FALLS IN THE OLDER

ADULT:
TOOLS FOR YOUR PRACTICE

Lisa N. Miura, MD, FACP

Associate Professor of Medicine, OHSU
Geriatrician, Portland VA Health Care System
 DISCLOSURES
Ihave no financial relationships with any
commercial interest related to the content of
this activity.
 OBJECTIVES
 By the end of this session you will be able to:
 1. Recognize the impact of falls on the lives of
older adults.
 2. Identify risk factors for falls.
 3. Perform at least 3 tests to assess a patient’s
balance and mobility.
 4. Describe interventions to reduce an older
person’s risk of falling.
 MR. CHASE
 83 yo male presents with 4 falls in the past
month.
 He lives alone and cannot remember the exact
events surrounding falls.
 + anxious about falling.

 Seen in ED 2X in the past year for falls.

 + walker but forgets to use it; doesn’t want to

look “old.”
 Sometimes feels dizzy.

 Wonders if it’s an “equilibrium” problem.

 WHAT IS A FALL?
“Anyone inadvertently coming to rest on the
ground or a lower level but not due to trauma
or other overwhelming medical event (stroke,
syncope)” -M.Tinetti, MD

 Falls are not random events

 Patient characteristics
 Activity at time of the fall
 Environment
 THE IMPACT OF FALLS
 30-40% over age 65 and 50% in long-term care
and age >80 years fall annually
 Complications from falls are a leading cause of
injury-death in those >65 years
 Fall injury hospitalizations cost more than all
other traumas combined
 OREGON: ~700 deaths and 8,000 hospitalizations are
due to falls

Oregon Dept. of Health, Fall & Injury Prevention 2018

Centers for Disease Control & Prevention 2010
 SEQUELAE OF FALLS
 Associated with:
 Decline in functional status
 Nursing home placement
 Increased use of medical services
 Serious injuries: fractures, head trauma, lacerations
 “Long lie”: Half of those who fall unable to get up
without help
 Rhabdo, dehydration/AKI, pressure ulcers
 Predicts lasting decline in functional status
 Post-fall Anxiety Syndrome
 ¼ of all fallers limit their activities due to fear of falling
 Increased risk of institutionalization and mortality

Tinetti, JAMA 1993

Visschedijk, JAGS 2010
 FALLS IN OLDER ADULTS
 Common and Expensive
 High Morbidity and Mortality
 Many Causes and Risk Factors
 Potentially Preventable
 AN OUNCE OF PREVENTION
 Educationand activity programs have been
shown to reduce fear of falling and improve
measures of stability and strength in
community dwelling seniors

 Riskfactor interventions have reduced the

risk of falling by more than 30%

Brouwer, JAGS 2003

Tinetti, NEJM 1994
 ISSUES WITH ADDRESSING FALLS IN
CLINICAL PRACTICE
 Lack of awareness of the morbidity and mortality
related to falls

 Lackof time during the office visit to adequately

address a multifactorial problem

 Lack of awareness of evidenced-based

interventions available for fall prevention

 Logisticalbarriers to patient access to

interventions

Chou, J Gen Intern Med 2006

 CAUSE OF FALLS
 Multiple causes usually involved

 Frequently not observed

 Often poor recall of event

 Different ways to categorize cause

 RISK FACTORS FOR FALLS:
SIXTEEN MULTIVARIATE STUDIES
FACTOR Mean RR
Muscle weakness 4.4
Prior fall 3.0
Balance deficit 2.9
Gait deficit 2.9
Assistive device 2.6
Vision deficit 2.5
Arthritis 2.4
ADL deficit 2.3
Depression 2.2
Cognitive deficit 1.8
Age > 80 1.7
Rubenstein & Josephson, Med Clin N Amer 2006
 WHEN AND HOW TO SCREEN FOR FALLS
 USPSTF: screening at age 65; identify older adults at
increased risk for falls - *history of falls, mobility
problems, and poor performance on TUG
 AGS, BGS, AAOS recommends yearly screening for
patients >65
 NNS to prevent 1 fall over 1 year is 20 (Tinetti, NEJM 1994)

 Screening questions:
 Have you fallen in the past year?
 If so how many times and under what circumstances?
 Do you feel unsteady when standing or walking?
 Do you worry about falling?

 If answer is “Yes” to any of these questions then proceed

with a fall risk assessment
 FALL RISK ASSESSMENT
 Determine multifactorial fall risk
 History of falls
 Gait, balance, mobility
 Neurologic impairment
 Muscle weakness
 Cognitive impairment
 Visual Acuity
 Cardiovascular risks (arrhythmias)
 Orthostatic hypotension
 Foot care and footwear
 Medications
 Environmental Hazards (home safety) AGS
 GAIT, BALANCE, MOBILITY

 Tinetti
– POMA (Performance
Oriented Mobility Assessment)
 Timed Up and Go test (TUG)
 Four-Stage Static Balance Test
 “Two of the most sensitive tests are the Static
Balance and TUG” McMichael, J Geri Nursing 2008
 30-Sec Sit-to-Stand
 Gait Speed
 TINETTI BALANCE AND GAIT
EVALUATION (AKA POMA)
BALANCE: GAIT:
 Sitting balance  Initiation of gait

 Arising (Immediately after being

told to go)
 Attempts to arise
 Step length and height
 Immediate standing
balance (first 5 secs)  Right Swing

 Standing Balance  Left Swing

 Nudging  Step Symmetry

 Turn 360*  Step Continuity

 Sitting Down  Path

 Trunk Alignment
Less than 19 = high fall risk
 Walking Stance
19-24 = medium fall risk
25-28 = low fall risk Amer J Med 1986
 TIMED UP AND GO (TUG)
 Technically it’s Timed Up, Go and Return
 Record the time it takes a person to:
1. Rise from a hard-backed chair
2. Walk 10 feet (3 meters)
3. Turn
4. Return to the chair
5. Sit down

Podsiadlo, JAGS 1991

TIMED UP AND GO
 TUG (TIMED UP AND GO)
 Most adults can complete in 10 seconds
 Most frail older adults can complete in <20 seconds
 ≥12 sec =  falls risk Lusardi, J Geriatr Phys Ther 2017

 >20 sec  comprehensive evaluation

 Association between the TUG score and mortality
observed in both men and women
 Addition of Cognitive or Physical Tasks can dramatically
increase the difficulty and can identify fallers that are
better compensated
Bohannon, J Geri PT 2006
Hofheinz & Schusterschitz, Clin Rehab 2010
Tang, Geri & Gerontol Int’l 2014
Cardon-Verbecq, Ann Phys Rehab 2017
FOUR-STAGE BALANCE TEST

STEADI
30-SECOND SIT-TO-STAND

Count and record the number of

times the patient can complete
the chair stand in 30 seconds.
30-SECOND SIT-TO-STAND

Rikli & Jones, Res Quart Exer & Sport 2001

 GAIT SPEED
 Almost the perfect measure Wade, Meas In Neuro Rehab 1992

 Reliable Richards, Gait and Posture 1996

 Valid Steffen, Phys Therapy 2002

 Sensitive van Iersel, J Clin Epidem 2008

 Specific Harada, Phys Therapy 1995

Correlates with …
 Functional Ability Perry, Stroke 1995
 Balance and Confidence Mangione, Physio Can J 2007
 Future Health Status Studenski, JAGS 2003; Purser, J Rehab Res & Dev 2005
 Functional Decline Brach, Phys Therapy 2002
 Rehabilitation Potential Goldie, Arch Phys Med & Rehab 1996
GAIT SPEED: 10 METER WALK TEST
 Reliable, inexpensive method Perera, JAGS 2006
 20 meter path
 Central 10 meters being the timing area

 Start your patient at the beginning of the 20 meter line

 Ask pt to walk “at a comfortable pace” to the end line

 Time during the central 10 meters

 Fritz, J Geri PT 2009

Gait Speed Correlates with:

 Functional ability (Perry, Stroke 1995)
 Balance confidence (Mangione, Physio Can 2007)
 Hospitalization (Studenski, JAGS 2003)
 Mortality (Hardy, JAGS 2007)
 Falls (Guimaraes, Int’l Rehab Med 1980)
 Fear of Falling (Maki, JAGS 1997)
 WALKING SPEED VARIES BY AGE, GENDER, &
ANTHROPOMETRICS

Walking Speed by Gender & Age

1.7

1.6

1.5
meters/second

1.4
Female
1.3 Male

1.2

1.1

1
6-12 Teens 20s 30s 40s 50s 60s 70s >80
Self selected walking speed categorized by gender & age : 6-12 & teens (Waters, Lunsford et al. 1988); 20s-50s (Bohannon 1997); & 60’s-80’s (Bohannon 2008)
 FALL RISK ASSESSMENT
 Clinical assessment
-Targeted H&P
 *History of previous falls

 *Lower extremity weakness

 Neuro exam including cognitive testing

 Cardiac exam including orthostatics

 Examine feet and footwear

 Vision and hearing

-Chronic medical issues: OA, Stroke, Parkinson’s,

Chronic Pain, Cognitive Impairment, Diabetes,
Neuropathy, Cardiopulmonary conditions
-Substance use: Alcohol intake
 HIGH-RISK MEDICATIONS FOR
FALLS
 Psychoactive medications (OR 1.47-1.68)

 Antipsychotics (e.g., haloperidol, risperidone)

 Antianxiety drugs (e.g., benzodiazepines)
 Hypnotics (e.g., zolpidem)
 Antidepressants (e.g., SSRI’s, TCA’s)

 Cardiovascular (OR 1.24)

 Antihypertensives
 Diuretics
Woolcott, Arch Int Med 2009
 ASSESSING FOR ORTHOSTASIS
 Checking orthostatics: 0,1, and 3 minutes
 Drop in systolic BP >20 mmHg or diastolic BP >10 or
+ symptoms
 Consider standing BP only if unable to perform full
orthostatics
 Treatment can reduce falls

 Medication reduction
 Fluid optimization (1.5-3 L)
 Elastic stockings (Waist high)
 Ankle Pumps / Isometrics
 Consider adding Salt (1g/BID)
 MEDS: Fludrocortisone, Midodrine, Droxidopa

Amer Geri Soc Clin Prac Guideline 2010

 DIAGNOSTICS
 TSH
 Vitamin B12

 Vitamin D (levels <10 ng/mL)

 Folate

 CBC

 Comprehensive panel (for renal/hepatic disease)

 RPR

 Brain imaging: CT or MRI

 X-ray of injuries

 Cardiac eval: EKG, Holter, ECHO -- If syncope,

arrhythmia, or cardiac contributors are suspected
 Bone density
 VITAMIN D
 Those>65 years with 25(OH)D levels <10
ng/mL at greater risk for loss of muscle mass,
strength, & increased risk for hip fracture

 Low risk of harm in appropriate doses

 Dosing recommendations:
 American Geriatrics Society and AHRQ : 800-1000
IU daily
Include calcium if needed! 1000 mg daily

Visser, J Clin Endo Metab 2003

Cauley, Ann Int Med 2008
 OTHER MODIFIABLE FACTORS
 Footwear & Podiatry Care
 Highest fall risk: socks or barefoot
 Best: athletic shoes or thin, hard soles
 Anti-slip shoe devices in icy conditions
 Multifaceted podiatry intervention led to 36%
decrease in falls
Kelsey, Footwear Sci 2010; Koepsell, JAGs 2004; Spink, BMJ 2011
 Vision
 Impairment has been associated with falls and hip
fracture Lord, JAGS 2002
 Increased falls with multifocal lenses
 Expedited surgery for first cataract reduced rate of
falls
Gillespie, Cochrane Database 2009
 STRENGTH AND ENDURANCE FOR FALL
PREVENTION
 Exercise as a single intervention can prevent falls
Sherrington, NSW Pub Hlth Bulletin 2011

 Exercise programs for lower-limb muscle endurance

significantly improved static and dynamic balance
Avelar, Physiotherapy Rev Brazil 2010

 Low-intensity strength training resulted in improved gait

stability and steadiness in disabled elderly
Krebs & Jette, Amer Congress of Rehab 1998
 Incidence of hip fracture in the older population can be cut
nearly in half with physical activity throughout one’s life
Beck & Snow, Exer & Sports Sci Rev 2003

 Exercise can improve postural and neuromuscular control

as well as reaction time, thereby reducing falls
Lord, Stroke Mag 1995
The Cochrane Collaboration - published in The Cochrane Library 2012
 TAI CHI FOR FALL PREVENTION
 Tai Chi exercise improves stride length and QoL scores in
older adults Chyu, Clin Rehab 2010

 Tai Chi improves muscle quality and posture

Hsu, J Formosan Med Assoc 2014
 Tai Chi subjects demonstrated decreased TUG times,
increased stride length and improved time on one limb
during gait
Quigley, Amer J Phys Med & Rehab 2014
 Comparing falls incidents in Taiwan with CDC data for
the same period seems to show that falls in Taiwanese
elders occur about half as often as in their U.S.
counterparts
Lai, Gait & Posture 2013
Tai
Chi
 HOME SAFETY
 Edges of stairs, uneven surfaces marked
 No throw rugs, mats, long electrical cords

37
 Less clutter
 Chairs, toilet at appropriate height
 Furniture arranged so provides assistance, not obstacles
 Night lights
 Nonslip pads in shower, tub
 Grab bars in shower, next to toilet (raised, handbars)
 Handrails along staircases
 Even, non-glare lighting
CDC HOME SAFETY CHECKLIST

STEADI, 2018
 STEADI (STOPPING ELDERLY ACCIDENTS,
DEATHS & INJURIES)

 Researchers at CDCs Injury Center have created this tool kit

for providers who treat older adults who are at risk of falling
or have fallen in the past

 Resources and tools that help make fall prevention an

integral part of clinical practice

 Falls screening algorithm (adapted from the American and

British Geriatric Societies’ Clinical Practice Guidelines)
 Risk factor check lists
 Gait and balance tests, instructions and videos
 List of medications linked to falls
 Educational handouts for providers and patients

http://www.cdc.gov/homeandrecreationalsafety/Falls/steadi/index.html
 REDUCTION OF FALLS
 Tai Chi: up to 49% reduced risk for falls
 Muscle strengthening / balance retrainin: 17%
reduced risk
 Vitamin D supplementation : 26% reduced
risk
 Withdrawal of psychotropic meds: 66%
reduced risk
 Home safety assessment for person with
history of falls: 34% reduced risk

Frick, JAGS 2010

 FALL EVALUATION
 Orthostatic BP check
 Vision check

 Cognitive screen with Mini-Cog

 Medication, substances, lab review

 Assess fear of falling with FES-I

 FES-I: Fall Efficacy Scale International
 PE, Gait and balance assessment
 Timed Up and Go (TUG)
 Sit-to-Stand
 Four-Stage Balance test
 Gait Speed
 Home safety checklist
 MR. CHASE
 83 yo male presents with 4 falls in the past
month.
 He lives alone and cannot remember the exact
events surrounding falls.
 + anxious about falling.

 Seen in ED 2X in the past year for falls.

 + walker but forgets to use it; doesn’t want to

look “old.”
 Sometimes feels dizzy.

 Wonders if it’s an “equilibrium” problem.

 CASE STUDY
 83 year old male with 4 falls in the past month.
 PMH: HTN, OA of the knees, DM2
 MEDS: Lisinopril 20 mg BID, furosemide 20 mg QD
Quetiapine 50 mg qhs
 EXAM:
 Arthritic deformity of both knees
 + abnormal monofilament
 + orthostatics with 25 point SBP drop
 Difficulty arising from chair without using arms
 30STS- 5; TUG 23 sec; Gait speed 0.74 m/s
 Balance: unable to close eyes w/feet together
 Mini-cog abnormal (2/5); FES-I: 20/28 (high)
 CASE STUDY
 MANAGEMENT
 Medication modification
 Address orthostatic hypotension – decrease
ACEI; discuss fluid intake
 Eliminate quetiapine & furosemide

 Scheduled acetaminophen for pain

 Vision screen

 Further cognitive evaluation

 Home safety handout

 Action plan for home exercises/PT/OT referral

 Check labs
 CASE STUDY #2
 61 yo male with a 2 year hx of intermittent
dizziness, near syncope, and difficulty with
urination. Admits to a change in sweating. He is
falling almost daily.

 Meds: MVI, diphenhydramine

 PE: 185/100, P 75 supine; 95/54, P 80 standing

 General exam relatively normal although
unsteady gait and some slowness of movement.
 IMPLICATIONS FOR CLINICAL
PRACTICE
 ASSESSMENT
 Inquire about falls annually in those >65
 Assess persons failing screen or with >1
fall
 Review risk factors for falls: chronic medical
conditions, exam, labs
 Consider a fall risk assessment note template
and screening/assessment tools
 IMPLICATIONS FOR CLINICAL
PRACTICE
 MANAGEMENT OF FALLERS
 Multicomponent interventions
 Exercise, Tai Chi, PT/OT

 Medication review and adjustment

 Treatment of underlying conditions:

vision, cardiac, orthostasis, cognitive
impairment, low vitamin D, podiatry
issues
 Environmental assessment and
modification
THANK YOU!

LISA MIURA, MD
MIURAL@OHSU.EDU