TIS

Geriatrics Chapter 8
Falls


 

1. Epidemiology

A. Hip fractures are 20% fatal and 50% disabling

B. Wrist fractures peak in the late 60's but hip fractures continue to go up into the 90's

C. Woman fall more, men hurt themselves just as much.
This is probably because high risk behaviors and high energy falls are more common among elderly men. (The foolishness of males knows no age barriers!)

D. Most adults fall about once every six months.

E. Somewhere around 7 % of falls result in serious injury although the data is sketchy.

2. Causes:

A. Weakness of legs is strongest correlate of falls; this would suggest that exercise is the best preventive, but the data is contradictory?! There are some disturbing data which suggests that inactivity may even protect from falls. This is difficult to study because distinguishing between fall avoidance from inactivity vs deconditioning is difficult.

B. Environmental hazards are rarely important! But should be minimized nonetheless

C. Neurological

1. Motor
2. Dyspraxia is more important than paralysis
3. Parkinson's confers a very high risk
4. Executive function deficit is the worst
5. Proprioception deficit
6. Blindness
7. Vestibular dysfuntion
8. TIA's: diagnosed much more often than they happen. Drop attacks are probably fictional.
9. Seizures are diagnosed less often than they actually happen, probably. Some estimates place seizure risk at 20% in Alzheimer's Disease and probably higher after CVA's.

D. Cardiovascular

1. Stokes Adams attacks due to arrhythmia.
2. Post prandial and postural hypotension
Syncope is actually an unusual cause of falls in elderly people. A recent study of syncope showed no greater risk of falls among those with syncope or postural hypotension than those without! Nonetheless, it bears consideration.

E. Drugs

1. Nitroglycerin (!) and other hypotensives correlate with falls.
2. Insulin does too supposedly even if you control for hypoglycemia and neuropathy
3. Benzodiazepines
Nothing is more widely "known" than that benzodiazepines cause falls. But the data is actually equivocal! It appears that recent intitiation or increases in benzodiazepine dose may be contribute to falls, but that long-term, constant doses do not.

F. Depression

Falls actually do correlate with depression. Whether this is becuase depressed people become weak, or don't care for themselves or some other effect is not known.

3. Clinical approaches

A. NOTHING except Tai Chi has been demonstrated to prevent fall with evidence!

B. Evaluation

1. How much is necessary? You can do many things, but only a few actually help.

2. Get as much information about the fall(s) as possible. Unfortunately the description of a fall is unreliable both because the faller may be demented and because they may hide or minimize the fall. Fallers often blame some environmental problem whether it really existed or not rather than admit to frailty.

a. Is there any evidence of syncope? Ask the faller if they remember hitting the floor.

b. Was there vertigo associated with the event? Do not askif they were dizzy. Why Not?

3. In the absence of indication of syncope, workup for arrythmnia is not useful and even then it is very difficult.

4. Neurologic evaluation considering Parkinson's Disease or dyspraxia is useful.

5. Physical therapy or detailed strength, gait and endurance evaluation is useful, in fact is often the most useful in most cases.

C. Environmental manipulation: Who can say it's bad? But nobody can prove it does any good either.

D. Physical therapy and gait training: weight training is probably better than walking and probably is very important.

1. Tai Chi has the best evidence behind it! This is an exercise involving slow movements emphasizing strength of the lower limbs, balance and balance during movements, some of which are uncommon in daily activity. Practice dealing with dynamic threats to balance and strengthening seem to be the key.

E. Eliminating medical hazards:

Unfortunately this is easier said than done as well. Of course unneccesary medications of all types should be reduced. Particular attention might be directed at sedatives and drugs that cause postural hypotension.


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