Falls and older people

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Falls and older people
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Consequences of falls

• Mortality
• Injury
• Psychological sequelae
• Loss of independence

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Why do older people fall?
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Staying upright

• Muscles and joints
• Eyes
• Acuity
• Contrast
• Depth perception
• Field- range of vision
• Ears
• Semicircular canals in 3 planes
• Utricle and saccule

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Staying upright

• Proprioception
• Receptors in skin and joints
• Vasoactive responses
• Blood pressure and heart rate correct for changes
  in position against gravity
• Neural processing
• Needed to put it all together

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Healthy ageing

• Reduced muscle strength and power
• Reduced reaction times
• Reduced proprioception
• Changes in vision
• Reduced bone strength
• Reduced neural processing power

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Falls in individuals

• Identify those at greatest risk
• Previous history of falling
• High number of risk factors
• Fear of falling
• Functional tests

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Effects of illness

• Stroke
• Parkinson's disease
• Arthritis
• Diabetes

• Weakness, balance , sensation
• Neural processing
• Strength power and proprioception
• Sensory loss, muscle weakness

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Effects of illness

• Cardiac problems
• Dementia
• Bladder problems

• Changes in blood pressure and heart rhythm
• Reduced processing
• need to move fast

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Falls risk factors

• Visual problems
• History of eye disease may cause difficulty with
  contrast and depth even if acuity ok
• Bifocal glasses
• Cognitive impairment
• Evidence of delirium in hospital
• Inability to walk and talk at same time is subtle
  clue to loss of processing

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Medications

• Psychotropics
• Analgesics
• Anticonvulsants
• Antihypertensive
• Antimuscarinics/ anticholinergics
• Diuretics

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FRAT Falls risk assessment tool

• Any history of fall in the last year
• On gt 4 medications
• History of Parkinson's disease or stroke
• Self reported problems with gait and balance
• Unable to rise from chair at knee height without
  use of arms

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Functional tests of falls risk

• Sit to stand 5
• Six meter walk test
• 180 degree turn test
• Stalk test

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Functional test of falls

• Tinetti gait and balance score
• Assesses falls risk as high , medium or low
• Elderly mobility score
• Assesses likelihood of independence with
  functional daily tasks

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Syncope and postural hypotension

• Neurocardiogenic syncope
• Carotid sinus syndrome
• Orthostatic hypotension

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Orthostatic hypotension

• Neurogenic
• Primary autonomic failure
• Secondary autonomic failure
• Non- neurogenic
• Reduced intravascular volume
• Vasodilatation
• Cardiac impairment
• Drugs
• hypertension

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Syncope and seizures

• Evidence of loss of consciousness causing fall
• No recollection of cause
• Fall with injury particularly facial
• Symptoms of faint
• Confusion after event

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Epilepsy/ syncope
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Syncope investigations

• Ambulatory ECG
• R wave recordings
• Head up tilt test carotid sinus massage
• Two or more episodes of blackout
• One blackout with injury

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Syncope invests

• Contraindications for tests
• Atrial fibrillation
• Carotid bruit
• Dementia

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Can falls be prevented?
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Interventions

• Single versus multifactorial inteventions

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Falls interventions

• There have been effective falls interventions
  using single and multiple components
• Reduced falls order of 20- 40
• Single interventions are effective if targeted to
  people where high proportion of falls risk is
  attributable to risk factor and is modifiable

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Modifiable single risk factors

• Reductions in psychotropic drugs ( Campbell 1999)
• Treatment of syncope ( Kenny 2001)
• Reductions of home hazards ( Cummings 1999)
• Cataract surgery ( Foss 2006)

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Gait and balance training

• Targeted gait and balance training is part of
  successful multi-factorial and single
  interventions
• Exception is for patients with dementia

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Medical falls clinic

• Examination for new or undiagnosed medical
  problems
• Investigation of blackouts and postural
  hypotension
• Review of medications especially sedatives or
  multiple cardiac medicines
• Screen for osteoporosis
• Recommendation for exercise/ rehabilitation if
  frail or high fear of falling

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Treatment of syncope

• Cardiac pacing- cardioinhibitory and mixed
  carotid sinus syndromes
• Midodrine hypotensive carotid sinus syndrome

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Orthostatic hypotension- general measures

• Hot weather
• Post prandial
• Drugs
• Leg crossing
• Diurnal
• Raised intrathoracic pressure

• Increase fluid intake
• Increase caffeine
• Isotonic exercises
• Bed head raise

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Orthostatic hypotension-medications

• Anaemia- erythropoietin
• Parkinson's disease- domperidone
• Fludrocortisone
• Midodrine

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Exercise

• One to one or group
• Targeted to individual
• Strength and balance
• Progressive
• Prolongued intervention

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Home hazards

• Stair design
• Maintenance of stairs
• Footwear
• Lighting
• Distracting events

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Health promotion in falls

• Reasons people dont exercise
• Health problems
• Associations with frailty
• Increased pain
• Other priorities

• Reasons people do
• Feeling better
• Less dizzy
• Able to do more
• Looking good!

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Summary

• Maintaining upright posture and mobility involves
  complex processes
• Therefore there maybe many contributors to falls
  risk including illness but also general ageing
  and lack of conditioning
• Assessment of new onset problems or deteriorating
  mobility is worthwhile

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Summary

• Interventions to reverse weakness and balance
  problems take time and effort and are not
  possible for all
• If a person is unable or unwilling to engage in
  rehabilitation and exercise then reducing the
  risk of falls with assisstive devices and
  environmental checks and aids is the best option

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Falls risk assessment

• Previous history of falls
• High number of risk factors
• Fear of falling
• Functional tests