Falls in Older Adults

1
Falls in Older Adults

• Joseph G. Ouslander, MD
• Professor of Medicine and NursingDirector,
  Division of Geriatric Medicine and
  GerontologyChief Medical OfficerWesley Woods
  Center of Emory UniversityDirector, Emory Center
  for Health in AgingResearch Scientist,
  Birmingham/Atlanta GRECC

Prepared for the Department of Otolaryngology Emor
y University School of Medicine
Supported by the John A. Hartford Foundation and
the Donald W. Reynolds Foundation
2
Falls in Older Adults

• Learning Objectives
• Review the epidemiology and consequences of falls
  in the elderly
• Understand common causes of falls in this
  population
• Determine the appropriate diagnostic of older
  people who fall
• Identify targeted management strategies for
  common causes of falls

3
Falls in Older Adults

• Definition
• An event which results in a person
  unintentionally coming to rest on the ground or
  some other lower level, and not being due to
  syncope, stroke, or sustaining a violent blow

4
Falls in Older Adults

• Epidemiology
• Community dwelling 1 in 3 fall in a year
• Nursing home 50 fall in a year

5
Falls in Older Adults

• Consequences of Falls
• Fractures
• Soft-tissue injuries
• Closed head injuries/subdural hematomas
• Prolonged lying on the ground (rhabdomyolysis)
• Fear of falling/restriction in activity
• Use of restraints
• Institutionalization
• Death

6
Falls in Older Adults

• Falls Affect Prognosis
• Falls occur in both frail and healthy older
  persons
• Single falls are not necessarily an indicator of
  poor prognosis
• Multiple falls are associated with disability and
  poor health outcomes
• Multiple falls are a marker for other underlying
  conditions that put older persons at increased
  risk for adverse health outcomes

7
Falls in Older Adults

• A Typical Case (1)
• Mr. C. is an 89 year old man who is referred to
  you for the evaluation of vertigo. His daughter
  says that he has fallen 3 times in the past month
  after discharge from the hospital for a small
  heart attack and heart failure.

8
Falls in Older Adults

• A Typical Case (2)
• Mr. C. has no prior history of falls.
• His chronic medical problems include
• Coronary artery disease
• Hypertension
• Congestive heart failure
• Degenerative joint disease mainly of the right
  hip and knee
• Insomnia related to pain in his knee

9
Falls in Older Adults

• A Typical Case (3)
• Mr. Cs medications include
• Furosemide and postassium supplement
• Enalapril
• Nitroglycerin patch 12 hours per day
• Propoxephene as needed for pain
• Zolpidem as needed for sleep

10
Falls in Older Adults

• A Typical Case (4)
• Further history reveals that each fall occurred
  in the morning after breakfast. He gets up, and
  when he starts walking he feels dizzy. He has
  not to his knowledge passed out or sustained any
  severe injury with these falls. There is no
  history suggestive of a seizure.

11
Falls in Older Adults

• A Typical Case (5)
• Physical Exam reveals
• Mr. C. appears well and has no signs of trauma
• Sitting BP and P are 102/58 and 66 standing BP
  and P after 1 minute are 88/52 and 72
• Heart rhythm and sounds are normal
• Lungs have bilateral crackles at both lung bases
• Musculoskeletal exam shows very limited range of
  motion of the right hip with pain on internal
  rotation, and crepitus and pain with flexion of
  the right knee
• Neurological exam is non-focal without evidence
  of peripheral neuropathy, but rapid movement of
  his head reproduces his vertigo

12
Falls in Older Adults

• A Typical Case (6)
• Get Up and Go observation reveals
• Difficulty arising without physical assistance
• Negative Romberg test
• Abnormal gait due to guarding his right side
• Difficulty and imbalance when turning

13
Falls in Older Adults

• A Typical Case (7)
• What do you think is contributing to Mr. Cs
  falls?
• What diagnostic tests would you order?
• What interventions would you implement?

14
Falls in Older Adults

• Causes of Falls
• Intrinsic Factors
• Acute Conditions
• Chronic Conditions
• Medications used to treat acute and chronic
  conditions
• Activity/Behavior
• Extrinsic factors
• Environment
• Often Multi-factorial

15
Falls in Older Adults

• Classifications of Falls
• Community-Dwelling
• 41 environment related
• 13 weakness, balance or gait disorder
• 8 dizziness or vertigo
• Nursing Home
• 16 environment related
• 26 weakness, balance or gait disorder
• 25 dizziness or vertigo
• Rubenstein, et al. Ann Intern Med 1994121442
  451

16
Falls in Older Adults

• Causes of Falls Acute Intrinsic Factors
• Any acute illness
• Infection, MI, stroke, CHF, etc
• Postural hypotension
• Medications

17
Falls in Older Adults

• Causes of Falls Postural Hypotension
• Volume depletion
• Deconditioing
• Post-prandial
• Autonomic dysfunction
• Parkinsons disease, diabetes, other
• Medications

18
Falls in Older Adults

• Causes of Falls Medications
• Decreased mental alertness
• Impaired cognitive function and/or judgment
• Hypotension
• Postural hypotension

19
Falls in Older Adults

• Causes of Falls Medications
• Antipsychotics
• Sedatives, hypnotics, anxiolytics
• Especially benzodiazepines
• Antihypertensives
• Diuretics
• Nitrates
• Others
• Antidepressants
• Antiarrythmics
• Anticonvulsants

20
Falls in Older Adults

• Intrinsic Factors Age-related Changes
• Reduced strength
• Decreased postural stability
• Prolonged reaction time
• Decreased visual acuity and depth perception
• Changes in gait
• Less ability to dual task (e.g. rushing to the
  toilet concentrating on urinary urgency)

21
Falls in Older Adults

• Neurological Components for Intact Balance and
  Gait
• Senory Input
• Visual
• Proprioceptive
• Motor Output
• Pyramidal
• Extrapyramidal
• Cerebellar
• Central Integration
• Postural reflexes
• Cognitive
• Affective

22
Falls in Older Adults

• Intrinsic Factors
• Neurological
• Cardiovascular
• Musculoskeletal
• Foot Disorders

23
Falls in Older Adults

• Neurological Disorders Contributing to Falls
• Impaired Sensory Input
• Visual (e.g. macular degeneration)
• Vestibular (e.g. benign positional vertigo)
• Proprioceptive (e.g. diabetic peripheral
  neuropathy)
• Motor Weakness or Control (e.g. stroke,
  Parkinsons Disease)
• Cerebellar Disorders (e.g. ataxia)
• Cognitive Disorders (e.g. Alzheimers Disease)

24
Falls in Older Adults

• Cardiovascular Disorders Contributing to Falls
• Arryhthmias
• Aortic Stenosis
• Severe peripheral edema

25
Falls in Older Adults

• Musculoskeletal Factors Contributing to Falls
• Joint Pain
• Previous Fractures
• Skeletal or Joint Deformities
• Unstable Joints
• Spine osteoarthritis with neurological
  involvement

26
Falls in Older Adults

• Foot Disorders Contributing to Falls
• Painful conditions
• Joint deformities
• Improperly fitted or risky shoes (e.g. slippery
  soles, high spiked heels)

27
Falls in Older Adults

• Activity and Behavioral Factors
• Excess alcohol intake
• Unsafe activities
• Poor judgment in patients with dementia

28
Falls in Older Adults

• Extrinsic Factors
• Over 70 of falls occur at home
• Environmental factors may be present in 50 of
  falls
• Most commonly these are objects that cause a trip
  or a slip
• Environmental difficulties depend on the
  individuals disabilities and susceptibilities

29
Falls in Older Adults

• Extrinsic Factors
• Ill-fitting clothes or footwear
• Furniture, rugs, lamp cords
• Physical features stairs, tight areas, clutter
• Poor lighting, visual distortions or distractions
• Slippery or wet surfaces
• Yard obstacles
• Pets that get under foot

30
Falls in Older Adults

• Evaluation
• Falls in the elderly are generally
  multi-factorial
• Risk of falling increases with the number of
  predisposing conditions
• Identify all potential contributing problems by
  systematic clinical evaluation
• Evaluation forms the basis for specific
  treatments and preventive strategies
• Goals are to identify
• Reversible conditions and environmental factors
• Modifiable impairments
• Fixed disabilities requiring compensation

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Falls in Older Adults

• Evaluation - Falls History
• SPLATT
• S ymptoms
• P revious falls
• L ocation
• A ctivity
• T ime
• T rauma

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Falls in Older Adults

• Evaluation - Falls History
• Detailed history of the fall
• What, When, Where, Why
• Activity
• Environmental factors
• Associated symptoms, e.g.
• Postural lightheadedness
• Vertigo
• Syncope or near syncope
• Seizure (tongue biting, incontinence)
• Circumstances of any previous falls
• History of any intrinsic risk factors
• Medication review
• Alcohol intake
• Assessment for acute illness (e.g. dehydration,
  infection, acute cardiac or neurological
  symptoms)

33
Falls in Older Adults

• Evaluation Physical Exam
• Postural vital signs
• Vision
• Cardiovascular (CHF, edema, arrhythmias)
• Musculoskeletal (pain, deformity)
• Feet and footwear
• Neurological (focal signs, peripheral neuropathy)
• Mental status (cognition, judgment)
• Balance and Gait (with assistive device if used)
• Watch the patient get up and walk!
• (Get Up and Go Test)

34
Falls in Older Adults

• Evaluation Get Up and Go Test

Task Observations
Sit in a chair at a comfortable height Sitting balance
Stand without using arms to help if possible Balance when standing Proximal leg muscle strength Judgment (to lock wheelchair if applicable)
Close eyes at rest Romberg test
Sternal nudge (eyes closed) Standing stability
Walk Step height and length, sway, unsteadiness
Turn around Stability, number of steps (gt 4 increases risk)
Walk back to chair and sit down Balance when sitting down
35
Falls in Older Adults

• Evaluation Diagnostic Tests
• Routine testing has limited value in the
  assessment of falls
• Extensive diagnostic work-up generally not
  required
• Should be guided by history and physical exam
• Helpful in evaluating acute problems
• Dehydration, infection, anemia, trauma
• EKG and event monitoring not necessary as part of
  routine evaluation after a fall

36
Falls in Older Adults

• Interventions
• Goals are to
• Minimize risk of falling
• Preserve mobility and independence
• Multi-component interventions should be based on
  the evaluation
• Preventive strategies should address intrinsic
  and environmental factors

37
Falls in Older Adults

• Interventions
• Medical
• Rehabilitative
• Environmental /Behavioral
• Surgical

38
Falls in Older Adults

• Examples of Medical Interventions
• Manage acute medical problems that may have
  contributed to the fall (s)
• Assess and treat postural hypotension
• Adjust medication (s) if indicated
• Reduce alcohol intake if indicated
• Optimize management of chronic medical conditions
  that increase fall risk
• Parkinsons disease
• Cardiovascular disease
• Musculoskeletal disorders
• Anemia
• Diabetes
• Ophthalmology assessment for visual problems
• Evaluate for treatable causes of neuropathy if
  present
• Assess and treat osteoporosis in those at risk

39
Falls in Older Adults

• Examples of Rehabilitative Interventions
• Gait and balance training
• Physical Therapy
• Tai Chi
• Strengthening exercises for muscular weakness
• Physical therapy modalities for pain (e.g. heat,
  cold, ultrasound, massage, etc.)
• Balance exercises for vestibular and
  proprioceptive problems
• Habituation exercises for benign positional
  vertigo
• Ensure patient has correct walking aid and uses
  it appropriately
• Training in safe performance of daily activities
• Braces e.g. ankle-foot orthotic (AFO) for foot
  drop
• Shoe orthotic for painful foot problems and leg
  length discrepancy

40
Falls in Older Adults

• Examples of Environmental and Behavioral
  Interventions
• Bathroom modifications grab bars, raised toilet
  seat, rubber mat in tub or shower
• Improve lighting, use of night light
• Nonskid throw rugs
• Remove obstacles from walking paths
• Stair safety
• Proper storage of items
• Bed and chairs at appropriate height
• Proper footwear and clothing
• Hip protectors for those at high risk

41
Falls in Older Adults

• Examples of Surgical Interventions
• Joint surgery or replacement for painful
  arthritis
• Neural decompression for neuropathic pain
• Cataract extraction for vision impairment
• Treatment of calluses, bunions, and foot
  deformities by podiatrist

42
Falls in Older Adults

• Summary
• Falls are common in both community and
  institutionalized older persons
• They are associated with significant morbidity
  and can cause mortality
• Most falls are multi-factorial, involving an
  interaction between intrinsic risk factors,
  activity, and environment
• The evaluation of the elderly faller should be
  directed towards identifying multiple risk
  factors that can contribute to falls
• Medical, rehabilitative, environmental/behavioral,
  and targeted surgical interventions may decrease
  the incidence of falls and fall-related injuries

43
Falls in Older Adults

• A Typical Case (1)
• Mr. C. is an 89 year old man who is referred to
  you for the evaluation of vertigo. His daughter
  says that he has fallen 3 times in the past month
  after discharge from the hospital for a small
  heart attack and heart failure.

44
Falls in Older Adults

• A Typical Case (2)
• Mr. C. has no prior history of falls.
• His chronic medical problems include
• Coronary artery disease
• Hypertension
• Congestive heart failure
• Degenerative joint disease mainly of the right
  hip and knee
• Insomnia related to pain in his knee

45
Falls in Older Adults

• A Typical Case (3)
• Mr. Cs medications include
• Furosemide and postassium supplement
• Enalapril
• Nitroglycerin patch 12 hours per day
• Propoxephene as needed for pain
• Zolpidem as needed for sleep

46
Falls in Older Adults

• A Typical Case (4)
• Further history reveals that each fall occurred
  in the morning after breakfast. He gets up, and
  when he starts walking he feels dizzy. He has
  not to his knowledge passed out or sustained any
  severe injury with these falls. There is no
  history suggestive of a seizure.

47
Falls in Older Adults

• A Typical Case (5)
• Physical Exam reveals
• Mr. C. appears well and has no signs of trauma
• Sitting BP and P are 102/58 and 66 standing BP
  and P after 1 minute are 88/52 and 72
• Heart rhythm and sounds are normal
• Lungs have bilateral crackles at both lung bases
• Musculoskeletal exam shows very limited range of
  motion of the right hip with pain on internal
  rotation, and crepitus and pain with flexion of
  the right knee
• Neurological exam is non-focal without evidence
  of peripheral neuropathy, but rapid movement of
  his head reproduces his vertigo

48
Falls in Older Adults

• A Typical Case (6)
• Get Up and Go observation reveals
• Difficulty arising without physical assistance
• Negative Romberg test
• Abnormal gait due to guarding his right side
• Difficulty and imbalance when turning

49
Falls in Older Adults

• A Typical Case (7)
• What do you think is contributing to Mr. Cs
  falls?
• What diagnostic tests would you order?
• What interventions would you implement?

50
Falls in Older Adults

• A Typical Case
• What do you think is contributing to Mr. Cs
  falls?
• Postural hypotension
• Volume depletion
• Drug-induced
• Post-prandial
• Painful poorly managed arthritis
• Proximal leg muscle weakness
• Benign positional vertigo
• Medications propxyphene, zolpidem
• Need to exclude acute problem, e.g. worsening CHF

51
Falls in Older Adults

• A Typical Case (7)
• What diagnostic tests would you order?
• Chemistry panel (BUN/Cr ratio)
• Chest xray (for CHF)
• Consider a brain natriuretic peptide level and/or
  echocardiogram to further evaluate for CHF
• EKG (to exclude new MI worsening CHF)

52
Falls in Older Adults

• A Typical Case (7)
• What interventions would you implement?
• Modification of cardiovascular medications
  depending on results of chemistry panel and
  evaluation of CHF
• Discontinue the propoxyphene and zolpidem
• Improve pain management, initially trying routine
  acetominophen - 1000 mg tid
• Physical therapy for leg strengthening and
  habituation exercises for positional vertigo
• Use of a cane in the left hand to unload painful
  joints
• Education on getting up too quickly after meals