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CHAMP A Geriatric Syndrome in the Hospital: The Case of Falls

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CHAMP A Geriatric Syndrome in the Hospital: The Case of Falls William Dale, MD, PhD University of Chicago Overview What is a geriatric syndrome ? – PowerPoint PPT presentation

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Title: CHAMP A Geriatric Syndrome in the Hospital: The Case of Falls


1
CHAMP A Geriatric Syndrome in the Hospital The
Case of Falls
  • William Dale, MD, PhD
  • University of Chicago

2
Overview
  • What is a geriatric syndrome?
  • How does one think about, and teach about,
    syndromes like falls?
  • Why worry about falls?
  • What are the causes of falls?
  • Differential diagnosis and falls teaching to
    medicine housestaff
  • Restraints and falls teaching housestaff about
    the dangers of restraints
  • Preventing and treating patients who fall
  • What should be done at discharge?
  • U of C Nursing initiative and pilot project

3
Falls As a Geriatric Syndrome
  • A sudden, unexpected descent from a standing
    sitting, or horizontal position.
  • When a person comes to rest inadvertently on the
    ground or a lower level
  • Excludes syncope and overwhelming trauma
  • A classic Geriatric Syndrome
  • When the nurse calls to report an event

4
What is a Geriatric Syndrome?
  • Manifestations of disturbances in complex
    systems, usually with more that one organ system
    involved
  • Examples
  • Functional Dependence
  • Delirium
  • Incontinence
  • Falls

5
Geriatric Syndrome Vs. Traditional Syndrome
6
How do complex systems, like older adults,
fail in causing syndromes?
  • Key Concepts
  • Physiologic reserve lower across multiple
    domains
  • Adaptive/redundant systems reduced
  • Possible Pathways to Failure
  • Major hit to one component (E.g. CVA)
  • Dominant deficit with exacerbations (E.g. MI ?
    CHF/COPD)
  • Multiple modest deficits (Geriatric Syndrome)

7
Yearly Incidence of Falls
  • Community-dwelling persons over 65 30-40
  • 20 of falls require medical attention
  • History of fall in last year 60
  • Falls in our hospital Data not currently
    available

8
Complications
  • Leading cause fact death from injury in older
    adults
  • Fracture risk 10-15
  • About 8 of 70 y.o. go to ED yearly for
    fall-related injury
  • Other common complications
  • Decline in functional status
  • Increased likelihood of nursing home placement
  • Increased use of medical services
  • Developing fear of falling ? Loss of function

9
Causes of Falls
  • Rarely due to a single cause
  • At least 25 risk factors identified across 5
    large cohort studies
  • Interaction across multiple domains more
    risk-factors, increased likelihood to fall
  • Intrinsic to individual
  • Environmental challenges to postural control
  • Mediating factors

10
Causes Intrinsic Patient Factors
  • Age
  • Female gender
  • Cognitive impairment
  • Chronic diseases
  • Arthritis
  • Parkinsons
  • Use of certain medications
  • Psychotropics
  • Diuretics
  • History of falls

11
History of Falls as a Risk Factor
  • One year risk of hospitalization by baseline self
    reported fall status (n444)

12
Causality Pathophysiology of Aging and Postural
Control
  • Postural control differences in older adults
  • Respond to balance perturbations using proximal
    muscles first, then distal
  • More slowly develop joint torque when disturbed
  • More likely to have decreased baroreflex
    sensitivity to hypotensive stimuli
  • More likely to have microvascular cerebral
    perfusion defects
  • Reduction in total body water

13
Causes Postural Control Challenges
  • Weakness, esp. lower extremity
  • Balance difficulties
  • Dangerous environment

14
Causes Mediating Factors
  • Risk-taking behaviors
  • Underlying mobility level/inclination
  • Principle Mismatch of risk-taking behavior with
    mobility

Probability of Fall
Mobility Skills
15
Causality Pathophysiology of Aging
  • Three sensory input systems involved in
    maintaining upright posture
  • Visual
  • Proprioceptive
  • Vestibular
  • All of these systems decline with aging

16
Differential Diagnosis and Falls
  • Traditional DDx
  • Multiple symptoms ? Possible single causes (I.e.
    diagnoses)
  • Causes prioritized by probability and severity
  • Search for underlying or unifying cause
  • Geriatric Syndromes DDx
  • Event/Condition ? Possible multiple causes
  • Causes prioritzed by probability and contribution
    to causing event/condition
  • Search for web of interacting causes

17
History and physical based on the components of
postural control
  • Sensory
  • Vision
  • Vestibular
  • Somatosensation
  • Central Processing
  • Global level of consciousness/perfusion
  • Attention/response time
  • Automatic postural responses
  • Effector
  • muscle strength
  • range of motion
  • endurance

18
Getting The Story
  • At time a fall occurs, get good history
  • Do this on cross-cover
  • Best history at time of fall
  • Earlier intervention important
  • Activity at time of fall (walking, transferring,
    sitting at bedside, going to bathroom, etc)
  • Prodromal symptoms
  • Lightheadedness?
  • Loss of balance?
  • Dizziness?
  • Location/Timing

19
Getting the Story
  • Observe environment/context of fall
  • Lighting
  • Flooring and footwear
  • Restraints (both formal and informal)
  • Furniture
  • Past History Has this happened before?
  • Strongest predictor of fall past fall
  • Context of last event
  • Review Medications
  • Recent Changes in Medications (Check MAR)
  • Biggest culprits
  • Vasodilators
  • Diuretics
  • Sedatives
  • Hypnotics

20
The Role of Medications
  • Specific meds in observational studies associated
    with hip fracture risk
  • Benzodiazepines
  • Antidepressants
  • Antipsychotics
  • Medication features associated with falls
  • Recent changes in dose
  • Total number of meds

21
Physical Exam
  • Orthostatics Do this yourself if you have time.
  • Cardiovascular System
  • Sensory Examination
  • Special senses
  • Proprioception
  • Musculoskeletal Exam
  • Proximal muscle weakness
  • Joint pain/swelling
  • Cognition brief assessment of mental status
    Orientation
  • Footwear/Floor combination
  • Socks on tile bare feet and wet floor

22
Physical Exam Special Tests
  • Gait Speed Get up and Go Test
  • Rise from (hard-backed) chair, walk 10 feet,
    turn, return to chair, sit down
  • Threshold greater than 10 seconds is abnormal
  • One foot balance
  • Threshold lt 30 seconds
  • Observe PT/OT evaluations for these
    patientsarrange time for team to meet with PT/OT

23
Laboratory Testing
  • No standard battery of tests
  • Instead, targeted to specific concerns

24
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25
Number of Restraints?
26
Falls and Restraints
  • Restraints increasingly recognized as a cause of
    falls and increasing serious falls

27
Mechanical Restraint Use and Fall-related injuries
  • Prospective study, SNFs, n397
  • Outcome falls after restraints placed
  • Logistic regression used to control for large
    number of confounders
  • Odds ratio for fall-related injury
  • Full cohort 10.2 (CI 2.8 36.9)
  • High-risk subgroup 6.2 (CI 1.7 22.2)

28
Mechanical Restraints
  • Increases risk of falls and other complications
    in hospitalized patients on a medicine service

29
Restraints Formal and Informal
  • Formal
  • Mittens
  • Wrist/Ankle Soft Restraints
  • 4-point Leathers
  • Full Side Rails
  • Posey Vests
  • Informal
  • IV Lines
  • O2 nasal canulas
  • NG tubes to suction or for feeds
  • Pulse oximetry
  • SCDs
  • Foley catheters

30
Risks/Benefits of Bedrails
  • Potential benefits
  • Aiding in repositioning
  • Hand-hold for support in getting in/out of bed
  • Reduce fall risk during transport
  • Enhance access to bed controls
  • Potential risks
  • Entrapment
  • Worse falls injuries from climbing
  • Skin trauma/bruising/scraping
  • Exacerbation of delerium when used as a restraint
  • Restricts activities (toileting, personal item
    retrieval)

31
Bed Rails and Entrapment
  • Incidence of entrapment by bed rails reported
    to FDA, 1985-1999 371
  • of beds in U.S. hospitals and LTC facilities
    2.5 million
  • Outcomes from entrapment
  • Death 61
  • Non-fatal injury 23
  • No injury 15

32
Safety Improvement Alternatives to Bed Rails
  • Lower bed for patient, raise for providers
  • Keep wheels of bed locked
  • Use transfer and mobility aids
  • Monitor patient frequently
  • Move patient closer to nursing station
  • Enlist others family, medical students
  • Identify and meet patient needs that lead to
    falls
  • Toileting available bedpans/urinal scheduled
    toileting
  • Pain adequate pain relief

33
Improving Safety of Bedrails When Used
  • Close monitoring
  • Lower at least one of rails
  • Not considered a restraint when used this way
  • Allows access to and from bed
  • Properly sized mattress to reduce gap between
    mattress and bedrail

34
Treatment and Prevention
  • No proven benefit in reducing falls
  • Untargeted exercise intervention alone
  • Untargeted health education alone
  • Untargeted exercise and health education
  • Assistive devices alone

35
Outpatient Prevention
  • Possible Benefit
  • Long-term exercise and balance training
  • Includes gait training and proper use of
    assistive devices
  • Tai Chi body consciousness, balance
  • Medication review for possible discontinuation
  • Esp. for those with 4 medications
  • Esp those on psychotropics

36
In Hospital Treatment and Prevention
  • Impact Protection
  • Lower beds and lock wheels
  • Hip Protectors
  • Significant protection against fracture
  • Adherence difficulties substantial
  • Diagnose and treat osteoporosis
  • Increased Vigilance
  • Enroll help of patient, family, nursing
  • Re-evaluate often
  • Visit yourself if possible

37
After Discharge
  • Proven benefit to reduce falls
  • Health screening with followup TARGETED
    intervention (OR 0.79 CI 0.65-0.95)
  • Primarily a balance issue?
  • Primarily a strength issue?
  • Home safety evaluation by OT (19 reduction of
    falls versus control decreased falls 36 in
    those with previous history of falls)

38
Intervention Targeted PT
  • Three pooled studies, n 566
  • Intervention individually tailored program of
    progressive muscle strengthening, balance
    retraining exercises, and a walking plan
  • One-year
  • Fall RR 0.80, CI 0.66-0.98
  • Serious injury RR 0.67, CI 0.51-0.89
  • Two-year (69 intervention, 74 controls)
  • Falls RR 0.69, CI 0.47-0.97
  • Moderate-Serious injury RR 0.63, CI 0.42-0.95

39
Home Safety Intervention
  • Home safety evaluation by OT
  • 1 well-designed study
  • n 530, outcome of falls
  • Stratified by falls history
  • Overall RR 0.81, CI 0.66-1.00
  • One or more falls, previous year, RR 0.64 (CI
    0.49 0.84)
  • No falls, previous year, RR 1.03 (CI 0.75-1.41)

40
Other Discharge Considerations
  • If sending for rehab/PT, be sure information
    about in-house fall is clearly communicated
  • Rehab a common location for falls people having
    mobility challenges with mobility difficulties
  • Previous fallers benefit most from intervention
  • Note fall in discharge summary to be added to
    patient problem list
  • Possibility of the development of fearfulness
    leading to disability and increased risk of falls

41
Summary
  • Falls as a geriatric syndrome
  • Multiple contributing causes with common final
    pathway
  • Most likely contributing causes
  • 1 History of falls
  • Patient factors balance difficulties, LE
    weakness, incontinence, medications, cognitive
    impairment
  • Environmental factors restraints (formal and
    informal), bed height, toileting needs, lighting,
    furniture
  • Mitigating factors mismatch of mobility with
    compensatory mechanisms ? patient, nursing,
    family education

42
Summary of Teaching Points
  • Exercises
  • Get up and Go Test
  • Bedside restraints memory test
  • Dangers of Restraints
  • Discharge Considerations
  • Targeted interventions observe PT evaluation
  • OT Home safety evaluation
  • Falls added to problem list

43
U. Of C. Nursing Initiative
  • Performance Improvement Initiative to Reduce
    Falls in the Hospital
  • Protocol based on University of Iowa
    Gerontological Nursing Interventions Research
    Center
  • Adapted from LTC setting to hospital
  • Pilot to be initiated on 4SE and 4NW floors
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