Strategy: Pilot Algorithm Box 5 Assessment Dr. Frank Molnar - PowerPoint PPT Presentation

Champlain LHIN Falls Prevention Strategy: Pilot Algorithm – Box 5 Assessment Dr. Frank Molnar Medical Director, Regional Geriatric Program of Eastern Ontario ( www.rgpeo.com ) Ottawa Geriatric Assessment Outreach Teams (GAOT) Champlain Geriatric Emergency Management (GEM) Program Staff Physician, Geriatric Medicine - The Ottawa Hospital - The Winchester District Memorial Hospital - The Cornwall Community Hospital

• It is estimated that one in three seniors are likely to fall at least once per year (World Health Organization (WHO 2007) • Falls are one of the most common cause of injury and the sixth leading cause of death for seniors. Senior Care Canada • Every 10 minutes in Ontario, at least one older adult visits an ED due to a fall • Ontario Injury Prevention Statistics, 2007-2008 • Every 30 minutes in Ontario, at least one older adult is admitted to hospital due to a fall • Ontario Injury Prevention Statistics, 2007-2008 • Falls are the leading cause of overall injury costs in Canada and account for $6.2 billion or 31% of total costs of all injuries • Smartrisk, 2009

The Good News !!!  The literature suggests that as many as 1/3 of falls- related adverse outcomes are preventable  Division of Aging and Seniors 2006  The Vital sign concept (opportunity to help)  The sudden onset of falls in someone who previously did not have a falling tendency most likely represents underlying illness

Why are FALLS so difficult to assess? No other mammals spend their  day standing upright - upright balance requires smooth functioning and integration of complex neurological and cardiovascular systems. Therefore FALLS can be  caused by multiple problems: vertigo, strokes, cardiac and neurological diseases, neck disorders, physical deconditioning, and medications that do not fall under a single organ-specific specialty. The Assessment of FALLS is  not a major focus of the medical curriculum.

In Office Assessment  Box 5 based on American Geriatrics Society and British Geriatrics Society Clinical Practice Guideline  Priority influenced by prevalence of problems seen by Geriatric Assessment Outreach Teams (GAOT see 1800 seniors per year)  Most modifiable first  This pilot is an ongoing iterative process. Your input throughout the study will help refine what is and is not realistic in Primary Care setting – you will drive refinements of the algorithm

Box 5 (section 2): Assessment Medications a. Postural Hypotension b. Gait, balance, mobility and muscle strength c. TUG and Chair Stand a. Evaluate Pain related mobility decreases b. Visual Acuity d. Other Neurological Impairments e. Heart rate and rhythm f. Bone Health; nutritional review g. Feet and Footwear h. Environmental Hazards i. Depression j.

Box 5 – 2a. Medications Slow reaction time (drugs that cause delirium and slow mentation) 1. Narcotics, benzodiazepines, ETOH, Anticholinergics (e.g.  Ditropan, Detrol, Tricyclic antidepressants ). Decrease cerebral perfusion (see Postural hypotension – 6 ANTIs 2. Anti-hypertensives,Anti-anginals,Anti-parkinsonian  medications (e.g. sinemet),Anti-depressants (e.g., Anti- cholinergic tricyclics),Anti-psychotics (Anti-cholinergic effect),Anti-BPH (e.g. Hytrin, Flomax) Cause parkinsonism 3. Antipsychotics  GI – Stemetil, Maxeran  Vestibular Toxicity 4. Aminoglycosides, High dose loop diretics  SSRIs 5. Evidence is building that SSRIs increase fall risk 

Decrease or stop drugs that can cause Delirium  Is the patient on delirium inducing drugs : Benzodiazepines  Narcotics  Alcohol  Antihistamines  Neuroleptics (Antipsychotics)  Haldol, Respiridone, Olanzepine  Anticonvulsants (Seizure medications)  Dilantin (Phenytoin), Gabapentin, Pregabalin  Keep dilantin level at level that previously controlled seizures – if this  info not available then try to keep level < 60) Anticholinergics (see next slides) 

How can one sort through this daunting list of medications?  Look for a time-based relationship  Falls or confusion worsened after starting this medication (or increasing the dose). Ask Pharmacist to review drugs  that may be contributing to falls and/or impairing cognition (theoretical perspective) and then apply a practical lens based on personal knowledge of patient to develop a tailored personalized plan for medication adjustments (“strategic deprescribing”).

Box 5 (section 2): Assessment Medications a. Postural Hypotension b. Gait, balance, mobility and muscle strength c. TUG and Chair Stand a. Evaluate Pain related mobility decreases b. Visual Acuity d. Other Neurological Impairments e. Heart rate and rhythm f. Bone Health; nutritional review g. Feet and Footwear h. Environmental Hazards i. Depression j.

Box 5 – 2b. Postural Hypotension  Lightheadedness 1-3 min after sitting or standing Perspiration, nausea, weakness, dizziness   Measure BP and Pulse after the person has been lying for at least 3-5 minutes and 1 - 3 minutes after standing  A decline of >20 mm Hg in systolic BP and/or >10 mm Hg in diastolic BP on the assumption of an upright posture with or without an increase in PR American Academy of Neurology   High incidence (as high as 30%) among older people (due to age-related changes in the CV & nervous systems & medication use)

Box 5 – 2b. Postural Hypotension 4D-AID acronym Causes associated with a compensatory tachycardia – 3 D s  D econditioning  D ysfunctional Heart  Myocardium (very low Left Ventricular Ejection Fraction)  Aortic Stenosis  D ehydration  Disease  Dialysis (post dialysis dry weight too low)  Drugs   Diuretics Anorexic Drugs – narcotics, digoxin, antibiotics, cholinesterase inhibitors  D rugs – 6 ANTIs  Anti-hypertensives  Anti-anginals  Anti-parkinsonian medications (e.g. sinemet)  Anti-depressants (e.g., Anti-cholinergic tricyclics)  Anti-psychotics (Anti-cholinergic effect)  Anti-BPH (e.g. Hytrin, Flomax)  Causes that present with lack of compensatory tachycardia - AID  A utonomic Dysfunction  Diabetic autonomic neuropathy (consider if patient has peripheral neuropathy)  Low B12  Hypothyroidism  ETOH abuse  Parkinsonism (Parkinson’s disease, Progressive Supranuclear Palsy, Multisystem Atrophy (e.g. Shy Drager))  I diopathic (Bradbury-Eggleston)  Depletion of Norepinephrine from sympathetic nerve terminals  D rugs  Beta-Blockers 

Box 5 (section 2): Assessment Medications a. Postural Hypotension b. Gait, balance, mobility and muscle strength c. TUG and Chair Stand a. Evaluate Pain related mobility decreases b. Visual Acuity d. Other Neurological Impairments e. Heart rate and rhythm f. Bone Health; nutritional review g. Feet and Footwear h. Environmental Hazards i. Depression j.

Box 5 – 2c. Gait, balance, mobility and muscle strength  Romberg  Get Up and Go  Timed Up and Go  30 second Chair Stand Test  Question?  Which, if any, of these do you feel are useful in clinical practice?

Romberg's Test is NOT a test of cerebellar function  It is a test of the proprioception receptors and pathways function.

Romberg’s Test  What is Being Tested in the Romberg Test? With the eyes open, three sensory systems provide input to the cerebellum to maintain truncal stability. These are vision, proprioception, and vestibular sense. Proprioception- The brain's awareness of a joint's or limb's position in relation to the rest of the body Vestibular Sense- Equilibrium

EYES CLOSED  If there is a mild lesion in the Vestibular or Proprioception systems, one is usually able to compensate with the eyes open. With the eyes closed, however, visual input is removed and instability can be brought out.  Increased swaying with eyes closed would indicate postural position sense is affected, posterior column disease or a peripheral neuropathy.

 When you do the Romberg maneuver, you need to stand close to the patient and be ready to catch them in case they fall

Romberg Test Instructions:  Stand with feet together, arms to the side, and eyes open.  Observe for substantial postural sway or break in position  Instruct to: close eyes and maintain that position with closed eyes

Romberg Test Scoring  Romberg Sign- P resent or A bsent  Present- if the sway is considerable and/or the patient breaks position.  (note- patients unable to stand with feet together while eyes are open are untestable )  Absent- perform task with no sway or minimal sway without breaking position

Get Up and Go Test The "Get Up and Go" test was developed by Mathias, Nayak, and Issacs in 1986.  A general physical performance test used to assess mobility, balance and locomotor performance in elderly people with balance disturbances. More specifically, it assesses the ability to perform sequential motor tasks relative to walking and turning

GET UP AND GO TEST  A simple & practical performance measure of gait & balance  Standardizes most of the “basic mobility” tasks  Subject is observed while he rises from a chair, walks 3 meters & returns to the chair