Fall Risk Assessment and Management. Elizabeth A. Phelan, MD, MS Assistant Professor, Medicine/Gerontology October 24, 2007

Transcription

1 Fall Risk Assessment and Management Elizabeth A. Phelan, MD, MS Assistant Professor, Medicine/Gerontology October 24, 2007

2 Slide 2

3 OBJECTIVES Know and understand: The importance of falls by older persons How to assess and treat falls Slide 3

4 CASE 1 (1 of 3) An 76-year-old woman presents to your office complaining of problems with her balance. She has a history of T II DM, hypertension, osteoporosis, and urge urinary incontinence. She has not had an acute illness or change in medication. She has no history of prior falls. She takes HCTZ, glipizide, aspirin, fosamax, and detrol. She is alert, fully oriented, with normal vital signs. Her timed up and go is 11 sec, with normal foot clearance and arm swing, but she is unable to perform a full tandem stand. Slide 4

5 CASE 1 (2 of 3) What is this patient s risk of falling? (A) Low (B) Moderate (C) High Slide 5

6 CASE 1 (2 of 3) What is this patient s risk of falling? (A) Low (B) Moderate (C) High Slide 6

7 FALLS Definition: coming to rest inadvertently on the ground or at a lower level One of the most common geriatric syndromes Most falls are not associated with syncope Falls literature usually excludes falls associated with loss of consciousness Slide 7

8 60 EPIDEMIOLOGY OF FALLS Community LT Care Each year 1/3 of community-dwelling persons aged 65, and 1/2 of residents of long-term-care facilities, experience falls Slide 8

9 MORBIDITY AND MORTALITY Most falls result in some injury 10% of falls result in serious injury (fracture, head trauma) Falls can result in death (13,700 deaths in US in 2003) The death rate attributable to falls increases with age and has been increasing over time Men more likely to die from a fall Slide 9

10 Functional decline SEQUELAE OF FALLS Decreased quality of life Loss of independence Nursing home placement Fear of falling Increased use of medical services (ED visits, hospitalizations) Slide 10

11 COSTS OF FALLS Total direct cost for falls among older adults in 2000: $19 billion By 2020, national annual cost for fall-related injuries: $43.8 billion Slide 11

12 How are we doing with addressing falls? History of falls rarely elicited in ED * Risk factors for future falls not identified * Most elders seen in ED for falls had no recommendation or appointment for follow-up beyond acute injury * Geriatric syndromes not always addressed in practice Systems changes more effective than educational interventions in achieving practice change * Paniagua MA, et al. Am J Emerg Med 2006;24: Wenger NS, et al. Ann Intern Med 2003;139: Bero LA, et al. BMJ 1998;317: Slide 12

13 CAUSES OF FALLS Rarely due to a single acute cause (MI, acute infection, stroke) Usually due to complex interaction of: Intrinsic factors (eg, aging changes, chronic disease) Extrinsic factors (environment, medications) Mediating factors (eg, risk taking) Slide 13

14 Age-related changes INTRINSIC CAUSES Proprioception Slowed righting reflexes Increased postural sway Step height Chronic disease Vision impairing diseases (cataracts, AMD) Vitamin D deficiency Osteoarthritis Slide 14

15 INTRINSIC CAUSES: VITAMIN D DEFICIENCY Low 25(OH) vitamin D levels (<10 ng/ml) associated with increased fall risk Vitamin D supplementation reduces fall risk even in those not D deficient 15 persons need to be treated with vitamin D to prevent one from falling 800 IU/day of vitamin D associated with reduction in proportion with falls among NH residents Slide 15

16 EXTRINSIC CAUSES: MEDICATIONS Psychoactive medications: Benzodiazepines Antidepressants Antipsychotic drugs Anticholinergic side effects (benadryl, atarax) Recent medication dosage adjustments 4 medications Slide 16

17 EXTRINSIC CAUSES: ALCOHOL 14 or more drinks/week increases fall risk - Mukamal JAGS 2004 A history of problem drinking ( 2 positive responses on CAGE) increases fall risk A history of heavy drinking ( 5 drinks/day) increases fall risk - Cawthon JAGS 2006 Slide 17

18 EXTRINSIC CAUSES: ENVIRONMENTAL Poor lighting Loose objects on the floor (throw rugs, electrical cords, torn carpet) Unsafe steps (uneven, broken, no railings) Clutter Items in hard to reach places Slippery tub/shower Improper footwear Slide 18

19 FOOTWEAR Foot position awareness with aging Good Evidence: Avoid going barefoot or in socks indoors Greater sole contact area reduces fall risk Higher heels increase fall risk Lower Quality Evidence: Thin, hard soles more stabilizing than thick/soft midsoles Ankle and heel supporting shoes enhance balance (avoid narrow heels) Non-stick, non-skid soles BOTTOM LINE: Advise well fitting, low-heeled shoes with slip resistant soles Slide 19

20 EXTRINSIC CAUSES: ASSISTIVE DEVICE ISSUES Improper device Lack of use of proper device Improper use of proper device Slide 20

21 What is the effect of age on risk of falling? Pretest probability of falling at least once in any given year for those aged 65 years: 27% Age not as important in predicting falls as: History of prior falls (+ LR 3) Gait or balance abnormalities Self-perceived mobility problem (+ LR 2) Unable to rise from chair without use of arms (+ LR 4) Unable to perform full tandem stand (+ LR 2) Slow gait (+ LR 2) Slide 21

22 Which elders at high risk for falls? * Recurrent fallers ( 2 falls in 6 months) Those with abnormalities of gait or balance on functional testing Those presenting for medical evaluation after a fall * AGS/BGS/AAOS Panel. Guideline for the prevention of falls in older persons. J Am Geriatr Soc 2001:49; Slide 22

23 FALLS ASSESSMENT: SCREENING Ask all older adults about falls in past year Single fall: check for disturbance of Gait Balance Recurrent falls or gait or balance disturbance: perform complete fall risk factor evaluation (Fall Prevention Clinic) AGS/BGS/AAOS Panel. J Am Geriatr Soc 2001:49; Slide 23

24 THE TIMED UP AND GO TEST (TUG) Record the time it takes a person to: 1. Rise from a hard-backed chair with arms 2. Walk 10 feet (3 meters) 3. Turn 4. Return to the chair 5. Sit down Slide 24

25 THE TIMED UP AND GO TEST (TUG) Most adults can complete in 10 sec Most frail elderly can complete in 11 to 20 sec 14 sec = falls risk >20 sec comprehensive evaluation Slide 25

26 OTHER GAIT ABNORMALITIES THAT MAY BE DETECTED BY TUG Spasticity Hemiplegia, hemiparesis (leg swings out) Parkinsonism (small shuffling steps, hesitation, festination, retropulsion, turning en block, absent arm swing) Cerebellar ataxia (wide-based gait with increased trunk sway, irregular stepping) Slide 26

27 CONDITIONS THAT CONTRIBUTE TO GAIT DISORDERS Osteoarthritis Foot problems (bunions, claw toes), footwear Peripheral neuropathy CNS disorders (Dementia, NPH, Parkinson s disease) Impairments following orthopedic surgery Impairments following stroke Dizziness, postural hypotension Fear of falling Usually multifactorial Slide 27

28 BALANCE SCREENING Feet together stand Semi tandem Full tandem Stand on one foot - 10 seconds each, stop when unable to perform task - No assistive device - Bare feet - Okay to assist to assume position Slide 28

29 COMPREHENSIVE FALLS ASSESSMENTS Slide 29

30 FALL HISTORY S symptoms P prior falls L location A activity T timing Slide 30

31 PHYSICAL EXAMINATION Vision screening Gait and balance LE joint function Basic CV exam (HR, rhythm, orthostatics) Basic neurologic exam (mental status, LE strength, LE sensation and proprioception, reflexes, cerebellar) Slide 31

32 MANAGEMENT Multifactorial intervention most effective (reduces falls by 30-40%) Exercise (including physical therapy) Environmental modifications Medication review Treatment of orthostatic BP Regular physical activity most important single intervention (reduces falls by 20%) Slide 32

33 HMC Fall Prevention Clinic Friday mornings Staffed by ARNP who conducts standardized assessment of patient s fall risk factors and develops management plan for risk factors identified does longitudinal follow-up to encourage adherence to management recommendations cialtycare/harborview/falls/index.htm Slide 33

34 Referring to Falls Clinic Whom to refer? Age 65+ History of prior falls OR difficulty with gait/balance How to refer? Complete standard form used for all referrals at HMC Indicate referral is to Fall Prevention Clinic Slide 34

35 CASE 2 (1 of 3) A 90-year-old woman presents to your clinic stating she has fallen 3 times in the past month. She has a history of mild dementia, hypertension, atrial fibrillation, osteoarthritis, and transient ischemic attacks. She walks with a walker. Medications include donepezil 10 mg daily, hydrochlorothiazide 25 mg daily, atenolol 50 mg daily, warfarin 2 mg daily, relafen 1000 mg daily, calcium carbonate 600 mg twice daily, a multivitamin daily, and lorazepam 0.25 mg twice daily as needed. Slide 35

36 CASE 2 (2 of 3) Which of the following should be done first as part of this patient s fall assessment? (A) Order 24-hour cardiac monitoring. (B) Measure her blood pressure when she is lying down, sitting, and standing. (C) Review the circumstances of her falls. (D) Ask the physical therapist to evaluate her gait, transfers, and walker. Slide 36

37 CASE 2 (3 of 3) Which of the following should be done first as part of this patient s fall assessment? (A) Order 24-hour cardiac monitoring. (B) Measure her blood pressure when she is lying down, sitting, and standing. (C) Review the circumstances of her falls. (D) Ask the physical therapist to evaluate her gait, transfers, and walker. Slide 37

38 SUMMARY Falls are common and usually multifactorial Falls are associated with adverse sequelae Falls are often preventable! Gait and balance Vision Medications Home environment Slide 38