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Sunday General Session                              

Preventing Falls in the Elderly 

       

Dale Moquist, MD Former Geriatric Coordinator Memorial Herman Family Medicine Residency, Sugar Land Horseshoe Bay, Texas      Educational Objectives By completing this educational activity, the participant should be better able to: 1. Identify risk factors for falls in the elderly.  2. Appropriately screen patients who may be experiencing falls.  3. Effectively evaluate patients who fall. 4. Discuss evidence‐based measures to reduce the risk for falls. 

    

    Speaker Disclosure Dr. Moquist has disclosed that neither he nor members of his immediate family have a relevant financial relationship with an ineligible company. 

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TAFP Annual Session & Primary Care SummitDale C. Moquist, MD

November 7, 2021

Preventing Falls in the Elderly

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DISCLOSURE

Dr. Moquist has disclosed that neither he nor members of his immediate family have a relevant financial relationship with an ineligible company.

Dr. Moquist will not discuss or present information that is related to an off-label or investigational use of any therapy, product, or device.

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Learning Objectives

By completing this educational activity, the participant should be better able to:1. Identify risk factors for falls in the elderly. 2. Appropriately screen patients who may be experiencing falls. 3. Effectively evaluate patients who fall.4. Discuss evidence-based measures to reduce the risk for falls.

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The 5 Ms of Geriatrics Mind Maintaining mental activity Manage Dementia Treat & prevent Delirium

Mobility Maintaining ability to walk and/or maintain balance Preventing falls

Medications Reducing polypharmacy De-Prescribing Prescribing treatments based on an older person’s needs

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….The 5 Ms of Geriatrics

Multi-Complexity Helping older adults manage a variety of health conditions Assessing living conditions when they are impacted by age, health

conditions, and social concerns

Matters Most Coordinating Advance Care Planning Helping manage goals of care Making sure a person’s individual, personally meaningful health

outcomes, goals, and care preferences are reflected in treatment plans5

Audience Question #1According to the CDC, how many adults >65 y/o report falling in the previous year?

1. One in Ten2. One in Four 3. One in Three4. One in Two

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Audience Question #2Among those with a history of a fall in the previous year, the annual incidence of falls is?

1. 25%2. 40%

3. 60%

4. 75%

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Audience Question #3What percentage of falls result in fracture, head trauma, or serious soft-tissue injury?

1. 5-10%

2. 25%

3. 50%

4. 75%

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Audience Question #4What percentage of hip fractures are caused by falls?

1. 10%

2. 20%

3. 40%

4. 75%5. 90%

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OUTLINE

Epidemiology

Causes

Evaluation

Intervention

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Epidemiology

Definition

Epidemiology

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Definition

Coming to rest inadvertently on the ground or at a lower level Very common geriatric syndrome

Most falls are NOT associated with syncope Falls literature usually excludes falls associated with LOC

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Epidemiology of Falls

Each year 30%–40% of community-dwelling persons aged ≥65, and about 50% of residents of long-term care facilities, experience falls

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Epidemiology of Falls

Annual incidence of falls is close to 60% among those with history of falls

Complications of falls are the leading cause of death from injury in people

Number increases progressively in both sexes and all racial and ethnic groups

Fall related injuries NOT common cause of death Recovery from falls often delayed in older persons

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…Epidemiology Significant Morbidity Decline in functional status Hospital stays are twice as long Greater likelihood of nursing home placement Increased use of medical services

Marker of Poor Health Sign of acute illness Acute exacerbation of chronic illness

Third of community-dwelling in 1 year 5-10% result in fractures Fractures: 75% of serious injuries 1-2% of falls: Hip FX

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…Epidemiology

90% of hip fracture occur with falls

Falls in the elderly rarely have a single cause

Only ½ of older adults can get UP Concerned about the “Long Lie”

Most falls DO NOT cause injury Fear of falling Self-Restriction of activities Increasing Immobility: > Risk for falls

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Causes

Risk Factors

Age-Related Changes

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Risk Factors: Nonmodifiable Older Age: > 80 yo

Cognitive impairment

Female gender

Past history of a fall

Stroke/TIA

Parkinson’s

History of falls

Arthritis

History of fractures

Recent discharge from hospital (< 1 month)18

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Modifiable Risk Factors

Leg/Gait problems Foot disorders Balance Anemia Hypovitaminosis D Psychotropic meds or polypharmacy Alcohol use Orthostatic Hypotension Environmental hazards Sensory impairment

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Age-Related Changes Visual Reduced visual acuity Reduced depth perception Reduced contrast sensitivity Reduced dark adaption

Proprioceptive loses sensitivity in the legs Vestibular Loss of labyrinthine hair cells Loss of ganglion cells Loss of nerve fibers

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More Age-Related Changes

Increase in measured sway

Gait speed deteriorates Older activate proximal then distal muscles

Decline in baroreflex sensitivity

Reduced total body water

Rigidity of leg muscles

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Evaluation

Screening Algorithm

Positive Screen

Evaluation Tools

History

Multifactorial Causes

Physical

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Screen for Fall Risk Yearly Fall in the past year? How many times? Were you injured?

Feels unsteady when standing or walking?

Worries About falling?

YES to any question: Evaluate gait, strength, and balance

Part of the Medicare Wellness Visit

STEADI uses a 12-question tool: At risk if score > 4

cdc.gov/steadi

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NO to ALL Screening Questions

Individualized fall interventions: Low risk Educate patient Assess Vitamin D intake Assess Calcium intake Refer for to community exercise or fall prevention program

Reassess yearly or any time patient presents with an acute fall

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YES to Any Screening Questions

Evaluate gait, strength, and balance using: Timed up and go test 30-second chair stand 4-stage balance test

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Timed Up and Go Test

Get up out of a standard armchair without using arms

Walk 10 feet

Turn around

Walk back to chair

Sit down without using arms

May or may not be timed

If timed, use 12 seconds as an increased risk of falls

Timing provides a measure of performance over time

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Chair Stand Test

Patients are asked to cross their arms over their chest while seated in a chair

It should be noted if the patient needs to use their arms

Clinician records how many times the patient can fully stand and sit in 30 seconds

In men 75-79, < 11 chair stands is abnormal

In women 75-79, < 10 chair stands is abnormal

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Chair Stand Test

755 Community Dwelling: 64.1% female

Mean Age: 78.1

Short physical performance battery: Gait, chair stand performance and balance

5 Repeated chair stands

16.7 Second cut-point: Independent predictor

Predictor of Falls: Not fall-related fractures

Fall history and slow chair stand: 2-year cumulative incidence rate of injurious fall of 46%

Ward R. Functional Performance as a Predictor of Injurious Falls in Older Adults. JAGS 2015 63:315-320.

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4 Stage Balance Test

Patients asked to stand for at least 10 seconds in following: Feet adjacent Semi-tandem stance Tandem stance On one foot

Unable to perform the semi-tandem test for 10 seconds are at increased risk of falling

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4 Stage Balance Test

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Results of Screening Normal timed Up and Go: Consider low risk If abnormal Up and Go: Consider Hx of falls and injury If NO fall history: Moderate risk Educate patient Refer to PT to improve gait, strength, and Balance Refer to community fall prevention program

If falls and or injury: Conduct multifactorial risk assessment Falls history Physical exam Use of mobility aids Footwear check

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Diagnostics Tests

No set of “standardized” tests Rare to find cause with blood or x-ray

Should consider CBC, UA, BMP Dehydration, anemia, diabetes mellitus

No role for “routine” EKG, Holter, ECHO, or CT scan Order driven by findings of H&P exam

Consider Vitamin D level

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History…

What was the activity at the time of the fall?

Were there any associated symptoms?

Where did the fall occur?

What is the condition of the environment?

Was the fall inside or outside?

Any furniture cause the fall? What was the lighting?

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…History

What footwear was she wearing?

Were stairs involved?

What type of flooring?

What is the lighting?

Was she using any assistive devices?

Is the device in good condition? Has she/he fallen before?

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Functional History

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THINK

CATASTROPHE

Functional Inquiry Caregiver & Housing Alcohol Treatment (Meds) Affect (Depression) Syncope Teetering Recent Illness Ocular Problems Pain With Mobility Hearing Environmental Hazards

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Risk Factor Assessment

Frequently: Related to accumulated effect of multiple disorders superimposed on age-related changes

Likelihood of fall increases with # of risk factors A single fall may have multiple causes Repeated falls may have a different etiology

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Intrinsic Risk Factors

Past History of Fall

LE Weakness

Age

Female Gender

Cognitive Impairment

Balance Problems

Anemia

Psychotropic Drug Use

Alcohol

Arthritis

History of Stroke

Orthostatic Hypotension

Dizziness

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Don’t Forget the MEDS!

Specific classes Benzodiazepines Antidepressants Antipsychotics

Recent med dosage adjustment

Total number of prescriptions > 4

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Drugs Associated with Falls

Sedative Hypnotics Tricyclic Antidepressants

Anticholinergics

Alcohol

Antihypertensives

Nonsteroidals

Hypoglycemic Drugs Cholinesterase Inhibitors

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Extrinsic Risk Factors

Environmental Hazards

Poor Footwear Restraints: Especially in the Nursing Home

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Environmental Hazards

Cracked or uneven pavement

Lack of adequate railings

Poor lighting

Slip rugs

Uneven stairs

Unstable furniture Wet or slippery surfaces

Poor footwear44

Precipitating Causes

Trips and slips

Drop attack

Syncope

Dizziness

Acute medical illness

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Multifactorial Causes of Falls

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Physical Findings

I HATE FALLING

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….Physical FindingsInflammation

HypotensionAuditory & Visual ABN.TremorEquilibrium: Balance

Foot ProblemsArrhythmiaLeg-length DiscrepancyLack of ConditioningIllnessNutritionGait Disturbance48

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Relative Risks for Falls

Muscle Weakness 4.4 History of Falls 3.0

Gait Deficit 2.9

Balance Deficit 2.9

Assistive Device 2.6

Visual Deficit 2.5

Arthritis 2.4 Impaired ADL 2.3

Depression 2.2

Cognitive Impairment 1.8

Age > 80 Years 1.7

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Intervention

Guideline Recommendations

Home Environment

Medications

Postural Hypotension

Foot Problems

Exercise

Vitamin D

Vision

Heart Rate50

USPSTF on Falling 2018

The USPSTF recommends exercise interventions to prevent falls in community-dwelling adults 65 years or older who are at increased risks for falls. Grade B

The USPSTF recommends that clinicians selectively offer multifactorial interventions to prevent falls to community-dwelling adults 65 years or older who are at increased risk for falls. Existing evidence indicates that the overall net benefit of routinely offering multifactorial interventions is small. Grade C

The USPSTF recommends against Vitamin D supplementation to prevent falls in community-dwelling adults 65 years or older. Grade D

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AGS Screening Recommendations

1. All older individuals should be asked whether they have fallen in the past year.

2. An older person who reports a falls should be asked about the frequency and circumstances of the falls.

3. Older individuals should be asked if they experience difficulties with walking or balance.

4. Older persons who present for medical attention because of a fall, report recurrent falls in the past year, or report difficulties in walking or balance should have a multifactorial fall risk assessment.

5. Older persons with a Single Fall should be evaluated for gait/balance

2010 American Geriatrics Society Clinical Practice Guideline: Prevention of Falls in Older Persons52

Modify Home Environment

Home assessment with environmental modification reduces the risk of falling among older adults who have fallen or are at high risk of falling because of visual impairment

Fall in Bathroom: Shower seats, grab bars, nonslip floor coverings

Fall on Stairs: Repair stairs, improve lighting, single-level housing

Order OT assessment to evaluate

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Minimize Medications

Gradual taper of psychotropic meds

Complete review of ALL meds including OTC Cessation of meds or dose reduction

Which meds are truly life preserving?

What meds were recently started?

Use Beers Criteria

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Manage Postural Hypotension

Sensation of dizziness is strongly associated with increased risk of falls Better control of systolic BP associated with decrease in postural

changes

Most Common: Dehydration, medications, and autonomic Neuropathy

Take lying and standing BPs

No single intervention decreases falls

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Manage Foot Problems & Footwear

Reduction in falls among older adults wearing a nonslip shoe covering during icy conditions

Higher heels and decreased surface area associated with an increased risk of falls

Use walking shoes with high contact surface area Avoid in those with a shuffling gait

Inspect for bunions, toe deformities, and ulcers

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FEATURES OF SAFE FOOTWEAR

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Prescribe Exercise Should be individually tailored

Tai Chi can be effective

Exercise classes in community using gait training, balance, and strengthening reduces the risk of falls

Home-based and group exercises reduces the risk of injurious falls in the community

Cochrane Review in 2017: 40% reduction in fractures in adults 50 years and older Functional task training: 24% reduction The addition of resistance: 34% reduction

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Vitamin D Supplement 5 years ago, I would inform you to definitely prescribe

Review for USPSTF did not reduce the risk of falls among community-dwelling adults

Vit D reduced the risk of falls in community-dwelling adults with a lowVitamin D at baseline

The effectiveness of Vit D supplementation on fall prevention is mixed.

High-dose Vitamin D supplementation is associated with increased risk of falls, 500,000 IU Q Yr or 60,000 IU Q month

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Vit D & Falls-Related Hospitalizations 1348 Community-dwelling Australian women aged > 70

Followed for 14.5 years

Baseline Vitamin D, grip strength, Timed Up and Go Low < 50 nmol: 384 Medium 50 to < 75 nmol: 491 High > 75 nmol: 473

Women in high significantly lower hazards for a fall-related hospitalization

Higher levels associated with better TUG performance

Sim M. Association Between Vitamin D Status and Long-term Falls-Related Hospitalization Risk in Older Women. JAGS October 2021 DOI:10.1111/jgs.17442

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Vision Impairment

First cataract surgery decreases rate of falls Second cataract surgery showed NO benefit in reducing falls

Routine eye screening with correction of visual defects is NOT effective in reducing falls

When visual RX with exercise the OR of falling was 0.17.

The AGS/BGS recommends cautioning older adults with multifocal lenses to be more attentive to falling when walking

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Manage Heart Rate & Arrhythmia

One trial demonstrated a reduction in the rate of falls among older adults with carotid sinus hypersensitivity treated with a pacemaker

Most Common: Carotid Sinus Hypersensitivity Vasovagal Syndrome Bradyarrhythmia

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Effect on Falls

Intervention % Reduction NNT Prevent 1

Exercise 6.9% 14

Vision 4.4% 23

Home Hazard 3.1% 32

EX + Vision 11.1% 9

EX + Home 9.9% 10

Vision + Home 7.4% 14

EX+Vision+Home 14.0% 7

Day L. Randomized Factorial Trial of Falls Prevention Among Older People Living in Their Own Homes. BMJ 2002;325:13066

Nursing Home Patients

Vitamin D supplementation demonstrated a reduction in the rate of fall

Vitamin D 800 IU daily Multifactorial interventions should be considered

Exercise programs should be considered

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Summary

Screen yearly or more often if patient falls Rarely caused by one factor Interaction of multiple and diverse risk factors High prevalence of comorbid diseases Greater number of risk factors, greater risk of falling Marker of poor health and declining function Remember to ASK!

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Questions?

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An 80-year-old woman comes to the urgent care center because she slipped on wet steps yesterday while watering her plants. She scraped her leg but did not hit her head.

She has fallen 3 other times in the last year. Her last fall was 3 months ago.

• On that occasion, she went to the ED because she struck her head on the bathroom vanity.

• Non-contrast CT of the head showed nonspecific microvascular ischemic changes and no acute bleeding.

History: Hypertension, well-controlled diabetes mellitus, atrial fibrillation Medications: Lisinopril, carvedilol, metformin, warfarin

CASE 1 (1 of 4)

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Examination• Blood pressure 132/86 mmHg (no postural changes), heart rate

80 bpm and irregularly irregular• Neurologic findings are normal• INR: 3.0• The posterior surface of her right leg has a superficial abrasion

with surrounding ecchymoses; there are no other injuries. • She walks slowly, with a shortened stride length on a slightly wide

base and turns in bloc.

CASE 1 (2 of 4)

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Which one of the following is the best next step?

1. Discontinue warfarin2. Refer to a community exercise program3. Begin cholecalciferol 50,000 IU weekly4. Provide educational materials about fall risk

Audience Question #5 – CASE 1 (3 of 4)

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79-year-old man is concerned about falling. He wants to get his eyes examined, because he thinks his vision has deteriorated. He lives alone.

Four days ago, he missed a step and slid down 5 or 6 steps• He had no injury other than bruising over his buttocks. • He purchased a medical alert necklace after the fall, and he is

thinking about moving his bedroom to a spare room downstairs. He last fell 1 year ago, when he got out of bed to go to the bathroom. History: Heart failure with preserved ejection fraction, gout, chronic

insomnia• Neurologic and cardiovascular findings are unremarkable

CASE 2 (1 of 4)

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Medications: Furosemide, carvedilol, lisinopril, aspirin, allopurinol, temazepam

At his last eye exam 2 years ago, findings were normal except for presbyopia and myopia in both eyes.

Examination• He completes the Timed Up and Go test in 20 seconds. • Using the Snellen eye chart, visual acuity is 20/40 in both eyes

when he wears his glasses. • Neurologic and cardiovascular findings are unremarkable

CASE 2 (2 of 4)

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Which one of the following would most likely reduce this patient’s fall risk?

1. Bifocal glasses

2. Cognitive-behavioral therapy for fall-related anxiety

3. Taper of temazepam

4. Lower bed

Audience Question #6 – CASE 2 (3 of 4)

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Resources

2010 American Geriatrics Society and British Geriatric Society Clinical Practice Guideline: Prevention of Falls in Older Persons. www.americangeriatrics.org. Accessed on October 7, 2015.

Geriatrics Review Syllabus 10th Edition. Falls. Updated March 2021

Ganz D. Prevention of Falls in Community-Dwelling Older Adults. NEJMVol. 382:734-743. February 20, 2020.

Liu-Ambrose T. Effect of a Home-Based Exercise Program on Subsequent Falls Among Community-Swelling High-Risk Older Adults After a Fall. A Randomized Clinical Trial. JAMA 2019;321(21):2092-2100.

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Resources

Guirguis-Blake J. Interventions to Prevent Falls in Older Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2018;319(16):1705-1716

Poulton G. Exercise to Reduce Falls in Older Adults. FPIN’s Clinical Inquiries. American Family Physician Vol 101(1):42-43. January 1, 2020.

www.cdc.gov/steadi. Accessed on Oct. 7, 2021.

Falls Prevention in Community-Dwelling Older Adults: Interventions. April 17, 2018.

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Notes