Falls: A Case Close to Home

1. Falls: A Case Closeto Home Geriatrics Interclerkship April 30, 2012 Gary Blanchard, M.D.

2. “Gait deferred”

3. Why are we so concernedabout falls?

5. Patient H.B. • 86 years old, independently living on Cape Cod with her husband x 65+ years. • She is largely independent with her ADLs – but requires IADL assistance. Inconsistently uses her walker. • She has frequent falls (16) – some of which have resulted in hospitalization – in the past 18 months.

6. Patient PMHx • Type 2 diabetes – oral medications • Cataracts, visual impairment • Mild cognitive impairment, anxiety features • Delirium episodes (hospitalizations) • Hypertension • Meds: lisinopril 20 mg once daily, carbamazepine 200 mg twice daily, lorezapam 0.5 mg nightly, metformin 500 mg twice daily, ASA 81 mg daily

7. Her perspective: • She wants to remain at home, where she has always been. She steadfastly wants to maintain her independence. • She acknowledges inherent risk of current living situation – and that her husband is also declining functionally.

8. Her grandson geriatrician’s perspective:

9. Underappreciated • “Can cause lasting discomfort and decreased function … cause discomfort and disability for older adults and stress for caregivers.” (JAMA, 2010) • Major contributor to functional decline and health care utilization. • Increased likelihood of nursing home placement. • Fear of falling – debilitating.

10. Pearls • Not a normal part of aging • Red flag – a sentinel event for illness, functional decline, frailty • Consider: presentation of acute illness

11. Not normal, but common • More than 1/3 of community-living adults >65 fall each year. At least half recur. • Roughly 1 in 4 fallers limit their lifestyle/activities due to fear of falling. • Roughly 10% of falls result in major injury (fracture, etc.). Also: inability to rise without help (rhabdomyolysis, pressure ulcers, dehydration)

12. Mortality • Accidents (commonly falls) are the 6th leading cause of death • Clustering of falls is associated with a high 6 month mortality • Falling increases the mortality rate of patients with Alzheimer's Disease

13. Morbidity • 4-6 % of falls result in a fracture • 1-2% of falls result in a hip fracture • >50% of older adults with a fall-related hospitalization are discharged to a nursing home • Falls account for 10% of ER visits and 6% of urgent hospitalizations for older adults

14. Why do people fall?: • Vulnerable host, wrong environment • Requires coordination among sensory (vision, vestibular, proprioception), CNS, peripheral nervous system, cardiopulmonary, musculoskeletal, and other systems. • Need >1 systems affected.

15. Risk factors (cumulative): • Previous falls • Balance impairment • Decreased muscle strength • Visual impairment • Medications (but chronic diseases can increase fall risk, too) • Gait impairment • Dizziness/orthostasis • Functional limitations

16. Systematic Approach Vestibular, cerebellar Orthostasis Decreased muscle strength Neuropathy http://www.technovelgy.com/graphics/content07/doctor-bot-operation.jpg

17. How do you evaluate the faller? • History, exam? • Why might my grandmother fall? • What workup would you do for my grandmother?

18. History

19. Patient PMHx • Type 2 diabetes – oral medications • Cataracts, visual impairment • Mild cognitive impairment, anxiety features • Delirium episodes (hospitalizations) • Meds: lisinopril 20 mg once daily, carbamazepine 200 mg twice daily, lorezapam 0.5 mg nightly, metformin 500 mg twice daily, ASA 81 mg daily

20. Patient PMHx • Type 2 diabetes – oral medications • Cataracts, visual impairment • Mild cognitive impairment, anxiety features • Delirium episodes (hospitalizations) • Meds: lisinopril 20 mg once daily, carbamazepine 200 mg twice daily, lorezapam 0.5 mg nightly, metformin 500 mg twice daily, ASA 81 mg daily

21. Physical Examination • Gait, balance, mobility, muscle stregth, lower extremity joints • Neurological: Cognition, peripheral nerves, cerebellar, proprioception, extrapyramidal • Cardiovascular: orthostatics, rate/rhythm • Visual acuity • Examine feet and footwear

23. Watch ‘em walk • Observation is critical Demonstrate: • Timed ‘Get up and Go’ • ADL performance screen

24. Functional assessment • Assess ADL skills (mobility aids) • Assess perceived functional abilities and fear of falling • Environmental: home safety assessment (PT, OT, VNA)

25. Workup/Management Plan

27. Effective Interventions • Best when customized, multidisciplinary • Best single: PT, exercise, cataract surgery, medication reduction. • Vitamin D strongest evidence for preventing fractures among older men at risk.

28. 2010 AGS Guidelines • Multifactorial assessment: feet and footwear, functional assessment, an environmental assessment (home safety), and ask about their perceived functional ability and fear of falling. • Medications, particularly antipsychotics and psychoactive medications, should be minimized or withdrawn. • Postural hypotension assessment.

29. 2010 AGS Guidelines • An 800-IU supplement of vitamin D. • An exercise regimen that focuses on balance, gait, and strength training, such as tai chi or physical therapy. • For older patients who need cataract surgery, the intervention should be expedited.

30. Effective Multi-factorial Interventions for Fall Prevention • Gait training/assistive device training • Review and modify medications • Critically evaluate need for psychotropic medication • Exercise programs (strength and balance) • Treat orthostatic hypotension • Modify environmental hazards and activities • Treat cardiovascular disorders

31. Our patient: H.B.

32. Our patient: H.B. • Safety v. independence • ASK!!! (Annual screen >70) • Targeted, multi-factorial interventions have been shown to be effective at reducing falls in the home.

33. Reference • Tinetti, M.; Kumar, C. “The Patient Who Falls: It’s Always a Trade-Off.” JAMA. 2010; 303(3):258-266. doi: 10.10.2010 • AGS Clinical Practice Guideline : Prevention of Falls in Older Persons (2010) • McGee, Sarah, MD, MPH. “Mobility and Functional Assessment.” UMMS Geriatrics Interclerkship, March 28, 2008. • Bradley, S.; Chang, C. “Falls,” POGOe. Mount Sinai School of Medicine. Brookdale Dept of Geriatrics and Adult Development. March 4, 2008.