Falls In The Elderly

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Contents 1 More Specific Terms 2 Introduction 3 Etiology 4 Epidemiology 5 History 6 Laboratory 7 Diagnostic-procedures 8 Radiology 9 Complications 10 Management 11 More General Terms 12 Additional Terms 13 References

More Specific Terms

• in hospital falls

Introduction

• Definition of a fall: A sudden, uncontrolled, unintentional, non-purposeful downward movement hitting the floor or an object such as a chair ( VA 96).

Etiology

• intrinsic factors

• syncope#
• neurologic disorders

• comorbidities in the elderly

• cognitive impairment, Alzheimer's disease [15]
• stroke [15]
• Parkinson's disease
• depression

• gait & balance disorders [15]

• vestibular dysfunction
• proprioceptive dysfunction

• neuropathies

• vitamin B12 deficiency
• pyridoxine toxicity
• GALOP syndrome
• chronic idiopathic ataxic neuropathy

• drop attack

• musculoskeletal disorders

• underlying pathology

• deconditioning
• arthritis
• paralysis

• muscular weakness
• sarcopenia
• joint pain
• foot problems

• sensory impairment

• visual disturbance

• multifocal eye glasses [20]

• hearing impairment
• chronic pain may perturb other sensory modalities [21]

• cardiovascular disorders

• postural hypotension [14]

• diminished baroreceptor sensitivity
• diminished arterial compliance, wide pulse pressure

• postprandial hypotension [3]
• cardiac arrhythmia
• carotid sinus syndrome

• acute medical illness
• medications

• psychotropic drugs top the list

• sedative/ hypnotics - benzodiazepines - barbiturates - anxiolytics
• antipsychotics (any or all) - risperidone (produces parkinsonism) [5]
• antidepressants - tricyclic antidepressants [5] - selective serotonin reuptake inhibitors ( SSRI) [5] - monoamine oxidase inhibitors [32]

• anticonvulsants [32]
• diuretics*
• class 1a antiarrhythmic agents
• antihypertensive agents
• Alzheimer agents
• glucocorticoids
• 4 or more medications

• risky behaviors

• hurrying or running, especially when carrying heavy load
• high-risk activities, particularly standing on unsteady object

• fear of falling is a risk factor for falls in the elderly [23]

• Extrinsic factors

• environmental obstacles
• slippery surfaces
• ill-fitting clothes & footwear
• poor lighting
• inappropriate furniture

• risk of a fall at home is greatest in the 2 weeks immediately following hospitalization [3]
• # establish syncope vs non- syncope in initial assessment
• * Ref 5 states diuretics NOT associated with falls

Epidemiology

• 1/3 of community-living individuals > 75 years of age fall at least once in a year; 1/2 of these have multiple falls
• 5% of falls in the elderly result in a fracture; 1% in hip fracture
• account for 40% of admission to nursing homes
• women more likely than men to sustain injury after fall
• risk of in home falls is greatest in 2 week period after hospitalization

History

• ask about previous falls

• circumstances of previous falls

• ask about risk factor for falls

Laboratory

• serum chemistries

• serum vitamin B12
• Chem 7 panel

• serum glucose, serum Na+, serum K+, serum creatinine, BUN

• serum Ca+2

• complete blood count ( CBC)
• thyroid function tests [32]

• serum TSH, thyroxine (total) in serum, free T4

• serum 25-hydroxyvitamin D [32]
• therapeutic drug test if indicated

• anticonvulsants, antiarrhythmics, tricyclic antidepressants, aspirin [32]

Diagnostic-procedures

• performance-based balance & gait testing

• have the patient rise from a chair, walk down a hall, turn, walk back & sit again
• Tinetti balance & gait evaluation [16]
• get-up & go test
• one leg balance [7]

• Morse fall risk assessment scale
• echocardiogram if syncope
• Holter if syncope: event-recorder is better

Radiology

• X-ray of injuries
• bone mineral density: men >= 70 years, women >= 65 years
• neuroimaging

• head injury
• new focal neurologic sign

• magnetic resonance imaging of spine for suspected

• cervical spondylosis
• lumbar spinal stenosis

Complications

• long- bone fractures, especially hip fracture
• pelvic fracture
• intracranial injury (11% vs 8%)
• death:

• strongest predictors of in- hospital mortality

• Glasgow Coma Scale score <15
• age >=70 [25]

Management

• a multidisciplinary approach

• physician
• physical therapist

• physical therapy in long term care facilities has resulted in improved physical performance & improvement in ADL but has not reduced falls [3]

• podiatrist [29]
• home assessment nurse

• risk factor reduction reduces incidence of falls by 46% [7,16,18]
• discontinue offending medications if possible [14,16]

• medications most readily modifiable risk factor [18]
• psychotropic agents top the list of implicated drugs [26]

• fludrocortisone for postural hypotension
• adequate nutrition & hydration
• physical therapy

• balance & gait training contributes more to fall reduction than does strength training [3] {see FICSIT trial}
• muscle strengthening

• combined strength & balance training may be better [5]

• walking exercise alone has NOT been shown to reduce risk of falls [3]

• correction of vision & hearing problems [16]
• treatment of underlying illnesses
• home safety evaluation ( occupational therapy)

• elimination of environmental hazards
• remove electrical cords & loose items from floor
• use shallow-pile carpet or non-skid wax on floor
• grab bars in bathroom (toilet & shower)
• properly fitting shoes
• improved lighting, eliminate glare

• individualize care plan [5,6]

• fall-prevention programs are labor-intensive
• fall- prevention programs can have unintended consequences among some patient populations [28]

• falls are especially difficult to prevent in

• patients with dementia [4]
• hospitalized or institutionalized elderly [13]

• warning posters placed over patient beds may be of benefit [24]

• vitamin D 800-1000 IU/day may reduce risk of falls by increasing muscle strength [8,12,19,22]

• number to treat: 15 to prevent one fall [8]
• hazzard ratio: 0.74 [12]

• most elderly who have alarms do not use them [17]
• see Veterans Administration guidelines below
• prognosis: unability to get up & longer down times portend poor outcomes [17]
• Follow-up:

• monthly for 3 months, then quarterly to assess risk factors
• keep diary of falls; falls are under-reported
  

• Veterans Administration guidelines, Falls management:
  
• LOW RISK

• the patient/family on the following Fall Prevention:

• Activity level and orders
• Making sure that <A9370>wheelchair</A9370> and commode brakes are locked
• Wear non-skid slippers
• How to maximize safety (i.e., eliminate <A228>spills</A228>, <A751>clutter</A751>, etc)
• <A342>Medication</A342> time/dose, side effects, and precautions
• <A140486>Call</A140486> for assistance with <A30556>activities</A30556> out of bed, as appropriate

• Maximize environmental safety as listed:

• Lock all moveable equipment
• Maintain occupied bed in low position
• Maintain adequate and appropriate lighting

• <A147012>HIGH</A147012> <A2427>RISK</A2427>

• the patient/family on <A350248>fall prevention</A350248> as listed above
• Maximize environmental safety as listed above
• Increase the frequency of rounds
• Anticipate ADL needs
• Assistance with <A30556>activities</A30556> <A2477>out of bed</A2477>
• Hip Protectors, consider for patients with:

• history of falling
• low bone density or osteoporosis
• over the age of 80
• normal or underweight,
• history of prior hip fracture

• data not very supportive of benefit for hip protectors
  

• guidelines, Falls management: .

• multifactorial assessment of fall risk including:
• examination of feet & footwear
• a functional assessment
• an environmental assessment that includes home safety
• assessing the patient's perceived functional ability & fear of falling

• minimize medications, particularly antipsychotics & other psychoactive drugs
• assess & treat postural hypotension
• vitamin D 800 IU per day for all older adults at increased risk for falling
• in community-dwelling elderly, a multifactorial intervention that includes exercise that focuses on balance, gait, & strength training, such as tai chi or physical therapy
• identify & treat cataracts, i.e. cataract surgery, ASAP

More General Terms

• geriatrics
• accidental fall

Additional Terms

• environmental assessment for fall risk
• get up & go test (timed up & go, TUG)
• hip fracture
• Morse fall risk assessment scale
• retropulsion (tendency to fall backward)
• risk factors for falls
• Tinetti gait & balance evaluation

References

1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1023-24
2. Rubenstein L, Intensive Course in Geriatric Medicine, UCLA School of Medicine, Marina De Ray, 09/01
3. Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004; 7th edition 2010
4. Journal Watch 23(4):36, 2003 Shaw FE, Bond J, Richardson DA, Dawson P, Steen IN, McKeith IG, Kenny RA. Multifactorial intervention after a fall in older people with cognitive impairment and dementia presenting to the accident and emergency department: randomised controlled trial. BMJ. 2003 Jan 11;326(7380):73. Erratum in: BMJ. 2003 Mar 29;326(7391):699. <PubMed> PMID: [1] <Internet> [2]
5. Journal Watch 24(10):81, 2004 Chang JT, Morton SC, Rubenstein LZ, Mojica WA, Maglione M, Suttorp MJ, Roth EA, Shekelle PG. Interventions for the prevention of falls in older adults: systematic review and meta-analysis of randomised clinical trials. BMJ. 2004 Mar 20;328(7441):680. Review. <PubMed> PMID: [3] <Internet> [4]
6. Journal Watch 24(10):81, 2004 Haines TP, Bennell KL, Osborne RH, Hill KD. Effectiveness of targeted falls prevention programme in subacute hospital setting: randomised controlled trial. BMJ. 2004 Mar 20;328(7441):676. <PubMed> PMID: [5] <Internet> [6]
7. Vellas BJ et al, One-leg balance is an important predictor of injurious falls in older persons J Am Geriatr Soc 1997, 45:735 PMID: [7]
8. Prescriber's Letter 11(6):32 2004 Detail-Document#: [8] (subscription needed) [9]
9. Falls: NIH Institute and Center Resources [10]
10. Veterans Affairs (VA) National Center for Patient Safety 2004 Falls Toolkit [11]
11. Preventive Health Care, 2005: Prevention of Falls in Long-Term Care Facilities Canadian Task Force on Preventive Health Care (CTFPHC) [12]
12. Flicker L et al, Should older people in residential care receive vitamin D to prevent falls?? Results of a randomised trial. J Am Geriatr Soc 2005; 53:1881 PMID: [13]
    - Prescriber's Letter 15(6): 2008 Vitamin D for Fall Prevention in the Elderly Detail-Document#: [14] (subscription needed) [15]
13. Oliver D et al, Strategies to prevent falls and fractures in hospitals and care homes and effect of cognitive impairment: systematic review and meta-analyses. BMJ. 2007 Jan 13;334(7584):82. Epub 2006 Dec 8. Review. PMID: [16]
14. van der Velde N, van den Meiracker AH, Pols HA, Stricker BH, van der Cammen TJ. Withdrawal of fall-risk-increasing drugs in older persons: effect on tilt-table test outcomes. J Am Geriatr Soc. 2007 May;55(5):734-9. PMID: [17]
15. Thurman DJ et al, Practice Parameter: Assessing patients in a neurology practice for risk of falls (a evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2008, 70:473 PMID: [18]
16. Tinetti ME et al, Effect of Dissemination of Evidence in Reducing Injuries from Falls NEJM 2008, 359:252 PMID: [19]
17. Fleming J et al. Inability to get up after falling, subsequent time on floor, and summoning help: Prospective cohort study in people over 90. BMJ 2008 Nov 17; 337:a2227 <PubMed> PMID: [20] <Internet> [21]
18. Medical Knowledge Self Assessment Program (MKSAP) 14, American College of Physicians, Philadelphia 2006
19. Bischoff-Ferrari HA et al, Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomised controlled trials. BMJ 2009;339:b3692 PMID: [22] doi:10.1136/bmj.b3692 [23]
20. Menant JC et al. Older people contact more obstacles when wearing multifocal glasses and performing a secondary visual task. J Am Geriatr Soc 2009 Oct; 57:1833. PMID: [24]
    - Haran MJ et al Effect on falls of providing single lens distance vision glasses to multifocal glasses wearers: VISIBLE randomised controlled trial. BMJ 2010;340:c2265 <PubMed> PMID: [25] <Internet> [26]
21. Leveille SG et al Chronic Musculoskeletal Pain and the Occurrence of Falls in an Older Population. JAMA. 2009;302(20):2214-2221 <PubMed> PMID: [27] <Internet> [28]
22. Prescriber's Letter 17(3): 2010 (subscription needed) [29]
    - Prescriber's Letter 17(4): 2010 Fall Prevention in the Elderly COMMENTARY: Fall Prevention in the Elderly GUIDELINES: Fall Prevention in Older Persons GUIDELINES: Prevention of Falls (Acute Care) Detail-Document#: [30] (subscription needed) [31]
    - Michael YL, Whitlock EP, Lin JS, et al. Primary care-relevant interventions to prevent falling in older adults: a systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med 2010 Dec; 153(12):815-825. PMID: [32]
    - Leipzig RM, Whitlock EP, Wolff TA, et al. Reconsidering the approach to prevention recommendations for older adults. Ann Intern Med 2010; 153:809-814. PMID: [33]
    - Tinnetti ME. Making prevention recommendations relevant for an aging population. Ann Intern Med 2010; 153:843-844 PMID: [34]
23. Delbaere K et al. Determinants of disparities between perceived and physiological risk of falling among elderly people: Cohort study. BMJ 2010 Aug 20; 341:c4165. [35] PMID: [36]
24. Dykes PC et al, Fall Prevention in Acute Care Hospitals JAMA. 2010;304(17):1912-1918 <PubMed> PMID: [37] <Internet> [38]
25. Spaniolas K et al Ground level falls are associated with significant mortality in elderly patients. J Trauma 2010 Oct; 69:821. PMID: [39]
26. Woolcott JC, Richardson KJ, Wiens MO, et al. Meta-analysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med 2009; 169(21):1952-1960. PMID: [40]
    - Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: a systematic review and meta-analysis, I: psychotropic drugs. J Am Geriatr Soc 1999; 47(1):30-39. PMID: [41]
    - Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: a systematic review and meta-analysis, II: cardiac and analgesic drugs. J Am Geriatr Soc 1999; 47(1):40-50. PMID: [42]
27. AGS Clinical Practice Guideline: Prevention of Falls in Older Persons (2010) The American Geriatrics Society [43]
28. Trombetti A et al. Effect of music-based multitask training on gait, balance, and fall risk in elderly people: A randomized controlled trial. Arch Intern Med 2011 Mar 28; 171:525 PMID: [44]
    - Haines TP et al. Patient education to prevent falls among older hospital inpatients: A randomized controlled trial. Arch Intern Med 2011 Mar 28; 171:516. PMID: [45]
29. Spink MJ et al. Effectiveness of a multifaceted podiatry intervention to prevent falls in community dwelling older people with disabling foot pain: Randomised controlled trial. BMJ 2011 Jun 16; 342:d3411 PMID: [46]
30. Cumming RG et al Home visits by an occupational therapist for assessment and modification of environmental hazards: a randomized trial of falls prevention. J Am Geriatr Soc. 1999 Dec;47(12):1397-402. PMID: [47]
31. Nikolaus T and Bach M Preventing falls in community-dwelling frail older people using a home intervention team (HIT): results from the randomized Falls-HIT trial. J Am Geriatr Soc. 2003 Mar;51(3):300-5. PMID: [48]
32. Geriatrics at your Fingertips, 13th edition, 2011 Reuben DB et al (eds) American Geriatric Society
33. National Guideline Clearinghouse
    - Falls and fall risk American Medical Directors Association (AMDA). ngc-guideline: [49]
    - Preventing falls in acute care. In: Evidence-based geriatric nursing protocols for best practice. Hartford Institute for Geriatric Nursing ngc-guideline: [50]
    - Clinical practice guideline for the assessment and prevention of falls in older people. (National Collaborating Centre for Nursing and Supportive Care) ngc-guideline: [51]
    - Fall management guidelines. (Health Care Association of New Jersey) ngc-guideline: [52] [53]
    - Practice parameter: assessing patients in a neurology practice for risk of falls (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. ngc-guideline: [54]
    - Prevention of falls (acute care). Health care protocol. Institute for Clinical Systems Improvement ngc-guideline: [55]
    - (1) Prevention of falls and fall injuries in the older adult. (2) Prevention of falls and fall injuries in the older adult 2011 supplement. Registered Nurses' Association of Ontario (RNAO) ngc-guideline: [56]
    - Fall prevention guidelines. In: Promoting active living (PAL): best practice guidelines for fall prevention in assisted living. British Columbia Injury Research and Prevention Unit & Fraser Health Authority ngc-guideline: [57]
    - National Guideline Clearinghouse Guideline syntheses Health Care Association of New Jersey (HCANJ) Hartford Institute for Geriatric Nursing (HIGN) Registered Nurses Association of Ontario (RNAO) ngc-guideline-synthesis: 25624

falls in the elderly