FALLS

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FALLS

• Slips, trips and fractured hips!

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Man Falling, by Giacometti
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Falling facts

• 1/3 of people gt 65 yo (community dwelling)
• 1/2 of people gt 90 yo
• Females gt Males
• 1/2 those who fall will have gt 2 falls

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Further Falling Facts

• 20 need medical attention
• 10 to AE
• 6 of all hospital admissions (gt 65)
• 2 of all deaths age gt65

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Fernando Botero Works on Paper Woman Falling
from Balcony
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Falling Freida

• 85-year-old, lives alone with Carl the Cat
• No home services, never married. Former Art
  Teacher.
• Mobile independently
• several falls recently - bruises only
• worried shell hurt herself if she falls again...
  

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Freidas Falls

• Unexpected visitor when Freida was watching The
  Bold and the Beautiful.
• Felt dizzy on standing, stumbled over coffee
  table and fell onto box of paints shed had
  delivered the day before. - just didnt see them!
• Out looking for Carl the Cat at dusk. Tripped
  over loose pavement in backyard. Difficulty
  gettting up
• now reluctant to leave the house

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Falling Friedas PMx

• Stroke 40 years ago - affecting L side - minimal
  weakness now.
• HTN
• Cholecystectomy
• nerves
• Macular Degeneration

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Examination

• Slightly frail, in high heels!
• BP 140/70, no postural drop
• P70, reg
• HS dual, no carotid bruits
• Abdo soft and non-tender
• CNS intact - slight decrease proprioception both
  feet

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Harold, the Home visiting nurse

• reports that the home is very cluttered, Lounge
  dark with curtains drawn.
• morning BP
• 180/100 lying 140/ 70 standing, assoc dizziness.
• Meds
• aspirin
• Perindopril Plus
• nifedipine Oros
• Nitrazepam 5mg nocte

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Falling Friedas follow-up

• Bloods
• Hb 130, MCV 87
• Na 124, K 3.7, Cr 110, Urea 7.9
• TFTs, LFTs, B12 folate normal
• MSU nad
• ECG - NSR, borderline LVH

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Why does Frieda Fall?
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Extrinsic

• lives alone
• visual impairment
• Poor lighting
• Loose carpets
• Badly fitting footwear

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Intrinsic

• Hyponatraemia
• Diuretics
• Postural Hypotension
• decreased righting reflexes
• Sedative Medication

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How to help.

• Decrease and aim to stop sedative (controversial
  after recent article?)
• Stop diuretic.
• Ensure Na normalises
• increase lighting in house
• de clutter
• Improve righting Reflexes

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Vaartkapoen, Tom Franzten
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Tumbling Thomas

• 87-year-old, former Army Officer
• Anglo-Indian, supportive family
• living in retirement village for last 2 months
  after his wife died.
• has had several unwitnessed falls in the
  bathroom, able to use call bell to alert staff.
• Carers concerned as unsteady on walk to dining
  room

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His PMx

• epilepsy - complex partial since childhood
• atrial fibrillation
• ischaemic heart disease
• osteoarthritis

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Medications

• sodium valproate 400mg bd
• digoxin 125mcg od
• ISMN 60mg
• aspirin
• diclofenac prn
• frusemide 80mg

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Further History

• Feeling generally weaker and more unsteady
  recently
• Difficulty getting to the bathroom on time -
  concerned he might become incontinent and need to
  wear nappies!
• Denied any seizures or post -ictal periods
  recently. Last2/12 ago at wifes funeral.

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Examination

• Serious, slightly vague
• MMSE 28/30 (-2 recall)
• BP 110/70, no postural drop
• HS dual with ESM, no radiation
• CNS
• marked quadriceps wasting of both legs
• decreased reflexes ankles
• osteoarthritis changes of knees.

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Investigations

• Hb 9.5, MCV 87
• urea 17.5 creatinine 157
• digoxin level 1.2
• ECG shows sinus rhythm with ST/T wave changes
  consistent with digoxin effect.

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Why was Thomas Tumbling?
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Extrinsic

• new environment, not used to bathroom

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Intrinsic

• ?digitoxic
• dehydrated
• deconditioned
• anaemic
• ?aortic stenosis

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How to help

• Meds altered
• Echo aortic sclerosis only
• Physio and hydrotherapy to increase quad strength
• Haematemics B thalassemia trait and folate
  deficiency - corrected

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ButThomas was still Tumbling!

• Why?..
• What should we do next.

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CT head
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Icarus Falling, Mildred Kaye
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Physiology of Falling -Normal Aging Changes

• Decreased height, flattening foot arch, increased
  hip flexion
• change in centre of gravity
• Muscle mass and type II fast Twitch fibres
  decrease
• decreased strength and impaired reaction time
• Cerebellar atrophy
• decreased co-ordination

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Physiology of Falling II

• Decreased Vision
• very important - decreased ability to perceive
  obstacles
• Decrease in Peripheral Vestibular Excitation
• loss of balance mechanism
• Decrease in Max Heart Rate
• decrease exercise tolerance

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How to help Falling Frieda and Tumbling Thomas...
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Ask, AssessExerciseImprove SurroundingsOsteopor
osis reviewUn-medicate
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ASK!

• Ask all patients over 65 if theyve had a fall or
  near fall in the last year.
• Ask about fear of falling
• Ask about urinary incontinence
• Ask about Home hazards

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Assess

• Assess vision
• Assess cognition
• MMSE/ IQ code
• Assess Cardiology
• rhythm, rate, evidence failure, murmurs, pulses
  (and bruits)
• Assess neurology
• Assess gait, balance, mobility and muscle weakness

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Exercise

• Balance and strength training -community and
  institutional settings.
• Must be structured and tailored to individual
• Post NOF
• Strengthening muscles around the hip
• Teach how to avoid a long lie
• Improve confidence
• try Tai Chi

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Improve surroundings

• Provide appropriate mobility and safety equipment
  
• Adapt the environment
• Educate re potential hazards

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Osteoporosis and fracture prevention

• Determine risk
• previous fracture?
• Family hx
• Evidence kyphoscoliosis?
• ?hip protectors in institutional settings
• Vitamin D and Calcium supplementation
• Bisphosphonate as required

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Un - Medicate

• Stop psychotropic medications
• benzodiazepines, sedatives
• decrease number of medications
• Pay close attention to meds that drop BP
• Anti-Hypertensives
• Diuretics
• L Dopa
• SSRI/TCAs

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Benzos, Falls and Fractures

• New York state has limited use of Benzodiazepines
• ?did this decrease the number of hip fractures in
  Elderly
• compared New York (limited use) and New Jersey
  (still unlimited)
• NY decreased benzo prescribing by 60
• NO reduction in hip fracture change

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Falling in Hospitals High Care Facilities

• Recent meta-analysis
• data often poor - 13 studies found for hospital,
  8 for care homes

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• Effective
• multifaceted interventions - but only for falls,
  NOT fractures, and only in Hospital setting
• Unknown Effectiveness
• Vitamin D (3 smallish trials effective, 1 large
  trial ineffective)
• Hip Protectors (still unproved - studies not
  enough POWER)
• alarms
• removing physical restraints

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Summary

• Falls are important
• Best improvement seen with multidisciplinary
  input
• Cause almost always multifactorial

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Whenever the horse stopped (which indeed very
often), The Knight fell off in front and,
whenever it went on again (which it generally did
rather suddenly), he fell off behind. John
Tenniel