Falls - Ipswich and East Suffolk CCG
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Transcript Falls - Ipswich and East Suffolk CCG
Falls – an over view for
GPs
Julie Brache
Consultant Geriatrician and Falls Lead
October, 2014
Overview
Why older people fall
Multifactorial risk assessment
Normal changes with ageing
Dizziness and syncope
Medication review
Multifactorial interventions
Where to get advice
Definition
when an individual comes to rest
unintentionally on the ground or
another lower level, with or without
loss of consciousness
Background
• 35% >65 living at home fall each year
£2.3 billion per year
10% injury
After a fall 50% have reduced mobility
Leading cause of injury related death in older adults
Preventable
N
Evidence based national
and international
guidelines
Fall is a symptom,
not a diagnosis
‘Old age starts with the first fall
and death comes with the
second’
Gabriel Garcia Marquez “Love in the time of cholera”
Frailty
Reduced ability to withstand illness without
loss of function
Muscle weakness, reduced walking speed,
reduced physical activity, weight loss, self
reported exhaustion
Would you be surprised if this person died in
the next year?
Falls are multifactorial
Why do older people fall?
Muscle weakness
Frailty
Poor balance
Environment
Gait deficit
Depression
Polypharmacy
Cognitive impairment
Sensory loss – vision,
hearing, peripheral
Incontinence
Medical illness
Nutrition
Dizziness
Osteoarthritis
Alcohol
Previous falls
CV problems
Neurological
History
Circumstances of falls
Activity at the time
Where and when
Lightheaded, dizzy, LoC, chest pain, palpitations, visual
disturbance?
Seizure markers?
How many falls in the last year?
Taking the history –some
pointers
Allow them to describe everything first,
then get the history you need
Describe a single fall in detail
Take them through it in fine detail
Then ask about
associated symptoms
Witness account is vital
History - pitfalls
“It was nothing”
“I haven’t fallen”
“I tripped over the cat”
“I must have…….”
“They had a fit, doctor”
Assess
Continence
Cognition
Frailty
Alcohol intake
Psychological consequences of falling
Fear, anxiety, depression
Examination
Cardiovascular
Pulse – rate and rhythm
Heart sounds
3 min lying and standing BP
Drop 20 systolic or 10 diastolic or to <90 significant
Only 23% will describe dizziness
ECG
Examination
Focused neurological examination
Lower limb strength – hip and ankle flexors
Peripheral sensation
Evidence of stroke, Parkinson’s cerebellar signs?
Gait and balance
Vision
Ageing and gait
Slower
Increased sway
Slowed postural support responses
Shorter stride length
Increased time in double support
Loss of rhythm
Loss muscle bulk, reduced postural reflexes, JPS
Gait disorders in the elderly
Parkinsonism
Cerebrovascular disease
Cervical spondolytic myelopathy
Sensory neuropathy
Foot drop
Don’t forget Normal Pressure
Hydrocephalus
Gait and balance assessment
Not all for the Physio!
Gait:
Get Up and Go
Balance:
Proprioception – vision- vestibular function
-> Romberg's
-> Head Thrust
Ageing and vision
↓Acuity
↓Depth perception
Lens density changes- glare
Decreased rod density - ↓Light adaptation
- ↓ contrast
sensitivity
↓ Visual processing speed
Vision
Test acuity and fields
ARMD, glaucoma, stroke,
diabetes, cataract
Bifocal / varifocal glasses, change in
prescription
SPECTACLE USE
5.7 Optometrists and dispensing
opticians should consider supplying an
additional pair of single vision
spectacles (to wear in outdoor and
unfamiliar settings) for older people
who take part in regular outdoor
activities
Examination
Other
Cognition
Foot wear and feet
Take the shoes off!
Dizziness
Vertigo
Pre-syncope
Dysequilibrium
Vertigo
Illusion of rotation
“The room was spinning”
Nystagmus during
episode
Labyrinth or vestibular
problem
Occasionally cerebellar
or CP angle
Treat acute attacks with
anti-histamines
Benign Paroxysmal Positional
Vertigo
Vertigo on change in position
Self limiting
Disabling
Hallpike- Dix test
Epley manoeuvre
Vestibular rehab
Cawthorne- Cooksey exercises
Brandt - Daroff
Pre-syncope
Sense of feeling faint or
light-headed
“Legs went weak”
“Vision blurred ”
Pallor, weak/slow pulse
Same causes as syncope
Often a sign of postural BP
drop
Cardiovascular assessment
Treat underlying cause
Dysequilibrium
Balance dysfunction
A sense of unsteadiness
“Thought I was going to fall”
Often multi-factorial
Sensory impairments and/or
CNS disease
Multidisciplinary management
Syncope
23% >65s over 10 years
High recurrence rate
Spontaneous LOC with complete recovery
Diagnosis difficult and often wrong
Syncope in the Elderly
Cerebral autoregulation impaired
Baroreflex sensitivity blunted
Volume regulation impaired
Comorbid illness and medications
Syncope diagnosis
All in the history
DETAIL
Posture
Prodrome
Eye movements
Tongue biting/incontinence
Injury
Duration
Confusion
Hemi weakness
Red flags
Abnormal ECG (NICE)
Heart failure
Syncope during exertion
FHx sudden death <40
New/unexplained SOB
Murmur (NICE)
Assessment
Vasovagal – 3Ps
Cardiovascular – if in doubt
ECG, 24 hour tape, event recorder, implantable
device, tilt table test + carotid sinus massage,
cardio ref
Neurological
CT head, EEG (?value in elderly), neuro ref
Tilt Tests
Unexplained, recurrent
syncope
Single syncope in high risk
settings
Unexplained recurrent falls
Falls and acute illness
Fall often the presentation of an
acute illness
Think of falls risk when unwell
diuretics, antihypertensive, steroids,
anticholinergics, sedatives
urinary urgency/frequency
Delirium
Medication review
Drugs in the elderly
UK elderly 18% pop – 45% all prescriptions
In NH in 1 year 97% will receive a prescribed
drug – 71% in community
Polypharmacy - >4 drugs = risk falls
Principles of Medication
review
Review indication – is there evidence?
Review dose
Reduce the number of medicines
Avoid complex regimes
Review benzodiazepines and other psychotropic
drugs
Check L&S BP – if drop review culprit drugs
Medication and Falls Risk
“Therapeutic effect”
Interactions
Side effects
2/52 after change in meds – high risk time
Stopping – can be difficult
“Therapeutic effect”
Meta-analysis – sedatives and hypnotics
Improve sleep duration and reduce night
time wakening
NNT sleep 13
NNT any adverse event 6
BMJ 2005;331:1169
Side effects –
anticholinergic activity
Antiemetics – cyclizine,
prochlorperazine
Antiparkinson –
amantadine, benzhexol
Antispasmodics –
oxybutynin
Bronchodilators ipatropium
Antiarrhythmics disopyramide, procainamide
Antidepressants –
tricyclics
Antipsychotics –
chlorpromazine,
prochlorperazine
Time to reconsider
warfarin?
50% elderly in AF not on warfarin
Falls is the main reason
>300 falls per year for bleeding risk to
outweigh stroke risk
Ageing and Pharmacokinetics /
Pharmacodynamics
Distribution
↑blood (& tissue) conc water sol drugs
↑ vol distribution lipophilic drugs
Hepatic metabolism
Metabolism by C P-450 reduced
Reduced 1st pass metabolism – some drugs
Renal elimination
Reduced GFR with age
Changes in drug-receptor interactions
Osteoporosis assessment
FRAX – but beware over 80s
Calcium and vitamin D
Reduce falls
All housebound fallers, and RH/NH
residents
800iu daily vit D
• Long term anticonvulsants – check vit
D level
Hip protectors
Controversial area!
At home –
ineffective
Institutions?
Current advice:
May be useful in
confused elderly in
institutional care
Multifactorial interventions
Treat any problems found
Evidence based recommendations:
Strength and balance training
Home hazards assessment & intervention
Vision assessment and referral
Medication review and
modification/withdrawal of psychotropics
Education
How to get advice
Geriatric Advice Line
07930 181236
Clinics
Falls clinic
Nurse, therapist and doctor, 2 hour appointment,
on-going therapy via referral to community teams
Geriatric clinic
Doctor, 45 min appointment
If you just want therapy – refer to community teams
If already seeing community team – refer to geriatric
clinic
PLEASE send as much information as possible
Take home messages
Some falls are preventable
Requires time consuming multifactorial
assessment, identification and intervention
Can’t do it alone
Always review medication
Don’t forget bones
A friendly geriatrician is always on the end
of the phone
Questions?