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Seminario Caídas en el anciano

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Seminario Caídas en el anciano

  1. 1. Caídas Sandra Milena Acevedo RuedaMD Residente Medicina Interna UNAB Enero de 2013 Page 1
  2. 2. Clin Geriatr Med 29 (2013) 137–150 Page 2
  3. 3. Caídas El individuo cae usualmente Son comunes y son los ocurren cuando principales factores quelas deficiencias en varios dominios amenazan su ponen en peligro la capacidad de independencia compensación del individuo JAMA. 1995;273(17):1348. Page 3
  4. 4. Falta de atención clínica… JAMA. 1995;273(17):1348. Page 4
  5. 5. “80 percent of older women “80 percent of older womenpreferred death to a "bad" hippreferred death to a "bad" hip fracture fracture that would result in that would result in nursing home admission” nursing home admission” BMJ. 2000;320(7231):341 Page 5
  6. 6. Epidemiología 12.6 billones de dolares (1995)30 – 40% > 65 años (comunidad) se caen cada año (50% para mayores de 80ª)En una encuesta de EE.UU. de más de 90.000 personas > 65 años, las caídas se registraron en los tres meses anteriores en un 16% N Engl J Med. 2003;348(1):42 Page 6
  7. 7. EpidemiologíaEstudio en mujeres mayores de 70 a (2 años) 41 % trauma menor 6% trauma mayorPacientes institucionalizados tienen más trauma mayor 5% serán hospitalizados N Engl J Med. 2003;348(1):42 Page 7
  8. 8. “In an Australian study, 9.5 percent “In an Australian study, 9.5 percent of patients hospitalized for falls of patients hospitalized for falls became first-time residents of a became first-time residents of along-term care facility at discharge” long-term care facility at discharge” Emerg Med J. 2012 Sep;29(9):742-7. Page 8
  9. 9. Page 9
  10. 10. “ In a large study of elderly persons“ In a large study of elderly personsseeking emergency care after a fall,seeking emergency care after a fall,2.2 percent of injurious falls resulted2.2 percent of injurious falls resulted in death” in death” Am J Epidemiol. 1990;131(6):1028 Page 10
  11. 11. Miedo a caer Después de una caída… 60% restricción moderada 15% restricción marcada50% después de una fx de cadera J Am Geriatr Soc. 2010;58(9):1739 Page 11
  12. 12. Page 12
  13. 13. Clin Geriatr Med 29 (2013) 137–150 Page 13
  14. 14. Órganos de los sentidos Lentes multifocales aumentan el riesgoAgudeza visual, percepción de profundidad, adaptación a la oscuridad Propiocepción alterada Sistema vestibular alterado J Am Geriatr Soc. 2002;50(11):1760 Page 14
  15. 15. Page 15
  16. 16. Activación y composición muscular Activación muscular proximalMayor activación de músculos antagónicos Recuperación alterada Infiltración grasa y riesgo de Fx cadera J Am Geriatr Soc. 2002;50(11):1760 Page 16
  17. 17. Historia de caídas Riesgo de segunda Fx de cadera “Framingham Study”: 14.8%tuvieron una segunda fractura en los siguientes 4 años J Am Geriatr Soc. 2002;50(11):1760 Page 17
  18. 18. Page 18
  19. 19. Presión arterial Hipotensión ortostáticaMenos % agua, diuréticos, climas cálidos J Am Geriatr Soc. 2002;50(11):1760 Page 19
  20. 20. Enfermedades crónicas Enfermedad de Parkinson Dolor musculo-esquelético crónico Osteoartritis Diabetes J Am Geriatr Soc. 2002;50(11):1760 Page 20
  21. 21. Deterioro cognitivo “ In one study of 1600 persons aged 75 years and “ In one study of 1600 persons aged 75 years andabove, the risk of hip fracture over six year follow-upabove, the risk of hip fracture over six year follow-up was twice as high when the score on the mini- was twice as high when the score on the mini- mental status examination was suggestive of mild mental status examination was suggestive of mild impairment (score 18 to 23) compared with those impairment (score 18 to 23) compared with those with no impairment” with no impairment” J Am Geriatr Soc. 2002;50(11):1760 Page 21
  22. 22. Medicamentos “ In a meta-analysis of 22 studies involving multiple “ In a meta-analysis of 22 studies involving multipleclasses of drugs, the likelihood of falling was increased classes of drugs, the likelihood of falling was increasedwith the use of sedatives and hypnotics (odds ratio [OR]with the use of sedatives and hypnotics (odds ratio [OR]1.47, 95% credible interval (CrI) 1.35-1.62), neuroleptics 1.47, 95% credible interval (CrI) 1.35-1.62), neuroleptics and antipsychotics (OR 1.59, 95% CrI 1.37-1.83), and antipsychotics (OR 1.59, 95% CrI 1.37-1.83), antidepressants (OR 1.68, 95% CrI 1.47-1.91), and antidepressants (OR 1.68, 95% CrI 1.47-1.91), and benzodiazepines (OR 1.57, 95% CrI 1.43-1.72)” benzodiazepines (OR 1.57, 95% CrI 1.43-1.72)” Arch Intern Med. 2009;169(21):1952 Page 22
  23. 23. Alcohol, calzado, factores medio-ambientalesA mayor consumo de alcohol, mayor riesgo Suelas, tacones Ayudas especiales Pacientes institucionalizados J Am Geriatr Soc. 2002;50(11):1760 Page 23
  24. 24. Reportar caídas recurrentesReportar alteración en la marcha o el balance Buscar atención médica ó presentarse aldepartamento de urgencias cuando haya una caída Page 24
  25. 25. Historia clínica completa, valoración funcional y cognitiva Función musculo-esquelética Examen físico Laboratorios e imágenes Page 25
  26. 26. Short Physical Performance Battery (SPPB) 1. Repeated Chair Stands 2. Balance Testing a. Semitandem Stand b. Side-by-Side stand c. Tandem Stand 3. 8’ Walk (2.44 meters) Page 26
  27. 27. The "Get up and go" test for gait The "Get up and go" test for gait assessment in elderly patients assessment in elderly patientsFleming KC, Evand JM, Weber DC, Chutka DS. Practical Functional Assessment of Elderly Persons: A Primary-Care Approach [Symposium on Geriatrics-Part III]. Mayo Clinic Proceedings 1995; 70:890. Copyright © 1995 Mayo Foundation. Page 27
  28. 28. Page 28
  29. 29. Tinetti Performance Oriented Mobility Tinetti Performance Oriented MobilityAssessment (POMA)* Assessment (POMA)* Tinetti ME. Performance-oriented assessment of mobility problems in elderly patients. JAGS 1986; 34: 119-126. (Scoring description: PT Page 29 Bulletin Feb. 10, 1993)
  30. 30. BalanceTinetti TinettiPerformance PerformanceOriented OrientedMobility MobilityAssessment Assessment(POMA) (POMA) Tinetti ME. Performance-oriented assessment of mobility problems in elderly patients. JAGS 1986; 34: 119-126. (Scoring description: PT Page 30 Bulletin Feb. 10, 1993)
  31. 31. MarchaTinetti TinettiPerformance PerformanceOriented OrientedMobility MobilityAssessment Assessment(POMA) (POMA) Tinetti ME. Performance-oriented assessment of mobility problems in elderly patients. JAGS 1986; 34: 119-126. (Scoring description: PT Page 31 Bulletin Feb. 10, 1993)
  32. 32. Diagram offunctional reachtest to assessbalance inelderly persons Fleming KC, Evand JM, Weber DC, Chutka DS. Practical Functional Assessment of Elderly Persons: A Primary-Care Approach [Symposium on Geriatrics-Part III]. Mayo Clinic Proceedings 1995; 70:890. Copyright © 1995 Mayo Foundation. Page 32
  33. 33. Page 33N Engl J Med. 2003;348(1):42
  34. 34. The Prevention of Falls in Older Persons: Clinical Practice Guideline(http://www.medcats.com/FALLS/frameset.htm) from the American Geriatrics Society. For more information visit the AGS online at www.americangeriatrics.org. Page 34
  35. 35. The Prevention of Falls in Older Persons: Clinical Practice Guideline(http://www.medcats.com/FALLS/frameset.htm) from the American Geriatrics Society. For more information visit the AGS online at www.americangeriatrics.org. Page 35
  36. 36. N Engl J Med. 2003;348(1):42 Page 36
  37. 37. Ejercicio • Marcha y balance • Fuerza • Flexibilidad• Movimientos (TaiChi o baile) • Actividad física general • Resistencia Page 37
  38. 38. Medicamentos• Modificación de dosis y fármacos • Vitamina D • Evitar toxicidad Page 38
  39. 39. Otras intervencionesHipersensibilidad seno carotídeo y marcapasos (RaR 0.42, 95% CI 0.23-0.75) Cataratas (RaR 0.66, 0.45-0.95) Suplemento nutricional Hipotensión ortostática: medias elásticas, líquidos, fludrocortisona, Intervención en podiatría Protectores de cadera Caminador ó bastón Page 39
  40. 40. Tiempo en el suelo ““ A study of 1100 individuals over age 72 A study of 1100 individuals over age 72 found that 47 percent of the 313 who found that 47 percent of the 313 whoexperienced non-injurious falls were unableexperienced non-injurious falls were unable to get up for at least one hour after falling” to get up for at least one hour after falling” JAMA. 1993;269(1):65 Page 40
  41. 41. Anticoagulación ““ A decision analysis has concluded that a A decision analysis has concluded that a predisposition to falls, with potential head predisposition to falls, with potential headtrauma, is rarely a contraindication to the use trauma, is rarely a contraindication to the use of anticoagulants in older adult patients with of anticoagulants in older adult patients with atrial fibrillation (AF)” atrial fibrillation (AF)” Page 41
  42. 42. Medio ambiente Page 42
  43. 43. Recommended Components of Clinical Assessment and Management for Older Persons Living in the Community Who Are at Risk for Falling N Engl J Med. 2003;348(1):42 Page 43
  44. 44. Recommended Components of Clinical Assessment and Management for Older Persons Living in the Community Who Are at Risk for Falling N Engl J Med. 2003;348(1):42 Page 44
  45. 45. Guau! Gracias! Page 45

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