1. M A R C E V A N S M . A B A T , M D , F P C P , F P C G M
H e a d , C e n t e r f o r H e a l t h y A g i n g
THE ELDERLY PATIENT
WITH FALL

3. • Leading cause of
mortality, injury,
hospitalization and
disability
• 1 in every 4 elderly
• In 2014, $31 billion as
cost of injuries
Why are falls important?
https://www.ncoa.org/news/resources-for-
reporters/get-the-facts/falls-prevention-facts/

4. Relative Risk
1. Muscle weakness 4.4
2. History of falls 3.0
3. Gait deficit 2.9
4. Balance deficit 2.9
5. Use of assistive device 2.6
6. Visual deficit 2.5
7. Arthritis 2.4
8. Impaired daily living activities 2.3
9. Depression 2.2
10.Cognitive impairment 1.8
11.Age > 80 years 1.7
What causes falls?
American Geriatric Society Panel on Falls Prevention,
Journal of the American Geriatric Society, 2001

7. Falls and Medications
• More medications
(polypharmacy),
the higher the fall
risk
• Stronger
relationship with
medications that
can cause falls
http://bmjopen.bmj.com/content/7/10/e016358
Nurs Midwifery Stud. 2013 Jun; 2(2): 171–175.

8. Antihypertensives
Antianginals
Diuretics
Anticoagulants
Antiplatelets
Antiarrhythmics
Digoxin
The Elderly with Cardiac Meds
Falls via
multiple
interacting
mechanisms

9. Fractures
Immobility and
Disability
Pressure Ulcers
Venous
thromboembolism
Pneumonia
Constipation
Chronic Pain
Insomnia
Delirium
OTHER
COMPLICATIONS
Depression
Polypharmacy
Increased Cost of
Care
Increased
Burden of Care
Increased risk of
DEATH!

10. • 30-day mortality higher in the
nonoperative group with odds ratio [OR]:
3.95, 95% confidence interval [CI]: 1.43-
10.96;
• 1-year mortality OR: 3.84, 95% CI: 1.57-
9.41
Complications of Non-Operative
Treatment
http://journals.sagepub.com/doi/full/10.1177/
2151458517713821

11. • Prevent the 1st fall
• Prevent future falls
• Prevent complications of
falls
• Treat the complications
• Rehabilitate to prevent the
disability
• Manage what can be
managed
How to manage?

12. • Detailed History
• Physical and Neurological
Examination
• Cognitive Evaluation
• Behavioral/Emotional
Evaluation
• Functional Evaluation
• Nutritional Evaluation
• Environmental Evaluation
• Social Evaluation

13. • The USPSTF does not recommend
automatically performing an in-depth
multifactorial risk assessment in
conjunction with comprehensive
management of identified risks to prevent
falls in community-dwelling adults aged 65
years or older because the likelihood of
benefit is small. (Grade C)
Screening for Falls

14. •BUT…..patients and clinicians
should consider the balance of benefits
and harms on the basis of the
circumstances of prior falls, comorbid
medical conditions, and patient values.

15. Morse Fall Scale

16. Timed Up and Go Test
• Prepare the following
– Armless chair
– A marker 10 feet away from the chair
• Procedure
10 ft.
Rise from chair Walk to the marker on the floor TurnReturn to the chairSit down again

17. Functional Reach

18. • In women aged 65 years and older and in
younger women whose fracture risk is
equal to or greater than that of a 65-year-
old white woman who has no additional
risk factors (Grade B)
Osteoporosis Screening
USPSTF

19. Fracture Risk Assessment

20. • Rule out secondary causes
• Pharmacologic
– Bisphosphonates
– SERMs
– Teriparitide
– Strontium ranelate
– Denosumab
– Calcium and Vitamin D
• Rehabilitation
Osteoporosis Treatment

21. • Early surgical intervention (within 24
hours)
– significantly lower 30-day mortality (5.8% vs.
6.5%; number needed to treat [NNT], 127)
– fewer postoperative complications (i.e.,
myocardial infarction, pneumonia, or venous
thromboembolism)
– significantly fewer adverse outcomes at 30
days (10% vs. 12%; NNT, 48).
Surgical Management
https://www.jwatch.org/na45700/2018/01/02
/timing-hip-fracture-repair

22. • Cardiac perioperative evaluation
– Weighing risks vs. benefits
• DVT and VTE prophylaxis
Perioperative Management

23. • improved ambulatory outcomes
• improved functional recovery
• improved strength and balance recovery
• decreased length of stay and increased falls
self-efficacy
• positive effect on lower-extremity power
generation
Rehabilitation after Hip Surgery
Arch Phys Med Rehabil. 2009 Feb;90(2):246-
62. doi: 10.1016/j.apmr.2008.06.036.

24. • Nutritional management
• Optimization of other medical conditions
• Pain management
Other Aspects of Care

25. Thank you!