Falls in the Elderly

Help! Ive Fallen and I Cant Get Up!

1#DEFINITIONfallsunintentional events in which a person comes to rest on the floor or ground that are not caused by loss of consciousness, stroke, seizure, or overwhelming force.

Falls in three different settingsthe community, skilled nursing facilities, and hospitalsare discussed; reasons for falling and, therefore, interventions differ by site.Falls in the ElderlyPrevalenceClinical ImportanceRisk Factors & EtiologyEvaluation Prevention & ManagementSummaryPrevalence30% of those over 65 fall annuallyHalf are repeat fallersFalls go up with each decade of lifeOver half of those in nursing homes and hospitals will fall each yearUCSF Division of Geriatrics Primary Care Lecture Series May 2001

Incidence rates of Falls in U.S.One of every three adults over 65 years fall in every year 5Among adults aged over 65 years, unintentional injuries are the seventh leading cause of death in the United States. Of these fatalities, deaths from fall-related injuries are the greatest number. In the United State, one of every three older persons (aged over 65 years) living in community fall every year. This trend increases to 50% by the age of 80 years (Blake et al., 1988; OLoughlin et al., 1993). An older person living in community has the likelihood of falling as 0.2 0.8 times per year. The incidence rate of falls is substantially higher in hospitals and nursing homes as of 1.5 falls per bed per year (range 0.2-3.6).

#Where are people likely to fall? For people 65 years old or older..

Home 60% Public Places 30%Nursing Home 10%6Did you know most falls happen to women in their homes in the afternoon?For adults 65 years old or older, 60%of fatal falls happen at home, 30% occur in public places, and 10% occur in health care institutions. However, injury rates are more higher with 10 ~ 25% of nursing home, or long-term care facilities resulting in fracture, or sever tissue injuries (Rubenstein, 1999)Falling will tend to occur within the first few days or first weeks upon entering a nursing home or transferring to a nursing home, It may be due to unfamiliar environment. Also, person who admitting in has more chronic illness, medications, and immobility due to long time sitting or in bed (Sorock 1988; Sattin 1992). 24% of nursing home falls are due to the weakness and gait problems of the residents. Falling caused by environmental hazards is approximately 16% of nursing home fall incidence. Higher use of psychotropic drugs (e.g. antidepressants) have been associated with risk of falling.

#Leading Causes of DeathAge GroupFirst Leading Cause of Trauma DeathSecond Leading Cause of Trauma Death35 64Motor Vehicle36.8%Falls29.6%65+Falls43.3%Motor Vehicle10.2%7#Falls in the ElderlyPrevalenceClinical ImportanceRisk Factors & EtiologyEvaluation Prevention & ManagementSummaryC. Bree Johnston, MD MPH , Copyright May 2001

Impact of Hip Fractures1% of falls result in hip fracture$2 billion + in medical costs annually25% die within 6 months60% have restricted mobility25% remain functionally more dependent

C. Bree Johnston, MD MPH , Copyright May 2001

#

Falls Cause Morbidity and MortalityMortality: indirect effectsFractures: 6% of fallsSoft tissue injury, head injury, subdural hematomaFear of falling can result in decreased activity, isolation, and further functional declineNursing home placement and loss of independenceC. Bree Johnston, MD MPH , Copyright May 2001

Falls in the ElderlyPrevalenceClinical ImportanceRisk Factors & EtiologyEvaluation Prevention & ManagementSummaryC. Bree Johnston, MD MPH , Copyright May 2001C. Bree Johnston, MD MPH , Copyright May 2001

Falls are Multifactorial

Intrinsic FactorsExtrinsic FactorsFALLSMedical conditionsImpaired vision and hearing

Age related changesMedications

Improper use of assistive devices

EnvironmentInteractions among intrinsic, pharmacologic, environmental, and situational factors that affect risk of falling in older persons. (Modified with permission from King MB, TinettiME. Falls in community-dwelling older persons. J Am Geriatr Soc. 43:1146, 1995.

Normal Changes with AgingNeurologicIncreased reaction timeDecreased righting reflexesDecreased proprioceptionVision ChangesDecreased accommodation & dark adaptationDecreased muscle massC. Bree Johnston, MD MPH , Copyright May 2001

#DysmobilityDysmobility and falling closely related15% of those over 65 have trouble walking1/4 men and 1/3 women over age 85 have difficulty with walking2/3 of people in hospital or NH unable to ambulate without assistanceC. Bree Johnston, MD MPH , Copyright May 2001

#Risk Factors for Falls Risk FactorORSedative use28Cognitive Impairment 5Lower extremity problem 4Pathologic Reflex 3Foot Problems 2> 3 balance/gait problems 1.4>5 balance/gait problems 1.9Tinetti NEJM 1988#Common Pathologies associated with FallsOphthalmologic diseasesArthritis Foot problems Neurologic illnessParkinsons & related disordersStrokesPeripheral neuropathyDizziness

C. Bree Johnston, MD MPH , Copyright May 2001

#Falls in the CommunityAccidents/environment37%Weakness, balance, gait12%Drop attack11%Dizziness or vertigo8%Orthostatic hypotension5%Acute illness, confusion, drugs, decreased vision18%Unknown 8%Rubenstein JAGS 1988Discussing the etiology of falls is a little misleading because almost all falls result from the combination of environmental + physiologic factors. For example, I was recently skiing with my husband.....#Falls in Residential CareGeneralized weakness31%Environmental hazard27%Orthostatic hypotension16%Acute illness5%Gait or balance disorder4%Drugs5%Other or unknown10% Rubenstein Ann Int Med 1990#Medications and FallsSedative-hypnotics, especially long acting benzodiazepines, increase fallsSmall association between most psychotropics and fallsSSRIs and TCAs both incrsease fallsWeak association between Type 1A antiarrythmics, digoxin, diuretics, and fallsLeipzig JAGS 1999Thapa NEJM 1998Falls in the ElderlyPrevalenceClinical ImportanceRisk Factors & EtiologyEvaluation Prevention & ManagementSummaryC. Bree Johnston, MD MPH , Copyright May 2001

Evaluation of Falls: HistoryLocation & circumstances of FallAssociated symptomsOther falls or near fallsMedications (including nonprescription) and alcoholInjury & ability to get upC. Bree Johnston, MD MPH , Copyright May 2001

#Evaluation of Falls: Physical ExaminationSupine and standing BP - alwaysRoutine physical examinationFocus on cardiovascular, neuro, feetVision and hearing evaluationConsider acute medical illness & deliriumFormal gait and balance assessmentC. Bree Johnston, MD MPH , Copyright May 2001

#Evaluation of Falls: Home EvaluationCan be performed by nurse, OT, PT, othersStairsLightingBathroomC. Bree Johnston, MD MPH , Copyright May 2001

#Evaluation of Falls: Risk Factors for InjuryOsteoporosis assessmentAnticoagulation: Usual benefits outweigh risks unless repeat or high risk fallerCan the person get up from fall?Is there a way to notify others in case of falling?C. Bree Johnston, MD MPH , Copyright May 2001

#Formal Gait EvaluationGet up and Go TestTinetti Gait and Balance Evaluation (POMA)Tinetti JAGS 1986Podsiallo jAGS 1991Mathias Arch Phys Med 1986

#Common Causes of Abnormal GaitDifficulty arising from chairWeakness ArthritisInstability on first standingHypotension, Weakness Instability with eyes closedProprioception Step height/lengthParkinsonismFrontal lobe Fear C. Bree Johnston, MD MPH , Copyright May 2001

Falls in the ElderlyPrevalenceClinical ImportanceRisk Factors & EtiologyEvaluation Prevention & ManagementSummaryC. Bree Johnston, MD MPH , Copyright May 2001

Prevention & TreatmentTreat acute injury & underlying medical conditionsRemove unnecessary medicationsRehab, exercises, assistive devicesCorrect sensory impairmentsEnvironmental modifications & safetyEvaluate for osteoporosis treatmentC. Bree Johnston, MD MPH , Copyright May 2001

#OsteoporosisCalcium and vitamin D for most elders at risk Dawson-Hughes, NEJM, 1997Osteoporosis evaluation and treatment Hip protectors appear to protect from hip fractures in those who wear themKannus, NEJM, 2000 Risk Factor Modifications for FracturesChangeEstimated Change in RiskQuit smoking38%Treat impaired vision50%Stop sedatives40%Add 1 Gram Calcium24%Hip Protectors50%? Adapted from Stteve Cummings

www.hipsavers.comFalls: Primary Prevention301 community dwelling elders with 1+ risk factors for fallingIntervention: adjustment in medications, behavioral instructions, exercise programs aimed at modifying risk factorsOne year follow upTinetti et al. 1994 NEJMRisk factorsPostural hypotensionUse of 4 or more Rx medsImpairment in arm or leg strength, ROM, balance, ability to transfer, or gait#Multifactorial Intervention

C. Bree Johnston, MD MPH , Copyright May 2001

P = .04 Tinetti et al 1994 NEJMWagner and his group found that a one time intervention in a group of HMO enrollees age 65 and older also reduced the incidence of falls. Benefits at one year, not sustained. AJPH 1994

#Tai Chi and FallingAtlanta FICSIT Trial 200 community dwelling elders 70+Intervention: 15 weeks of education, balance training, or Tai ChiOutcomes at 4 months: Strength, flexibility, CV endurance, composition, IADL, well being, fallsFalls reduced by 47% in Tai Chi group Wolf JAGS 1996Falls in the ElderlyPrevalenceClinical ImportanceRisk Factors & EtiologyEvaluation Prevention & ManagementSummaryC. Bree Johnston, MD MPH , Copyright May 2001

Algorithm summarizing screening, assessment, and management of falls. (Modified with permission from Anonymous. Guideline for the prevention of falls in older persons. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention. J Am Geriatr Soc. 49:664, 2001.)

Kronologis keluhan pasienMRSlemas, pusing-pusing penurunan nafsu makanlebih banyak berbaring di tempat tidur2minggu10 hariJatuh saat akan ke kamar mandi karena lemas1 mingguPanas badan tidak terlalu tinggi, batuk dengan dahak putih dalam jumlah sedikit dan sesak nafas2 hariBAB hitam, lunak , berbau busuk 3 kali, hampir memenuhi popok dewasa3 bulanBAB hitam, jumlah sedikit,, sembuh sendiri1 tahun20 tahunNyeri badan tidak spesifik, nyeri ulu hati hilang timbul, berobat ke bidanJatuh saat berjalan ke sawah, hanya diurut

Kesan: fraktur kolum femur sinistraSummaryFalls are common in the elderly & may lead to injuries and decline in functionEvaluation should included risk factor assessment, gait assessment, and home assessmentExercise can improve outcomesIdentitas penderitaNama: NMMUmur: 80 tahunJenis Kelamin: PerempuanAlamat: TabananPekerjaan: Ibu Rumah TanggaAgama : HinduPendidikan: Tidak sekolah (tidak bisa baca//tulis/ hitung)MRS: 05.08.2011Keluhan utama : buang air besar berwarna hitam#Riwayat Penyakit SekarangBuang air besar berwarna hitam sejak 2 hari Sebelum Masuk Rumah Sakit (SMRS)Hitam, lunak dan berbau busuk sebanyak 3 kali dalam jumlah sedang, hampir memenuhi popok dewasaPernah mengalami hal yang sama sebelumnya sekitar 3 bulan yang lalu, jumlah sedikit dan berhenti sendiri#rasa tidak enak di ulu hati berulang sejak sekitar 1 tahun yang lalu, hilang timbul, tidak dipengaruhi oleh makanan, hilang setelah minum obat-obat yang diberikan oleh bidan di kampung pasiennyeri badan dengan lokasi tidak spesifik hilang timbul sejak 1 tahun yang lalu. Biasanya berobat ke bidan. Nyeri hilang setelah diberi obat suntikan dan obat minum. Pasien dan keluarga tidak tahu jenis dan nama obat yang diberikan1 minggu SMRS pasien mengalami panas badan tidak terlalu tinggi, batuk dengan dahak putih dalam jumlah sedikit dan sesak nafasSejak 2 minggu SMRS pasien lemas, pusing-pusing dan mengalami penurunan nafsu makan sehingga lebih banyak berbaring di tempat tidur10 hari SMRS karena lemas pasien jatuh saat akan ke kamar mandi. Pasien menyangkal rasa berdebar, pusing, sesak ataupun nyeri dada sesaat sebelum jatuh. Saat jatuh, pasien harus dibantu berdiri oleh anaknyaHilangnya kesadaran, muntah, maupun kejang setelah jatuh disangkalSemenjak itu pasien hanya tiduran di tempat tidur dan menggunakan pokok dewasa karena tidak mampu berjalan ke kamar mandi. BAK pasien dikatakan tidak mengalami perubahan, nyeri saat BAK disangkalRiwayat Penyakit DahuluPernah jatuh terpeleset saat berjalan di sawah 20 tahun yang lalu karena jalan tanah yang licin, hanya diurut oleh tukang pijat di kampung. Pasien masih dapat berjalan dan beraktifitas walaupun dengan sedikit gangguan pada gerak pada kaki sebelah kiri.Pasien juga dikatakan sudah mengalami gangguan penglihatan dan pendengaran sejak sekitar 10 tahun yang lalu.

PEMERIKSAAN FISIKKesan sakit: beratKesadaran : somnolen (E4V4M6)Tekanan Darah: berbaring : 100/70 mmHg duduk: 100/70 mmHgNadi: 86 x/menit Respirasi: 24 x/menitSuhu tubuh: 37,6 CAntropometri: Berat badan + 38 kg tinggi lutut 44cm TB + 145 cm IMT : 18.07

#KepalaMata : conjungtiva anemis +/+, sclera tidak ikterikLeher: gerak normal, JVP 5+3cmThorax: sela iga normalParu: sonor, suara dasar vesikuler, ronkhi +/+, wheezing +/+Jantung dan pembuluh darah: Irama reguler, S1 dan S2 tunggal, murmur (-)Abdomen: distensi (-) bising usus (+) normal hepar dan lien tak terabaPunggung : luka ekscoriasi ukuran 2x2cm dengan dasar bersih, tanpa jaringan nekrotikEkstremitas: akral hangat, pitting edema +/+#PEMERIKSAAN LABORATORIUM04.08.1106.08.1108.11WBC11.36.66.2Neu96.1%84%84.8%Ly3.4%10%6.9%Mo0.1%5.4%5.9%Eo0.1%0.5%1.8%Ba0.3%0.1%0.3%Hb6.26.810.2Hct19.32130.5MCV88.888.886.4MCH28.728.828.9Plt201223214#

Kesan: fraktur kolum femur sinistraBuat daftar masalah pada pasien tersebut ?Sebutkan faktor risiko terjadinya jatuh pada pasien tersebut ?Apa saran untuk mencegah terjadinya jatuh berulang pada pasien tersebut ?Pasien menolak operasi, apa kemungkinan komplikasi yang bisa terjadi ?