Falls

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Falls Gait Disturbance in the Elderly

• ??.??. ???????? ?????????? MD FRCP (London)
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????????????????????????????????????????????????????????????? 1 ????????????????? ??????????????????????????????????????????????? I A
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• RAMPS
• Reduced body reserve
• Atypical presentation
• Multiple pathology
• Polypharmacy
• Social adversity

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Geriatric Giants - atypical presentation

• Instability (Fall)
• Immobility
• Intellectual impairment
• Incontinence
• Inappetite
• Insomnia
• Iatrogenesis

Big Is
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Pathophysiology of geriatric syndrome
Symptoms - weakness - fatigue - anorexia -
undernutrition - weight loss Signs - physiologic
changes - balance gait -deconditioning

• 1.Decline in physiologic
• function reserve
• 2.Disease

- falls - injury - acute illness -
hospitalization - disability - dependency - death
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• Prevalence in the community 20.
• Annual figure 279-387 cases per 1000 older
  population.
• The prevalence during the past 6 months 24.1
  (women) and 12.1(men)
• Prevalence of fracture of neck of femur 2.23
  times more common among the Thai female elderly
  than the Thai male elderly.

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• The higher the people aged, the more often will
  fall.
• Only 50 hospitalized elderly will survive 1 year
  later!!
• Fall accounts for 2/3 of accidental death.
• Fall-related death rises rapidly with increasing
  age for aged gt 75.

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Physical injury

• Soft tissue raised creatine phosphokinase
• Fracture 3-5 esp. body of vertebrae, neck of
  femur, distal end of radius(Collesfracture)
• Burn
• Hypothermia live alone all night
• Central cord lesion on top of cervical
  spondylosis
• Subdural hematoma even trivial injury

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Pathogenesis
Low peak bone mass
Low BMD
Ageing
High bone loss
Fracture
Menopause
Fall Trauma
Secondary causes
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Psychological injury

• delirium
• loss of confidence
• anxiety
• depression

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Social injury

• carers anxiety
• increased demand of social support
• need safer environment

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• Homeostatic control of posture
• Sensory inputs
• Vision
• Proprioceptive sense mechanoreceptor
• Vestibular function moving head
• Central information processing
• cerebrum, cerebellum, basal ganglia, brain stem
• Muscular activity

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CAUSES of FALLS

• 1.Insufficient lighting 1.Orthostatic
  hypotension
• 2.Unfamiliar surroundings 2.Circulatory
  disorders
• 3.Slippery floor 3.Neurological
  diseases
• 4.Objects in awkward 4.Musculo-skeletal
  disease
• places 5.Acute illness

EXTRINSIC
INTRINSIC
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• Orthostatic Hypotension
• -Low cardiac output
• Volume depletion diuretics, potent
  vasodilators, prolonged bed rest, impaired
  venous return
• ANS dysfunction DM, Parkinsons
  disease
• -Drug-induced antihypertensives,
• antipsychotics, sedatives,
  hypoglycemics,
• alcohol, tricyclic antidepressants

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• Circulatory system diseases
• Vasomotor syncope micturition, defecation, cough
• Arrhythmias
• Myocardial ischemia / infarction esp. silent MI
• Valvular heart disease aortic stenosis

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• Neurological diseases
• -Stroke / TIA both anterior and posterior
  circulations
• -Cerebellar disease
• -Parkinsons disease
• -Seizure
• -Vestibular disease
• -Peripheral nervous system disease peripheral
  neuropathy, cervical / lumbar spondylosis

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• Vision
• Cataract
• Macular degeneration
• Presbyopia
• Inappropriate spectacles
• Adverse drug reaction
• Benzodiazepine
• - chlormethiazole, lormetazepam, temazepam,
  midazolam, Iorazepam,
• - nitrazepam, flurazepam, flunitrazepam,
  diazepam,
• nordazepam

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• Acute illness Final Straw Syndrome
  ??????????????
• Infection UTI, pneumonia
• Hypoxemia CHF, PTE
• Musculoskeletal arthritis, muscle wasting,
  proximal myopathy
• Chiropody corn, in-growing toe nail, bunion
• Metabolic hypo/hyperglycemia, acute renal
  failure
• Electrolyte imbalance hyponatremia

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• Psychological disorders
• Dementia
• Depression
• Phobia
• Secondary gain

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• Complete and thorough examination
• - Degree of injury
• - Physiologic aging changes
• - Precipitating factors
• Some special tests
• - Get-up-and-go test
• - Rombergs sign with slight push rollator

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Innovation in Get-up-and-go-test

• Timed get-up-and-go test
• sit, stand from arm-chair, walk 3 meters,
  turn, walk back to chair and sit down
• one trial run before timed test
• Categorical scale scoring
• lt 10 sec. freely mobile
• lt 20 sec. mostly independent
• 20-29 sec. variable mobility
• gt 29 sec. impaired mobility

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• Aging changes
• Slow velocity no sexual differences at the same
  body weight and height
• - Weak knee extensor, ankle plantar flexors
• - Range of motion of hip, knee, ankle joints
• - Type of footwear
• - Nature of walking surface
• - Shortened step and stride length longer time
  spent in the stable phase of double support

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• Frontal lobe gait (frontal ataxia or apraxia)
• Difficult gait initiation and sway, wide-based,
  flexed posture, small shuffling, hesitant step
• Magnetic gait, slipping clutch syndrome
• DDx Alzheimers disease, Vascular dementia, NPH

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• Sensory Ataxic Gait
• Wide-based, foot stamping walk with high stepping
  due to loss of proprioceptive input, constantly
  observe the foot position
• Rombergs sign positive
• DDx Thiamin deficiency, Subacute combined
  degeneration of spinal cord, spinal cord
  compression, diabetic neuropathy

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Cerebellar Ataxic Gait

• Wide-based, small irregular unsteady, staggering,
  sudden lurching to either side, forward or
  backward like being drunk
• Abnormal tandem gait, en bloc turning
• Poor coordination proprioceptive, labyrinthine,
  visual
• DDx vestibular damage, stroke, chronic
  alcoholism, progressive supranuclear palsy,
  thiamin deficiency, hypothyroidism, drug
  intoxication

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Spastic Gait

• Hemiplegia
• - Stiff, flexed hip, extended knee,
  plantar-flexed foot
• - Affected arm flexed elbow across abdomen,
  impaired
• arm swing, toe scraping or dragging across
  the floor
• - Visual neglect or hemianopia
• Paralegia (scissoring gait)
• - Cervical spondylitic myolopathy, Subacute
  combined
• degeneration of spinal cord, chronic cord
  compression,
• lacunar infarcts

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Steppage gait

• Lifting the feet hight off the ground due to foot
  drop (pretibial, peroneal muscle weakness)
• DDx (peroneal nerve injury)
• Lumbar disc herniation(L4, L5, S1),
• Sciatic nerve trauma, spondylolisthesis,
• spinal stenosis, spinal cord injury,
• bone fractures (leg, vertebrae),
• stroke, tumor, DM,
• prolonged pressure

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• Festinating Gait
• Symmetric rapid shuffling of feet, stooped
  posture, flexed hip and knee
• Centre of gravity shifted forward
• DDx Parkinsonism, vascular dementia,
  hydrocephalus

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Podalgic Gait

• Foot disorders corns, calluses, in-growing toe
  nails, bunion, atrophy of plantar pads
• Loose or tight-fitting footwear

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Wadding Gait

• Duck or penguins walk
• Limb girdle muscle weakness, lateral trunk
  movement away from the foot as it lifts
• Difficulty climbing stair, getting up from
  low-seated chair
• DDx hypo/hyperthyroidism, polymyositis,
  osteomalacia, proximal myopathy

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Multisensory Deficit Gait

• Concurrent visual and proprioceptive impairment,
  vestibular dysfunction
• Dizzy, lightheadedness when walk or turn around,
  using canes or touch walls or other furnishings
• DM
• Antalgic Gonalgic Gait
• Painful hip and knee conditions, reluctant to
  place weight on the affected limb, avoid heel
  strike and push-off, less knee extension during
  gait

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• Assess and treat physical injury
• Treat underlying conditions
• Physical therapy and education gait retraining,
  muscle strengthening, aids to ambulation, proper
  shoes, adaptive behaviour
• Alter the environment
• - safe and proper-size furniture, no obstacles on
  the floor, slippery or uneven floor, lighting,
  rails(stairs, bathroom)
• Social support

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Fall__Is it preventable ?

• Yes, but not all.
• 2 kinds of fallers
• spontaneous fall
• primary prevention health promotion
• secondary prevention risk factors
• accidental fall

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Accidental fall__environment

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Strategy of fall prevention among Thais

• 1043 elderly subjects living in the urban area
  around Siriraj Hospital Medical School, Bangkok.
• 585 -- study group vs. 458 -- control group.
• A leaflet containing information on important
  risk factors of fall within their community. In
  addition, this particular group was allowed free
  access to the geriatric clinic at Siriraj
  Hospital if there was any health problem.
• Followed up every 2 months for 1 year

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• The Kaplan-Meier survival analysis of fall

P 0.012
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Take home message

• RAMPS
• The big Is
• Abnormal gait balance ? falls ? morbidity
  mortality
• Screening those at risk during clinical practice
• - Get-up-and-go test
• Consultation from orthopedic dept. preoperative
  assessment search for causes of fall
• Treat correct predisposing precipitating
  factors
• intrinsic extrinsic factors