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FALLS
Slips, trips and fractured hips!
Man Falling, by Giacometti
Falling facts
• 1/3 of people > 65 yo (community dwelling)
• 1/2 of people > 90 yo
• Females > Males
• 1/2 those who fall will have > 2 falls
Further Falling Facts
• 20% need medical attention
• ~10% to A&E
• 6% of all hospital admissions (> 65)
• 2% of all deaths age >65
Fernando Botero: Works on Paper: Woman Falling from Balcony
Falling Freida
• 85-year-old, lives alone with Carl the Cat
• No home services, never married. Former Art Teacher.
• Mobile independently
• several falls recently - bruises only
• worried she’ll hurt herself if she falls again...
Freida’s Falls
– Unexpected visitor when Freida was watching “The Bold and the Beautiful”.
– Felt dizzy on standing, stumbled over coffee table and fell onto box of paints she’d had delivered the day before. - just didn’t see them!
– Out looking for Carl the Cat at dusk. Tripped over loose pavement in backyard. Difficulty gettting up
– now reluctant to leave the house
Falling Frieda’s PMx
• Stroke 40 years ago - affecting L side - minimal weakness now.
• HTN
• Cholecystectomy
• “nerves”
• Macular Degeneration
Examination
• Slightly frail, in high heels!
• BP 140/70, no postural drop
• P=70, reg
• HS dual, no carotid bruits
• Abdo soft and non-tender
• CNS intact - slight decrease proprioception both feet
Harold, the Home visiting nurse• reports that the home is very cluttered, Lounge
dark with curtains drawn.
• morning BP:– 180/100 lying 140/ 70 standing, assoc dizziness.
• Meds:– aspirin
– Perindopril Plus
– nifedipine Oros
– Nitrazepam 5mg nocte
Falling Frieda’s follow-up
• Bloods:– Hb 130, MCV 87
– Na 124, K 3.7, Cr 110, Urea 7.9
– TFT’s, LFT’s, B12 &folate normal
• MSU nad
• ECG - NSR, borderline LVH
Why does Frieda Fall?
Extrinsic:
lives alone visual impairment Poor lighting Loose carpets Badly fitting footwear
Intrinsic:
Hyponatraemia Diuretics Postural Hypotension decreased righting reflexes Sedative Medication
How to help….
• Decrease and aim to stop sedative (controversial after recent article?)
• Stop diuretic.
• Ensure Na normalises
• increase lighting in house
• de clutter
• Improve righting Reflexes
Vaartkapoen, Tom Franzten
Tumbling Thomas
• 87-year-old, former Army Officer
• Anglo-Indian, supportive family
• living in retirement village for last 2 months after his wife died.
• has had several unwitnessed falls in the bathroom, able to use call bell to alert staff.
• Carers concerned as unsteady on walk to dining room
His PMx
• epilepsy - complex partial since childhood
• atrial fibrillation
• ischaemic heart disease
• osteoarthritis
Medications
• sodium valproate 400mg bd
• digoxin 125mcg od
• ISMN 60mg
• aspirin
• diclofenac prn
• frusemide 80mg
Further History
• Feeling generally weaker and more unsteady recently
• Difficulty getting to the bathroom on time - concerned he might become incontinent and need to wear nappies!
• Denied any seizures or post -ictal periods recently. Last~2/12 ago at wife’s funeral.
Examination• Serious, slightly vague
• MMSE 28/30 (-2 recall)
• BP 110/70, no postural drop
• HS dual with ESM, no radiation
• CNS:– marked quadriceps wasting of both legs– decreased reflexes ankles
• osteoarthritis changes +++ of knees.
Investigations• Hb 9.5, MCV 87
• urea 17.5 creatinine 157
• digoxin level 1.2
• ECG shows sinus rhythm with ST/T wave changes consistent with digoxin effect.
Why was Thomas Tumbling?
Extrinsic:
• new environment, not used to bathroom
Intrinsic:
• ?digitoxic
• dehydrated
• deconditioned
• anaemic
• ?aortic stenosis
How to help
• Meds altered
• Echo: aortic sclerosis only
• Physio and hydrotherapy to increase quad strength
• Haematemics: B thalassemia trait and folate deficiency - corrected
But…Thomas was still Tumbling!
• Why?…..
• What should we do next….
CT head
Icarus Falling, Mildred Kaye
Physiology of Falling -Normal Aging Changes
• Decreased height, flattening foot arch, increased hip flexion– change in centre of gravity
• Muscle mass and type II fast Twitch fibres decrease– decreased strength and impaired reaction time
• Cerebellar atrophy– decreased co-ordination
Physiology of Falling II
• Decreased Vision– very important - decreased ability to perceive
obstacles
• Decrease in Peripheral Vestibular Excitation– loss of balance mechanism
• Decrease in Max Heart Rate– decrease exercise tolerance
How to help Falling Frieda and Tumbling Thomas...
Ask, AssessExerciseImprove SurroundingsOsteoporosis reviewUn-medicate
ASK!
• Ask all patients over 65 if they’ve had a fall or near fall in the last year.
Ask about fear of falling Ask about urinary incontinence Ask about Home hazards
Assess Assess vision Assess cognition
MMSE/ IQ code
Assess Cardiology rhythm, rate, evidence failure, murmurs, pulses (and
bruits)
• Assess neurology • Assess gait, balance, mobility and muscle
weakness
Exercise Balance and strength training -community and
institutional settings. Must be structured and tailored to individual
Post #NOF Strengthening muscles around the hip
Teach how to avoid a long lie Improve confidence try Tai Chi
Improve surroundings
Provide appropriate mobility and safety equipment
Adapt the environment
• Educate re potential hazards
Osteoporosis and fracture prevention
• Determine risk– previous fracture?– Family hx– Evidence kyphoscoliosis?
• ?hip protectors in institutional settings
• Vitamin D and Calcium supplementation
• Bisphosphonate as required
Un - Medicate• Stop psychotropic medications
– benzodiazepines, sedatives
• decrease number of medications
• Pay close attention to meds that drop BP:– Anti-Hypertensives– Diuretics– L Dopa– SSRI/TCA’s
Wagner et al. Annals of Int Med. 16/01/07
Benzo’s, Falls and Fractures
• New York state has limited use of Benzodiazepines
• ?did this decrease the number of hip fractures in Elderly
• compared New York (limited use) and New Jersey (still unlimited)
• NY decreased benzo prescribing by 60%• NO reduction in hip fracture change
Oliver et al. BMJ 08/12/06
Falling in Hospitals +High Care Facilities
• Recent meta-analysis
• data often poor - 13 studies found for hospital, 8 for care homes
• Effective:– multifaceted interventions - but only for falls, NOT fractures,
and only in Hospital setting
• Unknown Effectiveness:– Vitamin D (3 smallish trials effective, 1 large trial ineffective)– Hip Protectors (still unproved - studies not enough POWER)– alarms– removing physical restraints
Summary
• Falls are important
• Best improvement seen with multidisciplinary input
• Cause almost always multifactorial
Whenever the horse stopped (which indeed very often), [The Knight] fell off in front; and, whenever it went on again (which it generally did rather suddenly), he fell off behind.
John Tenniel