Falls in the Elderly

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Falls in the Elderly

• Dr John Puxty
• puxtyj_at_post.queensu.ca
• Queens University

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Presentation of Disease in the Elderly

• Classical
• Silent
• Pseudosilent
• Atypical Presentations Weakness/Fatigue
  Dwindles Falls/Immobility Incontinence
  Cognition/Mood Change Social Crisis

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Epidemiology of Falls

• 25-35 of seniors fall within a year
• Less than one-third present to Medical services
• This subgroup at higher risk of further falls,
  decline in function, s , premature morbidity
  and mortality
• Prognosis is modifiable!

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Sobering Facts (1)

• 37,546 hospitalizations in Ontario in 1998-99
  were dues to falls (60 gt65 year olds)
• Life time risk for hip in males 11 and females
  27
• 2/3 of all s in women
• Estimated in 2001 one year cost of hip was
  26,527 (21,365 in those -gt community and
  44,156 -gt LTC)

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Sobering Facts (2)

• 40 of Fallers presenting to AE will within
  one year
• 23,375 Hips in Canada in 1993/94 (expected to
  rise to 88,125 in 2041)
• Average LOS 21 days so they use at least 465,000
  bed days per year
• 7 short-term mortality rising to 20-35 after
  one year!

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Sobering Facts (3)

• Less than 40 of hip patients will regain
  previous level of ambulation!
• 90 of fallers sent home from AE have no
  change in fall-risk factors
• Restraints increase incidence of serious falls
• 40 of admissions to LTC are frequent fallers
• Fall rate increases in first six weeks in LTC!

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Falls at different sites
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Value of Assessment and Treatment of Falls

• Randomized study of fallers presenting to AE
  -184 interventions vs 213 normally managed
  controls - resulted in reduction in further
  falls over one year (183 vs 510).
• Randomized study of fallers in LTC - 79
  intervention and 81 controls - resulted after 2
  years in 26 fewer hospitalizations and 52
  reduction in hospital days.

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Factors to consider in a Faller

• Predisposing factors
• Medical conditions causing problems with gait,
  balance, dizziness, syncope, impaired perception
  of environment or confusion
• Medications
• Environmental hazards

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Physiology of Falls
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Physiology of Falls (1)
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Physiology of Falls (2)
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Physiology of Falls (3)
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Physiology of Falls (4)
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Physiology of Falls (5)
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Common Causes of Falls
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Important Medical causes- Neromuscular

• Extra-Pyramidal Syndromes IPS, PSP, Shy Drager
  Syndrome, OPCDS
• Frontal Lobe Syndromes (NPH)
• Dementia
• Epilepsy
• CVA/TIAs
• Proximal myopathy

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Important Medical causes- Cardiovascular

• Postural Hypotension
• Carotid Sinus Hypersensitivy
• Effort Syncope
• Arrhythmias
• Ischemia

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Important Medical causes- General

• Anemia/Polycythemia
• Hyponatremia
• Hypoglycemia
• Pain
• Anxiety

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Medications and Falls
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Im a walking drugstore!
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Preventative approach to Falls

• Reduce Predisposing Factors

Nutrition Exercise Gait Training (dynamic
provocation) Avoid polypharmacy if possible
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Preventative approach to Falls

• Reduce Predisposing Factors
• Identify fall risk profile

Very old Living alone Impaired vision Impaired
cognition Psychotrophic medications Polypharmacy
Lower extremity pain Two or more trips
recently History of past falls Presence acute
illness Balance and gait problems
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Preventative approach to Falls

• Reduce Predisposing Factors
• Identify high risk fallers
• Careful assessment

Mobility
Intrinsic factors
Extrinsic factors
Balance and Gait
Risk factor profile
Performance based assessment e.g. Get Up and Go
Home hazard assessment
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Examples of Fall-related Questions
Frequency and description of falls Do the falls
occur in similar circumstances eg on
micturition/defaecation? Were there any
associated symptoms at the time? Specifically
did the patient lose consciousness? Were there
any changes in pulse preceding the event, or the
presence of palpitations? Were there features of
syncope, anginal chest pain or an epileptic aura?
Was there any weakness, speech or visual
disturbance associated with the falls?
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Key Physical Examination Points
Cognitive Assessment Vision - gaze paresis,
field/attention defects, acuity Balance
(Cerebellar and Vestibular Function) EPS Pyramidal
Tract deficits Peripheral and Autonomic
Neuropathy Proximal Weakness Feet and
Joints Balance, gait, foot clearance and use of
walking aids Pulse and BP Auscultation Palpable
faeces/bladder
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Performance based assessment
Balance getting up from chair neck
extension/flexion standing eyes
open/closed sternal nudge Gait step
height posture steadiness in straight
line steadiness on turning steadiness uneven
surfaces use of walking aid
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Preventative approach to Falls

• Reduce Predisposing Factors
• Identify high risk fallers
• Careful assessment
• Modify environment

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Environmental Hazards

• Lighting
• Floor surfaces
• Steps/stairs
• Chair/bed height
• Toilets/baths
• Walking aids

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Environmental Hazards
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Consequences of Immobility
Muscle atrophy Falls risk increased Reduced
ECV Orthostatic Hypotension Osteoporosis Arthritis
Recurrent sepsis Pressure sores Contractures
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Small changes can result in major functional
gains!
Foot wear Walking aides Surface
heights Chairs/bed Wall bars Lighting Flooring/mat
s
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Preventative approach to Falls

• Reduce Predisposing Factors
• Identify high risk fallers
• Careful assessment
• Modify environment
• Modify consequence of falls

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Modify consequences of falls
Osteoporosis Tx (Ca, Vit D, Biphosphanates) Exer
cise Protect-Alert System
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Exercise and Aging

• Exercise started at age 75 results in nearly 1/2
  year of life gain!