1. Falls – an over view for GPs
Julie Brache
Consultant Geriatrician and Falls Lead
October, 2014

2. Overview Why older people fall Multifactorial risk assessment
Normal changes with ageing
Dizziness and syncope
Medication review
Multifactorial interventions
Where to get advice

3. Definition
when an individual comes to rest unintentionally on the ground or another lower level, with or without loss of consciousness

4. Background 35% >65 living at home fall each year
£2.3 billion per year
10% injury
After a fall 50% have reduced mobility
Leading cause of injury related death in older adults

5. Preventable
Evidence based national and international guidelines N

6. Fall is a symptom, not a diagnosis

7. ‘Old age starts with the first fall and death comes with the second’
Gabriel Garcia Marquez “Love in the time of cholera”

8. Frailty Reduced ability to withstand illness without loss of function
Muscle weakness, reduced walking speed, reduced physical activity, weight loss, self reported exhaustion
Would you be surprised if this person died in the next year?

9. Falls are multifactorial

10. Why do older people fall?
Muscle weakness
Poor balance
Gait deficit
Polypharmacy
Sensory loss – vision, hearing, peripheral
Medical illness
Nutrition
Dizziness
Osteoarthritis
Frailty
Environment
Depression
Cognitive impairment
Incontinence
Alcohol
Previous falls
CV problems
Neurological

12. History Circumstances of falls How many falls in the last year?
Activity at the time
Where and when
Lightheaded, dizzy, LoC, chest pain, palpitations, visual disturbance?
Seizure markers?
How many falls in the last year?

13. Taking the history –some pointers
Allow them to describe everything first, then get the history you need
Describe a single fall in detail
Take them through it in fine detail
Then ask about
associated symptoms
Witness account is vital

14. History - pitfalls “It was nothing” “I haven’t fallen”
“I tripped over the cat”
“I must have…….”
“They had a fit, doctor”

15. Assess Continence Cognition Frailty Alcohol intake
Psychological consequences of falling
Fear, anxiety, depression

16. Examination Cardiovascular Pulse – rate and rhythm Heart sounds
3 min lying and standing BP
Drop 20 systolic or 10 diastolic or to <90 significant
Only 23% will describe dizziness
ECG

18. Examination Focused neurological examination
Lower limb strength – hip and ankle flexors
Peripheral sensation
Evidence of stroke, Parkinson’s cerebellar signs?
Gait and balance
Vision

19. Ageing and gait Slower Increased sway
Slowed postural support responses
Shorter stride length
Increased time in double support
Loss of rhythm
Loss muscle bulk, reduced postural reflexes, JPS

20. Gait disorders in the elderly
Parkinsonism
Cerebrovascular disease
Cervical spondolytic myelopathy
Sensory neuropathy
Foot drop
Don’t forget Normal Pressure Hydrocephalus

21. Gait and balance assessment
Not all for the Physio!
Gait:
Get Up and Go
Balance:
Proprioception – vision- vestibular function
-> Romberg's
-> Head Thrust

22. Ageing and vision ↓Acuity ↓Depth perception
Lens density changes- glare
Decreased rod density - ↓Light adaptation
- ↓ contrast sensitivity
↓ Visual processing speed

23. Vision Test acuity and fields
ARMD, glaucoma, stroke, diabetes, cataract
Bifocal / varifocal glasses, change in prescription

24. SPECTACLE USE
5.7 Optometrists and dispensing opticians should consider supplying an additional pair of single vision spectacles (to wear in outdoor and unfamiliar settings) for older people who take part in regular outdoor activities

25. Examination
Other
Cognition
Foot wear and feet

26. Take the shoes off!

27. Dizziness
Vertigo
Pre-syncope
Dysequilibrium

28. Vertigo Illusion of rotation “The room was spinning”
Nystagmus during episode
Labyrinth or vestibular
problem
Occasionally cerebellar or CP angle
Treat acute attacks with
anti-histamines

29. Benign Paroxysmal Positional Vertigo
Vertigo on change in position
Self limiting
Disabling
Hallpike- Dix test
Epley manoeuvre
Vestibular rehab
Cawthorne- Cooksey exercises
Brandt - Daroff

30. Pre-syncope Sense of feeling faint or light-headed “Legs went weak”
“Vision blurred ”
Pallor, weak/slow pulse
Same causes as syncope
Often a sign of postural BP drop
Cardiovascular assessment
Treat underlying cause

31. Dysequilibrium Balance dysfunction A sense of unsteadiness
“Thought I was going to fall”
Often multi-factorial
Sensory impairments and/or CNS disease
Multidisciplinary management

32. Syncope 23% >65s over 10 years High recurrence rate
Spontaneous LOC with complete recovery
Diagnosis difficult and often wrong

33. Syncope in the Elderly Cerebral autoregulation impaired
Baroreflex sensitivity blunted
Volume regulation impaired
Comorbid illness and medications

34. Syncope diagnosis All in the history DETAIL Posture Prodrome
Eye movements
Tongue biting/incontinence
Injury
Duration
Confusion
Hemi weakness

35. Red flags Abnormal ECG (NICE) Heart failure Syncope during exertion
FHx sudden death <40
New/unexplained SOB
Murmur (NICE)

36. Assessment Vasovagal – 3Ps Cardiovascular – if in doubt Neurological
ECG, 24 hour tape, event recorder, implantable device, tilt table test + carotid sinus massage, cardio ref
Neurological
CT head, EEG (?value in elderly), neuro ref

37. Tilt Tests Unexplained, recurrent syncope
Single syncope in high risk settings
Unexplained recurrent falls

38. Falls and acute illness
Fall often the presentation of an acute illness
Think of falls risk when unwell
diuretics, antihypertensive, steroids, anticholinergics, sedatives
urinary urgency/frequency
Delirium

39. Medication review

40. Drugs in the elderly UK elderly 18% pop – 45% all prescriptions
In NH in 1 year 97% will receive a prescribed drug – 71% in community
Polypharmacy - >4 drugs = risk falls

41. Principles of Medication review
Review indication – is there evidence?
Review dose
Reduce the number of medicines
Avoid complex regimes
Review benzodiazepines and other psychotropic drugs
Check L&S BP – if drop review culprit drugs

42. Medication and Falls Risk
“Therapeutic effect”
Interactions
Side effects
2/52 after change in meds – high risk time
Stopping – can be difficult

43. “Therapeutic effect” Meta-analysis – sedatives and hypnotics
Improve sleep duration and reduce night time wakening
NNT sleep 13
NNT any adverse event 6
BMJ 2005;331:1169

44. Side effects – anticholinergic activity
Antiarrhythmics - disopyramide, procainamide
Antidepressants – tricyclics
Antipsychotics – chlorpromazine, prochlorperazine
Antiemetics – cyclizine, prochlorperazine
Antiparkinson – amantadine, benzhexol
Antispasmodics – oxybutynin
Bronchodilators - ipatropium

46. Time to reconsider warfarin?
50% elderly in AF not on warfarin
Falls is the main reason
>300 falls per year for bleeding risk to outweigh stroke risk

47. Ageing and Pharmacokinetics / Pharmacodynamics
Distribution
↑blood (& tissue) conc water sol drugs
↑ vol distribution lipophilic drugs
Hepatic metabolism
Metabolism by C P-450 reduced
Reduced 1st pass metabolism – some drugs
Renal elimination
Reduced GFR with age
Changes in drug-receptor interactions

48. April 2014

51. Osteoporosis assessment
FRAX – but beware over 80s
Calcium and vitamin D
Reduce falls
All housebound fallers, and RH/NH residents
800iu daily vit D
Long term anticonvulsants – check vit D level

53. Hip protectors Controversial area! At home – ineffective Institutions?
Current advice:
May be useful in confused elderly in institutional care

54. Multifactorial interventions
Treat any problems found
Evidence based recommendations:
Strength and balance training
Home hazards assessment & intervention
Vision assessment and referral
Medication review and modification/withdrawal of psychotropics
Education

55. How to get advice

56. Geriatric Advice Line

57. Clinics Geriatric clinic Falls clinic Doctor, 45 min appointment
Nurse, therapist and doctor, 2 hour appointment, on-going therapy via referral to community teams
Geriatric clinic
Doctor, 45 min appointment
If you just want therapy – refer to community teams
If already seeing community team – refer to geriatric clinic
PLEASE send as much information as possible

58. Take home messages Some falls are preventable
Requires time consuming multifactorial assessment, identification and intervention
Can’t do it alone
Always review medication
Don’t forget bones
A friendly geriatrician is always on the end of the phone

59. Questions?