Falls: Preventing a Downward Course Thru Assessment of the Geriatric Patient Paula Bordelon, DO

Disclosure

• No conflicts of interest • No financial relationships with pharmaceuticals to disclosure

Objectives

• Teach a systematic approach to assessment of gait and balance • Highlight abnormalities commonly seen in elderly • Increase knowledge STEADI toolkit • Review AGS’s fall guidelines

Case History

• 78-year old female scheduled with you to establish care.

• Presents with her daughter.

• Lives alone and uses no assistive devices.

• Dtr reports 1 fall “mom slipped” • Dtr reports occasional dizziness and balance issues. Patient states “I’m fine”

Case History (cont)

• Meds: HCTZ, glyburide, ASA, temazepam prn • DEXA: osteoporosis of femoral neck • Did your new patient fall?

• Does your new patient need specific intervention to prevent falls?

Falls Affect Morbidity and Mortality

• Falls should not be viewed as normal aging! • Overall nonfatal fall injury rate was 43/100,000 falls (based on those seeking care) • 1 out of 3 seniors fall but < 50% report this • Among seniors falls are leading cause of fatal and nonfatal injuries • 1 in 5 falls cause serious injury

Falls: the Facts

• Falls are common: – About 35% of community-dwelling ages 65-69 fall – > 50% of community-dwelling > age 80 fall • 95% of hip fractures are caused by falls • FALLS CAUSE POOR OUTCOMES!

• Death rate from falls has risen sharply over past decade (64% men; 84% women)

Fall Prevention is Paramount

• Falls are a MAJOR health hazard, up to 30% who fall suffer injuries, lacerations, hip fractures, head trauma • Functional deterioration after falls is common and often leads to institutionalization • Of those who fall, only 50% can arise without assist • Falls are the most common cause of traumatic brain injuries in seniors • 75% of fall-related deaths occur in those > age 65

The Most Costly Fall: Hip Fractures

• Hip fractures are the most costly injuries in terms of mortality, health, reduced quality of life, and admission into nursing home • Recover more slowly • More adverse consequences post-op • 33% of hip fracture survivors spend at least one year in SNF • 20% of seniors hospitalized for hip fracture die within 1 year

What is a fall?

• Any incident that involves unintentionally coming to some lower level (or to the ground) is a fall.

• Older adults frequently have incidents that meet the definition of a fall, but deny falling • Slipping, tripping, stumbling or tumbling.

Who is at Risk?

• Intrinsic Factors – Advanced age – Cognitive Impairment – Sensory Impairment (e.g. decreased vision) – LE weakness – Poor mobility • Extrinsic Factor – Medications • Polypharmacy (> 4) • Psychoactive – Inactivity – Environmental

Who Should Be Screened?

• Anyone age 65 and over should be screened (that is, asked if they have fallen IN THE PAST YEAR!) • Alternative: Have patient answer CDC’s risk factor (12 question) screening

Screening (cont)

• Anyone senior who has fallen, feels unsteady, or a fear of falling, should be evaluated for gait and balance • If senior performs poorly on evaluation, should undergo multifactorial fall risk assessment

How Do You Screen?

• Simply use questionnaire from STEADI toolkit or • Inquire about history of falls: – Have you slipped, tripped, stumbled, or fallen in the last 6 weeks? In the last 12 months?

– Do you feel unsteady when standing or walking?

– Are you fearful about falling?

How Do You Screen? (cont.)

• For “yes” responses, inquire as to frequency, circumstances, and if have difficulty with balance. Getting an accurate history gives you info to prescribe the best plan

How Do We Balance?

• Balance via dynamic input: – Vision – Inner Ear (vestibular) – Proprioceptive Sensing – Strength and flexibility

How Does Aging Affect Balance?

•

• Successful fall prevention begins with knowledge of age-related changes

Vision

reduction in glare tolerance, nocturnal acuity, contrast sensitivity, reduction in peripheral vision and poor depth perception

How Does Aging Affect Balance?

• •

Vestibular

peripheral vestibular excitability declines with age while vestibular dysfunction (e.g. BPPV, Meniere falling ’ s) increases, with loss of hair cells and ganglion cells, contributing to

Proprioception

reduced function occurs in many d/o (e.g. DM, Etoh, malnutrition, cervical spondylosis)

Centers for Disease Control & American Geriatrics Society

• CDC www.CDC.gov/homeandrecreationalsafety/falls/STEA DI • AGS www.americangeriatrics.org/health_care_professional s/clinical_practice/clinical_guidelines_recommendation s/prevention_of_falls_summary_of_recommendations

Key Components of Fall HISTORY

• Get History: Get description of the circumstances of the fall: frequency, symptoms at time of fall, injuries (TARGET INTERVENTIONS) • Review Meds: All prescribed and over-the counter medications with dosages • Obtain History of relevant risk factors: Acute or chronic medical problems, (e.g., osteoporosis, urinary incontinence)

Key Components of PHYSICAL Evaluation

• 1. Lower Extremity Muscle Strength • 2. Exam feet & footwear • 3. Neurologic (cognitive eval, proprioception, peripheral nerves, reflexes, cerebellar function) • 4. Visual acuity (when to consider monocular) • 5. HR, rhythm, BP, check orthostatics

Components of FUNCTIONAL ASSESSMENT

• Assess ADL, including ability to use assistive devices and adaptive equipment • Assess for fear of falling and perceived functional abilities and health

Post-fall Syndrome

• Is a phobic response to the discordant and inaccurate sensory inputs • Creates a self-perpetuating cycle of increasing weakness and instability via joint mobility reductions, physical deconditioning, and poor balance • Loss of self-confidence to ambulate can result in self-imposed limitations Source: Journal of Rehabilitation Research and Development: 40 (1); January/February 2003: 49-58.

Exam of Lower Extremities

• Search for mechanical problems orthopaedic, vascular, podiatric, rheumatic • Examine ROM at hip, knee, ankle • Palpate for pulses at femoral, popliteal, dorsalis pedis, posterior tibial

Exam of Lower Extremity (cont)

•

Muscle Tone (resistance of extension) –

if increased and feet are “ stuck to the floor ” , consider NPH or frontal lobe dysfunction

Neurologic Dysfunction

• Cerebellar Ataxia – Cerebellum processes input from brain, spinal cord, and sensory receptors to provide timing of precise, coordinated movements of skeletal muscle system (e.g. limb position). With ataxia, have dizziness, imbalance, and difficulty coordinating movements

Neurologic Considerations

• Dizziness and Vestibular Ataxia– use inner ear (vestibular) and sensory to balance; consider an etiology for vascular, vestibular, brain stem, trauma, or medication problems

Neurologic Considerations

• •

Romberg

’

s (standing balance with eyes closed) –

presence means sensory deficit (abnormality of proprioception) in peripheral vestibular, peripheral neuropathy, decreased position sense (dorsal column) ; if due to neuropathy, ankle jerks will be absent; if a spinal cord issue, Babinski will be present

Treatment –

good footwear improve lighting, use assistive devices,

Neurologic Considerations

• •

Cerebellar signs –

presents with incoordination, ataxia, unsteadiness with eyes open. If positive, determine rapidity of onset. Acute: posterior fossa stroke; Subacute: mass, demyelinating or degenerative processes, metabolic disorder, or drug effect

Treatment –

assistive devices, reduce clutter, gait training

Neurologic Considerations

• •

Sternal nudge –

with staggering or becoming unstable, consider neurologic or back disease

Treatment –

remove clutter, prescribe assistive devices, avoid slippers or loose-fitting shoes

Neurologic Considerations

• •

Unstable with turns –

with instability, consider cerebellar, reduced proprioception, hemiparesis, or visual field cut

Treatment –

gait training, prescribe assistive devices, proper fitting shoes, reducing obstacles

Functional Examination

• Evaluate patient ’ s gait. Note symmetry, speed, and ability to walk in a straight line/path undeviating.

• Is center of gravity altered? (Wide-based?) • Look for hesitation with turns when pivoting.

• Note if good arm swing and if there is sound distance between floor and soles of feet.

Functional Evaluation of Gait: “ Timed Up and Go ” (TUG): per STEADI • “TUG” should be able to execute in < 13 seconds • Difficulty of arising from chair suggests proximal muscle weakness, arthritis, or neurologic disease • Treatment: portable seat lift, muscle strengthening exercises, increase functional mobility, treat specific illness

Functional Examination: 4-Stage Balance Test: per STEADI

• Test stance: Side-by-side, semi-tandem, tandem stances, and balancing one foot.

• If cannot perform side-by-side, semi tandem, or tandem stances, senior is at increased risk

Functional Exam: One Opinion*

• Failing – Side-by-side: if “ fail ” , need walker and PT – Semi-tandem: if break early, need walker and PT; mid-break, need cane; late break, order balance (e.g. Tai Chi) and exercise classes – Tandem: balance and exercise classes • *my personal opinion

Functional Examination: 30-second Chair Stand: per STEADI

• Results are based on sex and age and grid that details “Below Average Scores” • If patient scores are below average, he is at risk for falling and needs intervention

Other Aspects of Examination

• Psychiatric – Brief screen for cognitive functioning – Brief screen for mood (depression) – Assess for fear of falling: Do you have a fear of falling? If yes, does your fear decrease your activity level?

Appliances Recommended to Reduce Morbidity and Mortality • Reachers • Portable seat lift • Special step stools • Hip protectors (controversial, falling in and out of favor)

Interventions for Community Dwellers: According to AGS

• Adaptation/modification of home environment [A] • Withdrawal/minimization of psychoactive medications [B] • Withdrawal/minimization other medications [C] • Management of postural hypotension [C] • Management of foot problems and footwear [C] • Exercise, particularly balance, strength, and gait training [A]

Strength of Recommendation Rating System

• • [ A ] A strong recommendation that the clinicians provide the intervention to eligible patients.

Good evidence was found that the intervention improves health outcomes and the conclusion is that benefits substantially outweigh harm.

• • [ B ] A recommendation that clinicians provide this intervention to eligible patients.

At least fair evidence was found that the intervention improves health outcomes and the conclusion is that benefits outweigh harm.

• • [ C ] No recommendation for or against the routine provision of the intervention is made.

At least fair evidence was found that the intervention can improve health outcomes, but the balance of benefits and harms is too close to justify a general recommendation.

Strength of Recommendation Rating System

• • [ D ]Recommendation is made against routinely providing the intervention to asymptomatic patients.

At least fair evidence was found that the intervention is ineffective or that harm outweighs benefits.

• • [ I ] Evidence is insufficient to recommend for or against routinely providing the intervention.

Evidence that the intervention is lacking, or of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

Quick Tips

• Studies demonstrate that Vitamin D supplementation (800 IU/day) reduces falls • Patients using monocular (single vision) vision glasses when performing activities and walking are less likely to fall

The Bottom Line

• Falls are treatable geriatric syndrome • Screening for falls begins with one question • Falls can be reduced by up to 40% with intervention • Medicare typically covers services needed to treat patient ’ s risk factors

Conclusion

• Falls are complex and multifactorial • Marker of frailty • What predisposes persons to falling often produces observable disturbances in gait and balance —so assess in office • Interventions most likely to prevent injury are exercise and environmental modification