Geriatric Medicine Book

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Fall Prevention in the Elderly

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  1. See Also
    1. Osteoporosis Prevention
    2. No-fail Environment in Dementia
  2. Epidemiology
    1. Falls occur in >30% of age over 65 years in community
    2. Serious injury occurs in >20% of falls in older adults
    3. Most falls occur in and around the patient's home
  3. Risk Factors: Falls
    1. Environmental hazards (most common)
    2. Altered gait or balance
    3. Lower extremity Muscle Weakness
    4. Dizziness or Vertigo
    5. Syncope
    6. Postural Hypotension
    7. Decreased visual acquity
    8. Arthritis
    9. Dementia or Altered Level of Consciousness
    10. Major Depression
    11. Medication use (especially more than 4 medications)
      1. Class IA Antiarrhythmics
      2. Digoxin
      3. Diuretics
      4. Anticonvulsants
      5. Psychotropic medications
        1. Benzodiazepines
        2. Antipsychotics
  4. Evaluation: Fall risk
    1. Get Up and Go Test
    2. Cardiovascular exam
      1. Postural Hypotension
      2. Arrhythmias
      3. Carotid Bruits
    3. Neurologic Exam
      1. Assess coordination and balance
      2. Lower extremity muscle strength
      3. Proprioception and vibration sense
    4. Miscellaneous exam
      1. Visual Acuity
      2. Joint exam
    5. Diagnostics in cases of fall history
      1. Complete Blood Count
      2. Thyroid Function Tests
      3. Chemistry panel including Renal Function tests
      4. Serum Vitamin B12
      5. Electrocardiogram
      6. Echocardiogram
      7. Brain Imaging
  5. Management: Falls
    1. Treat falls as a sentinel event
    2. Use this to prompt team evaluation
      1. Fall safety and home safety evaluation
      2. Evaluate for Osteoporosis
      3. Hearing and sight evaluation
      4. Review medications (see Polypharmacy)
      5. Discuss Advanced Directives
  6. Prevention: Assistive Devices
    1. Wear flat, rubber soled shoes
    2. Use ambulatory aid as needed (cane or walker)
    3. Consider Hip protection device
      1. Two convex shields worn inside underwear pocket
      2. Greatly reduces Hip Fracture Incidence
        1. Wearing pads: 0.39 Hip Fractures per 100 falls
        2. Not wearing pads: 2.43 Hip Fractures per 100 falls
      3. May reduce Incidence of pelvic Fracture
      4. Pad availability
        1. Hipsaver
          1. http://www.hipsaver.com
        2. Safe Hip
          1. http://www.safehip.com
        3. Other online sources
          1. http://www.ozemail.com/au/~hipsaver
    4. References
      1. Heidrich (2003) AAFP Board Review, Seattle
      2. Kannus (2000) N Engl J Med 343:1506
  7. Prevention: Education
    1. Proper lifting technique
      1. No stooping; bend knees and keep back straight
  8. Prevention: Optimize Comorbid Conditions
    1. Assess number/type of medications
    2. Check Visual Acuity
      1. Vision <20/60 is a risk for falls
      2. Check for Cataracts
      3. Assess for depth perception
    3. Control systolic Hypertension
      1. Systolic Hypertension affects balance and fall risk
        1. Hausdorff (2003) Am J Cardiol 91:643
    4. Avoid medications that increase fall risk
      1. Medications causing hypotension or Dizziness
      2. Medications causing Sedation
        1. Benzodiazepines
          1. High risk of falls and Hip Fracture
          2. Highest risk within first 2 weeks of starting
          3. Wagner (2004) Arch Intern Med 164:1567
  9. Prevention: Modify home environment
    1. Consider occupational therapy evaluation
    2. Hand grips and safety mat in shower
    3. Treads and handrails in stairway
    4. Anchor rugs, non-skid rubber mats
    5. Remove clutter, exposed wire, or cord
    6. Keep halls and stairways well lit
    7. Use nightlights in bathrooms and bedrooms
  10. Prevention: Regular Exercise (30 minutes, 4-5/week)
    1. Walking Program
    2. Exercise classes twice weekly reduces fall risk
      1. Day (2002) BMJ 325:128
      2. Lord (2003) J Am Geriatr Soc 51:1685
    3. Encourage balance-type activities
      1. Dance
      2. Tai-chi
        1. Does not appear to decrease fall risk
        2. Wolf (2003) J Am Geriatr Soc 51:1693
  11. References
    1. Rao (2005) Am Fam Physician 72:81
    2. Tinetti (2003) N Engl J Med 348:42

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