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Overview
Prevalence Clinical Importance Risk Factors & Etiology Evaluation Prevention & Management Falls & restraint use Summary
Falls: Mrs. F.
Mrs. F. is an 80 year old woman who lives alone. She just came in to your office for follow up of a fall resulting in a Colles fracture. She has had two other falls over the past year and a half. She is scared of falling again. She has a history of osteoarthritis and anxiety/depressison. She is on naproxen 500mg BID and diazepam 5mg BID prn
UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Clinical Importance Risk Factors & Etiology Evaluation Prevention & Management Falls & restraint use Summary
Prevalence
30% of those over 65 fall annually Half are repeat fallers Falls go up with each decade of life Over half of those in nursing homes and hospitals will fall each year
Prevalence
Clinical
Importance
Risk Factors & Etiology Evaluation Prevention & Management Falls & restraint use Summary
UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Risk
Extrinsic Factors
Medications
FALLS
Environment
Dysmobility
Dysmobility and falling closely related 15% of those over 65 have trouble walking 1/4 men and 1/3 women over age 85 have difficulty with walking 2/3 of people in hospital or NH unable to ambulate without assistance
Risk Factor Sedative use Cognitive Impairment Lower extremity problem Pathologic Reflex Foot Problems > 3 balance/gait problems >5 balance/gait problems
OR 28 5 4 3 2 1.4 1.9
Tinetti NEJM 1988
Evaluation
Mrs. F.
History reveals that she fell at home in the bathroom at night, tripping over a bathmat. Both other falls have been in similar circumstances. She was able to get up. On PE, she has visual acuity of 20/100 with bilateral cataracts. She has mild OA of the knees, with bunyon deformities of her feet and poor fitting shoes.
Mrs. F.
Her gait assessment shoes that she is unable to get up out of the chair without help. Her gait is hesitant and slightly wide based. Home evaluation reveals poor lighting in all rooms, multiple throw rugs in every room, and no grab bars or safety equipment in the bathroom.
Mrs. F.
She is weaned off of her diazepam over 3 months T-score on dexa is 3.0, and she is begun on alendronate, vitamin D, and calcium She goes to ophthalmology and podiatry PT begins exercises, followed by weight lifting and exercise 3X a week at a Senior Center She gets home safety equipment, improved lighting, and gives away her throw rugs
Difficulty arising from chair Weakness Arthritis Instability on first standing Hypotension, Weakness Instability with eyes closed Proprioception Step height/length Parkinsonism Frontal lobe Fear
Prevention
& Management
Osteoporosis
Osteoporosis evaluation and treatment Hip protectors appear to protect from hip fractures in those who wear them
Stop sedatives
Add 1 Gram Calcium
40%
24%
Hip Protectors
50%?
Adapted from Stteve Cummings
RCT of 1801 frail subjects in Finland Nursing home or frail community patients Mean age 81 78% women 63% assisted walking
Kannus. NEJM;2000;343;1506-1513.
Fractures with Hip Protectors 2.1% per year vs. 4.6% per year (p<.01) 40 patients needed to be treated with hip protector for 1 year to prevent one fracture 2.4% of falls resulted in hip fracture when not wearing protector 0.4% resulted in hip fracture when wearing protector (80% risk reduction) But patient acceptance low
Kannus. NEJM;2000;343;1506-1513
UCSF Division of Geriatrics Primary Care Lecture Series May 2001
www.hipsavers.com
community dwelling elders with 1+ risk factors for falling Intervention: adjustment in medications, behavioral instructions, exercise programs aimed at modifying risk factors One year follow up
Tinetti et al. 1994 NEJM
UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Multifactorial Intervention
% Falling 50 40 30 20 10 0 0 3 6 Months
UCSF Division of Geriatrics Primary Care Lecture Series May 2001
i Mo
Control Intervent
P = .04
9 12
Exer Exer + Su Sup Control Exer Exer + Sup Su STUDY GROUP Control
Fiatarone et al NEJM 1994 UCSF Division of Geriatrics Primary Care Lecture Series May 2001
CI
(.81-.99) (.70-.98)
Falls
Summary
UCSF Division of Geriatrics Primary Care Lecture Series May 2001
Summary
Falls are common in the elderly & may lead to injuries and decline in function Evaluation should included risk factor assessment, gait assessment, and home assessment Exercise can improve outcomes We have no evidence that restraints reduce fall related injuries