FALLS

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FALLS

• Dr Alastair Kerr
• Swindon/Bath DRC April 2006

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Outline

• Incidence
• Sequelae
• Risk factors
• Assessment
• Interventions
• Osteoporosis
• NSF/NICE

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Incidence

• What gt65yrs fall in 1 year ?
• What gt75yrs fall in 1 year ?
• What gt85yrs fall in 1 year ?
• What elderly institutional care fall in 1 year
  ?
• What in previous fallers?

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Incidence

• What gt65yrs fall in 1 year ? 30
• What gt75yrs fall in 1 year ? 35
• What gt85yrs fall in 1 year ? 40
• What elderly institutional care fall in 1 year
  ? gt50
• What in previous fallers? 60-70

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Sequelae

• What people injure themselves after a fall ?
• What people fracture after falling ?

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Sequelae

• What people injure themselves after a fall
  ? 40-60
• What people fracture after falling ? 5

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Sequelae

• Name 3 common sequelae of falls
• Fracture
• Infection
• Fear of falling

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Sequelae

• What is your life space diameter ?
• How does a fall affect this ?
• How else is this known ?

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Sequelae

• What is your life space diameter ?
• A measure of your mobility potential.
• How does a fall affect this ? Reduces it
• How else is this known ? Fear of falling

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Fear of falling

• What percentage of pts develop this after a
  fall? 33
• Pts with fear of falling have higher risk of
  falling, reduced ADLs, lower quality of life
  scores, and increased institutionalisation.

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Risk Factors

• EXTRINSIC
• Environmental
• INTRINSIC
• Medication
• Disease
• Visual problems
• Neurological
• Cardiovascular
• Postural hypotension
• Locomotor
• Psychological
• Nutritional
• Acute illness

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Statistical summaries of risk factors for falls

• RISK FACTOR Mean RR/OR
• Muscle weakness 4.4
• Falls history 3.0
• Gait deficit 2.9
• Balance deficit 2.9
• Assistive devices 2.6
• Visual deficit 2.5
• Arthritis 2.4
• Impaired ADLs 2.3
• Depression 2.2
• Cognitive impairment 1.8
• Age gt80 1.7

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Age-related changes

• Increased postural sway
• Reduced muscle strength (NB Hand grip)
• Reduced proprioception/vibration sense/light
  touch
• Slower reaction time
• Impaired cerebral auto regulation
• Impaired fluid homeostasis
• Decreased visual acuity

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Balance
Vision
FALLS
Vestibular
Musculoskeletal
Proprioception
Environmental hazards
Tactile sensation
CNS
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Mortality

• What is mortality rate for NOF ?
• At 1 month?
• At 1 year?
• What is mortality rate for pubic ramus ?

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Mortality

• What is mortality rate for NOF ?
• At 1 month? 10
• At 1 year? 25
• What is mortality rate for pubic ramus ?
• 15-20

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Falls assessment

• HISTORY
• Simple fall v collapse
• Whats the most useful question to ask in taking
  the history in pt who has collapsed?
• What factors differentiate between cardiac and
  neurological collapse ?
• Which drugs are implicated ?

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Falls assessment

• HISTOR
• Whats the most useful question to ask in taking
  the history in pt who has collapsed?
• Do you remember falling
• What factors differentiate between cardiac and
  neurological collapse ?
• Cardiac-no warning, palpitations, rapid recovery,
  pallor, no tongue biting
• Which drugs are implicated ?
• Many !

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Examination

• Mental test score
• CVS (include postural BP)
• Cranial nerves (incl. vision)
• Vestibular assessment
• Peripheral nervous system (NB Neuropathy)
• Cerebellar function
• Muscles
• Joints
• Gait
• (Footwear)

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Investigation

• Bloods
• ECG (24 hr tape if ECG abnormal)
• Tilt table test
• Carotid sinus massage
• Dix - Hallpike

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Interventions to prevent falls the evidence

• Multidisciplinary Ax FICSIT Tinetti 1994
• PROFET Close 1999
• Withdrawing centrally acting meds Campbell
• Strength balance training Campbell 1997/1999
• Tai Chi Wolf 1996
• CVS Ax intervention of unexplained
  fallers Kenny 2001
• Cataract surgery Harwood 2005
• Vitamin D

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• THINK OF FALLS
• THINK OF OSTEOPOROSIS

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Fracture Risk

• Fracture risk Risk of falling
• BMD

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Osteoporosis

• Time bomb of old age
• Low bone mass, microarchitectural deterioration,
  increased fragility and fracture risk.
• 13 females 112 males (gt50yrs) will sustain
  osteoporotic fracture.
• lt5 on osteoporosis drugs.

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Age Related Changes in Bone Mass
Attainment of Peak Bone
Mass
Age-related Bone Loss
Consolidation
Menopause
Bone Mass
Men
Fracture Threshold
Women
0 10 20
30 40 50
60
Age (years)
Compston JE. Clin Endocrinol 1990 33653682.
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Clinical Impact of Osteoporosis Over Time

• Symptoms
• Weak neck and head falls forward
• Pain in whole or part of back
• Breathing difficulties
• Indigestion gastro-oesophageal reflux
• Stress incontinence
• Difficulty with mobility following

• Signs
• Kyphosis
• Loss of height
• Tummy bulges due to loss of space under the ribs
• Clinically diagnosed fracture

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Hip Fractures

• 60,000 /yr in UK
• Cost 1.7 billion
• 25 die at 1 year
• 50 do NOT regain independence
• Osteoporosis results in more deaths than Ca
  cervix/uterus/ovary combined.
• Nos will increase 5-fold in next 50 yrs

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Diagnosis

• DEXA Measures B.M.D. at forearm, hip and spine
• DEXA Normal tgt -1
• Osteopenia t -1 to -2.5
• Osteoporosis t lt -2.5
• DEXA - high specificity, low sensitivity

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Risk Factors

• Hx low trauma fracture
• Steroids (incl inhalers)
• Family Hx of O.P.
• Premature menopause (lt45yrs)
• Secondary pre-menopausal amenorrhea
• Low B.M.I. (lt19)
• Smoking, alcohol
• Prolonged immobilization
• XR suggestion of osteopenia/O.P.
• Secondary - malabsorption, IBD, hypogonadism,
  CRF, CLD, RA, primary hyperparathyroidism,
  Cushings, thyrotoxicosis.

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Investigations

• FBC - malabsorption
• U and Es - renal failure
• TFTs - hyperthyroidism
• LFTS - chronic liver disease
• FSH - detect menopause
• PV/ESR/electrophoresis - myeloma
• Calcium - hyperparathyroidism
• Testosterone/LH/SHBG - hypogonadism in males
• (Markers of bone turnover)

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Prevention of osteoporosis- lifestyle advice

• Diet
• Exercise
• Alcohol
• Smoking

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Interventions to prevent fracture

• Bisphosphonates
• Ca/vitamin D
• Selective oestrogen receptor modulators (SERMS)
• Hip protectors Cochrane 2005
• PTH
• Strontium ranelate

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Fracture prevention triangle
FRAGILITY
Drugs Lifestyle
Vitamin D Exercise
FORCE
FALLS
Hip protectors
Falls prevention measures
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(No Transcript)
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Problems with treatment

• No immediate benefit
• Side effects of medication
• Unwillingness to change

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N.S.F. Standard 6 (Falls)

• Prevention public health strategies
• Integrated falls services
• Prevention treatment of osteoporosis

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N.I.C.E. Clinical guideline Nov 2004

• Falls assessment and prevention of falls in
  older people
• 5 key priorities for implementation
• 1) Case /risk identification
• Routinely ask old people if fallen in past year
• If yes, frequency, context characteristic of
  fall
• If faller or high risk, observe for balance and
  gait deficits
• Refer to multifactorial risk Ax if
• Gait balance deficit
• Recurrent falls
• Present to healthcare

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N.I.C.E. Clinical guideline Nov 2004

• Falls assessment and prevention of falls in
  older people
• 2) Multifactorial falls risk Ax to include Ax of
• Falls Hx
• Gait and balance
• Mobility muscle weakness
• Osteoporosis risk
• Fear of falling
• Visual impairment

Urinary incontinence Home hazards Cognitive
impairment CNS examination CVS examination Medicat
ion review
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N.I.C.E. Clinical guideline Nov 2004

• Falls assessment and prevention of falls in
  older people
• 3) Multifactorial interventions
• All recurrent fallers/high risk should be
  considered for individualised multifactorial
  intervention.
• Including
• Strength and balance training
• Home hazard Ax and intervention
• Vision Ax and referral
• Medication review

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N.I.C.E. Clinical guideline Nov 2004

• Falls assessment and prevention of falls in
  older people
• 4) Encouraging participation of older people at
  risk of falling in falls prevention programmes
• Education and information regarding measures
  they can take to prevent falls
• Include carers in process

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N.I.C.E. Clinical guideline Nov 2004

• Falls assessment and prevention of falls in
  older people
• 5) Professional education
• All healthcare professionals dealing with
  patients known to be at risk of falling should
  develop and maintain basic professional
  competence in falls assessment and prevention.

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Summary

• Very common
• Can cause fractures and downward spiral
• History and witness very important
• Thorough examination required
• Multidisciplinary approach most effective
• Think falls, think osteoporosis
• Refer to Falls Clinic if not winning!