Evidence Based Approach To Falls

1. Evidence Based Approach To Falls Dr Larry Dian Division Of Geriatric Medicine U.B.C.

2. Evidence Based Approach This page is intentionally left blank

3. Epidemiology • Falls are common; 50% for those 80 years and older fall yearly • 60 % of those with a history of a fall in the previous year will have a subsequent fall • Most falls result in an injury of some type • 10% major injury, 5 % lead to hospitalization, >70% fear of falling

4. Scenario 1 • You receive a call from the emergency physician regarding your 86 year old patient who is being sent home after receiving sutures for a scalp laceration that occurred after a fall. CT head “normal”.

5. Acute Fall Why did the person Fall?

6. 5 Step Assessment • Question 1: Did the fall result as a loss of consciousness? If yes: Sz. or Stokes- Adams attack EEG, 24 hour holter, echocardiogram Micro burst of LOC likely not significant Confusion or drowsiness after fall somewhat supportive Collateral history very helpful

7. If No Loss of Consciousness • Was Fall preceded by dizziness?Type 1: Vertigo- Central/peripheral BPV commonest Type 2 Lightheadedness/ transient cerebral hypo-perfusion/orthostatic hypotension Type 3: “Dizziness of legs”/unsteadiness Type 4: De-afferentation /psychological

8. If No Dizziness • Was the fall associated with an acute medical illness? Atypical presentation Delirium “Round up all the usual suspects”

9. If No Acute Illness • What was the mechanism of the fall? Be as precise as possible recreating actions before and after the fall Avoid leading questions; patients may not remember Collateral history very useful

10. If No Mechanism For Fall • Falls are either multi-factorial or lower limb weakness • “Just Fall” fall –eccentric weakness of quadriceps muscle

11. 5 Step Algorhythm • Provides a rational strategy for mechanistic determination of the fall • Provides a strategy for fall risk reduction

12. Scenario 2 • The family of your 89 year old patient wants your opinion about moving their reluctant mother in a nursing home because of the concern that she might fall and “hurt herself”

13. Psychotropic drug use Arthritis History of stroke Orthostatic hypotension Dizziness Anemia Risk Factors • Past history of a fall • Lower extremity weakness • Age • Female gender • Cognitive impairment • Balance problems

14. Chronic Diseases • Parkinson's disease • Osteoarthritis of the knee, feet ankle • Cognitive impairment  (mmse 18-23) 2x increased risk of falls • Risk increases with increasing number of chronic diseases • Number and type of medications • Alcohol use

15. Targeted Physical Exam • Cardiovascular system • Central nervous system • Musculoskeletal system; lower limbs

16. Targeted Physical Exam • Postural blood pressure • Heart failure, Atrial fib, Aortic stenosis • Mental status, Parkinson’s disease, stroke peripheral neuropathy, visual acuity • Arthritis of knees feet, podiatric problems • Strength of hip flexors, ankle dorsi-flexors • Environmental factors, footwear, mobility aids

17. Supplemental Tests Get Up and Go Test Functional reach test Sternal nudge test; unipedal and tandem stance

18. Get Up and Go Test • Have the patient sit in a straight-backed high-seat chair • Instructions for patient: Get up (without use of armrests, if possible) • Stand still momentarily • Walk forward 10 ft (3 m) • Turn around and walk back to chair • Turn and be seated

19. Get Up and Go Test Factors to note: • Sitting balance • Transfers from sitting to standing • Pace and stability of walking • Ability to turn without staggering

20. Diagram of functional reach test to assess balance in elderly persons

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22. Therapy • Address medical issues • Review home environment • Provide appropriate walking aid • Gait and balance exercise training

23. Falls are not random events • Falls are common and are associated with significant morbidity and mortality • Standardized assessment tools exist • A coherent mechanism can be developed in most cases • Consider referral to falls clinic in complex cases