UCSF Division of Geriatrics Primary Care Lecture Series May 2001 Falls in the Elderly C. Bree Johnston, MD MPH Copyright May 2001

UCSF Division of Geriatrics Primary Care Lecture Series May 2001

Falls in the Elderly

C. Bree Johnston, MD MPHC. Bree Johnston, MD MPH

Copyright May 2001Copyright May 2001


Overview PrevalencePrevalence Clinical ImportanceClinical Importance Risk Factors & EtiologyRisk Factors & Etiology Evaluation Evaluation Prevention & ManagementPrevention & Management Falls & restraint useFalls & restraint use SummarySummary


Falls: Mrs. F. Mrs. F. is an 80 year old woman who lives Mrs. F. is an 80 year old woman who lives

alone. She just came in to your office for alone. She just came in to your office for follow up of a fall resulting in a Colles’ follow up of a fall resulting in a Colles’ fracture. She has had two other falls over the fracture. She has had two other falls over the past year and a half. She is scared of falling past year and a half. She is scared of falling again. She has a history of osteoarthritis and again. She has a history of osteoarthritis and anxiety/depressison. She is on naproxen anxiety/depressison. She is on naproxen 500mg BID and diazepam 5mg BID prn500mg BID and diazepam 5mg BID prn


Falls in the Elderly PrevalencePrevalence Clinical ImportanceClinical Importance Risk Factors & EtiologyRisk Factors & Etiology Evaluation Evaluation Prevention & ManagementPrevention & Management Falls & restraint useFalls & restraint use SummarySummary


Prevalence

30% of those over 65 fall annually30% of those over 65 fall annually Half are repeat fallersHalf are repeat fallers Falls go up with each decade of lifeFalls go up with each decade of life Over half of those in nursing homes and hospitals Over half of those in nursing homes and hospitals

will fall each yearwill fall each year




Impact of Hip Fractures 1% of falls result in hip fracture1% of falls result in hip fracture $2 billion + in medical costs annually$2 billion + in medical costs annually 25% die within 6 months25% die within 6 months 60% have restricted mobility60% have restricted mobility 25% remain functionally more dependent25% remain functionally more dependent


Falls Cause Morbidity and Mortality

Mortality: found down syndrome, indirect effectsMortality: found down syndrome, indirect effects Fractures: 6% of fallsFractures: 6% of falls Soft tissue injury, head injury, subdural hematomaSoft tissue injury, head injury, subdural hematoma Fear of falling can result in decreased activity, Fear of falling can result in decreased activity,

isolation, and further functional declineisolation, and further functional decline Nursing home placement and loss of Nursing home placement and loss of

independenceindependence




Falls are Multifactorial

Intrinsic Factors Extrinsic Factors

FALLS

Medical conditions

Impaired vision and hearing

Age related changes

Medications

Improper use of assistive devices

Environment


Normal Changes with Aging NeurologicNeurologic

Increased reaction timeIncreased reaction time Decreased righting reflexesDecreased righting reflexes Decreased proprioceptionDecreased proprioception

Vision ChangesVision Changes Decreased accommodation & dark adaptationDecreased accommodation & dark adaptation

Decreased muscle massDecreased muscle mass


Normal changes of Gait

Slower gaitSlower gait Decreased stride length and arm swingDecreased stride length and arm swing Forward flexion at head and torsoForward flexion at head and torso Increased flexion at shoulders and kneesIncreased flexion at shoulders and knees Increased lateral swayIncreased lateral sway


Dysmobility Dysmobility and falling closely relatedDysmobility and falling closely related 15% of those over 65 have trouble walking15% of those over 65 have trouble walking 1/4 men and 1/3 women over age 85 have 1/4 men and 1/3 women over age 85 have

difficulty with walkingdifficulty with walking 2/3 of people in hospital or NH unable to 2/3 of people in hospital or NH unable to

ambulate without assistanceambulate without assistance


Risk Factors for Falls Risk FactorRisk Factor OROR

Sedative useSedative use 2828 Cognitive ImpairmentCognitive Impairment 55 Lower extremity problemLower extremity problem 44 Pathologic ReflexPathologic Reflex 33 Foot ProblemsFoot Problems 22 > 3 balance/gait problems> 3 balance/gait problems 1.41.4 >5 balance/gait problems>5 balance/gait problems 1.91.9

Tinetti NEJM 1988


Common Pathologies associated with Falls Ophthalmologic diseasesOphthalmologic diseases Arthritis Arthritis Foot problems Foot problems Neurologic illnessNeurologic illness

Parkinson’s & related disordersParkinson’s & related disorders StrokesStrokes Peripheral neuropathyPeripheral neuropathy

Dizziness and dysequilibriumDizziness and dysequilibrium


Dizziness: A Multifactorial Syndrome Vertigo: BPV, Posterior CVA/TIA, Cervical Vertigo: BPV, Posterior CVA/TIA, Cervical Presyncope: Orthostatic, Dysrythmia, AnemiaPresyncope: Orthostatic, Dysrythmia, Anemia Dysequilibrium: Peripheral neuropathy, VisualDysequilibrium: Peripheral neuropathy, Visual Other: Anxiety, depressionOther: Anxiety, depression In older people, usually multifactorial In older people, usually multifactorial

Tinetti, Annals of Internal Med 2000Tinetti, Annals of Internal Med 2000


Falls in the Community Accidents/environmentAccidents/environment 37%37% Weakness, balance, gaitWeakness, balance, gait 12%12% Drop attackDrop attack 11%11% Dizziness or vertigoDizziness or vertigo 8%8% Orthostatic hypotensionOrthostatic hypotension 5%5% Acute illness, confusion, drugs, Acute illness, confusion, drugs,

decreased vision decreased vision 18%18%

UnknownUnknown 8% 8%

Rubenstein JAGS 1988


Falls in Residential Care

Generalized weaknessGeneralized weakness 31%31% Environmental hazardEnvironmental hazard 27%27% Orthostatic hypotensionOrthostatic hypotension 16%16% Acute illnessAcute illness 5%5% Gait or balance disorderGait or balance disorder 4%4% DrugsDrugs 5%5% Other or unknownOther or unknown 10% 10%

Rubenstein Ann Int Med 1990


Medications and Falls Sedative-hypnotics, especially long acting Sedative-hypnotics, especially long acting

benzodiazepines, increase fallsbenzodiazepines, increase falls Small association between most psychotropics Small association between most psychotropics

and fallsand falls SSRIs and TCAs both incrsease fallsSSRIs and TCAs both incrsease falls Weak association between Type 1A Weak association between Type 1A

antiarrythmics, digoxin, diuretics, and fallsantiarrythmics, digoxin, diuretics, and fallsLeipzig JAGS 1999

Thapa NEJM 1998


Falls in the Elderly PrevalencePrevalence Clinical ImportanceClinical Importance Risk Factors & EtiologyRisk Factors & Etiology EvaluationEvaluation Prevention & ManagementPrevention & Management Falls & restraint useFalls & restraint use SummarySummary


Evaluation of Falls: History Location & circumstances of FallLocation & circumstances of Fall Associated symptomsAssociated symptoms Other falls or near fallsOther falls or near falls Medications (including nonprescription) and Medications (including nonprescription) and

alcoholalcohol Injury & ability to get upInjury & ability to get up


Evaluation of Falls: Physical Examination

Supine and standing BP - alwaysSupine and standing BP - always Routine physical examinationRoutine physical examination

Focus on cardiovascular, MS, neuro, feetFocus on cardiovascular, MS, neuro, feet Vision and hearing evaluationVision and hearing evaluation Consider acute medical illness & deliriumConsider acute medical illness & delirium Formal gait and balance assessmentFormal gait and balance assessment


Evaluation of Falls: Home Evaluation Can be performed by nurse, OT, PT, othersCan be performed by nurse, OT, PT, others StairsStairs LightingLighting ClutterClutter BathroomBathroom Specific hazards: cords, throw rugsSpecific hazards: cords, throw rugs


Evaluation of Falls: Risk Factors for Injury

Osteoporosis assessmentOsteoporosis assessment Anticoagulation: Usual benefits outweigh risks Anticoagulation: Usual benefits outweigh risks

unless repeat or high risk fallerunless repeat or high risk faller Can the person get up from fall?Can the person get up from fall? Is there a way to notify others in case of falling?Is there a way to notify others in case of falling?


Mrs. F. History reveals that she fell at home in the History reveals that she fell at home in the

bathroom at night, tripping over a bathmat. bathroom at night, tripping over a bathmat. Both other falls have been in similar Both other falls have been in similar circumstances. She was able to get up.circumstances. She was able to get up.

On PE, she has visual acuity of 20/100 with On PE, she has visual acuity of 20/100 with bilateral cataracts. She has mild OA of the bilateral cataracts. She has mild OA of the knees, with bunyon deformities of her feet and knees, with bunyon deformities of her feet and poor fitting shoes.poor fitting shoes.


Mrs. F.

Her gait assessment shoes that she is unable to Her gait assessment shoes that she is unable to get up out of the chair without help. Her gait get up out of the chair without help. Her gait is hesitant and slightly wide based. is hesitant and slightly wide based.

Home evaluation reveals poor lighting in all Home evaluation reveals poor lighting in all rooms, multiple throw rugs in every room, rooms, multiple throw rugs in every room, and no grab bars or safety equipment in the and no grab bars or safety equipment in the bathroom.bathroom.


Mrs. F. She is weaned off of her diazepam over 3 monthsShe is weaned off of her diazepam over 3 months T-score on dexa is –3.0, and she is begun on T-score on dexa is –3.0, and she is begun on

alendronate, vitamin D, and calciumalendronate, vitamin D, and calcium She goes to ophthalmology and podiatry She goes to ophthalmology and podiatry PT begins exercises, followed by weight lifting PT begins exercises, followed by weight lifting

and exercise 3X a week at a Senior Centerand exercise 3X a week at a Senior Center She gets home safety equipment, improved She gets home safety equipment, improved

lighting, and gives away her throw rugs lighting, and gives away her throw rugs


Formal Gait Evaluation

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

Tinetti JAGS 1986

Podsiallo jAGS 1991

Mathias Arch Phys Med 1986


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


POMA: Gait Component

InitiationInitiation

Step length and heightStep length and height

Step symmetry & continuityStep symmetry & continuity

PathPath

Stance Stance

Ability to pick up speedAbility to pick up speed Tinetti JAGS 1986Tinetti JAGS 1986


Common Causes of Abnormal Gait Difficulty arising from chairDifficulty arising from chair WeaknessWeakness

ArthritisArthritis Instability on first standingInstability on first standing Hypotension, Hypotension,

Weakness Weakness Instability with eyes closedInstability with eyes closed Proprioception Proprioception

Step height/lengthStep height/length ParkinsonismParkinsonism

Frontal lobe Frontal lobe Fear Fear




Prevention & Treatment Treat acute injury & underlying medical Treat acute injury & underlying medical

conditionsconditions Remove unnecessary medicationsRemove unnecessary medications Rehab, exercises, assistive devicesRehab, exercises, assistive devices Correct sensory impairmentsCorrect sensory impairments Environmental modifications & safetyEnvironmental modifications & safety Evaluate for osteoporosis treatmentEvaluate for osteoporosis treatment


Osteoporosis Calcium and vitamin D for most elders at riskCalcium and vitamin D for most elders at risk

Dawson-Hughes, NEJM, 1997Dawson-Hughes, NEJM, 1997

Osteoporosis evaluation and treatment Osteoporosis evaluation and treatment Hip protectors appear to protect from hip Hip protectors appear to protect from hip

fractures in those who wear themfractures in those who wear them Kannus, NEJM, 2000 Kannus, NEJM, 2000

Thiazides may help slightlyThiazides may help slightly Statins?Statins?


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 Stteve Cummings

Risk Factor Modifications for Fractures


Hip pads to prevent hip fracture

““RCT” of 1801 frail subjects in FinlandRCT” of 1801 frail subjects in Finland Nursing home or frail community patients Nursing home or frail community patients Mean age 81Mean age 81 78% women78% women 63% assisted walking63% assisted walking

Kannus. NEJM;2000;343;1506-1513.Kannus. NEJM;2000;343;1506-1513.


Fractures with Hip ProtectorsFractures with Hip Protectors 2.1% per year vs. 4.6% per year 2.1% per year vs. 4.6% per year

(p<.01) (p<.01) 40 patients needed to be treated with 40 patients needed to be treated with

hip protector for 1 year to prevent one hip protector for 1 year to prevent one fracturefracture

2.4% of falls resulted in hip fracture 2.4% of falls resulted in hip fracture when not wearing protectorwhen not wearing protector

0.4% resulted in hip fracture when 0.4% resulted in hip fracture when wearing protector (80% risk reduction)wearing protector (80% risk reduction)

But patient acceptance lowBut patient acceptance lowKannus. NEJM;2000;343;1506-1513Kannus. NEJM;2000;343;1506-1513


www.hipsavers.com


Prevention of “Found Down” Syndrome

Lifelines

Accessible telephones

Teach in getting up off floor

Friendly phone calls or visitors for isolated elderly


Falls: Primary Prevention

301 community dwelling elders with 1+ 301 community dwelling elders with 1+ risk factors for fallingrisk factors for falling

Intervention: adjustment in medications, Intervention: adjustment in medications, behavioral instructions, exercise programs behavioral instructions, exercise programs aimed at modifying risk factorsaimed at modifying risk factors

One year follow upOne year follow upTinetti et al. 1994 NEJMTinetti et al. 1994 NEJM


Multifactorial Intervention

0

10

20

30

40

50

0 3 6 9 12

Months

% Falling

Control

InterventMoi

P = .04

Tinetti et al 1994 NEJM


Exercise Training & Nutrition

-20

0

20

40

60

80

100

120

140

Exer Exer +Su

Sup Control

STUDY GROUP

% Change Muscle

strength

Exer

Exer + Su

Sup

Control

Fiatarone et al NEJM 1994


Tai Chi and Falling Atlanta FICSIT Trial Atlanta FICSIT Trial

200 community dwelling elders 70+200 community dwelling elders 70+ Intervention: 15 weeks of education, balance training, Intervention: 15 weeks of education, balance training,

or Tai Chior Tai Chi Outcomes at 4 months: Strength, flexibility, CV Outcomes at 4 months: Strength, flexibility, CV

endurance, composition, IADL, well being, fallsendurance, composition, IADL, well being, falls Falls reduced by 47% in Tai Chi groupFalls reduced by 47% in Tai Chi group

Wolf JAGS 1996Wolf JAGS 1996


Exercise, Falls, and FrailtyFICSIT TrialsFICSIT Trials

8 independent prospective RCTs8 independent prospective RCTsGoal: reduction in falls and frailtyGoal: reduction in falls and frailty

Pre-planned Meta-analysisPre-planned Meta-analysisInterventionIntervention RRRR CICIAny ExerciseAny Exercise .90.90 (.81-.99)(.81-.99)Balance ComponentBalance Component .83.83 (.70-.98)(.70-.98)

Province JAMA 1995Province JAMA 1995


Campbell BMJ 1997

Training frail older persons: The New Zealand Study of Women

223 women >80 years223 women >80 yearsIntervention: PT tailored to individual needs, with Intervention: PT tailored to individual needs, with

resistance and balance trainingresistance and balance trainingResults:Results:

Clinical balance, chair rise improvedClinical balance, chair rise improvedRR for falls .47 (CI .04-.90)RR for falls .47 (CI .04-.90)RR for injurious falls .61 (.39-.97)RR for injurious falls .61 (.39-.97)


Falls in the Elderly

PrevalencePrevalence Clinical ImportanceClinical Importance Risk Factors & EtiologyRisk Factors & Etiology Evaluation Evaluation Prevention & ManagementPrevention & Management Falls & restraint useFalls & restraint use SummarySummary


Restraint Reduction and Injury

No evidence that restraints reduce fall injuries No evidence that restraints reduce fall injuries Restraints increase morbidity and may cause Restraints increase morbidity and may cause

deathdeath Reported strangulation deaths from restraints Reported strangulation deaths from restraints

every yearevery year Risk factor for delirium, decubitus ulcers, Risk factor for delirium, decubitus ulcers,

malnutrition, aspiration pneumoniamalnutrition, aspiration pneumonia


Restraint Reduction Decreases Injuries

816 bed Jewish Home for the Aged816 bed Jewish Home for the Aged- Restraints decreased from 39% to 4% over 3 years- Restraints decreased from 39% to 4% over 3 years - No change in falls, injuries, psychotropic use- No change in falls, injuries, psychotropic use

2 year educational intervention covering 2000+ 2 year educational intervention covering 2000+ bedsbeds - Restraint reduction 41% to 4% - Restraint reduction 41% to 4% - Decrease in serious injuries from 7.5% to 4.4%- Decrease in serious injuries from 7.5% to 4.4%

Tinetti 1992, Capezuti, Neufeld 1999, Evans 1997


Alternatives to Restraints For Patients with Lines and Tubes

Sedation (especially in ICU)Sedation (especially in ICU) Reducing delirium risk factors (drugs, Reducing delirium risk factors (drugs,

dehydration)dehydration) Does the benefit of tubes and lines (or Does the benefit of tubes and lines (or

hospitalization) outweigh the risks of restraints?hospitalization) outweigh the risks of restraints? Geriatric Consultation TeamGeriatric Consultation Team Sometimes restraints may be unavoidable in this Sometimes restraints may be unavoidable in this

settingsetting


Alternatives to Restraints for Patients Who Fall or Wander

Accept the risk of fallingAccept the risk of falling Hip protectorsHip protectors Environmental modifications, day rooms, Environmental modifications, day rooms,

low bedslow beds Least restrictive alternativesLeast restrictive alternatives AlarmsAlarms Sitters or familySitters or family Geriatric consultation team Geriatric consultation team


Summary

Falls are common in the elderly & may lead to Falls are common in the elderly & may lead to injuries and decline in functioninjuries and decline in function

Evaluation should included risk factor Evaluation should included risk factor assessment, gait assessment, and home assessment, gait assessment, and home assessmentassessment

Exercise can improve outcomesExercise can improve outcomes We have no evidence that restraints reduce fall We have no evidence that restraints reduce fall

related injuriesrelated injuries

Documents

UCSF Division of Geriatrics Primary Care Lecture Series May 2001 Falls in the Elderly C. Bree Johnston, MD MPH Copyright May 2001