Stand by Me! Reducing The Risk of Injurious Falls in Older Adults
Stand by Me! Reducing The Risk of Injurious Falls in Older Adults
Stand by Me! Reducing The Risk of Injurious Falls in Older Adults
CME
CREDIT
EDUCATIONAL OBJECTIVE: Readers will assess their elderly patients risk of falling and intervene appropriately
LEAH BEEGAN, DO
KEY POINTS
Practitioners can reduce fall-related injury by screening
older adults yearly with questions about problems with
balance and gait, performing a focused history and examination when necessary, and implementing evidencebased interventions.
Cognitive impairment itself is an independent predictor of
falls because it can reduce processing speed and impair
executive function.
An exercise program with resistance, balance, and gait
training is usually prescribed to patients at high risk,
along with a home assessment and withdrawal or minimization of psychoactive and antipsychotic medications.
Combined calcium and vitamin D supplements should be
given to most older adults in long-term care facilities to
reduce fracture rates.
There are no specific evidence-based recommendations
for fall prevention in community-living older adults with
cognitive impairment or dementia.
doi:10.3949/ccjm.82a.14041
301
Fall or balance
problem since last
visit or in the past
year?
No fall and
no reported balance
problem
Yes
Reassess periodically
Good results
on office evaluation,
including a simple
test of balance
Full evaluation
with multicomponent
intervention
SCREENING TESTS
The strongest
predictors of
falls are a
recent fall and
the presence
of a gait or
balance
disorder
302
TABLE 1
Odds ratio
Any psychotropic
1.73
Any antidepressant
1.66
Type 1a antiarrhythmics
1.59
Sedative-hypnotics 1.54
Tricyclic antidepressants
1.51
Neuroleptics 1.50
Benzodiazepines 1.48
Digoxin 1.22
Nitrates 1.13
Antihypertensives a
NS
a
Calcium channel blockers, diuretics, loop diuretics, angiotensin-converting enzyme
inhibitors, beta-blockers.
DATA FROM LEIPZIG RM, CUMMING RG, TINETTI ME. DRUGS AND FALLS IN OLDER PEOPLE:
A SYSTEMATIC REVIEW AND META-ANALYSIS: I. PSYCHOTROPIC DRUGS.
J AM GERIATR SOC 1999; 47:3039.
Exercise
recommendations should be
customized
to the patient
303
Mini-Cog
Recall = 0 items
Concern for
cognitive impairment
Recall = 12 items
Clock abnormal
Concern for impairment
Recall = 3 items
Cognition intact
Clock normal
Cognition intact
FIGURE 2. Interpretation of the Mini-Cog test, which requires the patient to recall
three words and draw an analog clock
304
TABLE 2
305
Up to 7%
of patients fall
in the first
week after
a stroke
306
ability to complete ADLs, improves mood, reduces hyperglycemia, and improves quality of
life. Some studies have found a greater risk of
falling with exercise therapy as independence
increased.40 However, a meta-analysis in 2013
found that exercise interventions, ranging from
3 to 24 months and consisting mainly of balance and resistance training, reduced the risk of
falls by 23%.41 Mixing several types of exercises
was helpful. Studies of a longer duration with
exercise sessions at least 2 to 3 times per week
demonstrated the most benefit.41 There was no
statistically significant reduction in fracture
risk in this meta-analysis,41 although, possibly,
more participants would have been needed for
a longer period to demonstrate a benefit. Additionally, no study combined osteoporosis treatment with exercise interventions.
WHAT EVIDENCE EXISTS FOR PATIENTS
WITH COGNITIVE IMPAIRMENT?
Currently, there are no specific evidencebased recommendations for fall prevention in
community-dwelling older adults with cognitive impairment and dementia.7 Cognitively
impaired adults are typically excluded from
community studies of fall prevention. The one
study that specifically investigated community-dwelling adults with cognitive impairment
was not able to demonstrate a fall reduction
with multifactorial intervention.42
PREVENTING FALLS IN ELDERLY PATIENTS
WHO RECENTLY HAD A STROKE
Falls are common in patients who have had a
cerebrovascular event. Up to 7% of patients
fall in the first week after a stroke. In the year
after a stroke, 55% to 75% of patients experience a fall.43 Falls account for the most common medical complication after a stroke.44
Several small studies found that vitamin D
supplementation after a stroke reduced both
the rate of falls and the number of people who
fall.45 Additional interventions such as exercise, medication, and visual aids have been
studied, but there is little evidence to support
their use. Mobile patients who have lower-extremity hemiparesis after a stroke may develop
osteoporosis in the affected limb, so evaluation and appropriate pharmacologic therapy
may be considered.
REFERENCES
1. Tromp AM, Pluijm SM, Smit JH, Deeg DJ, Bouter LM, Lips P. Fall-risk
screening test: a prospective study on predictors for falls in communitydwelling elderly. J Clin Epidemiol 2001; 54:837844.
2. Binder EF, Brown M, Sinacore DR, Steger-May K, Yarasheski KE, Schechtman KB. Effects of extended outpatient rehabilitation after hip fracture:
a randomized controlled trial. JAMA 2004; 292:837846.
3. Sterling DA, OConnor JA, Bonadies J. Geriatric falls: injury severity is
high and disproportionate to mechanism. J Trauma 2001; 50:116119.
4. Centers for Disease Control and Prevention (CDC). Web-based Injury
Statistics Query and Reporting System (WISQARSTM). www.cdc.gov/
injury/wisqars. Accessed April 8, 2015.
5. Tinetti ME, Baker DI, King M, et al. Effect of dissemination of evidence
in reducing injuries from falls. N Engl J Med 2008; 359:252261.
6. Ganz DA, Bao Y, Shekelle PG, Rubenstein LZ. Will my patient fall? JAMA
2007; 297:7786.
7. Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Summary of the Updated American
Geriatrics Society/British Geriatrics Society clinical practice guideline for
prevention of falls in older persons. J Am Geriatr Soc 2011; 59:148157.
8. Mathias S, Nayak US, Isaacs B. Balance in elderly patients: the get-up
and go test. Arch Phys Med Rehabil 1986; 67:387389.
9. Podsiadlo D, Richardson S. The timed Up & Go: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991; 39:142148.
10. Shumway-Cook A, Brauer S, Woollacott M. Predicting the probability
for falls in community-dwelling older adults using the Timed Up & Go
Test. Phys Ther 2000; 80:896903.
11. Springer BA, Marin R, Cyhan T, Roberts H, Gill NW. Normative values for
the unipedal stance test with eyes open and closed. J Geriatr Phys Ther
2007; 30:815.
12. Leipzig RM, Cumming RG, Tinetti ME. Drugs and falls in older people: a
systematic review and meta-analysis: I. Psychotropic drugs. J Am Geriatr
Soc 1999; 47:3039.
13. Hilmer SN, Mager DE, Simonsick EM, et al. A drug burden index to define the functional burden of medications in older people. Arch Intern
Med 2007; 167:781787.
14. Rudolph JL, Salow MJ, Angelini MC, McGlinchey RE. The anticholinergic risk scale and anticholinergic adverse effects in older persons. Arch
Intern Med 2008; 168:508513.
15. American Geriatrics Society 2012 Beers Criteria Update Expert Panel.
American Geriatrics Society updated Beers Criteria for potentially
inappropriate medication use in older adults. J Am Geriatr Soc 2012;
60:616631.
16. Gallagher P, Ryan C, Byrne S, Kennedy J, OMahony D. STOPP (Screening
Tool of Older Persons Prescriptions) and START (Screening Tool to Alert
doctors to Right Treatment). Consensus validation. Int J Clin Pharmacol
Ther 2008; 46:7283.
17. Sterke CS, Ziere G, van Beeck EF, Looman CW, van der Cammen TJ. Doseresponse relationship between selective serotonin re-uptake inhibitors
and injurious falls: a study in nursing home residents with dementia. Br J
Clin Pharmacol 2012; 73:812820.
18. Khalili H, Huang ES, Jacobson BC, Camargo CA Jr, Feskanich D, Chan
AT. Use of proton pump inhibitors and risk of hip fracture in relation
to dietary and lifestyle factors: a prospective cohort study. BMJ 2012;
344:e372.
19. Gill SS, Anderson GM, Fischer HD, et al. Syncope and its consequences in
patients with dementia receiving cholinesterase inhibitors: a populationbased cohort study. Arch Intern Med 2009; 169:867873.
20. Janssen HC, Samson MM, Verhaar HJ. Vitamin D deficiency, muscle function, and falls in elderly people. Am J Clin Nutr 2002; 75:611615.
21. Muir SW, Gopaul K, Montero Odasso MM. The role of cognitive impairment in fall risk among older adults: a systematic review and metaanalysis. Age Ageing 2012; 41:299308.
22. Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. The Mini-Cog: a
cognitive vital signs measure for dementia screening in multi-lingual
elderly. Int J Geriatr Psychiatry 2000; 15:10211027.
23. Cordell CB, Borson S, Boustani M, et al; Medicare Detection of Cognitive
Impairment Workgroup. Alzheimers Association recommendations
for operationalizing the detection of cognitive impairment during the
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
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