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Not all falls are
beautiful
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B Y : D R N I N I S H U H A I D A M A T H A R U N
S U P E R V I S O R : D R N U R S U H A I L A I D R I S
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Immobility and Falls in Elderly
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P R E T E S T S
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SBA Q14
A mildly demented 69 year-old male presents afterfalling. He sustained no apparent injuries and hismental status is unchanged. Which of the followingare routine tests that should be ordered in patientsthat fall?
A. Head CT scan
B. Hemoglobin
C.
Hip X- rayD. No routine testing ()
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Q25
Which is the following is a normal change in gait thatis associated with aging?
A. Loss of arm swing
B. Widening of the base
C. Decreased stride length ()
D. Variable step length and height
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Q36
Which of the following medications is associatedwith highest risk for falls in the elderly?
A. Pseudoephidrine
B. Lorazepam ()
C. Fludrocortisone
D. Bupropion
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Q47
An 80 year-old male who lives with his daughter andfamily presents for evaluation after a fall. He hasmild dementia and a history of hypertension. He istaking lorazepam prn and hydrochlorothiazide.
Other than a nontender contusion on his arm, hisphysical examination is normal. Regardingevaluation of fall,A. Exercise is beneficial in preventing falls. (T)
B. Restraints decrease the number of falls. (F)C. Use of psychotropic medications is associated with falling.
(T)
D. Environmental assessment can help prevent falls. (T)
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Overview8
Introduction
Epidemiology
Risk factors
Assessment Management
Prevention
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Complication: (within days)
CVS
Fluid shift, decreased CO, decreased peak O2 uptake, increaseresting HR
Muskuloskeletal Loss of contractile velocity and strength
others:
Pressure sore, DVT, Pulm embolism,
Postural hypotension, falls, skin breakdown
Recovery: weeks to months
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Prevention12
Avoid pressure sore: Frequent inspection at pressure points and shift position at least every
2hours
Minimize CVS deconditioning: Position pt as close to upright position as possible, several times daily
Reduced muscle contracture and weakness ROM and strengthening exercise started immediately after
immobilization and continued as long as pt in bed
Antithrombotic measures Avoid restraints
Discontinue invasive devices Gradual ambulation Advice from physical therapist: appropriate exercise, assistive
devices, safety modification & maintenance exercises
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Epidemiology14
2009- total elderly in Malaysia :- 2.02 billion
2010 (up to Sept) increase to 2.13 billionJabatan Statistik Negara
out of 3 adults age 65 falls every year 1
Hausdorff JM,Rios DA,Edelber HK.Gait variability and fall risk in community-living olderadults:a 1-year prospective study. Archives of Physical Medicine and Rehabilitation
2001;82(8):1050-6
30% of people who fall suffer moderate to severeinjuries.
TBI accounted for 46% of fatal falls 2Honbrook MC et al.Preventing falls among community-dwelling older persons:results from arandomized trial.The Gerontologist 1994:34(1):16-23
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Adults over 65: 1 in 3 fall every year
Archives of Physical Medicine and Rehabilitation, 2001
Falls are the leading cause of injury and death
9% of falls lead to ED visit 2.1 million nonfatal fall related injuries treated in ED in 2008 with more
than 500,000 hospital admissions
5-6% lead to fracture
Journal of Bone and Mineral Research, 2003
18,000 fall related deaths in 2007 46% related to TBI
Adults over 75: 4-5 times more likely to be admitted to long term care for a year or more
Age and Ageing, 1999
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Falls have significant consequences
20% -30% of people sustain lacerations, fractures or headtrauma
These injuries can decrease mobility and independence
American Journal of Public Health, 1992Journal of TraumaInjury, Infection and Critical Care, 2001
Older adults who have falls without injuries may develop fearof falling
Activities self-limited leading to decreased fitness and actuallyincreasing risk of falling
Age and Ageing, 1997
50% of community dwellers never return to pre-fall status
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Most fractures are caused by falls (spine, hip,forearm, ankle, pelvis and hand)
Many people who fall but not injured develop fear offalling- limit their activities, reduce mobility and loss
of physical illness.
Bell AJ,Talbot-Stern JK,Hennessy A.Characteristic and outcomes of older patients presenting to theemergency department after a fall:aretrospective analysis.medical Journal of Australia
2000;173(4):176-7
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Impact of Hip Fractures20
1% of falls result in hip fracture
25% die within 6 months
60% have restricted mobility
25% remain functionally more dependent
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Che Hassans story
Che Hassan 72 years old, widowed, living alone His daughter lives nearby, but work full time. Has history of hypertension, DM, BPH,
osteoarthritis of the knees. He takes multiple medications to manage his
medical conditions, but didnt bring these withhim today
He complaining of increased urinary frequency
and feeling bored. You note bent glasses frames and a small abrasion
on his forehead and right arm
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What risk factors does Che Hassan have for falls?
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What risk factors does Che Hassan have forfalls?
widowed, living alone
hypertension, DM, BPH, osteoarthritis of theknees.
multiple medications
increased urinary frequency
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Risk factors for falls25
Intrinsic Age and age-related physiologic changes Acute illness Chronic illness Mobility factors-gait disturbance, balance disorder
or weakness, pain related to arthritis
Extrinsic
Environmental factors Use of ambulatory assistive device Mechanical restraints
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Normal aging changes26
Neurologic
postural instability
slowed reaction time
diminished sensory awareness for light touch, vibrationand temperature
decline of central integration of visual, vestibular andproprioceptive senses
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Vision Changes decline in visual acuity
decline in accommodative capacity
glare intolerance
altered depth perception
presbyopia [near vision]
decreased night vision
decline in peripheral vision
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Normal changes of gait28
Gait Slower gait
Decreased stride length and arm swing
Forward flexion at head and torso
Increased flexion at shoulders and knees
Increased lateral sway
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Che Hassans story continue
On examination, thin elderly man wearing glasses withbent frames.
Afebrile BP: 135/80 - sitting
BP: 130/85 standing
PR : 80 regular rhythm Early cataract in right eye
Systemic review unremarkable except for suprapubic areatenderness
Urinalysis numerous WBC and bacteria You treat his UTI and ask him to return in a week time for a
review of medications and proper neurologicalexamination.
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Is the UTI significant with regard to Che Hassansfalls?
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Story continue..
Che Hassan returns feeling better and his urinarysymptoms improved. You further ask about the fall history,but Che Hassan reluctantly admits that he fell a week agoin his house and that was not the 1sttime. He has fallenmore than seven times.
I just trip over my own feet and sometimes fall backward
He doesnt want his daughter to know about the falls,because he would like to continue to live on his own anddoes not wish to be dependent on her.
He admits to limiting a lot of the activities he used to enjoybecause he was sure he would fall.
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Continue....
He brought a large bag of medications that includemetochlorpramide, acetaminophen, metoprolol,HCTZ, terazosin, gliclazide.
O/E:-cranial nerve intact. Strength normal
Sensory: decreased sensation on light touch andvibration on both lower extremities.
Slow gait. Difficulty rising without use of his arm.Arthritic changes both knees.
MMSE-29/30
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Based on this evaluation, what further risk factorsdoes Che Hassan have for falls?
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Intrinsic factors Extrinsic factors
Increasing age Female
Previous fall Visual impairment Urinary incontinence Functional limitations Decreased physical activity Gait and balance disorders Arthritis Cognitive Impairment Depression Muscle weakness Orthostasis
Poly-pharmarcy (>4 meds) Psychotropic meds most problematic
Alcohol Improper footwear Inadequate lighting Improper floor surfaces
Wet/slippery Loose rugs/carpets Uneven flooring
Inappropriate / inadequateassistive devices Grab bars, walker/cane
Improper seat or bed height
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New England Journal of Medicine, 2003Journal of the American Geriatrics Society, 2001
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A S S E S S M E N T O F F A L L S
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Essential components of fall history40
Ssymptoms
P previous fall or near fall
Llocation of fall
Aactivity at time of fall Ttime of fall
Ttrauma, both physical and psychological
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Drugs that may increase risk of falling41
Polypharmacy
Sedative-hypnotics
Antidepressant (TCA,SSRI)
Antihypertensive agent
Cardiac medications
Anticholinergic drugs
Hypoglycaemic agent
Antiparkinsonian medications
Topical eye medications
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Evaluation of Falls: Physical Examination42
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
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Common Causes of Abnormal Gait43
Difficulty arising from chair Weakness Arthritis
Instability on first standing
Hypotension Weakness
Instability with eyes closed Proprioception
Step height/length Parkinsonism Frontal lobe Fear
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Get up and go test45
ONLY VALID FOR PATIENTS NOT USING ANASSISTIVE DEVICE
Get up and walk 10ft (3m), and return to chair
Seconds Rating
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Get up and go test46
Sensitivity 88%Specificity 94%Time to complete
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Balance test47
(1) side-by-side: feet side by side, touching
(2) semi-tandem: side of the heel of one foottouching the big toe of the other
(3) tandem:heel of one foot directly in front of andtouching the toes of the other foot.
Each stance is progressively more difficult to holdPeople unable to hold a position for 10 seconds arenot asked to attempt further stand
Mechanisms of Fall
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Intrinsic :
Aging, poor balance
Occurrence of falls
Fall OutcomesNo injuries
Contributing
factors Extrinsic :
Home hazards
Loss of
ConfidenceFractures Soft tissues
injures,
trauma
Disability,
reduced
quality of life
Mechanisms of Fall
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Continue....49
You recommend discontinuation ofmetochlopramide and referfor physical therapy andophthalmology evaluation.
In discusion with the daughter, she agree to havefamily membersvisit more frequentlyand to assist
with patients medication changes.
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6 weeks later50
He walk with cane, and with new eyeglasses, withplan to follow up on his cataract.
He states that he more confidentwith walking andsteadier on his feet.
In fact he has no falls in the time since your last visit.
He been able to do more activities at home andcommunity.
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Complication of immobility51
Physical:- Muscle wasting
Contractures
Osteoporosis Pressure sores
Aspiration pneumonia
Constipation
Urinary tract infection
Deep vein thrombosis
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Complication of immobility52
Psychological and Social
Isolation
Loss of independence/confidence
Sensory deprivation Depression
Anxiety
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M A N A G E M E N T
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C i i l S i R d i h Ri k f F ll i h
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Critical Steps in Reducing the Risk of Falls in theElderly
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- Treat acute injury and underlying medical condition,modify medication, providebalancetraining
- Eliminate environmental hazards- environmental
modification and safety.
- Provide opportunities for socializationandencouragement
- Involve thefamily.- Provide follow-up.
Falls and injuries in frail and vigorous community elderly persons. J AmGeriatr Soc 1991;39:46-52.
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Risk factorsInterventions56
Postural hypotension:-Behavioral recommendations, such as ankle pumps or
hand clenching and elevation of the head of the bed
Decrease in the dosage of a medication that may contribute
to hypotension; if necessary, discontinuation of the drug orsubstitution of another medication
Review of medications
Education about appropriate use of sedative-hypnoticdrugs
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Evaluation of Falls: Home Evaluation58
Can be performed by nurse, OT, PT, others
Stairs
Lighting
Clutter Bathroom
Specific hazards: cords, throw rugs
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P R E V E N T I O N
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Home Safety Checklist
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Home Safety Checklist
63 All living spaces
_____ Remove throw rugs._____ Secure carpet edges._____ Remove low furniture and objects on the floor._____ Reduce clutter._____ Remove cords and wires on the floor._____ Check lighting for adequate illumination at night (especially in thepathway to the bathroom).
_____ Secure carpet or treads on stairs._____ Install handrails on staircases._____ Eliminate chairs that are too low to sit in and get out of easily._____ Avoid floor wax (or use nonskid wax)._____ Ensure that the telephone can be reached from the floor.
Bathrooms_____ Install grab bars in the bathtub or shower and by the toilet._____ Use rubber mats in the bathtub or shower._____ Take up floor mats when the bathtub or shower is not in use._____ Install a raised toilet seat.
Outdoors
_____ Repair cracked sidewalks._____ Install handrails on stairs and steps._____ Trim shrubbery along the pathway to the home._____ Install adequate lighting by doorways and along walkways leading todoors.
Falls. In: Yoshikawa TT, Cobbs EL, Brummel-Smith K, eds. Ambulatory geriatric care. St. Louis:Mosby, 1993:296-304.
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Illumination64
Sufficient lighting- esp at bathroom,stairways Provide illuminated light switches
Place nightlines along the pathway from the
bedroom to the bathroom Avoid lighting glare
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Floor surfaces65
Provide nonskid floor Avoid waxing kitchen floor
Cover slippery surfaces with nonskid carpeting
Replace throw rugs with nonskid rugs
Clean wet floors immediately
Avoid clutter and low lying object
Avoid thick pile carpets to minimize tripping
Ensure that loose lamp and telephone cords are notin walkways
Ensure that carpet edges are flat
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Furnishings66
Provide seating of proper height to permit safesitting and standing
Provide beds that permit safe movement
Arrange furniture to allow for clear walkways
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Stairways67
Ensure that stairways have secure handrails Mark step edges with bright, nonskip tape
Ensure that step surfaces are in good repair and
nonskid
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Bathroom68
Install grab bar Use toilet risers if the toilet seat is too low
Place nonskid strips or mats in the bathtub to
prevent slipping Install grab bars in the bathtub or shower for
support
O h
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Other69
Avoid restraints ( chemical or mechanical) Ensure that ambulatory assistive devices and
wheelchairs are properly fitted
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P O S T T E S T
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Post test
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Post test71
Which of the following is not an environmental riskfactor for falls?
A. Throw rug (T)
B. Freshly waxed kitchen floor (T) C. Grab bars (F)
D. Electrical cord lying on the floor (T)
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An elderly person may become so fearful of fallingthat they restrict mobility
A. True ()
B. False
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An 86y/o woman on 12 medications with a history ofhypertension, mild dementia and painful bunionscould potentially reduce her risk of falling with whichof the following?
A. Reduction in number of medications (T) B. An exercise program focused on balance and
strength (T)
C. A prescription for setraline (F)
D. Podiatry evaluation (F)
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T A K E H O M E M E S S A G E S
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T k H 7 t
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Take Home message: 7-steps
1. Falls in the elderly are a marker for acute medical event, therefore one has to beaware of multifactorial risk factorsfor falling. Investigate for infections,medication side-effects, and metabolic problems. Falls associated with loss ofconsciousness (syncope) suggests cardiovascular etiology.
2. Evaluate role of medication adjustment or withdrawal and side-effectsinpeople who fall. (CNS, Cardiovascular, warfarin and INR)
3. Meticulous history with structured assessmentof gait and balance, orthostatichypotension, muscle strength, vision and hearing is essential. Check Rombergs, Timedget up & Go test, Functional reach.
4. Home/Environmental safety assessmentshould be done with consideration forassistive devices.
5. Interventionsfor strength and balance trainingcan decrease the risk offalling. Timely Physical and Occupational therapy may help.
6. Osteoporosis prevention and use of protective devices(hip protectors) reducefractures, particularly hip. Calcium and Vitamin D supplementation for all.
7. Understand the significance of fear of falling in the older adults and its impact onmobility and functional status, hence counseling and encouragement ofactivity and routine exerciseis desirable.
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