This document discusses falls in the elderly and provides guidance on assessing risk and preventing falls. It outlines a case of a 78-year-old female presenting for care and notes her reported falls and balance issues. The document reviews intrinsic and extrinsic risk factors for falls and recommends screening all patients aged 65+ annually. It provides details on components of the history, physical exam, functional assessment, and interventions including exercise, home modifications, and medication management to reduce fall risk.
Comprehensive geriatric assessment (CGA) is a multidimensional, interdisciplinary diagnostic process to determine the medical, psychological and functional capabilities of a frail elderly person in order to develop a co-ordinated and integrated plan for treatment and long-term follow up
Comprehensive geriatric assessment (CGA) is a multidimensional, interdisciplinary diagnostic process to determine the medical, psychological and functional capabilities of a frail elderly person in order to develop a co-ordinated and integrated plan for treatment and long-term follow up
Ethical issues of Care of elderly patients:-
Decision making capacity.
Informed consent.
Refusal of treatment.
Advance directive.
Major ethical principles.
Psycho-social aspects of aging.
Health promotion is the process of enabling people to increase control over & improve their health by developing their resources to maintain or enhance well being.
This presentation is about geriatric Psychiatry awareness. it contains basic information about what is geriatric psychiatry, which are the main psychiatry disorder found in elderly and how to manage them?. it contains some detailed information about late life depression, delirium and dementia in geriatric population.
Ethical issues of Care of elderly patients:-
Decision making capacity.
Informed consent.
Refusal of treatment.
Advance directive.
Major ethical principles.
Psycho-social aspects of aging.
Health promotion is the process of enabling people to increase control over & improve their health by developing their resources to maintain or enhance well being.
This presentation is about geriatric Psychiatry awareness. it contains basic information about what is geriatric psychiatry, which are the main psychiatry disorder found in elderly and how to manage them?. it contains some detailed information about late life depression, delirium and dementia in geriatric population.
2015 geriatric pharma frontmatter fundamentals of geriatric pharmacotherapyROBERTO CARLOS NIZAMA
Fundamentals of Geriatric Pharmacotherapy, Second Edition - 2015
Author: Lisa C. Hutchison, Rebecca B. Sleeper
Publisher: American Society of Health-System Pharmacists - ASHP
Publication date: 2015
Format: Paperback, 1 volume
Pages: 500 pp.
Geriatric Population. Geriatric Clinician Practice. Your Medicare, Long-Term ...Michelle Peck
Michelle Peck | Legal Nurse Consultant | Adult & Geriatric Nurse Practitioner | Health Care | Consultant | Speaker | Educator | Researcher
Enjoy your journey through this slide deck of Geriatric Population. Geriatric Clinician Practice. Your Medicare, Long-Term Care Documentation.
Imagine if writing a progress note was really as simple as the note featured on the title slide. This physician progress note style filled the charts of a 120 bed nursing facility in rural Texas. Walking down the facility hallways I observed many unstable conditions and behaviors. Staff were numb to the yelling. When I questioned about the yelling "we don't medicate behaviors" was the most popular response. I needed to be medicated after a few hours of being there. Collecting data had never been this difficult. Stable and clinical documentation now had a whole new meaning.
This month I am instructing Nurse Practitioner students on Medicare and Long-Term Care Coding and Documentation. Revising this lecture reminds me of all of the clinician types I have met during my long-term care travels.
1. Amazing Clinicians
◾ They know state and federal regulations and practice perfectly.
◾ They don't cross your path very often.
◾ When you meet them you must stop, listen and absorb all their knowledge.
2. So-So Clinicians
◾ They don't know that there are regulations on state and federal levels.
◾ They are pretty common and are doing enough with meaningful practices.
◾ When you meet them you must stop, talk and they absorb your knowledge.
3. Corner Cutters
◾ They are not doing enough and practice out of compliance.
◾ Their colleagues are also clueless, there is guilt by association.
◾ When you meet them, run in the opposite direction.
What types of geriatric clinicians are crossing your path? The documentation is very telling as to the practice type. Are they awesome, so-so, or of the corner cutter breed?
Learn it-Live it-Love it-Your path for a more informed life!
Michelle Peck | Legal Nurse | Nurse Practitioner | Health Care | Geriatric | Consultant | Speaker | Educator | Researcher
Fall-related injuries can be some of the most common, disabling, and expensive health conditions encountered by adults, especially older adults. According to researcher Janice Morse, approximately 14% of all falls in hospitals are accidental, another 8% are unanticipated and 78% are anticipated falls. Guideline to prevent falls in the hospital has helped to bring down the numbers and improve patient safety.
Geriatric Special Focus, Pain Management and Analgesic Prescribing for Advanc...Michelle Peck
Michelle Peck | Geriatric Nurse Practitioner | Health Care Consultant | Professional Speaker | Nursing Faculty| Legal Nurse Consultant | Mindful Geriatrics
In collaboration with Dr. Linh Nguyen, Supportive Medicine at UTHealth Medical School, we have created this slide deck for Advanced Practice Nurses.
Our mission is to simplify the pharmacologic basics of good pain prescribing. We have not provided very much detail about schedule II controlled substances due to the current limitations on Texas Nurse Practitioner prescribing in primary care.
This lecture is designed to meet our Advanced Practice Nursing audience where they are at and provide tools, knowledge and practical tips. Areas where we detect mastery with our polling questions are briefly touched upon and more time and examples are given are to areas of audience identified needs. Prescribing pain medication for Advanced Practice Nurses is dynamic, complex and ever changing
We have also included a special focus (our passion) for pain prescribing in the geriatric population. Beer’s Criteria medications, to be used with caution or avoid completely in geriatrics are mentioned throughout this presentation.
This presentation starts with the audience writing down their biggest fear about pain prescribing. We then categorize these fears, so that throughout our lecture we can give special focus and alleviate fears with practical tips, guidelines and real life examples.
Our objectives are to discuss:
1. Benefits and side effects of common analgesics
2. The impact of patient-related factors on drug selection & dose based on knowledge of patient related changes
3. Medications to avoid, use with caution, explain why
4. Management of pain based on client care goals
We hope you Learn it-Live it-Love it!
Geriatric Population the 3 D's Geriatric Dementia, Delirium and Depression 2015Michelle Peck
Michelle Peck | Legal Nurse Consultant | Adult & Geriatric Nurse Practitioner | Health Care | Consultant | Professional Speaker | Educator | Researcher
Enjoy your journey through this slide deck!
During your journey through Geriatric Dementia, Delirium and Depression, you will experience how to:
• Differentiate delirium, depression & dementia.
• Describe the etiology & signs and symptoms of delirium, depression, and dementia.
• Identify risk factors for delirium, depression, and dementia.
• Identify types of medications that may cause depression.
• Communicate and care for people experiencing delirium.
• Explain non-pharmacologic interventions for treating dementia.
In order to minimize risk and customize interventions, we have to know where and how our clients are living.
The picture on the first slide is from geriatric simulation lab, where nursing students practice administering geriatric assessment scales to identify areas of risk. What risks and hazards can you see in this picture?
What you can't see is that the V8 Splash bottle is actually whiskey, medications and incontinence briefs are scattered all over the floor and our client is using oxygen via nasal cannula while smoking. Would picking up the trash and organizing the house fix the problem? Fifty percent of the students verbalized wanting to clean up during their assessment visit and some asked if they could tidy up upsetting the client.
Every problem deserves a viable solution. A comprehensive geriatric assessment is in order and interventions need to follow by assembling the geriatric team.
Our client's assessment findings were all high risk.
View the geriatric assessment scales with how to administer articles & videos at http://consultgerirn.org/resources.
What do we do next? We need to assemble the geriatric team to intervene.
View assembling the geriatric team "Assessments and Referrals" at http://www.environmentalgeriatrics.org/cme/extra/noCredit.html.
Hopefully at minimum the discharging physician ordered the home health care services necessary to bridge our client's hospital to home care.
If the geriatric assessment scales were performed prior to hospital discharge the physician should have recognized that with all her high risk findings she should not have been discharged home alone. At minimum she requires 24 hour supervision for safety.
The students all felt our client was confused and attributed it to her whiskey drinking, but after performing her Mini Cog they realized she was screening positive for dementia. How many clients slip through the cracks because of lack of assessment?
Our client confabulated and was quite convincing until the students saw her clock draw. Now they knew environmental observations were much more important than client self-report.
A picture is worth a thousand words. We fail our clients until we learn the assessment skills required to paint an accurate picture.
I won't Fall for that Again!, Evidence based fall prevention in the Elderly, by Neila Shumaker (M.D.), as presented within the GWEP 2018 January Conference
This presentation is a comprehensive summary about all aspects of back pain. Back pain is one of the most common orthopaedic morbidity or orthopedic disability. Sciatica and lumbar disc diseases are common cause of spinal disability. Back pain are divided into Red flags, green flags and yellow flags for quick clinical screening. both treatment, prevention aspects are covered. Spinal anatomy and Biomechanics are covered. Epidemiology and role of various types of spine surgery, microdiscectomy, endoscopic spine surgery are also described.
Cerebral palsy for MBBS (undergraduate medical teaching)Siddhartha Sinha
This presentation gives an overview regarding Cerebral palsy. Its causes, pathogenesis , classification, clinical and examination findings and an overview of its orthopaedic management. Please feel free to drop in any doubts or queries regarding the presentation.
What Money Are You Leaving on the Table Because You Don’t Know What’s in Your...PAFP
Plenty of health plans will provide incentive payments through various performance improvement and quality initiatives. You may already be doing the work. Learn how to mine that information from your EHR.
Speaker: Nancy Meisinger
Senior Consultant at HealthPower Advisors
Doylestown, Pennsylvania
Referral and Test Tracking: Developing a SystemPAFP
SOUTH CENTRAL October 30, 2013
Discuss the quality improvement and medico-legal aspects of referral and test tracking. Address barriers and consider low and high tech options for referrals and test tracking.
Speaker:
Christian Hermansen, MD
Downtown Family Medicine
Lancaster, PA
Learn best practices based on literature and how to perform a complex and accurate medication history. Recognize gaps/inconsistencies in systems that impede medication reconciliation and identify next steps in improving current medication reconciliation within your own practice.
Speaker:
Mary Pat Friedlander, MD
Lawrenceville Family Health Center
Pittsburgh, PA
So you can’t afford a new EHR system but you know it’ll help you achieve Meaningful Use and improve quality. Learn about two "free" systems in marketplace
(Practice Fusion, Kareo).
Speaker:
Bill Sonnenberg, MD, Titusville
Designing Winning "Transitions of Care" Processes!PAFP
2013 PAFP Regional Lectures Series
Session 2 - Southeast
Learn about best practices for transitions of care, how to bill for the new management codes payable by Medicare.
Bonus: pick up great resources to improve management.
Speaker:
Lee Radosh, MD, FAAFP
Reading Hospital – Family Health Care Center
West Reading, PA
Point of Care Testing for Enhancing Patient Centered Planned Care DeliveryPAFP
PAFP 2013 Regional Lecture Series
Session 1 - Northeast
Presenter: Linda Thomas-Hemak, MD
The Wright Center for Primary Care
Broadcast live through the PAFP Community.
October 2nd, 2013 12pm - 1pm
The Pennsylvania Academy of Family Physicians holds several events every year, from educational seminars and business meetings to auctions and cruises. Here's a look at some of what we do.
What an incredible year 2012 was! The news media were inundated with stories from every portion of the health care sphere – from dramatic , once-in-a-lifetime court decisions to some of “the usual suspects.”
What were the top 10 health care stories of 2012? The Pennsylvania Academy of Family Physicians has selected its biggest news stories of the year. Click through the following slides to relive 2012: a banner year for health care!
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists
Assessment of the Geriatric Patient
1. Falls: Preventing a
Downward Course
Thru Assessment of the
Geriatric Patient
Paula Bordelon, DO
2. Disclosure
• No conflicts of interest
• No financial relationships with
pharmaceuticals to disclosure
3. Objectives
• Teach a systematic approach to
assessment of gait and balance
• Highlight abnormalities commonly seen
in elderly
• Increase knowledge STEADI toolkit
• Review AGS’s fall guidelines
4. Case History
• 78-year old female scheduled with you to
establish care.
• Presents with her daughter.
• Lives alone and uses no assistive
devices.
• Dtr reports 1 fall “mom slipped”
• Dtr reports occasional dizziness and
balance issues. Patient states “I’m fine”
5. Case History (cont)
• Meds: HCTZ, glyburide, ASA,
temazepam prn
• DEXA: osteoporosis of femoral neck
• Did your new patient fall?
• Does your new patient need specific
intervention to prevent falls?
6. Falls Affect Morbidity and Mortality
• Falls should not be viewed as normal aging!
• Overall nonfatal fall injury rate was 43/100,000
falls (based on those seeking care)
• 1 out of 3 seniors fall but < 50% report this
• Among seniors falls are leading cause of fatal
and nonfatal injuries
• 1 in 5 falls cause serious injury
7. Falls: the Facts
• Falls are common:
– About 35% of community-dwelling ages 65-69 fall
– > 50% of community-dwelling > age 80 fall
• 95% of hip fractures are caused by falls
• FALLS CAUSE POOR OUTCOMES!
• Death rate from falls has risen sharply over
past decade (64% men; 84% women)
8. Fall Prevention is Paramount
• Falls are a MAJOR health hazard, up to 30%
who fall suffer injuries, lacerations, hip fractures,
head trauma
• Functional deterioration after falls is common
and often leads to institutionalization
• Of those who fall, only 50% can arise without
assist
• Falls are the most common cause of traumatic
brain injuries in seniors
• 75% of fall-related deaths occur in those > age
65
9. The Most Costly Fall: Hip Fractures
• Hip fractures are the most costly injuries in
terms of mortality, health, reduced quality of
life, and admission into nursing home
• Recover more slowly
• More adverse consequences post-op
• 33% of hip fracture survivors spend at least
one year in SNF
• 20% of seniors hospitalized for hip fracture die
within 1 year
10. What is a fall?
• Any incident that involves unintentionally
coming to some lower level (or to the
ground) is a fall.
• Older adults frequently have incidents
that meet the definition of a fall, but deny
falling
• Slipping, tripping, stumbling or tumbling.
11. Who is at Risk?
• Intrinsic Factors
– Advanced age
– Cognitive
Impairment
– Sensory Impairment
(e.g. decreased
vision)
– LE weakness
– Poor mobility
• Extrinsic Factor
– Medications
• Polypharmacy (> 4)
• Psychoactive
– Inactivity
– Environmental
12. Who Should Be Screened?
• Anyone age 65 and over should be
screened (that is, asked if they have
fallen IN THE PAST YEAR!)
• Alternative: Have patient answer CDC’s
risk factor (12 question) screening
13. Screening (cont)
• Anyone senior who has fallen, feels
unsteady, or a fear of falling, should be
evaluated for gait and balance
• If senior performs poorly on evaluation,
should undergo multifactorial fall risk
assessment
14. How Do You Screen?
• Simply use questionnaire from STEADI
toolkit or
• Inquire about history of falls:
– Have you slipped, tripped, stumbled, or
fallen in the last 6 weeks? In the last 12
months?
– Do you feel unsteady when standing or
walking?
– Are you fearful about falling?
15. How Do You Screen? (cont.)
• For “yes” responses, inquire as to
frequency, circumstances, and if have
difficulty with balance. Getting an
accurate history gives you info to
prescribe the best plan
16. How Do We Balance?
• Balance via dynamic input:
– Vision
– Inner Ear (vestibular)
– Proprioceptive Sensing
– Strength and flexibility
17. How Does Aging Affect Balance?
• Successful fall prevention begins with
knowledge of age-related changes
• Vision - reduction in glare tolerance,
nocturnal acuity, contrast sensitivity,
reduction in peripheral vision and poor
depth perception
18. How Does Aging Affect Balance?
• Vestibular - peripheral vestibular excitability
declines with age while vestibular dysfunction
(e.g. BPPV, Meniere’s) increases, with loss of
hair cells and ganglion cells, contributing to
falling
• Proprioception - reduced function occurs in
many d/o (e.g. DM, Etoh, malnutrition, cervical
spondylosis)
19. Centers for Disease Control &
American Geriatrics Society
• CDC
www.CDC.gov/homeandrecreationalsafety/falls/STEA
DI
• AGS
www.americangeriatrics.org/health_care_professional
s/clinical_practice/clinical_guidelines_recommendation
s/prevention_of_falls_summary_of_recommendations
20. Key Components of Fall HISTORY
• Get History: Get description of the
circumstances of the fall: frequency,
symptoms at time of fall, injuries (TARGET
INTERVENTIONS)
• Review Meds: All prescribed and over-the-counter
medications with dosages
• Obtain History of relevant risk factors: Acute or
chronic medical problems, (e.g., osteoporosis,
urinary incontinence)
22. Components of FUNCTIONAL
ASSESSMENT
• Assess ADL, including ability to use
assistive devices and adaptive
equipment
• Assess for fear of falling and perceived
functional abilities and health
23. Post-fall Syndrome
• Is a phobic response to the discordant and
inaccurate sensory inputs
• Creates a self-perpetuating cycle of increasing
weakness and instability via joint mobility
reductions, physical deconditioning, and poor
balance
• Loss of self-confidence to ambulate can result
in self-imposed limitations
Source: Journal of Rehabilitation Research and Development: 40
(1); January/February 2003: 49-58.
24. Exam of Lower Extremities
• Search for mechanical problems-orthopaedic,
vascular, podiatric,
rheumatic
• Examine ROM at hip, knee, ankle
• Palpate for pulses at femoral, popliteal,
dorsalis pedis, posterior tibial
25. Exam of Lower Extremity (cont)
• Muscle Tone (resistance of
extension)– if increased and feet are
“stuck to the floor” , consider NPH or
frontal lobe dysfunction
26. Neurologic Dysfunction
• Cerebellar Ataxia – Cerebellum processes
input from brain, spinal cord, and sensory
receptors to provide timing of precise,
coordinated movements of skeletal muscle
system (e.g. limb position). With ataxia, have
dizziness, imbalance, and difficulty
coordinating movements
27. Neurologic Considerations
• Dizziness and Vestibular Ataxia– use
inner ear (vestibular) and sensory to
balance; consider an etiology for
vascular, vestibular, brain stem, trauma,
or medication problems
28. Neurologic Considerations
• Romberg’s (standing balance with eyes
closed) – presence means sensory deficit
(abnormality of proprioception) in peripheral vestibular,
peripheral neuropathy, decreased position sense
(dorsal column) ; if due to neuropathy, ankle jerks will
be absent; if a spinal cord issue, Babinski will be
present
• Treatment – improve lighting, use assistive devices,
good footwear
29. Neurologic Considerations
• Cerebellar signs – presents with
incoordination, ataxia, unsteadiness with eyes
open. If positive, determine rapidity of onset.
Acute: posterior fossa stroke; Subacute:
mass, demyelinating or degenerative
processes, metabolic disorder, or drug effect
• Treatment – assistive devices, reduce
clutter, gait training
30. Neurologic Considerations
• Sternal nudge – with staggering or
becoming unstable, consider neurologic
or back disease
• Treatment – remove clutter, prescribe
assistive devices, avoid slippers or
loose-fitting shoes
31. Neurologic Considerations
• Unstable with turns – with instability,
consider cerebellar, reduced
proprioception, hemiparesis, or visual
field cut
• Treatment – gait training, prescribe
assistive devices, proper fitting shoes,
reducing obstacles
32. Functional Examination
• Evaluate patient’s gait. Note symmetry,
speed, and ability to walk in a straight line/path
undeviating.
• Is center of gravity altered? (Wide-based?)
• Look for hesitation with turns when pivoting.
• Note if good arm swing and if there is sound
distance between floor and soles of feet.
33. Functional Evaluation of Gait: “Timed Up
and Go” (TUG): per STEADI
• “TUG” should be able to execute in < 13
seconds
• Difficulty of arising from chair suggests
proximal muscle weakness, arthritis, or
neurologic disease
• Treatment: portable seat lift, muscle
strengthening exercises, increase functional
mobility, treat specific illness
34. Functional Examination: 4-Stage
Balance Test: per STEADI
• Test stance: Side-by-side, semi-tandem,
tandem stances, and balancing
one foot.
• If cannot perform side-by-side, semi-tandem,
or tandem stances, senior is at
increased risk
35. Functional Exam: One Opinion*
• Failing
– Side-by-side: if “fail”, need walker and PT
– Semi-tandem: if break early, need walker
and PT; mid-break, need cane; late break,
order balance (e.g. Tai Chi) and exercise
classes
– Tandem: balance and exercise classes
• *my personal opinion
36. Functional Examination: 30-second
Chair Stand: per STEADI
• Results are based on sex and age and
grid that details “Below Average Scores”
• If patient scores are below average, he
is at risk for falling and needs
intervention
37. Other Aspects of Examination
• Psychiatric
– Brief screen for cognitive functioning
– Brief screen for mood (depression)
– Assess for fear of falling: Do you have a
fear of falling? If yes, does your fear
decrease your activity level?
38. Appliances Recommended to Reduce
Morbidity and Mortality
• Reachers
• Portable seat lift
• Special step stools
• Hip protectors
(controversial,
falling in and out of
favor)
39. Interventions for Community Dwellers:
According to AGS
• Adaptation/modification of home environment [A]
• Withdrawal/minimization of psychoactive medications
[B]
• Withdrawal/minimization other medications [C]
• Management of postural hypotension [C]
• Management of foot problems and footwear [C]
• Exercise, particularly balance, strength, and gait
training [A]
40. Strength of Recommendation Rating
System
• [ A ] A strong recommendation that the clinicians provide the
intervention to eligible patients.
• Good evidence was found that the intervention improves health outcomes and the
conclusion is that benefits substantially outweigh harm.
• [ B ] A recommendation that clinicians provide this intervention to
eligible patients.
• At least fair evidence was found that the intervention improves health outcomes
and the conclusion is that benefits outweigh harm.
• [ C ] No recommendation for or against the routine provision of
the intervention is made.
• At least fair evidence was found that the intervention can improve health
outcomes, but the balance of benefits and harms is too close to justify a general
recommendation.
41. Strength of Recommendation
Rating System
•[ D ] Recommendation is made against routinely
providing the intervention to asymptomatic patients.
•At least fair evidence was found that the intervention is ineffective or that
harm outweighs benefits.
•[ I ] Evidence is insufficient to recommend for or
against routinely providing the intervention.
•Evidence that the intervention is lacking, or of poor quality, or conflicting,
and the balance of benefits and harms cannot be determined.
42. Quick Tips
• Studies demonstrate that Vitamin D
supplementation (800 IU/day) reduces
falls
• Patients using monocular (single vision)
vision glasses when performing activities
and walking are less likely to fall
43. The Bottom Line
• Falls are treatable geriatric syndrome
• Screening for falls begins with one
question
• Falls can be reduced by up to 40% with
intervention
• Medicare typically covers services
needed to treat patient’s risk factors
44. Conclusion
• Falls are complex and multifactorial
• Marker of frailty
• What predisposes persons to falling often
produces observable disturbances in gait and
balance—so assess in office
• Interventions most likely to prevent injury are
exercise and environmental modification