FALLS IN OLDER ADULTS: RISK ASSESSMENT AND INTERVENTIONSNEILA SHUMAKER M.D., UNIVERSITY OF NEVADA RENO SCHOOL OF MEDICINEMERCE VENERACION, PT, CCI, SAN DIEGO PACE PROGRAMKATRINA SOTOJEREMY NELSON, MPT, EXCEL HOME HEALTH

NOT THIS KIND OF FALLS

NOR THIS KIND: ROCK FALL ON NEW ZEALAND BEACH, WITNESSED BY DAUGHTER AT GEOLOGY SITE

OBJECTIVES

• Recognize the importance of falls in older people

• Learn causes of geriatric falls

• Assess and manage fall risk

FALL DEFINITION: COMING TO REST INADVERTENTLY ON THE GROUND OR AT A LOWER LEVEL

• A fall is one of the most common events threatening the independence of older adults

• Most falls are not associated with loss of consciousness

• Falls are associated with: Decline in functional status Nursing home placement Increased use of medical services Fear of falling

• Half of those who fall are unable to get up without help (“long lie”) – this is a predictor of lasting decline in functional status

COMPLICATIONS OF FALLS ARE THE LEADING CAUSE OF DEATH FROM INJURY IN PEOPLE AGED ≥65 YEARS• 1 in 3 adults ≥ 65 years reports falling each year -

one-half of those > 80 years, one-half of nursing-home residents, nearly 60% of those with a history of falls

• Most falls by older adults result in some injury

• 5%–10% of falls by older adults result in fracture or more serious soft-tissue injury or head trauma

• Mortality is highest in white men aged ≥85. WHY DO YOU THINK THAT IS?

COST OF FALLS – TO ELDERS, CARERS, SOCIETY• Emergency department visits and hospitalizations;

longer length of stay

• Indirect costs from fall-related injuries such as hip fractures

• Costs of moving from independent living to institutional setting

• Caregiver may stop working to take care of elder

FALLS ARE RARELY DUE TO A SINGLE CAUSE• Causes of falls are almost always multifactorial - due

to the accumulated effect of multiple impairments (similar to other geriatric syndromes)

• Causes of falls are a complex interaction of:Intrinsic factors (eg, chronic disease)Challenges to postural control (eg, changing

position)Mediating factors (eg, risk taking, situational

hazards)

FALLS CLINICAL GUIDELINES

• Ask all older adults about falls in the past year

• Single fall: check for balance or gait disturbance

• Recurrent falls or gait or balance disturbance: Pursue a multifactorial falls risk assessment For a summary of the recommendations of the expert panel on falls

prevention assembled by AGS and BGS, see www.americangeriatrics.org

PREHISTORIC FALLS WARNING SIGN: FALLING MAN PETROGLYPH, GOLD BUTTE AREA, SOUTHERN NEVADA

PREHISTORIC FALLS PREVENTION: WALKING MAN PETROGLYPH, GOLD BUTTE AREA, SOUTHERN NEVADA

CHALLENGE: ASSESSING FALLS RISK IN THE HOME ENVIRONMENT FROM YOUR OFFICE

INTRINSIC RISK FACTORS – FALL RISK GOES UP WITH THE NUMBER OF FACTORS• Older age• Cognitive impairment• Female gender• Past history of a fall• Leg weakness or gait

problems• Foot disorders

• Balance problems• Hypovitaminosis D• Pain• Parkinson’s disease• Stroke• Arthritis

CHALLENGE: UNDERLYING HEALTH OF BONE STRUCTURE IN THE ELDERLY

MEDICATIONS AND FALLS

• Specific classes, for example: Benzodiazepines Other sedatives Antidepressants Antipsychotic drugs Cardiac medications Hypoglycemic agents

• Recent medication dosage adjustments

• Total number of medications

FALLS HISTORY

• History of falls

• Activity at time of fall(s)

• Prodromal symptoms

• Location and time of fall(s)

• Medication history (new, changed, high-risk meds)

• Lighting

• Floor coverings

• Railings

• Door threshholds

• Furniture

• Footwear

EVALUATION AFTER A FALL

• Evaluate for acute, subacute illness with history, general exam, labs

• Do orthostatic BP, supine and standing• Perform Dix-Hallpike maneuver if history suggests

vestibular component• Visual acuity screen• Examine neck, back, legs, feet for pain, deformities,

decreased range of motion, contractures, leg-length discrepancy – measure the distance from the anterior superior iliac spine to the medial malleolus

FALLS NEUROLOGIC EXAM

• Assess strength, tone, sensation (including proprioception), coordination (including cerebellar function), station, and gait

• Use a gait assessment tool (eg, timed Get Up and Go) to determine a comfortable gait speed

• Perform the Romberg test to assess postural control and whether the proprioceptive and vestibular systems are functional

• Perform a cognitive screen such as the Cognistat or MoCA

FALLS INTERVENTIONS

• Multi-component interventions such as home safety assessment and modifications, physical and occupational therapy, balance training such as Tai Chi, vision correction and proper footwear have been shown to be effective in some trials

• In the nursing-home setting, vitamin D supplementation has been shown to decrease falls risk. Multicomponent interventions should be considered in this setting as well

• Hip protectors have not been consistently shown to reduce hip fractures in community dwelling or institutionalized older adults, and most of the commercially available products have never been used in clinical trials

GAIT DISORDERS PREDICT FUNCTIONAL DECLINE• Gait disorders are common and a predictor of functional decline in

older adults

• Age-related gait changes such as slowed speed are most apparent after age 75 or 80; the prevalence of walking limitations in community dwellers over 80 can be over 50%

• Age over 85, three or more chronic conditions at baseline, and the occurrence of stroke, hip fracture, or cancer predict loss of walking ability

• Community-dwelling older adults with gait disorders, particularly neurologically abnormal gaits, are at higher risk of institutionalization and death

SOME GAIT DISORDERS

• Antalgic gait - Pain-induced limp with shortened stance phase of gait on painful side

• Trendelenburg gait - Shift of the trunk over affected hip, which drops due to hip abductor weakness

• Circumduction - Outward swing of leg in semicircle from the hip • Equinovarus - Excessive plantar flexion and inversion of the ankle• Scissoring - Hip adduction such that the knees cross in front of each other with

each step • Foot drop, Steppage gait - Loss of ankle dorsiflexion due to weakness of ankle

dorsiflexors • Propulsion, Retropulsion, Festination, Freezing, Turn en bloc - Tendency to fall

forward or backward, accelerate, stop or slow suddenly, or move whole body while turning – characteristic of Parkinsonism

PERIPHERAL SENSORY AND MOTOR CAUSES OF GAIT DYSFUNCTION• Peripheral neuropathy, proprioceptive deficits – loss of touch,

position sense – gait may be wide-based, unsteady, steppage gait• Vestibular disorders – disequilibrium (balance impairment) –

“drunken” gait - abnormal Romberg test• Visual impairment – tentative gait• Arthritis, other pain and decreased motion of hip, knee, or spine –

antalgic gait, Trendelenburg gait, stooped posture, thoracic kyphosis• Focal weakness of muscle and nerve groups – proximal muscle

weakness, distal muscle weakness, exaggerated lumbar lordosis (secondary to pelvic girdle weakness), waddling and steppage gaits

HIGHER SENSORIMOTOR GAIT DISORDERS• Cerebellar ataxia - poor trunk control, incoordination or other

cerebellar signs – gait is wide-based with increased trunk sway, irregular stepping, staggering, especially on turns

• Parkinsonism – cardinal signs are rigidity, bradykinesia, tremor, stooped posture – gait has small shuffling steps, hesitation, festination, propulsion, retropulsion, turning en bloc, absent arm swing, freezing

• Hemiplegia or hemiparesis - arm and leg weakness, spasticity, equinovarus, genu recurvatum, leg circumduction, loss of arm swing, foot drag or scrape

• Paraplegia or paraparesis - leg weakness, spasticity, bilateral leg circumduction, scraping feet, possibly also scissoring

COGNITIVE AND WHITE MATTER GAIT DISORDERS• Frontal lobe disease, dementia, normal-pressure

hydrocephalus – cognitive impairment, weakness, spasticity, urinary incontinence – may have “magnetic” gait as though feet are glued to the floor

• Dementia (Alzheimer disease, vascular) – mid- to late-stage dementia, may have fear of falling, cautious gait with normal to widened base, shorter stride, slower, en bloc turns

FALLS TESTS OF INTEGRATED MUSCULOSKELETAL FUNCTION

Functional reach test – distance reached along a yardstick at shoulder height; less than six inches is abnormal

Up and Go test (with or without timing) – rise from chair w/o using arms, walk about 3 meters, turn, return to chair, sit down w/o using arms – over 15 seconds to complete suggests increased fall risk

Berg Balance Test – 14 balance items including tandem, semi-tandem stance. Score under 40 associated with increased fall risk

Performance-Oriented Mobility Assessment (POMA) – combines many items from other tests

FUNCTIONAL GAIT ASSESSMENT• Comfortable gait speed and related endurance measures

(such as 6-minute walk) are powerful predictors of falls, disability, hospitalization, institutionalization, and mortality

• Usual gait speed is tested from a standing start over a distance of 4 m

Speed of 0.6 m/s has been proposed as cut point for dysmobility

Speeds of >1.0-1.2 m/s are associated with better functional outcomes and increased life expectancy

FALLS WARNING SIGN

CURRENT FALLS PREVENTION

FALLS PREVENTION!