What are you trying to achieve? Falls Prevention, Assessment and Management Strategies Dr Adam Darowski Community: Falls risk assessment: Falls risk is 50% per year in 80yr population and higher in those coming to clinic Frailty scores may be best community guide to those at risk of falls Falls Clinic: Diagnosis find treatable possible causes Falls can be classified into four main groups: 1. Accidents slips and trips, as occur at any age. If such accidents recur, an underlying cause should be sought. 2. Illness - Falling can be the presentation of almost any illness in the elderly. Falls can be classified into four main groups: 1. An intrinsic tendency to fall because of impairments of gait, balance or vision. 1. neurological disease 2. musculoskeletal degeneration 3. disability caused by chronic disease (most commonly stroke, Parkinson s disease) 4. the effects of medicines or alcohol. 2. Paroxysmal events Syncope and pre-syncope Seizures Vascular events stroke, myocardial infarction, pulmonary embolus Vertigo Rarities eg cataplexy Causes of Falls About a half are simple accidents Most falls are multifactorial Of the rest 75% gait and balance 25% syncope and pre-syncope 1% have previously unknown neurological disorder The history is the key to diagnosis 1
Taking a history A 3 stage process: The narrative Direct questioning Corroboration from other sources Narrative What happened? Direct questions Duration and frequency of falls For last few falls ask detailed questions Before the fall During the fall?syncope?seizure After the fall Falls: their effects Injuries Fear of falling? Loss of confidence? Falls risk? Corroboration Witness, relative, GP Medical records Establish duration and frequency of falls Syncope, seizures Falls history Nocturia and frequency Fluid intake Depression Insomnia Past medical history Cardiac Neurological Musculoskeletal Diabetes Drug history: doses and indications of all drugs Osteoporosis risk factors 2
Berg balance score Berg balance score Good repeatable assessment for people who attend clinic 14 items scored out of 4 max 56 points Sit to stand Stand unsupported Sit unsupported Stand to sit Transfers Forward reach Pick up object from floor Turning to look behind Turning 360 degrees Placing alternate foot on low stool Standing eyes closed Standing feet together Tandem stand Standing on one foot Balance assessment Berg balance score 14 items each scored 1-4 Total score out of 56 Use last 4 items Romberg s Tandem stand Stand on one leg 15sec Neurological assessment Is impaired balance due to neurological disease? Parkinson s Old stroke Unsuspected stroke Peripheral neuropathy Diffuse white matter change (AF, BP, DM) Spinal disease TLOC, Syncope and Pre-syncope as a cause of falls May be a clear history of loss of consciousness usually not Legs gave way Don t remember What is syncope and what causes it? =fainting Loss of consciousness due to lack of blood to the brain Orthostatic hypotension drugs/b12/neuro Arrhythmias Vasovagal and dysautonomias 3
How common are syncopal falls? In falls clinics 25% of people give a history that suggests syncope or pre-syncope Of those attending ED, about 40% have a cardiovascular cause For recurrent and unexplained falls, 77% are found to have possible CVS disorder Cardiovascular assessment Pulse and ECG Lying and Standing Blood Pressure Systolic murmur Carotid sinus massage % taking culprit medication in 76 patients attending Oxfordshire Falls Prevention Service 45 40 35 39 Mean age 83yrs 30 25 83% take culprit drugs 20 15 17 21 20 10 5 0 0 1 2 3 4 number of culprit drugs 1 Sedation poor balance, slow reactions Hypotension Orthostatic hypotension Vasovagal syndrome Bradycardia Hyponatraemia Medications and falls Night sedation Tricyclics and atypicals SSRIs, SNRIs Antipsychotics Alpha receptor blockers Antianginals ACEIs Diuretics Beta blockers 4
Psychotropic medication withdrawal and a home based exercise program to prevent falls: a randomized, controlled trial Women and men aged 65 years registered with a general practitioner and currently taking psychotropic medication (n = 93) After 44 weeks, the relative hazard for falls in the medication withdrawal group compared with the group taking their original medication was.34 (95% CI,.16-.74) ie 66% reduction in relative hazard Campbell et al. J Am Geriatr Soc 1999; 47: 850 53. Control (n=329) Fluoxetine (26) Citalopram (103) Sertraline (20) Paroxetine (11) Amitriptyline (58) Mirtazapine (15) Trazodone (14) Lofepramine (6) Venlafaxine (14) Duloxetine (2) SSRIs (209) Tricyclic and atypical (93) Fig 1. Mean systolic drop mmhg in falls clinic patients taking an antidepressant SNRIs (13) 0 5 10 15 20 25 3 Withdrawing cardiovascular medications at a syncope clinic Data in all patients whose cardiovascular medications were stopped at a falls/syncope clinic were analysed to see if their symptoms were altered and if renewal of these medications was necessary at subsequent visits. Of 338 consecutive referrals, cardiovascular medications had been stopped in 65 (19%). At follow up 78% reported improvement in their original presenting symptoms - renewal of medication was not necessary in 77% off antianginals, 69% off antihypertensives, 36% off antiarrhythmics. Alsop and MacMahon Postgrad Med J 2001;77:403 405 Withdrawal of fall-risk-increasing drugs in older persons: effect on tilt-table test outcomes Withdrawal of cardiovascular medications with tilt testing before and after n=137 the adjusted odds ratio was carotid sinus hypersensitivity 0.13 (95% CI=0.03-0.59) orthostatic hypotension 0.44 (95% CI=0.18-1.0) vasovagal collapse 0.21 (95% CI=0.03-1.51). Van Der Velde et al J Am Geriatr Soc 2007; 55: 734 39. Drugs and Falls Least bad antihypertensive may be losartan Least bad antidepressant may be fluoxetine 5
Observed and expected numbers of hip fractures in Oxfordshire admitted from own home 750 60 700 50 650 No of hip # 600 550 500 450 40 30 20 Population >75s in 1000s PFFs Ex CH Expected PFFs No >75s 000s Linear (PFFs Ex CH) Linear (Expected PFFs) 400 350 Extrapolated to county based on JR data that are 10 69% of total, and expected based on >75s 300 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 0 6