Falls in t he Elderly Dr J ane Youde
Falls in t he Elderly
Falls in t he Elderly “ Falls in the elderly are best avoided” –David Barker 2003
Conc ept s Why best prevented? Why do older people fall? Can we stop falls?
Aim s To summarise the epidemiology of falls in the elderly To introduce concepts regarding the consequences, causes, assessment and prevention of falls in older people
Falls and Sync ope in Older People Fall: An event which results in a person coming to rest inadvertently at a lower level
Falls and Sync ope in Older People Syncope: A transient loss of consciousness, characterised by unresponsiveness and loss of postural tone with spontaneous recovery
Census Inform at ion A fifth of the population is > 60 years old Between 1995 and 2025 the number of people over the age of 80 is set to increase by almost a half and the number of people over 90 will double.
Census Inform at ion The NHS spent around 40% (10 billion) of its budget on people over the age of 65 in1998/99. In the same year social services spent nearly 50% of their budget on the over 65s (5.2 billion) Approximately 66% of general and acute hospital beds are used by people over 65
Falls in t he Elderly Important cause of morbidity and mortality in the elderly In 1 year 33% of people >65 years have 1 fall Commonest presenting complaint to A&E in patients >65 years (400,000 patients/year)
Falls in t he Elderly 20% 1 year mortality in people who have a fractured neck of femur (# NOF) Total Cost to the UK/year for care of # NOF is £1.7 billion
Falls In t he Elderly Cost of falls 45% for acute care 50% social/long term care 5% drugs/follow up
Falls in t he Elderly Recent evidence suggests fear of falling and the associated effect on health has a significant adverse effect on quality of life One of the Government ’ s health improvement targets is reducing mortality from accidents
Falls in t he Elderly 30% of cognitively intact older people are unable to recall documented falls 3 months after the event Eye witness accounts of falls are often unavailable Amnesia for a loss of consciousness is present in up to 50% of patients with syncope
Falls and Sync ope in Older People Integrated falls clinics: Up to 75% had a evidence of a cardiovascular cause of a fall/syncope/dizziness At least 25% had amnesia for syncope despite this being witnessed during carotid sinus massage
Consequenc es of Falls Trauma Soft Tissues Injuries Fractures and dislocations: Humerus, pelvic ramus, clavicle, femur
Consequenc es of Falls “Long Lies” Hypostatic pneumonia Pressure Sores Dehydration Hypothermia
Consequenc es of Falls Psychological “Fear of Falling”
Causes of Falls NSF for Older People Defines These MULTI-FACTORIAL
Causes of Falls Associated with physiological ageing E.g. impaired response times, impaired muscular strength Multi-factorial Multi-disciplinary
Int rinsic Fac t ors Balance and Gait > 4 medications Visual impairment Cognitive problems Postural hypotension and Cardiovascular causes
Int rinsic Fac t ors Gait and Balance Stroke Disease Parkinsonism Arthritic Changes Neuropathy Muscle Disease Vestibular Disease
Int rinsic Fac t ors
Int rinsic Fac t ors Medications Polypharmacy is common in older people Sedatives significantly increase the risk of falling Cardiovascular medications can contribute towards falls Medication is often incorrectly used
Adverse Drug Reac t ions Common in older people Risk increases with the number of medications prescribed Average number of medications taken by nursing home residents is 7
ADRs 66% of admissions with ADRs are over the age of 60 years Accounts for 3.4-16.6% of acute admissions Associated with 8-10% mortality
Beers Crit eria In the USA used to define medication to avoid using in the elderly, use with caution or will exacerbate pre-existing syndromes 27% of ADRs in the community and 42% of ADRs in NH/RH are preventable
Beers Crit eria In USA cost $7.2 billion If taking medication on the Beers lists there is an association with increased ADRs, hospitalisation and mortality Used for Quality monitoring
Beers Crit eria Medications to avoid: Chlorphenaramine Alpha-blockers Methyldopa NSAIDs Metoclopramide Benzodiazepines Amitryptiline
Medic at ion
Medic at ion List s 86% of admission drug lists had some form of discrepancy when cross-checked against GP prescription lists. 71% of individual prescriptions were discrepant. Cardiovascular and analgesic medications commonly differed. Pharmacists managed to check 67% of available patients medications.
Medic at ion List s Of 64 patients who were able to list their medications, only 64% described the same list as admitting doctors and only 43% described the same list as general practitioners. Hospital doctor and general practitioner lists were the same in only 37% of cases.
Falls Benzodiazepines and psychotropic drugs are significantly associated with an increase in falls 10-12% of the older population are prescribed benzodiazepines with 80% on long term treatment (>2 years) Withdrawal of psychoactive drugs can result in a 66% reduction in falls
Non Com plianc e Non-compliance with medication is related to the number of medications taken Lack understanding of the medication Change in medication regieme e.g. hospital discharge Not all aids are suitable Unable to take the prescribed form of the drug
Int rinsic Fac t ors Cognitive Impairment Any form of dementia is associated with an increase in falls If the cognitive impairment is advanced these patient do not benefit from rehabilitation
Int rinsic Fac t ors
Int rinsic Fac t ors Visual Impairment Common with increased age Bi-focals increase the risk of falling Glaucoma, macular degeneration and retinopathy increase the risk
Cardiovasc ular Responses t o St anding
Cardiovasc ular Causes of Falls in Older People Causes: Orthostatic Hypotension (OH) Postprandial Hypotension Carotid Sinus Syndrome Neurocardiogenic Syncope Arrhythmias Structural Heart Disease
Ort host at ic Hypot ension Defined as >20 mmHg fall in systolic blood pressure and/or a >10 mmHg fall in diastolic blood pressure within 3 minutes of standing WITH symptoms
Post prandial Hypot ension Definition: A fall of 20 mmHg in Systolic blood pressure after the ingestion of a meal Can have effect for up to 90 minutes
Carot id Sinus Syndrom e Cardio-inhibitory 3 seconds of asytole produced by carotid massage Vasodepressor a fall in systolic blood pressure of >50 mmHg with no heart rate change Mixed
Neuroc ardiogenic Sync ope Vasodepressive Fall in systolic blood pressure to <80 mmHg with no change in heart rate Cardio-inhibitory Fall in heart rate to <40 Mixed
Sync ope/Carot id Sinus Syndrom e Review medication May need a pacemaker May need medication to stop falls in blood pressure
Arrhyt hm ias Consider if have palpitations prior to syncope or if sudden onset If 12 lead ECG is within normal limits a 24 hour tape will only be diagnostic in 2% of cases Can be due to excessively fast or slow heart rates (tachycardias/bradycardias) or both
Valvular Disease The incidence of calcific aortic stenosis (narrowing of the aortic heart valve) increases with age Examination important Confirmed with echocardiogram Outcome for >80years old is good
Ex t rinsic Fac t ors
Ex t rinsic Fac t ors
Ex t rinsic Fac t ors Poor lighting Stairs Rugs/Floor surfaces Clothing/footwear Lack of equipment
Ex t rinsic Fac t ors
Ex t rinsic Fac t ors Walking Aids Must be appropriate and maintained Should be educated on the safe use of them
Falls in t he Elderly Full history ?First fall/multiple falls Eye witness account Associated features Risk Factors for falling Drug History Alcohol Intake
Falls in t he Elderly Management Remember multi-factorial Review drug regime
Falls in t he Elderly Prevention Regular evidence based exercise Assessment and treatment for osteoporosis Review especially to monitor medication and ongoing medical problems Environmental Issues
Falls in Older People Multifactorial Multidisciplinary Polypharmacy
The End
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