Falls in the Elderly

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Falls in the Elderly

• A geriatric giant

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Outline

• Frightening statistics
• an organized approach???
• Intrinsic Vs Extrinsic factors
• physiological Vs pathological
• preventative strategies
• specific gait disturbances related to falls

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LOLFOFSOS !!!

• An involuntary event producing a change in
  posture resulting in an individual adopting an
  unplanned supine position
• 1 in 3 people over age 65 fall each year
• increased to over 40 of octogenarians

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Keeping the orthopods busy

• 10 of falls result in injury
• 5 result in fractures
• 6th leading cause of death in elderly
• bad prognostic indicator
• 65 of LTC residents with gt6 falls were dead
  within 2 years

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Message to take with you

• Falls rarely associated with single factor
• intervention often reduces risk factors without
  eliminating risk
• any condition which decreases well being,will
  increases sway, reduces stability, decreases
  judgement compensatory mechanisms and will
  increases risk of falls

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Organizational schema

• Accidental Vs medical falls
• intrinsic factors extrinsic factors
• intrinsic physiological pathological

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Which medical conditions cause falls?

• Stroke/TIA
• fits
• faints
• postural hypotension
• carotid hypersensitivity
• syncope NYD
• cardiac arrythmia
• infection sepsis

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More commonly. Multiple factors associated with
falls!

• Intrinsic physiological factors
• vision
• dark adaptation
• cataracts?
• Glare
• hearing??
• Postural reflexes
• decreased sensory input
• decreased muscle strength
• changes in vestibular fxn

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A few pathological factors to consider

• Neurological
• Parkinsons
• Parkinsons Plus syndromes
• seizures
• cerebrovascular disease
• CVS
• MI
• arrythmia
• hypotension

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More pathology

• Metabolic
• hypoglycemia
• anemia
• hypokalemia
• hyponatremia
• GI
• acute bleeding
• defecation syncope

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Further pathology

• GU
• micturition syncope
• nocturia
• MSK
• proximal muscle weakness
• OA and lower extremity pain
• look at their shoes feet

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How does psychiatry interact with falls?

• Psychiatric factors
• dementia cognition
• depression
• fallophobia !!

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This is geriatrics- always think IATROGENIC

• Medications associated with falls
• diuretics
• antihypertensives
• sedative/hypnotics
• antipsychotics
• tricyclic antidepressants

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Falls in the Emerg.

• Remember ABCs
• follow cognition
• remember falls as premonition of impending
  major illness
• Stroke
• MI
• GI bleeding
• infection

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Visiting the old folks at home

• Extrinsic factors
• the majority of environmental falls happen during
  normal activities
• stairs are 1
• other common spots
• bedroom transfers
• kitchen cupboards
• tub and toilet transfers

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Preventing falls makes sense

• ?? Incorporate into your preventative health
  program
• first step Identify patients at risk
• family concerns
• office visits
• clinical acumen

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Preventing falls fractures

• Intrinsic factor assessment
• Review medications
• check postural vitals
• optimize visual acuity
• review lower extremity disorders
• screen for psychiatric factors

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Using the Get Up go test

• Get patient to rise up from chair
• check sway when first standing
• do cautious sternal nudge
• are they unsteady with eyes closed
• consider timed walking
• unsteadiness turning
• how safely do they sit down again?

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Consider the merits of home visits for
high-risk patients!

• OTs are excellent but can take a while!!
• Common sense prevails!!
• Common problems are common!

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Where can you intervene?

• House exterior
• unsafe steps
• poor lighting
• hazards (leaves, ice, toys)
• Lighting
• too little
• too much

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Checking out the house

• Floors
• scatter rugs
• shiny lino
• cords, carpets, cracks
• Stairs
• railings
• first last step

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Checking out the house

• Furniture
• obstructing routes
• inappropriate for elderly
• student-ghetto quality
• kitchen
• high cabinets/shelves
• stove safety

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Checking out the house

• Bathroom
• slippery tub
• inappropriate grab bars
• low toilet seat
• effective lock on the door
• Bedroom
• slippery sheets!
• furniture

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Gait disorders in the elderly 5 main conditions

• Parkinsonism
• cerebrovascular disease
• frontal lobe gaits
• cervical spondolytic myelopathy
• sensory neuropathy (B12, DM, tabetic)

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What is a normal senile gait?

• Slowed speed (lt 1.4 m/second)
• increased sway
• slowed postural support responses
• shorter step length
• increased time in double limb support

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Rule out Parkinsonism as the gait disturbance

• Idiopathic
• step length, late balance changes, festination
• PSNP
• early postural instability
• rigidity
• EOM changes

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How might cerebrovascular disease cause falls?

• Hemiparesis spasticity
• leukoaraiosis Binswangers disease
• Magnetic gait
• gait apraxia
• Parkinsonism

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Frontal lobe gaits?

• Gait apraxia
• NPH
• Picks disease
• others

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Cervical spondolytic myelopathy what is it?

• More common than you would think
• spasticity and hyperreflexia in legs
• stiff legs with ? circumduction
• dorsal column signs
• urinary urgency
• hand clumsiness

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Tertiary syphylis and falls?

• Sensory afferent neuropathy
• diabetes
• vitamin deficiencies
• tabes dorsalis
• EtOH

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Putting it all together

• Incorporate prevention into your practice
• take an organized approach
• rule out gait abnormalities
• decrease cumulative risk factors
• remember the value of home assessment
• in emergency setting ABCs premonitory falls