FALLS

1. FALLS Dr Alastair Kerr Swindon/Bath DRC April 2006

2. Outline • Incidence • Sequelae • Risk factors • Assessment • Interventions • Osteoporosis • NSF/NICE

3. Incidence • What % >65yrs fall in 1 year ? • What % >75yrs fall in 1 year ? • What % >85yrs fall in 1 year ? • What % elderly institutional care fall in 1 year ? • What % in previous fallers?

4. Incidence • What % >65yrs fall in 1 year ? 30 • What % >75yrs fall in 1 year ? 35 • What % >85yrs fall in 1 year ? 40 • What % elderly institutional care fall in 1 year ? >50 • What % in previous fallers? 60-70

5. Sequelae • What % people injure themselves after a fall ? • What % people fracture after falling ?

6. Sequelae • What % people injure themselves after a fall ? 40-60 • What % people fracture after falling ? 5

7. Sequelae Name 3 common sequelae of falls • Fracture • Infection • Fear of falling

8. Sequelae • What is your “life space diameter” ? • How does a fall affect this ? • How else is this known ?

9. Sequelae • What is your “life space diameter” ? A measure of your mobility potential. • How does a fall affect this ? Reduces it • How else is this known ? Fear of falling

10. Fear of falling • What percentage of pts develop this after a fall? 33% • Pts with fear of falling have higher risk of falling, reduced ADL’s, lower quality of life scores, and increased institutionalisation.

11. Risk Factors • EXTRINSIC Environmental • INTRINSIC • Medication • Disease • Visual problems • Neurological • Cardiovascular • Postural hypotension • Locomotor • Psychological • Nutritional • Acute illness

12. Statistical summaries of risk factors for falls • RISK FACTOR Mean RR/OR Muscle weakness 4.4 Falls history 3.0 Gait deficit 2.9 Balance deficit 2.9 Assistive devices 2.6 Visual deficit 2.5 Arthritis 2.4 Impaired ADL’s 2.3 Depression 2.2 Cognitive impairment 1.8 Age >80 1.7

13. Age-related changes • Increased postural sway • Reduced muscle strength (NB: Hand grip) • Reduced proprioception/vibration sense/light touch • Slower reaction time • Impaired cerebral auto regulation • Impaired fluid homeostasis • Decreased visual acuity

14. Balance Vision FALLS Vestibular Musculoskeletal Proprioception Environmental hazards Tactile sensation CNS

15. Mortality • What is mortality rate for #NOF ? • At 1 month? • At 1 year? • What is mortality rate for # pubic ramus ?

16. Mortality • What is mortality rate for #NOF ? • At 1 month? 10% • At 1 year? 25% • What is mortality rate for # pubic ramus ? 15-20%

17. Falls assessment • HISTORY • Simple fall v collapse • What’s the most useful question to ask in taking the history in pt who has collapsed? • What factors differentiate between cardiac and neurological collapse ? • Which drugs are implicated ?

18. Falls assessment • HISTOR • What’s the most useful question to ask in taking the history in pt who has collapsed? • Do you remember falling • What factors differentiate between cardiac and neurological collapse ? • Cardiac-no warning, palpitations, rapid recovery, pallor, no tongue biting • Which drugs are implicated ? • Many !

19. Examination • Mental test score • CVS (include postural BP) • Cranial nerves (incl. vision) • Vestibular assessment • Peripheral nervous system (NB Neuropathy) • Cerebellar function • Muscles • Joints • Gait (Footwear)

20. Investigation • Bloods • ECG (24 hr tape if ECG abnormal) • Tilt table test • Carotid sinus massage • Dix - Hallpike

21. Interventions to prevent falls – the evidence • Multidisciplinary Ax [FICSIT ;Tinetti 1994] [PROFET ;Close 1999] • Withdrawing centrally acting meds [Campbell] • Strength & balance training [Campbell 1997/1999] • Tai Chi [Wolf 1996] • CVS Ax & intervention of unexplained fallers [Kenny 2001] • Cataract surgery [Harwood 2005] • Vitamin D

22. THINK OF FALLS THINK OF OSTEOPOROSIS

23. Fracture Risk • Fracture risk = Risk of falling BMD

24. Osteoporosis • “Time bomb of old age” • Low bone mass, microarchitectural deterioration, increased fragility and fracture risk. • 1:3 females ; 1:12 males (>50yrs) will sustain osteoporotic fracture. • <5% on osteoporosis drugs.

25. Age Related Changes in Bone Mass Attainment of Peak Bone Mass Age-related Bone Loss Consolidation Menopause Bone Mass Men Fracture Threshold Women 0 10 20 30 40 50 60 Age (years) Compston JE. Clin Endocrinol 1990; 33:653–682.

26. Clinical Impact of Osteoporosis Over Time Symptoms • Weak neck and head falls forward • Pain in whole or part of back • Breathing difficulties • Indigestion & gastro-oesophageal reflux • Stress incontinence • Difficulty with mobility following # Signs • Kyphosis • Loss of height • Tummy bulges due to loss of space under the ribs • Clinically diagnosed fracture

27. Hip Fractures • 60,000 /yr in UK • Cost : £1.7 billion • 25% die at 1 year • 50% do NOT regain independence • Osteoporosis results in more deaths than Ca cervix/uterus/ovary combined. • Nos will increase 5-fold in next 50 yrs

28. Diagnosis • DEXA : Measures B.M.D. at forearm, hip and spine • DEXA : Normal t> -1 Osteopenia t -1 to -2.5 Osteoporosis t < -2.5 • DEXA - high specificity, low sensitivity

29. Risk Factors • Hx low trauma fracture • Steroids (incl inhalers) • Family Hx of O.P. • Premature menopause (<45yrs) • Secondary pre-menopausal amenorrhea • Low B.M.I. (<19) • Smoking, alcohol • Prolonged immobilization • XR suggestion of osteopenia/O.P. • Secondary - malabsorption, IBD, hypogonadism, CRF, CLD, RA, primary hyperparathyroidism, Cushing’s, thyrotoxicosis.

30. Investigations • FBC - malabsorption • U and E’s - renal failure • TFT’s - hyperthyroidism • LFT’S - chronic liver disease • FSH - detect menopause • PV/ESR/electrophoresis - myeloma • Calcium - hyperparathyroidism • Testosterone/LH/SHBG - hypogonadism in males • (Markers of bone turnover)

31. Prevention of osteoporosis-lifestyle advice • Diet • Exercise • Alcohol • Smoking

32. Interventions to prevent fracture • Bisphosphonates • Ca/vitamin D • Selective oestrogen receptor modulators (SERMS) • Hip protectors [Cochrane 2005] • PTH • Strontium ranelate

33. Fracture prevention triangle FRAGILITY Drugs Lifestyle Vitamin D Exercise FALLS FORCE Hip protectors Falls prevention measures

35. Problems with treatment • No immediate benefit • Side effects of medication • Unwillingness to change

36. N.S.F. – Standard 6 (Falls) • Prevention – public health strategies • Integrated falls services • Prevention & treatment of osteoporosis

37. N.I.C.E. Clinical guideline – Nov 2004 Falls: assessment and prevention of falls in older people 5 key priorities for implementation: 1) Case /risk identification Routinely ask old people if fallen in past year If yes, frequency, context & characteristic of fall If faller or high risk, observe for balance and gait deficits Refer to multifactorial risk Ax if: Gait & balance deficit Recurrent falls Present to healthcare

38. N.I.C.E. Clinical guideline – Nov 2004 Falls: assessment and prevention of falls in older people 2) Multifactorial falls risk Ax to include Ax of: Falls Hx Gait and balance Mobility & muscle weakness Osteoporosis risk Fear of falling Visual impairment Urinary incontinence Home hazards Cognitive impairment CNS examination CVS examination Medication review

39. N.I.C.E. Clinical guideline – Nov 2004 Falls: assessment and prevention of falls in older people 3) Multifactorial interventions: All recurrent fallers/high risk should be considered for individualised multifactorial intervention. Including: • Strength and balance training • Home hazard Ax and intervention • Vision Ax and referral • Medication review

40. N.I.C.E. Clinical guideline – Nov 2004 Falls: assessment and prevention of falls in older people 4) Encouraging participation of older people at risk of falling in falls prevention programmes Education and information regarding measures they can take to prevent falls Include carers in process

41. N.I.C.E. Clinical guideline – Nov 2004 Falls: assessment and prevention of falls in older people 5) Professional education All healthcare professionals dealing with patients known to be at risk of falling should develop and maintain basic professional competence in falls assessment and prevention.

42. Summary • Very common • Can cause fractures and downward spiral • History and witness very important • Thorough examination required • Multidisciplinary approach most effective • Think falls, think osteoporosis • Refer to Falls Clinic if not winning!