Falls: A Case Close
to Home
Geriatrics Interclerkship
April 30, 2012
Gary Blanchard, M.D.
“Gait deferred”
Why are we so concerned
about falls?
Patient H.B.
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86 years old, independently living on Cape
Cod with her husband x 65+ years.
She is largely independent with her ADLs
– but requires IADL assistance.
Inconsistently uses her walker.
She has frequent falls (16) – some of
which have resulted in hospitalization – in
the past 18 months.
Patient PMHx
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Type 2 diabetes – oral medications
Cataracts, visual impairment
Mild cognitive impairment, anxiety features
Delirium episodes (hospitalizations)
Hypertension
Meds: lisinopril 20 mg once daily, carbamazepine
200 mg twice daily, lorezapam 0.5 mg nightly,
metformin 500 mg twice daily, ASA 81 mg daily
Her perspective:
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She wants to remain at home, where she
has always been. She steadfastly wants
to maintain her independence.
She acknowledges inherent risk of current
living situation – and that her husband is
also declining functionally.
Her grandson geriatrician’s
perspective:
Underappreciated
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“Can cause lasting discomfort and decreased
function … cause discomfort and disability for
older adults and stress for caregivers.” (JAMA,
2010)
Major contributor to functional decline and
health care utilization.
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Increased likelihood of nursing home placement.
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Fear of falling – debilitating.
Pearls
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Not a normal part of aging
Red flag – a sentinel event for illness,
functional decline, frailty
Consider: presentation of acute illness
Not normal, but common
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More than 1/3 of community-living adults >65
fall each year. At least half recur.
Roughly 1 in 4 fallers limit their lifestyle/activities
due to fear of falling.
Roughly 10% of falls result in major injury
(fracture, etc.). Also: inability to rise without
help (rhabdomyolysis, pressure ulcers,
dehydration)
Mortality
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Accidents (commonly falls) are the 6th
leading cause of death
Clustering of falls is associated with a high
6 month mortality
Falling increases the mortality rate of
patients with Alzheimer's Disease
Morbidity
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4-6 % of falls result in a fracture
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1-2% of falls result in a hip fracture
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>50% of older adults with a fall-related
hospitalization are discharged to a nursing
home
Falls account for 10% of ER visits and 6% of
urgent hospitalizations for older adults
Why do people fall?:
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Vulnerable host, wrong environment
Requires coordination among sensory
(vision, vestibular, proprioception), CNS,
peripheral nervous system,
cardiopulmonary, musculoskeletal, and
other systems.
Need >1 systems affected.
Risk factors (cumulative):
1)
2)
3)
4)
5)
6)
7)
8)
Previous falls
Balance impairment
Decreased muscle strength
Visual impairment
Medications (but chronic diseases can increase
fall risk, too)
Gait impairment
Dizziness/orthostasis
Functional limitations
Systematic Approach
Vestibular, cerebellar
Orthostasis
Decreased muscle strength
Neuropathy
http://www.technovelgy.com/graphics/content07/doctor-bot-operation.jpg
How do you evaluate the faller?
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History, exam?
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Why might my grandmother fall?
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What workup would you do for my
grandmother?
History
Patient PMHx
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Type 2 diabetes – oral medications
Cataracts, visual impairment
Mild cognitive impairment, anxiety features
Delirium episodes (hospitalizations)
Meds: lisinopril 20 mg once daily,
carbamazepine 200 mg twice daily,
lorezapam 0.5 mg nightly, metformin 500
mg twice daily, ASA 81 mg daily
Patient PMHx





Type 2 diabetes – oral medications
Cataracts, visual impairment
Mild cognitive impairment, anxiety features
Delirium episodes (hospitalizations)
Meds: lisinopril 20 mg once daily,
carbamazepine 200 mg twice daily,
lorezapam 0.5 mg nightly, metformin 500
mg twice daily, ASA 81 mg daily
Physical Examination
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Gait, balance, mobility, muscle stregth,
lower extremity joints
Neurological: Cognition, peripheral nerves,
cerebellar, proprioception, extrapyramidal
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Cardiovascular: orthostatics, rate/rhythm
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Visual acuity
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Examine feet and footwear
Watch ‘em walk
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Observation is critical
Demonstrate:
 Timed ‘Get up and Go’
 ADL performance screen
Functional assessment
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Assess ADL skills (mobility aids)
Assess perceived functional abilities and
fear of falling
Environmental: home safety assessment
(PT, OT, VNA)
Workup/Management Plan
Effective Interventions
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Best when customized, multidisciplinary
Best single: PT, exercise, cataract surgery,
medication reduction.
Vitamin D strongest evidence for
preventing fractures among older men at
risk.
2010 AGS Guidelines
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Multifactorial assessment: feet and
footwear, functional assessment, an
environmental assessment (home safety),
and ask about their perceived functional
ability and fear of falling.
Medications, particularly antipsychotics
and psychoactive medications, should be
minimized or withdrawn.
Postural hypotension assessment.
2010 AGS Guidelines
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An 800-IU supplement of vitamin D.
An exercise regimen that focuses on
balance, gait, and strength training, such
as tai chi or physical therapy.
For older patients who need cataract
surgery, the intervention should be
expedited.
Effective Multi-factorial
Interventions for Fall Prevention
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Gait training/assistive device training
Review and modify medications
Critically evaluate need for psychotropic
medication
Exercise programs (strength and balance)
Treat orthostatic hypotension
Modify environmental hazards and activities
Treat cardiovascular disorders
Our patient: H.B.
Our patient: H.B.
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Safety v. independence
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ASK!!! (Annual screen >70)
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Targeted, multi-factorial interventions
have been shown to be effective at
reducing falls in the home.
Reference
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Tinetti, M.; Kumar, C. “The Patient Who Falls: It’s Always
a Trade-Off.” JAMA. 2010; 303(3):258-266. doi:
10.10.2010
AGS Clinical Practice Guideline : Prevention of Falls in
Older Persons (2010)
McGee, Sarah, MD, MPH. “Mobility and Functional
Assessment.” UMMS Geriatrics Interclerkship, March 28,
2008.
Bradley, S.; Chang, C. “Falls,” POGOe. Mount Sinai
School of Medicine. Brookdale Dept of Geriatrics and
Adult Development. March 4, 2008.