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Page 1 of 4 Falls & Gait Disorders ILOs At the end of this session, the student will be able to: ▪ Recognize the incidence of the problem. ▪ Identify the causes, risk factors for falling. ▪ Recognize the Fall Injuries. ▪ Order Assessment of patients who fall. ▪ Identify the main complications of fall. ▪ Outline the plan for prevention and management Annually, about one-third of people over age 65 fall, and the frequency of falls increases markedly with advancing age. About 10% of falls result in serious injuries. ➢ Definition: an event that occurs when a person inadvertently drops down to the ground or another lower level. ➢ Incidence: Approximately 40% of persons aged 65 years and over fall in a given year; Half of persons who fall do so more than once. Incidence increases steadily after age 60 years. Women are more likely to fall than men. ➢ Risk Factors for Falling • Age greater than 80 years • Need for assistance with activities of daily living, • Previous falls, • Vision: impaired contrast sensitivity and depth perception • Multifocal lenses, commonly worn by presbyopia older persons. • Hearing loss & impaired vestibular function • Proprioceptive dysfunction • Postural Hypotension • Postprandial hypotension may be suspected in persons complaining of dizziness or who fall after getting up from, or soon after, a meal. • Musculoskeletal Impairments • Foot problems, such as calluses, bunions, long nails, or joint deformity • The risk of a fall in older persons recently discharged from the hospital is about 4 folds higher than that for others in the community during the first 2 weeks after discharge. Page 2 of 4 ➢ Causes of fall in elders: Balance and ambulation require a complex interplay of cognitive, neuromuscular, and cardiovascular function. With age, balance mechanisms can become compromised, reaction time slows, and postural sway increases. These changes predispose the older person to a fall when challenged by an additional insult to any of these systems. Falls in older people are due to intrinsic and extrinsic. 1. Cognitive impairment: Alzheimer’s disease, delirium, confusion, psychosis, medications side effects as benzodiazepines. 2. Neurological problems: reduced position sense, reduced vibration sense, reduced balance, slow reactions. 3. Muscle weakness; frailty and Sarcopenia. 4. Visual defects: reduced visual field, cataract, bifocal or multifocal lenses. 5. Musculoskeletal: arthritis, stiff joints, giving way of the knee, weak muscles, deconditioning due to prolonged immobility. 6. Cardiac problems: drop attacks, arrhythmia, postural hypotension, medications side effects. 7. Unsafe environment: poor lightening, rugs, stairs, steps, slippery floors. 8. Medications: sedative/hypnotics, antidepressants, and benzodiazepines were the classes of medications most likely to be associated with falling. The use of multiple medications simultaneously has also been associated with an increased fall risk. 9. Others: unfitted shoes, unsuitable stick, … ➢ Consequences of falls: • Physical injuries: ✓ Lacerations. ✓ Serious soft-tissue injuries (rhabdomyolysis leading to acute kidney injury). ✓ Head trauma (cerebral hemorrhage or subdural hematoma). Chronic subdural hematoma is easily overlooked and should be considered in cases of new neurological or cognitive impairment or headache. ✓ Fractures (hip, wrist, vertebrae with high mortality rate in elderly women with hip fractures, particularly if they were debilitated prior to the time of the fracture. • Complications of prolonged lie on the floor: dehydration, pneumonia, hypothermia, electrolyte imbalance, death. • Loss of independence and fear of falling again (post-fall syndrome). Post Fall Syndrome Page 3 of 4 Patients expressed great fear of falling when they stood erect, tending to grab and clutch at objects within their view, and showing remarkable hesitancy and irregularity in their walking attempts. It may be mild, moderate or severe. severe syndrome was said to be present when following a fall (and in the absence of any neurological or orthopedic abnormality which in itself may adversely influence gait and balance )the patient was unable to stand or to walk unsupported When asked to do so, the patient assumed an expression of fear and anxiety clutched to any object within the field of vision staggered, stumbled or rushed forward and appeared to be in imminent danger of falling .When these patients were provided support their behavior was modified and fairly normal pattern of stepping took place. ➢ Assessment of patients who fall: • It should include postural blood pressure and pulse. • Cardiac examination. • Evaluations of strength of muscles (30 seconds stand up test), range of motion • Cognition, and proprioception. • Examination of feet and footwear. • Gait assessment should be performed in all older people. Gait and balance can be readily assessed by the “Up and Go Test,” in which the patient is asked to stand up from a sitting position without use of hands, walk 10 feet, turn around, walk back, and sit down. Patients who take less than 10 seconds are usually normal, while patients who take longer than 13.5 seconds are considered at increased risk for falling. • Assessment of balance: 4 stages balance test. • Since most falls occur in or around the home, a visit by a visiting nurse, physical therapist, or health care provider for a home safety evaluation may be beneficial in identifying environmental obstacles and is generally reimbursed by third-party payers, including Medicare. ➢ Prevention & Management • Exercise is the intervention that is most consistently reported to reduce the risk of falls. Balance focused exercises, gait, and strength training appear to be more effective for fall prevention than general exercise programs. • Teaching elderly how to get up from the floor in order to prevent a long lie after a fall. • minimizing environmental hazards • eliminating medications where the harms may outweigh the benefits (e.g., sedative-hypnotics). • Vitamin D supplementation might be considered for high-risk individuals (e.g., institutionalized elders) on a case-by-case basis. Page 4 of 4 • Assistive devices, such as canes and walkers, are useful for many older adults but are often used incorrectly. Canes should be used on the “good” side. The height of walkers and canes should generally be about the level of the wrist. Physical therapists are invaluable in assessing the need for an assistive device, selecting the best device, and training a patient in its correct use. • Eyeglasses, particularly bifocal or graduated lenses, may increase the risk of falls, particularly in the early weeks of use. Patients should be counseled about the need to take extra care when new eyeglasses are being used. • Patients with repeated falls are often reassured by the availability of telephones at floor level, a mobile telephone on their person, or a lightweight radio call system. • Their therapy should also include training in techniques for arising after a fall.

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