Injuries in the elderly Francesco Mattace Raso Head

Injuries in the elderly Francesco Mattace Raso Head Geriatric Medicine Department of Internal Medicine

Injuries in the elderly Francesco Mattace Raso Head Geriatric Medicine Department of Internal Medicine

Falls and injuries: The challenge § 3. 000 cases per year § 5. 3000. 000 Euro/year

Persons at risk ● Young adults ● Elderly ● Sporters

Falls and injuries in the elderly §A Big Issue?

Falls in community dwelling incidence in 65+ § 2001 600. 000 fallers community dwelling § 2009 800, 000 fallers community dwelling

Falls in community dwelling § 30% falls 1 x Year § 15% falls ≥ 2 x Year

Consequences of Falls (st) § 10% Severe injuries (1 -2% hip #) § 3 -5% Other fractures § 5% Less severe

Consequences of Falls (lt) § 1 - year Mortality 20% § 1/3 decreased function/ mobility (nursing homes) § Psychosocial problems (fear of falling, isolation)

Arch Intern Med. 2010; 170(10): 905 -911. doi: 10. 1001/archinternmed. 2010. 106 Table Title: Hartholt et al Arch Int Med 2010

Arch Intern Med. 2010; 170(10): 905 -911. doi: 10. 1001/archinternmed. 2010. 106 Table Title: Hartholt et al Arch Int Med 2010

Arch Intern Med. 2010; 170(10): 905 -911. doi: 10. 1001/archinternmed. 2010. 106 Table Title: Hartholt et al Arch Int Med 2010

Older patients= longer LOS Hartholt et al Arch Int Med 2010

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2300

Circumstances surrounding injurious falls Boye et al Injury 2014

Injuries following a fall Boye et al Injury 2014

Circumstances leading to all injurious falls Boye et al Injury 2014

Circumstances surrounding falls leading to brain injury Boye et al Injury 2014

Circumstances surrounding falls leading to a hip # Boye et al Injury 2014

Risk Factors for Falls

Risk Factors for Falls

Risk Factors for Falls

Different patterns In young persons mostly accidents (sport, transport) In old subjects mostly heterogeneous

Young adults Older persons § (Usually no) Comorbidities § (Usually no) Polipharmacy § (Usually not) Frail § (Usually no) Cognitive disorders § Rehab § (Challenging) Rehab

Risk Factors for Falls intrinsic extrinsic

Intrinsic Extrinsic § Previous fall § Obstacles (in the dark) § Medical conditions § Requires § Cognitive decline § Environmental changes § Physical functioning § Drugs § Strength, balance § Sensory declines

Decreased strength in the elderly § Decreased muscle mass § Decreased s. Vitamine D § White matter lesions § Changes in peripheral nerves function

Changes in the Population pyramids

Pathology that occurs with Age Prevalence of selected chronic conditions, expressed in percentages, as a function of age for the US population (2002 -2003 dataset). Source: National Center for Health Statistics, Data Warehouse on Trends in Health and Aging.

Sarcopenia • Degenerative loss of skeletal muscle mass • 1% loss per year after the age of 25 • It can be differentiated from cachexia in that cachexia includes malaise and is secondary to an underlying pathosis (such as cancer), whereas sarcopenia may occur in healthy people and does not necessarily include malaise

Sarcopenia • Simple circumference measurement does not provide enough data to determine whether or not an individual is suffering from severe sarcopenia • Extreme muscle loss is often a result of both diminishing anabolic signals, such as growth hormone and testosterone, and promotion of catabolic signals, such as pro-inflammatory markers

CHANGES IN MUSCLE MASS

CHANGES IN STRENGTH WITH AGING

Sarcopenia, so what? §High §risk of falls!!

Osteoporosis

Osteoporosis § Silent Killer § 1/ 3 of the women aged 50+

72 yrs woman 0. 2 mm

Osteoporosis §High §risk of fractures!!

Medications’ use increases the risk of falls

Medications, falls and fractures van Voast Moncada Am Fam Physician. 2011

Fall- risk increasing drugs Boye’et al, submitted

Psychotropic drug and physical performance Boye’et al, submitted

Title slide

How to do it? A 1 Het is aangetoond dat interventies die spierkrachtversterkende oefeningen en evenwichtsoefeningen bevatten, die specifiek aangepast zijn aan het individuele niveau van de ouderen, een absolute reductie in het aantal vallen en het aantal valincidenten met letsel geven. Robertson JAGS 2002 A 2 Er zijn aanwijzingen dat in multifactoriele interventies kracht- en evenwichtstraining bij thuiswonende ouderen van 70 jaar en ouder als afzonderlijke interventie een valreductie van 7% tot gevolg heeft. Day BMJ 2002

Summary

Summary

Summary

Fall prevention: does any?

Fall prevention: does any? § 159 trials with 79, 193 participants § Most trials compared intervention prevention vs no intervention or an intervention not expected to reduce falls. § The most common interventions tested were exercise as a single intervention (59 trials) and multifactorial programmes (40 trials)

Interventions § Overall, vitamin D did not reduce the risk of falling (RR 0. 96, 95% CI 0. 89 to 1. 03; 13 trials; n=26, 747). § Pacemakers did not reduce falls in people with carotid sinus hypersensitivity § No effect for cognitive behavioural interventions and the risk of falling (RR 1. 11, 95% CI 0. 80 to 1. 54; 2 trials; n=350).

Interventions § Multiple-component group exercise significantly reduced risk of falling (RR 0. 85, 95% CI 0. 76 to 0. 96; 22 trials; n=5333) § Tai Chi did significantly reduce risk of falling (RR 0. 71, 95% CI 0. 57 to 0. 87; 6 trials; n=1625). § Exercise interventions reduced the risk of a fall-related fracture (RR 0. 34, 95% CI 0. 18 to 0. 63; 6 trials; n= 810). § Home safety assessment and modification interventions were effective in reducing risk of falling (RR 0. 88, 95% CI 0. 80 to 0. 96; 7 trials; n=4051).

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When are you old? Will you still need me, will you still feed me, when I’m 64? The Beatles, “When I’m Sixty-Four”

Is this person old?

Is this person old? Several Intoxications Comfortably numb state of mild apparent confusion

Healthy aging

Will we be able to prevent falls and injuries? Prediction is very difficult, especially about the future (Niels Bohr, Nobel Prize Physics)

Conclusions § Falls and injuries are common in the elderly § Patterns of falls and injuries differ in young and old § Falls and injuries have severe consequences in the elderly

Difficult questions? f. mattaceraso@erasmusmc. nl