Malakouti SK Geriatric Medicine Department Iran University of Medical Sciences Seyed Kazem Malakouti, MD

 30-40% of people over age 65 will have a fall each year  In an elderly patient who has fallen, the risk of having a second fall within a year rises to 60%  8% of all people over age 70 will present to the ER each year after a fall. 1/3 will be admitted Seyed Kazem Malakouti, MD

 Many falls cause minor or no injury. Skin tears and lacerations may require ED treatment but generally cause no lasting harm.  Between 5 and 10% of community dwelling elderly patients who fall (up to 20-30% of elderly patients overall) will suffer a serious injury Seyed Kazem Malakouti, MD

 Hip Fractures -1% of falls in the elderly lead to hip fx  20-30% mortality in the year after hip fx  ¼ to ¾ of patients do not recover prior level of ADLs Seyed Kazem Malakouti, MD

 Picture the Geriatric Fall as a node on a decline spiral  Probably not the first step in the decline  Fall as symptom of underlying frailty  Frequently will create a marked acceleration of decline Self-limiting activity, worsening deconditioning, social isolation photoeverywhere.com Seyed Kazem Malakouti, MD

 Cognitive impairment  female gender  arthritis  podiatry problems  impaired vision  vitamin D deficiency  lower extremity weakness  Parkinsons  prior falls  gait impairment  poor balance  psychotrophic medications  age>80  neuropathy  vestibular dysfunction  orthostasis Seyed Kazem Malakouti, MD

 2 aspects of approaching a fall  Falling risk assessment  Falling management  requires the provision of immediate first aids, medium and longer term care. Seyed Kazem Malakouti, MD

 Falls Assessment includes the following: 1. Presenting medical condition 2. Past medical history 3. Living arrangement Seyed Kazem Malakouti, MD

 Assessment for confusion and level of consciousness  Delirium, dementia  Neurological examination  Speech, eye movements, facial symmetry, forces of limbs and reflexes  Pulse, Blood pressure, Tilt test  Head, neck, clavicles, shoulders, hips, wrists, ankles  Tenderness, deformity, swelling, shortening, abnormal rotations of limbs, painless complete range of motion and weight bearing  Assessment of post-fall mobility Seyed Kazem Malakouti, MD

 Should always take place, even if needed to wake the patient up  Should identify any injury sustained  Patient may not be aware of all of his injuries  Should seek to identify any acute underlying cause  Arrhythmia, Stroke, hypotension, etc. Seyed Kazem Malakouti, MD

a. History of falls: Detailed description of the circumstances of the fall(s), frequency, symptoms at time of fall, injuries, other consequences b. Medication review: All prescribed and over-the- counter medications with dosages c. History of relevant risk factors: Acute or chronic medical problems, (e.g., osteoporosis, urinary incontinence, cardiovascular disease) Seyed Kazem Malakouti, MD

The multifactorial fall risk assessment should be followed by direct interventions tailored to the identified risk factors The components most commonly included in efficacious interventions were: 1. Adaptation or modification of home environment 2. Withdrawal or minimization of psychoactive medications 3. Withdrawal or minimization of other medications 4. Management of postural hypotension 5. Management of foot problems and footwear 6. Exercise, particularly balance, strength, and gait training Seyed Kazem Malakouti, MD

 a multi-disciplinary team must evaluate individual risk based on :  1- Other medical conditions:  Parkinson’s disease, peripheral neuropathy, stroke  2- Previous falls  3- Living alone  A caregiver? A regular visiting family member?  Who supports the patient about the medical problems?  Include caregiver in care planning  4- environmental hazards at ward and at home  Discussed separately  5- Cognitive impairment  Separately discussed Seyed Kazem Malakouti, MD

 4+ drugs  Good understanding of his medication regimen  The impact of cognition on drug understanding and compliance  Compliance to medication  enough physical strength to manipulate and divide the tablets  Are they enough oriented to time to follow the medication program?  Do they need assistance for medication management? Seyed Kazem Malakouti, MD

 Greater risk at unfamiliar places  Return to familiar places ASAP, avoid moving bed  Ensure the elder’s glasses is accessible and clean  When was the last visual check-up? More than 12 months? => refer to optician  Discuss the risks of bifocal glasses on steps and uneven surfaces  Assessment of environments related to visual impairment  Bathrooms light kept on  Bed side rail for the ward’s bed  Environmental cues for visually impaired patients in unfamiliar places  Has the patient been oriented to unfamiliar place? Seyed Kazem Malakouti, MD

 Assess patient’s continence and toileting issues  Current management of continence issues? Pads? Bottle/bedside commode? How far is toilet?  How many times does he get up during night?  Able to mop up urine spills if happens?  Balance during mopping up spills and changing the clothes?  Liquid volume restriction preventing night wake ups?  Consequential constipation  Aids for toileting?  Toilet handles, Toilet rails Seyed Kazem Malakouti, MD

 Functional decline: Bed ridden reduced mobility  Impact on fall risk  Assess ADLs and implement intervention  Encourage patient to sit out of bed and participate in activities  ADL practice and implement changes needed to safety and independence  Risk at standing while showering? Need to sit or rails?  Develop muscle strength through participations  Provide equipment and environmental cues where needed Seyed Kazem Malakouti, MD

 Falls Efficacy Scale  History of reluctance to partake in normal activities?  Avoid activities due to fear?  Reproduction of confidence by participating in daily activities and education  Clinical psychology visit if anxiety and fear persisted after items above Seyed Kazem Malakouti, MD

 Assess foot wears  Ask caregiver to bring a suitable footwear  Discourage use of socks due to slip hazards  Other foot issues:  Long nails  Impaired sensation Seyed Kazem Malakouti, MD

 Identify risk areas and provide interventions  Training safe ADL activities  Prescription assistive equipments  Assess patient’s insight and cognitive situation  To understand which activities and positions are risky  IADL functions and practice: Safely reach low and high level? Need to recognize environment to reduce overbalancing? Seyed Kazem Malakouti, MD

UNDERLYING CARDIAC DISEASE  Cardiovascular status: Heart rate and rhythm, postural pulse, blood pressure, and, if appropriate, heart rate and blood pressure responses to carotid sinus stimulation  Dual chamber cardiac pacing should be considered for older persons with cardio-inhibitory carotid sinus hypersensitivity who experience unexplained recurrent falls. Seyed Kazem Malakouti, MD

 Evaluate environment: surfaces, steps, distances  Appropriate footwear?  Ability to carry items while using a walking aid? Having a kitchen trolley?  Do they remember to use their aids?  At ward, can they reach toilet or they need to use beside bed bottle?  Impact on falling fear. Avoidance of walking in crowds or using public transports.  Ability to dual task? i.e. walk and talk. Seyed Kazem Malakouti, MD

 Swallowing difficulty? Intentional weight loss?  Strength and muscle mass reduction due to malnutrition?  Impact of cognitive impairment on meal preparation  Ability to manipulate cutlery. Need to assistive equipments? Seating position while having meal?  Refer to a dietician if needed. Seyed Kazem Malakouti, MD

Postural Challenges Of Aging Medications And Comorbidities Behavioral Contributors ↓Baroreceptor Sensitivity ↓Balance from vestibular and proprioception ↓vision (esp night) ↓reflex speed for correction ↑impulsivity (esp in dementia) Dehydration/diuretics Bp meds causing orthostasis Benzodiazepines Psychotrophics Anticholinergics Alpha antagonists Parkinsons, Neuropathy Arthritis, podiatry problems Fall INJURY Frailty Osteoporosis Decreased muscle speed to deflect injury Seyed Kazem Malakouti, MD