DORON GARFINKEL, M.D.

1
Falls and Fall Prevention in the Elderly
DORON GARFINKEL, M.D. HEAD, GERIATRIC
PALIATIVE DEPARTMENT
SHOHAM GERIATRIC MEDICAL CENTER PARDES HANA,
I S R A E L
2
Overview
Falls in the Elderly

• Prevalence
• Clinical Importance
• Risk Factors Etiology
• Evaluation
• Prevention Management
• Falls restraint use
• Summary

3
Prevalence

• 30 of those over 65 fall annually
• Half are repeat fallers
• Falls go up with each decade of life
• Over half of those in nursing homes and hospitals
  will fall each year

4
FALLS - INCIDENCE

• The incidence of falls increase with age
• Each year 30 - 40 of community-dwelling persons
  gt 65 years old have a fall.
• The annual incidence of falls among people who
  experienced a fall in the previous year, is
  almost 60.

• 25 - AGE 65 74, 33 - AGE gt 75
• 120 AGE gt 80 ( gt ONE FALL / Year)

5
Clinical Importance Impact of Hip Fractures

• 1 of falls result in hip fracture
• 2 billion in medical costs annually
• 25 die within 6 months
• 60 have restricted mobility
• 25 remain functionally more dependent

6
Falls Cause Morbidity Mortality

• Mortality indirect effects
• Fractures 6 of falls
• Soft tissue injury, head injury, subdural
  hematoma
• Fear of falling can result in decreased activity,
  isolation, and further functional decline
• Nursing home placement loss of independence

7
FALLS - A LEADING CAUSE OF MORBIDITY,
DISABILITY DEATH

• Complications resulting from falls are the
  leading cause of death from injury in adults aged
  65 and older.
• Fear, Loss of Confidence
• Decreased Functioning
• Dependency
• Physical Trauma - 10
• FRACTURES - 5- 15

8
Risk Factors Etiology Falls are Multifactorial
Intrinsic Factors
Extrinsic Factors
Medications Improper use of assistive
devices Environment
Medical conditions Impaired vision and
hearing Age related changes
FALLS
9
Age - Related Changes

• Neurologic
• Increased reaction time
• Decreased righting reflexes
• Decreased proprioception
• Vision Changes
• Decreased accommodation dark adaptation
• Decreased muscle mass

10
Age - Related ChangesG A I T

• Slower gait
• Decreased stride length arm swing
• Forward flexion at head and torso
• Increased flexion at shoulders and knees
• Increased lateral sway

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D y s m o b i l i t y

• Dysmobility and falling closely related
• 15 of those over 65 have trouble walking
• 1/4 men and 1/3 women over age 85 have difficulty
  with walking
• 2/3 of people in hospital or NH unable to
  ambulate without assistance

12
Risk Factors for Falls
Risk Factor OR

• 28
• Cognitive Impairment 5
• Lower extremity problem 4
• Pathologic Reflex 3
• Foot Problems 2
• gt balance/gait problems 1.9

Sedative use
Tinetti NEJM 1988
13
Common Pathologies associated with Falls

• Ophthalmologic diseases
• Arthritis
• Foot problems
• Neurologic illness
• Parkinsons related disorders
• Strokes
• Peripheral neuropathy
• Dizziness and dysequilibrium

14
Dizziness A Multifactorial Syndrome

• Vertigo Posterior CVA/TIA, Cervical
• Presyncope Orthostatic, Dysrythmia, Anemia
• Dysequilibrium Peripheral neuropathy,
• Visual
• Other Anxiety, depression
• In older people, usually multifactorial

• Tinetti, Annals of Internal Med 2000

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Falls in the Community

• Accidents/environment 37
• Weakness, balance, gait 12
• Drop attack 11
• Dizziness or vertigo 8
• Orthostatic hypotension 5
• Acute illness, confusion, drugs,
  
  
  
  
  decreased vision 18
• Unknown 8

Rubenstein JAGS 1988
16
Falls in Residential Care

• Generalized weakness 31
• Environmental hazard 27
• Orthostatic hypotension 16
• Acute illness 5
• Gait or balance disorder 4
• Drugs 5
• Other or unknown 10

Rubenstein Ann Int Med 1990
17
Medications and Falls

• Sedative-hypnotics, especially long acting
  benzodiazepines,
• Small association between most psychotropics and
  falls
• SSRIs and TCAs both increase falls
• Weak association between Type 1A antiarrythmics,
  digoxin, diuretics, and falls

Leipzig JAGS 1999 Thapa NEJM 1998
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Evaluation of Falls in the Elderly Medical History

• Location circumstances of Fall
• Associated symptoms
• Other falls or near falls
• Medications (including nonprescription) and
  alcohol
• Injury ability to get up

19
Evaluation of Falls in the Elderly Physical
Examination

• Supine and standing BP - always
• Routine physical examination
• Focus on cardiovascular, MS, neuro, feet
• Vision and hearing evaluation
• Consider acute medical illness delirium
• Formal gait and balance assessment

20
Evaluation of Falls Home Evaluation

• Can be performed by nurse, OT, PT, others
• Stairs
• Lighting
• Bathroom
• Specific hazards cords, throw rugs

21
Evaluation of Falls Risk Factors for Injury

• Osteoporosis assessment
• Anticoagulation Usual benefits outweigh risks
  unless repeat or high risk faller
• Can the person get up from fall?
• Is there a way to notify others in case of
  falling?

22
Formal Gait Evaluation
Get up and Go Test Tinetti Gait Balance
Evaluation (POMA)

POMA Balance Component Sitting (in hard,
armless chair) Arising Standing balance
(immediate and delayed) Balance with
Nudge Balance with Eyes closed Balance with 360
degree turn Tinetti JAGS 1986
23
POMA Gait Component

• Initiation
• Step length and height
• Step symmetry continuity
• Path
• Stance
• Ability to pick up speed
• Tinetti
  JAGS 1986

24
Prevention Treatment

• Treat acute injury underlying medical
  conditions
• Remove unnecessary medications
• Rehab, exercises, assistive devices
• Correct sensory impairments
• Environmental modifications safety
• Evaluate for osteoporosis treatment

25
Osteoporosis

• Calcium and vitamin D for most elders at risk
• Dawson-Hughes, NEJM, 1997
• Osteoporosis evaluation and treatment
• Thiazides may help slightly
• Statins?
• Hip protectors appear to protect from hip
  fractures in those who wear them
• Kannus, NEJM, 2000

26
Risk Factor Modifications for Fractures
Change Estimated Change in
Risk Quit smoking 38 Treat impaired
vision 50 Stop sedatives 40 Add 1 Gram
Calcium 24 Hip Protectors 50?
Adapted from Steeve Cummings
27
Falls Primary Prevention

• 301 community dwelling elders with 1 risk
  factors for falling
• Intervention adjustment in medications,
  behavioral instructions, exercise programs aimed
  at modifying risk factors
• One year follow up

Tinetti et al. 1994 NEJM
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Multifactorial Intervention
P .04
Tinetti et al 1994 NEJM
29
Exercise Training Nutrition
Fiatarone et al NEJM 1994
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Tai Chi and Falling

• Atlanta FICSIT Trial
• 200 community dwelling elders 70
• Intervention 15 weeks of education, balance
  training, or Tai Chi
• Outcomes at 4 months Strength, flexibility, CV
  endurance, composition, IADL, well being, falls
• Falls reduced by 47 in Tai Chi group
  

Wolf JAGS 1996
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Training frail older persons The New Zealand
Study of Women

• 223 women gt80 years
• Intervention PT tailored to individual needs,
  with resistance and balance training
• Results
• Clinical balance, chair rise improved
• RR for falls .47 (CI .04-.90)
• RR for injurious falls .61 (.39-.97)

Campbell BMJ 1997
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Summary

• Falls are common in the elderly may lead to
  injuries and decline in function
• Evaluation should included risk factor
  assessment, gait assessment, and home assessment
• Exercise can improve outcomes
• We have no evidence that restraints reduce fall
  related injuries

33
EFFICACY OF HIP PROTECTORS IN THE PREVENTION OF
HIP FRACTURES IN PATIENTS WITH DEMENTIA
Doron Garfinkel
Shoham Geriatric Medical Center Pardes Hana,
Israel
34
THE VICIOUS CIRCLE
A G I N G
INSTABILITY
DEMENTIA
F A L L S
DISABILITY
SARCOPENIA
OSTEOPOROSIS
FRACTURE

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FALLS HIP FRACTURES

• 10-15 of Falls result in fractures
• In the US - 90 percent of more than 350,000
  hip fractures each year are the result of a
  fall.

• An estimate of 1.3 million hip fractures
  occurred worldwide in 1990, By 2050 in the US
  alone, there will be an estimated No. of
  650,000 hip fractures annually
• Nearly 1800 hip fractures a day!

36
????? ??????? ????? ?????? ???? ?? ?????
?
ESTIMATED
No. (x 1000)
USA
UK
1980
2000
2050
37
HIP FRACTURES - OUTCOMES
The death rate attributed to falls also increase
with age, reaching at age gt 85 180 deaths per
100,000 population

• Hip fractures is the commonest reason for
  admission of elderly people
  to an acute orthopedic ward

Johnell Kanis, Osteopor Int 2004 15 897
902.
38
HIP FRACTURES - OUTCOMES

• Each year, 8 of people gt 70 years old reach the
  Emergancy Room, as a result of Fall - related
  injuries
• Those admitted are hospitalized for an
  average of 8 days.
• These hip fractures may result in
  . permanent disability accounting for a
  significant portion of the
  Global Burden of Disease

39
HIP FRACTURES - OUTCOMES

• Only 25 percent of patients with hip
• fractures will make a full recovery
• 50 percent will need some assistance
• - cane or walker

• 40 will require Long Term Care (nursing
  homes nursing departments)
• In the US, the cost of fall-related
• injuries is estimated as
• 12,6 billion dollars yearly

40
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48
Hip pads to prevent hip fracture

• RCT of 1801 frail subjects in Finland
• Nursing home or frail community patients
• Mean age 81
• 78 women
• 63 assisted walking
• Kannus.
  NEJM20003431506-1513.

49
Hip pads to prevent hip fracture

• Fractures with Hip Protectors
• 2.1 per year vs. 4.6 per year (plt.01)
• 40 patients needed to be treated with hip
  protector for 1 year to prevent one fracture
• 2.4 of falls resulted in hip fracture when not
  wearing protector
• 0.4 resulted in hip fracture when wearing
  protector (80 risk reduction)
• But patient acceptance low

Kannus. NEJM20003431506-1513
50
?? ???? ???? ?? ?????? ????? ????????
Effectiveness of Hip Protectors for
Preventing Hip Fractures in Elderly People
Systematic Review. BMJ March 2, 2006
Parker MJ, et al, concluded that hip
protectors represent an Ineffective intervention
for elders living at home, while their
Effectiveness in preventing hip fractures in
Institutional setting may be regarded as
Uncertain.
51
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EXCLUSION CRITERIA

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54
www.hipsavers.com
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HIP SAVER - CHARACTERISTICS

• Third Generation...
• Nursing home type
• Worn over the underwear
• Both firm and elastic
• Quite resistant
• to wear and tear
• in the washing machine.

56
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HIP SAVER - CHARACTERISTICS

• Two sets of hip Savers available
• Personally fit for each patient
• While the patient is
• wearing one set,
• the other is cleaned
• in the departments
• washing machine.

57
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Mean Age Study group 82.8 (SD9.6),
Contrrol group 81.4 (SD9.6)
Females Study group 69 Controls 67
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67
Garfinkel D, Radomisalski Z, Jamal S, Ben Israel
J. High efficacy for hip protectors in the
Prevention of hip fractures among elderly people
with dementia. J AM MED DIR ASSOC 9 313 -
318, 2008.

68
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