DORON GARFINKEL, M.D. HEAD, GERIATRIC PALIATIVE DEPARTMENT

1. Falls and Fall Prevention in the Elderly DORON GARFINKEL, M.D. HEAD, GERIATRIC PALIATIVE DEPARTMENT SHOHAM GERIATRIC MEDICAL CENTER PARDES – HANA, I S R A E L

2. Falls in the Elderly Overview • Prevalence • Clinical Importance • Risk Factors & Etiology • Evaluation • Prevention & Management • Falls & restraint use • Summary

3. Prevalence • 30% of those over 65 fall annually • Half are repeat fallers • Falls go up with each decade of life • Over half of those in nursing homes and hospitals will fall each year

4. FALLS - INCIDENCE • The incidence of falls increase with age • Each year 30 - 40% of community-dwelling persons > 65 years old have a fall. • The annual incidence of falls among people who experienced a fall in the previous year, is almost 60%. • 25% - AGE 65 – 74, 33% - AGE > 75 • 120% AGE > 80 ( > ONE FALL / Year)

5. Clinical Importance Impact of Hip Fractures • 1% of falls result in hip fracture • $2 billion + in medical costs annually • 25% die within 6 months • 60% have restricted mobility • 25% remain functionally more dependent

6. Falls Cause Morbidity & Mortality • Mortality: indirect effects • Fractures: 6% of falls • Soft tissue injury, head injury, subdural hematoma • Fear of falling can result in decreased activity, isolation, and further functional decline • Nursing home placement & loss of independence

7. FALLS -A LEADING CAUSE OF MORBIDITY, DISABILITY & DEATH • Complications resulting from falls are the leading cause of death from injury in adults aged 65 and older. • Fear, Loss of Confidence • Decreased Functioning • Dependency • Physical Trauma - 10% • FRACTURES - 5%- 15%

8. Risk Factors & Etiology Falls are Multifactorial Intrinsic Factors Extrinsic Factors Medications Improper use of assistive devices Environment Medical conditions Impaired vision and hearing Age related changes FALLS

9. Age - Related Changes • Neurologic • Increased reaction time • Decreased righting reflexes • Decreased proprioception • Vision Changes • Decreased accommodation & dark adaptation • Decreased muscle mass

10. Age - Related ChangesG A I T • Slower gait • Decreased stride length & arm swing • Forward flexion at head and torso • Increased flexion at shoulders and knees • Increased lateral sway

11. D y s m o b i l i t y • Dysmobility and falling closely related • 15% of those over 65 have trouble walking • 1/4 men and 1/3 women over age 85 have difficulty with walking • 2/3 of people in hospital or NH unable to ambulate without assistance

12. Risk Factors for Falls Risk FactorOR • 28 • Cognitive Impairment 5 • Lower extremity problem 4 • Pathologic Reflex 3 • Foot Problems 2 • > balance/gait problems 1.9 Sedative use Tinetti NEJM 1988

13. Common Pathologies associated with Falls • Ophthalmologic diseases • Arthritis • Foot problems • Neurologic illness • Parkinson’s & related disorders • Strokes • Peripheral neuropathy • Dizziness and dysequilibrium

14. Dizziness: A Multifactorial Syndrome • Vertigo: Posterior CVA/TIA, Cervical • Presyncope: Orthostatic, Dysrythmia, Anemia • Dysequilibrium: Peripheral neuropathy, Visual • Other: Anxiety, depression • In older people, usually multifactorial Tinetti, Annals of Internal Med 2000

15. Falls in the Community • Accidents/environment 37% • Weakness, balance, gait 12% • Drop attack 11% • Dizziness or vertigo 8% • Orthostatic hypotension 5% • Acute illness, confusion, drugs, decreased vision 18% • Unknown 8% Rubenstein JAGS 1988

16. Falls in Residential Care • Generalized weakness 31% • Environmental hazard 27% • Orthostatic hypotension 16% • Acute illness 5% • Gait or balance disorder 4% • Drugs 5% • Other or unknown 10% Rubenstein Ann Int Med 1990

17. Medications and Falls • Sedative-hypnotics, especially long acting benzodiazepines, • Small association between most psychotropics and falls • SSRIs and TCAs both increase falls • Weak association between Type 1A antiarrythmics, digoxin, diuretics, and falls Leipzig JAGS 1999 Thapa NEJM 1998

18. Evaluation of Falls in the Elderly Medical History • Location & circumstances of Fall • Associated symptoms • Other falls or near falls • Medications (including nonprescription) and alcohol • Injury & ability to get up

19. Evaluation of Falls in the Elderly Physical Examination • Supine and standing BP - always • Routine physical examination Focus on cardiovascular, MS, neuro, feet • Vision and hearing evaluation • Consider acute medical illness & delirium • Formal gait and balance assessment

20. Evaluation of Falls: Home Evaluation • Can be performed by nurse, OT, PT, others • Stairs • Lighting • Bathroom • Specific hazards: cords, throw rugs

21. Evaluation of Falls: Risk Factors for Injury • Osteoporosis assessment • Anticoagulation: Usual benefits outweigh risks unless repeat or high risk faller • Can the person get up from fall? • Is there a way to notify others in case of falling?

22. Formal Gait Evaluation Get up and Go Test Tinetti Gait & Balance Evaluation (POMA) POMA: Balance Component Sitting (in hard, armless chair) Arising Standing balance (immediate and delayed) Balance with Nudge Balance with Eyes closed Balance with 360 degree turnTinetti JAGS 1986

23. POMA: Gait Component Initiation Step length and height Step symmetry & continuity Path Stance Ability to pick up speed Tinetti JAGS 1986

24. Prevention & Treatment • Treat acute injury & underlying medical conditions • Remove unnecessary medications • Rehab, exercises, assistive devices • Correct sensory impairments • Environmental modifications & safety • Evaluate for osteoporosis treatment

25. Osteoporosis • Calcium and vitamin D for most elders at risk • Dawson-Hughes, NEJM, 1997 • Osteoporosis evaluation and treatment • Thiazides may help slightly • Statins? • Hip protectors appear to protect from hip fractures in those who wear them • Kannus, NEJM, 2000

26. Risk Factor Modifications for Fractures ChangeEstimated Change in Risk Quit smoking 38% Treat impaired vision 50% Stop sedatives 40% Add 1 Gram Calcium 24% Hip Protectors 50%? Adapted from Steeve Cummings

27. Falls: Primary Prevention • 301 community dwelling elders with 1+ risk factors for falling • Intervention: adjustment in medications, behavioral instructions, exercise programs aimed at modifying risk factors • One year follow up Tinetti et al. 1994 NEJM

28. Multifactorial Intervention P = .04 Tinetti et al 1994 NEJM

29. Exercise Training & Nutrition Fiatarone et al NEJM 1994

30. Tai Chi and Falling • Atlanta FICSIT Trial • 200 community dwelling elders 70+ • Intervention: 15 weeks of education, balance training, or Tai Chi • Outcomes at 4 months: Strength, flexibility, CV endurance, composition, IADL, well being, falls • Falls reduced by 47% in Tai Chi group Wolf JAGS 1996

31. Training frail older persons: The New Zealand Study of Women 223 women >80 years Intervention: PT tailored to individual needs, with resistance and balance training Results: Clinical balance, chair rise improved RR for falls .47 (CI .04-.90) RR for injurious falls .61 (.39-.97) Campbell BMJ 1997

32. Summary • Falls are common in the elderly & may lead to injuries and decline in function • Evaluation should included risk factor assessment, gait assessment, and home assessment • Exercise can improve outcomes • We have no evidence that restraints reduce fall related injuries

33. EFFICACY OF HIP PROTECTORS IN THE PREVENTION OF HIP FRACTURES IN PATIENTS WITH DEMENTIA Doron Garfinkel Shoham Geriatric Medical Center Pardes – Hana, Israel

34. THE VICIOUS CIRCLE A G I N G INSTABILITY ± DEMENTIA F A L L S DISABILITY SARCOPENIA OSTEOPOROSIS FRACTURE

35. FALLS & HIP FRACTURES • 10-15% of Falls result in fractures • In the US - 90 percent of more than 350,000 hip fractures each year are the result of a fall. • An estimate of 1.3 million hip fractures occurred worldwide in 1990,By 2050 in the US alone, there will be an estimated No. of 650,000 hip fractures annually • Nearly 1800 hip fractures a day!

36. העליה בשכיחות שברים בצוואר הירך עם השנים ? ESTIMATED No. (x 1000) USA UK 1980 2000 2050

37. HIP FRACTURES - OUTCOMES The death rate attributed to falls also increase with age, reaching at age > 85 – 180 deaths per 100,000 population Hip fractures is the commonest reason for admission of elderly people to an acute orthopedic ward Johnell & Kanis, Osteopor Int 2004; 15: 897 – 902.

38. HIP FRACTURES - OUTCOMES • Each year, 8% of people > 70 years old reach the Emergancy Room, as a result of Fall - related injuries • Those admitted are hospitalized for an average of 8 days. • These hip fractures may result in .permanent disability accounting for a significant portion of the Global Burden of Disease

39. HIP FRACTURES - OUTCOMES • Only 25 percent of patients with hip fractures will make a full recovery • 50 percent will need some assistance - cane or walker • 40% will require Long – Term Care (nursing homes & nursing departments) • In the US, the cost of fall-related injuries is estimated as 12,6 billion dollars yearly

41. שכיחות שברי צוואר הירך בישראל בישראל כ- 700,000 קשישים מעל גיל 65 בישראל שכיחות שברי ירך כ - 6,000 בשנה ההוצאה לטיפול שבר אחד בצוואר הירך כ- 75,000 ש"ח כ-450 מיליון ₪ לשנה!!!

42. הערכת הסיכון לאורך זמן הסיכון של אישה מעל גיל 50 לחוות שבר אוסטאופורוטי במהלך חייה סיכון של אישה מעל גיל 50 לחלות במחלה קרדיווסקולרית = = 40% מספר ימי האשפוז כתוצאה משברי צוואר הירך מספר ימי האשפוז כתוצאהמסוכרת, התקפי לב וסרטן שד = לאחר שבר בצוואר הירך: - בשנה שאחרי השבר 40% אינם מסוגלים ללכת ללא סיוע, 60% זקוקים לעזרה בתפקוד יומיומי (ADL). - סיכון לתמותה/תחלואה עולה משמעותית כשהחולה אינו מנותח תוך 24 - 48 שעות, ובעיקר כאשר אינו מנותח כלל

43. הערכת הסיכון לשברבצוואר הירך

45. כיצד נגרם השבר? רוב שברי צוואר הירך נגרמים עקב נפילה ופגיעה ישירה של הטרוכאנטר על משטח קשיח. מעבר מהיר של אנרגיה מאזור הרקמות הרכות לעבר רקמות העצם, יוצר שבר בעצם צוואר הירך

46. הבסיס לפתרון : מניעה מגן הירכיים - מאפשר שכבת הגנה מכאנית, השומרת על אזור עצמות הירכיים. המגן בולם ומשכך את עוצמת המכה הנגרמת מנפילה ופגיעה ישירה.

47. מבחן ביו-מכאני במעבדות אוניברסיטת הרוארדתוצאות

48. Hip pads to prevent hip fracture • “RCT” of 1801 frail subjects in Finland • Nursing home or frail community patients • Mean age 81 • 78% women • 63% assisted walking Kannus. NEJM;2000;343;1506-1513.

49. Hip pads to prevent hip fracture Fractures with Hip Protectors 2.1% per year vs. 4.6% per year (p<.01) 40 patients needed to be treated with hip protector for 1 year to prevent one fracture 2.4% of falls resulted in hip fracture when not wearing protector 0.4% resulted in hip fracture when wearing protector (80% risk reduction) But patient acceptance low Kannus. NEJM;2000;343;1506-1513

50. מה באמת ידוע על יעילות מגיני הירכיים? Effectiveness of Hip Protectors for Preventing Hip Fractures in Elderly People: Systematic Review. BMJ: March 2, 2006 Parker MJ, et al, concluded that hip protectors represent an Ineffective intervention for elders living at home, while their Effectiveness in preventing hip fractures in Institutional setting may be regarded as Uncertain.