Polypharmacy is defined as the use of five or more prescription medications.   Polypharmacy is common among seniors and can lead to reduced adherence with medication regimens and problems with drug interactions. (4) Medication-related problems are common, costly, and often preventable in older adults and lead to poor outcomes. 

Why is this Important?

  • 27% of seniors reported taking five or more medications on a regular basis. (4)
  • 12% of seniors taking five or more medications experienced a side effect that required medical attention compared with 5% of seniors taking only one or two medications(4)
  • 27% of adverse drug events (ADEs) in primary care were preventable, with most problems occurring at the ordering and monitoring stages of care (1)
  • The number of prescription medications was associated with the rate of emergency department use. (4)
  • Less than 50% of all seniors reported receiving a prescription medication review from their physician identifying  potential side effects. (4)
  • The number of medications being taken increases the risk of adverse drug reactions (ADRs), which can increase the likelihood of hospital visits.

Key Considerations

  • When conducting a medication review ask for all prescribed medications, OTC and herbal preparations
  • Monitor compliance of medication adherence, ask about common side effects and adverse occurrences especially when new medications have been ordered
  • As patients become more frail, the potential harm from medications must be weighed against the potential benefits (1)
  • Follow the Beers criteria when prescribing and evaluating: 
    i)    medications to avoid in older adults regardless of disease or conditions
    ii)   medications considered inappropriate when used in older adults with certain conditions or syndromes
    iii)  medications to consider for use in certain individuals recognizing the potential for misuse and harm is substantial (5)

References

1.       Campanelli, C. (2012).  American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate
          Medication Use in Older Adult. 
Published online Feb 29, 2012.  Retrieved Feb.27, 2014 from:  
          http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3571677/

 2.      Frank, C.  (2010) Multiple medications in geriatric care.  OSMT Volume 17/Issue 2, Summer 2010. 
          Retrieved Feb. 2014 from:     
          http://www.osmt.org/uploads/Multiple%20medications%20in%20geriatric%20care.pdf

 3.      Institute for Safe Medication Practices Canada.  (2014). Safe Medication Use in Older Persons Information
          Page
. Retrieved Feb. 2014 from:    
          https://www.ismp-canada.org/beers_list/

 4.      Reason, B.  et al.  (2011) The impact of polypharmacy on the health of Canadian seniors. Oxford Journals.
          Medicine, Family Practice.  Volume 29, Issue 4Pp. 427- 432.  Retrieved Feb. 27, 2014 from:
          http://fampra.oxfordjournals.org/content/29/4/427.long  

5.       The American Geriatrics Society. (2012).American Geriatrics Society Updated Beers Criteria for
          Potentially Inappropriate Medication Use in Older Adults, Beers Criteria Update Expert panel, 
         
Journal of American Geriatrics Society (2012), 1-16, Retrieved May 2014 from:
        
 http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines

Prescription medications, over-the-counter (OTC) products, natural and alternative medicines are widely used in Canada, especially by seniors.(4)  Polypharmacy is the term usually used to describe multiple medication use by a single patient.  Although the term is often used to describe a patient taking multiple medications, the better definition is likely, “use of at least one inappropriate drug.” (1)  Potentially inappropriate medications (PIMs) continue to be prescribed and used as first-line treatment for the most vulnerable of older adults, despite evidence of poor outcomes from the use of PIMs in older adults. (3)

Why is this Important?

  • Multiple medication use (taking five or more different drugs in the past two days) was reported for 53% of seniors in health care institutions and 13% of those in private households (4)
  • Reports indicated the most commonly used medications were those which acted  on the nervous system, the alimentary tract and metabolism, and the cardiovascular system (4)
  • 78% of seniors in institutions and 37% of those in households took medications for the nervous system. Of these medications, analgesics were the most common, followed by psycholeptics, which include antipsychotics, anxiolytics, hypnotics and sedatives. (4)
  • Concurrent use of 5 or more medications was reported by 53% of seniors in institutions and 13% of those in households. (4)
  • Medication-related problems are common, costly, and often preventable in older adults and lead to poor outcomes.
  • Estimates from past studies in long-term care settings found  42% of ADEs in long-term care were preventable, with most problems occurring at the ordering and monitoring stages of care (2)
  • Institutionalized seniors who had Alzheimer’s disease or other dementia were less likely to be taking multiple medications versus those who were institutionalized without this condition (4)

Key Considerations

  • When conducting a medication review ask for all prescribed medications, OTC and herbal preparations
  • Medication reconciliation of newly transferred residents is valuable and an important quality process
  • Consider whether the medication is covered by Ontario Drug Benefit (ODB)
  • As patients become more frail, the potential harm from medications must be weighed against the potential benefits (1)
  • Follow the Beers criteria when prescribing and evaluating:
      • medications to avoid in older adults regardless of disease or conditions
      • medications considered inappropriate when used in older adults with certain conditions or syndromes
      • medications to consider for use in certain individuals recognizing the potential for misuse and harm is substantial (5)

References

1.     Campanelli, C. (2012).  American Geriatrics Society Updated Beers Criteria for Potentially
        Inappropriate Medication Use in Older Adult. 
Published online Feb 29,  2012. 
        Retrieved Feb.27, 2014 from:
        http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3571677/

2.     Frank, C.  (2010) Multiple medications in geriatric care.  OSMT Volume 17/Issue 2, Summer 2010. 
        Retrieved Feb. 2014 from:
        http://www.osmt.org/uploads/Multiple%20medications%20in%20geriatric%20care.pdf

3.     Institute for Safe Medication Practices Canada.  (2014). Safe Medication Use in Older Persons
        Information Page
.  Retrieved Feb. 2014 from:
        https://www.ismp-canada.org/beers_list/

4.     Reason, B.  et al.  (2011) The impact of polypharmacy on the health of Canadian seniors.
        Oxford Journals. Medicine, Family Practice.  Volume 29, Issue 4Pp. 427-432. 
        Retrieved Feb. 27, 2014 from:
        http://fampra.oxfordjournals.org/content/29/4/427.long  

5.     The American Geriatrics Society. (2012).American Geriatrics Society Updated Beers Criteria for
        Potentially Inappropriate Medication Use in Older Adults, Beers Criteria Update Expert panel, 
       
Journal of American Geriatrics Society (2012), 1-16, Retrieved May 2014 from:
       
http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines

Prescription medications, over-the-counter (OTC) products, natural and alternative medicines are widely used in Canada, especially by seniors.(4)  Polypharmacy is the term usually used to describe multiple medication use by a single patient. Although the term is often used to describe a patient taking multiple medications, the better definition is likely, “use of at least one inappropriate drug.”(2)  Potentially inappropriate medications (PIMs) continue to be prescribed and used as first-line treatment for the most vulnerable of older adults, despite evidence of poor outcomes from the use of PIMs in older adults.(3)

Why is this Important?

  • Multiple medication use (taking five or more different drugs in the past two days) was reported for 53% of seniors in health care institutions and 13% of those in private households. (4)
  • The medications reported most commonly were those that act on the nervous system, the alimentary tract and metabolism, and the cardiovascular system. (4)
  • 78% of seniors in institutions and 37% of those in households took medications for the nervous system. Of these medications, analgesics were the most common, followed by psycholeptics, which include antipsychotics, anxiolytics, hypnotics and sedatives. (4)
  • Concurrent use of 5 or more medications was reported by 53% of seniors in institutions and 13% of those in households. (4)
  • Medication-related problems are common, costly, and often preventable in older adults and lead to poor outcomes.
  • Estimates from past studies in long-term care settings found  42% of ADEs (Adverse Drug Events) in long-term care were preventable, with most problems occurring at the ordering and monitoring stages of care (2)
  • Institutionalized seniors who had Alzheimer’s disease or other dementia were less likely to be taking multiple medication users than were institutionalized seniors without this condition (4)

Key Considerations

  • When conducting a medication review ask for all prescribed medications, OTC and herbal preparations
  • Medication reconciliation of newly transferred residents is valuable and an important quality process
  • Consider whether the medication is covered by Ontario Drug Benefit (ODB)
  • As patients become more frail, the potential harm from medications must be weighed against the benefits (2)
  • Follow the Beers criteria when prescribing and evaluating:
      • medications to avoid in older adults regardless of disease or conditions
      • medications considered inappropriate when used in older adults with certain conditions or syndromes
      • medications to consider for use in certain individuals recognizing the potential for misuse and harm is substantial (5)

References

1.       Campanelli, C. (2012).  American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate
          Medication Use in Older Adult. 
Published online Feb 29, 2012.  Retrieved  Feb.27, 2014 from:   
          http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3571677/

2.        Frank, C.  (2010) Multiple medications in geriatric care.  OSMT Volume 17/Issue 2, Summer 2010. 
           Retrieved Feb. 2014 from:

           http://www.osmt.org/uploads/Multiple%20medications%20in%20geriatric%20care.pdf

3.        Institute for Safe Medication Practices Canada.  (2014).  Safe Medication Use in Older Persons Information
           Page.  Retrieved Feb. 2014 from:
           https://www.ismp-canada.org/beers_list/

4.        Ramage-Morin, P.  (2009).   Medication use among senior Canadians • Health Matters.   Statistics Canada,
           Catalogue no. 82-003-XPE • Health Reports, Vol. 20, no. 1, March 2009.  Retrieved Feb. 2014 from: 
           http://www.statcan.gc.ca/pub/82-003-x/2009001/article/10801-eng.pdf

5.        The American Geriatrics Society. (2012).American Geriatrics Society Updated Beers Criteria for
           Potentially Inappropriate Medication Use in Older Adults, Beers Criteria Update Expert panel, 
          
Journal of American Geriatrics Society (2012), 1-16, Retrieved May 2014 from:
          
http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines

The majority of older adults age well and enjoy health and wellness. A small subset, less than 10% of individuals over 65 years of age or about 30% of those over 80 years of age are “frail”. Such individuals are more likely to have problems of fatigue, weight loss, problems with walking and low mood or memory problems.  Often they have limited finances and social supports. They also are more likely to have multiple chronic diseases and be on many medications.

Frail older adults are at risk of further decline in function and well-being especially with new illness and tend to have to use more health and community support services. There is often a component of reversibility in their frailty which if acted upon can improve their outcomes and quality of life. 

Eating a balanced diet, staying active and being involved with friends and family are important in preventing frailty. Other important strategies for reducing risk of adverse events are regular health checks, attention to medication use and becoming informed about health challenges.

References

  1. B.C. Ministry of Health. (2012). Frailty in Older Adults- Early Identification and Management.  
    Retrieved February 2014 from:
    http://www.bcguidelines.ca/guideline_frailty.html

Frailty is a dynamic condition experienced by many older adults.  It is a vulnerability to adverse outcomes resulting from an interaction of physical, socio-economic and co-morbidity factors: major adverse events are more common among frail patients in comparison to non-frail patients. (1) 

Why is it important?

  • Prevalence of frailty is higher in women and increases with age
  • Social vulnerability, aging, and chronic disease lends to development of frail elderly individuals
  • When an individual is frail the impact of an “illness” further impairs function and ability to cope
  • Frailty causes increased risk of other diseases
  • In-hospital mortality is higher among frail patients than among non-frail patients (1)
  • Frail individuals are more likely to become functionally dependent; have a lower quality of life; and  are more often re-admitted to hospital than non-frail individuals
  • Frailty increases the risk for adverse health outcomes such as falls, hospitalization, increased lengthof stay, increased costs, with worsening of outcomes including mortality and need for long term placement (1) (3)

Common Causes

  • Physical: extreme age, weight loss, slow gait, fatigue, inactivity, poor grip strength
  • Socio-economic:  isolation, caregiver gaps, poverty, gender, immigration status
  • Co-morbidity factors:  impaired cognition/mood, poly-pharmacy, multiple chronic diseases

Key Considerations

  • CSHA Clinical Frailty Scale widely used to describe and classify the severity of frailty: based on function for Activities of Daily Living and Instrumental Activities of Daily Living (2)
    http://geriatricresearch.medicine.dal.ca/pdf/Clinical%20Faily%20Scale.pdf
  • Align goals and preferences of the patient and family
  • Focus should be on:
    • Early identification of onset and acute illness, optimizing sensory inputs, assessing cognition/mood, reviewing medications, and promoting regular exercise and nutrition supplementation.
    • Optimizing chronic disease management strategies and modify geriatric syndromes (e.g. falls, immobility, confusion, depression, incontinence)
    • Implementing  necessary environmental changes/adaptations and maximization of community and socio-economic supports
    • Encouraging activity and socialization in order to help prevent advancing frailty

References

1.  Bagshaw, S.M., et al (2014). Association between frailty and short and long-term outcomes among
     critically ill patients: a multicenter prospective cohort study.
CMAJ, 186 (2), doi: 10.1503/cmaj.
     130639. Retrieved Feb. 2014 from:
     http://www.cmaj.ca/content/186/2/E95

2.  B.C. Ministry of Health. (2012). Frailty in Older Adults- Early Identification and Management.  
     Retrieved February 2014 from:
     http://www.bcguidelines.ca/guideline_frailty.html

3.  Fried, L.P., et al (2001). Frailty in Older Adults: Evidence for a Phenotype. Journal of Gerontology:
     MEDICAL SCIENCES
, 56A(3), M146-M156.  Retrieved Feb. 2014 from: 
     https://rds185.epi-ucsf.org/ticr/syllabus/courses/83/2012/02/15/Lecture/readings/fried

Frailty is a dynamic condition experienced by many older adults.  It is a vulnerability to adverse outcomes resulting from an interaction of physical, socio-economic and co-morbidity factors: major adverse events are more common among frail patients in comparison to non-frail patients. (1)

Why is it important?

  • Prevalence of frailty is higher in women and increases with age
  • Many residents in LTC would be considered “frail” although there may be reversible components
  • Social vulnerability, aging, and chronic disease lends to development of frail elderly individuals
  • When an individual is frail the impact of an “illness” further impairs function and ability to cope
  • Frailty causes increased risk of other diseases
  • In-hospital mortality is higher among frail patients than among non-frail patients (1)
  • Frail survivors are more likely to become functionally dependent, had a lower quality of life, and more often re-admitted to hospitals than the non-frail survivors (1)
  • Frailty increases the risk for adverse health outcomes such as falls, hospitalization, increased length of stay, increased costs, with worsening of outcomes including mortality and need for long term placement (1) (3)

Common Causes

  • Physical: extreme age, weight loss, slow gait, fatigue, inactivity, poor grip strength
  • Socio-economic:  isolation, caregiver gaps, poverty, gender, immigration status
  • Co-morbidity factors:  impaired cognition/mood, poly-pharmacy, multiple chronic diseases

Key Considerations

  • CSHA Clinical Frailty Scale widely used to describe and classify the severity of frailty: based on function for Activities of Daily Living and Instrumental Activities of Daily Living (2)
    http://geriatricresearch.medicine.dal.ca/pdf/Clinical%20Faily%20Scale.pdf
  • Align goals and preferences of the patient and family
  • Focus should be on:
      • Early identification of onset and acute illness, optimizing sensory inputs, assessing cognition/mood,reviewing medications, and promoting regular exercise and nutrition supplementation.
      • Optimizing chronic disease management strategies and modify geriatric syndromes (e.g. falls, immobility, confusion, depression, incontinence)
      • Implementing  necessary environmental changes/adaptations and maximization of community and socio-economic supports
      • Encouraging activity and socialization in order to help prevent advancing frailty
      • Consult physiotherapist, occupational therapist, recreationist as feasible

References

1.   Bagshaw, S.M., et al (2014). Association between frailty and short and long-term outcomes among
      critically ill patients: a multicenter prospective cohort study.  CMAJ, 186 (2), doi: 10.1503/cmaj.
      130639.  Retrieved Feb. 2014 from:
      http://www.cmaj.ca/content/186/2/E95

2.   B.C. Ministry of Health. (2012). Frailty in Older Adults- Early Identification and Management
      Retrieved February 2014 from:
      http://www.bcguidelines.ca/guideline_frailty.html

3.   Fried, L.P., et al (2001). Frailty in Older Adults: Evidence for a Phenotype. Journal of Gerontology:
      MEDICAL SCIENCES
, 56A(3), M146-M156.  Retrieved Feb. 2014 from:
      https://rds185.epi-ucsf.org/ticr/syllabus/courses/83/2012/02/15/Lecture/readings/fried%20frailty
      %202001.pdf

Frailty is a dynamic condition experienced by many older adults.  It is a vulnerability to adverse outcomes resulting from an interaction of physical, socio-economic and co-morbidity factors: major adverse events are more common among frail patients in comparison to non-frail patients. (1)

Why is it important?

  • Prevalence of frailty is higher in women and increases with age
  • Social vulnerability, aging, and chronic disease lends to development of frail elderly individuals
  • When an individual is frail the impact of an “illness” further impairs function and ability to cope
  • Frailty causes increased risk of other diseases
  • In-hospital mortality is higher among frail patients than among non-frail patients (1)
  • Frail individuals are more likely to become functionally dependent; have a lower quality of life; and are more often re-admitted to hospital than non-frail individuals
  • Frailty increases the risk for adverse health outcomes such as falls, hospitalization, increased length of stay, increased costs, with worsening of outcomes including mortality and need for long term placement (1) (3)

Common Causes

  • Physical: extreme age, weight loss, slow gait, fatigue, inactivity, poor grip strength
  • Socio-economic:  isolation, caregiver gaps, poverty, gender, immigration status
  • Co-morbidity factors:  impaired cognition/mood, poly-pharmacy, multiple chronic diseases

Key Considerations

  • CSHA Clinical Frailty Scale widely used to describe and classify the severity of frailty: based on  function for  Activities of Daily Living and Instrumental Activities of Daily Living (2) 
    http://geriatricresearch.medicine.dal.ca/pdf/Clinical%20Faily%20Scale.pdf
  • Align goals and preferences of the patient and family www.sagelink.ca/GPHE_intro_all_related_documents_2014_geriatric_periodic_health_exam
  • Components of the Comprehensive Geriatric Exam can be used to flag issues for further review with Geriatric Periodic Health Exam Focus should be on:
        • Early identification of onset and acute illness, optimizing sensory inputs, assessing cognition/mood, reviewing medications, and promoting regular exercise and nutrition supplementation.
        • Optimizing chronic disease management strategies and modify geriatric syndromes (e.g. falls, immobility, confusion, depression, incontinence)
        • Implementing  necessary environmental changes/adaptations and maximization of community and socio-economic supports
        • Encouraging activity and socialization in order to help prevent advancing frailty

References

1.  Bagshaw, S.M., et al (2014). Association between frailty and short and long-term outcomes among critically
     ill patients: a multicenter prospective cohort study.  CMAJ, 186 (2), doi: 10.1503/cmaj.130639.
     Retrieved Feb. 2014 from:
     http://www.cmaj.ca/content/186/2/E95

2.  B.C. Ministry of Health. (2012). Frailty in Older Adults- Early Identification and Management.  
     Retrieved February 2014 from:
     http://www.bcguidelines.ca/guideline_frailty.html

3.  Fried, L.P., et al (2001). Frailty in Older Adults: Evidence for a Phenotype. Journal of Gerontology:
     MEDICAL SCIENCES
, 56A(3), M146-M156.  Retrieved Feb. 2014 from:
     https://rds185.epi-ucsf.org/ticr/syllabus/courses/83/2012/02/15/Lecture/readings/fried%20frailty%202001.pdf

Frailty is a dynamic condition experienced by many older adults.  It is a vulnerability to adverse outcomes resulting from an interaction of physical, socio-economic and co-morbidity factors: major adverse events are more common among frail patients in comparison to non-frail patients. (1)

Why is it important?

  • Prevalence of frailty is higher in women and increases with age
  • Social vulnerability, aging, and chronic disease lends to development of frail elderly individuals
  • When an individual is frail the impact of an “illness” further impairs function and ability to cope
  • Frailty causes increased risk of other diseases
  • In-hospital mortality is higher among frail patients than among non-frail patients (1)
  • Frailty increases the risk for adverse health outcomes such as falls, hospitalization, increased length of stay, increased costs, with worsening of outcomes including mortality and need for long term placement (1) (3)

Common Causes

  • Physical: extreme age, weight loss, slow gait, fatigue, inactivity, poor grip strength
  • Socio-economic:  isolation, caregiver gaps, poverty, gender, immigration status
  • Co-morbidity factors:  impaired cognition/mood, poly-pharmacy, multiple chronic diseases

Key Considerations

  • CSHA Clinical Frailty Scale widely used to describe and classify the severity of frailty: based on function for Activities of Daily Living and Instrumental Activities of Daily Living (2)
    http://geriatricresearch.medicine.dal.ca/pdf/Clinical%20Faily%20Scale.pdf
  • Align goals and preferences of the patient and family
  • Focus should be on:
    • Early identification of onset and acute illness, optimizing sensory inputs, assessing cognition/mood, reviewing medications, and promoting regular exercise and nutrition supplementation.
    • Optimizing chronic disease management strategies and modify geriatric syndromes (e.g. falls, immobility,confusion, depression, incontinence)
    • Implementing  necessary environmental changes/adaptations and maximization of community and socio-economic supports
    • Encouraging activity and socialization in order to help prevent advancing frailty
    • Consult physiotherapist, occupational therapist, recreationist as feasible

References

1.  Bagshaw, S.M., et al (2014). Association between frailty and short and long-term outcomes among
     critically ill patients: a multicenter prospective cohort study.  CMAJ, 186 (2), doi: 10.1503/cmaj.
     130639.  Retrieved Feb. 2014 

2.  B.C. Ministry of Health. (2012). Frailty in Older Adults- Early Identification and Management.
     Retrieved February 2014 from:
     http://www.bcguidelines.ca/guideline_frailty.html

3.  Fried, L.P., et al (2001). Frailty in Older Adults: Evidence for a Phenotype. Journal of Gerontology:
     MEDICAL SCIENCES, 56A(3), M146-M156.  Retrieved Feb. 2014 from:  
     https://rds185.epi-ucsf.org/ticr/syllabus/courses/83/2012/02/15/Lecture/readings

 

  • 30-50% of seniors experience a fall each year. About a 1/3 of these are serious falls.
  • In 2009 Ontario researchers found that 50% of injury-related hospitalizations were due to falls and over 90% of all hip fractures were due to falls. Fifty- five out of every 1,000 seniors went to the hospital emergency rooms as a result of a fall and 13 out of 1,000 seniors were hospitalized due to a fall.
  • As people age, there is an increased risk of falls due to decreased sight, hearing, posture changes  (tendency to bestooped over) and slower reaction speed.
  • Medical conditions such as arthritis, pain, cataracts, hip surgery, previous strokes and conditions such as Parkinson’sdisease also affect how individuals walk, and increase the risk of tripping and falling.  Balance can also be affected bychronic conditions such diabetes and heart disease. 
  • Side effects of medications such as sedatives (sleeping or medications to reduce anxiety), strong pain medication, and heart medications can contribute to an increased risk of falls. The more medications someone takes the more likely the side effects may contribute to falls. It is important to consult with the family physician and/or the nurse practitioner to review medications if falls (or near falls) is a concern.
  • A fear of falling may modify someone’s behaviour (reactions) and actually increase the risk of falls.
  • Most falls occur in the home: often in bedroom, bathroom and on the stairs. 
  • Prevention of falls is the goal. Creating a safer home environment can help reduce the risk of falls. A home assessment by a physiotherapist or occupational therapist can provide recommendations for improvements in certain areas of the home and also exercises to reduce risk of falls.

References

  1.  Public Health Agency of Canada, Division of Aging and Seniors.  (2009). Retrieved Feb. 2014 from:
      www.phac-aspc.gc.ca/seniors-aines
  2. The Kingston Frontenac Lennox and Addington Falls Coalition.  (2014). Retrieved Feb. 2014 from:
      www.stepsafe.com     

A fall is a sudden and unintentional change in position resulting in an individual landing at a lower level such as on an object, the floor, or the ground, with or without injury. Falls are among the most common and serious problems facing elderly persons. Most falls are predictable and preventable: a fall can cause a loss in confidence which can lead to a decline in health and function and contribute to future falls. (1)

Why is it important?                           

  • 30-50% of seniors experience a fall each year. About a 1/3 of these are serious falls with higher risk of adverse events. 
  • Factors which indicate higher risk are presentation to physician or ER because of fall, fear of falling, multiple frequent falls and abnormal gait (assessed by Timed Up and Go).
  • Falling is associated with increased mortality, morbidity, reduced functioning, and LTCH admissions
  • Increased risk of serious falls in first six weeks after admission to LTC
  • Almost 62% of injury-related hospitalizations for seniors are the result of falls.
  • Fall-related injury rate is 9 times greater among seniors over 65 than those less than 65 years of age.
  • 50% of seniors who fall experience a minor injury: 5% to 25% sustain an injury like a fracture or sprain
  • Falls cause 90% of all hip fractures in seniors: 20% die within a year of the fracture.
  • Often families are unable to provide care: 40% of LTCH admissions occur as a result of falls
  • Fall-related injury coupled with co-morbid diseases (e.g., osteoporosis) and age-related physiological decline (e.g., slower reflexes) make a mild fall dangerous.

Common Causes

The risk of falling dramatically increases as the number of risk factors increases.

Predisposing

Intrinsic

Extrinsic

Sensory input
   (vision, hearing and
    proprioception)

 Nerve conduction

 Number motor neurons

 Fast twitch fibers

 Muscle mass

 Vascular changes -
   prone to postural
   hypotension

  • Lower extremity weakness, balance / gait problems
  • Visual deficits, hearing loss
  • Acute or chronic illness
  • Decreased sensation
  • Depression, cognitive impairment
  • Dizziness / postural hypotension
  • Functional / ADL impairment

Certain medications:

  • Psychotropics/Benzodiazepines; Digoxin, Diuretics
  • Class 1a anti-arrhythmics
  • Polypharmacy (5 or more)

Behavioural:

  • History of falls, fear of falling
  • Excessive alcohol use (≥14 /wk)
  • Risk-taking behaviours (lack of insight)
  • Improper use of (or lack of use of)  assistive device
  • Stairs
  • Home hazards (kitchen, bathroom, bedroom)
  • Outdoor hazards
  • Public / community hazards
  • Improper footwear

 

Primary Care providers can significantly decrease the fall risk of their elderly patients by:

  • Screening for fall risk on admission and annularly.
  • Conducting a comprehensive post falls assessment to identify contributory causes and risk factors
  • Implementing multidisciplinary management strategies that target modifiable risk factor especially environmental factors and footwear
  • Review Beers criteria 2012:  http://www.americangeriatrics.org/files/documents/beers/PrintableBeersPocketCard.pdf
  • Assess for osteoporosis risk and presence of fragility fractures.  Consider use of bisphosphonates and/or equivalent treatments in presence of history of fragility fractures.
  • Consider use of hip protectors

References

1.  Public Health Agency of Canada, Division of Aging & Seniors.  (2005). Report on Seniors’ Falls in Canada.
    
Retrieved Feb. 2014 from:
     http://publications.gc.ca/collections/Collection/HP25-1-2005E.pdf

Recommended Readings / Guidelines

1.  Anderson, K.E. &  McKay C.  (2010).  How to manage falls in community dwelling older adults: 

     a review of the evidence. Postgrad Med J. 2010 May; 86 (1015):299-306.  Retrieved March, 2014 from: 
     http://www.ncbi.nlm.nih.gov/pubmed/20406801

2.   Cook, W.L., Donaldson, M.G., Janssen, P.A., Khan, K.M. and Sobolev B.  (2009). Analysis of recurrent events:
      a systematic review of randomised controlled trials of interventions to prevent falls
. Age Ageing. 2009 Mar;
      38(2):151-5. Retrieved March 2014 from:
      http://www.ncbi.nlm.nih.gov/pubmed/19106254

3.   National Institute for Health and Care Excellence. (2013).  Falls: assessment and prevention of falls in older
      people
: June 2013 NICE. Retrieved March 2014 from: 
      http://guidance.nice.org.uk/CG161

4.   Registered Nurses’ Association of Ontario. (2002, 2005, 2011).  Prevention of Falls and Fall Injuries in the
      Older Adult
.  Retrieved March 2014 from: 
      http://rnao.ca/bpg/guidelines/prevention-falls-and-fall-injuries-older-adult

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