Adult/Gerontological Health Care I

Overview of Fall Prevention, Impact & Evaluation

• One of every three people 65 years and older falls each year. 2/3 fall again within six months
• Of those who fall, 20-30% suffer moderate to severe injuries that reduce mobility and independence, and increase the risk of premature death
• For those 65 and greater, falls leading cause of injury deaths and serious injury
• Half the older adults hospitalized for hip fx can’t return home or live independently after their injuries

• Unintential falls account for 87% of all fxs in Ers
• Falls have serious psychological consequences

……>….FALL….Fear of Falling… Immobility…>… ….Deconditioning/Weakness…..Decreased Activity …>…

…Social isolation… Dependency….>…

• Falls can lead to the "fear of falling" phenomenon.
• As people fear falling, tend to restrict their activity more, leading to the problems associated with decreased mobility.

• Starting new drugs/ drug-drug interactions
• Dizziness/ orthostatic hypotension
• Muscle weakness, deconditioning
• Changes in vision
• Cognitive impairment/poor judgment
• Abnormal mobility/Changes in coordination
• New environment
• Environmental hazard
• Inadequate lighting

• Strength problems
• Alcohol
• Food associated hypotension
• Environmental factors
• Atherosclerotic disease (syncope)
• No freedom (restraints)
• Drugs
• Sight problems
• Orthostasis
• Unsteady balance
• Nocturia
• Delirium

Screening for Fall Risk

• Ask about history of falls every encounter?
• Better to have dynamic test rather than static
• Benefits of "Get up and Go"
• Sternal nudge/ hip pull?

Fall Evaluation

• Falls as complex combination of several intrinsic and extrinsic factors.
• Estimated 50% of falls are "accidents" that result primarily from extrinsic factors
• 50% result from intrinsic factors. (physiological mechanisms for the most part, the result of changes associated with aging, with diseases, or with medication use).
• Cause of a fall is usually multi-factorial, involving both the individual and the environment and what causes a fall in one person may or may not cause a fall in another person.

• Symptoms
• Previous Falls or Near Falls
• Location of Fall
• Activity at time of Fall
• Time of Fall
• Trauma, both physical and psychologic

FEAT: A Structured Approach to Falls (adapted from M. Mills )

1)Function, 2)Environment, 3)Acute Illness, 4)Threats to Postural Stability

1) Functional Categories of Risk: Vigorous –Transitional- Frail

• Vigorous persons -Can walk heel-to-toe, Descend steps step-over-step. Are least likely to fall, but impact force of a fall is more likely higher
• Frail people meet criteria for "disordered walking" - Use an assistive device or take steps that are shorter than twice the length of the foot. Have the highest risk for falls, and more likely to have falls indoors
• Transitional people -function midway between Vigorous and Frail people

• Assesses the interaction between an organism and the environment (extrinsic factors)
• See Environmental Checklist (financial considerations and appropriate referrals if indicated when recommending environmental changes).

3) Acute metabolic problems

• Not usual causation with longstanding hx of falls
• "Weak and dizzy" symptoms can be related to: Infection, Dehydration, Blood loss, Electrolyte imbalance, Hypoxemia, & Other acute illness

4) Threats to postural stability: Sensory, Central Processing, Effector

-Sensory

• Visual deficits (acuity, depth perception, visual fields, dark adaptation)
• Proprioception  (vestibular deficits-sensations of acceleration and gravitational sensation that determines the vertical upright position)
• Peripheral sensory deficits (peripheral neuropathy- very common, may be asymptomatic.  Leads to difficulty in determining the position of the foot and ankle. Limits detection of irregularities in the terrain. Reduces the ability to detect sway
• Multiple sensory deficits

-Central Processing 

-Coordinates movements smoothly and efficiently. Organization and speed of postural responses can be impaired by diseases such as Parkinson's disease, Cerebrovascular disease, Cerebellar syndromes, Dementias (impaired judgment and attention, deconditioning), Medications (sedation, delayed response time, orthostasis, extrapyramidal side effects). Also consider Reduced cerebral perfusion (arrhythmias, valvular lesions)

-Effector components 

Include: Muscle strength, Joint flexibility, Endurance. Effectors may be impaired by: Aging, Disease, Disuse, Foot problems (bunions, hammertoes, elongated nails, improper footwear).

General Interventions for fall prevention. A brief summary list includes:

• Treat what you find
• Medication reviews and meds minimized as possible
• High risk patient identification
• Family/patient/staff education
• System interventions such as Fall prevention programs, environmental modifications, increased toileting schedules, alarm systems
• Restraint use- avoid restraints if at all possible- Restraints contribute to Fall rate and not consistent with Standard of Care.

• Strength/balance for Vigorous/transitional patients: Maintain strengths with exercise programs
• Physical Therapy for Frail patients: Mobility, strengthening, gait training, endurance balance, low impact resistive exercises, tai chi, water exercises, formal weight training, Theraband, Assistive devices, hip protectors
• Home Safety Checklists and Environmental Modifications
• Foot care –card table clinic on foot care, foot evaluations, referrals to podiatry
• Use of assistive devices

• PT visit for assistive devices fitting and teaching
• Broader base of support better if…
• Stigma of assistive devices
• Technology and Protective Attire review Ham and Sloane

Patient Education

• Teaching to get up after a fall
• Fall "call" buttons/ how to access
• Fall checklist from AGS
• Environmental Checklist

U.S. Fall Prevention Programs for Seniors - National Center for Injury Prevention and Control. Includes home safety checklist http://www.cdc.gov/ncipc/falls/default.htm

AGS Falls Protocol http://www.americangeriatrics.org/news/media_adv_5.shtml

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