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Not all falls are

beautiful
BY: DR NI NI SHUHAI DA MAT HARUN
SUPERVI SOR: DR NUR SUHAI LA I DRI S
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Immobility and Falls in Elderly
PRE TESTS
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SBA Q1
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A mildly demented 69 year-old male presents after
falling. He sustained no apparent injuries and his
mental status is unchanged. Which of the following
are routine tests that should be ordered in patients
that fall?
A. Head CT scan
B. Hemoglobin
C. Hip X- ray
D. No routine testing ()
Q2
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Which is the following is a normal change in gait that
is associated with aging?
A. Loss of arm swing
B. Widening of the base
C. Decreased stride length ()
D. Variable step length and height
Q3
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Which of the following medications is associated
with highest risk for falls in the elderly?
A. Pseudoephidrine
B. Lorazepam ()
C. Fludrocortisone
D. Bupropion
Q4
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An 80 year-old male who lives with his daughter and
family presents for evaluation after a fall. He has
mild dementia and a history of hypertension. He is
taking lorazepam prn and hydrochlorothiazide.
Other than a nontender contusion on his arm, his
physical examination is normal. Regarding
evaluation of fall,
A. Exercise is beneficial in preventing falls. (T)
B. Restraints decrease the number of falls. (F)
C. Use of psychotropic medications is associated with falling.
(T)
D. Environmental assessment can help prevent falls. (T)
Overview
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Introduction
Epidemiology
Risk factors
Assessment
Management
Prevention
I NTRODUCTI ON
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Immobility
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Common in elderly
Never normal
Often treatable if causes identified
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Complication: (within days)
CVS
Fluid shift, decreased CO, decreased peak O2 uptake, increase
resting HR
Muskuloskeletal
Loss of contractile velocity and strength
others:
Pressure sore, DVT, Pulm embolism,
Postural hypotension, falls, skin breakdown
Recovery: weeks to months
Prevention
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Avoid pressure sore:
Frequent inspection at pressure points and shift position at least every
2hours
Minimize CVS deconditioning:
Position pt as close to upright position as possible, several times daily
Reduced muscle contracture and weakness
ROM and strengthening exercise started immediately after
immobilization and continued as long as pt in bed
Antithrombotic measures
Avoid restraints
Discontinue invasive devices
Gradual ambulation
Advice from physical therapist: appropriate exercise, assistive
devices, safety modification & maintenance exercises

Falls
Leading cause of nonfatal injuries in elderly
Complications are the leading cause of death from
injury in elderly
Hip fractures are common precursors to
Functional impairment
Nursing home placement
Death
Fear of falling restrict activities
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Epidemiology
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2009- total elderly in Malaysia :- 2.02 billion
2010 (up to Sept) increase to 2.13 billion
Jabatan Statistik Negara
out of 3 adults age 65 falls every year
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Hausdorff JM,Rios DA,Edelber HK.Gait variability and fall risk in community-living older
adults:a 1-year prospective study. Archives of Physical Medicine and Rehabilitation
2001;82(8):1050-6

30% of people who fall suffer moderate to severe
injuries.
TBI accounted for 46% of fatal falls
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Honbrook MC et al.Preventing falls among community-dwelling older persons:results from a
randomized trial.The Gerontologist 1994:34(1):16-23



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Adults over 65:
1 in 3 fall every year
Archives of Physical Medicine and Rehabilitation, 2001
Falls are the leading cause of injury and death
9% of falls lead to ED visit
2.1 million nonfatal fall related injuries treated in ED in 2008 with more
than 500,000 hospital admissions
5-6% lead to fracture
Journal of Bone and Mineral Research, 2003
18,000 fall related deaths in 2007
46% related to TBI
Adults over 75:
4-5 times more likely to be admitted to long term care for a year or more
Age and Ageing, 1999
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Falls have significant consequences
20% -30% of people sustain lacerations, fractures or head
trauma
These injuries can decrease mobility and independence
American Journal of Public Health, 1992
Journal of TraumaInjury, Infection and Critical Care, 2001
Older adults who have falls without injuries may develop fear
of falling
Activities self-limited leading to decreased fitness and actually
increasing risk of falling
Age and Ageing, 1997
50% of community dwellers never return to pre-fall status
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Falls have tremendous cost implications
Among community-dwelling older adults, fall-related injury is
one of the 20 most expensive medical conditions
Journal of Managed Care Pharmacy, 2005
In 2000, the total direct medical costs of all fall related injuries
for older adults exceeded $19 billion
$0.2 billion for fatal falls
$19 billion for nonfatal falls
Injury Prevention, 2006
By 2020, the annual direct and indirect cost of fall injuries is
expected to reach $54.9 billion (in 2007 dollars)
The Gerontologist, 1994
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Most fractures are caused by falls (spine, hip,
forearm, ankle, pelvis and hand)
Many people who fall but not injured develop fear of
falling- limit their activities, reduce mobility and loss
of physical illness.

Bell AJ,Talbot-Stern JK,Hennessy A.Characteristic and outcomes of older patients presenting to the
emergency department after a fall:aretrospective analysis.medical Journal of Australia
2000;173(4):176-7


Impact of Hip Fractures
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1% of falls result in hip fracture
25% die within 6 months
60% have restricted mobility
25% remain functionally more dependent


RI SK FACTORS
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Che Hassans story
Che Hassan 72 years old, widowed, living alone
His daughter lives nearby, but work full time.
Has history of hypertension, DM, BPH,
osteoarthritis of the knees.
He takes multiple medications to manage his
medical conditions, but didnt bring these with
him today
He complaining of increased urinary frequency
and feeling bored.
You note bent glasses frames and a small abrasion
on his forehead and right arm

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What risk factors does Che Hassan have for falls?

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What risk factors does Che Hassan have for
falls?
widowed, living alone
hypertension, DM, BPH, osteoarthritis of the
knees.
multiple medications
increased urinary frequency

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Risk factors for falls
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Intrinsic
Age and age-related physiologic changes
Acute illness
Chronic illness
Mobility factors-gait disturbance, balance disorder
or weakness, pain related to arthritis

Extrinsic
Environmental factors
Use of ambulatory assistive device
Mechanical restraints
Normal aging changes
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Neurologic
postural instability
slowed reaction time
diminished sensory awareness for light touch, vibration
and temperature
decline of central integration of visual, vestibular and
proprioceptive senses
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Vision Changes
decline in visual acuity
decline in accommodative capacity
glare intolerance
altered depth perception
presbyopia [near vision]
decreased night vision
decline in peripheral vision
Normal changes of gait
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Gait
Slower gait
Decreased stride length and arm swing
Forward flexion at head and torso
Increased flexion at shoulders and knees
Increased lateral sway

Che Hassans story continue
On examination, thin elderly man wearing glasses with
bent frames.
Afebrile BP: 135/80 - sitting
BP: 130/85 standing
PR : 80 regular rhythm
Early cataract in right eye
Systemic review unremarkable except for suprapubic area
tenderness
Urinalysis numerous WBC and bacteria
You treat his UTI and ask him to return in a week time for a
review of medications and proper neurological
examination.
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Is the UTI significant with regard to Che Hassans
falls?
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Story continue..
Che Hassan returns feeling better and his urinary
symptoms improved. You further ask about the fall history,
but Che Hassan reluctantly admits that he fell a week ago
in his house and that was not the 1
st
time. He has fallen
more than seven times.

I just trip over my own feet and sometimes fall backward

He doesnt want his daughter to know about the falls,
because he would like to continue to live on his own and
does not wish to be dependent on her.

He admits to limiting a lot of the activities he used to enjoy
because he was sure he would fall.
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Continue....
He brought a large bag of medications that include
metochlorpramide, acetaminophen, metoprolol,
HCTZ, terazosin, gliclazide.

O/E:-cranial nerve intact. Strength normal

Sensory: decreased sensation on light touch and
vibration on both lower extremities.

Slow gait. Difficulty rising without use of his arm.
Arthritic changes both knees.

MMSE-29/30
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Based on this evaluation, what further risk factors
does Che Hassan have for falls?
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Intrinsic factors Extrinsic factors
Increasing age
Female
Previous fall
Visual impairment
Urinary incontinence
Functional limitations
Decreased physical activity
Gait and balance disorders
Arthritis
Cognitive Impairment
Depression
Muscle weakness
Orthostasis
Poly-pharmarcy (>4 meds)
Psychotropic meds most problematic
Alcohol
Improper footwear
Inadequate lighting
Improper floor surfaces
Wet/slippery
Loose rugs/carpets
Uneven flooring
Inappropriate / inadequate
assistive devices
Grab bars, walker/cane
Improper seat or bed height
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New England Journal of Medicine, 2003
Journal of the American Geriatrics Society, 2001
ASSESSMENT OF FALLS
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Essential components of fall history
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S symptoms
P previous fall or near fall
L location of fall
A activity at time of fall
T time of fall
T trauma, both physical and psychological
Drugs that may increase risk of falling
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Polypharmacy
Sedative-hypnotics
Antidepressant (TCA,SSRI)
Antihypertensive agent
Cardiac medications
Anticholinergic drugs
Hypoglycaemic agent
Antiparkinsonian medications
Topical eye medications
Evaluation of Falls: Physical Examination
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Supine and standing BP - always
Routine physical examination
Focus on cardiovascular, MS, neuro, feet
Vision and hearing evaluation
Consider acute medical illness & delirium
Formal gait and balance assessment

Common Causes of Abnormal Gait
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Difficulty arising from chair
Weakness
Arthritis
Instability on first standing
Hypotension
Weakness
Instability with eyes closed
Proprioception
Step height/length
Parkinsonism
Frontal lobe
Fear

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Get up and go test
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ONLY VALID FOR PATIENTS NOT USING AN
ASSISTIVE DEVICE
Get up and walk 10ft (3m), and return to chair

Seconds Rating
<10 freely mobile
<20 mostly independent
20-29 variable mobility
>30 assisted mobility


Mathias S, Nayak US, Isaacs B. Balance in elderly patients: the Get-up and Go test. Arch phys
Med Rehabil. 1986; 67(6): 387-389.

Get up and go test
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Sensitivity 88%
Specificity 94%
Time to complete <1min.
Requires no special equipment


Cassel, C. Geriatric Medicine: An Evidence-Based Approach, 4
th

edition, Instruments to Assess Functional Status, p. 186.


Balance test
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(1) side-by-side: feet side by side, touching

(2) semi-tandem: side of the heel of one foot
touching the big toe of the other

(3) tandem: heel of one foot directly in front of and
touching the toes of the other foot.

Each stance is progressively more difficult to hold
People unable to hold a position for 10 seconds are
not asked to attempt further stand
Intrinsic :
Aging, poor balance
Occurrence of falls
Fall Outcomes


No injuries
Contributing
factors
Extrinsic :
Home hazards
Loss of
Confidence
Fractures
Soft tissues
injures,
trauma
Disability,
reduced
quality of life
Mechanisms of Fall
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Continue....
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You recommend discontinuation of
metochlopramide and refer for physical therapy and
ophthalmology evaluation.

In discusion with the daughter, she agree to have
family members visit more frequently and to assist
with patients medication changes.
6 weeks later
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He walk with cane, and with new eyeglasses, with
plan to follow up on his cataract.
He states that he more confident with walking and
steadier on his feet.
In fact he has no falls in the time since your last visit.
He been able to do more activities at home and
community.
Complication of immobility
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Physical:-
Muscle wasting
Contractures
Osteoporosis
Pressure sores
Aspiration pneumonia
Constipation
Urinary tract infection
Deep vein thrombosis
Complication of immobility
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Psychological and Social
Isolation
Loss of independence/confidence
Sensory deprivation
Depression
Anxiety


MANAGEMENT
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Critical Steps in Reducing the Risk of Falls in the
Elderly
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- Treat acute injury and underlying medical condition,
modify medication, provide balance training
- Eliminate environmental hazards- environmental
modification and safety.
- Provide opportunities for socialization and
encouragement
- Involve the family.
- Provide follow-up .

Falls and injuries in frail and vigorous community elderly persons. J Am
Geriatr Soc 1991;39:46-52.

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Risk factors Interventions
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Postural hypotension:-
Behavioral recommendations, such as ankle pumps or
hand clenching and elevation of the head of the bed
Decrease in the dosage of a medication that may contribute
to hypotension; if necessary, discontinuation of the drug or
substitution of another medication

Review of medications
Education about appropriate use of sedative-hypnotic
drugs
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Any impairment in gait- Gait training
Use of an appropriate assistive device
Balance or strengthening exercises if indicated

Environmental hazards for falling or tripping. Home safety
assessment with appropriate changes



A multifactorial intervention to reduce the risk of falling among elderly people living in
the community. N Engl J Med 1994;331:821-7.


Evaluation of Falls: Home Evaluation
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Can be performed by nurse, OT, PT, others
Stairs
Lighting
Clutter
Bathroom
Specific hazards: cords, throw rugs

PREVENTI ON
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Home Safety Checklist
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All living spaces
_____ Remove throw rugs.
_____ Secure carpet edges.
_____ Remove low furniture and objects on the floor.
_____ Reduce clutter.
_____ Remove cords and wires on the floor.
_____ Check lighting for adequate illumination at night (especially in the
pathway to the bathroom).
_____ Secure carpet or treads on stairs.
_____ Install handrails on staircases.
_____ Eliminate chairs that are too low to sit in and get out of easily.
_____ Avoid floor wax (or use nonskid wax).
_____ Ensure that the telephone can be reached from the floor.
Bathrooms
_____ Install grab bars in the bathtub or shower and by the toilet.
_____ Use rubber mats in the bathtub or shower.
_____ Take up floor mats when the bathtub or shower is not in use.
_____ Install a raised toilet seat.
Outdoors
_____ Repair cracked sidewalks.
_____ Install handrails on stairs and steps.
_____ Trim shrubbery along the pathway to the home.
_____ Install adequate lighting by doorways and along walkways leading to
doors.


Falls. In: Yoshikawa TT, Cobbs EL, Brummel-Smith K, eds. Ambulatory geriatric care. St. Louis:
Mosby, 1993:296-304.
Illumination
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Sufficient lighting- esp at bathroom,stairways
Provide illuminated light switches
Place nightlines along the pathway from the
bedroom to the bathroom
Avoid lighting glare

Floor surfaces
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Provide nonskid floor
Avoid waxing kitchen floor
Cover slippery surfaces with nonskid carpeting
Replace throw rugs with nonskid rugs
Clean wet floors immediately
Avoid clutter and low lying object
Avoid thick pile carpets to minimize tripping
Ensure that loose lamp and telephone cords are not
in walkways
Ensure that carpet edges are flat
Furnishings
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Provide seating of proper height to permit safe
sitting and standing
Provide beds that permit safe movement
Arrange furniture to allow for clear walkways
Stairways
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Ensure that stairways have secure handrails
Mark step edges with bright, nonskip tape
Ensure that step surfaces are in good repair and
nonskid

Bathroom
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Install grab bar
Use toilet risers if the toilet seat is too low
Place nonskid strips or mats in the bathtub to
prevent slipping
Install grab bars in the bathtub or shower for
support

Other
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Avoid restraints ( chemical or mechanical)
Ensure that ambulatory assistive devices and
wheelchairs are properly fitted
POST TEST
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Post test
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Which of the following is not an environmental risk
factor for falls?
A. Throw rug (T)
B. Freshly waxed kitchen floor (T)
C. Grab bars (F)
D. Electrical cord lying on the floor (T)
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An elderly person may become so fearful of falling
that they restrict mobility
A. True ()
B. False
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An 86y/o woman on 12 medications with a history of
hypertension, mild dementia and painful bunions
could potentially reduce her risk of falling with which
of the following?
A. Reduction in number of medications (T)
B. An exercise program focused on balance and
strength (T)
C. A prescription for setraline (F)
D. Podiatry evaluation (F)
TAKE HOME MESSAGES
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Take Home message: 7-steps
1. Falls in the elderly are a marker for acute medical event, therefore one has to be
aware of multifactorial risk factors for falling. Investigate for infections,
medication side-effects, and metabolic problems. Falls associated with loss of
consciousness (syncope) suggests cardiovascular etiology.
2. Evaluate role of medication adjustment or withdrawal and side-effects in
people who fall. (CNS, Cardiovascular, warfarin and INR)
3. Meticulous history with structured assessment of gait and balance, orthostatic
hypotension, muscle strength, vision and hearing is essential. Check Rombergs, Timed
get up & Go test, Functional reach.
4. Home/Environmental safety assessment should be done with consideration for
assistive devices.
5. Interventions for strength and balance training can decrease the risk of
falling. Timely Physical and Occupational therapy may help.
6. Osteoporosis prevention and use of protective devices (hip protectors) reduce
fractures, particularly hip. Calcium and Vitamin D supplementation for all.
7. Understand the significance of fear of falling in the older adults and its impact on
mobility and functional status, hence counseling and encouragement of
activity and routine exercise is desirable.
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