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FALLS

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Title: FALLS


1
FALLS
  • Dr Alastair Kerr
  • Swindon/Bath DRC April 2006

2
Outline
  • Incidence
  • Sequelae
  • Risk factors
  • Assessment
  • Interventions
  • Osteoporosis
  • NSF/NICE

3
Incidence
  • What gt65yrs fall in 1 year ?
  • What gt75yrs fall in 1 year ?
  • What gt85yrs fall in 1 year ?
  • What elderly institutional care fall in 1 year
    ?
  • What in previous fallers?

4
Incidence
  • What gt65yrs fall in 1 year ? 30
  • What gt75yrs fall in 1 year ? 35
  • What gt85yrs fall in 1 year ? 40
  • What elderly institutional care fall in 1 year
    ? gt50
  • What in previous fallers? 60-70

5
Sequelae
  • What people injure themselves after a fall ?
  • What people fracture after falling ?

6
Sequelae
  • What people injure themselves after a fall
    ? 40-60
  • What people fracture after falling ? 5

7
Sequelae
  • Name 3 common sequelae of falls
  • Fracture
  • Infection
  • Fear of falling

8
Sequelae
  • What is your life space diameter ?
  • How does a fall affect this ?
  • How else is this known ?

9
Sequelae
  • What is your life space diameter ?
  • A measure of your mobility potential.
  • How does a fall affect this ? Reduces it
  • How else is this known ? Fear of falling

10
Fear of falling
  • What percentage of pts develop this after a
    fall? 33
  • Pts with fear of falling have higher risk of
    falling, reduced ADLs, lower quality of life
    scores, and increased institutionalisation.

11
Risk Factors
  • EXTRINSIC
  • Environmental
  • INTRINSIC
  • Medication
  • Disease
  • Visual problems
  • Neurological
  • Cardiovascular
  • Postural hypotension
  • Locomotor
  • Psychological
  • Nutritional
  • Acute illness

12
Statistical summaries of risk factors for falls
  • RISK FACTOR Mean RR/OR
  • Muscle weakness 4.4
  • Falls history 3.0
  • Gait deficit 2.9
  • Balance deficit 2.9
  • Assistive devices 2.6
  • Visual deficit 2.5
  • Arthritis 2.4
  • Impaired ADLs 2.3
  • Depression 2.2
  • Cognitive impairment 1.8
  • Age gt80 1.7

13
Age-related changes
  • Increased postural sway
  • Reduced muscle strength (NB Hand grip)
  • Reduced proprioception/vibration sense/light
    touch
  • Slower reaction time
  • Impaired cerebral auto regulation
  • Impaired fluid homeostasis
  • Decreased visual acuity

14
Balance
Vision
FALLS
Vestibular
Musculoskeletal
Proprioception
Environmental hazards
Tactile sensation
CNS
15
Mortality
  • What is mortality rate for NOF ?
  • At 1 month?
  • At 1 year?
  • What is mortality rate for pubic ramus ?

16
Mortality
  • What is mortality rate for NOF ?
  • At 1 month? 10
  • At 1 year? 25
  • What is mortality rate for pubic ramus ?
  • 15-20

17
Falls assessment
  • HISTORY
  • Simple fall v collapse
  • Whats the most useful question to ask in taking
    the history in pt who has collapsed?
  • What factors differentiate between cardiac and
    neurological collapse ?
  • Which drugs are implicated ?

18
Falls assessment
  • HISTOR
  • Whats the most useful question to ask in taking
    the history in pt who has collapsed?
  • Do you remember falling
  • What factors differentiate between cardiac and
    neurological collapse ?
  • Cardiac-no warning, palpitations, rapid recovery,
    pallor, no tongue biting
  • Which drugs are implicated ?
  • Many !

19
Examination
  • Mental test score
  • CVS (include postural BP)
  • Cranial nerves (incl. vision)
  • Vestibular assessment
  • Peripheral nervous system (NB Neuropathy)
  • Cerebellar function
  • Muscles
  • Joints
  • Gait
  • (Footwear)

20
Investigation
  • Bloods
  • ECG (24 hr tape if ECG abnormal)
  • Tilt table test
  • Carotid sinus massage
  • Dix - Hallpike

21
Interventions to prevent falls the evidence
  • Multidisciplinary Ax FICSIT Tinetti 1994
  • PROFET Close 1999
  • Withdrawing centrally acting meds Campbell
  • Strength balance training Campbell 1997/1999
  • Tai Chi Wolf 1996
  • CVS Ax intervention of unexplained
    fallers Kenny 2001
  • Cataract surgery Harwood 2005
  • Vitamin D

22
  • THINK OF FALLS
  • THINK OF OSTEOPOROSIS

23
Fracture Risk
  • Fracture risk Risk of falling
  • BMD

24
Osteoporosis
  • Time bomb of old age
  • Low bone mass, microarchitectural deterioration,
    increased fragility and fracture risk.
  • 13 females 112 males (gt50yrs) will sustain
    osteoporotic fracture.
  • lt5 on osteoporosis drugs.

25
Age Related Changes in Bone Mass
Attainment of Peak Bone
Mass
Age-related Bone Loss
Consolidation
Menopause
Bone Mass
Men
Fracture Threshold
Women
0 10 20
30 40 50
60
Age (years)
Compston JE. Clin Endocrinol 1990 33653682.
26
Clinical Impact of Osteoporosis Over Time
  • Symptoms
  • Weak neck and head falls forward
  • Pain in whole or part of back
  • Breathing difficulties
  • Indigestion gastro-oesophageal reflux
  • Stress incontinence
  • Difficulty with mobility following
  • Signs
  • Kyphosis
  • Loss of height
  • Tummy bulges due to loss of space under the ribs
  • Clinically diagnosed fracture

27
Hip Fractures
  • 60,000 /yr in UK
  • Cost 1.7 billion
  • 25 die at 1 year
  • 50 do NOT regain independence
  • Osteoporosis results in more deaths than Ca
    cervix/uterus/ovary combined.
  • Nos will increase 5-fold in next 50 yrs

28
Diagnosis
  • DEXA Measures B.M.D. at forearm, hip and spine
  • DEXA Normal tgt -1
  • Osteopenia t -1 to -2.5
  • Osteoporosis t lt -2.5
  • DEXA - high specificity, low sensitivity

29
Risk Factors
  • Hx low trauma fracture
  • Steroids (incl inhalers)
  • Family Hx of O.P.
  • Premature menopause (lt45yrs)
  • Secondary pre-menopausal amenorrhea
  • Low B.M.I. (lt19)
  • Smoking, alcohol
  • Prolonged immobilization
  • XR suggestion of osteopenia/O.P.
  • Secondary - malabsorption, IBD, hypogonadism,
    CRF, CLD, RA, primary hyperparathyroidism,
    Cushings, thyrotoxicosis.

30
Investigations
  • FBC - malabsorption
  • U and Es - renal failure
  • TFTs - hyperthyroidism
  • LFTS - chronic liver disease
  • FSH - detect menopause
  • PV/ESR/electrophoresis - myeloma
  • Calcium - hyperparathyroidism
  • Testosterone/LH/SHBG - hypogonadism in males
  • (Markers of bone turnover)

31
Prevention of osteoporosis- lifestyle advice
  • Diet
  • Exercise
  • Alcohol
  • Smoking

32
Interventions to prevent fracture
  • Bisphosphonates
  • Ca/vitamin D
  • Selective oestrogen receptor modulators (SERMS)
  • Hip protectors Cochrane 2005
  • PTH
  • Strontium ranelate

33
Fracture prevention triangle
FRAGILITY
Drugs Lifestyle
Vitamin D Exercise
FORCE
FALLS
Hip protectors
Falls prevention measures
34
(No Transcript)
35
Problems with treatment
  • No immediate benefit
  • Side effects of medication
  • Unwillingness to change

36
N.S.F. Standard 6 (Falls)
  • Prevention public health strategies
  • Integrated falls services
  • Prevention treatment of osteoporosis

37
N.I.C.E. Clinical guideline Nov 2004
  • Falls assessment and prevention of falls in
    older people
  • 5 key priorities for implementation
  • 1) Case /risk identification
  • Routinely ask old people if fallen in past year
  • If yes, frequency, context characteristic of
    fall
  • If faller or high risk, observe for balance and
    gait deficits
  • Refer to multifactorial risk Ax if
  • Gait balance deficit
  • Recurrent falls
  • Present to healthcare

38
N.I.C.E. Clinical guideline Nov 2004
  • Falls assessment and prevention of falls in
    older people
  • 2) Multifactorial falls risk Ax to include Ax of
  • Falls Hx
  • Gait and balance
  • Mobility muscle weakness
  • Osteoporosis risk
  • Fear of falling
  • Visual impairment

Urinary incontinence Home hazards Cognitive
impairment CNS examination CVS examination Medicat
ion review
39
N.I.C.E. Clinical guideline Nov 2004
  • Falls assessment and prevention of falls in
    older people
  • 3) Multifactorial interventions
  • All recurrent fallers/high risk should be
    considered for individualised multifactorial
    intervention.
  • Including
  • Strength and balance training
  • Home hazard Ax and intervention
  • Vision Ax and referral
  • Medication review

40
N.I.C.E. Clinical guideline Nov 2004
  • Falls assessment and prevention of falls in
    older people
  • 4) Encouraging participation of older people at
    risk of falling in falls prevention programmes
  • Education and information regarding measures
    they can take to prevent falls
  • Include carers in process

41
N.I.C.E. Clinical guideline Nov 2004
  • Falls assessment and prevention of falls in
    older people
  • 5) Professional education
  • All healthcare professionals dealing with
    patients known to be at risk of falling should
    develop and maintain basic professional
    competence in falls assessment and prevention.

42
Summary
  • Very common
  • Can cause fractures and downward spiral
  • History and witness very important
  • Thorough examination required
  • Multidisciplinary approach most effective
  • Think falls, think osteoporosis
  • Refer to Falls Clinic if not winning!
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