Falls in the Elderly

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Falls in the Elderly

• David Cravens, MD, MSPH, CMD
• Assistant Professor of
• Clinical Family Medicine, Geriatrics

Department of Family Community
Medicine University of Missouri
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Case Presentation

• A 90 year old man was taken to the ER
  following a fall. He was known to have
  Parkinsons Disease, mild dementia, and
  depression. He was found at the bottom of a
  flight of 13 stairs with blood smeared on the
  floor when his wife returned after a six hour
  absence.

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Medications

• Sinemet 25/100, 5 tablets daily
• Amantadine 100 mg daily
• Trazodone 50 mg nightly
• Navane 1 mg daily
• Lasix 20 mg daily
• Lanoxin 0.25 mg daily
• Carafate 1 gm four times daily

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Initial Evaluation in the ERPhysical Exam

• T 93.3, P 84 and irregular, BP 174/110
• Facial lacerations and ecchymosis
• No pupil abnormalities
• Neck supple
• Lungs clear except for right
• basilar crackles
  

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Initial Evaluation in the ERPhysical Exam

• Heart tachycardia no abnormal sounds
• Abdomen soft
• No extremity injuries
• Confused and drowsy
• DTRs 1 and symmetrical. Toes downgoing

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Initial Evaluation in the ER Laboratory

• Hg/ Hct 15.1/46.8 WBC 13.1
• BUN/Cr 27/1.1 Lytes normal glu 318
• U/A 4-10 RBC, 1-5 WBC, 1 bacteria
• ABG pH 7.38, pCO2 38, pO2 64
• CT showed no acute brain injury

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Natural Hx of Falls and Fallers in the Elderly

• At least one fall per year
• ¼ to 1/3 of community dwelling ?????yr old
• Up to ½ of institutionalized elderly
• Incidence highest in the very old and multiply
  impaired

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Natural Hx of Falls and Fallers in the Elderly

• Leading cause of death from injury
• 10 of falls result in serious injury
• 4-6 of falls result in fracture
• ?1/4 are hip fractures

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Etiology of Falls in the Elderly

• Majority have intrinsic component
• consider fall a marker of underlying disease
  amenable to treatment
• Seldom appropriate to attribute fall solely to
  the presence of an environmental hazard
• LipsitzJAMA 1996 July 3
  276(1)59-66

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Age-Related Factors

• Progressive degeneration of large joint
  mechanoreceptors
• Vestibular function decline
• Diminished lower extremity proprioception
• Basal ganglion atrophy

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Age-Related Factors

• Diminished muscle mass and strength
• Impaired cardiovascular system regulation
• Impaired ability to maintain intravascular volume

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Disease-Related Factors

• Orthostatic Hypotension
• Postprandial Hypotension
• Chronic neurologic disease (Parkinsons)
• Sensory Impairments
• Visual
• Hearing
• Vestibular
• Peripheral neuropathy

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Disease-Related Factors

Musculoskeletal Disease Foot Problems Dementia
Acute Illness (Infection, MI, CVA)
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Medications

• Polypharmacy
• Drugs that cause--
• Drowsiness or confusion
• Balance or coordination problems
• Postural hypotension or syncope

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Psychotropic Medications

• Sedative-hypnotics
• Long-acting, particularly older agents worse
• Antidepressants
• Neuroleptics

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Antihypertensives/Diuretics

• Less well established
• More clearly associated with syncopal falls
• Rapid acting diuretics may cause a rush to the
  toilet

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Other Medications
Other Medications

• Antiarrythmic/Cardiac agents
• Anticonvulsants
• Hypoglycemics
• Alcohol

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Nursing Home Patients

• Impaired residents fall frequently
• serious injuries rare
• Less impaired fallers
• More prone to serious injury
• (particularly those with lower extremity
  weakness)
• Tinetti JAGS 87 July
  35(7) 644-8

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• The more risk factors, the more likely multiple
  falls

The more risk factors, the more likely multiple
falls
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Evaluation of Pt Who Has Fallen History

• Key Issues
• How did the fall occur?
• Was there a loss of consciousness?
• Other History
• Previous falls
• Impaired ability to perform ADL
• Environmental hazards
• Illnesses and medications

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Examination of FallerPhysical

• Postural vital signs
• Complete visualization of skin
• Bone and joint exam
• Heart exam for significant murmurs
• Bedside evaluation of hearing and vision

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Examination of FallerPhysical

• Comprehensive neurologic exam
• gait
• motor function
• coordination
• balance
• sensation

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Examination of FallerPhysical

• Balance assessment
• Rising from sitting to standing position
• Unsteadiness during neck turning and extension
• Unsteadiness after nudge on sternum

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Examination of FallerPhysical

• Gait assessment
• Have patient walk away about 10-20 feet, turn and
  walk back.
• Check for unsteadiness with turning
• a sensitive test for Parkinsonism

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Laboratory

• HPD
• for evidence of occult sepsis
• anemia
• BMP
• Lytes to assess electrolyte disturbance
• BUN, Cr to assess hydration
• Glucose
• Urinalysis
• CS if any suggestion of UTI

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Laboratory

• CXR
• EKG
• Pulse Ox or ABG
• Cardiac enzymes
• if any hx of chest pain associated with fall
• if any ischemic changes on EKG

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Laboratory Nonacute

• Keep a low threshold for checking thyroid status
• TSH is best screening test
• Check B12 status if any neuropsychiatric
  abnormalities

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Intervening to Prevent Falls

• RCT 301 community-living elders ? 70
• At least one risk factor for falling
• postural hypotension
• use of sedatives
• use of ? 4 prescription meds
• impairment of arm or leg strength, ROM, balance,
  transfer skills, or gait
• Tinetti,et al NEJM 94
  Sept 29 331(25)821-7

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Findings of Tinetti StudyInterventions and
results
Percentage Decrease in Falls

• Use of ? 4 prescription meds (p0.009)
• Inability to safely transfer to tub or toilet
  (p0.05)
• Impairment in balance or bed-to-chair transfer
  (p0.001)
• Gait Impairment (p0.07)

• Mean change in Environmental Hazard score
  (p0.13)
• No significant differences in intervention and
  control group re interventions for other risk
  factors

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Findings of Tinetti StudyInterventions and
results

• Use of ? 4 prescription meds
• Review of meds with primary physician
• 37 reduction in intervention group
• 14 reduction in control group
  (p0.009)
• Inability to safely transfer to tub or toilet
• Training in transfer skills and environmental
  alterations
• 51 reduction in intervention group
• 35 reduction in controls
  (p0.05)

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Findings of Tinetti StudyInterventions and
results

• Impairment in balance or bed-to-chair transfer
• Balance exercises, training in transfers,
  environmental alterations
• 79 reduction in intervention group
• 54 reduction in controls
  (p0.001)
• Gait Impairment
• Gait training, exercises, assistive devices
• 55 reduction in intervention group
• 38 reduction in controls
  (p0.07)

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Findings of Tinetti StudyInterventions and
results

• Environmental hazards for falls or tripping
• Appropriate changes (removal of hazards, use of
  safer furniture, grab bars, handrails)
• Slightly larger decrease in environmental hazard
  score in intervention group (p0.13)
• No significant differences in intervention and
  control group re interventions for other risk
  factors

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Tinetti Study Main Results

• Intervention Group vs Control
• 35 fell vs 47
• aRR 0.76 (age, sex, hx falls, risk factors)
• 95CI 0.58-0.98

• Falls/person/week 0.012 vs 0.018
• aRR 0.69
• 95CI 0.52-0.90

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Intervening to Prevent Falls

• RCT--resistance exercises in NH res.
• 63 women 37 men
• Mean age 87.1 yr Range, 72-98
• Significant improvement found in
• Strength
• Habitual gait velocity
• Stair climbing activity
• Level of physical activity
• Fiatarone,et al NEJM 1994
  Jun 23 330(25)1769-75

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Intervening to Prevent Falls

• RCT--Tai Chi, Computerized Balance Training, and
  Education arms
• 200 community dwelling ? 70, mean 76.2yr
• Rate of falls reduced 47.5 in TC group
• 95CI (0.321,0.860) p 0.01
• Half chose to continue meeting informally to
  practice TC after f/u assessment
• Wolf,et al
  JAGS 1996 May44(5)489-97

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Conclusions

• Multiple functional and environmental factors may
  be related to a hx of falling
• Older fallers may have a relatively poor
  prognosis
• particularly if nursing home residents are
  included

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Recommendations

• Look for acute illness with acute falls
• In the non-acute faller consider
• Medications
• Reversible neurologic disease
• Disorders of balance and gait
• Muscle weakness/decreased muscle mass
• Potential environmental hazards
• Interventions in all these areas hold promise