10 - Immobility
Editors: Kane, Robert L.; Ouslander, Joseph G.; Abrass, Itamar B.
Title: Essentials of Clinical Geriatrics, 5th Edition
Copyright 2004 McGraw-Hill
> Table of Contents > Part II - Differential Diagnosis and Management > Chapter 9 - Instability and Falls
Chapter 9
Instability and Falls
Falls are among the major causes of morbidity in the geriatric population. Falling is not only a problem in its own right; it is often a marker for frailty, and falls may be predictors of death as well as indirect causes (usually through fractures). Close to one-third of those aged 65 years and older living at home suffer a fall each year, and about 1 in 40 of those will be hospitalized. Only about half of the elderly patients hospitalized as the result of a fall will be alive a year later. Among geriatric nursing homes residents, as many as half suffer a fall each year; 10 to 25 percent have serious consequences. Accidents are the fifth leading cause of death in persons older than age 65, and falls account for two-thirds of these accidental deaths. Of deaths from falls in the United States, more than 70 percent occur in the 11 percent of the population older than age 65. However, it may be difficult to separate the effects of the accident from the underlying frailty that led to it. Fear of falling can adversely affect older persons' functional status. Repeated falls and consequent injuries can be important factors in the decision to institutionalize an elderly person.
Table 9-1 lists potential complications of falls. Fractures of the hip, femur, humerus, wrist, and ribs, and painful soft-tissue injuries are the most frequent physical complications. Many of these injuries will result in hospitalization, with the attendant risks of immobilization and iatrogenic illnesses (see Chaps. 5 and 10). Fractures of the hip and lower extremities often lead to prolonged disability because of impaired mobility. A less-common, but important, injury is subdural hematoma. Neurological symptoms and signs that develop days to weeks after a fall should prompt consideration of this treatable problem.
TABLE 9-1 COMPLICATIONS OF FALLS IN ELDERLY PATIENTS | |
|---|---|
|
Even when the fall does not result in serious injury, substantial disability may result from fear of falling, loss of self-confidence, and restricted ambulation (either self-imposed or imposed by caregivers).
Falls and their attendant complications should be preventable, but it is easier to identify risk factors for falling than to prevent its occurrence. A growing body of studies suggests that at least some types of falls can be prevented. Moreover, it is possible to prevent the untoward consequences of falls (i.e., fractures) by changing the way old people fall. The potential for prevention together with the use of falling as an indicator of underlying frailty combine to make an
P.220
understanding of the causes of falls and a practical approach to the evaluation and management of patients with instability and falls important components of geriatric care. Similar to many other conditions described throughout this text, the factors that can contribute to or cause falls are multiple, and very often more than one of these factors plays an important role (Fig. 9-1).
 |
FIGURE 9-1 Multifactorial causes and potential contributors to falls in older persons. |
Falling may be a useful indicator of frailty in general. Persons with a history of falling have higher levels of subsequent health care use and poor functional status. Fallers who were thoroughly assessed showed a benefit in functional outcomes over those who were not, even when the cause of the fall could not be determined or treated.
AGING AND INSTABILITY
Several age-related factors contribute to instability and falls (Table 9-2). Most accidental falls are caused by one or a combination of these factors interacting with environmental hazards.
TABLE 9-2 AGE-RELATED FACTORS CONTRIBUTING TO INSTABILITY AND FALLS | |
|---|---|
|
Aging changes in postural control and gait probably play a major role in many falls among older persons. Increasing age is associated with diminished proprioceptive
P.221
input, slower righting reflexes, diminished strength of muscles important in maintaining posture, and increased postural sway. All these changes can contribute to falling especially the ability to avoid a fall after encountering an environmental hazard or an unexpected trip. Changes in gait also occur with increasing age. Although these changes may not be sufficiently prominent to be labeled truly pathological, they can increase susceptibility to falls. In general, elderly people do not pick their feet up as high, thus increasing the tendency to trip. Elderly men develop wide-based, short-stepped gaits; elderly women often walk with a narrow-based, waddling gait. Orthostatic hypotension (defined as a drop in systolic blood pressure of 20 mm Hg or more when moving from a lying to a standing position) occurs in approximately 20 percent of older persons. Although not all elderly individuals with orthostatic hypotension are symptomatic, this impaired physiological response could play a role in causing instability and precipitating falls in a substantial proportion of patients. Older people have been shown to experience a postprandial fall in blood pressure as well.
Several pathological conditions that increase in prevalence with increasing age can contribute to instability and falling. Degenerative joint disease (especially of the neck, the lumbosacral spine, and the lower extremities) can cause pain, unstable joints, muscle weakness, and neurological disturbances. Healed fractures of the hip and femur can cause an abnormal and less steady gait. Residual muscle weakness or sensory deficits from a recent or remote stroke can cause instability.
Muscle weakness as a result of disuse and deconditioning (caused by pain and/or lack of exercise) can contribute to an unsteady gait and impair the ability
P.222
to right oneself after a loss of balance. Diminished sensory input, such as in diabetic and other peripheral neuropathies, visual disturbances, and impaired hearing diminish cues from the environment that normally contribute to stability and thus predispose one to falls. Impaired cognitive function may result in the creation of, or wandering into, unsafe environments and may lead to falls. Podiatric problems (bunions, calluses, nail disease, joint deformities, etc.) that cause pain, deformities, and alterations in gait are common, correctable causes of instability. Other specific disease processes common in older people (such as Parkinson's disease and cardiovascular disorders) can cause instability and falls and are discussed further below.
P.223
Inability to get up after a fall can be an indication of a poor prognosis. In one study almost half those who fell at least once reported being unable to get up. These older persons had poorer functional outcomes.
CAUSES OF FALLS IN OLDER PERSONS
Table 9-3 outlines the multiple and often interacting causes of falls among older persons. More than half of all falls are related to medically diagnosed conditions, emphasizing the importance of a careful medical assessment for patients who fall (see below). Several studies have examined risk factors for falls among older persons and have found a variety of these factors including cognitive impairment, disabilities of the lower extremities, gait and balance abnormalities, nocturia, and the number and nature of medications being taken as important risk factors. Frequently overlooked, environmental factors can increase susceptibility to falls and other accidents. Homes of elderly people are often full of environmental hazards (Table 9-4). Unstable furniture, rickety stairs with inadequate railings, throw rugs and frayed carpets, and poor lighting should be specifically looked for on home visits. Several factors are associated with falls among older nursing home residents (Table 9-5). Awareness of these factors can help prevent morbidity and mortality in these settings. Although attention to the environment makes sense, the role of environmental hazards may be overemphasized (Gill et al., 2000).
TABLE 9-3 CAUSES OF FALLS | |
|---|---|
|
TABLE 9-4 COMMON ENVIRONMENTAL HAZARDS | |
|---|---|
|
TABLE 9-5 FACTORS ASSOCIATED WITH FALLS AMONG OLDER NURSING HOME RESIDENTS | |
|---|---|
|
Several factors can hinder precise identification of the specific causes for falls. These factors include lack of witnesses, inability of the elderly person to recall the circumstances surrounding the event, the transient nature of several causes [e.g., arrhythmia, transient ischemic attack (TIA), postural hypotension], and the fact that the majority of elderly people who fall do not seek medical attention. Somewhat more detailed information is available on the circumstances surrounding falls in nursing homes (see Table 9-5), but these individuals represent a relatively low proportion and a highly select group among the total senior population.
Close to half of all falls can be classified as accidental. Usually an accidental trip or a slip can be precipitated by an environmental hazard, often in conjunction with factors listed in Table 9-2. Addressing the environmental hazards begins with a careful assessment of the patient's environment. Some older persons have developed a strong attachment to their cluttered surroundings and may need active encouragement to make the necessary changes, but many may simply take such environmental risks for granted until they are specifically identified.
Syncope, drop attacks, and dizziness are commonly cited causes of falls in elderly persons. Indeed, dizziness has been nominated as a possible geriatric syndrome, worthy of fuller exploration (Tinetti et al., 2000). If there is a clear history of loss of consciousness, a cause for true syncope should be sought. Although the complete differential diagnosis of syncope is beyond the scope of
P.224
P.225
this chapter, some of the more common causes of syncope in older people include vasovagal responses, cardiovascular disorders (such as brady- and tachyarrhythmias and aortic stenosis), acute neurological events (such as TIA, stroke, and seizure), pulmonary embolus, and metabolic disturbances (e.g., hypoxia, hypoglycemia). Cardiovascular causes for syncope are more common in the elderly than in younger populations. A precise cause for syncope may remain unidentified in 40 to 60 percent of elderly patients.
P.226
Drop attacks, described as sudden leg weakness causing a fall without loss of consciousness, are probably overdiagnosed in elderly people who fall. They are often attributed to vertebrobasilar insufficiency, frequently precipitated by a change in head position. Only a small proportion of older people who fall have truly had a drop attack. The underlying pathophysiology is poorly understood, and care should be taken to rule out other causes.
Dizziness and unsteadiness are extremely common complaints among elderly people who fall (as well as those who do not). A feeling of light-headedness can be associated with several different disorders, but is a nonspecific symptom and should be interpreted with caution. Patients complaining of light-headedness should be carefully evaluated for postural hypotension and intravascular volume depletion.
Vertigo (a sensation of rotational movement), on the other hand, is a more specific symptom and is probably an uncommon precipitant of falls in the elderly. It is most commonly associated with disorders of the inner ear, such as acute labyrinthitis, M ni re's disease, and benign positional vertigo. Vertebrobasilar ischemia and infarction and cerebellar infarction can also cause vertigo. Patients with vertigo caused by organic disorders often have nystagmus, which can be observed by having the patient quickly lie down and turning the patient's head to the side in one motion. Many older patients with symptoms of dizziness and unsteadiness are anxious, depressed, and chronically afraid of falling, and the evaluation of their symptoms is quite difficult. Some patients, especially those with symptoms suggestive of vertigo, will benefit from a thorough otological examination including auditory testing, which may help clarify the symptoms and differentiate inner-ear from central nervous system (CNS) involvement.
Orthostatic hypotension is best detected by taking the blood pressure and pulse in supine position, after 1 minute in the sitting position, and after 1 and 3 minutes in the standing position. A drop of more than 20 mm Hg in systolic blood pressure is generally considered to represent significant orthostatic hypotension. In many instances, this condition is asymptomatic; however, several conditions can cause orthostatic hypotension or worsen it to a severity sufficient to precipitate a fall.
These conditions include low cardiac output from heart failure or hypovolemia, autonomic dysfunction (which can result from diabetes or Parkinson's disease), impaired venous return (e.g., venous insufficiency), prolonged bed rest with deconditioning of muscles and reflexes, and several different drugs. Simply eating a full meal can precipitate a reduction in blood pressure in an older person that may be worsened and precipitate a fall when the person stands up. The association of orthostatic hypotension with elevated blood pressure but not with the use of antihypertensive medication suggests that treatment of hypertension may improve this condition.
Drugs that should be suspected of playing a role in falls include diuretics (hypovolemia), antihypertensives (hypotension), tricyclic antidepressants (postural
P.227
hypotension), sedatives (excessive sedation), antipsychotics (sedation, muscle rigidity, postural hypotension), hypoglycemics (acute hypoglycemia), and alcohol (intoxication). Combinations of these drug types may greatly increase the risk of a fall. Psychotropic drugs are commonly prescribed and appear to substantially increase the risk of falls and hip fractures, especially in patients prescribed tricyclic antidepressants.
Many disease processes, especially of the cardiovascular and neurological systems, can be associated with falls. Cardiac arrhythmias are common in ambulatory elderly persons and may be difficult to associate directly with a fall or syncope. In general, cardiac monitoring should document a temporal association between a specific arrhythmia and symptoms (or a fall) before the arrhythmia is diagnosed (and treated) as the cause of falls.
Syncope can be a symptom of aortic stenosis and is an indication of the need to evaluate a patient suspected of having significant aortic stenosis for valve replacement. Aortic stenosis is difficult to diagnose by physical examination alone, and all patients suspected of having this condition should have an echocardiogram.
Some elderly individuals have sensitive carotid baroreceptors and are susceptible to syncope resulting from reflex increase in vagal tone (caused by cough, straining at stool, micturition, etc.), which leads to bradycardia and hypotension. Carotid sinus sensitivity can be detected by bedside maneuvers (see below).
Cerebrovascular disease is often implicated as a cause or contributing factor for falls in older patients. Although cerebral blood flow and cerebrovascular autoregulation may be diminished, these aging changes alone are not enough to cause unsteadiness or falls. They may, however, render the elderly person more susceptible to stresses such as diminished cardiac output, which will more easily precipitate symptoms. Acute strokes (caused by thrombosis, hemorrhage, or embolus) can cause and may initially manifest themselves in falls. TIAs of both the anterior and posterior circulations frequently last only minutes and are often poorly described. Thus, care must be taken in making these diagnoses. Anterior circulation TIAs may cause unilateral weakness and thus precipitate a fall. Vertebrobasilar (posterior circulation) TIAs may cause vertigo, but a history of transient vertigo alone is not a sufficient basis for the diagnosis of a TIA. The diagnosis of posterior circulation TIA necessitates that one or more other symptoms (visual field cuts, dysarthria, ataxia, or limb weakness which can be bilateral) be associated with vertigo. Vertebrobasilar insufficiency, as mentioned above, is often cited as a cause of drop attacks; in addition, mechanical compression of the vertebral arteries by osteophytes of the cervical spine when the head is turned has also been proposed as a cause of unsteadiness and falling. Both of these conditions are poorly documented, are probably overdiagnosed, and should not be used as causes of a fall simply because nothing else can be found.
Other diseases of the brain and central nervous system can also cause falls. Parkinson's disease and normal-pressure hydrocephalus can cause disturbances of gait, which lead to instability and falls. Cerebellar disorders, intracranial
P.228
tumors, and subdural hematomas can cause unsteadiness, with a tendency to fall. A slowly progressive gait disability with a tendency to fall, especially in the presence of spasticity or hyperactive reflexes in the lower extremities, should prompt consideration of cervical spondylosis and spinal cord compression. It is especially important to consider these diagnoses because treatment may improve the condition before permanent disability ensues.
Despite this long list, the precise causes of many falls will remain unknown even after a thorough evaluation. The ultimate test of the etiology for falls is its reversibility. As noted earlier, we are better at finding putative causes than in correcting them.
EVIDENCE ON FALLS PREVENTION
The intense effort to identify risk factors for falls has been matched more recently with interventive efforts. A recent meta-analysis concluded that there was evidence that interventions could prevent the rate of falls, but the cost-effectiveness of falls prevention still remains unclear (RAND, 2002). Table 9-6 summarizes some of the findings from these studies. In general, they suggest that it is possible to reduce the rate of falling, but not the rate of injurious falls. Despite this mixed message, there is growing enthusiasm for undertaking preventive efforts. Moreover, good clinical sense still dictates active efforts to identify remediable risk factors. A randomized trial showed that targeted intervention to reduce the rate of falls did lower the overall rate (as compared with a control group) but there was no significant difference in the rate of serious falls. A meta-analysis of the several studies conducted under the auspices of the Frailty and Injuries: Cooperative Studies of Intervention Techniques (FICSIT) trials showed only modest results. In only two cases did an intervention lead to a significant reduction in falls; exercise and balance were associated with fewer falls, but not with falls with injuries. Tai Chi training was shown to increase the time to a fall but not to a serious fall compared with an educational control group. When a specific fall prevention program was compared with a more general chronic disease prevention program, the falls program achieved lower rates of falls and serious falls at the end of the first year, but by year 2, the differences disappeared. A New Zealand study showed that elderly patients could be taught at home to perform exercises that reduced the rate of falls. A fact to remember when interpreting the effect of exercise in falls prevention is that exercise needs to be sustained, probably for at least 6 months. The dropout rate for many of these exercise programs is quite high (approximately one-third to one-half of participants), suggesting that at least part of the problem in demonstrating an effect may lie in maintaining the intervention.
TABLE 9-6 SUMMARY OF FALLS INTERVENTION STUDIES | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
A successful multifactorial approach to reducing falls among nursing home patients employed training in environmental and personal safety, wheelchair use,
P.229
P.230
psychotropic drug management, and transferring and ambulation. Although not immediately connected to reducing fall risks, a study directed at frail nursing home patients showed that moderate exercise improved gait and stair-climbing ability. A multifactorial intervention study among residential care facility residents, which combined staff education with environmental modifications, attention to drug regimens, and exercise programs, reduced the rate of falls
P.231
significantly. If the falls per se cannot be prevented, the risk of fractures can be reduced by having those at high risk wear external hip protectors (Kannus et al., 2000; Parker, 2001).
Studies of instructional environments suggest that carpeted floors are associated with fewer falls than vinyl floors (Healey, 1994). Likewise, the use of bed alarms is associated with a reduction in the fall rate among hospitalized patients (Tideiksaar et al., 1993). Although many people think of physical restraints as a means of preventing falls, the evidence points in the opposite direction.
EVALUATING THE ELDERLY PATIENT WHO FALLS
Older patients who report a fall (or recurrent falls) that is not clearly the result of an accidental trip or slip should be carefully evaluated, even if the falls have not resulted in serious physical injury. A jointly developed set of recommendations for assessing people who fall has been issued by the American Geriatrics Society, The British Geriatrics Society, and the American Academy of Orthopaedic Surgeons (American Geriatrics Society et al., 2001). Table 9-7 lists the hallmarks of these recommendations. An example of an assessment from for older patients who fall is included in the Appendix. A thorough fall evaluation consists of a detailed history, physical examination, gait and balance assessment, and, in certain instances, selected laboratory studies.
TABLE 9-7 RECOMMENDATIONS FOR FALLS ASSESSMENT | |||
|---|---|---|---|
| |||
P.232
The history should focus on the general medical history and medications, the patient's thoughts about what caused the fall, the circumstances surrounding it, any premonitory or associated symptoms (such as palpitations caused by a transient arrhythmia or focal neurological symptoms caused by a TIA), and whether there was loss of consciousness (Table 9-8). A history of loss of consciousness after the fall (which is often difficult to document) is important information and should raise the suspicion of a cardiac event (transient arrhythmia or heart block) or a seizure (especially if there has been incontinence). Falls are often unwitnessed, and elderly patients may not recall any details of the circumstances surrounding the event. Detailed questioning can sometimes lead to identification of environmental factors that may have played a role in the fall and to symptoms that may lead to a specific diagnosis. Many elderly patients will not be able to give details about an unwitnessed fall and will simply report, I just fell down, I don't
P.233
know what happened. The skin, extremities, and painful soft-tissue areas should be assessed to detect any injury that may have resulted from a fall.
TABLE 9-8 EVALUATING THE ELDERLY PATIENT WHO FALLS: KEY POINTS IN THE HISTORY | |
|---|---|
|
Several other aspects of the physical examination can be helpful in determining the cause(s) (Table 9-9). Because a fall can herald the onset of a variety of acute illnesses ( premonitory falls), careful attention should be given to vital signs. Fever, tachypnea, tachycardia, and hypotension should prompt a search for an acute illness (such as pneumonia or sepsis, myocardial infarction, pulmonary embolus, or gastrointestinal bleeding). Postural blood pressure and pulse determinations taken supine, sitting, and standing (after 1 and 3 minutes) are critical in the diagnosis and management of falls in older patients. As noted earlier, postural hypotension occurs in a substantial number of healthy, asymptomatic elderly persons as well as in those who are deconditioned from immobility or have venous insufficiency. This finding can also be a sign of dehydration, acute blood loss (occult gastrointestinal bleeding), or a drug side effect. Visual acuity should be assessed for any possible contribution to instability and falls. The cardiovascular examination should focus on the presence of arrhythmias (many of which are easily missed during a brief examination) and signs of aortic stenosis. Because both of these conditions are potentially serious and treatable, yet difficult to diagnose by physical examination, the patient should be referred for continuous monitoring and echocardiography if they are suspected. If the history suggests carotid sinus sensitivity, the carotid can be gently massaged for 5 seconds to observe whether this precipitates a profound bradycardia (50 percent reduction in heart rate) or a long pause (2 seconds). The extremities should be examined for evidence of deformities, limits to range of motion, or active inflammation that might underlie instability and cause a fall.
TABLE 9-9 EVALUATING THE ELDERLY PATIENT WHO FALLS: KEY ASPECTS OF THE PHYSICAL EXAMINATION | |
|---|---|
|
Special attention should be given to the feet because deformities, painful lesions (calluses, bunions, ulcers), and poorly fitted, inappropriate, or worn-out shoes are common and can contribute to instability and falls.
Neurological examination is also an important aspect of this physical assessment. Mental status should be assessed (see Chap. 6), with a careful search for focal neurological signs. Evidence of muscle weakness, rigidity, or spasticity should be noted, and signs of peripheral neuropathy (especially posterior column signs such as loss of position or vibratory sensation) should be ruled out. Abnormalities in cerebellar function (especially heel-to-shin testing) and signs of Parkinson's disease (such as resting tremor, muscle rigidity, and bradykinesia) should be sought.
Gait and balance assessments are a critical component of the examination and are probably more useful in identifying remediable problems than is the standard neuromuscular exam. Although sophisticated techniques have been developed to assess gait and balance, careful observation of a series of maneuvers is the most practical and useful assessment technique. The get-up-and-go test and other practical performance-based balance and gait assessments have been developed. Tables 9-10 and 9-11 provide examples of these types of assessment. Abnormalities on these assessments may be helpful in identifying patients who
P.234
P.235
are likely to fall again and potentially remediable problems that might prevent future falls.
TABLE 9-10 EXAMPLE OF A PERFORMANCE- BASED ASSESSMENT OF GAIT | |||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| |||||||||||||||||||||||||||||||||||
TABLE 9-11 EXAMPLE OF A PERFORMANCE BASED-ASSESSMENT OF BALANCE | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
There is no specific laboratory workup for an elderly patient who falls. Laboratory studies should be ordered based on information gleaned from the history and physical examination. If the cause of the fall is obvious (such as a slip or a trip) and no suspicious symptoms or signs are detected, laboratory studies are unwarranted. If the history or physical examination (especially vital signs) suggests an acute illness, appropriate laboratory studies (such as complete blood count, electrolytes, blood urea nitrogen, chest films, electrocardiogram) should be ordered. If a transient arrhythmia or heart block is suspected, ambulatory electrocardiographic monitoring should be done. Although the sensitivity and specificity of this procedure for determining the cause of falls in the elderly is unknown, and many elderly people have asymptomatic ectopy, cardiac abnormalities detected on continuous monitoring that are clearly related to symptoms should be treated.
Because it is difficult to diagnose aortic stenosis on physical examination, echocardiography should be considered in all patients with suggestive histories and a systolic heart murmur or those who have a delay in the carotid upstroke. If the history suggests anterior circulation TIA, noninvasive vascular studies should be considered to rule out treatable vascular lesions. Computed tomography (CT) scans and electroencephalograms should be reserved for those patients in whom there is a high suspicion of an intracranial lesion or seizure disorder.
MANAGEMENT
Table 9-12 outlines the basic principles of managing elderly patients with instability problems and a history of falls. Assessment and treatment of physical injury should not be overlooked because it may be helpful in preventing recurrent falls.
TABLE 9-12 PRINCIPLES OF MANAGEMENT FOR ELDERLY PATIENTS WITH COMPLAINTS OF INSTABILITY AND/OR FALLS | |
|---|---|
|
When specific conditions are identified by history, physical examination, and laboratory studies, they should be treated in order to minimize the risk of subsequent falls, morbidity, and mortality. Table 9-13 lists examples of treatments for some of the more common conditions. This table is meant only as a general outline; most of these topics are discussed in detail in general textbooks of medicine.
TABLE 9-13 EXAMPLES OF TREATMENT FOR UNDERLYING CAUSES OF FALLS | ||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| ||||||||||||||||||||||||||||||||||||||||||||||||||
Physical therapy and patient education are important aspects of the management of these elderly patients. Gait training, muscle strengthening, the use of assistive devices, and adaptive behaviors (such as rising slowly, using rails or furniture for balance, and techniques of getting up after a fall) are all helpful in preventing subsequent morbidity from instability and falls.
Environmental manipulations can be critical in preventing further falls. The environments of the elderly are often unsafe (see Table 9-4), and appropriate interventions can often be instituted to improve safety (see Table 9-13). Physical restraints (vests, belts, mittens, geri-chairs, etc.) are commonly used in institutional settings for those felt to be at high risk of falling. Nursing home regulations
P.236
P.237
P.238
P.239
P.240
P.241
in the Omnibus Budget Reconciliation Act of 1987, and the increasing recognition that physical restraints probably do not decrease and may in fact increase falls and injuries (Tinetti et al., 1992; Neufeld et al., 1999), have led to the reduced and more appropriate use of these devices in many institutional settings.
The same multiorganization group noted earlier has also offered a series of recommendations on interventions. Table 9-14 summarizes these recommendations. Here, too, the scientific strength of the recommendations is limited.
TABLE 9-14 RECOMMENDED FALL INTERVENTIONS TO PREVENT FALLS | |||
|---|---|---|---|
| |||
P.242
References
American Geriatrics Society, British Geriatrics Society, American Academy of Orthopaedic Surgeons Panel on Falls Prevention: Guideline for the prevention of falls in older persons. J Am Geriatr Soc 49:664 672, 2001.
Buchner DM, Cress ME, deLateur BJ, et al. The effect of strength and endurance training on gait, balance, fall risk and health services use in community-living older adults. J Gerontol A Biol Sci Med Sci 52A:M218 M224, 1997.
Campbell AJ, Robertson MC, Gardener MM, et al: Randomised controlled trial of a general practice programme of home-based exercise to prevent falls in elderly women. BMJ 315:1065 1069, 1997.
Campbell AJ, Robertson MC, Gardner MM, et al: Falls prevention over 2 years: a randomised controlled trial in women 80 years and older. Age Ageing 28:513 518, 1999.
Close J, Ellis M, Hooper R, et al: Prevention of Falls in the Elderly Trial (PROFET): a randomized controlled trial. Lancet 353:93 97, 1999.
Cumming RG, Thomas M, Szonyi G, et al: Home visits by an occupational therapist for assessment and modification of environmental hazards: a randomized trial of falls prevention. J Am Geriatr Soc 47:1397 1402, 1999.
Fiatarone MA, O'Neill EF, Ryan ND, et al: Exercise training and nutritional supplementation for physical frailty in very elderly people. N Engl J Med 330:1769 1775, 1994.
Gill TM, Williams CS, Tinetti ME: Environmental hazards and the risk of nonsyncopal falls in the homes of community-living older persons. Med Care 38:1174 1183, 2000.
Healey F: Does flooring type affect risk of injury in older patients? Nursing Times 90:40 41, 1994.
P.243
Hornbrook MC, Stevens VJ, Wingfield DJ, et al: Preventing falls among community-dwelling older persons: results from a randomized trial. Gerontologist 34:16 23, 1994.
Jensen J, Lundin-Olsson L, Nyberg L, Gustafson Y. Fall and injury prevention in older people living in residential care facilities: a cluster randomized trial. Ann Intern Med 136:733 741, 2002.
Kannus P, Parkkari J, Niemi S, et al: Prevention of hip fracture in elderly people with use of a hip protector. N Engl J Med 343:1506 1513, 2000.
Lauritzen JB, Petersen MM, Lund B: Effect of external hip protectors on hip fractures. Lancet 341:11 13, 1993.
Mathias SN, Nayak USL, Isaacs B: Balance in elderly patients: the get up and go test. Arch Phys Med Rehabil 67:387 389, 1986.
McMurdo MET, Mole PA, Paterson CR: Controlled trial of weight-bearing exercise in older women in relation to bone density and falls. BMJ 314:569, 1997.
McMurdo ME, Millar AM, Daly F: A randomized controlled trial of fall prevention strategies in old peoples' homes. Gerontology 46(2):83 87, 2000.
Neufeld RR, Libow LS, Foley WJ, Dunbar JM, Cohen C, Breuer B: Restraint reduction reduces serious injuries among nursing home residents. J Am Geriatr Soc 47:1202 1207, 1999.
Parker MJ, Gillespie LD, Gillespie WJ: Hip protectors for preventing hip fractures in the elderly (Cochrane Review): Oxford (update http://www.software.com): The Cochrane Library, 2001, Issue 2, 2001.
Province MA, Hadley EC, Hornbrook MC, et al: The effects of exercise on falls in elderly patients: a preplanned meta-analysis of the FICSIT trials. JAMA 273:1341 1347, 1995.
RAND: Falls prevention interventions in the Medicare population. Contract No. 500 98 0281. Prepared for the Centers for Medicare and Medicaid Services. Santa Monica, CA, RAND, 2002.
Ray WA, Taylor JA, Meador KG, et al: A randomized trial of a consultation service to reduce falls in nursing homes. JAMA 278:557 562, 1997.
Reinsch S, MacRae P, Lachenbruch PA, Tobis JS: Attempts to prevent falls and injury: a prospective community study. Gerontologist 32:450 456, 1992.
Robertson MC, Devlin N, Gardner MM, Campbell AJ: Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 1: randomized controlled trial. BMJ 322:697 701, 2001.
Rubenstein LZ, Robbins AS, Josephson KR, et al: The value of assessing falls in an elderly population. Ann Intern Med 113:308 316, 1990.
Steinberg M, Cartwright C, Peel N, Willimas G: A sustainable programme to prevent falls and near falls in community-dwelling older people: results of a randomized trial. J Epidemiol Community Health 54:227 232, 2000.
Stevens M, Holman CDJ, Bennett N, de Klerk N: Preventing falls in older people: outcome evaluation of a randomized controlled trial. J Am Geriatr Soc 49:1448 1455, 2001.
Tideiksaar R, CF Feiner, Maby J: Falls prevention: the efficacy of a bed alarm system in an acute-care setting. Mt Sinai J Med 60:522 527, 1993.
P.244
Tinetti ME: Performance-oriented assessment of mobility problems in elderly patients. J Am Geriatr Soc 34:119 126, 1986.
Tinetti M, Baker D, McAvay G, et al: A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med 331:821 827, 1994.
Tinetti ME, Liu W, Ginter SF: Mechanical restraint use and fall-related injuries among residents of skilled nursing facilities. Ann Intern Med 116:369 374, 1992.
Tinetti ME, Williams CS, Gill TM: Dizziness among older adults: a possible geriatric syndrome. Ann Intern Med 132:337 344, 2000.
Wagner EH, LaCroix AZ, Grothaus L, et al: Preventing disability and falls in older adults: a population-based randomized trial. Am J Public Health 84:1800 1806, 1994.
Wolf SL, Barnhart HX, Kutner NG, et al: Reducing frailty and falls in older persons: an investigation of Tai Chi and computerized balance training. J Am Geriatr Soc 44:489 497, 1996.
Wolfson L, Whipple R, Amerman P, et al: Gait assessment in the elderly: a gait abnormality rating scale and its relation to falls. J Gerontol Med Sci 45:M12 M19, 1990.
Suggested Readings
Agostini JV, Baker DI, Bogardus STJ: Prevention of falls in hospitalized and institutionalized older people: Making Health Care Safer: A Critical Analysis of Patient Safety Practices. Rockville, MD, Agency for Healthcare Research and Quality, 2001.
Alexander N: Gait disorders in older adults. J Am Geriatr Soc 44:434 451, 1996.
Connell B: Role of the environment in falls prevention. Clin Geriatr Med 12:859 880, 1996.
Gillespie LD, Gillespie WJ, Robertson MC, et al: Interventions for preventing falls in elderly people. Cochrane Database of Syst Rev 3:CD000340, 2001.
King MB, Tinetti ME: Falls in community-dwelling older persons. J Am Geriatr Soc 43:1146 1154, 1995.
Luukinen H, Koski K, Konkanen R: Incidence of injury-causing falls among older adults by place of residence: a population-based study. J Am Geriatr Soc 43:871 876, 1995.
Tinetti ME: Preventing falls in elderly persons. N Engl J Med 348:42 49, 2003.
EAN: 2147483647
Pages: 23