CHAMPCHAMPA Geriatric Syndrome in the A Geriatric Syndrome in the Hospital: The Case of FallsHospital: The Case of Falls

William Dale, MD, PhDWilliam Dale, MD, PhD

University of ChicagoUniversity of Chicago

OverviewOverview

• What is a “geriatric syndrome”? What is a “geriatric syndrome”? • How does one think about, and teach about, How does one think about, and teach about,

syndromes like falls? syndromes like falls? • Why worry about falls? Why worry about falls? • What are the causes of falls? What are the causes of falls? • Differential diagnosis and falls: teaching to Differential diagnosis and falls: teaching to

medicine housestaffmedicine housestaff• Restraints and falls: teaching housestaff about the Restraints and falls: teaching housestaff about the

dangers of restraintsdangers of restraints• Preventing and treating patients who fallPreventing and treating patients who fall• What should be done at discharge?What should be done at discharge? • U of C Nursing initiative and pilot projectU of C Nursing initiative and pilot project

Falls As a “Geriatric Falls As a “Geriatric Syndrome”Syndrome”

• A sudden, unexpected descent from a A sudden, unexpected descent from a standing sitting, or horizontal position. standing sitting, or horizontal position.

• When a person comes to rest When a person comes to rest inadvertently on the ground or a lower inadvertently on the ground or a lower levellevel– Excludes syncope and overwhelming traumaExcludes syncope and overwhelming trauma– A A classic Geriatric Syndromeclassic Geriatric Syndrome

• When the nurse calls to report “an When the nurse calls to report “an event” event”

What is a Geriatric What is a Geriatric Syndrome?Syndrome?

• Manifestations of disturbances in Manifestations of disturbances in complex systems, usually with more complex systems, usually with more that one organ system involvedthat one organ system involved

• ExamplesExamples– Functional DependenceFunctional Dependence– DeliriumDelirium– Incontinence Incontinence – FallsFalls

Geriatric Syndrome Vs. Traditional SyndromeGeriatric Syndrome Vs. Traditional Syndrome

How do complex systems, like How do complex systems, like older adults, “fail” in causing older adults, “fail” in causing syndromes?syndromes?

• Key ConceptsKey Concepts– Physiologic reserve lower across multiple Physiologic reserve lower across multiple

domainsdomains– Adaptive/redundant systems reducedAdaptive/redundant systems reduced

• Possible Pathways to FailurePossible Pathways to Failure– Major hit to one component (E.g. CVA)Major hit to one component (E.g. CVA)– Dominant deficit with exacerbations (E.g. MI Dominant deficit with exacerbations (E.g. MI

CHF/COPD) CHF/COPD)– Multiple modest deficits (Geriatric Multiple modest deficits (Geriatric

Syndrome)Syndrome)

Sources: Tinetti, 1988; Tinetti, 1994

Yearly Incidence of FallsYearly Incidence of Falls

• Community-dwelling persons over Community-dwelling persons over 65: 30-40%65: 30-40%– 20% of falls require medical attention20% of falls require medical attention

• History of fall in last year: 60%History of fall in last year: 60%• Falls in our hospital: Data not Falls in our hospital: Data not

currently availablecurrently available

Source: Sattin, 1992.

ComplicationsComplications

• ““Leading cause” fact: death from injury in Leading cause” fact: death from injury in older adultsolder adults

• Fracture risk: 10-15% Fracture risk: 10-15% – About 8% of 70+ y.o. go to ED yearly for fall-About 8% of 70+ y.o. go to ED yearly for fall-

related injuryrelated injury

• Other common complicationsOther common complications– Decline in functional statusDecline in functional status– Increased likelihood of nursing home placementIncreased likelihood of nursing home placement– Increased use of medical servicesIncreased use of medical services– Developing fear of falling Developing fear of falling Loss of function Loss of function

Causes of FallsCauses of Falls

• Rarely due to a single causeRarely due to a single cause– At least 25 risk factors identified across 5 At least 25 risk factors identified across 5

large cohort studieslarge cohort studies

• Interaction across multiple domains: Interaction across multiple domains: more risk-factors, increased likelihood to more risk-factors, increased likelihood to fallfall– Intrinsic to individualIntrinsic to individual– Environmental challenges to postural controlEnvironmental challenges to postural control– Mediating factorsMediating factors

Causes: Intrinsic Patient Causes: Intrinsic Patient FactorsFactors

• AgeAge• Female genderFemale gender• Cognitive impairmentCognitive impairment• Chronic diseasesChronic diseases

– ArthritisArthritis– Parkinson’sParkinson’s

• Use of certain medicationsUse of certain medications– PsychotropicsPsychotropics– DiureticsDiuretics

• History of fallsHistory of falls

History of Falls as a Risk History of Falls as a Risk FactorFactor

• One year risk of hospitalization by One year risk of hospitalization by baseline self reported fall status baseline self reported fall status (n=444)(n=444)History of History of

fallsfallsHospitalized over 12 Hospitalized over 12

monthsmonths

nonenone 61/316 (19%)61/316 (19%)

oneone 18/79 (23%)18/79 (23%)

two or moretwo or more 19/49 (39%)19/49 (39%)

Causality: Pathophysiology of Causality: Pathophysiology of Aging and Postural ControlAging and Postural Control

• Postural control differences in older adultsPostural control differences in older adults– Respond to balance perturbations using Respond to balance perturbations using

proximal muscles first, then distalproximal muscles first, then distal– More slowly develop joint torque when More slowly develop joint torque when

disturbeddisturbed– More likely to have decreased baroreflex More likely to have decreased baroreflex

sensitivity to hypotensive stimuli sensitivity to hypotensive stimuli – More likely to have microvascular cerebral More likely to have microvascular cerebral

perfusion defectsperfusion defects– Reduction in total body waterReduction in total body water

Causes: Postural Control Causes: Postural Control ChallengesChallenges

• Weakness, esp. lower extremityWeakness, esp. lower extremity• Balance difficultiesBalance difficulties• Dangerous environmentDangerous environment

Source: Studenski, 1991

Causes: Mediating FactorsCauses: Mediating Factors

• Risk-taking behaviorsRisk-taking behaviors• Underlying mobility level/inclinationUnderlying mobility level/inclination• Principle: Mismatch of risk-taking Principle: Mismatch of risk-taking

behavior with mobilitybehavior with mobility

Probability of Fall

Mobility Skills

Causality: Pathophysiology of Causality: Pathophysiology of AgingAging

• Three sensory input systems Three sensory input systems involved in maintaining upright involved in maintaining upright postureposture– VisualVisual– ProprioceptiveProprioceptive– VestibularVestibular

• All of these systems decline with All of these systems decline with agingaging

Differential Diagnosis and Differential Diagnosis and FallsFalls

• Traditional DDx:Traditional DDx:– Multiple symptoms Multiple symptoms Possible single causes Possible single causes

(I.e. diagnoses)(I.e. diagnoses)– Causes prioritized by probability and severityCauses prioritized by probability and severity– Search for underlying or unifying causeSearch for underlying or unifying cause

• Geriatric Syndromes DDx:Geriatric Syndromes DDx:– Event/Condition Event/Condition Possible multiple causes Possible multiple causes– Causes prioritzed by probability and Causes prioritzed by probability and

contribution to causing event/conditioncontribution to causing event/condition– Search for web of interacting causes Search for web of interacting causes

History and physical based History and physical based on the components of on the components of postural controlpostural control

• SensorySensory: : – VisionVision– VestibularVestibular– SomatosensationSomatosensation

• Central ProcessingCentral Processing: : – Global level of consciousness/perfusionGlobal level of consciousness/perfusion– Attention/response timeAttention/response time– Automatic postural responsesAutomatic postural responses

• EffectorEffector: : – muscle strengthmuscle strength– range of motionrange of motion– enduranceendurance

Getting “The Story”Getting “The Story”

• At time a fall occurs, get good historyAt time a fall occurs, get good history– Do this on cross-coverDo this on cross-cover– Best history at time of fallBest history at time of fall– Earlier intervention importantEarlier intervention important

• Activity at time of fall (walking, transferring, sitting Activity at time of fall (walking, transferring, sitting at bedside, going to bathroom, etc)at bedside, going to bathroom, etc)

• Prodromal symptoms Prodromal symptoms – Lightheadedness?Lightheadedness?– Loss of balance? Loss of balance? – Dizziness?Dizziness?

• Location/TimingLocation/Timing

Getting the StoryGetting the Story

• Observe environment/context of fallObserve environment/context of fall– LightingLighting– Flooring and footwearFlooring and footwear– Restraints (both formal and informal)Restraints (both formal and informal)– FurnitureFurniture

• Past History: Has this happened before? Past History: Has this happened before? – Strongest predictor of fall: past fallStrongest predictor of fall: past fall– Context of last eventContext of last event

• Review MedicationsReview Medications– Recent Changes in Medications (Check MAR)Recent Changes in Medications (Check MAR)– Biggest culpritsBiggest culprits

• VasodilatorsVasodilators• DiureticsDiuretics• SedativesSedatives• HypnoticsHypnotics

The Role of MedicationsThe Role of Medications

• Specific meds in observational studies Specific meds in observational studies associated with hip fracture riskassociated with hip fracture risk– BenzodiazepinesBenzodiazepines– AntidepressantsAntidepressants– AntipsychoticsAntipsychotics

• Medication features associated with Medication features associated with fallsfalls– Recent changes in doseRecent changes in dose– Total number of medsTotal number of meds

Physical ExamPhysical Exam

• Orthostatics: Do this Orthostatics: Do this yourselfyourself if you have time if you have time. . • Cardiovascular SystemCardiovascular System• Sensory ExaminationSensory Examination

– Special sensesSpecial senses– ProprioceptionProprioception

• Musculoskeletal ExamMusculoskeletal Exam– Proximal muscle weaknessProximal muscle weakness– Joint pain/swellingJoint pain/swelling

• Cognition: brief assessment of mental status: Cognition: brief assessment of mental status: OrientationOrientation

• Footwear/Floor combinationFootwear/Floor combination– Socks on tile; bare feet and wet floorSocks on tile; bare feet and wet floor

Physical Exam: Special Physical Exam: Special TestsTests

• Gait Speed – Gait Speed – “Get up and Go” Test“Get up and Go” Test– Rise from (hard-backed) chair, walk 10 Rise from (hard-backed) chair, walk 10

feet, turn, return to chair, sit downfeet, turn, return to chair, sit down– Threshold greater than 10 seconds is Threshold greater than 10 seconds is

abnormalabnormal• One foot balanceOne foot balance

– Threshold: < 30 secondsThreshold: < 30 seconds• Observe PT/OT evaluations for Observe PT/OT evaluations for

these patients—arrange time for these patients—arrange time for team to meet with PT/OTteam to meet with PT/OT

Laboratory TestingLaboratory Testing

• No “standard” battery of testsNo “standard” battery of tests• Instead, targeted to specific concernsInstead, targeted to specific concerns

Number of Restraints?Number of Restraints?

Falls and RestraintsFalls and Restraints

• Restraints increasingly recognized as Restraints increasingly recognized as a cause of falls and increasing a cause of falls and increasing serious fallsserious falls

Source: Tinetti ME, et al, 1992

Mechanical Restraint Use Mechanical Restraint Use and Fall-related injuriesand Fall-related injuries

• Prospective study, SNFs, n=397Prospective study, SNFs, n=397• Outcome: falls Outcome: falls afterafter restraints restraints

placedplaced• Logistic regression used to control for Logistic regression used to control for

large number of confounderslarge number of confounders• Odds ratio for fall-related injuryOdds ratio for fall-related injury

– Full cohort: 10.2 (CI 2.8 – 36.9)Full cohort: 10.2 (CI 2.8 – 36.9)– High-risk subgroup: 6.2 (CI 1.7 – 22.2)High-risk subgroup: 6.2 (CI 1.7 – 22.2)

Source: Mion LC, Et al, 1989.

Mechanical RestraintsMechanical Restraints

• IncreasesIncreases risk of falls and other risk of falls and other complications in hospitalized patients on a complications in hospitalized patients on a medicine service:medicine service: ComplicatioComplicationn

RestrainRestraineded

(n = 35)(n = 35)

UnrestrainUnrestraineded

(n= 243)(n= 243)

P - valueP - value

FallFall 17%17% 1%1% 0.0010.001Immobility-Immobility-relatedrelated

9%9% 2%2% 0.0450.045

Nosocomial Nosocomial infectioninfection

23%23% 5%5% 0.0010.001

Restraints: Formal and Restraints: Formal and InformalInformal

• FormalFormal– MittensMittens– Wrist/Ankle Soft RestraintsWrist/Ankle Soft Restraints– 4-point “Leathers”4-point “Leathers”– Full Side RailsFull Side Rails– Posey VestsPosey Vests

• InformalInformal– IV LinesIV Lines– O2 nasal canulasO2 nasal canulas– NG tubes to suction or for feedsNG tubes to suction or for feeds– Pulse oximetryPulse oximetry– SCDsSCDs– Foley cathetersFoley catheters

Risks/Benefits of BedrailsRisks/Benefits of Bedrails

• Potential benefitsPotential benefits– Aiding in repositioning Aiding in repositioning – Hand-hold for support in getting in/out of bedHand-hold for support in getting in/out of bed– Reduce fall risk Reduce fall risk during transportduring transport– Enhance access to bed controls Enhance access to bed controls

• Potential risksPotential risks– EntrapmentEntrapment– Worse falls injuries from climbingWorse falls injuries from climbing– Skin trauma/bruising/scrapingSkin trauma/bruising/scraping– Exacerbation of delerium when used as a restraintExacerbation of delerium when used as a restraint– Restricts activities (toileting, personal item Restricts activities (toileting, personal item

retrieval)retrieval)

Bed Rails and EntrapmentBed Rails and Entrapment

• Incidence of “entrapment” by bed Incidence of “entrapment” by bed rails reported to FDA, 1985-1999: rails reported to FDA, 1985-1999: 371371– # of beds in U.S. hospitals and LTC # of beds in U.S. hospitals and LTC

facilities: 2.5 millionfacilities: 2.5 million– Outcomes from entrapmentOutcomes from entrapment

• Death 61%Death 61%• Non-fatal injury 23%Non-fatal injury 23%• No injury 15%No injury 15%

Safety Improvement Safety Improvement Alternatives to Bed RailsAlternatives to Bed Rails

• Lower bed for patient, raise for providersLower bed for patient, raise for providers• Keep wheels of bed lockedKeep wheels of bed locked• Use transfer and mobility aidsUse transfer and mobility aids• Monitor patient frequentlyMonitor patient frequently

– Move patient closer to nursing stationMove patient closer to nursing station– Enlist others: family, medical studentsEnlist others: family, medical students

• Identify and meet patient needs that lead to Identify and meet patient needs that lead to fallsfalls– Toileting: available bedpans/urinal; scheduled Toileting: available bedpans/urinal; scheduled

toiletingtoileting– Pain: adequate pain reliefPain: adequate pain relief

Improving Safety of Improving Safety of Bedrails When UsedBedrails When Used

• Close monitoring Close monitoring • Lower at least one of railsLower at least one of rails

– Not considered a restraint when used Not considered a restraint when used this waythis way

– Allows access to and from bedAllows access to and from bed

• Properly sized mattress to reduce Properly sized mattress to reduce gap between mattress and bedrailgap between mattress and bedrail

Treatment and PreventionTreatment and Prevention

• No proven benefitNo proven benefit in reducing falls in reducing falls– UntargetedUntargeted exercise intervention alone exercise intervention alone– UntargetedUntargeted health education alone health education alone– UntargetedUntargeted exercise and health exercise and health

educationeducation– Assistive devices Assistive devices alonealone

Outpatient PreventionOutpatient Prevention

• Possible BenefitPossible Benefit– Long-term exercise and balance trainingLong-term exercise and balance training

• Includes gait training and proper use of Includes gait training and proper use of assistive devicesassistive devices

– Tai Chi: body “consciousness”, balanceTai Chi: body “consciousness”, balance– Medication review for possible Medication review for possible

discontinuationdiscontinuation• Esp. for those with 4+ medications Esp. for those with 4+ medications • Esp those on psychotropicsEsp those on psychotropics

In Hospital Treatment and In Hospital Treatment and PreventionPrevention

• Impact ProtectionImpact Protection– Lower beds and lock wheelsLower beds and lock wheels– Hip ProtectorsHip Protectors

• Significant protection against fractureSignificant protection against fracture• Adherence difficulties substantialAdherence difficulties substantial

– Diagnose and treat osteoporosisDiagnose and treat osteoporosis

• Increased VigilanceIncreased Vigilance– Enroll help of patient, family, nursingEnroll help of patient, family, nursing– Re-evaluate oftenRe-evaluate often– Visit yourself if possibleVisit yourself if possible

After DischargeAfter Discharge

• Proven benefit to reduce fallsProven benefit to reduce falls– Health screening with followup Health screening with followup

TARGETED interventionTARGETED intervention (OR = 0.79; CI = (OR = 0.79; CI = 0.65-0.95)0.65-0.95)• Primarily a balance issue? Primarily a balance issue? • Primarily a strength issue?Primarily a strength issue?

– Home safety evaluation by OTHome safety evaluation by OT (19% (19% reduction of falls versus control; reduction of falls versus control; decreased falls 36% in those with decreased falls 36% in those with previous history of falls)previous history of falls)

Intervention: Targeted PTIntervention: Targeted PT

• Three pooled studies, n = 566Three pooled studies, n = 566– Intervention: individually tailored program Intervention: individually tailored program

of progressive muscle strengthening, of progressive muscle strengthening, balance retraining exercises, and a balance retraining exercises, and a walking planwalking plan

• One-year: One-year: – Fall RR 0.80, CI 0.66-0.98; Fall RR 0.80, CI 0.66-0.98; – Serious injury: RR 0.67, CI 0.51-0.89Serious injury: RR 0.67, CI 0.51-0.89

• Two-year (69% intervention, 74% controls): Two-year (69% intervention, 74% controls): – Falls RR 0.69, CI 0.47-0.97Falls RR 0.69, CI 0.47-0.97– Moderate-Serious injury RR 0.63, CI 0.42-0.95Moderate-Serious injury RR 0.63, CI 0.42-0.95

Home Safety InterventionHome Safety Intervention

• Home safety evaluation by OTHome safety evaluation by OT• 1 well-designed study1 well-designed study

– n = 530, outcome: # of fallsn = 530, outcome: # of falls– Stratified by falls historyStratified by falls history

• Overall RR 0.81, CI 0.66-1.00Overall RR 0.81, CI 0.66-1.00• One or more falls, previous year, RR 0.64 (CI 0.49 – One or more falls, previous year, RR 0.64 (CI 0.49 –

0.84)0.84)• No falls, previous year, RR 1.03 (CI 0.75-1.41)No falls, previous year, RR 1.03 (CI 0.75-1.41)

Other Discharge Other Discharge ConsiderationsConsiderations

• If sending for rehab/PT, be sure information If sending for rehab/PT, be sure information about in-house fall is clearly communicatedabout in-house fall is clearly communicated– Rehab a common location for falls: people Rehab a common location for falls: people

having mobility challenges with mobility having mobility challenges with mobility difficultiesdifficulties

– Previous fallers benefit most from Previous fallers benefit most from interventionintervention

• Note fall in discharge summary to be added to Note fall in discharge summary to be added to patient “problem list” patient “problem list”

• Possibility of the development of fearfulness Possibility of the development of fearfulness leading to disability and increased risk of fallsleading to disability and increased risk of falls

SummarySummary

• Falls as a geriatric syndrome:Falls as a geriatric syndrome:– Multiple contributing causes with common final Multiple contributing causes with common final

pathwaypathway

• Most likely contributing causes:Most likely contributing causes:– #1 – History of falls#1 – History of falls– Patient factorsPatient factors: : balance difficulties, LE weaknessbalance difficulties, LE weakness, ,

incontinence, incontinence, medicationsmedications, cognitive impairment, cognitive impairment– Environmental factorsEnvironmental factors: : restraints (formal and informal),restraints (formal and informal),

bed height, toileting needs, lighting, furniture bed height, toileting needs, lighting, furniture – Mitigating factorsMitigating factors: mismatch of mobility with : mismatch of mobility with

compensatory mechanisms compensatory mechanisms patient, patient, nursing, family nursing, family education education

Summary of Teaching Summary of Teaching PointsPoints

• Exercises Exercises – ““Get up and Go” TestGet up and Go” Test– Bedside restraints “memory” testBedside restraints “memory” test

• Dangers of RestraintsDangers of Restraints• Discharge ConsiderationsDischarge Considerations

– Targeted interventions: Targeted interventions: observe PT observe PT evaluationevaluation

– OT Home safety evaluationOT Home safety evaluation – Falls added to problem listFalls added to problem list

U. Of C. Nursing InitiativeU. Of C. Nursing Initiative

• Performance Improvement Initiative Performance Improvement Initiative to Reduce Falls in the Hospitalto Reduce Falls in the Hospital

• Protocol based on University of Iowa Protocol based on University of Iowa Gerontological Nursing Interventions Gerontological Nursing Interventions Research CenterResearch Center

• Adapted from LTC setting to hospitalAdapted from LTC setting to hospital• Pilot to be initiated on 4SE and 4NW Pilot to be initiated on 4SE and 4NW

floorsfloors