Falls – an over view for
GPs
Julie Brache
Consultant Geriatrician and Falls Lead
October, 2014
Overview
 Why older people fall
 Multifactorial risk assessment
 Normal changes with ageing
 Dizziness and syncope
 Medication review
 Multifactorial interventions
 Where to get advice
Definition
when an individual comes to rest
unintentionally on the ground or
another lower level, with or without
loss of consciousness
Background
• 35% >65 living at home fall each year
 £2.3 billion per year
 10% injury
 After a fall 50% have reduced mobility
 Leading cause of injury related death in older adults
Preventable
N
 Evidence based national
and international
guidelines
Fall is a symptom,
not a diagnosis
‘Old age starts with the first fall
and death comes with the
second’
Gabriel Garcia Marquez “Love in the time of cholera”
Frailty
 Reduced ability to withstand illness without
loss of function
 Muscle weakness, reduced walking speed,
reduced physical activity, weight loss, self
reported exhaustion
 Would you be surprised if this person died in
the next year?
Falls are multifactorial
Why do older people fall?
 Muscle weakness
 Frailty
 Poor balance
 Environment
 Gait deficit
 Depression
 Polypharmacy
 Cognitive impairment
 Sensory loss – vision,
hearing, peripheral
 Incontinence
 Medical illness
 Nutrition
 Dizziness
 Osteoarthritis
 Alcohol
 Previous falls
 CV problems
 Neurological
History
 Circumstances of falls
 Activity at the time
 Where and when
 Lightheaded, dizzy, LoC, chest pain, palpitations, visual
disturbance?
 Seizure markers?
 How many falls in the last year?
Taking the history –some
pointers
 Allow them to describe everything first,
then get the history you need
 Describe a single fall in detail
 Take them through it in fine detail
 Then ask about
associated symptoms
 Witness account is vital
History - pitfalls
 “It was nothing”
 “I haven’t fallen”
 “I tripped over the cat”
 “I must have…….”
 “They had a fit, doctor”
Assess
 Continence
 Cognition
 Frailty
 Alcohol intake
 Psychological consequences of falling
 Fear, anxiety, depression
Examination
 Cardiovascular
 Pulse – rate and rhythm
 Heart sounds
 3 min lying and standing BP
 Drop 20 systolic or 10 diastolic or to <90 significant
 Only 23% will describe dizziness
 ECG
Examination
 Focused neurological examination
 Lower limb strength – hip and ankle flexors
 Peripheral sensation
 Evidence of stroke, Parkinson’s cerebellar signs?
 Gait and balance
 Vision
Ageing and gait
 Slower
 Increased sway
 Slowed postural support responses
 Shorter stride length
 Increased time in double support
 Loss of rhythm
 Loss muscle bulk, reduced postural reflexes, JPS
Gait disorders in the elderly
 Parkinsonism
 Cerebrovascular disease
 Cervical spondolytic myelopathy
 Sensory neuropathy
 Foot drop
 Don’t forget Normal Pressure
Hydrocephalus
Gait and balance assessment
 Not all for the Physio!
 Gait:
 Get Up and Go
 Balance:
 Proprioception – vision- vestibular function
-> Romberg's
-> Head Thrust
Ageing and vision
 ↓Acuity
 ↓Depth perception
 Lens density changes- glare
 Decreased rod density - ↓Light adaptation
- ↓ contrast
sensitivity
 ↓ Visual processing speed
Vision
 Test acuity and fields
 ARMD, glaucoma, stroke,
diabetes, cataract
 Bifocal / varifocal glasses, change in
prescription
SPECTACLE USE
5.7 Optometrists and dispensing
opticians should consider supplying an
additional pair of single vision
spectacles (to wear in outdoor and
unfamiliar settings) for older people
who take part in regular outdoor
activities
Examination
 Other
 Cognition
 Foot wear and feet
Take the shoes off!
Dizziness
 Vertigo
 Pre-syncope
 Dysequilibrium
Vertigo
 Illusion of rotation
 “The room was spinning”
 Nystagmus during
episode
 Labyrinth or vestibular
 problem
 Occasionally cerebellar
or CP angle
 Treat acute attacks with
 anti-histamines
Benign Paroxysmal Positional
Vertigo
 Vertigo on change in position
 Self limiting
 Disabling
 Hallpike- Dix test
 Epley manoeuvre
 Vestibular rehab
 Cawthorne- Cooksey exercises
 Brandt - Daroff
Pre-syncope
 Sense of feeling faint or
light-headed
 “Legs went weak”
 “Vision blurred ”
 Pallor, weak/slow pulse
 Same causes as syncope
 Often a sign of postural BP
drop
 Cardiovascular assessment
 Treat underlying cause
Dysequilibrium
 Balance dysfunction
 A sense of unsteadiness
 “Thought I was going to fall”
 Often multi-factorial
 Sensory impairments and/or
CNS disease
 Multidisciplinary management
Syncope
 23% >65s over 10 years
 High recurrence rate
 Spontaneous LOC with complete recovery
 Diagnosis difficult and often wrong
Syncope in the Elderly
 Cerebral autoregulation impaired
 Baroreflex sensitivity blunted
 Volume regulation impaired
 Comorbid illness and medications
Syncope diagnosis
 All in the history
 DETAIL








Posture
Prodrome
Eye movements
Tongue biting/incontinence
Injury
Duration
Confusion
Hemi weakness
Red flags
 Abnormal ECG (NICE)
 Heart failure
 Syncope during exertion
 FHx sudden death <40
 New/unexplained SOB
 Murmur (NICE)
Assessment
 Vasovagal – 3Ps
 Cardiovascular – if in doubt
 ECG, 24 hour tape, event recorder, implantable
device, tilt table test + carotid sinus massage,
cardio ref
 Neurological
 CT head, EEG (?value in elderly), neuro ref
Tilt Tests
 Unexplained, recurrent
syncope
 Single syncope in high risk
settings
 Unexplained recurrent falls
Falls and acute illness
 Fall often the presentation of an
acute illness
 Think of falls risk when unwell
 diuretics, antihypertensive, steroids,
anticholinergics, sedatives
 urinary urgency/frequency
 Delirium
Medication review
Drugs in the elderly
 UK elderly 18% pop – 45% all prescriptions
 In NH in 1 year 97% will receive a prescribed
drug – 71% in community
 Polypharmacy - >4 drugs = risk falls
Principles of Medication
review
 Review indication – is there evidence?
 Review dose
 Reduce the number of medicines
 Avoid complex regimes
 Review benzodiazepines and other psychotropic
drugs
 Check L&S BP – if drop review culprit drugs
Medication and Falls Risk
 “Therapeutic effect”
 Interactions
 Side effects
 2/52 after change in meds – high risk time
 Stopping – can be difficult
“Therapeutic effect”
 Meta-analysis – sedatives and hypnotics
 Improve sleep duration and reduce night
time wakening
 NNT sleep 13
 NNT any adverse event 6
BMJ 2005;331:1169
Side effects –
anticholinergic activity
 Antiemetics – cyclizine,
prochlorperazine
 Antiparkinson –
amantadine, benzhexol
 Antispasmodics –
oxybutynin
 Bronchodilators ipatropium
 Antiarrhythmics disopyramide, procainamide
 Antidepressants –
tricyclics
 Antipsychotics –
chlorpromazine,
prochlorperazine
Time to reconsider
warfarin?
 50% elderly in AF not on warfarin
 Falls is the main reason
 >300 falls per year for bleeding risk to
outweigh stroke risk
Ageing and Pharmacokinetics /
Pharmacodynamics
 Distribution
 ↑blood (& tissue) conc water sol drugs
 ↑ vol distribution lipophilic drugs
 Hepatic metabolism
 Metabolism by C P-450 reduced
 Reduced 1st pass metabolism – some drugs
 Renal elimination
 Reduced GFR with age
 Changes in drug-receptor interactions
Osteoporosis assessment
 FRAX – but beware over 80s
 Calcium and vitamin D
 Reduce falls
 All housebound fallers, and RH/NH
residents
 800iu daily vit D
• Long term anticonvulsants – check vit
D level
Hip protectors
 Controversial area!
 At home –
ineffective
 Institutions?
 Current advice:
May be useful in
confused elderly in
institutional care
Multifactorial interventions
 Treat any problems found
 Evidence based recommendations:
 Strength and balance training
 Home hazards assessment & intervention
 Vision assessment and referral
 Medication review and
modification/withdrawal of psychotropics
 Education
How to get advice
Geriatric Advice Line
07930 181236
Clinics
 Falls clinic
 Nurse, therapist and doctor, 2 hour appointment,
on-going therapy via referral to community teams
 Geriatric clinic
 Doctor, 45 min appointment
 If you just want therapy – refer to community teams
 If already seeing community team – refer to geriatric
clinic
PLEASE send as much information as possible
Take home messages
 Some falls are preventable
 Requires time consuming multifactorial
assessment, identification and intervention
 Can’t do it alone
 Always review medication
 Don’t forget bones
 A friendly geriatrician is always on the end
of the phone
Questions?