Geriatric MedicinePrinciples

Falls

Robert Kirby, MD, FACPClinical Professor of Medicine

Geriatric Medicine

Geriatric MedicinePrinciples/ Falls

Learning Objectives:1. List two characteristics of the geriatric

population. 2. Describe two instruments to assess function.3. Define geriatric syndrome. Name three.4. List four risk factors for falls.5. Outline three interventions to reduce fall risk.

Biology of Aging

GeneticOxidative Stress

Mitochondrial DysfunctionHormonal Changes

Telomere Shortening (Hayflick Limit)Defective Host Defenses

Accumulation of Senescent Cells

Harrison on Line

Demographics

USA 2020 >65 yo 16%

Dependency Ratio-Europe

2050 22% to >50% Harrison on LineMerck Manual Geriatrics

Demographics

Over Age 65

40% of Hospital Resources24% of Office Visits

25% of Prescription Drug Costs

25% of Medicare expenditure in last year of life- Half of this in last 60 days

Residents of Nursing Homes Age 65 1%

Age 85 17%Merck Manual of Geriatrics

Chronic Disease Burden

Arthritis 50 54

Hypertension

Heart

36

32

39

39

Hearing

Cataracts

28

16

36

24

Diabetes

Vision

10

8

11

11

Condition Age 65 % Age 75 %

Merck Manual Geriatrics

Life Expectancy

Walter LC, Covinsky KE, JAMA 2001

Function: Activities of Daily Living

Basic Intermediate

Dressing ShoppingEating HouseworkAmbulating AccountingToileting Food PreparationHygiene Transportation

Function with Aging

0

10

20

30

40

50

60

ADL problem IADL Problem

% w

ith

Dif

ficu

lty

Age 65-7470-7475-7980-8485+

Principles in a Flash1. Aging is not a disease.2. Geriatric conditions are chronic, multiple,

multifactorial3. Reversible conditions are underdiagnosed and

undertreated4. Function and quality of life are critical

outcomes5. Social support and patient preferences are

critical aspects6. Geriatrics is multidisciplinary7. Cognitive and affective disorders prevalent and

undiagnosed at early stages8. Iatrogenic disease common and often

preventable9. Care is provided in multiple settings10. Ethical and end of life issues guide practicewww.cha.emory.edu/reynoldsprogram

Clinical Approach

Not what disease caused the problem

But what combination of physiologic change, impairments and diseases are contributing

And which ones can be modified

Modawal

Geriatric Syndromes

Dementia and DeleriumFallsPolypharmacyPressure UlcersUrinary Incontinence

Mary Anderson

This 85 year old widow presents after a fall in the bedroom of the home where she has raised her family and lives independently.

She does not know why she fell, was able to ambulate after the fall and presents six hours later with a bruise on her left cheek and an abrasion on the left forearm.

Daughter reports occasional confusion and some limitation of activities due to weakness. She reports a fall four months ago.

PMHDJD hips and knees with chronic painHypertensionMacular degenerationDiabetes 2Urinary urgency and rare incontinence

Medications: Hydrochlorothiazide, Fentanyl patch, KCL,Tylenol, MVIExamination:

BP supine 160/88; standing 3 minutes 168/92Vision 20/50Chest – rare crackles right baseNeuro: absent achilles, romberg normal

Gait antalgic secondary to right hip painGet up and go test: 18 seconds. Uses arms to arise

from chairFunctional Reach test 5 inches

Laboratory:Hemoglobin 11 gm/dlK 3.0 meq/LGlucose 212 mg/dlCreatinine 1.4 mg/dlBUN 24 mg/dlUrinalysis wbc 20, nitrite positive

Questions aboutMary Anderson

1. What is the most important risk factor for her recent fall?

2. What is the most important physical examination finding related to her fall?

3. What additional diagnostic studies will be helpful?4. What is the most important initial step in managing

Mary’s fall?5. What consultations/referrals would be most useful?

Importance Risk Factors Clinical Assessment

History Physical Examination Laboratory Management

Fall

“Unintentional coming to rest at a lower position unrelated to obvious intrinsic or environmental factor.”

Importance

Prevalence Ambulatory Adults >65 30% per year

ConsequencesDeathInjury

Fractures 10-15% Hip 1-2% Long Lie Fear of Falling

Reduced Activity/Independence (25%)

Causes Extrinsic

EnvironmentIntrinsic

AgeGait/Balance DisorderSarcopenia VestibularOrthostatic Hypotension

Special Senses –Vision/Hearing

DiseaseDementiaDepressionDrugsFoot problemsIncontinence

Risk Factors

Muscle weakness: 4.4 History of falls: 3.0

Gait or balance deficit: 2.9 Use of assistive device: 2.6 Visual deficit: 2.5 Arthritis: 2.4 Depression: 2.2 Cognitive impairment: 1.8 Age over 80 years: 1.7

Mean RR or OR of risk factors for falls from 16 studies

Data from AGS Panel on Falls Prevention. Guideline for the prevention of fallsin older persons. J Am Geriatr Soc 2001;49(5):664–72.

Gait

Stride LengthArm SwingSlowForward Flex

Head and TorsoFlexion shoulders kneesLateral Sway

Normal Gait Video

History-Physical

InjuryDetails of FallInability to Get UpAssociated Disease and DisabilityDrugs

GeneralOrthostatic BPVisionCognition ( MMSE)Gait/Balance/Coordination

LaboratoryCBCCMP

EKG

Get Up and Go

Normal

Abnormal

Modified Single Leg Stance

Functional Reach

Sharpened Romberg

Fall Risk Next Treatment Year (%) Reduces

Risk(%)

Fall Past Year 50 30Gait Problem 30 20One Risk 20 10Two Risks 30 20Three Risks 60 40Four or More 80 50 Treatable Risks: 1. Problem walking or moving 2. Orthostatic hypotension 3. Four or more meds or one psychoactive 4. Unsafe footwear or foot problems 5. Environmental hazard

Reducing Fall Risk

www.fallprevention.org

Guideline for Fall Prevention

JAGS 2001. 49:664-672

ManagementReduce Fall Risk

EnvironmentExercise and BalanceCardiovascular

(orthostasis)VisionAssistive DevicesMedication ReviewFootwearBehavior EducationRestraints

Rubinstein Med Clin N Am 2006

ManagementReduce Fall Risk

Exercise

Wolf JAGS 1996

MMWR Rep 2004;53(2):25-28

-47%

Reduce Fracture Risk Hip Protectors

Vitamin D/Calcium 400-800IU / 1200-1500

Lauritzen JB, Peterson MM et al Lancet 1993; 341:11-13.

Questions aboutMary Anderson

1. What is the most important risk factor for her recent fall?

a. History of previous fallsb. Medicationsc. Possible urinary infection and/or dementiad. Gait disordere. Visual impairment

Questions aboutMary Anderson

2. What is the most important physical examination finding related to her fall?

a. Extent of injury and painb. Result of blood pressurec. Result of “Up and Go Test”d. Visual acuitye. Neurologic findings

Questions aboutMary Anderson

3. What additional diagnostic studies will be helpful?

a. Twenty four hour ambulatory EKG ( Holter) monitorb. Carotid Doppler study

c. Brain MRId. Head-up tilt teste. Radiograph of chest and hipsf. Electoroencephalogram (EEG)

Questions aboutMary Anderson

4. What is the most important initial step in managing Mary’s fall?

a. Reduce hydrochlorothiazide and fentanyl

b. Hydrate and treat UTIc. Treat injury and paind. Osteoporosis treatmente. Counsel on “fear of falling” f. Recommend hip protectors

Questions aboutMary Anderson

5. What consultations/referrals would be most useful?

a. Ophthalmologyb. Physical Therapy for

strengthening exercisec. Home safety evaluation by

Occupational Therapyd. Neurology consultatione. Cardiology consultation

Geriatric MedicinePrinciples/ Falls

Learning Objectives:

1. List two characteristics of the geriatric

population. 2. Describe two instruments to assess function.3. Define geriatric syndrome. Name three.4. List four risk factors for falls.5. Outline three interventions to reduce fall risk.