doron garfinkel, m.d. head, geriatric paliative department

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Falls and Fall Prevention in the Elderly. DORON GARFINKEL, M.D. HEAD, GERIATRIC PALIATIVE DEPARTMENT. SHOHAM GERIATRIC MEDICAL CENTER PARDES – HANA, I S R A E L. Falls in the Elderly. Overview. Prevalence Clinical Importance Risk Factors & Etiology Evaluation - PowerPoint PPT Presentation

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  • DORON GARFINKEL, M.D.HEAD, GERIATRIC PALIATIVE DEPARTMENT SHOHAM GERIATRIC MEDICAL CENTERPARDES HANA, I S R A E LFalls and Fall Prevention in the Elderly

  • OverviewPrevalenceClinical ImportanceRisk Factors & EtiologyEvaluation Prevention & ManagementFalls & restraint useSummaryFalls in the Elderly

  • Prevalence30% of those over 65 fall annuallyHalf are repeat fallersFalls go up with each decade of lifeOver half of those in nursing homes and hospitals will fall each year

  • The incidence of falls increase with age Each year 30 - 40% of community-dwelling persons > 65 years old have a fall.The annual incidence of falls among people who experienced a fall in the previous year, is almost 60%.

    FALLS - INCIDENCE 25% - AGE 65 74, 33% - AGE > 75 120% AGE > 80 ( > ONE FALL / Year)

  • Clinical Importance Impact of Hip Fractures1% of falls result in hip fracture$2 billion + in medical costs annually25% die within 6 months60% have restricted mobility25% remain functionally more dependent

  • Falls Cause Morbidity & MortalityMortality: indirect effectsFractures: 6% of fallsSoft tissue injury, head injury, subdural hematomaFear of falling can result in decreased activity, isolation, and further functional declineNursing home placement & loss of independence

  • FALLS - A LEADING CAUSE OF MORBIDITY, DISABILITY & DEATHComplications resulting from falls are the leading cause of death from injury in adults aged 65 and older.Fear, Loss of ConfidenceDecreased FunctioningDependencyPhysical Trauma - 10% FRACTURES - 5%- 15%

  • Risk Factors & Etiology Falls are MultifactorialIntrinsic FactorsExtrinsic FactorsFALLSMedical conditionsImpaired vision and hearing

    Age related changesMedications

    Improper use of assistive devices

    Environment

  • Age - Related Changes NeurologicIncreased reaction timeDecreased righting reflexesDecreased proprioceptionVision ChangesDecreased accommodation & dark adaptationDecreased muscle mass

  • Age - Related ChangesG A I T Slower gaitDecreased stride length & arm swingForward flexion at head and torsoIncreased flexion at shoulders and kneesIncreased lateral sway

  • D y s m o b i l i t yDysmobility and falling closely related15% of those over 65 have trouble walking1/4 men and 1/3 women over age 85 have difficulty with walking2/3 of people in hospital or NH unable to ambulate without assistance

  • Risk Factors for Falls 28

    Cognitive Impairment 5Lower extremity problem 4Pathologic Reflex 3Foot Problems 2> balance/gait problems 1.9Tinetti NEJM 1988Risk Factor ORSedative use

  • Common Pathologies associated with FallsOphthalmologic diseasesArthritis Foot problems Neurologic illnessParkinsons & related disordersStrokesPeripheral neuropathyDizziness and dysequilibrium

  • Dizziness: A Multifactorial SyndromeVertigo: Posterior CVA/TIA, Cervical Presyncope: Orthostatic, Dysrythmia, AnemiaDysequilibrium: Peripheral neuropathy, VisualOther: Anxiety, depressionIn older people, usually multifactorial Tinetti, Annals of Internal Med 2000

  • Falls in the CommunityAccidents/environment37%Weakness, balance, gait12%Drop attack 11%Dizziness or vertigo8%Orthostatic hypotension5%Acute illness, confusion, drugs, decreased vision18%Unknown 8%Rubenstein JAGS 1988

  • Falls in Residential CareGeneralized weakness31%Environmental hazard27%Orthostatic hypotension16%Acute illness 5%Gait or balance disorder 4%Drugs 5%Other or unknown 10% Rubenstein Ann Int Med 1990

  • Medications and FallsSedative-hypnotics, especially long acting benzodiazepines, Small association between most psychotropics and fallsSSRIs and TCAs both increase fallsWeak association between Type 1A antiarrythmics, digoxin, diuretics, and fallsLeipzig JAGS 1999Thapa NEJM 1998

  • Evaluation of Falls in the Elderly Medical HistoryLocation & circumstances of FallAssociated symptomsOther falls or near fallsMedications (including nonprescription) and alcoholInjury & ability to get up

  • Evaluation of Falls in the Elderly Physical ExaminationSupine and standing BP - alwaysRoutine physical examinationFocus on cardiovascular, MS, neuro, feetVision and hearing evaluationConsider acute medical illness & deliriumFormal gait and balance assessment

  • Evaluation of Falls: Home EvaluationCan be performed by nurse, OT, PT, othersStairsLightingBathroomSpecific hazards: cords, throw rugs

  • Evaluation of Falls: Risk Factors for InjuryOsteoporosis assessmentAnticoagulation: Usual benefits outweigh risks unless repeat or high risk fallerCan the person get up from fall?Is there a way to notify others in case of falling?

  • POMA: Balance ComponentSitting (in hard, armless chair)ArisingStanding balance (immediate and delayed)Balance with NudgeBalance with Eyes closedBalance with 360 degree turn Tinetti JAGS 1986Formal Gait EvaluationGet up and Go TestTinetti Gait & Balance Evaluation (POMA)

  • POMA: Gait ComponentInitiationStep length and heightStep symmetry & continuityPathStance Ability to pick up speed Tinetti JAGS 1986

  • Prevention & TreatmentTreat acute injury & underlying medical conditionsRemove unnecessary medicationsRehab, exercises, assistive devicesCorrect sensory impairmentsEnvironmental modifications & safetyEvaluate for osteoporosis treatment

  • OsteoporosisCalcium and vitamin D for most elders at risk Dawson-Hughes, NEJM, 1997Osteoporosis evaluation and treatment Thiazides may help slightlyStatins?Hip protectors appear to protect from hip fractures in those who wear themKannus, NEJM, 2000

  • Change Estimated Change in RiskQuit smoking 38%Treat impaired vision50%Stop sedatives40%Add 1 Gram Calcium24%Hip Protectors50%? Adapted from Steeve CummingsRisk Factor Modifications for Fractures

  • Falls: Primary Prevention301 community dwelling elders with 1+ risk factors for fallingIntervention: adjustment in medications, behavioral instructions, exercise programs aimed at modifying risk factorsOne year follow upTinetti et al. 1994 NEJM

  • Multifactorial InterventionP = .04 Tinetti et al 1994 NEJM

  • Exercise Training & NutritionFiatarone et al NEJM 1994

  • Tai Chi and FallingAtlanta FICSIT Trial

    200 community dwelling elders 70+Intervention: 15 weeks of education, balance training, or Tai ChiOutcomes at 4 months: Strength, flexibility, CV endurance, composition, IADL, well being, fallsFalls reduced by 47% in Tai Chi group Wolf JAGS 1996

  • Campbell BMJ 1997Training frail older persons: The New Zealand Study of Women223 women >80 yearsIntervention: PT tailored to individual needs, with resistance and balance training

    Results:Clinical balance, chair rise improvedRR for falls .47 (CI .04-.90)RR for injurious falls .61 (.39-.97)

  • SummaryFalls are common in the elderly & may lead to injuries and decline in functionEvaluation should included risk factor assessment, gait assessment, and home assessmentExercise can improve outcomesWe have no evidence that restraints reduce fall related injuries

  • Doron Garfinkel

    EFFICACY OF HIP PROTECTORS IN THE PREVENTION OF HIP FRACTURES IN PATIENTS WITH DEMENTIA Shoham Geriatric Medical CenterPardes Hana, Israel

  • A G I N G INSTABILITYSARCOPENIADISABILITY DEMENTIAOSTEOPOROSISFRACTURE THE VICIOUS CIRCLE F A L L S

  • 10-15% of Falls result in fractures In the US - 90 percent of more than 350,000 hip fractures each year are the result of a fall. FALLS & HIP FRACTURES An estimate of 1.3 million hip fractures occurred worldwide in 1990, By 2050 in the US alone, there will be an estimated No. of 650,000 hip fractures annually Nearly 1800 hip fractures a day!

  • No.(x 1000)USAUK ?198020002050ESTIMATED

  • Hip fractures is the commonest reason for admission of elderly people to an acute orthopedic wardHIP FRACTURES - OUTCOMESJohnell & Kanis, Osteopor Int 2004; 15: 897 902. The death rate attributed to falls also increase with age, reaching at age > 85 180 deaths per 100,000 population

  • Each year, 8% of people > 70 years old reach the Emergancy Room, as a result of Fall - related injuries Those admitted are hospitalized for an average of 8 days. These hip fractures may result in . permanent disability accounting for a significant portion of the Global Burden of Disease

    HIP FRACTURES - OUTCOMES

  • Only 25 percent of patients with hip fractures will make a full recovery 50 percent will need some assistance - cane or walker HIP FRACTURES - OUTCOMES 40% will require Long Term Care (nursing homes & nursing departments) In the US, the cost of fall-related injuries is estimated as 12,6 billion dollars yearly

  • - 700,000 65 - 6,000

    - 75,000 "

    - 450 !!!

  • 50 50 ==40% = , :- 40% , 60% (ADL).

    - / 24 - 48 ,