UNT Health Science Center - Grand Rounds - May 25, 2011 ...

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“THE GERIATRICS SYNDROME OF FALLS”

Edmund Duthie, Jr, MDProfessor of Medicine

Chief, Division of Geriatrics/Gerontology

Department of Medicine

Medical College of Wisconsin

UNT Health Science Center -Grand Rounds - May 25, 2011

Outline

Define falls Introduce the AAMC student

competencies related to falls Describe the epidemiology Provide a differential diagnosis Present interventions that can help

with the management Summarize a clinical approach

Definition

Unintentional change in position that occurs in the absence of overwhelming intrinsic events such as syncope or overwhelming environmental hazards such as being hit by a car.

Source: Tinetti AGS GRS 1991

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MortalityFalls: #1 cause of accidental death in the elderly For persons age 75+ there is a 2x greater

risk of dying from falls than MVA. 70% of fall fatalities in the U.S. occur in

people aged 65+.

Death Rate:<65 1.5/100,000>65 147/100,000

Morbidity Fracture/serious trauma

15 - 20% of falls- should not be the major focus

Anxiety/fear of falling40 - 73% of fallers experience

this20 - 46% of non-fallers will

experience this Decreased activity

41 - 43% of fallers experience this

Don’t Kill Granny AAMC Geriatric Competencies for

Medical Students http://knowledgemap2.mc.vanderbilt.

edu/pogoe/node/472 What should a beginning PG1 know in

regard to geriatrics? 8 domains with 3-5 competencies in

each domain

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AAMC Domains1. Cognitive and behavioral disorders2. Medication management3. Self-care capacity4. Falls, balance, gait disorders5. Atypical presentation of disease6. Palliative care7. Hospital care for elders8. Health care planning and promotion

AAMC Domains

Falls, balance, gait disorders

Ask all patients over 65 about falls once in the last year

EpidemiologyLocation % of population Annual Fall incidences

who fall / year # / 1000 person days

Community 34% 772

Hospital 26% 1400

Long-Term Care 43% 1600

Source: Rubenstein Clin Ger Med 2002; 18:142-143.

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AAMC Domains


In a patient who has fallen, construct a

differential diagnosis and evaluation

plan that address the multiple

etiologies identified by history, physical

examination, and functional assessment

“I can assess an older adult patient’s fall risk, identify underlying causative factors, and make recommendations for further evaluation and initial management”

Prepared by Office of Educational Services

Results: Tag Along 2010

June July Total

Total M3 students observed

23 15 38

Patient interactions observed

75 36 111

Patients age 65 or older 19 (25%) 12 (33%) 31 (28%)

• Response rate: 53% in June, 17% in July

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Results: Tag Along 2010June July Total

Total M3 students observed 23 15 38

Patient interactions observed 75 36 111

Patients age 65 or older 19 (25%) 12 (33%) 31 (28%)

Assessed gait 5 (26%) 1 (8%) 6 (19%)

Asked about falls* 9 (47%) 1 (8%) 10 (32%)

Explored fall etiology 6 (75%) 1 (100%) 7 (78%)

Created plan for fallers 2 (25%) 0 (0%) 2 (22%)

* 9 of 10 who were asked about falls reported a fall in the prior year Statistics: Intraclass correlation coefficient (ICC) = .72

Accidental : environment

vs.

Intrinsic: diseases

Cause of Falls (12 Studies)

Source: Rubenstein Clin Ger Med 2002; 18:146

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Falls - other

Acute illness

Alcohol

Arthritis

Drugs

Epilepsy

Falling from Bed

Types of Environmental Problems

TripsSlipsMisjudging stepsOverreachingPoor light on stairsLoose slip rugsObstruction on floor

Management

Environmental assessment/home safety evaluation

Drug evaluationAlcohol history “CAGE”Sensory function (Host environment

interface)“Maladaptive” equipment: canes

walkerswheelchairs

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Drugs & FallsBenzodiazepines

Phenothiazines OR 2.83

Antidepressants

Antihypertensives ?

Antiarrhythmics ?

Anticonvulsants ?

Diuretics ?>4 drugs O.R.:4.5

Source: Ray WA et al NEJM 1987;316:363-9

Drugs OR for falls Systematic review and meta-analysis Psychotropic 1.73 Sedative/hypnotic 1.66 Antidepressant 1.51 Neuroleptic 1.50 Digoxin 1.22 Diuretic 1.08 ACE-I, CCB, Beta blockers NS Analgesics (incl opioids) NS

Source Leipzig et al JAGS 1999; 47:30-39 and 40-50

Interventions for Preventing Falls in Elderly People

Withdrawal of psychotropic

medications

[1 trial, N = 93, RR 0.34 (95% CI

0.16 - 0.74)]

Source – Gillespie Cochrane Database Syst Rev 2009;CD007146

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Does intervention work?

Behavioral Training - Elevate head of bedAnkle pumps / hand Orthostasisclenching before arising

Exercise program - Balance exercisesStrengthening exercisesGait Training

Tinetti NEJM 1994;331 821-827


Medication adjustment> 4 prescription meds #Benzo, Sed-Hypnotic: Substitute

treatment Environmental Change

Grab bars Hand rails on stairsNon skid mats Remove hazardsRaised toilet seats Safer furniture

Tinetti NEJM 1994,331 821-827


% Subjects falling over one year35% intervention fell

vs.47% control fell

75% reduction of total # of falls

66% reduction of falls per person/week

Tinetti NEJM 1994,331 821-827

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Multifactorial interventions consist of more than one main category of intervention, but participants receive different combinations of interventions based on an individual assessment.

Reduced the rate of falls (15 Trials N=8141 RaR 0.75 [0.65-0.86]) but not the risk of falling (number of fallers).

Source – Gillespie Cochrane Database Syst Rev 2009;(4):CD007146


Exercise classes containing multiple components (i.e. a combination of two or more categories of exercise) achieved a statistically significant reduction in rate of falls[14 trials, N = 2364, RaR 0.78(95% CI 0.71 - 0.86)]

Source – Gillespie Cochrane Database Syst Rev 2009:CD007146

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Tai Chai Group Exercise reduced

rate of falls

[4 trials, N = 1294 RaR 0.63 (95%

CI 0.52 - 0.78)]

Source – Gillespie Cochrane Database Syst Rev 2009;:CD007146

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Home hazard assessment and modifications

that are professionally prescribed for older

people with a history of falling or one or more

risk factors

[2 trials, N = 491 RaR 0.56 (95% CI 0.42 -

0.76)]



Cardiac pacing in fallers with cardioinhibitory

carotid sinus hypersensitivity was associated

with a statistically significant reduction in

rate of falls (RaR 0.42, 95% CI 0.23 to 0.75;

171 participants)



Significant reduction in rate of falls in people

receiving expedited cataract surgery for the

first eye (RaR 0.66, 0.45 to 0.95; 306

participants), but not in risk of falling (RR

0.95, 95% CI 0.68 to 1.33)


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Modification of the Home Environment for the Reduction of Injuries 5 studies in children no benefit

14 studies in older people: no

injury reduction, 2 reports noted

fall reduction

Source – Lyons Cochrane Database Syst Rev 2006;(4):CD003600

Vitamin D

Meta-analysis 5 RCTs, 1237

subjects aged 60 and over

Vitamin D reduced falls by 22%

(OR 0.78 CI 0.64-0.92)

NNT 15 to prevent a fall

Source Bischoff-Ferrari et al JAMA 2004;1999-2006

Clinical Evaluation

History

Exclude syncope

Witnesses - ? Environment

Environment history/assessment

Drugs/alcohol

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Vital Signs

Temperature

Respiratory rate

Pulse and blood pressure

lying - sitting - standing

Orthostasis and Age

Investigator Rodstein Johnson Caird

Age 61 - 95 70+ 65 - 74 75+

n 250 160 268 226

20 mmHg 11 17 16 30systolic drop (%)

40 mmHg 4 5 3 8systolic drop (%)

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Skin

Trauma

Visual AcuityPresbyopia

Ability to

– see objects clearly

– focus at different distances

– function in low light

– discern color intensity (blue/green less sharp)

– judge distance

Cardiovascular

ArrhythmiaCarotid bruitSigns of aortic stenosis

BLSA: Holter not specific - 78% PVC35% multiform11% couplets4% V tach

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Extremities

Check feet!

Check Footwear!

AAMC Domains


Watch the patient rise from a chair

and walk (or transfer), then

record and interpret the findings.

Neurological

Gait Assessment

Arise without arm support

Walk

Turn

Toe/heel support

Stand eyes open/closed

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Source – Murray MP et al J Gerontology 1969;24:169-78

Source – Bohannon RW et al Physical Therapy 1984; 64:1067-1070

Source – Tinetti NEJM 2003; 348:42-49

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Summary

Ask about falls in all elders annually

Treat a fall as a critical incident

Know the differential diagnosis of falls

Assess gait and balance in geriatric patients

Conclusion: Falls are common - geriatric

system review should incorporate Etiology - often multifactorial

Define etiologies - Treat the treatable,

reverse the reversible

Approach - Avoid “band aid” i.e. Rx trauma only

The Medical College of Wisconsin

UNT Health Science Center - Grand Rounds - May 25, 2011 ...

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