1. Geriatric Medicine Principles Falls Robert Kirby, MD, FACP Clinical Professor of Medicine

2. Geriatric Medicine

3. Geriatric Medicine Principles/ Falls Learning Objectives: 1. List two characteristics of the geriatric population. 2. Describe two instruments to assess function. 3. Define geriatric syndrome. Name three. 4. List four risk factors for falls. 5. Outline three interventions to reduce fall risk.

4. Biology of Aging Genetic Oxidative Stress Mitochondrial Dysfunction Hormonal Changes Telomere Shortening (Hayflick Limit) Defective Host Defenses Accumulation of Senescent Cells Harrison on Line

5. Demographics USA 2020 >65 yo 16% Dependency Ratio-Europe 2050 22% to >50% Harrison on Line Merck Manual Geriatrics

6. Demographics Over Age 65 40% of Hospital Resources 24% of Office Visits 25% of Prescription Drug Costs 25% of Medicare expenditure in last year of life- Half of this in last 60 days Residents of Nursing Homes Age 65 1% Age 85 17% Merck Manual of Geriatrics

7. Chronic Disease Burden Arthritis5054 Hypertension Heart 36 32 39 Hearing Cataracts 28 16 36 24 Diabetes Vision 10 8 11 Condition Age 65 % Age 75 % Merck Manual Geriatrics

8. Life Expectancy Walter LC, Covinsky KE, JAMA 2001

9. Function: Activities of Daily Living BasicIntermediate DressingShopping EatingHousework AmbulatingAccounting ToiletingFood Preparation HygieneTransportation

10. Function with Aging

11. Principles in a Flash 1.Aging is not a disease. 2.Geriatric conditions are chronic, multiple, multifactorial 3.Reversible conditions are underdiagnosed and undertreated 4.Function and quality of life are critical outcomes 5.Social support and patient preferences are critical aspects 6.Geriatrics is multidisciplinary 7.Cognitive and affective disorders prevalent and undiagnosed at early stages 8.Iatrogenic disease common and often preventable 9.Care is provided in multiple settings 10.Ethical and end of life issues guide practice www.cha.emory.edu/reynoldsprogram

12. Clinical Approach Not what disease caused the problem But what combination of physiologic change, impairments and diseases are contributing And which ones can be modified Modawal

13. Geriatric Syndromes Dementia and Delerium Falls Polypharmacy Pressure Ulcers Urinary Incontinence

14. Mary Anderson This 85 year old widow presents after a fall in the bedroom of the home where she has raised her family and lives independently. She does not know why she fell, was able to ambulate after the fall and presents six hours later with a bruise on her left cheek and an abrasion on the left forearm. Daughter reports occasional confusion and some limitation of activities due to weakness. She reports a fall four months ago. PMH DJD hips and knees with chronic pain Hypertension Macular degeneration Diabetes 2 Urinary urgency and rare incontinence

15. Medications: Hydrochlorothiazide, Fentanyl patch, KCL,Tylenol, MVI Examination: BP supine 160/88; standing 3 minutes 168/92 Vision 20/50 Chest – rare crackles right base Neuro: absent achilles, romberg normal Gait antalgic secondary to right hip pain Get up and go test: 18 seconds. Uses arms to arise from chair Functional Reach test 5 inches Laboratory: Hemoglobin 11 gm/dl K 3.0 meq/L Glucose 212 mg/dl Creatinine 1.4 mg/dl BUN 24 mg/dl Urinalysis wbc 20, nitrite positive

16. Questions about Mary Anderson 1.What is the most important risk factor for her recent fall? 2.What is the most important physical examination finding related to her fall? 3.What additional diagnostic studies will be helpful? 4.What is the most important initial step in managing Mary’s fall? 5.What consultations/referrals would be most useful?

17. Importance Risk Factors Clinical Assessment History Physical Examination Laboratory Management Fall “Unintentional coming to rest at a lower position unrelated to obvious intrinsic or environmental factor.”

18. Importance Prevalence Ambulatory Adults >65 30% per year Consequences Death Injury Fractures 10-15% Hip 1-2% Long Lie Fear of Falling Reduced Activity/Independence (25%)

19. Causes Extrinsic Environment Intrinsic Age Gait/Balance Disorder Sarcopenia Vestibular Orthostatic Hypotension Special Senses –Vision/Hearing Disease Dementia Depression Drugs Foot problems Incontinence

20. Risk Factors Muscle weakness: 4.4 History of falls: 3.0 Gait or balance deficit: 2.9 Use of assistive device: 2.6 Visual deficit: 2.5 Arthritis: 2.4 Depression: 2.2 Cognitive impairment: 1.8 Age over 80 years: 1.7 Mean RR or OR of risk factors for falls from 16 studies Data from AGS Panel on Falls Prevention. Guideline for the prevention of falls in older persons. J Am Geriatr Soc 2001;49(5):664–72.

21. Gait Stride Length Arm Swing Slow Forward Flex Head and Torso Flexion shoulders knees Lateral Sway Normal Gait Video

22. History-Physical Injury Details of Fall Inability to Get Up Associated Disease and Disability Drugs General Orthostatic BP Vision Cognition ( MMSE) Gait/Balance/Coordination Laboratory CBC CMP EKG

23. Get Up and Go Normal Abnormal

24. Modified Single Leg Stance

25. Functional Reach

26. Sharpened Romberg

27. Fall Risk Next Treatment Year (%) Reduces Risk(%) Fall Past Year5030 Gait Problem3020 One Risk2010 Two Risks3020 Three Risks6040 Four or More8050 Treatable Risks: 1. Problem walking or moving 2. Orthostatic hypotension 3. Four or more meds or one psychoactive 4. Unsafe footwear or foot problems 5. Environmental hazard Reducing Fall Risk www.fallprevention.org

28. Guideline for Fall Prevention JAGS 2001. 49:664-672

29. Management Reduce Fall Risk Environment Exercise and Balance Cardiovascular (orthostasis) Vision Assistive Devices Medication Review Footwear Behavior Education Restraints Rubinstein Med Clin N Am 2006

30. Management Reduce Fall Risk Exercise Wolf JAGS 1996 MMWR Rep 2004;53(2):25-28 -47%

31. Reduce Fracture Risk Hip Protectors Vitamin D/Calcium 400-800IU / 1200-1500 Lauritzen JB, Peterson MM et al Lancet 1993; 341:11-13.

32. Questions about Mary Anderson 1.What is the most important risk factor for her recent fall? a. History of previous falls b. Medications c. Possible urinary infection and/or dementia d. Gait disorder e. Visual impairment

33. Questions about Mary Anderson 2. What is the most important physical examination finding related to her fall? a. Extent of injury and pain b. Result of blood pressure c. Result of “Up and Go Test” d. Visual acuity e. Neurologic findings

34. Questions about Mary Anderson 3.What additional diagnostic studies will be helpful? a. Twenty four hour ambulatory EKG ( Holter) monitor b. Carotid Doppler study c. Brain MRI d. Head-up tilt test e. Radiograph of chest and hips f. Electoroencephalogram (EEG)

35. Questions about Mary Anderson 4. What is the most important initial step in managing Mary’s fall? a. Reduce hydrochlorothiazide and fentanyl b. Hydrate and treat UTI c. Treat injury and pain d. Osteoporosis treatment e. Counsel on “fear of falling” f. Recommend hip protectors

36. Questions about Mary Anderson 5. What consultations/referrals would be most useful? a. Ophthalmology b. Physical Therapy for strengthening exercise c. Home safety evaluation by Occupational Therapy d. Neurology consultation e. Cardiology consultation

37. Geriatric Medicine Principles/ Falls Learning Objectives: 1. List two characteristics of the geriatric population. 2. Describe two instruments to assess function. 3. Define geriatric syndrome. Name three. 4. List four risk factors for falls. 5. Outline three interventions to reduce fall risk.

38. Curriculum in Geriatric Medicine Attitudes Survey Orientation and before subject examination. Web Page Hartford Objectives-Document in Portfolio. Forward when requested. Learning Resources Patient Care Tools Patient Education Resources Preparation for Lecture: On Line. Mary Anderson. Evaluation Knowledge Test- Do as a group and submit one answer set for group A and one for group B. Deadline is Friday before lecture.

39. Gait Let’s Practice:

41. Geriatric Medicine