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
Intermediate
Dressing
Eating
Ambulating
Toileting
Hygiene
Shopping
Housework
Accounting
Food Preparation
Transportation
Function with Aging
60
% with Difficulty
50
40
Age 65-74
70-74
75-79
80-84
85+
30
20
10
0
ADL problem
IADL Problem
Principles in a Flash
1.
2.
3.
Aging is not a disease.
Geriatric conditions are chronic, multiple, multifactorial
Reversible
conditions
are
underdiagnosed
and
undertreated
4. Function and quality of life are critical outcomes
5. Social support and patient preferences are critical aspects
6. Geriatrics is multidisciplinary
7. 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
Fall Risk Next
Year (%)
Fall Past Year
Gait Problem
One Risk
Two Risks
Three Risks
Four or More
50
30
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
Treatment
Reduces Risk(%)
30
20
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
400-800IU / 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.