Evidence Based Approach To Falls 2008
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Evidence Based Approach To Falls 2008



Dr Larry Dian

Dr Larry Dian



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Evidence Based Approach To Falls 2008 Evidence Based Approach To Falls 2008 Presentation Transcript

  • Evidence Based Approach To Falls Dr Larry Dian Division Of Geriatric Medicine U.B.C.
  • Evidence Based Approach This page is intentionally left blank
  • Epidemiology
    • Falls are common; 50% for those 80 years and older fall yearly
    • 60 % of those with a history of a fall in the previous year will have a subsequent fall
    • Most falls result in an injury of some type
    • 10% major injury, 5 % lead to hospitalization, >70% fear of falling
  • Scenario 1
    • You receive a call from the emergency physician regarding your 86 year old patient who is being sent home after receiving sutures for a scalp laceration that occurred after a fall. CT head “normal”.
  • Acute Fall Why did the person Fall?
  • 5 Step Assessment
    • Question 1: Did the fall result as a loss of consciousness? If yes: Sz. or Stokes- Adams attack
    • EEG, 24 hour holter, echocardiogram
    • Micro burst of LOC likely not significant
    • Confusion or drowsiness after fall somewhat supportive
    • Collateral history very helpful
  • If No Loss of Consciousness
    • Was Fall preceded by dizziness? Type 1: Vertigo- Central/peripheral BPV commonest Type 2 Lightheadedness/ transient cerebral hypo-perfusion/orthostatic hypotension
    • Type 3: “Dizziness of legs”/unsteadiness Type 4: De-afferentation /psychological
  • If No Dizziness
    • Was the fall associated with an acute medical illness? Atypical presentation Delirium “Round up all the usual suspects”
  • If No Acute Illness
    • What was the mechanism of the fall? Be as precise as possible recreating actions before and after the fall Avoid leading questions; patients may not remember Collateral history very useful
  • If No Mechanism For Fall
    • Falls are either multi-factorial or lower limb weakness
    • “ Just Fall” fall –eccentric weakness of quadriceps muscle
  • 5 Step Algorhythm
    • Provides a rational strategy for mechanistic determination of the fall
    • Provides a strategy for fall risk reduction
  • Scenario 2
    • The family of your 89 year old patient wants your opinion about moving their reluctant mother in a nursing home because of the concern that she might fall and “hurt herself”
  • Risk Factors
    • Past history of a fall
    • Lower extremity weakness
    • Age
    • Female gender
    • Cognitive impairment
    • Balance problems
    • Psychotropic drug use
    • Arthritis
    • History of stroke
    • Orthostatic hypotension
    • Dizziness
    • Anemia
  • Chronic Diseases
    • Parkinson's disease
    • Osteoarthritis of the knee, feet ankle
    • Cognitive impairment  (mmse 18-23) 2x increased risk of falls
    • Risk increases with increasing number of chronic diseases
    • Number and type of medications
    • Alcohol use
  • Targeted Physical Exam
    • Cardiovascular system
    • Central nervous system
    • Musculoskeletal system; lower limbs
  • Targeted Physical Exam
    • Postural blood pressure
    • Heart failure, Atrial fib, Aortic stenosis
    • Mental status, Parkinson’s disease, stroke peripheral neuropathy, visual acuity
    • Arthritis of knees feet, podiatric problems
    • Strength of hip flexors, ankle dorsi-flexors
    • Environmental factors, footwear, mobility aids
  • Supplemental Tests
    • Get Up and Go Test
    • Functional reach test
    • Sternal nudge test; unipedal and tandem stance
  • Get Up and Go Test
    • Have the patient sit in a straight-backed high-seat chair
    • Instructions for patient: Get up (without use of armrests, if possible)
    • Stand still momentarily
    • Walk forward 10 ft (3 m)
    • Turn around and walk back to chair
    • Turn and be seated
  • Get Up and Go Test
    • Factors to note:
    • Sitting balance
    • Transfers from sitting to standing
    • Pace and stability of walking
    • Ability to turn without staggering
  • Diagram of functional reach test to assess balance in elderly persons
  •     e- mail this to a colleague Algorithm summarizing the assessment and management of falls                                                                         
  • Therapy
    • Address medical issues
    • Review home environment
    • Provide appropriate walking aid
    • Gait and balance exercise training
    • Falls are not random events
    • Falls are common and are associated with significant morbidity and mortality
    • Standardized assessment tools exist
    • A coherent mechanism can be developed in most cases
    • Consider referral to falls clinic in complex cases