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Geriatric Medicine Principles Falls Robert Kirby, MD, FACP Clinical Professor of Medicine. Geriatric Medicine. Geriatric Medicine Principles/ Falls. Learning Objectives: 1. List two characteristics of the geriatric population. 2. Describe two instruments to assess function. - PowerPoint PPT Presentation
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Geriatric MedicinePrinciples
Falls
Robert Kirby, MD, FACPClinical Professor of Medicine
Geriatric Medicine
Geriatric MedicinePrinciples/ Falls
Learning Objectives:1. List two characteristics of the geriatric
population. 2. Describe two instruments to assess function.3. Define geriatric syndrome. Name three.4. List four risk factors for falls.5. Outline three interventions to reduce fall risk.
Biology of Aging
GeneticOxidative Stress
Mitochondrial DysfunctionHormonal Changes
Telomere Shortening (Hayflick Limit)Defective Host Defenses
Accumulation of Senescent Cells
Harrison on Line
Demographics
USA 2020 >65 yo 16%
Dependency Ratio-
Europe 2050 22% to >50%
Harrison on LineMerck Manual Geriatrics
Demographics
Over Age 6540% of Hospital Resources
24% of Office Visits25% of Prescription Drug Costs
25% of Medicare expenditure in last year of life- Half of this in last 60 days
Residents of Nursing Homes Age 65 1%
Age 85 17%Merck Manual of Geriatrics
Chronic Disease Burden
Arthritis 50 54
HypertensionHeart
3632
3939
HearingCataracts
2816
3624
DiabetesVision
108
1111
Condition Age 65 % Age 75 %
Merck Manual Geriatrics
Life Expectancy
Walter LC, Covinsky KE, JAMA 2001
Function: Activities of Daily Living
Basic Intermediate
Dressing ShoppingEating HouseworkAmbulating AccountingToileting Food PreparationHygiene Transportation
Function with Aging
0
10
20
30
40
50
60
ADL problem IADL Problem
% w
ith D
iffic
ulty
Age 65-7470-7475-7980-8485+
Principles in a Flash1. Aging is not a disease.2. Geriatric conditions are chronic, multiple,
multifactorial3. Reversible conditions are underdiagnosed and
undertreated4. Function and quality of life are critical
outcomes5. Social support and patient preferences are
critical aspects6. Geriatrics is multidisciplinary7. Cognitive and affective disorders prevalent and
undiagnosed at early stages8. Iatrogenic disease common and often
preventable9. Care is provided in multiple settings10. Ethical and end of life issues guide practicewww.cha.emory.edu/reynoldsprogram
Clinical Approach
Not what disease caused the problem
But what combination of physiologic change, impairments and diseases are contributing
And which ones can be modified
Modawal
Geriatric Syndromes
Dementia and DeleriumFallsPolypharmacyPressure UlcersUrinary Incontinence
Mary Anderson
This 85 year old widow presents after a fall in the bedroom of the home where she has raised her family and lives independently.
She does not know why she fell, was able to ambulate after the fall and presents six hours later with a bruise on her left cheek and an abrasion on the left forearm.
Daughter reports occasional confusion and some limitation of activities due to weakness. She reports a fall four months ago.
PMHDJD hips and knees with chronic painHypertensionMacular degenerationDiabetes 2Urinary urgency and rare incontinence
Medications: Hydrochlorothiazide, Fentanyl patch, KCL,Tylenol, MVIExamination:
BP supine 160/88; standing 3 minutes 168/92Vision 20/50Chest – rare crackles right baseNeuro: absent achilles, romberg normal
Gait antalgic secondary to right hip painGet up and go test: 18 seconds. Uses arms to arise
from chairFunctional Reach test 5 inches
Laboratory:Hemoglobin 11 gm/dlK 3.0 meq/LGlucose 212 mg/dlCreatinine 1.4 mg/dlBUN 24 mg/dlUrinalysis wbc 20, nitrite positive
Questions aboutMary Anderson
1. What is the most important risk factor for her recent fall?
2. What is the most important physical examination finding related to her fall?
3. What additional diagnostic studies will be helpful?4. What is the most important initial step in managing
Mary’s fall?5. What consultations/referrals would be most useful?
Importance Risk Factors Clinical Assessment
History Physical Examination Laboratory Management
Fall
“Unintentional coming to rest at a lower position unrelated to obvious intrinsic or environmental factor.”
Importance
Prevalence Ambulatory Adults >65 30% per year
ConsequencesDeathInjury
Fractures 10-15% Hip 1-2% Long Lie Fear of Falling
Reduced Activity/Independence (25%)
Causes Extrinsic
EnvironmentIntrinsic
AgeGait/Balance DisorderSarcopenia VestibularOrthostatic Hypotension
Special Senses –Vision/HearingDisease
DementiaDepressionDrugsFoot problemsIncontinence
Risk Factors Muscle weakness: 4.4
History of falls: 3.0 Gait or balance deficit: 2.9 Use of assistive device: 2.6 Visual deficit: 2.5 Arthritis: 2.4 Depression: 2.2 Cognitive impairment: 1.8 Age over 80 years: 1.7
Mean RR or OR of risk factors for falls from 16 studies
Data from AGS Panel on Falls Prevention. Guideline for the prevention of fallsin older persons. J Am Geriatr Soc 2001;49(5):664–72.
Gait
Stride LengthArm SwingSlowForward Flex
Head and TorsoFlexion shoulders kneesLateral Sway
Normal Gait Video
History-PhysicalInjuryDetails of FallInability to Get UpAssociated Disease and DisabilityDrugs
GeneralOrthostatic BPVisionCognition ( MMSE)Gait/Balance/Coordination
LaboratoryCBCCMPEKG
Get Up and Go
Normal
Abnormal
Modified Single Leg Stance
Functional Reach
Sharpened Romberg
Fall Risk Next Treatment Year (%) Reduces
Risk(%)Fall Past Year 50 30Gait Problem 30 20One Risk 20 10Two Risks 30 20Three Risks 60 40Four or More 80 50 Treatable Risks: 1. Problem walking or moving 2. Orthostatic hypotension 3. Four or more meds or one psychoactive 4. Unsafe footwear or foot problems 5. Environmental hazard
Reducing Fall Risk
www.fallprevention.org
Guideline for Fall Prevention
JAGS 2001. 49:664-672
ManagementReduce Fall Risk
EnvironmentExercise and BalanceCardiovascular
(orthostasis)VisionAssistive DevicesMedication ReviewFootwearBehavior EducationRestraints
Rubinstein Med Clin N Am 2006
ManagementReduce Fall Risk
Exercise
Wolf JAGS 1996
MMWR Rep 2004;53(2):25-28
-47%
Reduce Fracture Risk Hip Protectors
Vitamin D/Calcium 400-800IU / 1200-1500
Lauritzen JB, Peterson MM et al Lancet 1993; 341:11-13.
Questions aboutMary Anderson
1. What is the most important risk factor for her recent fall?
a. History of previous fallsb. Medicationsc. Possible urinary infection and/or dementiad. Gait disordere. Visual impairment
Questions aboutMary Anderson
2. What is the most important physical examination finding related to her fall?
a. Extent of injury and painb. Result of blood pressurec. Result of “Up and Go Test”d. Visual acuitye. Neurologic findings
Questions aboutMary Anderson
3. What additional diagnostic studies will be helpful?
a. Twenty four hour ambulatory EKG ( Holter) monitorb. Carotid Doppler study
c. Brain MRId. Head-up tilt teste. Radiograph of chest and hipsf. Electoroencephalogram (EEG)
Questions aboutMary Anderson
4. What is the most important initial step in managing Mary’s fall?
a. Reduce hydrochlorothiazide and fentanyl
b. Hydrate and treat UTIc. Treat injury and paind. Osteoporosis treatmente. Counsel on “fear of falling” f. Recommend hip protectors
Questions aboutMary Anderson
5. What consultations/referrals would be most useful?
a. Ophthalmologyb. Physical Therapy for
strengthening exercisec. Home safety evaluation by
Occupational Therapyd. Neurology consultatione. Cardiology consultation
Geriatric MedicinePrinciples/ Falls
Learning Objectives:
1. List two characteristics of the geriatric
population. 2. Describe two instruments to assess function.3. Define geriatric syndrome. Name three.4. List four risk factors for falls.5. Outline three interventions to reduce fall risk.
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