Falls in the Elderly. Causes and solutions.

Transcription

1 Falls in the Elderly. Causes and solutions. Brent Tipping Sub-specialist Geriatrician and Specialist Physician Division of Geriatric Medicine University of the Witwatersrand 6 th Annual congress of the Faculty of Consulting Physicians of SA, Cape Town, Friday 19 th May 2017.

2 Fall = when a person unintentionally comes to rest on the ground, floor, or other lower level = represents an acute musculoskeletal failure event

3 WHY ARE FALLS IMPORTANT? COMMON Incidence - 30% per year in > those 65 year old - 50% per year in institutionalized elderly - recurrent falls in ½ institutionalized fallers - 75% those > 85 years old fall in 2 years CONSEQUENCES 10% serious injury + 5% fracture 1/3 develop fear of falling syndrome with decline in function WARNING 10% of falls occur during acute illness

4 Estimated all-cause and hip-fracture-associated mortality rates Calcified tissue int. 1997;61:

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6 Restriction in activity over the past 3 years in patients reporting fear of falling 0 = no activity restriction 1-2 = moderate activity restriction >2 = severe activity restriction 59.6% 25.5% 14.9% Deshpande et al. J Am Geriatr Soc 2008;56: Rixt Zijlstra et al. J Am Geriatr Soc 2009; 57:

7 Predictable changes of normal ageing that affect gait and balance Stiffening of connective tissue - > decreased range of joint motion Loss of muscle mass - > reduced muscle strength Slowing of nerve conduction - > prolonged reaction time Decreased visual acuity - > impaired depth perception Impaired proprioception - > increased postural sway Forward displacement center gravity - > impaired righting reflexes

8 WHY DO THE ELDERLY FALL? EXTRINSIC environmental INTRINSIC Failure to maintain postural control SITUATIONAL risk taking

9 HOW IS BALANCE /POSTURE MAINTAINED? SENSORY INPUTS peripheral nerve vision vestibular CENTRAL PROCESSING global cerebral failure motor cortex + connections basal ganglia/extrapyramidal cerebellum spinal cord NEUROMUSCULAR OUTPUT peripheral nerve muscles skeleton and joints Cerebral perfusion

10 Fredrick T. Sherman

11 GAIT AND BALANCE ASSESMENT 1. Get-up-and-go (>14 seconds high risk; 87% sensitivity, 87% specificity) 2. Sternal nudge 3. Rhomberg 4. One-legged-stance (<5 seconds; sens 37%,spec 76%) 5. Tandem walk 6. Sit to stands (unable or taking >15 seconds abnormal) 7. Stops walking when talking (sens 48%, specificity 98%)

12 Clinical assessment of falls in the older patient History of falls in the past year Recurrent falls Single fall No fall Multifactorial fall management program Balance and gait assessment e.g. Time up and go test >14 seconds Abnormal gait and balance Normal gait and balance Consider: Carotid sinus hypersensitivity Orthostasis Vision Consider an exercise program that includes balance and strengthening

13 Multifactorial Falls Risk Assessment and Management Assessment and management includes the following: Falls history and medication review Older person s perceived functional ability and fear relating to falling Gait, balance and mobility, and muscle weakness Cardiovascular examination Osteoporosis risk Visual impairment Nutrition Cognitive impairment and salient neurological examination Incontinence Home hazards 12 fewer falls per 100 patients treated per month BMJ 2004;328;680

14 MULTIDISCIPLINARY INTERVENTION PLAN 1. Physiotherapy/Biokinetics for individualized strength and balance training (preferably embedded within daily routine), assessment for assistive devices and to address fear of falling 2. Medical practitioner Manage contributory medical problems Rationalize medication 3. Occupational therapy to modify environment to minimize risks and educate. 4. Behavior modification situational factors usually addressed by physio and OT; remember alcohol

15 Studensky et al, JAMA. 2011;305:50-58 Gait speed : strong predictor of mortality The faster you walk, the longer you live Survival rate and life expectancy Gait speed <0.7m/sec m/sec Male >1.1m/sec

16 Exercise for Falls Prevention: Systematic Review PROGRAM High dose and walking High dose, no walking Low dose and walking Low dose, no walking High Balance Challenge Lower Balance Challenge 0.76 ( )* 0.96 ( ) 0.58 ( )* 0.73 ( )* 0.95 ( ) 1.20 ( ) 0.72 ( )* 0.91 ( ) Sherrington et al. J Am Geriatr Soc 2008;56:

17 82 year old lady with newly diagnosed hypertension. Three weeks previously primary care practitioner at the local clinic had been commenced on hydrochlorothiazide 12.5mg and enalapril 10mg (Blood pressure 199/104) Amlodipine 5mg added 2 weeks later (BP 175/98).

18 The Trial: International, multi-centre, randomised double-blind placebo controlled Endpoints Primary: reduction of stroke (fatal plus nonfatal): exp 35% Secondary: total mortality cardiovascular mortality cardiac mortality stroke mortality skeletal fracture rate n = 3845 Inclusion Criteria: Age 80 or more Systolic BP; mmhg + diastolic BP < 110mmHg Informed consent Step III + perindopril 4 mg Step II + perindopril 2 mg Step I indapamide SR 1.5 mg Exclusion Criteria: Standing SBP < 140mmHg Stroke in last 6 months Dementia Need daily nursing care Placebo Target BP 150/80 mmhg Placebo + Pla cebo + Pla cebo M-2 M-1 M0 M3 M6 M9 M12 M18 M24 M60 Bulpitt C, et al. Drugs and Aging 2001;18(3):

19 Reduction in Mortality All cause Mortality Placebo Active 21% reduction Patients at risk placebo active Number of reported serious adverse events: 448 in the placebo group vs 358 in active (p=0.001) Fewer fractures in the actively treated group (38 vs. 52) active treatment was associated with a reduction in incident fractures (HR 0.58, 95% CI , P=0.0498) Becket NS, et al. NEJM 2008;358:

20 Falls are an adverse drug event Hypertensive elderly persons who began receiving treatment have increased risk of having a hip fracture during the first 45 days following treatment initiation (incidence rate ratio, 1.43; 95% CI, ). Particularly at risk are older persons who have fallen (OR 2.31( ) Butt et al. Arch Intern Med. 2012;172(22): Tinetti et al. JAMA Intern Med. 2014;174(4):

21 Drugs as fall risk factors Drugs Odds ratio (Fixed, 95% CI) Laxatives 2.03 [ ] Psychotropic drugs 1.95 [ ] Benzodiazepines 1.86 [ ] IPD treatments 1.85 [ ] Hypotensive drugs 1.64 [ ] Hypnotic drugs 1.63 [ ] Antidepressants 1.61 [ ] Mary Tinetti IAGG 2009

22 Treatment with fall-risk-increasing drugs before and after a hip fracture: an observational study - Sweden Numbers of patients treated with fall-risk-increasing drugs Admission 93% Discharge 100% 6-Month follow-up 94% Drugs Aging Aug 1;27(8):653-61

23 Preventing Falls in the Community Cochrane Review 2012 Intervention RR (95% CI) Group exercise program 0.71 ( )* Home based exercises 0.68 ( )* Tai chi 0.72 ( ) Multifactorial interventions 0.76 ( )* Vitamin D supplements 1.00 ( ) Home modifications 0.81 ( )*

24 Home Modifications for Falls Prevention: A Systematic Review Figure 1 Meta-analysis of environmental interventions to reduce falls Study name Rate ratio and 95% CI Rate Lower Upper ratio limit limit Cumming Stevens Day Pardessus Nikolaus Campbell Favours Intervention Favours Control Heterogeneity Q = 16, p = 0.007, I squared = 69 Clemson et al. J Aging and Health 2008;20:954-71

25 High risk groups: Meta-analysis of environmental interventions to reduce falls. Clemson et al. J Aging and Health 2008;20:954-71

26 Environmental Assessment and Modification to Prevent Falls in Older People Pighills et al. J Am Geriatr Soc 2011;59:26 33

27 Vitamin D and Falls: Studies in Community Group No. of studies RR (95% CI) All studies ( ) Subjects with low vitamin D ( )* Subjects with various levels of vitamin D ( ) Gillespie LD et al. Cochrane Library 2012

28 Vitamin D vs. placebo, 302 vitamin D deficient older persons. Change in Get Up and Go Test over 12 months according to baseline tertile. Supplementation of vitamin D2 1,000 IU/d improved TUAG time 17.5% in participants with baseline values longer than 12 seconds J Am Geriatr Soc 58: , 2010

29 Smaller studies of effective interventions Psychotropic medication withdrawal Anti-slip device for shoes for icy conditions Cardiac pacemaker for cardio-inhibitory carotid sinus hypersensitivity Cataract surgery Single lens glasses for person s undertaking regular outdoor activity (vs. multi-focals) Nutritional supplementation in high risk malnourished older persons (for 6 weeks postacute illness).

30 Cataract correction Compared with 1-year hip fracture incidence in patients with cataract who did not have cataract surgery, adjusted OR of hip fracture within 1 year after cataract surgery was 0.80 (95% CI, ) Absolute risk difference of 0.20% Tseng et al. JAMA. 2012;308(5):

31 Interventions that are NOT effective Multidisciplinary assessment programs that are not strongly linked to interventions Walking programs Home modifications by non-ots Vitamin D if not vitamin D deficient New glasses??exercise in very frail older people??

32 Interventions for hospitalised patients 1 in 200 hospitalised patients fall. Injury rate is up to 30%. And between 2007 and 2012 rate of fall related serious injuries increased by 11%. 3 times more likely to fall in a single bedded room (p<0.01). A RCT of 24 wards including admissions in Australia shows 6-PACK programme including a fall risk tool and individualised use of one or more of six interventions: falls alert sign, supervision of patients in the bathroom, ensuring patients walking aids are within reach, a toileting regimen, use of a low-low bed, and use of a bed/chair alarm. Caused positive changes in prevention practice but difference in falls or fall related injuries between groups. Barker et al. BMJ 2016;352:h6781 Singh et al. Age & Ageing 2015:44:

33 NHS UK in-patient fall rate ranges from 2.9 to 13 falls/1,000 patient-bed days Wits Donald Gordon Medical Centre ward section C: 42 bed ward primarily admitting geriatric, neurological/neurosurgical, and orthopaedic patients. Year Bed Days Falls Fall rate/ ,5 27 2, , ,5 28 2,2 Fagan Sydney, Pauline Bergamasco, Brent Tipping, Sharon Sunny, Lindiwe Ntuli.

34 Conclusions Community dwelling Many falls are preventable it is possible to reduce risk of falling among people living in the community by at least 30% Effective interventions: Multi-factorial assessment and individualized intervention (some) exercise programs home modifications (by OTs) in high risk vitamin D supplements (if low vitamin D) medication rationalization cataract surgery

35 Conclusions Hospital falls High quality evidence showing the effectiveness of falls prevention interventions in acute wards remains absent. However, there is an obligation to monitor falls and implement reasonable systematic measures to minimise fall risk in identified patients with high fall risk. Thanks