Falls: A Case CloseFalls: A Case Closeto Hometo Home

Geriatrics InterclerkshipGeriatrics Interclerkship

April 30, 2012April 30, 2012

Gary Blanchard, M.D.Gary Blanchard, M.D.

““Gait deferred”Gait deferred”

Why are we so concernedWhy are we so concernedabout falls?about falls?

Patient H.B.Patient H.B. 86 years old, independently living on 86 years old, independently living on

Cape Cod with her husband x 65+ years.Cape Cod with her husband x 65+ years.

She is largely independent with her ADLs She is largely independent with her ADLs – but requires IADL assistance. – but requires IADL assistance. Inconsistently uses her walker.Inconsistently uses her walker.

She has frequent falls (16) – some of She has frequent falls (16) – some of which have resulted in hospitalization – which have resulted in hospitalization – in the past 18 months.in the past 18 months.

Patient PMHxPatient PMHx Type 2 diabetes – oral medicationsType 2 diabetes – oral medications Cataracts, visual impairmentCataracts, visual impairment Mild cognitive impairment, anxiety featuresMild cognitive impairment, anxiety features Delirium episodes (hospitalizations)Delirium episodes (hospitalizations) HypertensionHypertension

MedsMeds: lisinopril 20 mg once daily, : lisinopril 20 mg once daily, carbamazepine 200 mg twice daily, carbamazepine 200 mg twice daily, lorezapam 0.5 mg nightly, metformin 500 mg lorezapam 0.5 mg nightly, metformin 500 mg twice daily, ASA 81 mg dailytwice daily, ASA 81 mg daily

Her perspective:Her perspective:

She wants to remain at home, where She wants to remain at home, where she has always been. She steadfastly she has always been. She steadfastly wants to maintain her independence.wants to maintain her independence.

She acknowledges inherent risk of She acknowledges inherent risk of current living situation – and that her current living situation – and that her husband is also declining functionally.husband is also declining functionally.

Her grandson geriatrician’s Her grandson geriatrician’s perspective:perspective:

UnderappreciatedUnderappreciated ““Can cause lasting discomfort and Can cause lasting discomfort and

decreased function … cause discomfort decreased function … cause discomfort and disability for older adults and stress and disability for older adults and stress for caregivers.” (for caregivers.” (JAMAJAMA, 2010), 2010)

Major contributor to Major contributor to functional declinefunctional decline and and health care utilization.health care utilization.

Increased likelihood of nursing home Increased likelihood of nursing home placement.placement.

Fear of fallingFear of falling – debilitating. – debilitating.

PearlsPearls

NotNot a normal part of aging a normal part of aging

Red flag – a sentinel event for illness, Red flag – a sentinel event for illness, functional decline, frailtyfunctional decline, frailty

Consider: presentation of acute Consider: presentation of acute illnessillness

Not normal, but commonNot normal, but common More than 1/3 of community-living adults More than 1/3 of community-living adults

>65 fall each year. At least half recur.>65 fall each year. At least half recur.

Roughly 1 in 4 fallers limit their Roughly 1 in 4 fallers limit their lifestyle/activities due to fear of falling.lifestyle/activities due to fear of falling.

Roughly 10% of falls result in major injury Roughly 10% of falls result in major injury (fracture, etc.). Also: inability to rise (fracture, etc.). Also: inability to rise without help (rhabdomyolysis, pressure without help (rhabdomyolysis, pressure ulcers, dehydration)ulcers, dehydration)

MortalityMortality Accidents (commonly falls) are the Accidents (commonly falls) are the

66thth leading cause of death leading cause of death

Clustering of falls is associated with a Clustering of falls is associated with a high 6 month mortalityhigh 6 month mortality

Falling increases the mortality rate of Falling increases the mortality rate of patients with Alzheimer's Diseasepatients with Alzheimer's Disease

MorbidityMorbidity 4-6 % of falls result in a fracture4-6 % of falls result in a fracture

1-2% of falls result in a hip fracture1-2% of falls result in a hip fracture

>50% of older adults with a fall-related >50% of older adults with a fall-related hospitalization are discharged to a hospitalization are discharged to a nursing homenursing home

Falls account for 10% of ER visits and 6% Falls account for 10% of ER visits and 6% of urgent hospitalizations for older adultsof urgent hospitalizations for older adults

Why do people fall?:Why do people fall?:

Vulnerable host, wrong environmentVulnerable host, wrong environment Requires coordination among Requires coordination among

sensory (vision, vestibular, sensory (vision, vestibular, proprioception), CNS, peripheral proprioception), CNS, peripheral nervous system, cardiopulmonary, nervous system, cardiopulmonary, musculoskeletal, and other systems.musculoskeletal, and other systems.

Need >1 systems affected.Need >1 systems affected.

Risk factors Risk factors (cumulative):(cumulative):

1)1) Previous fallsPrevious falls

2)2) Balance impairmentBalance impairment

3)3) Decreased muscle strengthDecreased muscle strength

4)4) Visual impairmentVisual impairment

5)5) Medications (but chronic diseases can Medications (but chronic diseases can increase fall risk, too)increase fall risk, too)

6)6) Gait impairmentGait impairment

7)7) Dizziness/orthostasisDizziness/orthostasis

8)8) Functional limitationsFunctional limitations

Systematic ApproachSystematic Approach

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Decreased muscle strength

Neuropathy

Orthostasis

Vestibular, cerebellar

How do you evaluate the How do you evaluate the faller?faller?

History, exam?History, exam?

Why might my grandmother fall?Why might my grandmother fall?

What workup would you do for my What workup would you do for my grandmother?grandmother?

HistoryHistory

Patient PMHxPatient PMHx Type 2 diabetes – oral medicationsType 2 diabetes – oral medications Cataracts, visual impairmentCataracts, visual impairment Mild cognitive impairment, anxiety Mild cognitive impairment, anxiety

featuresfeatures Delirium episodes (hospitalizations)Delirium episodes (hospitalizations)

MedsMeds: lisinopril 20 mg once daily, : lisinopril 20 mg once daily, carbamazepine 200 mg twice daily, carbamazepine 200 mg twice daily, lorezapam 0.5 mg nightly, metformin lorezapam 0.5 mg nightly, metformin 500 mg twice daily, ASA 81 mg daily500 mg twice daily, ASA 81 mg daily

Patient PMHxPatient PMHx Type 2 diabetes – oral medicationsType 2 diabetes – oral medications Cataracts, visual impairmentCataracts, visual impairment Mild cognitive impairmentMild cognitive impairment, anxiety , anxiety

featuresfeatures Delirium episodes (hospitalizations)Delirium episodes (hospitalizations)

MedsMeds: : lisinopril 20 mg once dailylisinopril 20 mg once daily, , carbamazepine 200 mg twice dailycarbamazepine 200 mg twice daily, , lorezapam 0.5 mg nightlylorezapam 0.5 mg nightly, metformin , metformin 500 mg twice daily, ASA 81 mg daily500 mg twice daily, ASA 81 mg daily

Physical ExaminationPhysical Examination Gait, balance, mobility, muscle stregth, Gait, balance, mobility, muscle stregth,

lower extremity jointslower extremity joints NeurologicalNeurological: Cognition, peripheral : Cognition, peripheral

nerves, cerebellar, proprioception, nerves, cerebellar, proprioception, extrapyramidalextrapyramidal

CardiovascularCardiovascular: orthostatics, rate/rhythm: orthostatics, rate/rhythm

Visual acuityVisual acuity Examine feet and footwearExamine feet and footwear

Watch ‘em walkWatch ‘em walk

Observation is criticalObservation is critical

DemonstrateDemonstrate:: Timed ‘Get up and Go’Timed ‘Get up and Go’ ADL performance screenADL performance screen

Functional assessmentFunctional assessment

Assess ADL skills (mobility aids)Assess ADL skills (mobility aids) Assess perceived functional abilities Assess perceived functional abilities

and fear of fallingand fear of falling

EnvironmentalEnvironmental: home safety : home safety assessment (PT, OT, VNA)assessment (PT, OT, VNA)

Workup/Management Workup/Management PlanPlan

Effective InterventionsEffective Interventions

Best when customized, multidisciplinaryBest when customized, multidisciplinary

Best singleBest single: PT, exercise, cataract : PT, exercise, cataract surgery, medication reduction.surgery, medication reduction.

Vitamin D strongest evidence for Vitamin D strongest evidence for preventing fractures among older men preventing fractures among older men at risk.at risk.

2010 AGS Guidelines2010 AGS Guidelines

Multifactorial assessment: feet and Multifactorial assessment: feet and footwear, functional assessment, an footwear, functional assessment, an environmental assessment (home environmental assessment (home safety), and ask about their perceived safety), and ask about their perceived functional ability and fear of falling.functional ability and fear of falling.

Medications, particularly antipsychotics Medications, particularly antipsychotics and psychoactive medications, should and psychoactive medications, should be minimized or withdrawn.be minimized or withdrawn.

Postural hypotension assessment.Postural hypotension assessment.

2010 AGS Guidelines2010 AGS Guidelines

An 800-IU supplement of vitamin D.An 800-IU supplement of vitamin D.

An exercise regimen that focuses on An exercise regimen that focuses on balance, gait, and strength training, balance, gait, and strength training, such as tai chi or physical therapy.such as tai chi or physical therapy.

For older patients who need cataract For older patients who need cataract surgery, the intervention should be surgery, the intervention should be expedited.expedited.

Effective Multi-factorial Effective Multi-factorial Interventions for Fall Interventions for Fall

PreventionPrevention Gait training/assistive device trainingGait training/assistive device training Review and modify medicationsReview and modify medications Critically evaluate need for psychotropic Critically evaluate need for psychotropic

medicationmedication Exercise programs (strength and balance)Exercise programs (strength and balance) Treat orthostatic hypotensionTreat orthostatic hypotension Modify environmental hazards and activitiesModify environmental hazards and activities Treat cardiovascular disordersTreat cardiovascular disorders

Our patient: H.B.Our patient: H.B.

Our patient: H.B.Our patient: H.B.

Safety v. independenceSafety v. independence

ASK!!! (Annual screen >70)ASK!!! (Annual screen >70)

Targeted, multi-factorial interventions Targeted, multi-factorial interventions have been shown to be effective at have been shown to be effective at reducing falls in the home.reducing falls in the home.

ReferenceReference

Tinetti, M.; Kumar, C. “The Patient Who Falls: It’s Tinetti, M.; Kumar, C. “The Patient Who Falls: It’s Always a Trade-Off.” Always a Trade-Off.” JAMAJAMA. 2010; 303(3):258-. 2010; 303(3):258-266. doi: 10.10.2010266. doi: 10.10.2010

AGS Clinical Practice Guideline : Prevention of AGS Clinical Practice Guideline : Prevention of Falls in Older Persons Falls in Older Persons (2010)(2010)

McGee, Sarah, MD, MPH. “Mobility and Functional McGee, Sarah, MD, MPH. “Mobility and Functional Assessment.” UMMS Geriatrics Interclerkship, Assessment.” UMMS Geriatrics Interclerkship, March 28, 2008.March 28, 2008.

Bradley, S.; Chang, C. “Falls,” POGOe. Bradley, S.; Chang, C. “Falls,” POGOe. Mount Mount Sinai School of MedicineSinai School of Medicine. Brookdale Dept of . Brookdale Dept of Geriatrics and Adult Development. March 4, 2008.Geriatrics and Adult Development. March 4, 2008.