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Geriatric Medicine Principles Falls Robert Kirby, MD, FACP Clinical Professor of Medicine. Geriatric Medicine. Geriatric Medicine Principles/ Falls. Learning Objectives: 1. List two characteristics of the geriatric population. 2. Describe two instruments to assess function.

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geriatric medicine principles falls robert kirby md facp clinical professor of medicine

Geriatric MedicinePrinciplesFallsRobert Kirby, MD, FACPClinical Professor of Medicine

geriatric medicine principles falls

Geriatric MedicinePrinciples/ Falls

Learning Objectives:

1. List two characteristics of the geriatric

population.

2. Describe two instruments to assess function.

3. Define geriatric syndrome. Name three.

4. List four risk factors for falls.

5. Outline three interventions to reduce fall risk.

biology of aging

Biology of Aging

Genetic

Oxidative Stress

Mitochondrial Dysfunction

Hormonal Changes

Telomere Shortening (Hayflick Limit)

Defective Host Defenses

Accumulation of Senescent Cells

Harrison on Line

demographics

Demographics

USA 2020 >65 yo 16%

Dependency Ratio-Europe

2050 22% to >50%

Harrison on Line

Merck Manual Geriatrics

demographics1

Demographics

Over Age 65

40% of Hospital Resources

24% of Office Visits

25% of Prescription Drug Costs

25% of Medicare expenditure in last year of life- Half of this in last 60 days

Residents of Nursing Homes

Age 65 1%

Age 85 17%

Merck Manual of Geriatrics

life expectancy

Life Expectancy

Walter LC, Covinsky KE, JAMA 2001

function activities of daily living

Function: Activities of Daily Living

Basic Intermediate

Dressing Shopping

Eating Housework

Ambulating Accounting

Toileting Food Preparation

Hygiene Transportation

principles in a flash

Principles in a Flash

Aging is not a disease.

Geriatric conditions are chronic, multiple, multifactorial

Reversible conditions are underdiagnosed and undertreated

Function and quality of life are critical outcomes

Social support and patient preferences are critical aspects

Geriatrics is multidisciplinary

Cognitive and affective disorders prevalent and undiagnosed at early stages

Iatrogenic disease common and often preventable

Care is provided in multiple settings

Ethical and end of life issues guide practice

  • www.cha.emory.edu/reynoldsprogram
clinical approach

Clinical Approach

Notwhat diseasecaused the problem

But what combinationof physiologic change, impairments and diseases are contributing

And which onescan be modified

Modawal

geriatric syndromes

Geriatric Syndromes

Dementia and Delerium

Falls

Polypharmacy

Pressure Ulcers

Urinary Incontinence

mary anderson

Mary Anderson

This 85 year old widow presents after a fall in the bedroom of the home where she has raised her family and lives independently.

She does not know why she fell, was able to ambulate after the fall and presents six hours later with a bruise on her left cheek and an abrasion on the left forearm.

Daughter reports occasional confusion and some limitation of activities due to weakness. She reports a fall four months ago.

PMH

DJD hips and knees with chronic pain

Hypertension

Macular degeneration

Diabetes 2

Urinary urgency and rare incontinence

slide15

Medications: Hydrochlorothiazide, Fentanyl patch, KCL,Tylenol, MVI

Examination:

BP supine 160/88; standing 3 minutes 168/92

Vision 20/50

Chest – rare crackles right base

Neuro: absent achilles, romberg normal

Gait antalgic secondary to right hip pain

Get up and go test: 18 seconds. Uses arms to arise from chair

Functional Reach test 5 inches

Laboratory:

Hemoglobin 11 gm/dl

K 3.0 meq/L

Glucose 212 mg/dl

Creatinine 1.4 mg/dl

BUN 24 mg/dl

Urinalysis wbc 20, nitrite positive

slide16

Questions about

Mary Anderson

What is the most important risk factor for her recent fall?

What is the most important physical examination finding related to her fall?

What additional diagnostic studies will be helpful?

What is the most important initial step in managing Mary’s fall?

What consultations/referrals would be most useful?

slide17

Fall

“Unintentional coming to rest at a lower position unrelated to obvious intrinsic or environmental factor.”

Importance

Risk Factors

Clinical Assessment

History

Physical Examination

Laboratory

Management

importance

Importance

Prevalence

Ambulatory Adults >65 30% per year

Consequences

Death

Injury

Fractures 10-15%

Hip 1-2%

Long Lie

Fear of Falling

Reduced Activity/Independence (25%)

causes

Causes

Extrinsic

Environment

Intrinsic

Age

Gait/Balance Disorder

Sarcopenia

Vestibular

Orthostatic Hypotension

Special Senses –Vision/Hearing

Disease

Dementia

Depression

Drugs

Foot problems

Incontinence

risk factors

Risk Factors

Muscle weakness: 4.4

History of falls: 3.0

Gait or balance deficit: 2.9

Use of assistive device: 2.6

Visual deficit: 2.5

Arthritis: 2.4

Depression: 2.2

Cognitive impairment: 1.8

Age over 80 years: 1.7

Mean RR or OR of risk factors for falls from 16 studies

Data from AGS Panel on Falls Prevention. Guideline for the prevention of falls

in older persons. J Am Geriatr Soc 2001;49(5):664–72.

slide21

Stride Length

Arm Swing

Slow

Forward Flex

Head and Torso

Flexion shoulders knees

Lateral Sway

Gait

Normal Gait Video

history physical

Laboratory

CBC

CMP

EKG

History-Physical

Injury

Details of Fall

Inability to Get Up

Associated Disease and Disability

Drugs

General

Orthostatic BP

Vision

Cognition ( MMSE)

Gait/Balance/Coordination

g et up and go

Get Up and Go

Normal

Abnormal

slide27

Reducing Fall Risk

Fall Risk Next Treatment

Year (%) Reduces Risk(%)

Fall Past Year 50 30

Gait Problem 30 20

One Risk 20 10

Two Risks 30 20

Three Risks 60 40

Four or More 80 50

Treatable Risks:

1. Problem walking or moving

2. Orthostatic hypotension

3. Four or more meds or one psychoactive

4. Unsafe footwear or foot problems

5. Environmental hazard

www.fallprevention.org

guideline for fall prevention
Guideline for Fall Prevention

JAGS 2001. 49:664-672

management reduce fall risk

ManagementReduce Fall Risk

Environment

Exercise and Balance

Cardiovascular (orthostasis)

Vision

Assistive Devices

Medication Review

Footwear

Behavior Education

Restraints

Rubinstein Med Clin N Am 2006

management reduce fall risk1

ManagementReduce Fall Risk

-47%

Exercise

MMWR Rep 2004;53(2):25-28

Wolf JAGS 1996

reduce fracture risk

Hip Protectors

Reduce Fracture Risk

Vitamin D/Calcium

400-800IU / 1200-1500

Lauritzen JB, Peterson MM et al Lancet 1993; 341:11-13.

slide32

Questions about

Mary Anderson

What is the most important risk factor for her recent fall?

a. History of previous falls

b. Medications

c. Possible urinary infection and/or dementia

d. Gait disorder

e. Visual impairment

slide33

Questions about

Mary Anderson

2. What is the most important physical examination finding related to her fall?

a. Extent of injury and pain

b. Result of blood pressure

c. Result of “Up and Go Test”

d. Visual acuity

e. Neurologic findings

slide34

Questions about

Mary Anderson

What additional diagnostic studies will be helpful?

a. Twenty four hour ambulatory EKG ( Holter) monitor

b. Carotid Doppler study

c. Brain MRI

d. Head-up tilt test

e. Radiograph of chest and hips

f. Electoroencephalogram (EEG)

slide35

Questions about

Mary Anderson

4. What is the most important initial step in managing Mary’s fall?

a. Reduce hydrochlorothiazide and fentanyl

b. Hydrate and treat UTI

c. Treat injury and pain

d. Osteoporosis treatment

e. Counsel on “fear of falling”

f. Recommend hip protectors

slide36

Questions about

Mary Anderson

5. What consultations/referrals would be most useful?

a. Ophthalmology

b. Physical Therapy for strengthening exercise

c. Home safety evaluation by Occupational Therapy

d. Neurology consultation

e. Cardiology consultation

geriatric medicine principles falls1

Geriatric MedicinePrinciples/ Falls

Learning Objectives:

1. List two characteristics of the geriatric

population.

2. Describe two instruments to assess function.

3. Define geriatric syndrome. Name three.

4. List four risk factors for falls.

5. Outline three interventions to reduce fall risk.