Geriatric Syndromes m A comprehensive fall evaluation to reduce fall risk in older adults

Joseph 0. Nnodim, iVID, PiiD • Neii B. Aiexander, iVID

Falls account for significant morbidity and mortality in the oider adult popuiation. A comprehensive fall evaluation (CFE) is proposed, particuiariy for use in recurrent faliers, those who seek medicai attention for a faii, and those with a gait and/or baiance disorder. The CFE focuses on key factors In the medicai and faii history, review of falls within 12 months), those who systems, and physical examination, interventions utilize a present for medical attention because muitifactorial model, although baiance exercise may be the most of a fall, and those who demonstrate a critical component. Whiie some components may be marginaiiy gait and/or balance disorder should successfui when presented individuaiiy as an Intervention (such as undergo a comprehensive fall evalua- correction of vision impairment or environmental hazard reduction), tion (CFE). when presented together, faii risk can be significantiy reduced. The goalofCFEisto identify fall risk Nnodim JO, Alexander NB. Assessing fails in oider aduits: A comprehensive faii evaiuation factors based on a review of key factors to reduce faii risk in oider aduits. 2005 60(10):24-28. in the medical and fall history, review Key words: falls • exercise • of systems, physical examination, and other screening (table). The circum- stances of a fall help identify common fall risk situations. Premonitory signs (eg, chest pain) are important, although alls are events in which an indi- This paper will discuss a directed actual loss of consciousness prior to the vidual inadvertently comes to rest evaluation that can be used with recur- fall leads to a more traditional syncope, F on a lower-than-usual level in the rent fallers (such as two or more falls rather than falls, work-up. Acute illness absence of an overwhelming force, syn- within 12 months), those who seek accounts for approximately 10% of falls cope, or . Falls cause substantial medical attention for, a fall, and those in older adults, and syncope for an even morbidity and mortality in older adults, with a gait and/or balance disorder. lower percentage, and the fall assess- including 5.3% of all older-adult hospi- ment and intervention differs from the talizations in the United States.' Falls Clinicai evaiuation more common, subacute or chronic fall and fall-related injury may not be com- Based on a recent consensus confer- causation and intervention model. pletely preventable, but with a directed ence guideline, older adults should be Intrinsic risk factors from the med- evaluation and intervention, the risk of asked about falls at least once a year.^ ical and surgical history are important, falls and injury can be reduced. Recurrent fallers (such as two or more such as Parkinson's or a previ- ous repair. A thorough re- view of the patient's medications for fall-causing potential, with a particu- lar focus on psychotropic medications, Dr. Nnodim is fellow, division of geriatric medicine, department of internal medi- is critical. cine and institute of . University of iViichigan, and speciai fellow, program in advanced geriatrics. Veterans Affairs Ann Arbor Heaith Care System Geriatric Evaluation of daily activities and Research Education and Ciinical Center, Ann Arbor, Michigan. habits is highly relevant: both func- Dr. Aiexander is professor, division of geriatric medicine, department of internai tional (ADL) dependency and excess • medicine, and research professor, institute of gerontoiogy. University of Michigan; alcohol use (>2 drinks/day) increase and associate director for research and research scientist. Veterans Affairs Ann fall risk. Assessment of the home en- Arbor Heaith Care System Geriatric Research Education and Clinicai Center, Ann Arbor, IViichigan. vironment for physical hazards may Disciosure: The authors report no conflicts of interest related to the subject under require a home visit. Questions about discussion. dizziness, paresthesia, focal weakness.

24 Geriatrics October 2005 Voiume 60, Number 10 and memory problems help determine the extent of vestibular, cognitive, or other neurologic disease. Leg pain, MEOW manifested by arthralgia or myalgia, M Multifactorial may destabilize gait and increase the iVIedical (Acute) likelihood of falls. Urinary urgency, Medical (chronic) causing a need to rush to the bathroom, Medicines may increase fall risk as well. Mental Physical examination Maladaptive assistive devices The physical examination begins with Muitifocal lens a general assessment of fluid and nu- . Environmental tritional status. Blood pressure and Eyes pulse are measured with the patient supine, then immediately after stand- thanol ing and after at least two minutes of 0 standing to check for orthostatic hy- potension. Positional dizziness should OUCH! (pain) also prompt administration of the Dix- Hallpike maneuver. the lower extremities The precordium and neck are aus- cultated for rhythm, murmurs, and GERIATRICS Medical Editor Fredrick T. Sherman, MD, MSc, has developed the "MEOW" mnemonic to give the primary care practitioner a logical approach for bruits. Carotid sinus massage, to iden- evaluation of elderly patients who have fallen. See page 5. tify a highly select group of those with Illustration for Geriatrics by Jeff Suntala carotid sinus hypersensitivity who might benefit from a pacemaker, should is monitored for appropriateness, fit, tandem and unipedal (eyes open) stance be performed only under EKG moni- and efficacy. While classical gait pat- (at least 10 seconds) and tandem walk toring with IV access. terns (such as festination in Parkin- (10 steps); patients who can perform Examination of the lower extremi- son's disease) maybe encountered, an these tests generally do not have a sig- ties includes an inspection of leg joints abnormally appearing gait in an older nificant balance or gait disorder. and the feet for deformities and limi- adult usually has a multifactorial eti- Screening for cognition (Mini-Men- tations in range of motion. Footwear tal State Examination), depression should be checked for appropriateness; (Geriatric Depression Scale) and vision the sole wear pattern may provide in- (visual acuity and, if possible, contrast sight into abnormal weight distribu- b© checked; sole sensitivity using, for example, a 10% tion while walking. contrast letter chart and the Pelli-Rob- Neurologic examination should be wear pattern may son chart respectively) are advocated. thorough, including assessments of Laboratory testing is ordinarily not cerebellar coordination, muscle tone provide insight a key component of fall risk assessment. and power, deep tendon reflexes, and However, some findings (eg, mucosal peripheral sensory perception. pallor, low back pain with radiculopa- Of the measures of gait and balance thy) may require either blood work or disorder, gait speed and, in particular, imaging for fuller characterization. As- the Timed Up and Go (TUG: rise from sessment batteries of varying degrees of a chair, walk 10 feet, turn, and return technical complexity have been devel- to the chair) are thought to be partic- oped, with defined cut-points for pa- ularly strong predictors of clinical out- ology, requiring exploration of the fac- tient stratification for fall risk. Some comes (TUG over 14 seconds suggests tors already reviewed elsewhere.^ of these instruments are listed in Ru- an increased risk of falls).^ In a stan- Assessment of bipedal (feet together) binstein et al.' dard gait evaluation, gait initiation, stance with eyes open and then with base width, stride length, speed, floor eyes closed, establishes whether the pa- Intervention clearance, trajectory, truncal posture, tient has low-level stance ability and The goal of intervention is to eliminate arm swing, and quality of turn are ob- functional proprioception and vestibu- or minimize remediable risk factors. served. The use of an assistive device lar function. High-level testing includes The Panel on Falls Prevention^ has en-

October 2005 Volume 60. Number 10 Geriatrics 25 provement in intermediate fall risk Table Coinponents of Oft measures.'^ Gomppehensive fall evaluatioii Medications: Careful review of the pa- tient's medications (including over- History the-counter agents) is essential.^ Med- Circumstances of fall exercise should be ications should be limited to those ab- Medical and surgical history customized, ®f solutely essential, given that the risk Medications of falls increases with multiple med- ications. Whenever possible, non- Social History pharmacologic modalities should be Review of systems tried first (eg, sleep hygiene and eval- Neurologic uation for sleep-disordered breathing (including ophthalmologic, otologic) for insomnia). If medications are deemed neces- Cardiovascular strate fall reduction.* Nevertheless, risk sary, fall-inducing potential should be Musculoskeietal factors consistently observed in the in- considered as well as dose adjustments. Genitourinary patient setting, namely a history of pre- Both short-acting and long-acting ben- vious falls, gait instability, agitated con- zodiazepines increase fall risk. While Physical examination fusion, urinary incontinence/frequency, tricyclic antidepressants have been tra- Vital signs and medications, such as sedatives/hyp- ditionally implicated in falls, falls have Head and neck notics, suggest that a multifactorial ap- also been associated with selective sero- proach might be useful in this setting. tonin-reuptake inhibitors, particularly Cardiovascular Such an approach resulted in a 21% at high doses. Extremities relative risk reduction in acute wards.^ Medications, especially psychotrop- Neurologic (including gait, balance) In the subacute setting, while one re- ics, should be initiated at a low dose cent study found no significant bene- and then slowly titrated upward. Com- Screening tests fit of a multifactorial program,* an- plete removal of psychotropics can re- Mini Mental State Examination other study of similar design reported duce fall risk by as much as 66% but Geriatric Depression Scale a 30% reduction in falls.' many patients will eventually be placed Visual acuity back on a psychotropic medication.'^ Specific interventions Drug interactions and acute condi- Laboratory and radiological testing Exercise: Exercise maybe the most cru- tions, such as sepsis, may increase fall Source: Developed for Geriatrics by JO cial component of successful com- risk by altering drug pharmacokinetics. Nnodim, iVlD, PhD, and NB Alexander, MD. munity-based multifactorial pro- Medication use to treat disease grams, and an effective single inter- symptoms may increase fall risk. Nar- dorsed a multifactorial intervention vention according to a recent meta- cotics are associated with injurious model. In the community setting, the analysis.'" In older adults at high risk falls and should be prescribed judi- following are recommended: for falls, exercise likely needs to be in- ciously. For chronic pain, scheduled • exercise (such as balance training) dividualized, of long duration (at least dosing is more effective than use "as • correct use of assistive devices 10 weeks), and include balance rou- needed." Advanced osteoarthritis, with • medications review tines.^ The optimal type, duration, rest pain and functional compromise, • environmental hazard elimination and intensity remain to be deter- may merit surgical evaluation. • treatment of postural hypotension mined. Recent studies suggest group While recurrent falls occur in those and cardiovascular disorders, if present. exercise may also be effective, al- with extrapyramidal syndromes, such In long-term care facilities, the crit- though fall reduction outcomes for as Parkinson's, as well as in patients ical component is staff and resident ed- an initially promising program, Tai with cognitive impairment, adminis- ucation. Other specific recommenda- Chi, were more modest: in follow-up tration of appropriate medications (eg, tions are: with a more physically impaired co- dopaminomimetic and cholinesterase • gait training hort." In a physical therapy-rehabil- inhibitor medications, respectively) has • correct use of assistive devices itation model, patients with specific not been proven to reduce falls. • medications review. disease-related impairments who are Whether medication treatment may Studies of interventions in the acute at high risk for falls, such as patients somehow facilitate participation in care setting have methodological prob- with vestibular impairment, may re- other interventions, such as exercise, lems and may not conclusively demon- duce their fall risk as indicated by im- in these two cohorts is also not clear.

26 Geriatrics October 2005 Volume60, Number 10 Environmentai modification: As a single fracture risk but also high non-com- However, without a history of syncope, intervention in controlled trials, envi- pliance and drop-out rates.'^ The Am- an evaluation for possible cardioin- ronmental modification to increase sterdam Hip Protector Study,"" in hibitory carotid sinus syndrome is usu- safety does not reduce fall risk. How- which data analysis was by intention- ally not undertaken. Cardiac pacing of ever, as a component of multifactorial to-treat, failed to show a hip fracture recurrent fallers with cardioinhibitory programs, environmental safety meas- preventive benefit with use of the de- carotid sinus syndrome reduced events ures are thought to contribute only vice. In other studies, fall risk was not by two-thirds in the SAFE PACE study modestly to risk reduction. Use of an reduced but falls self-efficacy appeared in a highly select sample.'^ occupational therapist, presumably to to be enhanced.'* The optimal clinical Vision: Prescription lenses correct provide home hazard assessment and use of hip pads to reduce hip fractures acuity errors. Single-lens glasses are safety instruction, however, results in is still not clear. preferred to muitifocal glasses since significant fall risk reductions post-dis- Footwear: Walking in stocking feet is the latter lead to impaired edge con- charge from the hospital, with a 31% discouraged. Shoes should be well-fit- trast and depth perception and in- fall reduction in a group receiving two ting, sturdy, and well-contoured, with creased fall risk. home safety visits.'* A facilitated home a non-skid sole and low broad heel. Cataract extraction, even in unilat- environmental assessment is thus rec- Footwear with laces or Velcro fasten- eral disease, reduces fall risk. Whereas ommended for at-risk older patients ers are favored over slip-ons. Athletic vision modification is generally not ef- upon discharge from the hospital.^ and canvas shoes are the footwear styles fective as a single intervention, vision Beiiavior modification: Behavioral least associated with falls in commu- may contribute to fall risk reduction strategies, as a single intervention to nity-dwelling elders. as part of a multifactorial risk reduc- reduce falls, are generally unsuccess- tion program. ful. However, as part of a multifactor- : In a recent meta-analy- ial fall risk intervention, patients should Athletic and sis, treatment with vitamin D resulted be provided with their individual risk in 20% fall risk reduction, independ- factors and counseled regarding cop- canvas shoes are ent of calcium supplementation.^" ing with fall risk. Patients with vision the footwear The proposed physiologic basis of this loss or those with vestibular or propri- benefit is increased muscle strength oceptive loss, who are particularly de- styles least but the extent of musculoskeletal im- pendent on vision, must maximize provement associated with this re- lighting in the home and develop safe associated with duction in fall risk is modest. There navigation strategies and paths. Pa- are no current recommendations for tients with cognitive loss may need su- falls In community- supplementation, although targeting pervision and maintenance of a dis- women and using doses of 800 IU may traction- and clutter-free environment. dwelling elders be beneficial. Assistive/protective devices: Assistive devices (eg, cane or walker) increase Cardiac and circuiatory interventions: In Conclusion stability by augmenting the base of sup- successful programs, the measures tar- A comprehensive fall evaluation port, providing proprioceptive input, geted at orthostatic hypotension in- (CFE) is proposed, particularly for and redistributing weight off an im- clude elimination or adjustment of any use in recurrent fallers, those who paired (painful or weak) limb. Trained suspect medications (especially diuret- seek medical attention for a fall, and help is essential in choosing and fitting ics and antihypertensives), oral rehy- those with a gait and/or balance dis- all assistive devices because the wrong dration, judicious salt loading, pre- order. The CFE focuses on key fac- equipment or incorrect fitting will ex- standing ankle pumping, hand clench- tors in the medical and fall history, acerbate the fall risk. No fall reduction ing, and waiting at the edge ofabedor review of systems and physical exam- benefits are seen with the use of phys- upon immediate stance prior to walk- ination. Interventions utilize a mul- ical restraints. Instead, restraints in- ing. Compression stockings are used tifactorial model, although balance crease the fall risk when applied to con- to counteract venous pooling and fiu- exercise may be the most critical com- fused persons and have been associated drocortisone or midodrine are also ponent. While some components may with serious injuries, even deaths.'' sometimes considered. be marginally successful when pre- Hip pads (foam with a hard shell) In patients with carotid sinus hyper- sented individually as an interven- deflect the force of impact during a hip sensitivity, bradyarrhythmic episodes tion (such as vision impairment or landing to the soft tissues around the can precipitate falls. Many such falls environmental hazard reduction), joint. Their use has been shown to re- may well be syncopal, with the patients when presented together, fall risk can sult in a three-fold reduction in hip amnesic of their loss of consciousness. be significantly reduced.

October 200S Volume 60, NumberiO Geriatrics 27 Acknowledgments: The authors wish to 4. Alexander NB, Goldberg A. Common gait 10. Chang JT, Morton SC, Rubenstein LZ, et acknowledge the support of National Insti- disorders: A clinical overview. In: al. Interventions for the prevention of tute on Aging (NIA) Claude Pepper Older Evaluation and management of gait falls in older adults: Systematic review Adults Independence Center grant disorders, Hausdorff J, Alexander NB, and meta-analysis of randomised AG08808, and the Department of Veterans eds. Taylor and Francis, Boca Raton, clinical trials. BMJ 2004; Affairs Research and Development and the 2005. 328(7441);680-7. VA Ann Arbor Health Care System GRECC. 5. Rubinstein TC, Alexander NB, Hausdorff Dr. Nnodim is the recipient of the VA Special 11. Wolf SL, Sattin RW, Kutner M, O'Grady Fellowship in Advanced Geriatrics. Dr. JM. Evaluating fall risk in older M, Greenspan Al, Gregor RJ. Intense Tai Alexander is also a recipient of a K24 Mid- adults: steps and missteps. Clinicai Chi exercise training and fall Career Investigator Award In Patient-Oriented Geriatrics 2003; ll(l):52-60. occurrences in older, transitionally fraii Research AG109675 from NIA. We also' 6. Oliver D, Hopper A, Seed P Do hospital adults: A randomized, controlled trial. J gratefully acknowledge the contributions of fall prevention programs work? A Am Geriatr Soc 2003; Debbie Strasburg and Diane Scarpace.B systematic review. J Am Geriatr Soc 51(12):1693-701. 2000; 48(12);1679-89. 12. Herdman SJ, Schubert MC, Tusa RJ. References 7. Healey F, Monro A, Cockram A, Adams V, Strategies for balance rehabilitation. 1. Alexander BH, Rivara FT? Wolf ME. The Heseltine D. Using targeted risk factor Faii risk and treatment. Ann N Y Acad cost and frequency of hospitalization for reduction to prevent falls in oider in- Sci 2001; 942 (Oct):394-412. fall-related injuries in older adults. Am J patients: A randomized controlled trial. 13. Campbell AJ, Robertson MC, Gardner Public Health 1992; 82{7):1020-3. Age Ageing 2004; 33(4):390-5. MM, Norton RN, Buchner DM. 2. Guideline for the prevention of falls in 8. Vassallo M, Vignaraja R, Sharma JC, et Psychotropic medication withdrawal and older persons. American Geriatrics al. The effect of changing practice on a home-based exercise program to Society, British Geriatrics Society, fall prevention in a rehabilitative prevent falls: A randomized triai. J Am American Academy of Orthopedic hospital: The Hospital Injury Prevention Geriatr Soc 1999; 47(7):850-3. Surgeons Panel on Falls Prevention. J Study. J Am Geriatr Soc 2004; 14. Nikolaus T, Bach M. Preventing falls in Am Geriatr Soc 2001; 49(5);664-72. 52(3);335-9. community-dwelling frail older people 3. Shumway-Cook A, Brauer S, Woollacott 9. Haines TR Bennell KL, Osborne RH, Hill using a home intervention team (HIT): M. Predicting the probability for falls in KD. Effectiveness of targeted fails Results from the randomized falls-HIT community-dwelling older adults using prevention program in subacute . trial. J Am Geriatr Soc 2003; the Timed Up & Go Test. Phys Ther hospital setting: Randomized controlled 51(3):300-5. 2000; 80(9);896-903. trial. BMJ 2004; 328(7441);676-81. 15. Parker K, Miles SH. Deaths caused by bedraiis. J Am Geriatr Soc 1997; 45(7):797-802. 16. Parker MJ, Gillespie LD, Gillespie WJ. GERIATRICIAN Hip protectors for preventing hip fractures in the elderly. Cochrane The Departments of Community and Family Medicine and Medicine Database Systematic Review Dartmouth-Hitchcock Medical Center seek a full-time clinical faculty member at 2001(2):CD001255. the Assistant, Associate or Professor level, vy'ho will see patients and serve as 17. van Schoor NM, Smit JH, Twisk JWR, Medical Director of Lebanon Genesis Elder Care. This position Includes a faculty Bouter LM, Lips P Prevention of hip appointment at the Dartmouth Medical School at a rank commensurate with fractures by external hip protectors. A experience.These are dynamic departments with a well-established clinical quality randomized controlled trial. JAMA 2003; improvement focus and educational and research programs. Opportunities include 289(15):1957-62. teaching in Quality Improvement fellowship and medical student education, as well 18. Cameron ID, Stafford B, Cumming RG, as opportunities for research projects. Candidates should be a board-certified fam- et al. Hip protectors improve falls self- ily physician or internist with 3-7 years of academic and/or clinical experience. efficacy. Age Ageing 2000;29(l):57-62. Send letter of interest, CV and references to: 19. Kenny RA, Richardson DA, Steen N, Bexton RS, Shaw FE, Bond J. Carotid Geriatrician Search Committee, c/o Merilee Perlcins sinus syndrome: a modifiable risk factor Department of Community and Family Medicine for non-accidental falls in older 204A Strasenburgh Hall - HB 7250 adults (SAFE PACE). J Am Coil Cardiol Dartmouth Medical School, Hanover, NH 03755 2001; 38(5):1491-6. Phone: (603) 650-1893, or e-mail in Microsoft Word format to: 20. Bischoff-Ferrari HA, Dawson-Hughes B, [email protected] Willett we, Staehelin HB, Bazemore MG, Zee RY, Wong JB. Effect of vitamin D on falls: a meta-analysis. JAMA 2004; DARTMOUTH-HITCHCOCK 291(16):1999-2006. MEDICAL CENTER

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28 Geriatrics October 2005 Volume 60, Number 10