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falls in the elderly


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what is the definition of "fall"
an unintentional change in position that would not occur in an otherwise fit individual.
how might an elderly person define falling?
i think i slipped
i dont remember what happened
i was in a hurry
i tripped
i lost my balance
true or false: false are the leading cause of accidental death in persons over the age of 65
what percentage of community dwelling persons 65 and older fall annually?
how many pts that experience one fall will experience another?
what is a serious consequence of falls?
hip fractures - leads to hospitalization
when do most falls occur?
during everyday activities
true or false: usually there is only one factor that caused a fall
false: falls are multifactorial, usually w/ a combo of extrinsic and intrinsic factors
what sensory changes occur in elderly that might contribute to falling?
vision: decreased acuity, contrast sensitivity and depth perception, greater sensitivity to glare
proprioception: delayed sensory or motor input from muscle and joint receptors
vestibular: impaired speech comprehension and reduced selectivity
what musculoskeletal changes occur in elderly that might contribute to falling?
decline in muscle strength (esp lower extrem)
degeneration of cartilage in both hips and knees
forward lean in posture, alters body's balance
what changes in gait might contribute to falling?
decline in walking speed
increase in stride width
decrease in steppage height
loss of normal arm swing
decrease in hip and knee rotation
not all older adults have gait changes and certain characteristics might be preferred
what chronic diseases are related to falls?
visual: cataracts, glaucoma
musculoskel: prolonged bedrest, immobility, OA, neuropathy, foot deformaties
neuro: CVA, dementia (alzheimer's), parkinson's
cardiovascular: orthostatic hypotension, syncope
other: anxiety and depression
which acute diseases are associated w/ falls?
febrile conditions
which medications are associated w/ an increased risk of falls?
analgesics and psychoactive drugs: reduce alertness or retard central processing
antihypertensives, antiarrhythmics, diuretics: impaired cerebral perfusion
phenothiazines: induce EPS
what are some extrinsic risk factors concerning physical environment associated w/ falls?
physical environment: clutter, slick/irregular floor surfaces, frayed carpets and throw rugs, lack of grab bars/rails, edges w/o contrasting color, curbs not clearly marked, poorly illuminated areas, armless chairs and low toilet seats
what are some extrinsic factors concerning ambulation devices that are associated w/ falls?
improper use
defective/faulty equipment
what are some extrinsic factors concerning footwear that are associated w/ falls?
high-heels, slippers, improper fit
what are three categories of extrinsic factors associated w/ falls?
physical environment, ambulation devices, footwear
what are four categories of intrinsic risk factors associated w/ falls?
age-related physiologic changes, chronic dx, acute dx, drugs
describe the screening process for falls. how often should pts be screened?
no consensus about optimal time to initiate screening
ask about falls, as well as observe balance and gait at least YEARLY
complete functional and risk assessment during the pt interview
describe the "up and go" test for gait and balance assessment
task: get up out of standard armchair, walk 3 meters, turn, walk back to chair and sit down
requirement: ambulate w/ or w/o assistive devices and follow a three step command
trials: one practice trial, three actual trials: times are averaged from tree trials
time: 1-2 minutes
equipment: armachair, stopwatch, measured path
predictive results: <10s is freely mobile, <20s is mostly independent
what is the morse fall scale and how is it used?
utilized in some inpt care settings, including hospital and long term care
complete on admission, after a change in condition, following a fall, or routinely
what are the item on the morse fall scale?
hx of falling, immediate or w/in three months (no/yes)
secondary diagnosis (no/yes)
ambulatory aid (bedrest,nurse assist/crutches,cane,walker/furniture)
IV/Hep lock (no/yes)
gait (normal, bedrest, immobile/weak/impaired)
mental status (oriented to own ability/forgets limitations)
according to the morse scale, which scores are no risk, low risk, and high risk and what action is taken for each?
no risk: 0-24, no action
low risk: 25-50 standard fall prevention strategies
high risk: >51 high risk fall prevention strategies
when assessing a fall, what items are included for history?
circumstances of fall (SPLATT) Syptoms Previous falls Location Activity Time Trauma
ask open ended ?s, ask witnesses ?s about circumstances
medical problems
medications (what meds do you take - Rx, OTC, herbal?, do you manage own meds or have help?, do you take your meds as the Dr prescribed?
when assessing a fall, what is measured during the physical exam
postural blood pressure
mental status
what lab tests and imaging studies should be performed when assessing a fall?
CBC and electrolytes
BUN and SCr
what fraction of falls result in injury that requires medical attention?
what percentage result in minor physical injury
1 in 10 require medical attention
over 50% result in minor injury
what are some physical injuries associated w/ falls?
distal forearm fracture (pain and decrease range of motion)
musculoskeletal injuries (sprains, joint dislocations, and skin tears)
hip fractures (disabilities and nursing home placement rehabilitation services influence recovery)
head trauma (EtOH is a factor in some cases, rule out subdural hematoma if mental confusion)
what types of complications are associated w/ falls?
physical injury, long lies, restricted activity, psychological effects, health care costs
long lies after a fall can result in what?
dehydration, pressure sores, rhabdomyolysis
true or false: falls account for more resticted activity days than arthritis or DM
what are some results of restricted activity following a fall?
defecits in ADLs or IADLs
functional decline due to physical injury, fear of further falls or the environment
describe the psychological effects of falls
depression, shame, anxiety, or loss of confidence may result; fear of falling may result in impaired gait and balance or loss of independence
describe the impact of falls on health care costs
direct and indirect costs involving the pt, caregiver and institution
increased utilization of health care services and their sequelae: ER visit, acute hospital admission, nursing home placement
what are some clinical management strategies for falls?
medical, rehabilitative, injury prevention devices, environmental strategies, behavioral/psychosocial strategies
describe the medical strategies in clinical management of falls
treat concomitant medical problems, d/c inappropriate meds, consider Ca/Vit D supplements, d/c excessive EtOH consumption
describe the rehab strategies in the clinical management of falls
exercise: muscle stengthening, individualzied programs
ambulation devices: canes/walkers (use should be tailored for individual pt)
consultants: PT, podiatric, opthalmic
name some injury prevention devices
hip protectors/padding
emergency help systems
what are some environmental strategies in the prevention of falls
home safety checklists, unobstructed clear pathways, lighting sources and access, slip resistant floor surfaces, handrails on stairs, shower seats and grab bars, proper bed and seat height, bed supports and rails
what are some behavioral and psychosocial strategies in the clinical management of falls?
pt education
social service referral
increase person's confidence
increase person's independence

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