Falls – an over view for GPs

1. Falls – an over view for GPs Julie Brache Consultant Geriatrician and Falls Lead October, 2014

2. Overview • Why older people fall • Multifactorial risk assessment • Normal changes with ageing • Dizziness and syncope • Medication review • Multifactorial interventions • Where to get advice

3. Definition when an individual comes to rest unintentionally on the ground or another lower level, with or without loss of consciousness

4. Background • 35% >65 living at home fall each year • £2.3 billion per year • 10% injury • After a fall 50% have reduced mobility • Leading cause of injury related death in older adults

5. Preventable N • Evidence based national and international guidelines

6. Fall is a symptom, not a diagnosis

7. ‘Old age starts with the first fall and death comes with the second’ Gabriel Garcia Marquez “Love in the time of cholera”

8. Frailty • Reduced ability to withstand illness without loss of function • Muscle weakness, reduced walking speed, reduced physical activity, weight loss, self reported exhaustion • Would you be surprised if this person died in the next year?

9. Falls are multifactorial

10. Why do older people fall? • Muscle weakness • Poor balance • Gait deficit • Polypharmacy • Sensory loss – vision, hearing, peripheral • Medical illness • Nutrition • Dizziness • Osteoarthritis • Frailty • Environment • Depression • Cognitive impairment • Incontinence • Alcohol • Previous falls • CV problems • Neurological

12. History • Circumstances of falls • Activity at the time • Where and when • Lightheaded, dizzy, LoC, chest pain, palpitations, visual disturbance? • Seizure markers? • How many falls in the last year?

13. Taking the history –some pointers • Allow them to describe everything first, then get the history you need • Describe a single fall in detail • Take them through it in fine detail • Thenask about associated symptoms • Witness account is vital

14. History - pitfalls • “It was nothing” • “I haven’t fallen” • “I tripped over the cat” • “I must have…….” • “They had a fit, doctor”

15. Assess • Continence • Cognition • Frailty • Alcohol intake • Psychological consequences of falling • Fear, anxiety, depression

16. Examination • Cardiovascular • Pulse – rate and rhythm • Heart sounds • 3 min lying and standing BP • Drop 20 systolic or 10 diastolic or to <90 significant • Only 23% will describe dizziness • ECG

18. Examination • Focused neurological examination • Lower limb strength – hip and ankle flexors • Peripheral sensation • Evidence of stroke, Parkinson’s cerebellar signs? • Gait and balance • Vision

19. Ageing and gait • Slower • Increased sway • Slowed postural support responses • Shorter stride length • Increased time in double support • Loss of rhythm • Loss muscle bulk, reduced postural reflexes, JPS

20. Gait disorders in the elderly • Parkinsonism • Cerebrovascular disease • Cervical spondolytic myelopathy • Sensory neuropathy • Foot drop • Don’t forget Normal Pressure Hydrocephalus

21. Gait and balance assessment • Not all for the Physio! • Gait: • Get Up and Go • Balance: • Proprioception– vision- vestibular function -> Romberg's -> Head Thrust

22. Ageing and vision • ↓Acuity • ↓Depth perception • Lens density changes- glare • Decreased rod density - ↓Light adaptation - ↓contrastsensitivity • ↓ Visual processing speed

23. Vision • Test acuity and fields • ARMD, glaucoma, stroke, diabetes, cataract • Bifocal / varifocal glasses, change in prescription

24. SPECTACLE USE 5.7 Optometrists and dispensing opticians should consider supplying an additional pair of single vision spectacles (to wear in outdoor and unfamiliar settings) for older people who take part in regular outdoor activities

25. Examination • Other • Cognition • Foot wear and feet

26. Take the shoes off!

27. Dizziness • Vertigo • Pre-syncope • Dysequilibrium

28. Vertigo • Illusion of rotation • “The room was spinning” • Nystagmusduring episode • Labyrinth or vestibular • problem • Occasionally cerebellar or CP angle • Treat acute attacks with • anti-histamines

29. Benign Paroxysmal Positional Vertigo • Vertigo on change in position • Self limiting • Disabling • Hallpike- Dix test • Epley manoeuvre • Vestibular rehab • Cawthorne- Cooksey exercises • Brandt - Daroff

30. Pre-syncope • Sense of feeling faint or light-headed • “Legs went weak” • “Vision blurred ” • Pallor, weak/slow pulse • Same causes as syncope • Often a sign of postural BP drop • Cardiovascular assessment • Treat underlying cause

31. Dysequilibrium • Balance dysfunction • A sense of unsteadiness • “Thought I was going to fall” • Often multi-factorial • Sensory impairments and/or CNS disease • Multidisciplinary management

32. Syncope • 23% >65s over 10 years • High recurrence rate • Spontaneous LOC with complete recovery • Diagnosis difficult and often wrong

33. Syncope in the Elderly • Cerebral autoregulation impaired • Baroreflex sensitivity blunted • Volume regulation impaired • Comorbid illness and medications

34. Syncope diagnosis • All in the history • DETAIL • Posture • Prodrome • Eye movements • Tongue biting/incontinence • Injury • Duration • Confusion • Hemi weakness

35. Red flags • Abnormal ECG (NICE) • Heart failure • Syncope during exertion • FHx sudden death <40 • New/unexplained SOB • Murmur (NICE)

36. Assessment • Vasovagal – 3Ps • Cardiovascular – if in doubt • ECG, 24 hour tape, event recorder, implantable device, tilt table test + carotid sinus massage, cardio ref • Neurological • CT head, EEG (?value in elderly), neuro ref

37. Tilt Tests • Unexplained, recurrent syncope • Single syncope in high risk settings • Unexplained recurrent falls

38. Falls and acute illness • Fall often the presentation of an acute illness • Think of falls risk when unwell • diuretics, antihypertensive, steroids, anticholinergics, sedatives • urinary urgency/frequency • Delirium

39. Medication review

40. Drugs in the elderly • UK elderly 18% pop – 45% all prescriptions • In NH in 1 year 97% will receive a prescribed drug – 71% in community • Polypharmacy - >4 drugs = risk falls

41. Principles of Medication review • Review indication – is there evidence? • Review dose • Reduce the number of medicines • Avoid complex regimes • Review benzodiazepines and other psychotropic drugs • Check L&S BP – if drop review culprit drugs

42. Medication and Falls Risk • “Therapeutic effect” • Interactions • Side effects • 2/52 after change in meds – high risk time • Stopping – can be difficult

43. “Therapeutic effect” • Meta-analysis – sedatives and hypnotics • Improve sleep duration and reduce night time wakening • NNT sleep 13 • NNT any adverse event 6 BMJ 2005;331:1169

44. Side effects – anticholinergic activity • Antiemetics – cyclizine, prochlorperazine • Antiparkinson – amantadine, benzhexol • Antispasmodics – oxybutynin • Bronchodilators - ipatropium • Antiarrhythmics - disopyramide, procainamide • Antidepressants – tricyclics • Antipsychotics – chlorpromazine, prochlorperazine

46. Time to reconsider warfarin? • 50% elderly in AF not on warfarin • Falls is the main reason • >300 falls per year for bleeding risk to outweigh stroke risk

47. Ageing and Pharmacokinetics / Pharmacodynamics • Distribution • ↑blood (& tissue) conc water sol drugs • ↑ vol distribution lipophilic drugs • Hepatic metabolism • Metabolism by C P-450 reduced • Reduced 1st pass metabolism – some drugs • Renal elimination • Reduced GFR with age • Changes in drug-receptor interactions