1. Fall Prevention: What to Expect from Health Care Providers? Betsy Baum, M.D. CMD Associate Professor of Internal Medicine NEOMED Geriatric Consultant Aultman Hospital Medical Director Bethany Nursing Facility Clinical Faculty, Canton Residency Education

2. Objectives  Review the AGS ( American Geriatric Society) Guidelines of the evidenced - based fall risk assessment recommended to health care providers  Review effective interventions to prevent falls and injuries  Discuss community programs that will enhance fall prevention

3. Two Most Important Things to Know About Falls in the Elderly  Falling is a symptom not a diagnosis  Most falls in elderly people are multifactorial

4. WHY SO DIFFICULT TO PREVENT FALLS ?  Complex unless systematic approach  ID mutifactorial causes or risk factors  Tailor interventions to that person’s specific risk factors  Followup that interventions get done

5. Most Common Risk Factors for Falls D rugs Dementia Depression Disease O ther Falls G ait O rthostasis, old (>80) S ensory (vision, hearing), surroundings L ost Balance O steoarthritis W eak lower extremity

6. Most Common Risk Factors for Falls I ncontinence, Insomnia I ncontinence, Insomnia D rugs Dementia Depression, D deficiency O ther Falls G ait O rthostasis, old (>80) S ensory (vision),surroundings, shoes L ost Balance O steoarthritis W eak lower extremity

8. Which is the Most Predictive of a Patient’s Fall Risk?  A) orthostatic hypotension  B) polypharmacy  C) history of previous falls  D) Parkinson’s Disease

9. AGS Algorithm Suggests Full Office Fall Assessment if:  Single Fall in last year with abnormal gait  No falls, but difficulty with walking or balance  Two or more falls in last year even if gait WNL  Patient presents after an acute fall

10. Fall Risk Assessment I. Detailed history II. Physical exam III. Functional Assessment  Observe gait and balance(Get up and go test)  Cognitive assessment  ADLs/ IADLs IV. Lab only as indicated by I-III V. Medication review

11. Timed ‘Get Up and Go’ Test  Simple test of observing a person stand up from a chair, walk 10 feet, turn around, walk back, and sit down again.  Correlates with ADLs  Normal person takes <10 seconds to complete the task  Persons who take > 30 seconds are at increased fall risk and likely to have some dependency in ADLs JAGS 1991;39: 142-48

12. Determine Multifactorial Fall Risk  History of falls  Medications  Gait, balance and mobility  Visual acuity  Muscle strength and neurologic exam  CV exam and orthostatic BP check  Feet and footwear  Environmental Hazards

13. Initiate Multifactorial Intervention Tailored to Individual Risks ID  Minimize medications  Tailored exercise program  Treat vision impairment  Manage postural hypotension  SUPPLEMENT VITAMIN D  Manage foot and footwear problems  Modify home environment

14. Office Evaluation of Mrs. T.  Pt: 84 y/o female  PMH: HTN, spinal stenosis, depression, anxiety  HPI: Medical conditions stable, difficulty living alone d/t mild back and knee pain, near falls, notes some lightheadedness mainly in the AM, does c/o general weakness.  Medications: amlodipine 10mg AM; lisinopril 40 mg AM; HCTZ 25mg AM; lorazepam 0.5mg bid; sertraline 100mg daily

15. Mrs. T. Physical Exam  Vitals:  BP Lying 140/80, HR 64  BP Standing 110/60, HR 80  HEENT WNL, Cardiopulmonary WNL  Extremities: mild swelling rt. knee, decrease ROM, pulses ¼  Neurologic: WNL except proximal leg weakness 4/5 and mild intention tremor

16. Mrs. T.’s Functional Assessment Mrs. T.’s Functional Assessment  Gait: flexed, decreased stride and foot clearance, does not extend rt. knee well, does not grasp walker well due to tremor  ADLs: needs help with dressing and bath  IADLs: daughter had been assisting with all except for meds and paying bills  GUG: 35 seconds  MMSE: 26/30

17. Mrs. T.’S Problem List  Diseases: Spinal Stenosis, Depression, Hypertension  Orthostatic Hypotension  Osteoarthritis  Tremor  Gait abnormal /Muscle weakness  Medications: sertraline, lorazepam, BP medications

18. Interventions for Mrs. T.  Medications rearranged:  Lisinopril 40 mg continued in AM  HCTZ dose decreased to 12.5mg AM  Amlodipine moved to PM  Began to taper lorazepam with AM dose  Sertraline decreased from 100mg to 50mg  PT/OT muscle strengthening and balance  Acetaminophen scheduled 650 tid  Check BMP, CBC and 25 OH vitamin D

19. AGS Medication Recommendations  Psychoactive medications ( including sedative hypnotics, anxiolytics, antidepressants, antipsychotics) should be minimized or withdrawn, with appropriate tapering if indicated  Reduce total number of medications or dose of individual medications should be pursued

20. Division of Geriatric Medicine St. Louis Univ.

21. Vitamin D  The most common vitamin deficiency in older adults  Vitamin D not only strengthens bone, but also muscles  A number of studies have demonstrated Vitamin D supplementation of at least 800IU daily for 1 year can decrease falls by 20 % BMJ 2009;339:b3692.

22. Other Measures to Prevent Orthostatic Hypotension  Correct underlying cause i.e adjust medications, correct anemia or dehydration  Drink plenty of fluid  Rise slowly, ankle pumps, sleep with head of bed elevated  Wear support stockings  Caffeine with meals can help prevent postprandial hypotension

23. Community Programs for Fall Prevention  Develop more group exercise programs tailored for different levels of ability  Develop community walking groups through senior centers and health clubs  Educate older adults on what they should expect from their health care provider for a full fall assessment risk  Over the counter meds associated with falls and confusion TYLENOL/ADVIL PM

25. Division of Geriatric Medicin, St. Louis Univ.

28. Reference  http:www.americangeriatrics.org/health_care_pr ofessionals/clinical_practice/clinical_guidelines_r ecommendations/2010/