Case Discussion for Pharmacy Undergraduates

Geriatric FallsBy,By,

Dr. Lokesh ShettyDr. Lokesh Shetty

MPHARM – PharmacologyMPHARM – Pharmacology

Lecturer - RCsDPLecturer - RCsDP

Falls in Geriatrics

Falls: Mrs. F. Mrs. F. is an 80 year old woman who lives alone. Mrs. F. is an 80 year old woman who lives alone.

She just came in to your office for follow up of a She just came in to your office for follow up of a

fallfall resulting in a resulting in a Colles’ fracture (Colles’ fracture (fracture fracture of the distal radius in the forearm). of the distal radius in the forearm). She has had She has had two other falls over the past year. She is scared two other falls over the past year. She is scared of falling again. She has a history of of falling again. She has a history of

osteoarthritisosteoarthritis and and anxiety/ depressionanxiety/ depression. She is . She is

on on naproxennaproxen 500mg BID and 500mg BID and diazepamdiazepam 5mg 5mg BID when necessary.BID when necessary.

Overview PrevalencePrevalence Clinical ImportanceClinical Importance Risk Factors & EtiologyRisk Factors & Etiology Evaluation Evaluation Prevention & ManagementPrevention & Management Falls & restraint useFalls & restraint use SummarySummary

Prevalence

30% of those over the 30% of those over the age of 65 age of 65 fall annuallyfall annually Half are repeat fallersHalf are repeat fallers Falls go up with each decade of life as inclining Falls go up with each decade of life as inclining

ageage

1% of falls result in hip fracture

Impact of Hip Fractures

25% die within 6 months25% die within 6 months 60% have restricted mobility60% have restricted mobility 25% remain functionally more dependent25% remain functionally more dependent

Falls Causes

Mortality (death)Mortality (death) Fractures: 6% of fallsFractures: 6% of falls Soft tissue injury, head injury etcSoft tissue injury, head injury etc Fear of falling can result in Fear of falling can result in

decreased activity, isolation, and further decreased activity, isolation, and further functional declinefunctional decline

Nursing home placement and loss of Nursing home placement and loss of independenceindependence

Falls are Multifactorial

Intrinsic Factors Extrinsic Factors

FALLS

Medical conditions

Impaired vision and hearing

Age related changes

Medications

Improper use of assistive devices

Environment

Normal Changes with Aging NeurologicNeurologic

Increased reaction timeIncreased reaction time Decreased righting reflexes (Decreased righting reflexes (regain back former regain back former

body position)body position) Vision ChangesVision Changes

Decreased accommodation & dark adaptationDecreased accommodation & dark adaptation Decreased muscle massDecreased muscle mass Old Age Old Age Slower gait Slower gait (manner in which human or (manner in which human or

animal moves using limbs) animal moves using limbs) FallsFalls

Risk Factors for Falls Risk FactorRisk Factor

Sedative useSedative use Cognitive ImpairmentCognitive Impairment Lower extremity problemLower extremity problem Pathologic ReflexPathologic Reflex Foot ProblemsFoot Problems gait problemsgait problems

Common Pathologies associated with Falls Ophthalmologic diseasesOphthalmologic diseases Arthritis Arthritis Foot problems Foot problems Neurologic illnessNeurologic illness

Parkinson’s & related disordersParkinson’s & related disorders StrokesStrokes Peripheral neuropathyPeripheral neuropathy

Dizziness and disequilibriumDizziness and disequilibrium

Medications and Falls Sedative-hypnotics, especially long acting Sedative-hypnotics, especially long acting

benzodiazepines, increase fallsbenzodiazepines, increase falls Small association between most psychotropics Small association between most psychotropics

and fallsand falls SSRIs and TCAs both incrsease fallsSSRIs and TCAs both incrsease falls Weak association between Type 1A Weak association between Type 1A

antiarrythmics, digoxin, diuretics, and fallsantiarrythmics, digoxin, diuretics, and falls

Evaluation of Falls: History Location & circumstances of FallLocation & circumstances of Fall Associated symptomsAssociated symptoms Other falls or near fallsOther falls or near falls Medications (including nonprescription) and Medications (including nonprescription) and

alcoholalcohol Injury & ability to get upInjury & ability to get up

Evaluation of Falls: Physical Examination

Supine and standing BP - alwaysSupine and standing BP - always Routine physical examinationRoutine physical examination

Focus on cardiovascular, MS, neuro, feetFocus on cardiovascular, MS, neuro, feet Vision and hearing evaluationVision and hearing evaluation Consider acute medical illness & deliriumConsider acute medical illness & delirium Formal gait and balance assessmentFormal gait and balance assessment

Evaluation of Falls: Home Evaluation

Can be performed by nurse or othersCan be performed by nurse or others ? Reason for fall? Reason for fall

Evaluation of Falls:Evaluation of Falls: Risk Factors AssessmentRisk Factors Assessment

Common Causes of Abnormal Gait Difficulty arising from chairDifficulty arising from chair WeaknessWeakness ArthritisArthritis Instability on first standingInstability on first standing Hypotension, Hypotension,

Weakness Weakness Instability with eyes closedInstability with eyes closed ProprioceptionProprioception Step height/lengthStep height/length ParkinsonismParkinsonism Frontal lobe Frontal lobe

Fear Fear

Prevention & Treatment

Treat acute injury & underlying medical Treat acute injury & underlying medical conditionsconditions

Remove unnecessary medicationsRemove unnecessary medications Rehabitation, exercises, assistive devicesRehabitation, exercises, assistive devices Correct sensory impairmentsCorrect sensory impairments Environmental modifications & safetyEnvironmental modifications & safety Evaluate for osteoporosis treatmentEvaluate for osteoporosis treatment

Osteoporosis Calcium and vitamin D for most elders at riskCalcium and vitamin D for most elders at risk

Osteoporosis evaluation and treatment Osteoporosis evaluation and treatment Hip protectors appear to protect from hip Hip protectors appear to protect from hip

fractures in those who wear themfractures in those who wear them Thiazides may help slightlyThiazides may help slightly Statins?Statins?

Quit smoking

Treat impaired vision

Stop sedatives

Add 1 Gram Calcium

Hip Protectors

Risk Factor Modifications for Fractures

Falls: Primary Prevention

Intervention: adjustment in medications, Intervention: adjustment in medications, behavioral instructions, exercise programs behavioral instructions, exercise programs aimed at modifying risk factorsaimed at modifying risk factors

One year follow upOne year follow up

Restraint (Restriction to movement) Reduction and Injury

No evidence that restraints reduce fall injuries No evidence that restraints reduce fall injuries Restraints increase morbidity and may cause Restraints increase morbidity and may cause

deathdeath Risk factor for delirium, malnutrition, aspiration Risk factor for delirium, malnutrition, aspiration

pneumoniapneumonia

Alternatives to Restraints for Patients Who Fall or Wander

Accept the risk of fallingAccept the risk of falling Hip protectorsHip protectors Environmental modifications, day rooms, low Environmental modifications, day rooms, low

bedsbeds Least restrictive alternativesLeast restrictive alternatives AlarmsAlarms Sitters or familySitters or family Geriatric consultation team Geriatric consultation team

Summary

Falls are common in the elderly & may lead to Falls are common in the elderly & may lead to injuries and decline in functioninjuries and decline in function

Evaluation should included risk factor Evaluation should included risk factor assessment, gait assessment, and home assessment, gait assessment, and home assessmentassessment

Exercise can improve outcomesExercise can improve outcomes We have no evidence that restraints reduce fall We have no evidence that restraints reduce fall

related injuriesrelated injuries