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The Essentials of Preventing Falls in the Older Adult The Essentials of Preventing Falls in the Older Adult

The Essentials of Preventing Falls in the Older Adult - PowerPoint Presentation

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The Essentials of Preventing Falls in the Older Adult - PPT Presentation

Jessica L Colburn MD Johns Hopkins School of Medicine Division of Geriatric Medicine amp Gerontology April 15 2015 Discuss prevalence of falls in older adults Develop an approach for fall risk screening and postfall assessment in older adults ID: 708037

falls risk older fall risk falls fall older patient assessment factors adults physical balance exam gait medical assistive medications

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Slide1

The Essentials of Preventing Falls in the Older Adult

Jessica L. Colburn, MD

Johns Hopkins School of Medicine

Division of Geriatric Medicine & Gerontology

April 15, 2015Slide2

Discuss prevalence of falls in older adultsDevelop an approach for fall risk screening and post-fall assessment in older adults

Discuss interventions that reduce fall risk in older adults

ObjectivesSlide3

PrevalenceOutcomes

Risk Factors

Common Medical Conditions

Changes with Aging

Overview

Screening

Evaluation

Risk Reduction

Community Resources

Take Home PointsSlide4

Prevalence of FallsSlide5

Falls Are A Big ProblemSlide6

One-third of older adults in the

community

fall each year

Prevalence

One-half of older adults in

long term care

fall each yearSlide7

Falls are the leading cause of traumatic injuries in adults over the age of 65

Increased mortality secondary to falls with each decade of life

Estimated direct medical costs for injuries in older adults due to falls was $32 billion in the year 2013

Prevalence

www.cdc.gov

/

HomeandRecreationalSafety

/Falls/

fallcost.htmlSlide8

Fall Outcomes

Kannus

et al, Lancet 2005

20% need medical attention

5% fractures

5-10% other serious injuries (lacerations, head injuries, dislocations, bleeding)Slide9

Hip fractureIncreased risk of dying within the 3-6 months following a hip fracture

Functional impairment – 20-30% of older adults do not return to baseline function

Pain, difficult recovery

Found down – risk of injury due to delay to medical care, can lead to functional impairment

Fear of falling – leads to social withdrawal, admission to long term care facilities

Fall Outcomes

Sterling et al, Journal of Trauma 2001Slide10

Risk Factors for FallsSlide11

Patients who have fallen in the past year are more likely to fall againMost consistent predictor of future falls is abnormal gait or balance

Think about conditions that your patient has that contribute to abnormal gait

Risk Factors

Ganz

et al, JAMA 2007Slide12

Risk Factors for Falls

Falls

External Factors

Medications

Alcohol use

Using an assistive device improperly

Patient (Intrinsic) Factors

Environmental hazards

Medical conditions

Age-related changes

Vision and hearing impairment

Cognitive impairment

Kannus

et al, Lancet 2005Slide13

Patient Factors

Medical Conditions

Age-related changes

Parkinson’s disease

Stroke

Seizures

Dementia

Depression

Dizziness

Orthostatic hypotension

Arrhythmia

Osteoarthritis

Diabetes

Peripheral neuropathy

Changes in balance

Vision changesLoss of muscleSlide14

Cell death in

substantia

nigra -> reduction in brain dopamine levels

Clinical features:

Tremor at rest (pill-rolling)

Cogwheeling rigidityMasked

facies

Bradykinesia

Shuffling gait

Treatment:

Symptomatic relief only

Dopaminergic

agents

Parkinson’s Disease

Image: careplanning.blogspot.comSlide15

Early stage – Same fall risk as other community-dwelling older adults

Middle stage - patients may forget that they need an assistive device or have knee pain until they get up and start to walk

Lose fine motor skills, forget how to navigate environment

Late stage– patients forget how to perform motor tasks like walking or even swallowing

Muscle wasting, weight loss

DementiaSlide16

Change in blood pressure with position changes

Reflex mechanisms needed to counteract gravity are less effective with age

Vasoconstriction

Elevated heart rate

Comorbid

medical conditions

Medications – beta blockers,

diuretics,

antihypertensives

Volume depletion

Orthostatic (Postural) Hypotension

Image: nlm.nih.govSlide17

Very common in older adults

Major contributor to gait and balance problems

Joint pain is commonly reported in primary careBalance changes due to joint abnormalities

Fear of falling

Pain control: Acetaminophen is safe

NSAIDs (ibuprofen, naproxen) are less safe due to renal and GI effects

Opiates increase risk of falls and confusion

Physical therapy very useful

OsteoarthritisSlide18

Tight control in older adults has been shown to increase severe hypoglycemic events and mortality

Oral

hypoglycemics (except for metformin

) and insulin are associated with high rates of hospitalization in older adults

Peripheral neuropathy also

contributes to falls

DiabetesSlide19

External Factors

Antihypertensives

Diuretics

Digoxin

Anticholinergics

Benadryl

Ditropan

(incontinence)

Polypharmacy

MEDICATIONS!

Antidepressants

Sedatives/Pain Meds

Benzodiazepines

Opiates

Antipsychotics

Dementia agents (

acetylcholinesterase

inhibitors)

Dopaminergic

agentsSlide20

External Factors

Improper use of assist devices

Loose rugs

Cords

Clutter

Low lighting

Hand rails

Cane

Walker

Wheelchair/scooter

Environmental hazardsSlide21

Medications that could increase risk of injuryBlood thinners (benefit may outweigh risk but important to think about)

Improper use of assistive devices

Hand-me-down devices

Osteoporosis

Increased risk of fracture with a fall

Risk Factors for InjuriesSlide22

Screening, Evaluation & Fall Risk ReductionSlide23

Acute fall?

Two or more falls in the past year?

Difficulty with walking or balance?

Screening for Falls

Adapted from AGS Guideline for Prevention of Falls in Older Persons, 2010

YES

NO

Gait and balance

assessment

Fall in the

past year?

YES

NO

Abnormal?

FALL ASSESSMENT

YES

NO

Reassess periodicallySlide24

Obtain relevant medical history, physical exam, cognitive and functional assessmentDetermine multifactorial fall risk:

History of falls Feet/footwear

Medications Environmental hazards

Gait, balance, mobility

Visual acuity

Other neurologic impairmentsMuscle strength

Heart rate and rhythm

Orthostatic hypotension

Fall Assessment

Adapted from AGS Guideline for Prevention of Falls in Older Persons, 2010Slide25

How did the fall happen?Did the patient have any symptoms?

Was there an injury?

Patient risk factors for falls (medical problems, gait imbalance, footwear)Patient risk factors for injury (anticoagulants, osteoporosis)

Where there any environmental hazards?

Are there any new or problem medications?

Any change in mental status or functioning?

Evaluation - History

Moncada

LV. Am

Fam

Phys 2011 Slide26

Vital signs (

orthostatics

)Vision exam

Cognitive assessment

Other

neurologic impairmentsMuscle strengthHeart

rate and

rhythm

Gait and balance assessment

Watch your patient walk!

Evaluation – Physical ExamSlide27

Drop in systolic blood pressure of 20 mm Hg with position change (sitting to standing) within 3 minutes

Five minutes of rest before first blood pressure

Drop may be delayed so typically I check immediately with standing and again at 2-3 minutes later

Assess for lightheadedness, but not all patients who are orthostatic get lightheaded

Physical Exam –

Orthostatic HypotensionSlide28

Snellen chartPocket card okay

Wearing glasses?

Glasses appropriate?Reading vs. distance

Bifocals may increase

fall risk

Physical Exam – Visual AcuitySlide29

3 word recall + Clock Draw TestSensitivity/specificity comparable to using a

cutpoint

of 25 on the MMSE

Sensitivity 76

%

(vs 79% MMSE)

Specificity 89

%

(

vs

88

% MMSE)

Shorter to administer in practice than the MMSE

Physical Exam - Cognitive Assessment – Mini-Cog

Borson et al, JAGS, 2003Borson et al, Int

Jnl Geri Psych, 2011 Slide30

Physical Exam - Cognitive Assessment – Mini-Cog

Mini-Cog

Give the patient 3 words to

remember

B

anana, chair, sunriseAdminister the Clock Drawing Test – “ten past eleven” or “two forty-five” or “eight twenty”

3 word recall

Scoring:

1 point for each word recalled (0-3 points)

Clock draw test = 2 points normal, 0 points abnormal

0-2 = positive screen (“possibly impaired”)

3-5 = negative screen (“probably normal”)

Borson

et al,

Int

Jnl Geri Psych, 2011 Slide31

Clock Draw Test ExamplesSlide32

Neurologic exam to assess for causes of fallsParkinsonian

features

Muscle strengthSensation

Gait/balance

Physical Exam – Neurologic ImpairmentsSlide33

Cardiac examinationEvaluation for abnormalities that would affect balance or positioning

Irregular heart rhythm

Bradycardia

or tachycardia

Physical Exam – Heart Rate and RhythmSlide34

Timed Up and Go

Start with patient seated in a chair

Instruct patient to stand, walk 3 meters (10 feet), turn around, come back, and sit down in the chair

Time from when you say go until when patient is re-seated in the chair

Patient may use his or her assistive device

Scoring:

>/= 12 seconds associated with increased risk of falls

87% sensitivity & specificity

Gait & Balance Assessment

Shumway

-Cook et al, PT, 2000 Slide35

Home/Environmental Assessment

Assess home environment for risks for falling

Rugs, clutter, cords, lighting

Consider ways to improve safety in the home environment with assistive devicesSlide36

Initiate multifactorial intervention to address identified risks:

Minimize/adjust medications

Recommend appropriate exercise program

Treat vision impairment (consider cataracts, bifocals)

Manage orthostatic hypotension

Manage heart rate and rhythm abnormalitiesSupplement vitamin D

Manage foot/footwear problems

Modify the home environment

Consider risks for injury (osteoporosis, blood thinners)

Provide education and information

Indication for Intervention?

Adapted from AGS Guideline for Prevention of Falls in Older Persons, 2010Slide37

Fall Risk Reduction

Check

orthostatics

(some patients do not report dizziness

)Goal

BP based on JNC 8 guidelines is 140 – 150

systolic, reduce

antihypertensives

if appropriate

Encourage fluid intake

Vision

screening

Cautious

use of bifocals, can increase fall risk especially with navigating curbs and stepsHome safety evaluationMedicare no longer reimburses for home safety evaluation unless it is done as part of home physical therapy treatment

Can provide instructions for patient/caregiver to assess home environmentSlide38

Vitamin D therapy

(Grade B evidence

) - 800 IU daily for at least 12 months, regardless of serum

level

Physical therapy or exercise

referral (Grade B evidence)

PT for gait & balance training

Assessment of appropriate assistive device and training to use assistive device

Many types of exercise will reduce falls – Tai Chi, low to high intensity, group or in home, many are effective

Multifactorial risk assessment not needed for every patient, tailor interventions to individual needs

Fall Risk Reduction –

USPSTF Recommendations

Moyer, Ann

Int

Med, 2012 Slide39

Department of Aging –> Resources for Fitness and Fall Prevention/Risk ReductionBaltimore County Department of Aging –> Maryland Access Point:

410-887-2594

Baltimore City Department of Aging -> Maryland Access Point: 410-396-

2273

Senior Centers, exercise programs, fall prevention programs (

ie. Stepping On)

Online tools to help patients/caregivers do their own home safety assessments

Community ResourcesSlide40

Falls are a common problem for older adults

Falls are dangerous – increased risk of functional impairment and death

Risk can be modified with screening, assessment, and intervention

You can prevent an older adult from falling!

Take Home PointsSlide41

Email:Jessica Colburn, MD

jcolbur1@jhmi.edu

Thank you!

Questions?