Managing falls in the elderly: real world approach DR PRISCILLA NG
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1 Managing falls in the elderly: real world approach DR PRISCILLA NG
2 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
3 Falls in Singapore Falls in over 60s annually No falls 83% Falls 17% 1 fall 11% Recurrent falls 6% 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):
4 Sequelae of falls Fractures Head injuries Fear of falling Loss of mobility Loss of independence Death within 2 years 20% Ambulant 18% Institutionalisation Death Functionally dependent 20% Decreased ambulation 42%
5 Algorithm for Assessing Fall Risk in Older Adults Living in the Community Health Promotion Board- Ministry of Health Clinical Practice Guidelines: Falls Prevention among Older Adults Living in the Community.
6 Screening
7 #1: Falls history
8 #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
9 #2: Timed up and go test
10 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.
11 #3: Medication review Drugs with CNS effect Drugs for chronic medical conditions Anxiolytics/hypnotics Neuroleptics Antidepressants Anticonvulsants Drugs for symptom relief Analgesics Antihistamines Skeletal muscle relaxants Antivertigo drugs Antihypertensives Hypoglycaemics Antiarrhythmics Nitrates and other vasodilators β-adrenoceptor blocking eye drops Urinary antispasmodics American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults 2015
12 #4: Visual acuity Snellen chart
13 1. History Comprehensive assessment 2. Physical examination 3. Functional assessment 4. Environmental assessment
14 1. History: Anatomy of a fall Predisposing factors Precipitating factors Fall Complications
15 Past medical history: Predisposing factors Neurological Stroke Parkinson s disease Cognitive impairment Depression Musculoskeletal Arthritis of knees Cervical/lumbar spondylosis Chronic medical Diabetes Hypertension Functional Urinary incontinence Functional dependence
16 Falls history: Precipitating factors When Where How (Activity, footwear, symptoms pre- and post-, able to get up?) Current fall Cruise ship While going to toilet, ship hit a large wave 2 nd fall 6 months ago MRT station Slipped on a high curb. LOC after fall Complications LBP for investigation, unable to walk Stable HI and R hip contusion. Admitted to CH for rehab for 1 month 3 rd fall 9 months ago Bedroom No LOC. Unable to get up Nil 3 near misses Various locations Buckling of LL Nil
17 Syncope is defined as a transient, self-limited loss of consciousness with an inability to maintain postural tone that is followed by spontaneous recovery.
18 2. Physical examination Vision: Cataracts, vision aids Neurological: Parkinsonism, stroke, neuropathy, spinal degeneration, vestibular disorders, gait Musculoskeletal: Osteoarthritis, foot deformities, muscle weakness Higher cortical function: Cognition, safety awareness, fear of falls, mood Cardiovascular: Structural heart disease, arrhythmias, orthostatic hypotension Nutritional status Frailty Footwear Walking aids
19 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
20 Single interventions Interventions Multicomponent / multifactorial interventions Exercise Environment Medication Medical Education
21 1. Exercise
22 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 Mar 20;328(7441):680.
23 2. Enviroment
24 Enhancement For Active Seniors (EASE) 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 singlestep main entrance
25 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 Executive You pay $125 (5%) $ (7.5%) $250 (10%) $ (12.5%) Government pays $2,375 (95%) $2, (92.5%) $2,250 (90%) $2, (87.5%)
26 Footwear No loose laces Wide toe box Low heel Slip-resistant sole
27 3. Medication review
28 4. Medical interventions
29 Postural hypotension Non-pharmacological Slow rising Ankle pumps Adequate fluid intake Elevate head of bed 20 degrees TED stockings Pharmacological Fludrocortisone mg/day Midodrine mg tds
30 Vitamin D
31 Vision
32 Pacemaker
33 5. Education
34 Multifactorial interventions
35 Osteoporosis
36 FRAX WHO Fracture Risk Assessment Tool
37 When to treat? BMD T-score Interpretation Management < fracture Severe/established osteoporosis Treat <-2.5 Osteoporosis Treat -1 to -2.5 Osteopenia Treat if high risk Vertebral, forearm, humerus + hip >20% >3%
38 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
39 Considerations regarding bisphosphonate therapy Indications Functional mobility Lifespan Contraindications Dysphagia/NGT/GERD Inability to sit up Renal impairment (CrCl <30) Adverse effects Oesophagitis Osteonecrosis of jaw Atypical femoral # Bone/joint/muscle pain?af
40 Thank you
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