Falls and older people

Consequences of falls

• Mortality

• Injury

• Psychological sequelae

• Loss of independence

Why do older people fall?

Staying upright

• Muscles and joints• Eyes:

– Acuity– Contrast – Depth perception– Field- range of vision

• Ears– Semicircular canals in 3 planes– Utricle and saccule

Staying upright

• Proprioception– Receptors in skin and joints

• Vasoactive responses– Blood pressure and heart rate correct for

changes in position against gravity

• Neural processing– Needed to put it all together

Healthy ageing

• Reduced muscle strength and power

• Reduced reaction times

• Reduced proprioception

• Changes in vision

• Reduced bone strength

• Reduced neural processing power

Falls in individuals

Identify those at greatest risk

• Previous history of falling

• High number of risk factors

• Fear of falling

• Functional tests

Effects of illness

• Stroke:

• Parkinson's disease• Arthritis

• Diabetes

• Weakness, balance , sensation

• Neural processing

• Strength power and proprioception

• Sensory loss, muscle weakness

Effects of illness

• Cardiac problems

• Dementia

• Bladder problems

Changes in blood pressure and heart rhythm

Reduced processing

need to move fast

Falls risk factors

• Visual problems• History of eye disease: may cause difficulty with

contrast and depth even if acuity ok

• Bifocal glasses

• Cognitive impairment • Evidence of delirium in hospital

• Inability to walk and talk at same time is subtle clue to loss of processing

Medications

• Psychotropics

• Analgesics

• Anticonvulsants

• Antihypertensive

• Antimuscarinics/ anticholinergics

• Diuretics

FRAT Falls risk assessment tool

• Any history of fall in the last year

• On > 4 medications

• History of Parkinson's disease or stroke

• Self reported problems with gait and balance

• Unable to rise from chair at knee height without use of arms

Functional tests of falls risk

• Sit to stand 5

• Six meter walk test

• 180 degree turn test

• Stalk test

Functional test of falls

• Tinetti gait and balance score– Assesses falls risk as high , medium or low

• Elderly mobility score– Assesses likelihood of independence with

functional daily tasks

Syncope and postural hypotension

• Neurocardiogenic syncope

• Carotid sinus syndrome

• Orthostatic hypotension

Orthostatic hypotension

• Neurogenic– Primary autonomic failure

– Secondary autonomic failure

• Non- neurogenic– Reduced intravascular volume

– Vasodilatation

– Cardiac impairment

– Drugs

– hypertension

• Evidence of loss of consciousness causing fall

• No recollection of cause

• Fall with injury particularly facial

• Symptoms of faint

• Confusion after event

Syncope and seizures

Epilepsy/ syncopeVasovagal Cardiac Epilepsy

Trigger Common Rare Rare

Prodrome Almost always Uncommon/ brief Common/ aura

Onset Gradual Sudden Sudden usually

Duration 1-30 secs Variable 1-3 mins

Colour Pale Pale Cyanosed

Jerks Brief Brief Common

Lat tongue bite Rare Occasional Common

Breathing Quiet Quiet apnoeic

Injury Rare Occasional Common

Recovery Sleepy- mins – hours

Rapid Slow-often with confusion

Syncope investigations

• Ambulatory ECG

• R wave recordings

• Head up tilt test + carotid sinus massage– Two or more episodes of blackout– One blackout with injury

Syncope invests

• Contraindications for tests– Atrial fibrillation– Carotid bruit– Dementia

Can falls be prevented?

Interventions

Single versus multifactorial inteventions

Falls interventions

• There have been effective falls interventions using single and multiple components

• Reduced falls order of 20- 40 %

• Single interventions are effective if targeted to people where high proportion of falls risk is attributable to risk factor and is modifiable

Modifiable single risk factors

• Reductions in psychotropic drugs ( Campbell 1999)

• Treatment of syncope ( Kenny 2001)

• Reductions of home hazards ( Cummings 1999)

• Cataract surgery ( Foss 2006)

Gait and balance training

• Targeted gait and balance training is part of successful multi-factorial and single interventions

• Exception is for patients with dementia

Medical falls clinic

• Examination for new or undiagnosed medical problems

• Investigation of blackouts and postural hypotension

• Review of medications especially sedatives or multiple cardiac medicines

• Screen for osteoporosis• Recommendation for exercise/ rehabilitation if

frail or high fear of falling

Treatment of syncope

• Cardiac pacing- cardioinhibitory and mixed carotid sinus syndromes

• Midodrine –hypotensive carotid sinus syndrome

Orthostatic hypotension- general measures

• Hot weather• Post prandial• Drugs• Leg crossing• Diurnal• Raised intrathoracic

pressure

• Increase fluid intake• Increase caffeine• Isotonic exercises• Bed head raise

Orthostatic hypotension-medications

• Anaemia- erythropoietin

• Parkinson's disease- domperidone

• Fludrocortisone

• Midodrine

Exercise

• One to one or group

• Targeted to individual

• Strength and balance

• Progressive

• Prolongued intervention

Home hazards

• Stair design

• Maintenance of stairs

• Footwear

• Lighting

• Distracting events

Health promotion in falls

• Reasons people don’t exercise:

• Health problems• Associations with

frailty• Increased pain• Other priorities

• Reasons people do:• Feeling better• Less dizzy• Able to do more• Looking good!

Summary:

• Maintaining upright posture and mobility involves complex processes

• Therefore there maybe many contributors to falls risk including illness but also general ageing and lack of conditioning

• Assessment of new onset problems or deteriorating mobility is worthwhile

Summary

• Interventions to reverse weakness and balance problems take time and effort and are not possible for all

• If a person is unable or unwilling to engage in rehabilitation and exercise then reducing the risk of falls with assisstive devices and environmental checks and aids is the best option

Falls risk assessment

• Previous history of falls

• High number of risk factors

• Fear of falling

• Functional tests