Brache
Consultant Geriatrician and Falls LeadOctober, 2014
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Overview
Why older people fall
Multifactorial risk assessment
Normal changes with ageing
Dizziness and syncope
Medication review
Multifactorial interventions
Where to get advice
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Definition
when an individual comes to rest unintentionally on the ground or
another lower level, with or without loss of consciousness
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Background
• 35% >65 living at home fall each year
£2.3 billion per year
10% injury
After a fall 50% have reduced mobility
Leading cause of injury related death in older adults
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Preventable
Evidence based national and international guidelines
N
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Fall is a symptom, not a diagnosis
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‘Old age starts with the first fall and death comes with the second’Gabriel Garcia Marquez “Love in the time of cholera”
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Frailty
Reduced ability to withstand illness without loss of function
Muscle weakness, reduced walking speed, reduced physical activity, weight loss, self reported exhaustion
Would you be surprised if this person died in the next year?
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Falls are multifactorial
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Why do older people fall?Muscle weakness
Poor balance
Gait deficit
Polypharmacy
Sensory loss – vision, hearing, peripheral
Medical illness
Nutrition
Dizziness
Osteoarthritis
Frailty
Environment
Depression
Cognitive impairment
Incontinence
Alcohol
Previous falls
CV problems
Neurological
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History
Circumstances of fallsActivity at the timeWhere and when Lightheaded, dizzy, LoC, chest pain, palpitations,
visual disturbance?Seizure markers?
How many falls in the last year?
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Taking the history –some pointers
Allow them to describe everything first, then get the history you need
Describe a single fall in detail
Take them through it in fine detail
Then ask about
associated symptoms
Witness account is vital
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History - pitfalls“It was nothing”
“I haven’t fallen”
“I tripped over the cat”
“I must have…….”
“They had a fit, doctor”
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Assess
Continence
Cognition
Frailty
Alcohol intake
Psychological consequences of fallingFear, anxiety, depression
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Examination
CardiovascularPulse – rate and rhythmHeart sounds3 min lying and standing BP
Drop 20 systolic or 10 diastolic or to <90 significantOnly 23% will describe dizziness
ECG
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Examination
Focused neurological examination
Lower limb strength – hip and ankle flexorsPeripheral sensationEvidence of stroke, Parkinson’s cerebellar
signs?
Gait and balance Vision
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Ageing and gait
Slower
Increased sway
Slowed postural support responses
Shorter stride length
Increased time in double support
Loss of rhythm
Loss muscle bulk, reduced postural reflexes, JPS
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Gait disorders in the elderly
Parkinsonism
Cerebrovascular disease
Cervical spondolytic myelopathy
Sensory neuropathy
Foot drop
Don’t forget Normal Pressure Hydrocephalus
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Gait and balance assessment
Not all for the Physio!
Gait:Get Up and Go
Balance:Proprioception – vision- vestibular
function
-> Romberg's
-> Head Thrust
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Ageing and vision↓Acuity↓Depth perception Lens density changes- glare Decreased rod density - ↓Light
adaptation - ↓ contrast
sensitivity↓ Visual processing speed
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Vision
Test acuity and fields
ARMD, glaucoma, stroke, diabetes, cataract
Bifocal / varifocal glasses, change in prescription
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SPECTACLE USE5.7 Optometrists and dispensing opticians should consider supplying an additional pair of single vision spectacles (to wear in outdoor and unfamiliar settings) for older people who take part in regular outdoor activities
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Examination
Other
Cognition
Foot wear and feet
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Take the shoes off!
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Dizziness
Vertigo
Pre-syncope
Dysequilibrium
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VertigoIllusion of rotation
“The room was spinning”
Nystagmus during episode
Labyrinth or vestibular
problem
Occasionally cerebellar or CP angle
Treat acute attacks with
anti-histamines
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Benign Paroxysmal Positional Vertigo
Vertigo on change in position
Self limiting
Disabling
Hallpike- Dix test
Epley manoeuvre
Vestibular rehabCawthorne- Cooksey exercisesBrandt - Daroff
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Pre-syncopeSense of feeling faint or
light-headed
“Legs went weak”
“Vision blurred ”
Pallor, weak/slow pulse
Same causes as syncope
Often a sign of postural BP drop
Cardiovascular assessment
Treat underlying cause
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Dysequilibrium
Balance dysfunction
A sense of unsteadiness
“Thought I was going to fall”
Often multi-factorial
Sensory impairments and/or CNS disease
Multidisciplinary management
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Syncope
23% >65s over 10 years
High recurrence rate
Spontaneous LOC with complete recovery
Diagnosis difficult and often wrong
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Syncope in the Elderly
Cerebral autoregulation impaired
Baroreflex sensitivity blunted
Volume regulation impaired
Comorbid illness and medications
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Syncope diagnosis
All in the history
DETAILPostureProdromeEye movementsTongue biting/incontinenceInjuryDurationConfusionHemi weakness
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Red flags
Abnormal ECG (NICE)
Heart failure
Syncope during exertion
FHx sudden death <40
New/unexplained SOB
Murmur (NICE)
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Assessment
Vasovagal – 3Ps
Cardiovascular – if in doubtECG, 24 hour tape, event recorder,
implantable device, tilt table test + carotid sinus massage, cardio ref
Neurological CT head, EEG (?value in elderly), neuro ref
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Tilt Tests
Unexplained, recurrent
syncope
Single syncope in high
risk settings
Unexplained recurrent
falls
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Falls and acute illness
Fall often the presentation of an acute illness
Think of falls risk when unwelldiuretics, antihypertensive, steroids,
anticholinergics, sedativesurinary urgency/frequencyDelirium
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Medication review
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Drugs in the elderly
UK elderly 18% pop – 45% all
prescriptions
In NH in 1 year 97% will receive a
prescribed drug – 71% in community
Polypharmacy - >4 drugs = risk falls
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Principles of Medication review
Review indication – is there evidence?
Review dose
Reduce the number of medicines
Avoid complex regimes
Review benzodiazepines and other psychotropic drugs
Check L&S BP – if drop review culprit drugs
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Medication and Falls Risk
“Therapeutic effect”
Interactions
Side effects
2/52 after change in meds – high risk time
Stopping – can be difficult
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“Therapeutic effect”
Meta-analysis – sedatives and hypnotics
Improve sleep duration and reduce night time wakening
NNT sleep 13
NNT any adverse event 6BMJ 2005;331:1169
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Side effects – anticholinergic activity
Antiemetics – cyclizine, prochlorperazine
Antiparkinson – amantadine, benzhexol
Antispasmodics – oxybutynin
Bronchodilators - ipatropium
Antiarrhythmics - disopyramide, procainamide
Antidepressants – tricyclics
Antipsychotics – chlorpromazine, prochlorperazine
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Time to reconsider
warfarin?
50% elderly in AF not on warfarinFalls is the main reason
>300 falls per year for bleeding risk to outweigh stroke risk
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Ageing and Pharmacokinetics / Pharmacodynamics
Distribution ↑blood (& tissue) conc water sol drugs ↑ vol distribution lipophilic drugs
Hepatic metabolism Metabolism by C P-450 reduced Reduced 1st pass metabolism – some drugs
Renal elimination Reduced GFR with age
Changes in drug-receptor interactions
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Osteoporosis assessment
FRAX – but beware over 80s
Calcium and vitamin DReduce fallsAll housebound fallers, and RH/NH
residents800iu daily vit D
• Long term anticonvulsants – check vit D level
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Hip protectorsControversial area!
At home – ineffective
Institutions?
Current advice:
May be useful in confused elderly in institutional care
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Multifactorial interventions
Treat any problems found
Evidence based recommendations:Strength and balance trainingHome hazards assessment &
interventionVision assessment and referralMedication review and
modification/withdrawal of psychotropicsEducation
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How to get advice
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Geriatric Advice Line
07930 181236
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ClinicsFalls clinic
Nurse, therapist and doctor, 2 hour appointment, on-going therapy via referral to community teams
Geriatric clinicDoctor, 45 min appointment
If you just want therapy – refer to community teams
If already seeing community team – refer to geriatric clinic
PLEASE send as much information as possible
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Take home messagesSome falls are preventable
Requires time consuming multifactorial assessment, identification and intervention
Can’t do it alone
Always review medication
Don’t forget bones
A friendly geriatrician is always on the end of the phone
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Questions?