Immobility and Falls in Elderly 120114

8/12/2019 Immobility and Falls in Elderly 120114

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Not all falls are

beautiful


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B Y : D R N I N I S H U H A I D A M A T H A R U N

S U P E R V I S O R : D R N U R S U H A I L A I D R I S

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Immobility and Falls in Elderly


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P R E T E S T S

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SBA Q14

A mildly demented 69 year-old male presents afterfalling. He sustained no apparent injuries and hismental status is unchanged. Which of the followingare routine tests that should be ordered in patientsthat fall?

A. Head CT scan

B. Hemoglobin

C.

Hip X- rayD. No routine testing ()


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Q25

Which is the following is a normal change in gait thatis associated with aging?

A. Loss of arm swing

B. Widening of the base

C. Decreased stride length ()

D. Variable step length and height


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Q36

Which of the following medications is associatedwith highest risk for falls in the elderly?

A. Pseudoephidrine

B. Lorazepam ()

C. Fludrocortisone

D. Bupropion


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Q47

An 80 year-old male who lives with his daughter andfamily presents for evaluation after a fall. He hasmild dementia and a history of hypertension. He istaking lorazepam prn and hydrochlorothiazide.

Other than a nontender contusion on his arm, hisphysical examination is normal. Regardingevaluation of fall,A. Exercise is beneficial in preventing falls. (T)

B. Restraints decrease the number of falls. (F)C. Use of psychotropic medications is associated with falling.

(T)

D. Environmental assessment can help prevent falls. (T)


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Overview8

Introduction

Epidemiology

Risk factors

Assessment Management

Prevention


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Complication: (within days)

CVS

Fluid shift, decreased CO, decreased peak O2 uptake, increaseresting HR

Muskuloskeletal Loss of contractile velocity and strength

others:

Pressure sore, DVT, Pulm embolism,

Postural hypotension, falls, skin breakdown

Recovery: weeks to months


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Prevention12

Avoid pressure sore: Frequent inspection at pressure points and shift position at least every

2hours

Minimize CVS deconditioning: Position pt as close to upright position as possible, several times daily

Reduced muscle contracture and weakness ROM and strengthening exercise started immediately after

immobilization and continued as long as pt in bed

Antithrombotic measures Avoid restraints

Discontinue invasive devices Gradual ambulation Advice from physical therapist: appropriate exercise, assistive

devices, safety modification & maintenance exercises


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Epidemiology14

2009- total elderly in Malaysia :- 2.02 billion

2010 (up to Sept) increase to 2.13 billionJabatan Statistik Negara

out of 3 adults age 65 falls every year 1

Hausdorff JM,Rios DA,Edelber HK.Gait variability and fall risk in community-living olderadults:a 1-year prospective study. Archives of Physical Medicine and Rehabilitation

2001;82(8):1050-6

30% of people who fall suffer moderate to severeinjuries.

TBI accounted for 46% of fatal falls 2Honbrook MC et al.Preventing falls among community-dwelling older persons:results from arandomized trial.The Gerontologist 1994:34(1):16-23


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Adults over 65: 1 in 3 fall every year

Archives of Physical Medicine and Rehabilitation, 2001

Falls are the leading cause of injury and death

9% of falls lead to ED visit 2.1 million nonfatal fall related injuries treated in ED in 2008 with more

than 500,000 hospital admissions

5-6% lead to fracture

Journal of Bone and Mineral Research, 2003

18,000 fall related deaths in 2007 46% related to TBI

Adults over 75: 4-5 times more likely to be admitted to long term care for a year or more

Age and Ageing, 1999

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Falls have significant consequences

20% -30% of people sustain lacerations, fractures or headtrauma

These injuries can decrease mobility and independence

American Journal of Public Health, 1992Journal of TraumaInjury, Infection and Critical Care, 2001

Older adults who have falls without injuries may develop fearof falling

Activities self-limited leading to decreased fitness and actuallyincreasing risk of falling

Age and Ageing, 1997

50% of community dwellers never return to pre-fall status

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Most fractures are caused by falls (spine, hip,forearm, ankle, pelvis and hand)

Many people who fall but not injured develop fear offalling- limit their activities, reduce mobility and loss

of physical illness.

Bell AJ,Talbot-Stern JK,Hennessy A.Characteristic and outcomes of older patients presenting to theemergency department after a fall:aretrospective analysis.medical Journal of Australia

2000;173(4):176-7


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Impact of Hip Fractures20

1% of falls result in hip fracture

25% die within 6 months

60% have restricted mobility

25% remain functionally more dependent


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Che Hassans story

Che Hassan 72 years old, widowed, living alone His daughter lives nearby, but work full time. Has history of hypertension, DM, BPH,

osteoarthritis of the knees. He takes multiple medications to manage his

medical conditions, but didnt bring these withhim today

He complaining of increased urinary frequency

and feeling bored. You note bent glasses frames and a small abrasion

on his forehead and right arm

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What risk factors does Che Hassan have for falls?

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What risk factors does Che Hassan have forfalls?

widowed, living alone

hypertension, DM, BPH, osteoarthritis of theknees.

multiple medications

increased urinary frequency

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Risk factors for falls25

Intrinsic Age and age-related physiologic changes Acute illness Chronic illness Mobility factors-gait disturbance, balance disorder

or weakness, pain related to arthritis

Extrinsic

Environmental factors Use of ambulatory assistive device Mechanical restraints


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Normal aging changes26

Neurologic

postural instability

slowed reaction time

diminished sensory awareness for light touch, vibrationand temperature

decline of central integration of visual, vestibular andproprioceptive senses


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Vision Changes decline in visual acuity

decline in accommodative capacity

glare intolerance

altered depth perception

presbyopia [near vision]

decreased night vision

decline in peripheral vision


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Normal changes of gait28

Gait Slower gait

Decreased stride length and arm swing

Forward flexion at head and torso

Increased flexion at shoulders and knees

Increased lateral sway


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Che Hassans story continue

On examination, thin elderly man wearing glasses withbent frames.

Afebrile BP: 135/80 - sitting

BP: 130/85 standing

PR : 80 regular rhythm Early cataract in right eye

Systemic review unremarkable except for suprapubic areatenderness

Urinalysis numerous WBC and bacteria You treat his UTI and ask him to return in a week time for a

review of medications and proper neurologicalexamination.

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Is the UTI significant with regard to Che Hassansfalls?

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Story continue..

Che Hassan returns feeling better and his urinarysymptoms improved. You further ask about the fall history,but Che Hassan reluctantly admits that he fell a week agoin his house and that was not the 1sttime. He has fallenmore than seven times.

I just trip over my own feet and sometimes fall backward

He doesnt want his daughter to know about the falls,because he would like to continue to live on his own anddoes not wish to be dependent on her.

He admits to limiting a lot of the activities he used to enjoybecause he was sure he would fall.

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Continue....

He brought a large bag of medications that includemetochlorpramide, acetaminophen, metoprolol,HCTZ, terazosin, gliclazide.

O/E:-cranial nerve intact. Strength normal

Sensory: decreased sensation on light touch andvibration on both lower extremities.

Slow gait. Difficulty rising without use of his arm.Arthritic changes both knees.

MMSE-29/30

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Based on this evaluation, what further risk factorsdoes Che Hassan have for falls?

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Intrinsic factors Extrinsic factors

Increasing age Female

Previous fall Visual impairment Urinary incontinence Functional limitations Decreased physical activity Gait and balance disorders Arthritis Cognitive Impairment Depression Muscle weakness Orthostasis

Poly-pharmarcy (>4 meds) Psychotropic meds most problematic

Alcohol Improper footwear Inadequate lighting Improper floor surfaces

Wet/slippery Loose rugs/carpets Uneven flooring

Inappropriate / inadequateassistive devices Grab bars, walker/cane

Improper seat or bed height

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New England Journal of Medicine, 2003Journal of the American Geriatrics Society, 2001


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A S S E S S M E N T O F F A L L S

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Essential components of fall history40

Ssymptoms

P previous fall or near fall

Llocation of fall

Aactivity at time of fall Ttime of fall

Ttrauma, both physical and psychological


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Drugs that may increase risk of falling41

Polypharmacy

Sedative-hypnotics

Antidepressant (TCA,SSRI)

Antihypertensive agent

Cardiac medications

Anticholinergic drugs

Hypoglycaemic agent

Antiparkinsonian medications

Topical eye medications


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Evaluation of Falls: Physical Examination42

Supine and standing BP - always

Routine physical examination

Focus on cardiovascular, MS, neuro, feet Vision and hearing evaluation

Consider acute medical illness & delirium

Formal gait and balance assessment


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Common Causes of Abnormal Gait43

Difficulty arising from chair Weakness Arthritis

Instability on first standing

Hypotension Weakness

Instability with eyes closed Proprioception

Step height/length Parkinsonism Frontal lobe Fear


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Get up and go test45

ONLY VALID FOR PATIENTS NOT USING ANASSISTIVE DEVICE

Get up and walk 10ft (3m), and return to chair

Seconds Rating


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Get up and go test46

Sensitivity 88%Specificity 94%Time to complete


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Balance test47

(1) side-by-side: feet side by side, touching

(2) semi-tandem: side of the heel of one foottouching the big toe of the other

(3) tandem:heel of one foot directly in front of andtouching the toes of the other foot.

Each stance is progressively more difficult to holdPeople unable to hold a position for 10 seconds arenot asked to attempt further stand

Mechanisms of Fall


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Intrinsic :

Aging, poor balance

Occurrence of falls

Fall OutcomesNo injuries

Contributing

factors Extrinsic :

Home hazards

Loss of

ConfidenceFractures Soft tissues

injures,

trauma

Disability,

reduced

quality of life

Mechanisms of Fall

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Continue....49

You recommend discontinuation ofmetochlopramide and referfor physical therapy andophthalmology evaluation.

In discusion with the daughter, she agree to havefamily membersvisit more frequentlyand to assist

with patients medication changes.


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6 weeks later50

He walk with cane, and with new eyeglasses, withplan to follow up on his cataract.

He states that he more confidentwith walking andsteadier on his feet.

In fact he has no falls in the time since your last visit.

He been able to do more activities at home andcommunity.


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Complication of immobility51

Physical:- Muscle wasting

Contractures

Osteoporosis Pressure sores

Aspiration pneumonia

Constipation

Urinary tract infection

Deep vein thrombosis


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Complication of immobility52

Psychological and Social

Isolation

Loss of independence/confidence

Sensory deprivation Depression

Anxiety


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M A N A G E M E N T

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C i i l S i R d i h Ri k f F ll i h


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Critical Steps in Reducing the Risk of Falls in theElderly

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- Treat acute injury and underlying medical condition,modify medication, providebalancetraining

- Eliminate environmental hazards- environmental

modification and safety.

- Provide opportunities for socializationandencouragement

- Involve thefamily.- Provide follow-up.

Falls and injuries in frail and vigorous community elderly persons. J AmGeriatr Soc 1991;39:46-52.


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Risk factorsInterventions56

Postural hypotension:-Behavioral recommendations, such as ankle pumps or

hand clenching and elevation of the head of the bed

Decrease in the dosage of a medication that may contribute

to hypotension; if necessary, discontinuation of the drug orsubstitution of another medication

Review of medications

Education about appropriate use of sedative-hypnoticdrugs


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Evaluation of Falls: Home Evaluation58

Can be performed by nurse, OT, PT, others

Stairs

Lighting

Clutter Bathroom

Specific hazards: cords, throw rugs


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P R E V E N T I O N

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Home Safety Checklist


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Home Safety Checklist

63 All living spaces

_____ Remove throw rugs._____ Secure carpet edges._____ Remove low furniture and objects on the floor._____ Reduce clutter._____ Remove cords and wires on the floor._____ Check lighting for adequate illumination at night (especially in thepathway to the bathroom).

_____ Secure carpet or treads on stairs._____ Install handrails on staircases._____ Eliminate chairs that are too low to sit in and get out of easily._____ Avoid floor wax (or use nonskid wax)._____ Ensure that the telephone can be reached from the floor.

Bathrooms_____ Install grab bars in the bathtub or shower and by the toilet._____ Use rubber mats in the bathtub or shower._____ Take up floor mats when the bathtub or shower is not in use._____ Install a raised toilet seat.

Outdoors

_____ Repair cracked sidewalks._____ Install handrails on stairs and steps._____ Trim shrubbery along the pathway to the home._____ Install adequate lighting by doorways and along walkways leading todoors.

Falls. In: Yoshikawa TT, Cobbs EL, Brummel-Smith K, eds. Ambulatory geriatric care. St. Louis:Mosby, 1993:296-304.

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Illumination64

Sufficient lighting- esp at bathroom,stairways Provide illuminated light switches

Place nightlines along the pathway from the

bedroom to the bathroom Avoid lighting glare

l f


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Floor surfaces65

Provide nonskid floor Avoid waxing kitchen floor

Cover slippery surfaces with nonskid carpeting

Replace throw rugs with nonskid rugs

Clean wet floors immediately

Avoid clutter and low lying object

Avoid thick pile carpets to minimize tripping

Ensure that loose lamp and telephone cords are notin walkways

Ensure that carpet edges are flat

i hi


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Furnishings66

Provide seating of proper height to permit safesitting and standing

Provide beds that permit safe movement

Arrange furniture to allow for clear walkways

S i


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Stairways67

Ensure that stairways have secure handrails Mark step edges with bright, nonskip tape

Ensure that step surfaces are in good repair and

nonskid

B h


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Bathroom68

Install grab bar Use toilet risers if the toilet seat is too low

Place nonskid strips or mats in the bathtub to

prevent slipping Install grab bars in the bathtub or shower for

support

O h


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Other69

Avoid restraints ( chemical or mechanical) Ensure that ambulatory assistive devices and

wheelchairs are properly fitted


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P O S T T E S T

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Post test


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Post test71

Which of the following is not an environmental riskfactor for falls?

A. Throw rug (T)

B. Freshly waxed kitchen floor (T) C. Grab bars (F)

D. Electrical cord lying on the floor (T)


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An elderly person may become so fearful of fallingthat they restrict mobility

A. True ()

B. False


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An 86y/o woman on 12 medications with a history ofhypertension, mild dementia and painful bunionscould potentially reduce her risk of falling with whichof the following?

A. Reduction in number of medications (T) B. An exercise program focused on balance and

strength (T)

C. A prescription for setraline (F)

D. Podiatry evaluation (F)


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T A K E H O M E M E S S A G E S

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T k H 7 t


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Take Home message: 7-steps

1. Falls in the elderly are a marker for acute medical event, therefore one has to beaware of multifactorial risk factorsfor falling. Investigate for infections,medication side-effects, and metabolic problems. Falls associated with loss ofconsciousness (syncope) suggests cardiovascular etiology.

2. Evaluate role of medication adjustment or withdrawal and side-effectsinpeople who fall. (CNS, Cardiovascular, warfarin and INR)

3. Meticulous history with structured assessmentof gait and balance, orthostatichypotension, muscle strength, vision and hearing is essential. Check Rombergs, Timedget up & Go test, Functional reach.

4. Home/Environmental safety assessmentshould be done with consideration forassistive devices.

5. Interventionsfor strength and balance trainingcan decrease the risk offalling. Timely Physical and Occupational therapy may help.

6. Osteoporosis prevention and use of protective devices(hip protectors) reducefractures, particularly hip. Calcium and Vitamin D supplementation for all.

7. Understand the significance of fear of falling in the older adults and its impact onmobility and functional status, hence counseling and encouragement ofactivity and routine exerciseis desirable.


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Immobility and Falls in Elderly 120114

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