to fill yhe gsap

2. Geriatric Medicine

3. Geriatric Medicine
Principles/ Falls
Learning Objectives:
1. List two characteristics of the geriatric
population.
2. Describe two instruments to assess function.
3. Define geriatric syndrome. Name three.
4. List four risk factors for falls.
5. Outline three interventions to reduce fall risk.

4. Genetic
Oxidative Stress
Mitochondrial Dysfunction
Hormonal Changes
Telomere Shortening (Hayflick Limit)
Defective Host Defenses
Accumulation of Senescent Cells
Harrison on Line

5. Demographics
USA 2020 >65 yo 16%
Dependency Ratio-Europe
2050 22% to >50%
Harrison on Line
Merck Manual Geriatrics

6. Demographics
Over Age 65
40% of Hospital Resources
24% of Office Visits
25% of Prescription Drug Costs
25% of Medicare expenditure in last year of life- Half
of this in last 60 days
Residents of Nursing Homes
Age 65 1%
Age 85 17%
Merck Manual of Geriatrics

7. Arthritis 50 54
Hypertension
Heart
36
32
39
39
Hearing
Cataracts
28
16
36
24
Diabetes
Vision
10
8
11
11
Condition Age 65 % Age 75 %
Merck Manual Geriatrics

8. Life Expectancy
Walter LC, Covinsky KE, JAMA 2001

9. Function: Activities of Daily
Living
Basic Intermediate
Dressing Shopping
Eating Housework
Ambulating Accounting
Toileting Food Preparation
Hygiene Transportation

10. Function with Aging
0
10
20
30
40
50
60
ADL problem IADL Problem
%
with
Difficulty
Age 65-74
70-74
75-79
80-84
85+

11. Principles in a Flash
1. Aging is not a disease.
2. Geriatric conditions are chronic, multiple, multifactorial
3. Reversible conditions are underdiagnosed and
undertreated
4. Function and quality of life are critical outcomes
5. Social support and patient preferences are critical aspects
6. Geriatrics is multidisciplinary
7. Cognitive and affective disorders prevalent and
undiagnosed at early stages
8. Iatrogenic disease common and often preventable
9. Care is provided in multiple settings
10. Ethical and end of life issues guide practice
www.cha.emory.edu/reynoldsprogram

12. Clinical Approach
Not what disease caused the problem
But what combination of physiologic
change, impairments and diseases are
contributing
And which ones can be modified
Modawal

13. Geriatric Syndromes
Dementia and Delerium
Falls
Polypharmacy
Pressure Ulcers
Urinary Incontinence

14. Mary Anderson
This 85 year old widow presents after a fall in the bedroom of the home
where she has raised her family and lives independently.
She does not know why she fell, was able to ambulate after the fall and
presents six hours later with a bruise on her left cheek and an abrasion
on the left forearm.
Daughter reports occasional confusion and some limitation of activities
due to weakness. She reports a fall four months ago.
PMH
DJD hips and knees with chronic pain
Hypertension
Macular degeneration
Diabetes 2
Urinary urgency and rare incontinence

15. Medications: Hydrochlorothiazide, Fentanyl patch, KCL,Tylenol, MVI
Examination:
BP supine 160/88; standing 3 minutes 168/92
Vision 20/50
Chest – rare crackles right base
Neuro: absent achilles, romberg normal
Gait antalgic secondary to right hip pain
Get up and go test: 18 seconds. Uses arms to arise from chair
Functional Reach test 5 inches
Laboratory:
Hemoglobin 11 gm/dl
K 3.0 meq/L
Glucose 212 mg/dl
Creatinine 1.4 mg/dl
BUN 24 mg/dl
Urinalysis wbc 20, nitrite positive

16. Questions about
Mary Anderson
1. What is the most important risk factor for her recent fall?
2. What is the most important physical examination finding related to
her fall?
3. What additional diagnostic studies will be helpful?
4. What is the most important initial step in managing Mary’s fall?
5. What consultations/referrals would be most useful?

17. Importance
Risk Factors
Clinical Assessment
History
Physical Examination
Laboratory
Management
Fall
“Unintentional coming to rest at a lower position
unrelated to obvious intrinsic or environmental
factor.”

18. Importance
Prevalence
Ambulatory Adults >65 30% per year
Consequences
Death
Injury
Fractures 10-15%
Hip 1-2%
Long Lie
Fear of Falling
Reduced Activity/Independence (25%)

19. Causes
Extrinsic
Environment
Intrinsic
Age
Gait/Balance Disorder
Sarcopenia
Vestibular
Orthostatic Hypotension
Special Senses –Vision/Hearing
Disease
Dementia
Depression
Drugs
Foot problems
Incontinence

20. Risk Factors
Muscle weakness: 4.4
History of falls: 3.0
Gait or balance deficit: 2.9
Use of assistive device: 2.6
Visual deficit: 2.5
Arthritis: 2.4
Depression: 2.2
Cognitive impairment: 1.8
Age over 80 years: 1.7
Mean RR or OR of risk factors for falls from 16 studies
Data from AGS Panel on Falls Prevention. Guideline for the prevention of falls
in older persons. J Am Geriatr Soc 2001;49(5):664–72.

21. Gait
Stride Length
Arm Swing
Slow
Forward Flex
Head and Torso
Flexion shoulders knees
Lateral Sway
Normal Gait Video

22. History-Physical
Injury
Details of Fall
Inability to Get Up
Associated Disease and
Disability
Drugs
General
Orthostatic BP
Vision
Cognition ( MMSE)
Gait/Balance/Coordination
Laboratory
CBC
CMP
EKG

23. Get Up and Go
Normal
Abnormal

24. Modified Single Leg Stance

25. Functional Reach

26. Sharpened Romberg

27. Fall Risk Next Treatment
Year (%) Reduces Risk(%)
Fall Past Year 50 30
Gait Problem 30 20
One Risk 20 10
Two Risks 30 20
Three Risks 60 40
Four or More 80 50
Treatable Risks:
1. Problem walking or moving
2. Orthostatic hypotension
3. Four or more meds or one psychoactive
4. Unsafe footwear or foot problems
5. Environmental hazard
Reducing Fall Risk
www.fallprevention.org

28. Guideline for Fall Prevention
JAGS 2001. 49:664-672

29. Management
Reduce Fall Risk
Environment
Exercise and Balance
Cardiovascular (orthostasis)
Vision
Assistive Devices
Medication Review
Footwear
Behavior Education
Restraints Rubinstein Med Clin N Am 2006

30. Management
Reduce Fall Risk
Exercise
Wolf JAGS 1996
MMWR Rep 2004;53(2):25-28
-47%

31. Reduce Fracture Risk
Hip Protectors
Vitamin D/Calcium
400-800IU / 1200-1500
Lauritzen JB, Peterson MM et al Lancet 1993; 341:11-13.

32. Questions about
Mary Anderson
1. What is the most important risk factor for her
recent fall?
a. History of previous falls
b. Medications
c. Possible urinary infection and/or dementia
d. Gait disorder
e. Visual impairment

33. Questions about
Mary Anderson
2. What is the most important physical
examination finding related to her fall?
a. Extent of injury and pain
b. Result of blood pressure
c. Result of “Up and Go Test”
d. Visual acuity
e. Neurologic findings

34. Questions about
Mary Anderson
3. What additional diagnostic studies will be helpful?
a. Twenty four hour ambulatory EKG ( Holter)
monitor
b. Carotid Doppler study
c. Brain MRI
d. Head-up tilt test
e. Radiograph of chest and hips
f. Electoroencephalogram (EEG)

35. Questions about
Mary Anderson
4. What is the most important initial step in
managing Mary’s fall?
a. Reduce hydrochlorothiazide and fentanyl
b. Hydrate and treat UTI
c. Treat injury and pain
d. Osteoporosis treatment
e. Counsel on “fear of falling”
f. Recommend hip protectors

36. Questions about
Mary Anderson
5. What consultations/referrals would be most
useful?
a. Ophthalmology
b. Physical Therapy for strengthening exercise
c. Home safety evaluation by Occupational
Therapy
d. Neurology consultation
e. Cardiology consultation

37. Geriatric Medicine
Principles/ Falls
Learning Objectives:
1. List two characteristics of the geriatric
population.
2. Describe two instruments to assess function.
3. Define geriatric syndrome. Name three.
4. List four risk factors for falls.
5. Outline three interventions to reduce fall risk.