Falls in Older Adults 2008 Update

1. Falls in Older Adults2008 Update Joseph G. Ouslander, MD Director, Boca Institute for Quality Aging University of Miami Miller School of Medicine at Florida Atlantic University and Thomas Price, MD Division of Geriatric Medicine and Gerontology Emory University School of Medicine

2. Learning Objectives • Review the epidemiology and consequences of falls in the elderly • Identify common risk factors for falls in this population • Identify the pros and cons of prevention and management strategies

3. Falls Case • Mr. C. is an 89 year old man who is referred to you for the evaluation of dizziness. His daughter says that he has fallen 3 times in the past month after discharge from the hospital for a “small heart attack and heart failure”. • Mr. C. has no prior history of falls.

4. Falls Case Past Medical History: • Coronary artery disease • Hypertension • Congestive heart failure (chronic, systolic) • Degenerative joint disease mainly of the right hip and knee • Insomnia

5. Falls Case Medications: • Furosemide 40 mg BID • K-dur 20 meq daily • Enalapril 10 mg daily • Carvedilol 6.25 mg po BID • Simvastatin 20 mg PO QHS • Nitroglycerin 0.4 mg/hr patch TOP 12 hours per day • Propoxyphene/Acetaminophen 1 tab Q4hr PRN pain • Amitriptyline 50 mg po QHS prn insomnia

6. Falls Case • Further history reveals that each fall occurred in the morning after breakfast. He gets up, and when he starts walking he feels “light-headed”. The sensation eases when he lies down. He has not to his knowledge passed out or sustained any severe injury with these falls. There is no history suggestive of a seizure.

7. Falls Case Physical Exam: • GEN: No signs of trauma • Vitals: Sitting 102/58;66  Standing 88/52;72 (after 2 minutes) • Heart: RRR +s1,s2 no s3, s4; 2/6 SEM at apex • Lungs: Mild rales bilateral bases • MS: Reduced ROM rt hip with pain on internal rotation; crepitus and pain with flexion of the rt knee • Neuro: No peripheral proprioceptive/fine touch abnormalities; ear exam shows minimal cerumen; Dix-Hallpike maneuver to elicit nystagmus is negative

8. Falls Case Get Up and Go observation reveals: • Difficulty arising without physical assistance • Negative Romberg test • Abnormal gait due to guarding his right side • Difficulty and imbalance when turning

9. Falls Case • What do you think is contributing to Mr. C’s falls? • What diagnostic tests would you order? • What interventions would you implement?

10. Falls

11. Definition A fall is defined as a sudden, uncontrolled, unintentional, downward displacement of the body to the ground or other object, excluding falls resulting from violent blows or other purposeful actions. An unwitnessed falloccurs when a patient is found on the floor and neither the patient nor anyone else knows how he or she got there.

12. Epidemiology • Annual incidence in patients >65y • 35-40% of community dwelling older persons • Rates increase threefold if in NH or hospital • Injury rate • 1 in 20 require hospitalization • 75% of falls-related deaths occur in patients >65y • Falls a major reason for NH admission (40%) Tinetti NEJM 348:1, 2003

13. Morbidity of Falls • Soft tissue injury • Fractures • Intracranial bleed • Rhabdomyolysis • Reduced Mobility • NH admission • Death • Restraint use • Fear of Falling

14. Prognosis of Falls • Falls occur in both frail and healthy older persons • Single falls are not necessarily an indicator of poor prognosis • Multiple falls are associated with disability and poor health outcomes • Multiple falls are a marker for other underlying conditions that put older persons at increased risk for adverse health outcomes

15. Contributors to Falls

16. Contributors to Falls Community-Dwelling: 41% environment related 13% weakness, balance or gait disorder 8% dizziness or vertigo Nursing Home: 16% environment related 26% weakness, balance or gait disorder 25% dizziness or vertigo Rubenstein, et al. Ann Intern Med 1994;121;442 – 451

17. Intrinsic Risk Factors for Falls AGS Panel on falls prevention, JAGS 49(5):2001, 665

18. Extrinsic Risk Factors for Falls • Environmental hazards • Loose rugs, cords, etc • Iatrogenic • Medications • Behavioral • Alcohol, poor judgment, impulsiveness • Clothing • Poorly (loose) fitting clothes and footwear

19. The Morse Fall Risk Assessment Tool • Morse Fall Scale • High Risk: 45+ • Med Risk: 25 – 44 • Low Risk: 0 – 24 • Everyone may score high risk in a nursing home environment • Adjust score based on your patient population

20. Simplified Risk Factors • 100% chance of fall in one year for all three of the following: • More than three medications • Hip weakness • Unstable balance

21. Clinical Assessment and Management • Falls History • Medication Use • Vision • Postural BP • Balance and Gait • Neurologic exam • Musculoskeletal exam • Cardiovascular exam • Post-discharge home-hazard evaluation

22. Falls History • S P L A T T Symptoms Previous falls Location Activity Time Trauma

23. Falls History • Detailed history of the fall • Activity, environmental factors • Symptoms: Postural lightheadedness Syncope / near syncope Vertigo Seizure • Circumstances of any previous falls • Alcohol intake • Assessment for acute illness (e.g. dehydration, infection, acute cardiac or neurological symptoms)

24. Medication Use • Assessment • Evaluate for high-risk medications • Four or more medications • Management • Discontinue or replace potentially harmful medications

25. High-Risk Medications • Serotonin-reuptake inhibitors • Sertraline, fluoxetine • Tricyclic antidepressants • Nortriptyline • Neuroleptics • Haloperidol, risperidone, quetiapine • Benzodiazepines • Alprazolam, clonazepam, lorazepam • Anticonvulsants • Phenobarbital, phenytoin • Class IA antiarrhythmics • Procainamide, quinidine Tinetti NEJM 348:1, 2003

26. Vision • Assessment • Mid-range and far vision using Snellen wall chart • Check peripheral vision/visual fields • Light reflex (cataracts) • Management • Referral to ophthalmologist • Avoid bifocals when walking • Improve lighting in enclosed areas of home

27. Postural Blood Pressure • First 5 minutes SUPINE • Then check BP • Then STAND • Immediately check BP • Wait 2 minutes • Then check BP • Positive test if SBP drops 20% or more either immediately or after 2 minutes

28. Postural Blood Pressure • Assessment • Check for 20mm Hg (or 20% drop) in systolic pressure with or without symptoms • Pulse not as reliable an indicator in older patients • Management • Check for acute or chronic causes • Hydration, compensation strategies (pressure stockings, etc) if idiopathic

29. Balance and Gait • Assessment • Patient’s report • Get up and Go test • Management • Diagnosis and treatment of underlying cause • Medications that cause gait imbalance (see above) • Environmental obstacles modification • Referral to physical therapist for gait/progressive balance training, assist device

30. Neurologic Examination • Assessment • Proprioception • Cognition • Neuromuscular (Parkinsonism, etc) • Management • Diagnose and treat underlying cause • Medication adjustment • Reduction of environmental risk factors • Physical Therapy Evaluation

31. Musculoskeletal Examination • Assessment • Joints and range of motion (arthritis) • Foot exam (ulcers, fallen arch, etc) • Strength testing (Get Up and Go) • Management • Identify and treat underlying causes • Physical therapy referral • Podiatry referral

32. The Get Up And Go Test • Time it takes a patient to get up from a seated position, walk 8 feet, then sit back down • Patient must rise from chair without use of hands • If takes more than 8 seconds, then patient has high fall risk

33. Cardiovascular Exam • Assessment • Syncope (Tilt) • Arrhythmia (ECG) • Management • Referral to cardiologist • Assessment of cardiac anatomic and electrophysiologic status (echo, signal avg. ECG)

34. Prevention Strategies • Chang et al. BMJ 2004 • Meta-analysis comparing 40 trials • Effective falls reduction is achieved only when assessment is coupled with aggressive management • Referral is not sufficient • When actively managed, falls were reduced by a composite 37% Chang et al. BMJ 328(7441): 2004

35. Prevention Strategies • New Zealand Falls Intervention (2007) • Intervention: At-home nurse evaluation of risk factors and referral to community interventions and/or PT • Population: 312 patients with history of falls, avg. age 81, F>M • No statistical significance between intervention and control group Elley et al. JAGS 56(8), 2008

36. Prevention Strategies • Maastricht GP Cooperative study (Netherlands, 2007) • Intervention: Medical/OT eval with recommendations and referral if needed • Population: 333 persons >65 yo, F>M with recent fall • No statistical significance between intervention and control groups in # new falls, fear of falling, or activity avoidance Hendriks et. al JAGS 56(8), 2008

37. Prevention Strategies • Multifactorial evaluations useless without aggressive pursuit of treatment • Elements of the multifactorial evaluation: -- Orthostatic BP -- Vision testing -- Balance and gait testing -- Drug review -- IADL/ADL assessment -- Cognitive evaluation -- Assessment for environmental hazards

38. Prevention Strategies • Bang for the buck? Balance and gait training = 14-27% reduction Reduction in home hazards = 19% Stop psychotropics = 39% Multifactorial risk E&M = 25-39% Balance and strength exercise* = 29-49% * Community based

39. Falls Case • Mr. C. is an 89 year old man who is referred to you for the evaluation of dizziness. His daughter says that he has fallen 3 times in the past month after discharge from the hospital for a “small heart attack and heart failure”. • Mr. C. has no prior history of falls.

40. Falls Case Past Medical History: • Coronary artery disease • Hypertension • Congestive heart failure (chronic, systolic) • Degenerative joint disease mainly of the right hip and knee • Insomnia

41. Falls Case Medications: • Furosemide 40 mg BID • K-dur 20 meq daily • Enalapril 10 mg daily • Carvedilol 6.25 mg po BID • Simvastatin 20 mg PO QHS • Nitroglycerin 0.4 mg/hr patch TOP 12 hours per day • Propoxyphene/Acetaminophen 1 tab Q4hr PRN pain • Amitriptyline 50 mg po QHS prn insomnia

42. Falls Case • Further history reveals that each fall occurred in the morning after breakfast. He gets up, and when he starts walking he feels “light-headed”. The sensation eases when he lies down. He has not to his knowledge passed out or sustained any severe injury with these falls. There is no history suggestive of a seizure.

43. Falls Case Physical Exam: • GEN: No signs of trauma • Vitals: Sitting 102/58;66  Standing 88/52;72 (after 2 minutes) • Heart: RRR +s1,s2 no s3, s4; 2/6 SEM at apex • Lungs: Mild rales bilateral bases • MS: Reduced ROM rt hip with pain on internal rotation; crepitus and pain with flexion of the rt knee • Neuro: No peripheral proprioceptive/fine touch abnormalities; ear exam shows minimal cerumen; Dix-Hallpike maneuver to elicit nystagmus is negative

44. Falls Case Get Up and Go observation reveals: • Difficulty arising without physical assistance • Negative Romberg test • Abnormal gait due to guarding his right side • Difficulty and imbalance when turning

45. Falls Case • What do you think is contributing to Mr. C’s falls? • What diagnostic tests would you order? • What interventions would you implement?

46. Falls Case • Contributors • Arthritis of hip and knee • Vasodilators (nitroglycerin) • Iatrogenic cognitive impairment? (propoxyphene, amitriptyline) • Post-prandial orthostasis? • Postural hypotension (too much BP med?) • Proximal muscle strength weakness • Balance disorder

47. Falls Case • Diagnostics • Basic Labs (volume depletion? Diabetes?) • Comprehensive chemistry • Complete blood count (orthostasis) • Other labs • B12 level abnormal? • CT of head? • Assessment of thyroid function? • Cognitive performance test (MMSE)

48. Falls Case • Interventions • Physical therapy for gait training and strengthening • Replace amitriptyline with alternative agent, or discontinue completely • Same with propoxyphene • Home safety assessment • Adaptive?

49. Summary • Falls are common in both community and institutionalized older persons • Associated with significant morbidity and mortality • Most falls are multi-factorial • Evaluation should be directed towards identifying multiple contributory risk factors • Multi-modal interventions can decrease the incidence of falls and fall-related injuries