Managing falls in the

elderly:

real world approachDR PRISCILLA NG

”

“A fall is defined as an event which

results in a person coming to rest

inadvertently on the ground or floor

or other lower level.

FALL: WHO DEFINITION

Falls in Singapore

No falls

83%

1 fall

11%

Recurrent falls

6%

Falls

17%

Falls in over 60s annually

487,600 over 65 = 82,892 falls

Chan KM, Pang WS, Ee CH, Ding YY and Choo P. Epidemiology of falls among the elderly community dwellers in Singapore. Singapore Medical Journal. 1997;38(10):427-31.

Sequelae of falls

Fractures

Head injuries

Fear of falling

Loss of mobility

Loss of independence

Institutionalisation

Death

Ambulant

18%

Decreased

ambulation

42%

Functionally

dependent

20%

Death

within 2

years 20%

Algorithm for

Assessing Fall Risk

in Older Adults

Living in the

CommunityHealth Promotion Board-

Ministry of Health Clinical Practice Guidelines: Falls Prevention among Older Adults Living in the Community.

Screening

#1: Falls history

#1: Falls history

1. Presenting with a fall

2. More than 1 fall in past year

3. Report gait or balance problems

AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons 2010

#2: Timed up and go test

Timed up and go test interpretation

< 10 s: freely mobile

< 20 s: mostly

independent

> 30 s: impaired

mobility

Podsiadlo D, Richardson S. The timed "Up & Go": a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991;39:142-8.

#3: Medication review

Drugs with CNS effect

Anxiolytics/hypnotics

Neuroleptics

Antidepressants

Anticonvulsants

Analgesics

Antihistamines

Skeletal muscle relaxants

Antivertigo drugs

Drugs for chronic medical conditions

Antihypertensives

Hypoglycaemics

Antiarrhythmics

Nitrates and other vasodilators

β-adrenoceptor blocking eye drops

Urinary antispasmodics

Drugs for symptom relief

American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults 2015

#4: Visual acuitySnellen chart

Comprehensive

assessment

1. History

2. Physical examination

3. Functional assessment

4. Environmental assessment

1. History: Anatomy of a fall

ComplicationsFallPrecipitating

factorsPredisposing

factors

Past medical history: Predisposing

factors

Neurological

Stroke

Parkinson’s disease

Cognitive impairment

Depression

Arthritis of knees

Cervical/lumbar spondylosis

Chronic medical

Diabetes

Hypertension

Urinary incontinence

Functional dependenceMusculoskeletal

Functional

Falls history: Precipitating factors

When Where How (Activity, footwear, symptoms

pre- and post-, able to get up?)

Complications

Current fall Cruise ship While going to toilet, ship hit a large

wave

LBP for investigation,

unable to walk

2nd fall

6 months ago

MRT station Slipped on a high curb. LOC after

fall

Stable HI and R hip

contusion. Admitted to

CH for rehab for 1 month

3rd fall

9 months ago

Bedroom No LOC. Unable to get up Nil

3 near misses Various locations Buckling of LL Nil

”

“Syncope is defined as a transient,

self-limited loss of consciousness with

an inability to maintain postural tone

that is followed by spontaneous

recovery.

2. Physical examinationHigher cortical function:

Cognition, safety awareness,

fear of falls, mood

Neurological: Parkinsonism, stroke,

neuropathy, spinal degeneration,

vestibular disorders, gait

Musculoskeletal: Osteoarthritis,

foot deformities, muscle

weakness

Nutritional status

Frailty

Vision: Cataracts, vision aids

Cardiovascular: Structural heart

disease, arrhythmias, orthostatic

hypotension

Footwear

Walking aids

Risk factors for falls

Intrinsic Age >80 Female Lower extremity weakness Previous falls Gait & balance disorder Visual impairment Depression Functional and cognitive impairment Dizziness Low BMI Urinary incontinence Orthostatic hypotension

Extrinsic

Polypharmacy (> 4 medications)

Psychotropic medications

Environmental hazards e.g. poor lighting, loose carpets, lack of

bathroom safety equipment

Interventions

Single interventions

Multicomponent / multifactorial interventions

• Exercise

• Environment

• Medication

• Medical

• Education

1. Exercise

1. Exercise

Most positive trials consisted of a

programme > 12 weeks, 1-3 times per

week, up to 90 minutes

16% reduction in falls

NNT 16

Balance

Gait

Strength

Tai Chi

Chang JT et al. Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials. BMJ. 2004 Mar 20;328(7441):680.

2. Enviroment

Enhancement For Active Seniors (EASE)

www.hdb.gov.sg/EASE-Application

8 or 10 grab bars for first

toilet and within flat,

and 6 grab bars for second toilet

Slip-resistant treatment

to existing floor tiles of 2 bathrooms/ toilets

Up to 5 ramps within

flat to negotiate one

level difference in the

flat and/ or at single-step main entrance

Enhancement For Active Seniors (EASE)

An elderly member in the household is 65 years old and above

An elderly member in the household aged between 60 and 64 years

requires assistance for one or more of the Activities of Daily Living (ADL)

Functional Assessment Report required

Singapore Citizen Households

Flat type 1-/ 2-/ 3-Room 4-Room 5-Room ExecutiveYou pay $125 (5%) $187.50 (7.5%) $250 (10%) $312.50

(12.5%)Government pays

$2,375 (95%) $2,312.50 (92.5%)

$2,250 (90%) $2,187.50 (87.5%)

Footwear

No loose laces

Wide toe box

Low heel Slip-resistant sole

3. Medication review

4. Medical interventions

Postural hypotension

Non-pharmacological

Slow rising

Ankle pumps

Adequate fluid intake

Elevate head of bed 20 degrees

TED stockings

Pharmacological

Fludrocortisone 0.05 -0.3 mg/day

Midodrine 2.5-10 mg tds

Vitamin D

Vision

Pacemaker

5. Education

Multifactorial interventions

Osteoporosis

FRAX WHO Fracture

Risk Assessment Toolhttp://www.shef.ac.uk/FRAX/tool.jsp

When to treat?

BMD T-score Interpretation Management

<-2.5 + fracture Severe/established osteoporosis Treat

<-2.5 Osteoporosis Treat

-1 to -2.5 Osteopenia Treat if high risk

>3%>20%Vertebral, forearm,

humerus + hip

Treatment

Pharmacotherapy

Bisphosphonates

Oral: alendronate 70 mg, risedronate

35 mg weekly

IV: zoledronic acid 5 mg yearly

Denosumab: SC 60 mg 6-monthly

Supplements

Calcium: 1200mg/day

Vitamin D: 800 IU/day

Considerations regarding

bisphosphonate therapy

Indications

Functional mobility

Lifespan

Dysphagia/NGT/GERD

Inability to sit up

Renal impairment (CrCl <30)

Adverse effects

Oesophagitis

Osteonecrosis of jaw

Atypical femoral #

Bone/joint/muscle pain

?AF

Contraindications

Thank you