Falls

1. Falls By Dr. Cuong Ngo-Minh Back to Basics April 16th 2009

2. Falls prevalence in the older person • 30% of seniors living in community fall each year. • 50% of nursing home and hospital residents fall annually each year. • 1 in 10 falls result in serious injury (6% require hospitalization)

3. Risk for falls • Usually multiple factors; age >75 is risk factor (screen Hx of falls) • only 1/3 falls have a single cause • Risk of falling is highest the month post-discharge and w/ acute illness or exacerbation of chronic illness • Interactions between long term or short term predisposing factors & short term precipitating factors in person’s environment

4. History Focused data gathering • Thoroughly detailing the fall and preceding moments • Look for contributing factors • 1st or recurrent fall…..strongest predictor for fall is prior fall • Location and time of fall • Events, activities, & symptoms preceding the fall: -lightheadedness or positional changes - palpitations, chest pain -following fall: LOC, incontinence, confusion

5. Falls causes • Extrinsic factors a) Environment: Loose rugs; slippery floors; uneven door thresholds; poor lighting; furniture and fixtures of inappropriate height, stairs, chairs lacking arm support b) Medications & alcohol: 1. polypharmacy (more than 3 prescription meds) 2. use of alcohol, leisure drugs 3. psychotropic drugs double risk(also sleeping pills) 4. anticonvulsants & antiarrythmics (class 1A)

6. Intrinsic factors 1 • Hypotension (orthostatic, post-prandial, or drug-related) - assoc w/ up to 20% of falls - affects 15% of seniors, 30 % of those treated for hypertension -age-related changes (decreased vascular compliance, impaired baroreflex sensitivity, predisposition to postprandial hypotension) - Antihypertensives, diuretics, anticholinergics, psychoactive drugs, benzodiazepines, SSRIs, tricyclic meds, neuroleptics

7. Intrinsic Factors 2 • Acute illness • Visual impairment • Gait, balance, and mobility disorders • Lower limb weakness • Fear of falling (post-fall syndrome)

8. Acute illness • Falls may be a nonspecific sign of acute illness or acute exacerbation of chronic conditions (cardiac arrythmia, valvular heart disease, syncope, lumbar stenosis) • 10-20% of falls are related to acute illness (think delirium in the elderly)

9. Visual impairment • Age-related including visual acuity, decline in accommodation, altered depth perception • Cataracts, glare intolerance • Slowed light-dark adaptation

10. Gait, balance & mobility disorders • 3-fold increase in risk • Age-related changes: postural instability, decreased central integration from all senses, slowed reaction time • Associated w/ arthritis, stroke, parkinson’s disease, foot problems

11. Lower limb weakness • Common, 5 –fold increase in falls • Arises from inactivity with arthritis, immobilisation syndrome

12. Preventing falls • Ask all pts> 75 yrs about falls in past yr and gait or balance difficulties • 2 or more falls or balance or gait difficulties require to Observe pts getting up and out of chair w/o using arms and walking. The “Get up and Go test” - Screening test for safe mobility - Observe standing up, walking, turning, stopping and sitting down.

13. Fall evaluation • Assessment • History (from client and collateral info, witness of fall) • Meds (all list with over the counter products) • Physical exam, Vitals with orthostatic BP • Vision • Gait and Balance • Lower limb joints • Neuro/ Cardiovascular

14. Physical exam • Cardio and vitals: - postural changes in BP - pulse rate and rhythm - increased resp rate? (CHF, pneumonia or early sepsis) - recent wt changes ( dehydration or serious illness) • MSK exam: joint ROM, and muscle strength • * Gait, Balance, mobility, GET UP AND GO TEST • Common foot problems, check Footwear • Neuro exam: tone, power, reflexes, proprioception, sensation, cerebellar, visual acuity and fields, hearing • Mental status: screen for depression or cognitive Impairment.

15. Multifactorial intervention • Gait, balance, exercise programs • Medication/polypharmacy modification • Postural hypotension treatment • Environment hazard modification • Targeted medical and cardiovascular disorder tx

16. Lab tests and imaging • Complete blood count • Serum, lytes, bun/creatinine • Glucose • Vit B12, TSH • Neuro imaging-only if head trauma/focal deficit • Rarely EEG, Holter (depending if suspect seizure disorder or arrhytmia)

17. Counsel and educate • Educate about falls risk (extrinsic and intrinsic factors) • How to fall safely and get up when fallen • Personal-emergency response team • Community-based exercise program • Progressive balance/ strengthening • Home hazard reduction • Low bone-density-hip protectors.

18. Confidentiality and legal aspect (Cleo 4.2 and 5.3)and Medical records (Cleo 6.5) • By default, not disclose info unless specific consent from client • Reporting to Ministry of Transportation is a duty if safety of public is at sake • “patients who have had a fall should be evaluated for ability to drive. If identified as unsafe, authorities in charge of driving may need to be informed for on-the-road evaluation” • Duty to warn threatened individuals • Duty to maintain adequate records (re SOAP )

19. Ressources • 1) Practice Based Learning Program from McMaster University, Module on Falls in the Elderly, Vol 11(9), August 2003