Fall Prevention:Fall Prevention:What to Expect from Health What to Expect from Health Care Providers?Care Providers?

Betsy Baum, M.D. CMDBetsy Baum, M.D. CMD

Associate Professor of Internal MedicineAssociate Professor of Internal MedicineNEOMEDNEOMED

Geriatric Consultant Aultman HospitalGeriatric Consultant Aultman Hospital

Medical Director Bethany Nursing FacilityMedical Director Bethany Nursing Facility

Clinical Faculty, Canton Residency EducationClinical Faculty, Canton Residency Education

ObjectivesObjectives

Review the AGS ( American Geriatric Review the AGS ( American Geriatric Society) Guidelines of the evidenced -Society) Guidelines of the evidenced -based fall risk assessment recommended based fall risk assessment recommended to health care providersto health care providers

Review effective interventions to prevent Review effective interventions to prevent falls and injuriesfalls and injuries

Discuss community programs that will Discuss community programs that will enhance fall prevention enhance fall prevention

Two Most Important Things Two Most Important Things to Know About Falls in the to Know About Falls in the

ElderlyElderly

Falling is a symptom Falling is a symptom notnot a a diagnosisdiagnosis

Most falls in elderly people are Most falls in elderly people are multifactorialmultifactorial

WHY SO DIFFICULT TO WHY SO DIFFICULT TO PREVENT FALLS ?PREVENT FALLS ?

Complex unless systematic approachComplex unless systematic approach

ID mutifactorial causes or risk factorsID mutifactorial causes or risk factors

Tailor interventions to that person’s Tailor interventions to that person’s specific risk factorsspecific risk factors

Followup that interventions get doneFollowup that interventions get done

Most Common Risk Factors for FallsMost Common Risk Factors for Falls

DD rugs Dementia Depression Diseaserugs Dementia Depression Disease

OO ther Fallsther Falls

GG aitait

OO rthostasis, old (>80)rthostasis, old (>80)

SS ensory (vision, hearing), surroundingsensory (vision, hearing), surroundings

LL ost Balanceost Balance

OO steoarthritis steoarthritis

WW eak lower extremityeak lower extremity

Most Common Risk Factors for FallsMost Common Risk Factors for Falls

I I ncontinence, Insomniancontinence, Insomnia

DD rugs Dementia Depression, rugs Dementia Depression, D deficiencyD deficiency

OO ther Fallsther Falls

GG aitait

OO rthostasis, old (>80)rthostasis, old (>80)

SS ensory (vision),surroundings, ensory (vision),surroundings, shoesshoes

LL ost Balanceost Balance

OO steoarthritis steoarthritis

WW eak lower extremityeak lower extremity

Which is the Most Predictive Which is the Most Predictive of a Patient’s Fall Risk?of a Patient’s Fall Risk?

A) orthostatic hypotensionA) orthostatic hypotension

B) polypharmacyB) polypharmacy

C) history of previous fallsC) history of previous falls

D) Parkinson’s DiseaseD) Parkinson’s Disease

AGS Algorithm Suggests Full AGS Algorithm Suggests Full Office Fall Assessment if:Office Fall Assessment if:

Single Fall in last year with abnormal gaitSingle Fall in last year with abnormal gait

No falls, but difficulty with walking or No falls, but difficulty with walking or balancebalance

Two or more falls in last year even if gait Two or more falls in last year even if gait WNLWNL

Patient presents after an acute fall Patient presents after an acute fall

Fall Risk AssessmentFall Risk Assessment

I.I. Detailed historyDetailed history

II.II. Physical exam Physical exam

III.III. Functional AssessmentFunctional Assessment Observe gait and balance(Get up and go test)Observe gait and balance(Get up and go test)

Cognitive assessment Cognitive assessment

ADLs/ IADLsADLs/ IADLs

IV.IV. Lab only as indicated by I-IIILab only as indicated by I-III

V.V. Medication reviewMedication review

Timed ‘Get Up and Go’ TestTimed ‘Get Up and Go’ Test Simple test of observing a person stand Simple test of observing a person stand

up from a chair, walk 10 feet, turn around, up from a chair, walk 10 feet, turn around, walk back, and sit down again. walk back, and sit down again.

Correlates with ADLsCorrelates with ADLs

Normal person takes <10 seconds to Normal person takes <10 seconds to complete the task complete the task

Persons who take > 30 seconds are at Persons who take > 30 seconds are at increased fall risk and likely to have some increased fall risk and likely to have some dependency in ADLsdependency in ADLs

JAGS 1991;39: 142-48JAGS 1991;39: 142-48

Determine Multifactorial Fall Determine Multifactorial Fall RiskRisk

History of fallsHistory of falls

MedicationsMedications

Gait, balance and mobilityGait, balance and mobility

Visual acuityVisual acuity

Muscle strength and neurologic examMuscle strength and neurologic exam

CV exam and orthostatic BP checkCV exam and orthostatic BP check

Feet and footwearFeet and footwear

Environmental HazardsEnvironmental Hazards

Initiate Multifactorial Initiate Multifactorial Intervention Tailored to Intervention Tailored to

Individual Risks IDIndividual Risks ID Minimize medicationsMinimize medications

Tailored exercise programTailored exercise program

Treat vision impairmentTreat vision impairment

Manage postural hypotensionManage postural hypotension

SUPPLEMENT VITAMIN DSUPPLEMENT VITAMIN D

Manage foot and footwear problemsManage foot and footwear problems

Modify home environmentModify home environment

Office Evaluation of Mrs. T.Office Evaluation of Mrs. T.

Pt:Pt: 84 y/o female 84 y/o female

PMH:PMH: HTN, spinal stenosis, depression, anxiety HTN, spinal stenosis, depression, anxiety

HPI:HPI: Medical conditions stable, difficulty living Medical conditions stable, difficulty living alone d/t mild back and knee pain, near falls, alone d/t mild back and knee pain, near falls, notes some lightheadedness mainly in the AM, notes some lightheadedness mainly in the AM, does c/o general weakness. does c/o general weakness.

Medications:Medications: amlodipine 10mg AM; lisinopril 40 amlodipine 10mg AM; lisinopril 40 mg AM; HCTZ 25mg AM; lorazepam 0.5mg bid; mg AM; HCTZ 25mg AM; lorazepam 0.5mg bid; sertraline 100mg dailysertraline 100mg daily

Mrs. T. Physical ExamMrs. T. Physical Exam

Vitals: Vitals: BP Lying 140/80, HR 64BP Lying 140/80, HR 64

BP Standing 110/60, HR 80BP Standing 110/60, HR 80

HEENT WNL, Cardiopulmonary WNLHEENT WNL, Cardiopulmonary WNL

Extremities: mild swelling rt. knee, Extremities: mild swelling rt. knee, decrease ROM, pulses ¼decrease ROM, pulses ¼

Neurologic: WNL except proximal leg Neurologic: WNL except proximal leg weakness 4/5 and mild intention tremorweakness 4/5 and mild intention tremor

Mrs. T.’s Functional Mrs. T.’s Functional Assessment Assessment

Gait:Gait: flexed, decreased stride and foot flexed, decreased stride and foot clearance, does not extend rt. knee well, clearance, does not extend rt. knee well, does not grasp walker well due to tremordoes not grasp walker well due to tremor

ADLs:ADLs: needs help with dressing and bath needs help with dressing and bath

IADLs:IADLs: daughter had been assisting with daughter had been assisting with all except for meds and paying billsall except for meds and paying bills

GUG:GUG: 35 seconds 35 seconds

MMSEMMSE: 26/30: 26/30

Mrs. T.’S Problem ListMrs. T.’S Problem List

Diseases: Spinal Stenosis, Depression, Diseases: Spinal Stenosis, Depression, HypertensionHypertension

Orthostatic HypotensionOrthostatic Hypotension

OsteoarthritisOsteoarthritis

TremorTremor

Gait abnormal /Muscle weaknessGait abnormal /Muscle weakness

Medications: sertraline, lorazepam, BP Medications: sertraline, lorazepam, BP medicationsmedications

Interventions for Mrs. T.Interventions for Mrs. T.

Medications rearranged: Medications rearranged: Lisinopril 40 mg continued in AM Lisinopril 40 mg continued in AM HCTZ dose decreased to 12.5mg AM HCTZ dose decreased to 12.5mg AM Amlodipine moved to PMAmlodipine moved to PM Began to taper lorazepam with AM doseBegan to taper lorazepam with AM dose Sertraline decreased from 100mg to 50mgSertraline decreased from 100mg to 50mg

PT/OT muscle strengthening and balancePT/OT muscle strengthening and balance

Acetaminophen scheduled 650 tidAcetaminophen scheduled 650 tid

Check BMP, CBC and 25 OH vitamin DCheck BMP, CBC and 25 OH vitamin D

AGS Medication AGS Medication RecommendationsRecommendations

Psychoactive medications ( including Psychoactive medications ( including sedative hypnotics, anxiolytics, sedative hypnotics, anxiolytics, antidepressants, antipsychotics) should be antidepressants, antipsychotics) should be minimized or withdrawn, with appropriate minimized or withdrawn, with appropriate tapering if indicatedtapering if indicated

Reduce total number of medications or Reduce total number of medications or dose of individual medications should be dose of individual medications should be pursuedpursued

Division of Geriatric Medicine St. Louis Univ.Division of Geriatric Medicine St. Louis Univ.

Vitamin DVitamin D

The most common vitamin deficiency in The most common vitamin deficiency in older adultsolder adults

Vitamin D not only strengthens bone, but Vitamin D not only strengthens bone, but also musclesalso muscles

A number of studies have demonstrated A number of studies have demonstrated Vitamin D supplementation of at least Vitamin D supplementation of at least 800IU daily for 1 year can decrease falls 800IU daily for 1 year can decrease falls by 20 %by 20 %

BMJ 2009;339:b3692.

Other Measures to Prevent Other Measures to Prevent Orthostatic HypotensionOrthostatic Hypotension

Correct underlying cause i.e adjust Correct underlying cause i.e adjust medications, correct anemia or dehydrationmedications, correct anemia or dehydration

Drink plenty of fluidDrink plenty of fluid

Rise slowly, ankle pumps, sleep with head Rise slowly, ankle pumps, sleep with head of bed elevatedof bed elevated

Wear support stockingsWear support stockings

Caffeine with meals can help prevent Caffeine with meals can help prevent postprandial hypotensionpostprandial hypotension

Community Programs for Fall Community Programs for Fall PreventionPrevention

Develop more group exercise programs Develop more group exercise programs tailored for different levels of abilitytailored for different levels of ability

Develop community walking groups through Develop community walking groups through senior centers and health clubssenior centers and health clubs

Educate older adults on what they should Educate older adults on what they should expect from their health care provider for a expect from their health care provider for a full fall assessment riskfull fall assessment risk

Over the counter meds associated with falls Over the counter meds associated with falls and confusion TYLENOL/ADVIL PMand confusion TYLENOL/ADVIL PM

Division of Geriatric Medicin, St. Louis Univ.

ReferenceReference

http:www.americangeriatrics.org/http:www.americangeriatrics.org/health_care_professionals/clinical_practice/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2010/clinical_guidelines_recommendations/2010/