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FALLS

FALLS. Slips, trips and fractured hips!. Man Falling, by Giacometti. Falling facts. 1/3 of people > 65 yo (community dwelling) 1/2 of people > 90 yo Females > Males 1/2 those who fall will have > 2 falls. Further Falling Facts. 20% need medical attention ~10% to A&E

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FALLS

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  1. FALLS Slips, trips and fractured hips!

  2. Man Falling, by Giacometti

  3. Falling facts • 1/3 of people > 65 yo (community dwelling) • 1/2 of people > 90 yo • Females > Males • 1/2 those who fall will have > 2 falls

  4. Further Falling Facts • 20% need medical attention • ~10% to A&E • 6% of all hospital admissions (> 65) • 2% of all deaths age >65

  5. Fernando Botero: Works on Paper: Woman Falling from Balcony

  6. Falling Freida • 85-year-old, lives alone with Carl the Cat • No home services, never married. Former Art Teacher. • Mobile independently • several falls recently - bruises only • worried she’ll hurt herself if she falls again...

  7. Freida’s Falls • Unexpected visitor when Freida was watching “The Bold and the Beautiful”. • Felt dizzy on standing, stumbled over coffee table and fell onto box of paints she’d had delivered the day before. - just didn’t see them! • Out looking for Carl the Cat at dusk. Tripped over loose pavement in backyard. Difficulty gettting up • now reluctant to leave the house

  8. Falling Frieda’s PMx • Stroke 40 years ago - affecting L side - minimal weakness now. • HTN • Cholecystectomy • “nerves” • Macular Degeneration

  9. Examination • Slightly frail, in high heels! • BP 140/70, no postural drop • P=70, reg • HS dual, no carotid bruits • Abdo soft and non-tender • CNS intact - slight decrease proprioception both feet

  10. Harold, the Home visiting nurse • reports that the home is very cluttered, Lounge dark with curtains drawn. • morning BP: • 180/100 lying 140/ 70 standing, assoc dizziness. • Meds: • aspirin • Perindopril Plus • nifedipine Oros • Nitrazepam 5mg nocte

  11. Falling Frieda’s follow-up • Bloods: • Hb 130, MCV 87 • Na 124, K 3.7, Cr 110, Urea 7.9 • TFT’s, LFT’s, B12 &folate normal • MSU nad • ECG - NSR, borderline LVH

  12. Why does Frieda Fall?

  13. Extrinsic: • lives alone • visual impairment • Poor lighting • Loose carpets • Badly fitting footwear

  14. Intrinsic: • Hyponatraemia • Diuretics • Postural Hypotension • decreased righting reflexes • Sedative Medication

  15. How to help…. • Decrease and aim to stop sedative (controversial after recent article?) • Stop diuretic. • Ensure Na normalises • increase lighting in house • de clutter • Improve righting Reflexes

  16. Vaartkapoen, Tom Franzten

  17. Tumbling Thomas • 87-year-old, former Army Officer • Anglo-Indian, supportive family • living in retirement village for last 2 months after his wife died. • has had several unwitnessed falls in the bathroom, able to use call bell to alert staff. • Carers concerned as unsteady on walk to dining room

  18. His PMx • epilepsy - complex partial since childhood • atrial fibrillation • ischaemic heart disease • osteoarthritis

  19. Medications • sodium valproate 400mg bd • digoxin 125mcg od • ISMN 60mg • aspirin • diclofenac prn • frusemide 80mg

  20. Further History • Feeling generally weaker and more unsteady recently • Difficulty getting to the bathroom on time - concerned he might become incontinent and need to wear nappies! • Denied any seizures or post -ictal periods recently. Last~2/12 ago at wife’s funeral.

  21. Examination • Serious, slightly vague • MMSE 28/30 (-2 recall) • BP 110/70, no postural drop • HS dual with ESM, no radiation • CNS: • marked quadriceps wasting of both legs • decreased reflexes ankles • osteoarthritis changes +++ of knees.

  22. Investigations • Hb 9.5, MCV 87 • urea 17.5 creatinine 157 • digoxin level 1.2 • ECG shows sinus rhythm with ST/T wave changes consistent with digoxin effect.

  23. Why was Thomas Tumbling?

  24. Extrinsic: • new environment, not used to bathroom

  25. Intrinsic: • ?digitoxic • dehydrated • deconditioned • anaemic • ?aortic stenosis

  26. How to help • Meds altered • Echo: aortic sclerosis only • Physio and hydrotherapy to increase quad strength • Haematemics: B thalassemia trait and folate deficiency - corrected

  27. But…Thomas was still Tumbling! • Why?….. • What should we do next….

  28. CT head

  29. Icarus Falling, Mildred Kaye

  30. Physiology of Falling -Normal Aging Changes • Decreased height, flattening foot arch, increased hip flexion • change in centre of gravity • Muscle mass and type II fast Twitch fibres decrease • decreased strength and impaired reaction time • Cerebellar atrophy • decreased co-ordination

  31. Physiology of Falling II • Decreased Vision • very important - decreased ability to perceive obstacles • Decrease in Peripheral Vestibular Excitation • loss of balance mechanism • Decrease in Max Heart Rate • decrease exercise tolerance

  32. How to help Falling Frieda and Tumbling Thomas...

  33. Ask, AssessExerciseImprove SurroundingsOsteoporosis reviewUn-medicate

  34. ASK! • Ask all patients over 65 if they’ve had a fall or near fall in the last year. • Ask about fear of falling • Ask about urinary incontinence • Ask about Home hazards

  35. Assess • Assess vision • Assess cognition • MMSE/ IQ code • Assess Cardiology • rhythm, rate, evidence failure, murmurs, pulses (and bruits) • Assess neurology • Assess gait, balance, mobility and muscle weakness

  36. Exercise • Balance and strength training -community and institutional settings. • Must be structured and tailored to individual • Post #NOF • Strengthening muscles around the hip • Teach how to avoid a long lie • Improve confidence • try Tai Chi

  37. Improve surroundings • Provide appropriate mobility and safety equipment • Adapt the environment • Educate re potential hazards

  38. Osteoporosis and fracture prevention • Determine risk • previous fracture? • Family hx • Evidence kyphoscoliosis? • ?hip protectors in institutional settings • Vitamin D and Calcium supplementation • Bisphosphonate as required

  39. Un - Medicate • Stop psychotropic medications • benzodiazepines, sedatives • decrease number of medications • Pay close attention to meds that drop BP: • Anti-Hypertensives • Diuretics • L Dopa • SSRI/TCA’s

  40. Benzo’s, Falls and Fractures • New York state has limited use of Benzodiazepines • ?did this decrease the number of hip fractures in Elderly • compared New York (limited use) and New Jersey (still unlimited) • NY decreased benzo prescribing by 60% • NO reduction in hip fracture change Wagner et al. Annals of Int Med. 16/01/07

  41. Falling in Hospitals +High Care Facilities • Recent meta-analysis • data often poor - 13 studies found for hospital, 8 for care homes Oliver et al. BMJ 08/12/06

  42. Effective: • multifaceted interventions - but only for falls, NOT fractures, and only in Hospital setting • Unknown Effectiveness: • Vitamin D (3 smallish trials effective, 1 large trial ineffective) • Hip Protectors (still unproved - studies not enough POWER) • alarms • removing physical restraints

  43. Summary • Falls are important • Best improvement seen with multidisciplinary input • Cause almost always multifactorial

  44. Whenever the horse stopped (which indeed very often), [The Knight] fell off in front; and, whenever it went on again (which it generally did rather suddenly), he fell off behind. John Tenniel

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