Falls – an over view for GPsJulie Brache

Consultant Geriatrician and Falls LeadOctober, 2014

Overview

Why older people fall

Multifactorial risk assessment

Normal changes with ageing

Dizziness and syncope

Medication review

Multifactorial interventions

Where to get advice

Definition

when an individual comes to rest unintentionally on the ground or

another lower level, with or without loss of consciousness

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

Preventable

Evidence based national and international guidelines

N

Fall is a symptom, not a diagnosis

‘Old age starts with the first fall and death comes with the second’Gabriel Garcia Marquez “Love in the time of cholera”

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?

Falls are multifactorial

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

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?

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

History - pitfalls“It was nothing”

“I haven’t fallen”

“I tripped over the cat”

“I must have…….”

“They had a fit, doctor”

Assess

Continence

Cognition

Frailty

Alcohol intake

Psychological consequences of fallingFear, anxiety, depression

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

Examination

Focused neurological examination

Lower limb strength – hip and ankle flexorsPeripheral sensationEvidence of stroke, Parkinson’s cerebellar

signs?

Gait and balance Vision

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

Gait disorders in the elderly

Parkinsonism

Cerebrovascular disease

Cervical spondolytic myelopathy

Sensory neuropathy

Foot drop

Don’t forget Normal Pressure Hydrocephalus

Gait and balance assessment

Not all for the Physio!

Gait:Get Up and Go

Balance:Proprioception – vision- vestibular

function

-> Romberg's

-> Head Thrust

Ageing and vision↓Acuity↓Depth perception Lens density changes- glare Decreased rod density - ↓Light

adaptation - ↓ contrast

sensitivity↓ Visual processing speed

Vision

Test acuity and fields

ARMD, glaucoma, stroke, diabetes, cataract

Bifocal / varifocal glasses, change in prescription

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

Examination

Other

Cognition

Foot wear and feet

Take the shoes off!

Dizziness

Vertigo

Pre-syncope

Dysequilibrium

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

Benign Paroxysmal Positional Vertigo

Vertigo on change in position

Self limiting

Disabling

Hallpike- Dix test

Epley manoeuvre

Vestibular rehabCawthorne- Cooksey exercisesBrandt - Daroff

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

Dysequilibrium

Balance dysfunction

A sense of unsteadiness

“Thought I was going to fall”

Often multi-factorial

Sensory impairments and/or CNS disease

Multidisciplinary management

Syncope

23% >65s over 10 years

High recurrence rate

Spontaneous LOC with complete recovery

Diagnosis difficult and often wrong

Syncope in the Elderly

Cerebral autoregulation impaired

Baroreflex sensitivity blunted

Volume regulation impaired

Comorbid illness and medications

Syncope diagnosis

All in the history

DETAILPostureProdromeEye movementsTongue biting/incontinenceInjuryDurationConfusionHemi weakness

Red flags

Abnormal ECG (NICE)

Heart failure

Syncope during exertion

FHx sudden death <40

New/unexplained SOB

Murmur (NICE)

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

Tilt Tests

Unexplained, recurrent

syncope

Single syncope in high

risk settings

Unexplained recurrent

falls

Falls and acute illness

Fall often the presentation of an acute illness

Think of falls risk when unwelldiuretics, antihypertensive, steroids,

anticholinergics, sedativesurinary urgency/frequencyDelirium

Medication review

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

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

Medication and Falls Risk

“Therapeutic effect”

Interactions

Side effects

2/52 after change in meds – high risk time

Stopping – can be difficult

“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

Side effects – anticholinergic activity

Antiemetics – cyclizine, prochlorperazine

Antiparkinson – amantadine, benzhexol

Antispasmodics – oxybutynin

Bronchodilators - ipatropium

Antiarrhythmics - disopyramide, procainamide

Antidepressants – tricyclics

Antipsychotics – chlorpromazine, prochlorperazine

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

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

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

Hip protectorsControversial area!

At home – ineffective

Institutions?

Current advice:

May be useful in confused elderly in institutional care

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

How to get advice

Geriatric Advice Line

07930 181236

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

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

Questions?