Help!

Ive Fallen and I Cant

Get Up!

DEFINITION
fallsunintentional events in which a person
comes to rest on the floor or ground that are
not caused by loss of consciousness, stroke,
seizure, or overwhelming force.
Falls in three different settingsthe
community, skilled nursing facilities, and
hospitalsare discussed; reasons for falling
and, therefore, interventions differ by site.

Falls in the Elderly

Prevalence

Clinical Importance
Risk Factors & Etiology
Evaluation
Prevention & Management
Summary

Prevalence

30% of those over 65 fall annually

Half are repeat fallers
Falls go up with each decade of life
Over half of those in nursing homes and
hospitals will fall each year

UCSF Division of Geriatrics Primary

Care Lecture Series May 2001

Incidence rates of Falls in U.S.

One of every three adults

over 65 years fall in every year

Where are people likely to fall?

For people 65 years old or older..
Nursing Home 10%

Public Places 30%

Home 60%

Leading Causes of Death

Age Group

First Leading Cause

of Trauma Death

Second Leading
Cause of Trauma
Death

35 64

Motor Vehicle
36.8%

Falls
29.6%

65+

Falls
43.3%

Motor Vehicle
10.2%

Falls in the Elderly

Prevalence

Clinical Importance

Risk Factors & Etiology

Evaluation
Prevention & Management
Summary

C. Bree Johnston, MD MPH , Copyright May

2001

Impact of Hip Fractures

1% of falls result in hip fracture

$2 billion + in medical costs annually
25% die within 6 months
60% have restricted mobility
25% remain functionally more dependent

C. Bree Johnston, MD MPH , Copyright May

2001

Falls Cause Morbidity and Mortality

Mortality: indirect effects
Fractures: 6% of falls
Soft tissue injury, head injury, subdural
hematoma
Fear of falling can result in decreased
activity, isolation, and further functional
decline
Nursing home placement and loss of
independence
C. Bree Johnston, MD MPH , Copyright May
2001

Falls in the Elderly

Prevalence
Clinical Importance

Risk Factors & Etiology

Evaluation
Prevention & Management
Summary

C. Bree Johnston, MD MPH , Copyright May

2001

Falls are Multifactorial

Intrinsic Factors

Extrinsic Factors

Medical
conditions
Impaired vision
and hearing

Medications

FALLS

Age related
changes

Improper use of
assistive devices
Environment

C. Bree Johnston, MD MPH , Copyright May

2001

Interactions among intrinsic, pharmacologic, environmental, and situational factors that affect risk of falling in older persons. (Modified
with permission from King MB, Tinetti
ME. Falls in community-dwelling older persons. J Am Geriatr Soc. 43:1146, 1995.

Normal Changes with Aging

Neurologic

Increased reaction time

Decreased righting reflexes
Decreased proprioception

Vision Changes
Decreased accommodation & dark adaptation

Decreased muscle mass

C. Bree Johnston, MD MPH , Copyright May
2001

Dysmobility

Dysmobility and falling closely related

15% of those over 65 have trouble
walking
1/4 men and 1/3 women over age 85 have
difficulty with walking
2/3 of people in hospital or NH unable to
ambulate without assistance
C. Bree Johnston, MD MPH , Copyright May
2001

Risk Factors for Falls

Risk Factor
OR
Sedative use
28
Cognitive Impairment
5
Lower extremity problem
4
Pathologic Reflex
3
Foot Problems
2
> 3 balance/gait problems
1.4
>5 balance/gait problems
1.9
Tinetti NEJM 1988

Common Pathologies associated with

Falls

Ophthalmologic diseases
Arthritis
Foot problems
Neurologic illness

Parkinsons & related disorders

Strokes
Peripheral neuropathy

Dizziness
C. Bree Johnston, MD MPH , Copyright May
2001

Falls in the Community

Accidents/environment 37%
Weakness, balance, gait 12%
Drop attack 11%
Dizziness or vertigo 8%
Orthostatic hypotension 5%
Acute illness, confusion, drugs,
decreased vision 18%

Unknown

8%
Rubenstein JAGS 1988

Falls in Residential Care

Generalized weakness
31%
Environmental hazard
27%
Orthostatic hypotension
16%
Acute illness
5%
Gait or balance disorder
4%
Drugs
5%
Other or unknown
10%
Rubenstein Ann Int Med 1990

Medications and Falls

Sedative-hypnotics, especially long
acting benzodiazepines, increase falls
Small association between most
psychotropics and falls
SSRIs and TCAs both incrsease falls
Weak association between Type 1A
antiarrythmics, digoxin, diuretics, and
falls
Leipzig JAGS 1999
Thapa NEJM 1998

Falls in the Elderly

Prevalence
Clinical Importance
Risk Factors & Etiology

Evaluation
Prevention & Management
Summary

C. Bree Johnston, MD MPH , Copyright May

2001

Evaluation of Falls: History

Location & circumstances of Fall

Associated symptoms
Other falls or near falls
Medications (including nonprescription)
and alcohol
Injury & ability to get up

C. Bree Johnston, MD MPH , Copyright May

2001

Evaluation of Falls: Physical

Examination
Supine and standing BP - always
Routine physical examination
Focus on cardiovascular, neuro, feet

Vision and hearing evaluation

Consider acute medical illness & delirium
Formal gait and balance assessment

C. Bree Johnston, MD MPH , Copyright May

2001

Evaluation of Falls: Home

Evaluation

Can be performed by nurse, OT, PT, others

Stairs
Lighting
Bathroom

C. Bree Johnston, MD MPH , Copyright May

2001

Evaluation of Falls: Risk Factors for

Injury
Osteoporosis assessment
Anticoagulation: Usual benefits outweigh
risks unless repeat or high risk faller
Can the person get up from fall?
Is there a way to notify others in case of
falling?

C. Bree Johnston, MD MPH , Copyright May

2001

Formal Gait Evaluation

Get up and Go Test
Tinetti Gait and Balance Evaluation
(POMA)
Tinetti JAGS 1986
Podsiallo jAGS 1991
Mathias Arch Phys Med 1986

Common Causes of Abnormal

Gait

Difficulty arising from chair Weakness

Arthritis
Instability on first standing Hypotension,
Weakness
Instability with eyes closed Proprioception

Step height/lengthParkinsonism
Frontal lobe
Fear

C. Bree Johnston, MD MPH , Copyright May

2001

Falls in the Elderly

Prevalence
Clinical Importance
Risk Factors & Etiology
Evaluation

Prevention & Management

Summary

C. Bree Johnston, MD MPH , Copyright May

2001

Prevention & Treatment

Treat acute injury & underlying medical
conditions
Remove unnecessary medications
Rehab, exercises, assistive devices
Correct sensory impairments
Environmental modifications & safety
Evaluate for osteoporosis treatment
C. Bree Johnston, MD MPH , Copyright May
2001

Osteoporosis
Calcium and vitamin D for most elders
at risk
Dawson-Hughes, NEJM, 1997

Osteoporosis evaluation and treatment

Hip protectors appear to protect from
hip fractures in those who wear them
Kannus, NEJM, 2000

Risk Factor Modifications for

Fractures
Change
Quit smoking

Estimated Change in Risk

38%

Treat impaired vision

Stop sedatives

40%

Add 1 Gram Calcium

Hip Protectors

50%
24%

50%?
Adapted from Stteve Cummings

www.hipsavers.co
m

Falls: Primary Prevention

301 community dwelling elders with
1+ risk factors for falling
Intervention: adjustment in
medications, behavioral instructions,
exercise programs aimed at
modifying risk factors
One year follow up
Tinetti et al. 1994 NEJM

Multifactorial Intervention
Tinetti et al 1994 NEJM

P = .04

C. Bree Johnston, MD
MPH , Copyright May
2001

Tai Chi and Falling

Atlanta FICSIT Trial
200 community dwelling elders 70+
Intervention: 15 weeks of education,
balance training, or Tai Chi
Outcomes at 4 months: Strength,
flexibility, CV endurance, composition,
IADL, well being, falls

Falls reduced by 47% in Tai Chi group

Wolf JAGS 1996

Falls in the Elderly

Prevalence
Clinical Importance
Risk Factors & Etiology
Evaluation
Prevention & Management
Summary

C. Bree Johnston, MD MPH , Copyright May

2001

Algorithm summarizing
screening, assessment, and
management of falls.
(Modified with permission
from Anonymous. Guideline
for the prevention of falls in
older persons. American
Geriatrics Society, British
Geriatrics Society, and
American Academy of
Orthopaedic Surgeons Panel
on Falls Prevention. J Am
Geriatr Soc. 49:664, 2001.)

Kronologis keluhan pasien

BAB hitam,
jumlah
sedikit,,
sembuh
sendiri

BAB hitam, lunak

, berbau busuk
3 kali, hampir
memenuhi
popok dewasa

Jatuh saat
Jatuh saat
berjalan ke
akan ke kamar
sawah,
mandi karena
hanya
lemas
diurut
20
2mingg 10 hari
1
1 tahun3 bulan
2 hari
tahun
u
minggu
lemas, pusingpusing
Panas badan
penurunan nafsu
tidak terlalu
Nyeri badan
makanlebih
tinggi, batuk
tidak spesifik,
banyak
dengan dahak
nyeri ulu hati
berbaring di
putih dalam
hilang timbul,
tempat tidur
jumlah sedikit
berobat ke
dan sesak nafas
bidan

MRS

Kesan: fraktur kolum femur sinistra

Summary
Falls are common in the elderly &
may lead to injuries and decline in
function
Evaluation should included risk factor
assessment, gait assessment, and
home assessment
Exercise can improve outcomes

Identitas penderita

Nama
: NMM
Umur
: 80 tahun
Jenis Kelamin
: Perempuan
Alamat
: Tabanan
Pekerjaan
: Ibu Rumah Tangga
Agama
: Hindu
Pendidikan
: Tidak sekolah
(tidak bisa baca//tulis/ hitung)
MRS
: 05.08.2011
Keluhan utama
: buang air besar berwarna hitam

Riwayat Penyakit Sekarang

- Buang air besar berwarna hitam sejak 2
hari Sebelum Masuk Rumah Sakit (SMRS)
- Hitam, lunak dan berbau busuk sebanyak
3 kali dalam jumlah sedang, hampir
memenuhi popok dewasa
- Pernah mengalami hal yang sama
sebelumnya sekitar 3 bulan yang lalu,
jumlah sedikit dan berhenti sendiri

 rasa tidak enak di ulu hati berulang sejak

sekitar 1 tahun yang lalu, hilang timbul, tidak
dipengaruhi oleh makanan, hilang setelah
minum obat-obat yang diberikan oleh bidan
di kampung pasien
nyeri badan dengan lokasi tidak spesifik
hilang timbul sejak 1 tahun yang lalu.
Biasanya berobat ke bidan. Nyeri hilang
setelah diberi obat suntikan dan obat minum.
Pasien dan keluarga tidak tahu jenis dan
nama obat yang diberikan

 1 minggu SMRS pasien mengalami panas

badan tidak terlalu tinggi, batuk dengan
dahak putih dalam jumlah sedikit dan sesak
nafas
Sejak 2 minggu SMRS pasien lemas, pusingpusing dan mengalami penurunan nafsu
makan sehingga lebih banyak berbaring di
tempat tidur

 10 hari SMRS karena lemas pasien jatuh saat

akan ke kamar mandi. Pasien menyangkal rasa
berdebar, pusing, sesak ataupun nyeri dada
sesaat sebelum jatuh.
Saat jatuh, pasien harus dibantu berdiri oleh
anaknya
Hilangnya kesadaran, muntah, maupun kejang
setelah jatuh disangkal
Semenjak itu pasien hanya tiduran di tempat
tidur dan menggunakan pokok dewasa karena
tidak mampu berjalan ke kamar mandi.
BAK pasien dikatakan tidak mengalami
perubahan, nyeri saat BAK disangkal

Riwayat Penyakit Dahulu

Pernah jatuh terpeleset saat berjalan di sawah
20 tahun yang lalu karena jalan tanah yang
licin, hanya diurut oleh tukang pijat di kampung.
Pasien masih dapat berjalan dan beraktifitas
walaupun dengan sedikit gangguan pada gerak
pada kaki sebelah kiri.
Pasien juga dikatakan sudah mengalami
gangguan penglihatan dan pendengaran sejak
sekitar 10 tahun yang lalu.

PEMERIKSAAN FISIK
Kesan sakit
: berat
Kesadaran
: somnolen (E4V4M6)
Tekanan Darah : berbaring : 100/70 mmHg
duduk : 100/70 mmHg
Nadi
: 86 x/menit
Respirasi
: 24 x/menit
Suhu tubuh
: 37,6 C
Antropometri
: Berat badan + 38 kg
tinggi lutut 44cm
TB + 145 cm
IMT : 18.07

Kepala
Mata
: conjungtiva anemis +/+, sclera tidak ikterik
Leher
: gerak normal, JVP 5+3cm
Thorax : sela iga normal
Paru : sonor, suara dasar vesikuler, ronkhi +/+,
wheezing +/+
Jantung dan pembuluh darah:
Irama reguler, S1 dan S2 tunggal, murmur (-)
Abdomen : distensi (-) bising usus (+) normal
hepar dan lien tak teraba
Punggung
: luka ekscoriasi ukuran 2x2cm dengan
dasar bersih, tanpa jaringan nekrotik
Ekstremitas : akral hangat, pitting edema +/+

PEMERIKSAAN LABORATORIUM
04.08.11

06.08.11

08.11

WBC

11.3

6.6

6.2

Neu

96.1%

84%

84.8%

Ly

3.4%

10%

6.9%

Mo

0.1%

5.4%

5.9%

Eo

0.1%

0.5%

1.8%

Ba

0.3%

0.1%

0.3%

Hb

6.2

6.8

10.2

Hct

19.3

21

30.5

MCV

88.8

88.8

86.4

MCH

28.7

28.8

28.9

Plt

201

223

214

Kesan: fraktur kolum femur sinistra

1. Buat daftar masalah pada pasien

tersebut ?
2. Sebutkan faktor risiko terjadinya jatuh
pada pasien tersebut ?
3. Apa saran untuk mencegah terjadinya
jatuh berulang pada pasien tersebut ?
4. Pasien menolak operasi, apa
kemungkinan komplikasi yang bisa
terjadi ?