Falls: Mrs. F. Mrs. F. is an 80 year old woman who lives alone. She just came in to your office for follow up of a fall resulting in a Colles’ fracture (fracture of the distal radius in the forearm). She has had two other falls over the past year. She is scared of falling again. She has a history of osteoarthritis and anxiety/ depression. She is on naproxen 500mg BID and diazepam 5mg BID when necessary.
Prevalence 30% of those over the age of 65 fall annually Half are repeat fallers Falls go up with each decade of life as inclining age
1% of falls result in hip fractureImpact of Hip Fractures 25% die within 6 months 60% have restricted mobility 25% remain functionally more dependent
Falls Causes Mortality (death) Fractures: 6% of falls Soft tissue injury, head injury etc Fear of falling can result in decreased activity, isolation, and further functional decline Nursing home placement and loss of independence
Falls are Multifactorial Intrinsic Factors Extrinsic FactorsMedical MedicationsconditionsImpaired visionand hearing Improper use of FALLS assistive devicesAge relatedchanges Environment
Normal Changes with Aging Neurologic Increased reaction time Decreased righting reflexes (regain back former body position) Vision Changes Decreased accommodation & dark adaptation Decreased muscle mass Old Age Slower gait (manner in which human or animal moves using limbs) Falls
Risk Factors for Falls Risk Factor Sedative use Cognitive Impairment Lower extremity problem Pathologic Reflex Foot Problems gait problems
Common Pathologies associated with Falls Ophthalmologic diseases Arthritis Foot problems Neurologic illness Parkinson’s & related disorders Strokes Peripheral neuropathy Dizziness and disequilibrium
Medications and Falls Sedative-hypnotics, especially long acting benzodiazepines, increase falls Small association between most psychotropics and falls SSRIs and TCAs both incrsease falls Weak association between Type 1A antiarrythmics, digoxin, diuretics, and falls
Evaluation of Falls: History Location & circumstances of Fall Associated symptoms Other falls or near falls Medications (including nonprescription) and alcohol Injury & ability to get up
Evaluation of Falls: 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
Evaluation of Falls: Home Evaluation Can be performed by nurse or others ? Reason for fallEvaluation of Falls: Risk Factors Assessment
Common Causes of Abnormal Gait Difficulty arising from chair Weakness Arthritis Instability on first standing Hypotension, Weakness Instability with eyes closed Proprioception Step height/length Parkinsonism Frontal lobe Fear
Osteoporosis Calcium and vitamin D for most elders at risk Osteoporosis evaluation and treatment Hip protectors appear to protect from hip fractures in those who wear them Thiazides may help slightly Statins?
Risk Factor Modifications for Fractures Quit smoking Treat impaired vision Stop sedatives Add 1 Gram Calcium Hip Protectors
Falls: Primary Prevention Intervention: adjustment in medications, behavioral instructions, exercise programs aimed at modifying risk factors One year follow up
Restraint (Restriction to movement)Reduction and Injury No evidence that restraints reduce fall injuries Restraints increase morbidity and may cause death Risk factor for delirium, malnutrition, aspiration pneumonia
Alternatives to Restraints for PatientsWho Fall or Wander Accept the risk of falling Hip protectors Environmental modifications, day rooms, low beds Least restrictive alternatives Alarms Sitters or family Geriatric consultation team
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
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