Evaluation of fragility and factors influencing falls in nursing homes. Dr Marie-Laure Seux Geriatrics Broca Hospital May 2013

Transcription

1 Evaluation of fragility and factors influencing falls in nursing homes Dr Marie-Laure Seux Geriatrics Broca Hospital May 2013

2 Epidemiological data Among the over 65s: 1/3 present at least one fall per year The risk of falling increases with age 2 times more frequent in women and in the event of deterioration of the cognitive functions Falls in care are 3 times more frequent than at home: 30 to 50% of patients in care fall If you fall once, you'll fall again: 50% of patients having presented a fall repeat at least once in the year Falls cause more than deaths per year in the elderly and aggravate the loss of autonomy

3 Fall risk factors FALL Intrinsic risk Precipitating Extrinsic factors factors factors Osteoarthritis, visual impairment, Parkinson s, dementia, stroke, polyneuropathy Fragility Multiple causes Cardiac disorders Hypoglycemia, dehydration, anaemia fever medication+++, Terrain, floor, lighting, footwear «mechanical fall»

4 The concept of fragility capacities Definition: : reduction in reserve capacities which affects stress-adaptation mechanisms Good health STRESS Pre-fragile Or fragile Dependents time

5 The elderly: 3 categories Successful ageing The elderly in good health 50% of patients > 65 years Absence or very tiny influence of physiological functions Absence of pathologies Principal objective of preventive gerontology Fragile ageing Fragile or pre-fragile elderly people 30% of pre-fragile patients > 65 years and 15% fragile Unstable but reversible state Signs of fragility: fatigue, slowness when walking, loss of weight, inactivity, difficulties with memory or movement Ageing with dependence Dependent elderly people 5-10% of patients > 65 years Frequently associated with severe evolutionary or complicated pathologies and/or handicap Frequently hospitalized or in care *Fried LP, Tangen CM, Walston J, et al. Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001; 56:

6 Fragility: Fried criteria Loss of weight involunary 5 kg or 5%/year Exhaustion yes no Level of physical activity zero or low Facteur de risque de mortalité yes no some short walks OR other physical activities of very light intensity (without perspiration and while being able t speak) yes no Speed of slow walk <1m/s yes no Weak grip strength woman<21, man <37 kg yes no 0 criterion : ROBUST 1-2 criterion(a) PRE-FRAGILE 3 criteria : FRAGILE

7 Fragility and falls Risk Ratios* at 3 years Fragile Incidence of falls 1.29 Degradation of motor skills 1.50 Increasing dependency 1.98 Hospitalizations 1.29 Death 2.24 * Adjusted to covariables, p.05

8 Fragility and sarcopenia

9 Evaluation of potential or proven fall patient Who : High-risk fall patients, in particular: Dependent Cognitive disorders, dementia, dysexecutive disorders Having already fallen High-risk traumatic fall patients, in particular: Osteoporitic Anticoagulant patients Malnourished Isolated Patients at risk of weaker but real falls: Fragile 9

10 Evaluation of potential or proven fall patient When : On entering a nursing home During a standard geriatric assessment at the time of other symptoms or signs (memory consultation for example) After any fall, whatever the causes and consequences 10

11 Evaluation of fall patients How : No systematic complementary examination but orientation according to the Standardized geriatric assessment: Clinical examination (neuro, rheumato, foot, cardiovascular) Sensory examination (sight, hearing) Cognitive examination (MOCA) Nutritional examination and bone brittleness Medication treatments Examination of gait and balance: Monopedal support Timed Up and Go Test: predictor of falls but ceiling effect Speed of walk: predictor of fragility/mortality Time to raise chair 5 times: reflects sarcopenia/fragility Hand grip: requires a dynamometer Short Physical Performance Battery : composite test 11

12 Functional evaluation: Short Physical Performance Battery (SPPB) Timing Interpretation score Speed of walk over 4 m..., secondes Non executable > 8,70 sec 6,21-8,70 sec 4,82-6,20 sec < 4,82 sec Chair raise test 5 times..., secondes Non executable > 16,70 sec 13,70-16,69 sec 11,20-13,69 sec < 11,19 sec

13 Functional evaluation: Short Physical Performance Battery (SPPB) Réalisation score Balance test Balance with feet together not maintained 10 sec Balance with feet together maintained 10 sec but balance semi-tandem not maintained 10 sec Balance semi-tandem maintained 10 sec but tandem not maintained more than 2 sec Balance tandem maintained 3 to 9 sec Balance tandem maintained 10 sec Total score = Gait + Rising + Balance / Total score SPPB Interpretation 10 to 12 Good performances 7 to 9 Average performances 0 to 6 Weak performances

14 Fragility: a reversible state Age and Ageing 1996; 25:386-91

15 Fragility: a reversible state Evolution 3 months 6 months 12 months Robust to robust 22 (61.1 %) 25 (73.5 %) Robust to pre-fragile 13 (36.1 %) 9 (26.5 %) Robust to fragile 1 (2.8 %) 0 (0 %) Pre-fragile to robust 33 (32.4 %) 12 (16.7 %) 10 (14.5 %) Pre-fragile to pre-fragile 66 (64.7 %) 54 (75.0 %) 58 (84.1 %) Pre-fragile to fragile 3 (2.9 %) 6 (8.3 %) 1 (1.4 %) Fragile to robust 3 (20.0 %) 0 (0 %) 0 (0 %) Fragile to pre-fragile 6 (40.0 %) 2 (22.2 %) 3 (21.4 %) Fragile to fragile 6 (40.0 %) 7 (77.8 %) 11 (78.6 %) Chan et al. BMC Geriatrics 2012, 12:58

16 Conclusion The damaging impact of falls on autonomy and mortality justifies tracing the risk factors of occurrence and the severity factors in the elderly at risk. Preventive measures must relate to all possible causes, often multiple. The early detection of falls is a major element of the functional forecast. 16

17 For more information..