Falls: Risk Factors, Assessment, and Prevention - PowerPoint Presentation PDF

FALLS  Fall - definition  The unintentional change in position resulting in a person coming to rest on the floor, ground, or another lower level.  Although Mrs. Pierce wouldn’t characterize her “sudden sitting” as a fall, it meets the definition and would qualify. Th...

FALLS  Fall - definition  The unintentional change in position resulting in a person coming to rest on the floor, ground, or another lower level.  Although Mrs. Pierce wouldn’t characterize her “sudden sitting” as a fall, it meets the definition and would qualify. This fall means that she is at high risk for falling in the future.  One-third of people aged over 65 years will fall each year.  Falls may be common, but that doesn’t mean they are without consequence.  Injuries: 10% of falls result in major injuries including hip fracture and traumatic brain injury.  ED and hospital use: 16% of ER visits and 7% of hospitalizations in older patients are for fall related injuries.  Loss of independence: Falls are the major reason for 40% of nursing home placements  Morbidity / Mortality Complications resulting from falls is the 5th leading cause of death in older adults. Nearly 95% of hip fractures are caused by falls. For adults 65 and older, 60% of fatal falls happen at home, 30% in public places, and 10% in healthcare institutions. Fear of falling, called the post-fall anxiety syndrome, associated with living alone, cognitive impairment, depression, and balance and mobility impairments Almost 60% of those with a history of a fall in the previous year will have a subsequent fall. Risk Factors  Fall Risk Assessment Include in the H&P examination of all geriatric patients. Guidelines issued by the American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopedic Surgeons panel on falls prevention include: All older patients (or their caregivers) should be asked at least once a year about falls, frequency of falling, and difficulties in gait or balance. Evaluation of Fall Risk Patients Targeted History: Activity of the person at the time of the previous fall Underlying chronic diseases that increase falls risk. Complete medication history & History of alcohol use Environmental factors DDROPP (diseases, drugs, recovery, onset, precipitants)  Evaluation of Fall Risk Patients General physical examination Postural vital signs Visual acuity Hearing function Examination of extremities Targeted neurologic examination  Evaluation of Fall Risk Patients Physical Exam Musculoskeletal Function Get up and Go test - >12 sec increased risk: 30 second chair stand STEADI Performance Oriented Mobility Assessment tool (POMA)  Post Fall Assessment The AGS recommends that clinicians focus on the following physical exam parameters when evaluating an older adult after a fall: 1. Gait, balance, and mobility assessment: Detailed assessment of gait, balance, and mobility levels and lower extremity joint function 2. Neurological function including cognitive evaluation: Evaluate lower extremity peripheral nerves, proprioception, reflexes, tests of cortical, extrapyramidal and cerebellar function; check for cogwheeling and rigidity. 3. Muscle strength: Test lower extremities for strength and range of motion. 4.Cardiovascular status: Complete a thorough cardiovascular and pulmonary assessment. Check: a. heart rate and rhythm b. orthostatic vital signs c. presence or absence of peripheral edema  Carotid sinus massage or tilt table testing can be done, and may be useful in patients with unexplained syncope or falls. Carotid sinus massage, however, must be done in a monitored environment with continuous ECG monitoring. False positives are common in the older patient. 5. Visual acuity assessment 6. Foot and footwear examination  Evaluation Fall Risk Patients Diagnosti Complete Blood Count (to rule out anemia and c Testing infections) Electrolytes, BUN, creatinine (to rule out electrolyte imbalance and dehydration) Serum glucose and stool occult blood test ECG (to rule out rhythm disturbances) CT if on blood thinners and head injury MRI (to rule out brain and spinal cord lesions if neurologic exam is positive)  Recommendations for fall prevention  U.S. Preventive Services Task Force (USPSTF): exercise and vitamin D for 65 y.old and older community-dwelling adults (Grade B)  The National Institute on Aging (NIA): exercise, environmental hazards, and regular medical care (hearing and vision; medication management)  American Geriatric Society (AGS) and Center of Disease Control and Prevention (CDC): exercise, vitamin D, home environment modification, medication revision, management of postural hypotension, vision and foot problems (footwear)  STEADI CDC (2017):  Strength/ balance program  Vitamin D supplementation  Medication management  Corrective eyewear  Cataract surgery  Orthotics and exercise  Home modification  Postural hypotension  Fall Prevention Interventions Low risk Moderate risk High risk ❏ Educate patient ❏ Educate patient ❏ Moderate risk ❏ Vitamin D +/- ❏ Vitamin D +/- interventions + calcium calcium ❏ Manage & monitor ❏ Refer for ❏ Refer to PT to hypotension strength & improve gait, ❏ Manage balance exercise strength, and medications (community balance OR ❏ Address foot exercise or fall refer problems prevention to a fall ❏ Optimize vision program) prevention ❏ Optimize home program safety  HIGH RISK patient - Follow up  Within 30 days  Review care plan  Assess and encourage fall risk reduction behaviors  Discuss and address barriers to adherence  Transition to maintenance exercise program when patient is ready.  Exercise/Physical Therapy Recommendations group classes and at-home at least 150 min/week of moderate-intensity or 75 min/week of vigorous-intensity aerobic physical activity muscle-strengthening activities twice per week balance training 3 or more days/week (for older adults at risk for falling because of a recent fall or difficulty walking) Tai Chi  Chair Rise Exercise  Strengthens the muscles in your thighs and buttocks.  Goal: To do this exercise without using your hands as you become stronger. Vitamin D supplementation  800 IU daily x 12 months for community- dwelling adults 65 y. old and older at increased risk for falls (USPSTF)  800 IU daily for persons at increased risk for falls (AGS)  600 IU for adults aged 51 to 70 years and 800 IU for adults older than 70 years  Referrals Physical therapist (gait, mobility, balance, lower body weakness) Occupational therapist (home modification) Ophtalmologist (vision correction/surgery)/ ENT (hearing devices) Cardiologist (postural hypotension, heart murmurs, Holter monitor) Neurologist (Parkinson’s, lumbar stenosis, gait disorders) Orthotist (proper footwear) Psychologist (depression) (UpToDate, 2017)