1. Fall and prevention Kamolsak Sukhonthamarn, MD Orthopaedic department KKU

2. At least 1 fall a year 34% of patients ≥ 65 years old, 50% of non-institutionalized octogenarians, 26% of inpatients, 43% of patients in nursing homes. Clin Geriatr Med 2002;18:141-58

3. In older adults, 30% of falls can result in moderate to severe injuries, lacerations, hip fractures and head trauma, resulting in an increased risk of early death. Sterling DA et al. J Trauma Acute Care Surg 2001;50:116–9.

4. A fall may lead to a fear of falling, avoidance of daily activities, social isolation, lowered quality of life, precipitate a move to residential aged care. Delbaere K et al. Age Ageing 2004;33:368–73

5. Prevalence of fall PACE 2011; 34:278–283

6. Incidence of fall Community-dwelling patients older than 65 is 28-35%, 40% in ≥ 75 years old. Age Ageing 2006;35 Suppl 2:ii37-ii41

7. Then, 5-10% of patients have fractures, concussions, hospitalization, In 1% occurs a femur fracture, with a 20-30% one-year mortality. In 30-70% of the cases a depressive syndrome occurs. Tinetti ME et al. N Engl J Med 1997;337:1279-84 Malottoli RA et al. J Am Geriatr Soc 1992;40:861-6

8. Why older people fall Pathogenesis is multifactorial factors Key intrinsic risk factors are age, sensory decline, reduced lower limb strength and comorbidity, Cognitive impairment, even subtle deficits, increases risk.

9. Physiologic aged-related changes

10. Pathological factors

11. Ambulatory problems and muscle weakness 10-25% of falls. Distal muscle weakness leads postural instability, Proximal muscle weakness reduces movement of the arms, Horlings CG, Neuroscience 2009

12. Environment Environmental barrier, 30-50% of falls, Almost older fall at home, due to spend most of time there, feeling more confident, more careless. Nevitt MC et al. JAMA 1989;261:2663-2668

13. At home, barriers are thresholds, stairs, carpets, slippery surfaces. Inadequate lighting or, excessive or dazzling.

14. Outdoor, barriers are sidewalks, curb, curbside, unprotected crossing

15. Drugs Meta-analysis show, taking more than 4 drugs are significant risk of falling, antiarrhythmic, digoxin, diuretics, antidepressants, benzodiazepines, antipsychotics. Hartikainen S et al. J Gerontol 2007;62A:1172-81

16. Multifactorial factors Proportion of patients with falls increases from 10% to 69% number of risk factors increases from 1 to 4 or more. Nevitt MC et al. JAMA 1989;261:2663-2668

17. Evaluation American geriatrics society, British geriatrics society, AAOS. Guideline for the Prevention of Falls in Older Persons. J Am Geriatr Soc 2001

18. Screening test

19. History taking

20. Prevention strategies The cornerstone of effective falls prevention is identifying modifiable risk factors, intervening with effective strategies. Discussing the positive aspects of falls prevention, social and health benefits, family improves adherence

21. Prevention strategies Pathologic conditions have specific treatments, Attention re-evaluated drug, adjust dose or withdrawal, Antihypertensive, Diuretics, Benzodiazepines.

22. Exercise program well-designed exercise can reduce falls. Systematic reviews have also identified that ‘tai chi’ can reduce falls by 37% Gillespie LD et al. Cochrane Database Syst Rev 2009(2):CD00714 6

23. Evidence for fall prevention

24. Home modification

25. Syncope VS Falls Syncope is one of major caused of falls, Syncope-related fall is 0.3-5%, Underestimated. Difficult to obtain.

26. because.... Retrograde amnesia for a loss of consciousness. 40-60% of syncopal episodes happen without witnesses. Parry SW et al. J Am Coll Cardiol 2005;45:1840-1843.

27. Pre-syncope occurs in transient arrhythmias, orthostatic hypotension, cause of fall and predicts occur of future syncopal episode. 26% of older patients referred to the ER had a syncope- related fall. Davies AJ et al. Age Ageing 1996;25:362-366

28. High risk of trauma Syncope-related fractures or major trauma 10-23%. Risk of a major trauma is 5.9 times higher Higher risk of remaining on the ground for a longer time. Nevitt MC et al. JAMA 1989;261:2663-2668

29. Older patients with syncope have 13-33% one-year mortality. 79% four-year mortality, compared to the expected value. Rubenstein LZ et al. Clin Geriatr Med 2002;18:141-58

30. Syncope study from 71,299 cases at ER, 14%(3,384) had had an unexplained fall(non-accident fall) 34% had carotid sinus hypersensitivity, cardio-inhibitory rate of fall and trauma respectively was reduced by 70 to 75% after a pacemaker implantation Kenny RA et al. J Am Coll Cardiol 2001;38:1491-1496

31. Older patients with history of falls should undergo a cardiovascular and neuroautonomic assessment besides the survey of other risk factors. Patients with prodomal symptoms

32. Conclusion Fall is multifactorial factors affect, identifying modifiable risk factors, multiple health professionals, followed by development and implementation, Common interventions include exercise, a home safety review, optimizing management of medical conditions and a medication review.