Falls in the elderly - Revision history

Aidan: /* Clinical Presentation */

2021-10-29T15:46:06Z

Clinical Presentation

← Older revision		Revision as of 15:46, 29 October 2021
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	* Gait & balance impairment		* Gait & balance impairment
	* Peripheral neuropathy		* [[Peripheral neuropathy]]
	* Vestibular dysfunction		* Vestibular dysfunction
	* Muscle weakness		* Muscle weakness
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	* Advanced age		* Advanced age
	* Impaired ADLs		* Impaired ADLs
	* Orthostasis		* [[Orthostasis]]
	* Dementia		* [[Dementia]]
	* Drugs		* Drugs

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	* Trips and slips		* Trips and slips
	* Drop attack		* [[Drop attack]]
	* Syncope		* [[Syncope]]
	* Dizziness		* [[Dizziness]]
	* Acute medical illness		* Acute medical illness

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	** Age-related changes: sensory input, central processing, motor output		** Age-related changes: sensory input, central processing, motor output
	** Comorbidities		** Comorbidities
	*** Dementia		*** [[Dementia]]
	*** ~~AFib~~, heart failure, COPD, DM		*** [[Atrial fibrillation]], [[heart failure]], [[COPD]], [[diabetes]]
	*** Cataracts, glaucoma		*** [[Cataracts]], [[glaucoma]]
	*** BPPV, Parkinson disease, stroke		*** [[BPPV]], [[Parkinson disease]], [[stroke]]
	** Situational		** Situational
	*** Drugs: SSRIs, benzodiazepines, ~~BP meds~~		*** Drugs: [[SSRIs]], [[benzodiazepines]], [[antihypertensives]]
	**** Highest risk are benzodiazepines, alcohol, and antidepressants		**** Highest risk are [[benzodiazepines]], [[alcohol]], and [[antidepressants]]
	**** Having 4+ prescribed medications		**** Having 4+ prescribed medications
	*** Environment: carpet, slippery floors		*** Environment: carpet, slippery floors
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	* Cognitive testing, with MMSE		* Cognitive testing, with MMSE
	* Vision and hearing screen		* Vision and hearing screen
	* Cardiovascular: rule our aortic stenosis, arrhythmia, carotid bruits		* Cardiovascular: rule our [[aortic stenosis]], [[arrhythmia]], carotid bruits
	* Gait assessment: ~~time~~ up and go, 30-second chair stand, or 4-stage balance test		* Gait assessment: timed up and go, 30-second chair stand, or 4-stage balance test
	* Neuro: power and tone, lower extremity sensation and proprioception, finger-nose and heel-shin, and Parkinsonism (glabellar tap, diminution, toe tap)		* Neuro: power and tone, lower extremity sensation and proprioception, finger-nose and heel-shin, and Parkinsonism (glabellar tap, diminution, toe tap)
	* MSK: examine feet, rule out osteoarthritis, rheumatoid arthritis, and osteoporosis		* MSK: examine feet, rule out osteoarthritis, rheumatoid arthritis, and osteoporosis

Aidan: /* Assessment */

2021-10-29T15:44:03Z

Assessment

← Older revision		Revision as of 15:44, 29 October 2021
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	* Acute medical illness		* Acute medical illness

	== ~~Assessment~~ ==		== Clinical Presentation ==

	* Assess circumstances, causes, consequences, and comorbidities		* Assess circumstances, causes, consequences, and comorbidities
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	* Neuro: power and tone, lower extremity sensation and proprioception, finger-nose and heel-shin, and Parkinsonism (glabellar tap, diminution, toe tap)		* Neuro: power and tone, lower extremity sensation and proprioception, finger-nose and heel-shin, and Parkinsonism (glabellar tap, diminution, toe tap)
	* MSK: examine feet, rule out osteoarthritis, rheumatoid arthritis, and osteoporosis		* MSK: examine feet, rule out osteoarthritis, rheumatoid arthritis, and osteoporosis
			=== Prognosis===

			*After hip fracture, 2 year mortality is 30%
	== Management ==		== Management ==

Aidan at 15:43, 29 October 2021

2021-10-29T15:43:42Z

← Older revision		Revision as of 15:43, 29 October 2021
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	== ~~Definition~~ ==		== Background ==

			=== Definition ===

	* Event which results in a person coming to rest inadvertently on the ground or floor or other lower level		* Event which results in a person coming to rest inadvertently on the ground or floor or other lower level

	== Etiology ==		=== Etiology ===

	* Falls are caused by a combination of intrinsic and extrinsic risk factors combined with a precipitating factor		* Falls are caused by a combination of intrinsic and extrinsic risk factors combined with a precipitating factor

	=== Intrinsic ~~risk~~ ~~factors~~ ===		==== Intrinsic Risk Factors ====

	* Gait & balance impairment		* Gait & balance impairment
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	* Drugs		* Drugs

	=== Extrinsic ~~risk~~ ~~factors~~ ===		==== Extrinsic Risk Factors ====

	* Environmental hazards		* Environmental hazards
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	* Restraints		* Restraints

	=== Precipitating ~~causes~~ ===		==== Precipitating Causes ====

	* Trips and slips		* Trips and slips
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	* Neuro: power and tone, lower extremity sensation and proprioception, finger-nose and heel-shin, and Parkinsonism (glabellar tap, diminution, toe tap)		* Neuro: power and tone, lower extremity sensation and proprioception, finger-nose and heel-shin, and Parkinsonism (glabellar tap, diminution, toe tap)
	* MSK: examine feet, rule out osteoarthritis, rheumatoid arthritis, and osteoporosis		* MSK: examine feet, rule out osteoarthritis, rheumatoid arthritis, and osteoporosis

	== Investigations ==

	== Management ==		== Management ==
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	* NNT of 8 to prevent 1 fall		* NNT of 8 to prevent 1 fall

			{\| class="wikitable"
	{\|
	! Risk Factor		! Risk Factor
	! Assessor		! Assessor
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	\| resistance and range of motion exercises		\| resistance and range of motion exercises
	\|}		\|}

	== Prognosis ==

	* After hip fracture, 2 year mortality is 30%

	== Further Reading ==		== Further Reading ==

Maintenance script: Imported from text file

2020-07-04T01:17:34Z

Imported from text file

New page

== Definition ==

* Event which results in a person coming to rest inadvertently on the ground or floor or other lower level

== Etiology ==

* Falls are caused by a combination of intrinsic and extrinsic risk factors combined with a precipitating factor

=== Intrinsic risk factors ===

* Gait & balance impairment
* Peripheral neuropathy
* Vestibular dysfunction
* Muscle weakness
* Vision impairment
* Advanced age
* Impaired ADLs
* Orthostasis
* Dementia
* Drugs

=== Extrinsic risk factors ===

* Environmental hazards
* Poor footwear
* Restraints

=== Precipitating causes ===

* Trips and slips
* Drop attack
* Syncope
* Dizziness
* Acute medical illness

== Assessment ==

* Assess circumstances, causes, consequences, and comorbidities
* History
** What happened before? Were there any preceding symptoms or prodrome?
** What happened? How long were they down? How did they get up?
*** Loss of consciousness due to syncope or seizures
** What happened after? Was there any traume, fracture, anxiety?
* Risk of falls
** History of prior falls or gait instability
** Age-related changes: sensory input, central processing, motor output
** Comorbidities
*** Dementia
*** AFib, heart failure, COPD, DM
*** Cataracts, glaucoma
*** BPPV, Parkinson disease, stroke
** Situational
*** Drugs: SSRIs, benzodiazepines, BP meds
**** Highest risk are benzodiazepines, alcohol, and antidepressants
**** Having 4+ prescribed medications
*** Environment: carpet, slippery floors
** Orthostatic vitals: supine BP/HR, then BP/HR at 1 and 3 minutes
** Neurological exam, including proprioception
* Functional history

=== Physical Examination ===

* Vitals, including orthostatics
* Cognitive testing, with MMSE
* Vision and hearing screen
* Cardiovascular: rule our aortic stenosis, arrhythmia, carotid bruits
* Gait assessment: time up and go, 30-second chair stand, or 4-stage balance test
* Neuro: power and tone, lower extremity sensation and proprioception, finger-nose and heel-shin, and Parkinsonism (glabellar tap, diminution, toe tap)
* MSK: examine feet, rule out osteoarthritis, rheumatoid arthritis, and osteoporosis

== Investigations ==

== Management ==

=== Individuals Interventions ===

* Refer to [1] below
* Otago exercise program (incidence rate ratio 0.68, 0.56-0.79)
* Home assessment and modification (RR 0.79, 0.65-0.97)
* Hazard assessment and modification for fallers (2 trials, RR 0.56, 0.42-0.76)
* Withdrawal of psychotropic medication (RR 0.34, 0.16-0.74)
* Academic detailing and feedback to clinicians on medication modification (1 trial, RR 0.61, 0.41-0.91)
* Cardiac pacing in fallers with cardioinhibitory carotid sinus hypersensitivity (1 trial, RR 0.42, 0.23-0.75)
* Antislip shoe device for icy conditions (RR 0.42, 0.22-0.78)
* Expedited first cataract surgery, in women (1 trial, RR 0.60, 0.36-0.98)
* Tai Chi (RR 0.65, 0.51-0.82)
* Vitamin D (RR 0.72, 0.55-0.95) in long-term care

=== Multifactorial Intervention to Reduce Falls ===

* Refer to [2] below
* NNT of 8 to prevent 1 fall

{|
! Risk Factor
! Assessor
! Intervention
|-
| postural hypotension (SBP ≥20, or to <90 standing)
| RN
| ankle pumps, hand clenching, elevation of head of bed, change/adjust culprit medications if possible
|-
| use of benzos or other sedative/hypnotic drugs
| RN
| education about medcation use, nonpharmacologic treatment of sleep disorder, discontinuation of medications
|-
| ≥4 prescription medications
| RN
| review of medications with primary physician
|-
| inability to transfer safely to bathtub or toilet
| RN
| training in transfer skills, environmental alterations (grab bars, raised toilet seats)
|-
| environmental hazards for falls
| RN
| removal of hazards, safer furniture, grab bars, handrails
|-
| any gait impairment
| PT
| gait training, assistive device
|-
| any transfer or balance impairment
| PT
| balance exercises, environmental alterations
|-
| impairment in limb strength or range of motion
| PT
| resistance and range of motion exercises
|}

== Prognosis ==

* After hip fracture, 2 year mortality is 30%

== Further Reading ==

# Gillespie LD, ''et al''. [https://doig.org/10.1002/14651858.CD007146.pub3 Interventions for preventing falls in older people living in the community]. ''Cochrane Database Syst Rev''. 2012;9:CD007146.
# Tinetti ME, ''et al''. [https://doi.org/10.1056/NEJM199409293311301 A multifactorial intervention to reduce the risk of falling among elderly people living in the community]. ''N Engl J Med''. 1994;331(13):821-7.

[[Category:Geriatrics]]