1. Jessica L. Colburn, MD Johns Hopkins School of Medicine Division of Geriatric Medicine & Gerontology April 15, 2015

2.  Discuss prevalence of falls in older adults  Develop an approach for fall risk screening and post-fall assessment in older adults  Discuss interventions that reduce fall risk in older adults

3.  Prevalence  Outcomes  Risk Factors ◦ Common Medical Conditions ◦ Changes with Aging  Screening  Evaluation  Risk Reduction  Community Resources  Take Home Points

6.  One-third of older adults in the community fall each year  One-half of older adults in long term care fall each year

7.  Falls are the leading cause of traumatic injuries in adults over the age of 65  Increased mortality secondary to falls with each decade of life  Estimated direct medical costs for injuries in older adults due to falls was $32 billion in the year 2013 www.cdc.gov/HomeandRecreationalSafety/Fal ls/fallcost.html

8. Kannus et al, Lancet 2005 20% need medical attention 5% fractures 5-10% other serious injuries (lacerations, head injuries, dislocations, bleeding)

9.  Hip fracture ◦ Increased risk of dying within the 3-6 months following a hip fracture ◦ Functional impairment – 20-30% of older adults do not return to baseline function ◦ Pain, difficult recovery  Found down – risk of injury due to delay to medical care, can lead to functional impairment  Fear of falling – leads to social withdrawal, admission to long term care facilities Sterling et al, Journal of Trauma 2001

11.  Patients who have fallen in the past year are more likely to fall again  Most consistent predictor of future falls is abnormal gait or balance  Think about conditions that your patient has that contribute to abnormal gait Ganz et al, JAMA 2007

12. Falls External Factors Medications Alcohol use Using an assistive device improperly Patient (Intrinsic) Factors Environmental hazards Medical conditions Age-related changes Vision and hearing impairment Cognitive impairment Kannus et al, Lancet 2005

13. Medical ConditionsAge-related changes  Parkinson’s disease  Stroke  Seizures  Dementia  Depression  Dizziness  Orthostatic hypotension  Arrhythmia  Osteoarthritis  Diabetes  Peripheral neuropathy  Changes in balance  Vision changes  Loss of muscle

14.  Cell death in substantia nigra -> reduction in brain dopamine levels  Clinical features: ◦ Tremor at rest (pill-rolling) ◦ Cogwheeling rigidity ◦ Masked facies ◦ Bradykinesia ◦ Shuffling gait  Treatment: ◦ Symptomatic relief only ◦ Dopaminergic agents Image: careplanning.blogspot.com

15.  Early stage – Same fall risk as other community-dwelling older adults  Middle stage - patients may forget that they need an assistive device or have knee pain until they get up and start to walk ◦ Lose fine motor skills, forget how to navigate environment  Late stage– patients forget how to perform motor tasks like walking or even swallowing ◦ Muscle wasting, weight loss

16.  Change in blood pressure with position changes  Reflex mechanisms needed to counteract gravity are less effective with age ◦ Vasoconstriction ◦ Elevated heart rate  Comorbid medical conditions  Medications – beta blockers, diuretics, antihypertensives  Volume depletion Image: nlm.nih.gov

17.  Very common in older adults  Major contributor to gait and balance problems ◦ Joint pain is commonly reported in primary care ◦ Balance changes due to joint abnormalities ◦ Fear of falling  Pain control: Acetaminophen is safe ◦ NSAIDs (ibuprofen, naproxen) are less safe due to renal and GI effects ◦ Opiates increase risk of falls and confusion ◦ Physical therapy very useful

18.  Tight control in older adults has been shown to increase severe hypoglycemic events and mortality  Oral hypoglycemics (except for metformin) and insulin are associated with high rates of hospitalization in older adults  Peripheral neuropathy also contributes to falls

19.  Antihypertensives  Diuretics  Digoxin  Anticholinergics  Benadryl  Ditropan (incontinence)  Polypharmacy MEDICATIONS!  Antidepressants  Sedatives/Pain Meds  Benzodiazepines  Opiates  Antipsychotics  Dementia agents (acetylcholinesterase inhibitors)  Dopaminergic agents

20. Improper use of assist devices  Loose rugs  Cords  Clutter  Low lighting  Hand rails  Cane  Walker  Wheelchair/scooter Environmental hazards

21.  Medications that could increase risk of injury ◦ Blood thinners (benefit may outweigh risk but important to think about)  Improper use of assistive devices ◦ Hand-me-down devices  Osteoporosis ◦ Increased risk of fracture with a fall

23. Acute fall? Two or more falls in the past year? Difficulty with walking or balance? Adapted from AGS Guideline for Prevention of Falls in Older Persons, 2010 YES NO Gait and balance assessment Fall in the past year? YES NO Abnormal ? FALL ASSESSMENT YES NO Reassess periodically

24.  Obtain relevant medical history, physical exam, cognitive and functional assessment  Determine multifactorial fall risk: ◦ History of fallsFeet/footwear ◦ MedicationsEnvironmental hazards ◦ Gait, balance, mobility ◦ Visual acuity ◦ Other neurologic impairments ◦ Muscle strength ◦ Heart rate and rhythm ◦ Orthostatic hypotension Adapted from AGS Guideline for Prevention of Falls in Older Persons, 2010

25.  How did the fall happen?  Did the patient have any symptoms?  Was there an injury?  Patient risk factors for falls (medical problems, gait imbalance, footwear)  Patient risk factors for injury (anticoagulants, osteoporosis)  Where there any environmental hazards?  Are there any new or problem medications?  Any change in mental status or functioning? Moncada LV. Am Fam Phys 2011

26.  Vital signs (orthostatics)  Vision exam  Cognitive assessment  Other neurologic impairments  Muscle strength  Heart rate and rhythm  Gait and balance assessment  Watch your patient walk!

27.  Drop in systolic blood pressure of 20 mm Hg with position change (sitting to standing) within 3 minutes  Five minutes of rest before first blood pressure  Drop may be delayed so typically I check immediately with standing and again at 2-3 minutes later  Assess for lightheadedness, but not all patients who are orthostatic get lightheaded

28.  Snellen chart  Pocket card okay  Wearing glasses?  Glasses appropriate?  Reading vs. distance  Bifocals may increase fall risk

29.  3 word recall + Clock Draw Test  Sensitivity/specificity comparable to using a cutpoint of 25 on the MMSE ◦ Sensitivity 76% (vs 79% MMSE) ◦ Specificity 89% (vs 88% MMSE)  Shorter to administer in practice than the MMSE Borson et al, JAGS, 2003 Borson et al, Int Jnl Geri Psych, 2011

30.  Mini-Cog ◦ Give the patient 3 words to remember  Banana, chair, sunrise ◦ Administer the Clock Drawing Test – “ten past eleven” or “two forty-five” or “eight twenty” ◦ 3 word recall  Scoring: ◦ 1 point for each word recalled (0-3 points) ◦ Clock draw test = 2 points normal, 0 points abnormal ◦ 0-2 = positive screen (“possibly impaired”) ◦ 3-5 = negative screen (“probably normal”) Borson et al, Int Jnl Geri Psych, 2011

32.  Neurologic exam to assess for causes of falls  Parkinsonian features  Muscle strength  Sensation  Gait/balance

33.  Cardiac examination  Evaluation for abnormalities that would affect balance or positioning  Irregular heart rhythm  Bradycardia or tachycardia

34.  Timed Up and Go ◦ Start with patient seated in a chair ◦ Instruct patient to stand, walk 3 meters (10 feet), turn around, come back, and sit down in the chair ◦ Time from when you say go until when patient is re-seated in the chair ◦ Patient may use his or her assistive device  Scoring: ◦ >/= 12 seconds associated with increased risk of falls  87% sensitivity & specificity Shumway-Cook et al, PT, 2000

35.  Assess home environment for risks for falling ◦ Rugs, clutter, cords, lighting  Consider ways to improve safety in the home environment with assistive devices

36.  Initiate multifactorial intervention to address identified risks: ◦ Minimize/adjust medications ◦ Recommend appropriate exercise program ◦ Treat vision impairment (consider cataracts, bifocals) ◦ Manage orthostatic hypotension ◦ Manage heart rate and rhythm abnormalities ◦ Supplement vitamin D ◦ Manage foot/footwear problems ◦ Modify the home environment ◦ Consider risks for injury (osteoporosis, blood thinners) ◦ Provide education and information Adapted from AGS Guideline for Prevention of Falls in Older Persons, 2010

37.  Check orthostatics (some patients do not report dizziness) ◦ Goal BP based on JNC 8 guidelines is 140 – 150 systolic, reduce antihypertensives if appropriate ◦ Encourage fluid intake  Vision screening ◦ Cautious use of bifocals, can increase fall risk especially with navigating curbs and steps  Home safety evaluation ◦ Medicare no longer reimburses for home safety evaluation unless it is done as part of home physical therapy treatment ◦ Can provide instructions for patient/caregiver to assess home environment

38.  Vitamin D therapy (Grade B evidence) - 800 IU daily for at least 12 months, regardless of serum level  Physical therapy or exercise referral (Grade B evidence) ◦ PT for gait & balance training ◦ Assessment of appropriate assistive device and training to use assistive device ◦ Many types of exercise will reduce falls – Tai Chi, low to high intensity, group or in home, many are effective  Multifactorial risk assessment not needed for every patient, tailor interventions to individual needs Moyer, Ann Int Med, 2012

39.  Department of Aging –> Resources for Fitness and Fall Prevention/Risk Reduction ◦ Baltimore County Department of Aging –> Maryland Access Point: 410-887-2594 ◦ Baltimore City Department of Aging -> Maryland Access Point: 410-396-2273 ◦ Senior Centers, exercise programs, fall prevention programs (ie. Stepping On) ◦ Online tools to help patients/caregivers do their own home safety assessments

40.  Falls are a common problem for older adults  Falls are dangerous – increased risk of functional impairment and death  Risk can be modified with screening, assessment, and intervention  You can prevent an older adult from falling!

41.  Email: ◦ Jessica Colburn, MD ◦ jcolbur1@jhmi.edu jcolbur1@jhmi.edu Thank you!