Geriatric Medicine Principles Falls Robert Kirby MD FACP

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. 3. Define geriatric syndrome. Name three. 4. List four risk factors for falls. 5. Outline three interventions to reduce fall risk.

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 USA 2020 >65 yo 16% Dependency Ratio-Europe 2050 22% to >50% Harrison on Line Merck Manual Geriatrics

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

Chronic Disease Burden Condition Age 65 % Age 75 % Arthritis 50 54 Hypertension Heart Hearing Cataracts Diabetes Vision 36 32 28 16 10 8 39 39 36 24 11 11 Merck Manual Geriatrics

Life Expectancy Walter LC, Covinsky KE, JAMA 2001

Function: Activities of Daily Living Basic Dressing Eating Ambulating Toileting Hygiene Intermediate Shopping Housework Accounting Food Preparation Transportation

Function with Aging

Principles in a Flash 1. 2. 3. 4. 5. 6. 7. 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 8. Iatrogenic disease common and often preventable 9. Care is provided in multiple settings 10. Ethical and end of life issues guide practice www. cha. emory. edu/reynoldsprogram

Clinical Approach Not what disease caused the problem But what combination of physiologic change, impairments and diseases are contributing And which ones can be modified Modawal

Geriatric Syndromes Dementia and Delerium Falls Polypharmacy Pressure Ulcers Urinary Incontinence

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

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

Questions about Mary Anderson 1. 2. 3. 4. 5. 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?

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 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 Extrinsic Environment Intrinsic Age Gait/Balance Disorder Sarcopenia Vestibular Orthostatic Hypotension Special Senses –Vision/Hearing Disease Dementia Depression Drugs Foot problems Incontinence

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.

Gait Stride Length Arm Swing Slow Forward Flex Head and Torso Flexion shoulders knees Lateral Sway Normal Gait Video

History-Physical Injury Details of Fall Inability to Get Up Associated Disease and Disability Drugs General Orthostatic BP Vision Cognition ( MMSE) Gait/Balance/Coordination Laboratory CBC CMP EKG

Get Up and Go Normal Abnormal

Modified Single Leg Stance

Functional Reach

Sharpened Romberg

Reducing Fall Risk Next Year (%) Fall Past Year Gait Problem One Risk Two Risks Three Risks Four or More Treatment Reduces Risk(%) 50 30 30 20 20 30 60 80 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 10 20 40 50 www. fallprevention. org

Guideline for Fall Prevention JAGS 2001. 49: 664 -672

Management Reduce 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 Risk Exercise -47% MMWR Rep 2004; 53(2): 25 -28 Wolf JAGS 1996

Reduce Fracture Risk Hip Protectors Vitamin D/Calcium 400 -800 IU / 1200 -1500 Lauritzen JB, Peterson MM et al Lancet 1993; 341: 11 -13.

Questions about Mary Anderson 1. 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

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

Questions about Mary Anderson 3. 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)

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

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/ 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.