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Taha H

on 3 February 2014

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Case presentation
Mrs S. is a 91 y/o woman from home with dizziness and 3 falls in past week
PMHx: Recurrent falls ( rib and hip fx), Osteoporosis, HTN, toes OA
Meds: Coversyl, CaCo3, Etidronate, ?sleeping pill
SHx: Lives at an apt. alone, 50hrs/week home support,4wheel walker
Etiologies of falls
Fall Assessment
US Preventive Services Task Force Statement:

History of falls
History mobility problems
Timed Get-Up-and-Go Test (TUG) >10s

Evidences for fall prevention strategies
Challenges in Fall Prevention
Vancouver Based Fall Prevention Resources
Epidemiology of falls in the elderly
Between 30 and 40 percent of community-dwelling people over the age of 65 years fall each year, increasing to about 50 percent for those 80 years and older

In Canada in 2008/09 15.5 per 1,000 seniors were hospitalized for a fall
Brittany Rance
Taha Heydari

FP Residents R1

Physical exam
Get up and go test
30 sec chair stand
4 stage balance test

General P/E:
postural vitals
visual acuity
feet exam
targeted N/E(lower ext. strength, sensation, gait, postural stability)
Our findings
-BP 130/62
-No orthostatic change
-Normal visual acuity
-Hammer toes and Bunions worse on Lt.
-Bilateral lower ext. weakness
, no sensory deficit
-Failed the GEN walk test

-Lab tests normal
-Holter normal
-No acute change in head CT scan

ECG/ 24h Holter/ Trop.

Morbidity and Mortality of Falls
50% minor injuries

5-25% more severe (sprain,fracture)

#1 cause hip fractures in elderly

1 in 5 elderly with hip fracture die within 12 months

In the Hospital
25% -50% of pts at SPH/MSJ >70yo

7.3% of hospital cases in adults >65 are fall-related

Average fall LOS: 15 days + 6.5 ALC days

3x more days ALC than non-falls

67% of ALC days waiting for transfer into residential care

Medication Review
Vitamin D
Home Intervention

Medication Review
Medication assessment and withdrawal of therapy alone
not associated
with reduced fall rate

education program
significantly reduced rates of falls
Physician education to improve prescribing
patient self assessment
medication review

Vitamin D
Cochrane 2012
in rate and risk of falls ONLY in subgroup deficient in Vitamin D

: 17%
in fall risk up to 36 months of follow up, NNT = 10

Vitamin D deficiency in elderly Canadians: 2-13% depending on season, 50% ‘suboptimal’ levels (<75 nmol/L)

Osteoporosis Canada

: 800IU – 2000IU daily

Comprehensive eye exam and treatment lead to
proportion and frequency of falls (65% vs. 49%)
?due to increase in level of activity

Switching multifocal glasses to single lens glasses decreased fall rate

First eye cataract surgery found to reduce rate of falls, but not second eye cataract surgery x

Home intervention
In home assessment and modification of hazards (e.g. non slip tape rugs, grab bars) reduced falls by 7%

More effective in people at higher risk falling

Most effective when delivered by OT

Exercise must contain multiple categories of exercise (balance, strength, functional training) to reduce fall rate

Both individual and group programs effective

risk of fall by 13%

Exercise – Sustained Effects
2005 study from UBC Aging, Mobility and Cognitive Neurosciences Lab
Three exercise arms - resistance training, agility training, and general stretching
6 month program
Beneficial effects sustained for 12 months after program with no further intervention
37-43% reduction in fall risk value at end of follow up as compared to baseline

Seniors perceptions

Use of aids and restriction of activity
Not relevant, only for disabled individuals
A threat to independent living
More likely to choose activities based on other positive benefits:

enjoyment, confidence, better health, increased independence


of physiotherapy and other programs
Interdisciplinary Clinics
Elder Care Ambulatory Clinic at SPH

Complex medical, cognitive, social problems
PT, OT, SW, geriatricians

Falls and Fracture Prevention Clinic SPH

Management of osteoporosis
Multifactorial assessment
VCH Falls Prevention Clinic at VGH

1 month wait
No hip #/replacement in past 2 years
No progressive neuro conditions (Parkinson’s, MS)
MMSE >24

Holy Family Hospital Out-Patient Clinic

Primary services: occupational therapy; physiotherapy; speech and language; and social work
-Concrete, realistic goals
-Ability to transfer independently or with one person assisting minimally
-Activity tolerance of at least 2 hours

OASIS (OsteoArthritis Service Integration System)

PT/OT assessment of arthritis
educational classes
OA does not need to be severe – refer early
Average wait 3 weeks – 2 mo depending on triage
Need OASIS referral from GP, Surgery, Rheum

Physical Activity Line
BC Ministry of Health
Monday to Friday, 9 a.m. to 5 p.m.
Toll-free: 1-877-725-1149 
Lower Mainland: (604) 241-2266
CSEP Certified Exercise Physiologists

Cost = free
Physical Activity Line
Help connect to community exercise classes
Free Move For Life DVD
Design personalized exercise programs

GOAL Trial
Group exercise programs out of the YMCA including Robert Lee YMCA

Program developed by BC Women’s Hospital
Certified exercise, education and falls prevention program
osteoporosis, low bone density, fall/# risk
Widely available in Vancouver community centers
Available in Cantonese, Mandarin
Cost = $78 for 12 week session

Get up and Go!
BC Women’s and Fraser Health
Entry level exercise program
Seniors at high risk for falls
Seniors with balance and mobility impairments
Seniors using mobility aids (canes, walkers and wheelchairs)

88% improved their balance scores
77% reported feeling more confident in their abilities
70% reported improvement in performing daily activities

Community PT
Access through Central Intake: 604.263.7377
Anyone can refer
Home visit PT for homebound patients

Home support workers can do balance exercises if already visiting pt – not a reason for a referral

Mrs. S.
What we did:
Medication: tapered and stopped her Coversyl. BP remained stable 140s SBP
Started Vitamin D 1000IU daily
Tylenol for lower extremity pain management
Seen by Geri Med, PT, OT, SW in hospital
Referred to Out-Patient Physiotherapy
Referred to a case manager in community to look at alternate living arrangements

Falls in elderly common and have significant and serious morbidity and mortality
Significant risk factors: muscle weakness, history of falls, gait and balance disturbances
Quick screen with Get-Up-and-Go test
Evidence for interventions variable
AGS Recommends: modification of home, minimization psychoactive meds, postural hypotension management, management foot problems, exercise and vitamin D supplementation.
Family physicians have a number of hospital and community based options to refer patients to


Faculty/Presenter Disclosures
Presenter: Brittany Rance
Disclosures: None

Presenter: Taha Heydari
Disclosures: None

- Dr. Valentyna Rembez, Department of Family Medicine
- Dr. Diana Barrigar, Department of Family Medicine
- Dr. Amanda Hill, Department of Geriatric Medicine
- Dr. Wendy Cook, Department of Geriatric Medicine
Review the epidemiology of falls in the elderly
Highlight the multifactorial etiologies of falls
Discuss a basic falls work-up
Review the evidence for different fall prevention strategies
Discuss some different resources in the community for referring our elderly patients at risk of falls

Risk factors for falls
Perell (2001)
e.g. street
Full transcript