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
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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?