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CHAMP A Geriatric Syndrome in the Hospital: The Case of Falls. William Dale, MD, PhD University of Chicago. Overview. What is a “geriatric syndrome”? How does one think about, and teach about, syndromes like falls? Why worry about falls? What are the causes of falls?

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champ a geriatric syndrome in the hospital the case of falls

CHAMPA Geriatric Syndrome in the Hospital: The Case of Falls

William Dale, MD, PhD

University of Chicago

overview
Overview
  • What is a “geriatric syndrome”?
  • How does one think about, and teach about, syndromes like falls?
  • Why worry about falls?
  • What are the causes of falls?
  • Differential diagnosis and falls: teaching to medicine housestaff
  • Restraints and falls: teaching housestaff about the dangers of restraints
  • Preventing and treating patients who fall
  • What should be done at discharge?
  • U of C Nursing initiative and pilot project
falls as a geriatric syndrome
Falls As a “Geriatric Syndrome”
  • A sudden, unexpected descent from a standing sitting, or horizontal position.
  • When a person comes to rest inadvertently on the ground or a lower level
    • Excludes syncope and overwhelming trauma
    • A classic Geriatric Syndrome
  • When the nurse calls to report “an event”
what is a geriatric syndrome
What is a Geriatric Syndrome?
  • Manifestations of disturbances in complex systems, usually with more that one organ system involved
  • Examples
    • Functional Dependence
    • Delirium
    • Incontinence
    • Falls
how do complex systems like older adults fail in causing syndromes
How do complex systems, like older adults, “fail” in causing syndromes?
  • Key Concepts
    • Physiologic reserve lower across multiple domains
    • Adaptive/redundant systems reduced
  • Possible Pathways to Failure
    • Major hit to one component (E.g. CVA)
    • Dominant deficit with exacerbations (E.g. MI  CHF/COPD)
    • Multiple modest deficits (Geriatric Syndrome)
yearly incidence of falls
Yearly Incidence of Falls
  • Community-dwelling persons over 65: 30-40%
    • 20% of falls require medical attention
  • History of fall in last year: 60%
  • Falls in our hospital: Data not currently available

Sources: Tinetti, 1988; Tinetti, 1994

complications
Complications
  • “Leading cause” fact: death from injury in older adults
  • Fracture risk: 10-15%
    • About 8% of 70+ y.o. go to ED yearly for fall-related injury
  • Other common complications
    • Decline in functional status
    • Increased likelihood of nursing home placement
    • Increased use of medical services
    • Developing fear of falling  Loss of function

Source: Sattin, 1992.

causes of falls
Causes of Falls
  • Rarely due to a single cause
    • At least 25 risk factors identified across 5 large cohort studies
  • Interaction across multiple domains: more risk-factors, increased likelihood to fall
    • Intrinsic to individual
    • Environmental challenges to postural control
    • Mediating factors
causes intrinsic patient factors
Causes: Intrinsic Patient Factors
  • Age
  • Female gender
  • Cognitive impairment
  • Chronic diseases
    • Arthritis
    • Parkinson’s
  • Use of certain medications
    • Psychotropics
    • Diuretics
  • History of falls
history of falls as a risk factor
History of Falls as a Risk Factor
  • One year risk of hospitalization by baseline self reported fall status (n=444)
causality pathophysiology of aging and postural control
Causality: Pathophysiology of Aging and Postural Control
  • Postural control differences in older adults
    • Respond to balance perturbations using proximal muscles first, then distal
    • More slowly develop joint torque when disturbed
    • More likely to have decreased baroreflex sensitivity to hypotensive stimuli
    • More likely to have microvascular cerebral perfusion defects
    • Reduction in total body water
causes postural control challenges
Causes: Postural Control Challenges
  • Weakness, esp. lower extremity
  • Balance difficulties
  • Dangerous environment
causes mediating factors
Causes: Mediating Factors
  • Risk-taking behaviors
  • Underlying mobility level/inclination
  • Principle: Mismatch of risk-taking behavior with mobility

Probability of Fall

Mobility Skills

Source: Studenski, 1991

causality pathophysiology of aging
Causality: Pathophysiology of Aging
  • Three sensory input systems involved in maintaining upright posture
    • Visual
    • Proprioceptive
    • Vestibular
  • All of these systems decline with aging
differential diagnosis and falls
Differential Diagnosis and Falls
  • Traditional DDx:
    • Multiple symptoms  Possible single causes (I.e. diagnoses)
    • Causes prioritized by probability and severity
    • Search for underlying or unifying cause
  • Geriatric Syndromes DDx:
    • Event/Condition  Possible multiple causes
    • Causes prioritzed by probability and contribution to causing event/condition
    • Search for web of interacting causes
history and physical based on the components of postural control
History and physical based on the components of postural control
  • Sensory:
    • Vision
    • Vestibular
    • Somatosensation
  • Central Processing:
    • Global level of consciousness/perfusion
    • Attention/response time
    • Automatic postural responses
  • Effector:
    • muscle strength
    • range of motion
    • endurance
getting the story
Getting “The Story”
  • At time a fall occurs, get good history
    • Do this on cross-cover
    • Best history at time of fall
    • Earlier intervention important
  • Activity at time of fall (walking, transferring, sitting at bedside, going to bathroom, etc)
  • Prodromal symptoms
    • Lightheadedness?
    • Loss of balance?
    • Dizziness?
  • Location/Timing
getting the story1
Getting the Story
  • Observe environment/context of fall
    • Lighting
    • Flooring and footwear
    • Restraints (both formal and informal)
    • Furniture
  • Past History: Has this happened before?
    • Strongest predictor of fall: past fall
    • Context of last event
  • Review Medications
    • Recent Changes in Medications (Check MAR)
    • Biggest culprits
      • Vasodilators
      • Diuretics
      • Sedatives
      • Hypnotics
the role of medications
The Role of Medications
  • Specific meds in observational studies associated with hip fracture risk
    • Benzodiazepines
    • Antidepressants
    • Antipsychotics
  • Medication features associated with falls
    • Recent changes in dose
    • Total number of meds
physical exam
Physical Exam
  • Orthostatics: Do this yourself if you have time.
  • Cardiovascular System
  • Sensory Examination
    • Special senses
    • Proprioception
  • Musculoskeletal Exam
    • Proximal muscle weakness
    • Joint pain/swelling
  • Cognition: brief assessment of mental status: Orientation
  • Footwear/Floor combination
    • Socks on tile; bare feet and wet floor
physical exam special tests
Physical Exam: Special Tests
  • Gait Speed – “Get up and Go” Test
    • Rise from (hard-backed) chair, walk 10 feet, turn, return to chair, sit down
    • Threshold greater than 10 seconds is abnormal
  • One foot balance
    • Threshold: < 30 seconds
  • Observe PT/OT evaluations for these patients—arrange time for team to meet with PT/OT
laboratory testing
Laboratory Testing
  • No “standard” battery of tests
  • Instead, targeted to specific concerns
falls and restraints
Falls and Restraints
  • Restraints increasingly recognized as a cause of falls and increasing serious falls
mechanical restraint use and fall related injuries
Mechanical Restraint Use and Fall-related injuries
  • Prospective study, SNFs, n=397
  • Outcome: falls after restraints placed
  • Logistic regression used to control for large number of confounders
  • Odds ratio for fall-related injury
    • Full cohort: 10.2 (CI 2.8 – 36.9)
    • High-risk subgroup: 6.2 (CI 1.7 – 22.2)

Source: Tinetti ME, et al, 1992

mechanical restraints
Mechanical Restraints
  • Increases risk of falls and other complications in hospitalized patients on a medicine service:

Source: Mion LC, Et al, 1989.

restraints formal and informal
Restraints: Formal and Informal
  • Formal
    • Mittens
    • Wrist/Ankle Soft Restraints
    • 4-point “Leathers”
    • Full Side Rails
    • Posey Vests
  • Informal
    • IV Lines
    • O2 nasal canulas
    • NG tubes to suction or for feeds
    • Pulse oximetry
    • SCDs
    • Foley catheters
risks benefits of bedrails
Risks/Benefits of Bedrails
  • Potential benefits
    • Aiding in repositioning
    • Hand-hold for support in getting in/out of bed
    • Reduce fall risk during transport
    • Enhance access to bed controls
  • Potential risks
    • Entrapment
    • Worse falls injuries from climbing
    • Skin trauma/bruising/scraping
    • Exacerbation of delerium when used as a restraint
    • Restricts activities (toileting, personal item retrieval)
bed rails and entrapment
Bed Rails and Entrapment
  • Incidence of “entrapment” by bed rails reported to FDA, 1985-1999: 371
    • # of beds in U.S. hospitals and LTC facilities: 2.5 million
    • Outcomes from entrapment
      • Death 61%
      • Non-fatal injury 23%
      • No injury 15%
safety improvement alternatives to bed rails
Safety Improvement Alternatives to Bed Rails
  • Lower bed for patient, raise for providers
  • Keep wheels of bed locked
  • Use transfer and mobility aids
  • Monitor patient frequently
    • Move patient closer to nursing station
    • Enlist others: family, medical students
  • Identify and meet patient needs that lead to falls
    • Toileting: available bedpans/urinal; scheduled toileting
    • Pain: adequate pain relief
improving safety of bedrails when used
Improving Safety of Bedrails When Used
  • Close monitoring
  • Lower at least one of rails
    • Not considered a restraint when used this way
    • Allows access to and from bed
  • Properly sized mattress to reduce gap between mattress and bedrail
treatment and prevention
Treatment and Prevention
  • No proven benefit in reducing falls
    • Untargeted exercise intervention alone
    • Untargeted health education alone
    • Untargeted exercise and health education
    • Assistive devices alone
outpatient prevention
Outpatient Prevention
  • Possible Benefit
    • Long-term exercise and balance training
      • Includes gait training and proper use of assistive devices
    • Tai Chi: body “consciousness”, balance
    • Medication review for possible discontinuation
      • Esp. for those with 4+ medications
      • Esp those on psychotropics
in hospital treatment and prevention
In Hospital Treatment and Prevention
  • Impact Protection
    • Lower beds and lock wheels
    • Hip Protectors
      • Significant protection against fracture
      • Adherence difficulties substantial
    • Diagnose and treat osteoporosis
  • Increased Vigilance
    • Enroll help of patient, family, nursing
    • Re-evaluate often
    • Visit yourself if possible
after discharge
After Discharge
  • Proven benefit to reduce falls
    • Health screening with followup TARGETED intervention (OR = 0.79; CI = 0.65-0.95)
      • Primarily a balance issue?
      • Primarily a strength issue?
    • Home safety evaluation by OT (19% reduction of falls versus control; decreased falls 36% in those with previous history of falls)
intervention targeted pt
Intervention: Targeted PT
  • Three pooled studies, n = 566
    • Intervention: individually tailored program of progressive muscle strengthening, balance retraining exercises, and a walking plan
  • One-year:
    • Fall RR 0.80, CI 0.66-0.98;
    • Serious injury: RR 0.67, CI 0.51-0.89
  • Two-year (69% intervention, 74% controls):
    • Falls RR 0.69, CI 0.47-0.97
    • Moderate-Serious injury RR 0.63, CI 0.42-0.95
home safety intervention
Home Safety Intervention
  • Home safety evaluation by OT
  • 1 well-designed study
    • n = 530, outcome: # of falls
    • Stratified by falls history
      • Overall RR 0.81, CI 0.66-1.00
      • One or more falls, previous year, RR 0.64 (CI 0.49 – 0.84)
      • No falls, previous year, RR 1.03 (CI 0.75-1.41)
other discharge considerations
Other Discharge Considerations
  • If sending for rehab/PT, be sure information about in-house fall is clearly communicated
    • Rehab a common location for falls: people having mobility challenges with mobility difficulties
    • Previous fallers benefit most from intervention
  • Note fall in discharge summary to be added to patient “problem list”
  • Possibility of the development of fearfulness leading to disability and increased risk of falls
summary
Summary
  • Falls as a geriatric syndrome:
    • Multiple contributing causes with common final pathway
  • Most likely contributing causes:
    • #1 – History of falls
    • Patient factors: balance difficulties, LE weakness, incontinence, medications, cognitive impairment
    • Environmental factors: restraints (formal and informal), bed height, toileting needs, lighting, furniture
    • Mitigating factors: mismatch of mobility with compensatory mechanisms  patient, nursing, family education
summary of teaching points
Summary of Teaching Points
  • Exercises
    • “Get up and Go” Test
    • Bedside restraints “memory” test
  • Dangers of Restraints
  • Discharge Considerations
    • Targeted interventions: observe PT evaluation
    • OT Home safety evaluation
    • Falls added to problem list
u of c nursing initiative
U. Of C. Nursing Initiative
  • Performance Improvement Initiative to Reduce Falls in the Hospital
  • Protocol based on University of Iowa Gerontological Nursing Interventions Research Center
  • Adapted from LTC setting to hospital
  • Pilot to be initiated on 4SE and 4NW floors