Falls in the Elderly

C. Bree Johnston, MD MPH Copyright May 2001

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Overview
Prevalence Clinical Importance Risk Factors & Etiology Evaluation Prevention & Management Falls & restraint use Summary

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Falls: Mrs. F.

Mrs. F. is an 80 year old woman who lives alone. She just came in to your office for follow up of a fall resulting in a Colles fracture. She has had two other falls over the past year and a half. She is scared of falling again. She has a history of osteoarthritis and anxiety/depressison. She is on naproxen 500mg BID and diazepam 5mg BID prn
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Falls in the Elderly

Prevalence

Clinical Importance Risk Factors & Etiology Evaluation Prevention & Management Falls & restraint use Summary

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Prevalence
30% of those over 65 fall annually Half are repeat fallers Falls go up with each decade of life Over half of those in nursing homes and hospitals will fall each year

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Falls in the Elderly

Prevalence

Clinical

Importance

Risk Factors & Etiology Evaluation Prevention & Management Falls & restraint use Summary
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Impact of Hip Fractures

1% of falls result in hip fracture $2 billion + in medical costs annually 25% die within 6 months 60% have restricted mobility 25% remain functionally more dependent

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Falls Cause Morbidity and Mortality

Mortality: found down syndrome, indirect effects Fractures: 6% of falls Soft tissue injury, head injury, subdural hematoma Fear of falling can result in decreased activity, isolation, and further functional decline Nursing home placement and loss of independence

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Falls in the Elderly

Prevalence Clinical Importance

Risk

Factors & Etiology

Evaluation Prevention & Management Falls & restraint use Summary

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Falls are Multifactorial

Intrinsic Factors
Medical conditions Impaired vision and hearing

Extrinsic Factors
Medications

FALLS

Improper use of assistive devices

Age related changes

Environment

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Normal Changes with Aging

Neurologic Increased reaction time Decreased righting reflexes Decreased proprioception Vision Changes Decreased accommodation & dark adaptation Decreased muscle mass

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Normal changes of Gait

Slower gait Decreased stride length and arm swing Forward flexion at head and torso Increased flexion at shoulders and knees Increased lateral sway

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Dysmobility
Dysmobility and falling closely related 15% of those over 65 have trouble walking 1/4 men and 1/3 women over age 85 have difficulty with walking 2/3 of people in hospital or NH unable to ambulate without assistance

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Risk Factors for Falls

Risk Factor Sedative use Cognitive Impairment Lower extremity problem Pathologic Reflex Foot Problems > 3 balance/gait problems >5 balance/gait problems

OR 28 5 4 3 2 1.4 1.9
Tinetti NEJM 1988

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Common Pathologies associated with Falls

Ophthalmologic diseases Arthritis Foot problems Neurologic illness Parkinsons & related disorders Strokes Peripheral neuropathy Dizziness and dysequilibrium

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Dizziness: A Multifactorial Syndrome

Vertigo: BPV, Posterior CVA/TIA, Cervical Presyncope: Orthostatic, Dysrythmia, Anemia Dysequilibrium: Peripheral neuropathy, Visual Other: Anxiety, depression In older people, usually multifactorial
Tinetti, Annals of Internal Med 2000
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Falls in the Community

Accidents/environment Weakness, balance, gait Drop attack Dizziness or vertigo Orthostatic hypotension Acute illness, confusion, drugs, decreased vision Unknown

Rubenstein JAGS 1988

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

37% 12% 11% 8% 5% 18% 8%

Falls in Residential Care

Generalized weakness Environmental hazard Orthostatic hypotension Acute illness Gait or balance disorder Drugs Other or unknown

Rubenstein Ann Int Med 1990

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

31% 27% 16% 5% 4% 5% 10%

Medications and Falls

Sedative-hypnotics, especially long acting benzodiazepines, increase falls Small association between most psychotropics and falls SSRIs and TCAs both incrsease falls Weak association between Type 1A antiarrythmics, digoxin, diuretics, and falls

Leipzig JAGS 1999

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Thapa NEJM 1998

Falls in the Elderly

Prevalence Clinical Importance Risk Factors & Etiology

Evaluation

Prevention & Management Falls & restraint use Summary

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Evaluation of Falls: History

Location & circumstances of Fall Associated symptoms Other falls or near falls Medications (including nonprescription) and alcohol Injury & ability to get up

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Evaluation of Falls: Physical Examination

Supine and standing BP - always Routine physical examination Focus on cardiovascular, MS, neuro, feet Vision and hearing evaluation Consider acute medical illness & delirium Formal gait and balance assessment

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Evaluation of Falls: Home Evaluation

Can be performed by nurse, OT, PT, others Stairs Lighting Clutter Bathroom Specific hazards: cords, throw rugs

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Evaluation of Falls: Risk Factors for Injury

Osteoporosis assessment Anticoagulation: Usual benefits outweigh risks unless repeat or high risk faller Can the person get up from fall? Is there a way to notify others in case of falling?

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Mrs. F.
History reveals that she fell at home in the bathroom at night, tripping over a bathmat. Both other falls have been in similar circumstances. She was able to get up. On PE, she has visual acuity of 20/100 with bilateral cataracts. She has mild OA of the knees, with bunyon deformities of her feet and poor fitting shoes.

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Mrs. F.
Her gait assessment shoes that she is unable to get up out of the chair without help. Her gait is hesitant and slightly wide based. Home evaluation reveals poor lighting in all rooms, multiple throw rugs in every room, and no grab bars or safety equipment in the bathroom.

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Mrs. F.
She is weaned off of her diazepam over 3 months T-score on dexa is 3.0, and she is begun on alendronate, vitamin D, and calcium She goes to ophthalmology and podiatry PT begins exercises, followed by weight lifting and exercise 3X a week at a Senior Center She gets home safety equipment, improved lighting, and gives away her throw rugs

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Formal Gait Evaluation

Get up and Go Test Tinetti Gait and Balance Evaluation (POMA)
Tinetti JAGS 1986 Podsiallo jAGS 1991

Mathias Arch Phys Med 1986

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

POMA: Balance Component

Sitting (in hard, armless chair)
Arising Standing balance (immediate and delayed) Balance with Nudge Balance with Eyes closed Balance with 360 degree turn
Tinetti JAGS 1986
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

POMA: Gait Component

Initiation Step length and height Step symmetry & continuity Path Stance Ability to pick up speed
Tinetti JAGS 1986
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Common Causes of Abnormal Gait

Difficulty arising from chair Weakness Arthritis Instability on first standing Hypotension, Weakness Instability with eyes closed Proprioception Step height/length Parkinsonism Frontal lobe Fear

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Falls in the Elderly

Prevalence Clinical Importance Risk Factors & Etiology Evaluation

Prevention

& Management

Falls & restraint use Summary

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Prevention & Treatment

Treat acute injury & underlying medical conditions Remove unnecessary medications Rehab, exercises, assistive devices Correct sensory impairments Environmental modifications & safety Evaluate for osteoporosis treatment

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Osteoporosis

Calcium and vitamin D for most elders at risk

Dawson-Hughes, NEJM, 1997

Osteoporosis evaluation and treatment Hip protectors appear to protect from hip fractures in those who wear them

Kannus, NEJM, 2000

Thiazides may help slightly Statins?

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Risk Factor Modifications for Fractures

Change Quit smoking Treat impaired vision Estimated Change in Risk 38% 50%

Stop sedatives
Add 1 Gram Calcium

40%
24%

Hip Protectors

50%?
Adapted from Stteve Cummings

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Hip pads to prevent hip fracture

RCT of 1801 frail subjects in Finland Nursing home or frail community patients Mean age 81 78% women 63% assisted walking

Kannus. NEJM;2000;343;1506-1513.

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Fractures with Hip Protectors 2.1% per year vs. 4.6% per year (p<.01) 40 patients needed to be treated with hip protector for 1 year to prevent one fracture 2.4% of falls resulted in hip fracture when not wearing protector 0.4% resulted in hip fracture when wearing protector (80% risk reduction) But patient acceptance low

Kannus. NEJM;2000;343;1506-1513
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

www.hipsavers.com

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Prevention of Found Down Syndrome

Lifelines
Accessible telephones

Teach in getting up off floor

Friendly phone calls or visitors for isolated elderly
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Falls: Primary Prevention

301

community dwelling elders with 1+ risk factors for falling Intervention: adjustment in medications, behavioral instructions, exercise programs aimed at modifying risk factors One year follow up
Tinetti et al. 1994 NEJM
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Multifactorial Intervention
% Falling 50 40 30 20 10 0 0 3 6 Months
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Tinetti et al 1994 NEJM

i Mo

Control Intervent

P = .04
9 12

Exercise Training & Nutrition

140 120 100 % 80 Change 60 Muscle strength 40 20 0 -20

Exer Exer + Su Sup Control Exer Exer + Sup Su STUDY GROUP Control

Fiatarone et al NEJM 1994 UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Tai Chi and Falling

Atlanta FICSIT Trial

200 community dwelling elders 70+ Intervention: 15 weeks of education, balance training, or Tai Chi Outcomes at 4 months: Strength, flexibility, CV endurance, composition, IADL, well being, falls

Falls reduced by 47% in Tai Chi group

Wolf JAGS 1996
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Exercise, Falls, and Frailty

FICSIT Trials
8 independent prospective RCTs Goal: reduction in falls and frailty

Pre-planned Meta-analysis Intervention RR

Any Exercise Balance Component .90 .83

CI
(.81-.99) (.70-.98)

Province JAMA 1995

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Training frail older persons: The New Zealand Study of Women

223 women >80 years Intervention: PT tailored to individual needs, with resistance and balance training Results: Clinical balance, chair rise improved RR for falls .47 (CI .04-.90) RR for injurious falls .61 (.39-.97)
Campbell BMJ 1997
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Falls in the Elderly

Prevalence Clinical Importance Risk Factors & Etiology Evaluation Prevention & Management

Falls

& restraint use

Summary
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Restraint Reduction and Injury

No evidence that restraints reduce fall injuries Restraints increase morbidity and may cause death Reported strangulation deaths from restraints every year Risk factor for delirium, decubitus ulcers, malnutrition, aspiration pneumonia

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Restraint Reduction Decreases Injuries

816 bed Jewish Home for the Aged
- Restraints decreased from 39% to 4% over 3 years - No change in falls, injuries, psychotropic use

2 year educational intervention covering 2000+ beds

- Restraint reduction 41% to 4% - Decrease in serious injuries from 7.5% to 4.4%
Tinetti 1992, Capezuti, Neufeld 1999, Evans 1997
UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Alternatives to Restraints For Patients with Lines and Tubes

Sedation (especially in ICU) Reducing delirium risk factors (drugs, dehydration) Does the benefit of tubes and lines (or hospitalization) outweigh the risks of restraints? Geriatric Consultation Team Sometimes restraints may be unavoidable in this setting

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Alternatives to Restraints for Patients Who Fall or Wander

Accept the risk of falling Hip protectors Environmental modifications, day rooms, low beds Least restrictive alternatives Alarms Sitters or family Geriatric consultation team

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Summary
Falls are common in the elderly & may lead to injuries and decline in function Evaluation should included risk factor assessment, gait assessment, and home assessment Exercise can improve outcomes We have no evidence that restraints reduce fall related injuries

UCSF Division of Geriatrics Primary Care Lecture Series May 2001