La prevenzione delle cadute in casa di riposo

Transcription

Convegno per Medici, Infermieri e Educatori accreditato al programma di
Educazione Continua in Medicina della Regione Lombardia.
Fondazione Madre Cabrini ONLUS
Sant’Angelo Lodigiano (LO)
6 Ottobre 2010
La prevenzione delle cadute in casa di
riposo: è realmente possibile?
Corrado Carabellese
Responsabile Sanitario Fondazione Bresciana di Iniziative Sociali Onlus
Gruppo di Ricerca Geriatrica
PREVALENZA
-Il 30% degli adulti oltre 65 anni cade ogni anno
- la metà di esse sono una “recidiva”
- Approssimativamente il 10% delle cadute riporta conseguenze gravi
(fratture di femore, ematoma subdurale cronico, trauma cranico, lesioni dei
tessuti molli) e nelle RSA sino al 25%
- Le cadute sono la quinta causa di morte negli anziani
- il numero delle cadute aumenta progressivamente con l’età in entrambi i
sessi senza differenza per razza.
- più della metà dei residenti in “nursing home” e negli ospedali cade ogni
anno.
(Tinetti ME 2003 e Rubenstein LZ 2006)
EPIDEMIOLOGIA IN RSA
- E’ stimato che Il 40% dei ricoveri in RSA è dovuto a cadute
- L’incidenza in RSA è in media pari a 1.5 cadute/postoletto/anno
- molti ospiti presentano recidive di caduta
- La percentuale è superiore di 3 volte rispetto all’incidenza in comunità
- Il 5-20% degli ospiti viene ricoverato in ospedale
Cadute in RSA
Residenze “Carabellese”
RSA
“Anni Azzurri”
2006
Pl.166
150
0.90
16 (10.6%)
60.0%
87.5%
12.5%
Cadute in RSA - Dati “Anni Azzurri” Rezzato 2006
Most common Risk factors for falls
(Rubenstein, JAGS 2001)
MARKER DI DISFUNZIONE OMEOSTATICA
Eventi a genesi multifattoriale (Alexander 1996)
Fattori di rischio intrinseci (Trueblood 1991);
(invecchiamento fisiologico, malattie acute e croniche);
Fattori di rischio estrinseci (Trueblood 1991);
(attività del soggetto e ostacoli ambientali)
Rubenstein, Age Ageing, 2006
Modificazioni
fisiologiche
età-correlate
Condizioni
patologiche
Alterazioni del cammino
Turbe dell’equilibrio *
Fattori ambientali
* 20-40% > 65 anni, 40-50% > 85 anni
Rubenstein, 2006
Modificazioni fisiologiche età-correlate
 Si riducono l’acuità visiva, l’adattamento al buio, la capacità
di accomodazione e la percezione della profondità
 Declinano le sensibilità propiocettiva, vibratoria e tattile
 Si riduce l’efficienza del sistema vestibolare, con aumento
delle oscillazioni spontanee in posizione eretta
 E’ alterata l’integrazione a livello centrale degli input
sensoriali e delle risposte motorie; si allungano i tempi di
reazione; le risposte posturali volontarie possono essere
ritardate anche da un diminuito livello di attenzione
 Si riducono la massa muscolare, la forza, la potenza e la
resistenza muscolare, in particolare nei muscoli
antigravitazionali (quadricipiti ed estensori dell’anca)
 Si riduce la flessibilità articolare
 Vi è un’aumentata tendenza alla cifosi dorsale, con
spostamento in avanti del baricentro rispetto alla base di
appoggio del corpo
Condizioni patologiche che predispongono alle cadute (1)
Patologie neurologiche:
Malattie della vista:




TIA e ictus
Morbo di Parkinson
Crisi epilettiche
Insufficienza vertebrobasilare
 Patologie cerebellari
 Delirium
 Demenza
 Cataratta
 Glaucoma
 Degenerazione maculare
 Neuropatie
 Vertigini
 Sensazione di
sbandamento (dizziness)
 Depressione
 Ansia
 Paura di cadere
 Uso di lenti bifocali
Malattie psichiatriche:
Patologie cardiovascolari:
Disordini metabolici:


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



Aritmie
Infarto miocardico
Ipotensione ortostatica
Ipotensione postprandiale
Ipersensibilità del seno
carotideo
 Cardiopatie con
insufficiente gettata
sistolica (cardiomiopatie,
stenosi aortica, …)
 Flebopatie (insufficiente
ritorno venoso)
Ipoglicemia
Disidratazione
Iponatriemia
Ipokaliemia
Ipotiroidismo
 Anemia
Patologie dell’apparato
locomotore:
Varie:
 Artropatie
 Miopatie
 Esiti di fratture
 Sincope da defecazione
 Sarcopenia
 Patologie “minori” dei
piedi (callosità, deformità
delle unghie e delle dita
dei piedi, borsiti
dell’alluce, …)
 Sincope post-minzionale
 Sincope da tosse
 Iperventilazione
 Processo infettivo
 Emorragia in atto
Livello di cognitività molto basso con
demenza grave (MMSE 0-7) si associa
ad un basso livello funzionale ed ad un
più basso rischio di caduta
Livello di cognitività medio con demenza
severa (MMSE 9-16) si associa ad un
livello di funzionalità intermedio e ad un
più alto rischio di caduta
(Kallin K. 2004)
Farmaci che aumentano il rischio di cadute:






antiipertensivi e diuretici
benzodiazepine (spt a lunga emivita)
neurolettici
antidepressivi (inclusi SSRI)
anticonvulsivanti
antiparkinsoniani
 antiaritmici
 steroidi
 FANS
 alcool
l’assunzione di 4 o più farmaci è un fattore di
rischio indipendente di caduta (M Tinetti, 2003)
Fattori ambientali
 Sedie senza braccioli, di
altezza inadeguata
 Scaffali troppo alti
 Presenza di ostacoli
 Eccessivo ingombro
 Calzature e abbigliamento
inadeguati
 Pavimenti scivolosi, o irregolari
 Presenza di gradini (non
segnalati, troppo alti, …)
 Pavimenti troppo lucidi
(abbaglianti)
 Tappetini
 Mancanza di corrimano
 Letto di altezza inadeguata,
senza piano rigido
 Ruote del letto (o del
comodino) sbloccate
 Illuminazione notturna
inadeguata
 Vasca da bagno o doccia
scivolosi
 Mancanza di maniglioni
 Altezza inadeguata di wc e
bidet
 Scarsa illuminazione
 Eccessivo abbagliamento
 Ambiente non familiare
Fattori di rischio di caduta confermati da 2 o più studi
(M Tinetti, 2003)
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
Artrosi
Ipotensione ortostatica
Depressione
Compromissione cognitiva (demenza)
Deficit visivo
Alterazioni dell’equilibrio e dell’andatura
Ridotta forza muscolare
Assunzione contemporanea di 4 o più farmaci
Precedenti episodi di caduta
Fattori di rischio di caduta
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Storia di precedenti cadute
Paura di cadere
Polifarmacoterapia e assunzione di farmaci particolari
Alterazione della mobilita’
Alterazione della vista
Rischi domestici
Isolamento sociale
David A. Ganz, MD, MPH; Yeran Bao, MD; Paul G. Shekelle,
MD, PhD; Laurence Z. Rubenstein, MD, MPH
JAMA. 2007;297:77-86.
Objective To identify the prognostic value of risk factors
for future falls among older patients.
Data Synthesis Eighteen studies met inclusion criteria …
Patients who have fallen in the past year are more likely to
fall again [likelihood ratio range, 2.3-2.8]. The most
consistent predictors of future falls are clinically detected
abnormalities of gait or balance (likelihood ratio range, 1.72.4).
Incidenza delle cadute in rapporto al
numero dei fattori di rischio
Tinetti et al
N Engl J Med 1988
Robbins et al
Arch Intern Med 1989
Nevitt et al.
JAMA 1999
0-1
4
27%
78%
0
3
12%
100%
0
4
10%
69%
VALUTAZIONE
Poiché esiste una complessa interazione tra
le cause di caduta che riconoscono natura
multifattoriale (Alexander 1996):
si rende necessaria una valutazione
dell’anziano di tipo globale, che ne
permetta un inquadramento clinico
completo, spesso anche di difficile
interpretazione.
AGS, BGS, AAOS Guidelines (2001)
1.
2.
3.
4.
Tutti gli anziani devono essere interrogati almeno
una volta all’anno su eventuali cadute
Tutti gli anziani che segnalano una singola caduta
devono essere osservati nell’esecuzione del “Get
up and go test”
Anziani che mostrano difficoltà o instabilità
nell’esecuzione del test richiedono un ulteriore
approfondimento
Anziani che si rivolgono al medico a causa di una
caduta o che riferiscono ripetute cadute nell’ultimo
anno o che evidenziano turbe della deambulazione
e/o dell’equilibrio devono essere sottoposti ad una
valutazione approfondita
JAGS, 2001
AGS, BGS, AAOS Guidelines:
fall evaluation
 Anamnesi: circostanze della caduta, farmaci,
patologie acute e croniche in atto, livelli di autonomia
motoria
 Valutazione della vista, deambulazione ed equilibrio,
funzionalità delle articolazioni degli arti inferiori
 Valutazione neurologica (stato cognitivo, forza
muscolare, nervi periferici, sensibilità propriocettiva,
riflessi, funzione corticale, extrapiramidale e
cerebellare)
 Valutazione cardiovascolare (frequenza cardiaca e
ritmo, PA ed FC in ortostatismo e, se opportuno,
dopo stimolazione del seno carotideo)
JAGS, 2001
Assessing care of vulnerable olders (ACOVE):
indicatori di qualità
1.
2.
3.
4.
5.
In tutti gli anziani vulnerabili verificare eventuali
cadute almeno una volta all’anno
Verificare almeno una volta la presenza di
eventuali disturbi del cammino e dell’equilibrio
Se un anziano è caduto 2 o più volte nel corso
dell’anno o una volta sola ma con lesioni che
hanno richiesto un trattamento, deve essere
sottoposto ad una valutazione approfondita
Lo stesso se riferisce o presenta turbe del
cammino e dell’equilibrio
Proporre un programma di esercizi fisici adeguati e
la fornitura di ausili per la deambulazione
Ann Intern Med, 2001
Strumenti di valutazione del rischio di caduta
• Timed Get Up and Go Test (Podsiadlo et al,
1991)
• Tinetti Balance Scale (Tinetti, 1986)
• On leg balance
• Falls Efficacy Scale (Tinetti et al, 1990)
• Tinetti’s Falls Efficacy Scale (Tinetti et al.,
1990)
Tinetti Balance Scale
questa scala permette di:
•
•
•
•
associare un punteggio alle abilità valutate
verificare la variazione dell’indice di rischio di caduta nel tempo
verificare l’efficacia degli interventi adottati.
Si compone di due parti: equilibrio (0-16) ed andatura (0-12)
• Punteggio 0 – 1: soggetto non deambulante
• Punteggio 2 – 19: soggetto deambulante a rischio di caduta
• Punteggio 20 – 28: soggetto deambulante a basso rischio di caduta
Get up and Go Test
ESECUZIONE:
• alzarsi dalla sedia (Altezza seduta 46 cm circa) senza
l’aiuto delle mani,
• camminare per 3 m., girarsi, tornare e restare fermo.
• sedersi senza l’aiuto delle mani.
• Tempo <20 secondi (adeguato ed indipendente nei trasferimenti e
mobilità)
• Tempo >30 secondi (dipendenza e rischio di caduta)
• AUTORI: Mathias S, Nayak USL, Isaacs B, 1986.
• FINALITA’: prima valutazione della mobilità di base.
• CARATTERISTICHE:
è
rapido
e
facile
somministrare.
• LIMITI: L’assegnazione del punteggio è discutibile
da
On Leg Balance
• AUTORI: Wellas, Wayne, Romero, Baumagartner,
Rubenstein, Garry ,1997.
• FINALITA’: vuole essere un fattore predittivo
significativo per le cadute con le complicanze più gravi.
• CARATTERISTICHE: è un test facile da somministrare e
da riprodurre.
• LIMITI: scala di tipo descrittivo, non abbastanza
sensibile per essere predittiva nella maggior parte degli
eventi caduta.
Fall Risk Index
•
•
•
•
AUTORE: Tinetti, Williams, Mayewski, 1986.
FINALITA’: mettere in relazione l’aumento del rischio di caduta con il
numero delle aree funzionali affette da disabilità significative
CARATTERISTICHE: suggerire che, oltre a fattori come l’andatura e
l’equilibrio, esistono altre condizioni responsabili di caduta.
LIMITI: non prende in considerazione la severità o la cronicità dei fattori di
rischio valutati
INDICE: include 9 fattori di rischio di caduta, fra quelli ritenuti più importanti:
- grado di mobilità,
- vista,
- udito,
- tono dell’umore,
-stato mentale,
- esame del dorso,
- pressione arteriosa,
- farmaci somministrati
- A.D.L. all’ammissione in Istituto
TINNETTI’S FALLS EFFICACY SCALE
In una scala da 1 a 10, dove 1 significa estremamente sicuro e 10 assolutamente insicuro,
quanto ti senti sicuro nel……….
(J Gerontol Psych Sci, 1990)
Molto sicuro
Per nulla sicuro
Fare il bagno o la doccia?
1
2
3
4
5
6
7
8
9
10
Cercare qualcosa in un armadio?
1
2
3
4
5
6
7
8
9
10
Preparare il pranzo (non include
portare oggetti pesanti o bollenti)?
1
2
3
4
5
6
7
8
9
10
Camminare per la casa?
1
2
3
4
5
6
7
8
9
10
Entrare/uscire dal letto?
1
2
3
4
5
6
7
8
9
10
Rispondere alla porta o al telefono?
1
2
3
4
5
6
7
8
9
10
Alzarsi/sedersi dalla sedia?
1
2
3
4
5
6
7
8
9
10
Vestirsi/vestirsi?
1
2
3
4
5
6
7
8
9
10
Fare lavori domestici leggeri?
1
2
3
4
5
6
7
8
9
10
Fare piccole spese?
1
2
3
4
5
6
7
8
9
10
• Un semplice test clinico: stop walking when talking è
predittivo di caduta con un potere predittivo positivo
del 83%.
(Lundin Olson L. Stop walking when talking as predictor of falls in
elderly people The lancet 349, 1997 617)
EZIOLOGIA MULTIFATTORIALE DELLE CADUTE
Gerontology. 2006;52(1):1-16.
Force platform measurements as predictors of falls among older people - a review.
Piirtola M, Era P.
BACKGROUND: Poor postural balance is one of the major risk factors for falling. The force platform
technique has widely been used as a tool to assess balance.
METHODS: The study was done as a systematic literature review. PubMed, the Cochrane Central Register
of Controlled Trials, and CINAHL databases from 1950 to April 2005 were used.
Results: Nine original prospective studies were included in the final analyses. In
five studies
fall-related outcomes were associated with some force
platform measures and in the remaining four studies
associations were not found. For the various parameters derived on the basis of the
force platform data, the mean speed of the mediolateral (ML) movement of the center of pressure (COP)
during normal standing with the eyes open and closed, the mean amplitude of the ML movement of the COP
with the eyes open and closed, and the root-mean-square value of the ML displacement of COP were the
indicators that showed significant associations with future falls. Measures related to dynamic posturography
(moving platforms) were not predictive of falls.
The results suggest that certain aspects of force
platform data may have predictive value for subsequent
falls, especially various indicators of the lateral control of
posture. However, the small number of studies available
makes it difficult to draw definitive conclusions.
CONCLUSION:
J Gerontol A Biol Sci Med Sci. 1995 Nov;50 Spec No:64-7.
Strength is a major factor in balance, gait, and the occurrence of falls.
Wolfson L, Judge J, Whipple R, King M.
Department of Neurology, University of Connecticut School of Medicine, Farmington, USA.
We studied the effects of lower extremity strength as well as gait and balance on the occurrence of falls in
nursing home residents. Nursing home residents with a history of falls had less than half of the knee and
ankle strength of nonfalling subjects residing in the same home. The differences were more
prominent at the ankle than the knee, and were most pronounced in the ankle
dorsiflexors, where they were one-tenth that of controls. Also of note was the fact that
this same group of fallers had slowed gait velocity (58% of control) as well as an impaired
response to postural perturbation as determined on the Postural Stress Test (55% of control). In a recently
completed study we measured strength as balance (EquiTest balance platform) of community-dwelling
subjects. The data from both nursing home and community-dwelling subjects
indicate a strong relationship of lower extremity strength to balance and gait.
Protocollo di raccolta dati in caso di caduta
 data, ora e luogo della caduta
 modalità: cosa stava facendo, in che direzione è
caduto, dove ha urtato
 eventuali rischi ambientali
 parametri vitali
 segni di lesione
 sintomatologia soggettiva, prima e dopo la caduta
caduta
preceduta da capogiri
sì
no
Correlata alla postura:
 nell’alzarsi: ipotensione posturale, manovra di Valsalva
 in corso di attività fisica: insufficiente gettata sistolica
 nel muovere il collo: insuff. vertebro-basilare, ipersensibilità seno carotideo
Non correlata alla postura:
 associata con sordità e tinnito: sindrome di Meniere, patologie orecchio int.
 associata con deficit neurologici a focolaio: TIA
preceduta da palpitazioni
sì
no
aritmia
si è inciampato
no
sì
fattori ambientali
Inadeguata percezione
dell’ambiente:
 deficit visivo
 neuropatie periferiche
artropatie
perdita
dell’equilibrio
miopatie
epilessia
 aumentata instabilità
 drop attack
 m. Di Parkinson
 degenerazione cerebellare
 aprassia
 TIA
abuso di alcool,
sedazione
cause
psicogene
Questionario Infermiere per valutare il rischio di caduta in RSA all’ingresso.
A) Paziente a letto
Altezza del letto è adeguata per il paziente?
Riesce il pz ad utilizzare il campanello di chiamata?
Ha imparato dove sono gli interruttori della luce?
Il comodino è facilmente raggiungibile?
E’ confuso?
Vanno applicate le spondine a letto?
Spondine sono sufficientemente alte?
B) Paziente in movimento
Può alzarsi e camminare da solo o necessita di aiuto?
Deve essere accompagnato ai servizi igienici?
Nel caso non è permesso, per il grave rischio di cadute, di alzarsi da solo il
pz tende ad alzarsi autonomamente?
B) Paziente in movimento
Usa correttamente il bastone o il tripode?
Ci vede bene da lontano?
Calzature e vestiario sono idonei?
E’ necessario l’intervento del callista?
Catetere vescicale e sacchetto ostacolano il cammino?
C) Monitoraggio Infermieristico
Dopo assunzione psicofarmaci ha variazione di coscienza o sicurezza nel
cammino?
E’ monitorato sufficientemente nelle ore successive all’assunzione di
diuretici?
In caso di ipotensione ortostatica il pz ha capito la necessità di assumere la
posizione eretta gradualmente?
In caso di nicturia è sufficiente il monitoraggio notturno?
Scala di valutazione del rischio di caduta di Conley
1) E’ caduto nel corso degli ultimi 3 mesi? (Si=2, No=0)
2) Ha mai avuto vertigini o capogiri negli ultimi 3 mesi?
(Si=1, No=0)
3) Le è mai capitato di perdere urine o feci mentre si
recava al bagno negli ultimi 3 mesi? (Si=1, No=0)
4) Compromissione della marcia, passo strisciante, ampia
base d’appoggio, marcia instabile. (Si=1, No=0)
5) Irrequietezza, eccessiva attività motoria. (Si=2, No=0)
6) Decadimento cognitivo e assenza di giudizio del
pericolo. (Si=3, No=0)
Valutazione punteggio: l’anziano è considerato a rischio per punteggio
uguale o superiore a 2.
Scopo degli interventi
ridurre al minimo il rischio e le
conseguenze delle cadute,
non limitare la capacità e la volontà di
movimento, nonché l’indipendenza
funzionale del paziente.
Anamnesi accurata
Forza, andatura ed
equilibrio
Eliminare
ostacoli
domestici
FKT entro
3-6 mesi
Consiglia
re ausili,
educare
all’uso
Stop BDZ
Visita
oculistica
PA, FC,
ECG
Valutazione stato
cognitivo ultimi 3-6 mesi
ACOVE-3 (JAGS Oct 2007)
Rethinking individual and community fall prevention
strategies: a meta-regression comparing single and
multifactorial interventions
Campbell AJ, Robertson MC.
Age and Ageing 2007;36:656–662
The meta-analyses demonstrate that the delivery of single factor
interventions to selected populations is as effective in reducing falls
as delivering multifactorial interventions to at risk community
populations (mean reduced falls = 24%).
Single interventions need to be carefully directed to the appropriate
population. Such interventions are highly successful when used in
populations where the risk factor addressed accounts for a large
proportion of the falls risk. Such a specific intervention is ineffective if
it does not alter the risk factor, or the risk factor accounts for a small
proportion of the risk.
Fall prevention
- single intervention strategy
Risk Reduction
 Strength and balance training
(not only individually tailored training but also more
untargeted group exercise programmes)
 Vitamin D and calcium
15-50%
20-50%
(unresolved)
 Reduction of psychotropic medication
66%
 Expedited cataract surgery
34%
 Cardiac pacing
58%
 Home hazard assessment and
modification
30%
- multiple intervention strategy (strength, balance, gait training, aidscanes, footwear, medical problems and medication review, optometrist, hip
protectors, staff education, post-fall assessment, environmental assessment)
 Risk Reduction: 30% in hospital, no effects in NH, 20-45% in community
(Lancet 2005)
Prevenzione delle cadute:
componenti degli interventi multifattoriali

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




Revisione della terapia farmacologica
Correzione di eventuali condizioni patologiche
Adeguamento dell’ambiente
Esercizio fisico
Fornitura di servizi
Educazione del paziente
Educazione dei caregiver
Fornitura di servizi
LA CURA DEL PIEDE
Un piede in buono stato di salute permette una migliore qualità della
deambulazione;
assicurarsi dello stato di salute della cute e delle unghie del piede,
verificare la sensibilità della cute;
evitare che l’anziano indossi calze che possano ostacolare la
circolazione o che possiedano cuciture tali da favorire lesioni da pressione;
L’igiene del piede va curata.
Clin Podiatr Med Surg. 2003 Jul;20(3):383-94.
Nursing and long-term care concerns of foot care in the elderly.
Warner I.
The elderly are particularly susceptible to foot problems caused by
underlying disease states, foot deformities, and alteration in the normal
perfusion to the lower leg and foot. As a consequence, mobility may be
compromised and quality of life threatened. Nurses, regardless of
the setting in which they practice, are able to provide
assessment, treatment, and education to geriatric patients
to promote the care of the foot.
Servizio di Podologia
Cambiamenti del piede correlati all’età
Aumento dello strato corneo
Progressiva disidratzione e riduzione dell’elasticità della cute
Ipercheratosi cutanea
Malattie ossee, neurologiche, metaboliche, vascolari, cardiache.
Causano:
Callosità e Duroni
Vescicole e bolle
Appiattimento arco plantare
deformazioni artrosiche metatarso-falangeee (alluce valgo, dito a martello,
speroni calcaneali, ecc)
Neuropatie, Dolore, Edema
Fragilità delle unghie (unghia incarnita, onicomicosi)
piodermite e ulcere
Il servizio di podologia risulta fondamentale nella
gestione dei problemi dell’anziano.
Revisione della terapia
farmacologica
Am J Epidemiol. 1995 Jul 15;142(2):202-11.
Psychotropic drugs and risk of recurrent falls in ambulatory nursing home residents.
Thapa PB, Gideon P, Fought RL, Ray WA.
Department of Preventive Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA.
Although psychotropic drug use has been associated with increased risk of falls in long-term care settings;
this association may be confounded by the high prevalence of dementia and depression and other fall risk
factors. This question was addressed in a prospective cohort study of recurrent falls among 282 ambulatory
residents of 12 Tennessee nursing homes during 1991-1992. Eligible subjects were > or = 65 years of age,
ambulatory, able to provide study data, and expected to remain in the nursing home for > or = 3 months..
Falls were ascertained from facility incident reports and nursing home charts. During follow-up, 111
residents had > or = 2 falls, an incidence rate of 54.9 recurrent falls per 100 person-years. With the use of
Cox proportional hazards modeling, the authors found incidence density ratios (95% confidence intervals
(Cl)) showing that the following risk factors were independently associated with recurrent falls: age > or = 75
years (1.66 (1.01-2.72)); > or = 4 assisted activities of daily living (1.94 (1.09-3.47)); middle (2.08 (1.203.61)) and upper (2.54 (1.44-4.49)) tertiles of balance impairment; fall in the 90 days preceding assessment
(2.01 (1.32-3.06)); and upper tertile of behavior problems (1.65 (1.03-2.64)). The rate of recurrent falls
increased tenfold as the number of these risk factors increased from 0 to 5 (21.4 to 231.5 per 100 personyears, p < 0.0002). After controlling for symptoms of dementia and depression and other fall risk factors, the
incidence density ratio for recurrent falls in baseline regular psychotropic drug users (n = 178) compared
with nonusers (n = 104) was 1.97 (95% Cl 1.28-3.05). Within groups defined by number of other
independent fall risk factors present, regular psychotropic users had a recurrent fall rate that was greater
than that for nonusers: 44.1 versus 22.9 per 100 person-years (p = 0.03) in the low risk (< or = 2 factors)
group and 98.7 versus 64.3 (p = 0.08) in the high risk (> 2 factors) group. The attributable risk of
recurrent falls for regular psychotropic drug users was 36%, which suggests
optimal management of psychopharmacotherapy is an essential component
of fall prevention programs for ambulatory nursing home residents.
Int Psychogeriatr. 2008 Oct;20(5):890-910. Epub 2008 Apr 17.
The influence of drug use on fall incidents among nursing home residents: a systematic review.
Sterke CS, Verhagen AP, van Beeck EF, van der Cammen TJ.
BACKGROUND: Falls are a major health problem among the elderly, particularly in nursing homes.
Abnormalities of balance and gait, psychoactive drug use, and dementia have been shown to contribute to
fall risk.
METHODS: We conducted a systematic review of the literature to investigate which psychoactive drugs
increase fall risk and what is known about the influence of these drugs on gait in nursing home residents
with dementia.
RESULTS: Seventeen studies were included in the review. We assessed the strength of evidence for
psychoactive drugs as a prognostic factor for falls by defining four levels of evidence: strong, moderate,
limited or inconclusive. Strong
evidence was defined as consistent findings (>
or =80%) in at least two high quality cohorts. We found strong
evidence that the use of multiple drugs (3/3 cohorts, effect sizes 1.301 xs 0.30), antidepressants (10/12 cohorts, effect sizes 1.10-7.60), and
anti-anxiety drugs (2/2 cohorts, effect sizes 1.22-1.32) is associated
with increased fall risk. The evidence for the association of other
psychoactive drug classes with fall risk was limited or inconclusive.
CONCLUSIONS: Research on the contribution of psychoactive drugs to fall risk in nursing home residents
with dementia is limited. The scarce evidence shows, however, that multiple drugs, antidepressants and
anti-anxiety drugs increase fall risk in nursing home populations with residents with dementia.
BMC Health Serv Res. 2009 Dec 11;9:228.
Fall-related injuries in a nursing home setting: is polypharmacy a risk factor?
Baranzini F, Diurni M, Ceccon F, Poloni N, Cazzamalli S, Costantini C, Colli C, Greco L, Callegari C.
BACKGROUND: Polypharmacy is regarded as an important risk factor for fallingand several studies and meta-analyses have
shown an increased fall risk in users of diuretics, type 1a antiarrhythmics, digoxin and psychotropic agents. In particular,
recent evidence has shown that fall risk is associated with the use of
polypharmacy regimens that include at least one established fall risk-increasing drug, rather than with
polypharmacy per se. We studied the role of polypharmacy and the role of well-known fall risk-increasing drugs on the
incidence of injurious falls.
METHODS: A retrospective observational study was carried out in a population of elderly nursing home residents. An
unmatched, post-stratification design for age class, gender and length of stay was adopted. In all, 695 falls were recorded in
293 residents.
RESULTS: 221 residents (75.4%) were female and 72 (24.6%) male, and 133 (45.4%) were recurrent fallers. 152 residents
sustained no injuries when they fell, whereas injuries were sustained by 141: minor in 95 (67.4%) and major in 46 (32.6%).
Only fall dynamics (p = 0.013) and drugs interaction between antiarrhythmic or antiparkinson class and polypharmacy regimen
(> or =7 medications) seem to represent a risk association for injuries (p = 0.024; OR = 4.4; CI 95% 1.21 - 15.36).
This work reinforces the importance of routine medication
reviews, especially in residents exposed to polypharmacy regimens
that include antiarrhythmics or antiparkinson drugs, in order to
reduce the risk of fall-related injuries during nursing home stays.
CONCLUSION:
Drugs Aging. 2006;23(4):271-87.
Use of sleep-promoting medications in nursing home residents : risks versus benefits.
Conn DK, Madan R.
This paper reviews the use of sleep-promoting medications in nursing home residents with reference to risks versus benefits.
Up to two-thirds of elderly people living in institutions experience sleep disturbance. The aetiology of sleep disturbance
includes poor sleep hygiene, medical and psychiatric disorders, sleep apnoea, periodic limb movements and restless leg
One key factor in the development of sleep disturbance in the
nursing home is the environment, particularly with respect to high
levels of night-time noise and light, low levels of daytime light, and
care routines that do not promote sleep. Clinical assessment should include a comprehensive
syndrome.
medical, psychiatric and sleep history including a review of prescribed medications. Nonpharmacological interventions for
insomnia are underutilised in many clinical settings despite evidence that they are often highly effective. International studies
suggest that 50-80% of nursing home residents have at least one prescription for psychotropic medication. Utilisation rates
vary dramatically from country to country and from institution to institution. The most commonly prescribed medications for
sleep are benzodiazepines and nonbenzodiazepine hypnotics (Z-drugs). The vast majority of studies of these medications are
short-term, i.e. < or =2 weeks, although some longer extension trials have recently been carried out. Clinicians are advised to
avoid long-acting benzodiazepines and to use hypnotics for as brief a period as possible, in most cases not exceeding 2-3
Patients receiving benzodiazepines are at increased risk of
daytime sedation, falls, and cognitive and psychomotor impairment.
weeks of treatment.
Zaleplon, zolpidem, zopiclone and eszopiclone may have some advantages over the benzodiazepines, particularly with
respect to the development of tolerance and dependence. Ramelteon, a novel agent with high selectivity for melatonin
receptors, has recently been approved in the US. Use of the antidepressant trazodone for sleep in nondepressed patients is
somewhat controversial. Atypical antipsychotics should not be used to treat insomnia unless there is also evidence of severe
behavioural symptoms or psychosis.
Drugs Aging. 2009;26(5):381-94. doi: 10.2165/00002512-200926050-00002.
Antidepressants and falls in the elderly.
Darowski A, Chambers SA, Chambers DJ.
John Radcliffe Hospital, Oxford, UK. [email protected]
Antidepressants have long been recognized as a contributory factor to falls and many studies show an
association between antidepressants and falls. There are extensive data for tricyclic antidepressants (TCAs)
and related drugs, and for selective serotonin reuptake inhibitors (SSRIs), but few data for other classes of
antidepressants. Sedation, insomnia and impaired sleep, nocturia, impaired postural reflexes and increased
reaction times, orthostatic hypotension, cardiac rhythm and conduction disorders, and movement disorders
have all been postulated as contributing factors to falls in patients taking antidepressants. Sleep disturbance
is a cardinal feature of depression, and all antidepressants have effects on sleep. TCAs and related drugs
cause marked sedation with daytime drowsiness. SSRIs and related drugs have an alerting effect, impairing
sleep duration and quality and causing insomnia, which may result in nocturia and daytime drowsiness.
Daytime drowsiness is a significant risk factor for falls, both in untreated depression and in depression
treated with antidepressants. Clinically significant orthostatic hypotension is common with TCAs and related
drugs, the older monoamine oxidase inhibitors and serotonin-norepinephrine reuptake inhibitors (SNRIs). It
occurs less commonly with SSRIs, and rarely with moclobemide and bupropion, and is not reported as a
significant adverse effect of hypericum (St John's wort). Cardiac rhythm and conduction disturbances are
well recognized with TCAs, tetracyclics and SNRIs, but have also been reported with SSRIs. The
contribution of antidepressant-induced conduction and rhythm disturbances to falls cannot be assessed with
current data. There
are insufficient data to exonerate any individual
antidepressant or class of antidepressants as a potential cause of
falls. The magnitude of the increased risk of falling with an antidepressant is about the same as the
excess risk found in patients with untreated depression.
Adeguamento dell’ambiente
MODIFICAZIONI DELL’AMBIENTE
Alcune semplici misure e modificazioni nelle abitudini di
vita quotidiana possono evitare o ridurre il rischio di cadute.
Adeguare l’ambiente alla persona anziana non significa
apportare modifiche tali da peggiorare l’estetica di un
appartamento: è possibile infatti, senza privare l’anziano
dei propri ricordi, migliorare la funzionalità dell’ambiente in
cui vive, e renderlo più sicuro.
• Garantire una buona illuminazione degli ambienti e
sistemare gli interruttori della luce in posizioni sicure
• Evitare tappeti, sgabelli, sedie instabili e/o troppo
basse
• Evitare prodotti pericolosi (tipo cera) per la pulizia dei
pavimenti
• Ridurre l’uso dei gradini e far installare dei corrimani
lungo i muri ben visibili e di facile presa
• Proteggere l’accesso ai locali con superfici bagnate
• Installare nei bagni i maniglioni che facilitino i
movimenti e controllare la stabilità dei rialza-water
•
•
•
•
Utilizzare superfici antiscivolo
Liberare le zone di passaggio
Utilizzare sedie rigide con braccioli
Verificare che gli ausili per la deambulazione, dove
necessari, siano in buone condizioni (parte gommata di
appoggio dei bastoni, stabilità delle ruote dei
deambulatori)
Age Ageing. 2004 May;33(3):242-6.
Does the type of flooring affect the risk of hip fracture?
Simpson AH, Lamb S, Roberts PJ, Gardner TN, Evans JG.
Department of Orthopaedics and Trauma, University of Edinburgh, UK. [email protected]
BACKGROUND: The number of hip fractures occurring worldwide in 1990 was estimated at 1.7 million and
is predicted to rise to 6.3 million by 2050. The vast majority occur as a result of simple falls and the impact of
the femoral trochanter with the floor. Previous studies have addressed the problem from the patient's side of
the impact. Little research has been carried out on the other surface involved in the impact, the floor.
STUDY
LOCATION: 34 residential care homes.
METHODS: (1) The mechanical properties of the floor were measured with force transducers. (2) The
number and location of falls and fractures on the various floors were recorded prospectively for 2 years. The
threshold for reporting falls in different care homes was assessed using a standardised set of scenarios.
Wooden carpeted
floors were associated with the lowest number of
fractures per 100 falls. The risk of fracture resulting from a fall was significantly lower
RESULTS: A total of 6,641 falls and 222 fractures were recorded.
compared to all other floor types (odds ratio 1.78, 95% CI 1.33-2.35). The mean impact force was
significantly lower on wooden carpeted floors: 11.9 kN compared to the other floor types.
DISCUSSION: The possible implications of our findings are considerable. Residents of homes are typically
frail and many have a propensity to falls. In
designing safer environments for older
people, the type of floor should be chosen to minimise the risk of
fracture. This may result in a major reduction in fractures in the elderly.
Correzione di eventuali
condizioni patologiche
Conseguenze delle cadute
 paura di cadere e ansia post-caduta
 riduzione dell’attività motoria
 riduzione dei livelli di autonomia
Fear of falling and the post-fall anxiety syndrome result in loss of selfconfidence and selfimposed functional limitations in both home-living
and institutionalized elderly persons who have fallen
Rubenstein et al, ACOVE, 2001
Falls and Fear of Falling: Which Comes First? A Longitudinal
Prediction Model Suggests Strategies for Primary and
Secondary Prevention
Susan M. Friedman , MD, MPH,* Beatriz Munoz , MS, † Sheila K. West ,
PhD, † Gary S. Rubin , PhD, ‡ and Linda P. Fried , MD, MPH §
J Am Geriatr Soc 2002;50:1329-1335
RESULTS:Falls at baseline were an independent predictor of
developing fear of falling 20 months later (odds ratio (OR) = 1.75;
P < .0005), and fear of falling at baseline was a predictor of falling
at 20 months (OR = 1.79; P < .0005).
INTERVENTI DI PREVENZIONE
Cochrane Database Syst Rev. 2010 Jan 20;(1):CD005465.
Interventions for preventing falls in older people in nursing care facilities and
hospitals.
Cameron ID, Murray GR, Gillespie LD, Robertson MC, Hill KD, Cumming RG, Kerse
BACKGROUND: Falls in nursing care facilities and hospitals are common events
that cause considerable morbidity and mortality for older people.
MAIN RESULTS: We included 41 trials (25,422 participants).In nursing care
facilities, the results from seven trials testing supervised exercise interventions were
inconsistent. A post hoc subgroup analysis, however, indicated that where provided
by a multidisciplinary team, multifactorial interventions reduced the rate of falls (RaR
0.60, 95% CI 0.51 to 0.72; 4 trials, 1651 participants) and risk of falling (RR 0.85,
95% CI 0.77 to 0.95; 5 trials, 1925 participants). Vitamin D supplementation
reduced the rate of falls (RaR 0.72, 95% CI 0.55 to 0.95; 4 trials, 4512 participants),
but not risk of falling (RR 0.98, 95% CI 0.89 to 1.09; 5 trials, 5095 participants).
AUTHORS' CONCLUSIONS: There
is evidence that multifactorial
interventions reduce falls and risk of falling in hospitals
and may do so in nursing care facilities. Vitamin D
supplementation is effective in reducing the rate of falls in
nursing care facilities. Exercise in subacute hospital
settings appears effective but its effectiveness in nursing
care facilities remains uncertain.
Am J Med. 2006 Apr;119(4 Suppl 1):S3-S11.
Preventing osteoporosis-related fractures: an overview.
Gass M, Dawson-Hughes B.
Department of Obstetrics and Gynecology, University of Cincinnati College of
Medicine, Cincinnati, Ohio 45267-0526, USA. [email protected]
Osteoporosis is a skeletal disorder characterized by compromised bone strength,
which predisposes a person to increased risk of fracture.
The report recommends a pyramidal approach to
osteoporosis treatment that includes calcium and vitamin
D supplementation, physical activity, and fall prevention
as the first line in fracture prevention. The second level consists of
treating secondary causes of osteoporosis; the third and top level consists of
pharmacotherapy. Pharmacotherapeutic interventions (e.g., bisphosphonates,
selective estrogen receptor modulators, calcitonin, and teriparatide) in women with
postmenopausal osteoporosis provide substantial reduction in fracture risk over and
above risk reduction with calcium and vitamin D supplementation alone. Despite the
effectiveness of therapy, most patients who receive treatment do not remain on
treatment for >1 year. An important approach to reducing the rate of fractures is first
to target our treatments to patients at high risk for fracture and then to develop
strategies to improve treatment continuation rates.
JAMA. 2004 Apr 28;291(16):1999-2006.
Effect of Vitamin D on falls: a meta-analysis.
Bischoff-Ferrari HA, Dawson-Hughes B, Willett WC, Staehelin HB, Bazemore MG, Zee RY, Wong JB.
CONTEXT: Falls among elderly individuals occur frequently, increase with age, and lead to substantial
morbidity and mortality. The role of vitamin D in preventing falls among elderly people has not been well
established.
OBJECTIVE: To assess the effectiveness of vitamin D in preventing an older person from falling.
DATA SYNTHESIS: Based on 5 RCTs involving 1237 participants, vitamin D reduced the corrected odds
ratio (OR) of falling by 22% (corrected OR, 0.78; 95% confidence interval [CI], 0.64-0.92) compared with
patients receiving calcium or placebo. From the pooled risk difference, the number needed to treat (NNT)
was 15 (95% CI, 8-53), or equivalently 15 patients would need to be treated with vitamin D to prevent 1
person from falling. The inclusion of 5 additional studies, involving 10 001 participants, in a sensitivity
analysis resulted in a smaller but still significant effect size (corrected RR, 0.87; 95% CI, 0.80-0.96).
Subgroup analyses suggested that the effect size was independent of calcium supplementation, type of
vitamin D, duration of therapy, and sex, but reduced sample sizes made the results statistically
nonsignificant for calcium supplementation, cholecalciferol, and among men.
Vitamin D supplementation appears to reduce
the risk of falls among ambulatory or institutionalized
older individuals with stable health by more than 20%.
CONCLUSIONS:
Age Ageing. 2010 Mar;39(2):239-45. Epub 2010 Jan 11.
The association between various visual function tests and low fragility hip fractures among the
elderly: a Malaysian experience.
Chew FL, Yong CK, Mas Ayu S, Tajunisah I.
BACKGROUND: hip fractures are an increasing source of morbidity and mortality in older people. The role
of visual function tests such as visual impairment, stereopsis, contrast sensitivity and visual field defects in
low fragility hip fractures in Asian populations is not well understood.
METHODS: both cases and controls underwent a detailed ophthalmological examination, which included
visual acuity, stereopsis, contrast sensitivity and visual field testing.
RESULTS: poorer visual acuity (odds ratio, OR = 4.08; 95% confidence interval, CI: 1.44, 11.51), stereopsis
(OR = 3.60, 95% CI: 1.55, 8.38), contrast sensitivity (OR = 3.34, 95% CI: 1.48, 7.57) and visual field defects
(OR = 11.60, 95% CI: 5.21, 25.81) increased the risk of fracture. Increased falls were associated with poorer
visual acuity (OR = 2.30, 95% CI: 1.04, 5.13), stereopsis (OR = 2.11, 95% CI: 1.03, 4.32), contrast
sensitivity (OR = 2.12, 95% CI: 1.05, 4.30) and visual field defects (OR = 3.40, 95% CI: 1.69, 6.86).
CONCLUSION: impaired
visual acuity, stereopsis, contrast sensitivity and
visual field defects are associated with an increased risk of low
fragility hip fractures. We recommend that all patients aged > or = 55
should have an annual ophthalmological examination that includes
visual acuity, contrast sensitivity, stereopsis and visual field testing to
assess the risks for falls and low fragility fractures.
Age Ageing. 2006 Sep;35 Suppl 2:ii42-ii45.
Visual risk factors for falls in older people.
Lord SR.
Prince of Wales Medical Research Institute, University of New South Wales, Sydney, Australia.
[email protected]
Poor vision reduces postural stability and significantly increases the risk of falls and fractures in older
people. Most studies have found that poor visual acuity increases the risk of falls. However, studies that
have included multiple visual measures have found that reduced contrast sensitivity and depth perception
are the most important visual risk factors for falls. Multifocal glasses may add to this risk because their nearvision lenses impair distance contrast sensitivity and depth perception in the lower visual field. This reduces
There is now evidence
that maximising vision through cataract surgery is an
effective strategy for preventing falls. Further randomised controlled trials
the ability of an older person to detect environmental hazards.
are required to determine whether individual strategies (such as restriction of use of multifocal glasses) or
multi-strategy visual improvement interventions can significantly reduce falls in older people. Public health
the importance
of regular eye examinations and use of appropriate
prescription glasses.
initiatives are required to raise awareness in older people and their carers of
J Am Geriatr Soc. 2002 Nov;50(11):1760-6.
Multifocal glasses impair edge-contrast sensitivity and depth perception and increase the risk of
falls in older people.
Lord SR, Dayhew J, Howland A.
OBJECTIVES: To determine the extent to which multifocal glasses impair contrast sensitivity and depth
perception at critical distances required for detecting hazards in the environment and whether multifocal
glasses use increases the risk of falls in older people.
MEASUREMENTS: Contrast sensitivity, depth perception, accidental falls.
RESULTS: Eighty-seven subjects (55.8%) were regular wearers of multifocal (bifocal, trifocal, or
progressive lens) glasses. These subjects performed significantly worse in the distant depth perception and
distant edge-contrast sensitivity tests in conditions that forced them to view test stimuli through the lower
segments of their glasses. Multifocal glasses wearers were more than twice as likely to fall in the follow-up
period than nonmultifocal glasses wearers (odds ratio (OR) = 2.29, 95% confidence interval (CI) = 1.064.92), when adjusting for age, poor vision, reduced lower limb sensation and strength, slow reaction time,
and increased postural sway. Multifocal glasses wearers were also more likely to fall because of a trip (OR =
2.79, 95% CI = 1.08-7.22), when outside their homes (OR = 2.55, 95% CI = 1.14-5.70), and when walking
up or down stairs (P <.01). The population attributable risks of regular multifocal glasses use were 35.2% for
any falls, 40.9% for falls due to a trip, and 40.9% for falls outside the home.
The study findings indicate that multifocal
glasses impair depth perception and edge-contrast
sensitivity at critical distances for detecting obstacles in
the environment. Older people may benefit from wearing
nonmultifocal glasses when negotiating stairs and in
unfamiliar settings outside the home.
CONCLUSIONS:
Acta Otolaryngol Suppl. 1988;449:165-9.
Postural hypotension--cochleo-vestibular hypoxia--deafness.
Hansen S.
The postural hypotension syndrome i.e. a sudden fall in blood pressure as a
result of sudden rising, leading to severe vertigo and fainting has been known
for a very long time, but the diagnostic criteria for hypotension has changed
recently. Medical textbooks claim that unless systolic B.P. falls more than 20
mm upon rising it is not hypotension. A recent British investigation employing
radio-active isotope tomography has shown that an orthostatic fall in B.P. of 10
mm in elderly persons may cause a 60% decrease in cerebral blood-flow
lasting several minutes (2). It
has been estimated that at least
30% of the patients in nursing-homes suffer from
vertigo. Last year 6000 elderly persons in Denmark were treated for fracture
of the femoral neck. This study points out that concurrent with vertigo and
fainting the cochlea does suffer from decreased blood supply, and hearing
subsequently deteriorates. The reason why this has not been recognized until
now is that while vertigo comes and disappears within minutes and is distinctly
felt by the patient, the hearing loss develops nearly as slowly as does hearing
loss caused by moderate noise exposure over many years. Axelsson et al. in a
recent study point out that at least TTS is influenced by cochlear blood flow (4).
J Gerontol A Biol Sci Med Sci. 2006 Feb;61(2):165-9.
Long-term effects of analgesics in a population of elderly nursing home residents
with persistent nonmalignant pain.
Won A, Lapane KL, Vallow S, Schein J, Morris JN, Lipsitz LA.
BACKGROUND: Little is known about the long-term effects of analgesics on functional
status and well-being of nursing home residents with chronic pain.
RESULTS: There was no change in the analgesic class for at least 6 months for 35.4%
of residents, including 40% who received no analgesics during this time. Use of
nonopioids was 37.9%, short-acting opioids was 18.9%, and long-acting opioids was
3.3%. We found improvement in functional status (adjusted
hazard ratio = 1.85; 95% confidence interval [CI], 1.05-3.23) and social engagement
(adjusted hazard ratio = 1.58; 95%, CI, 0.99-2.50) with
long-acting opioids
compared with short-acting opioids. There were no changes in
cognitive status or mood status, or increased risk of depression with use of any
analgesics, including opioids. There
was a trend toward a lower
risk of falls with use of any analgesics (adjusted odds ratio =
0.87; 95% CI, 0.70-1.06). Rates of other adverse events (i.e., constipation, delirium,
dehydration, pneumonia) were not found to be higher among chronic opioid users
compared to those taking no analgesics or nonopioids.
CONCLUSIONS: The use of long-acting opioids may be a relatively safe option in the
management of persistent nonmalignant pain in the nursing home population, yielding
benefits in functional status and social engagement
Br J Nutr. 2009 May;101(9):1300-5.
BMI: a simple, rapid and clinically meaningful index of under-nutrition in the oldest
old?
Miller MD, Thomas JM, Cameron ID, Chen JS, Sambrook PN, March LM, Cumming RG,
Lord SR.
Department of Nutrition and Dietetics, Flinders University, Adelaide, SA, Australia.
BMI is commonly used as a sole indicator for the assessment of nutritional status. While
it is a good predictor of morbidity and mortality among young and middle-aged adults, its
predictive ability among the oldest old remains unclear. The objective of the present
study was to investigate the relationship between BMI and risk of falls, fractures and allcause mortality among older Australians in residential aged care facilities.
Cox proportional hazards regression models were calculated to determine the
relationship between baseline BMI and time to fall, fracture or death, within 2 years
following the baseline measures taken to be the censoring date. After adjustments were
made for age, sex and level of care, low
BMI increased the risk of
fracture by 38% (hazard ratio = 1.38, 95% CI 1.11, 1.73).
In conclusion, BMI has predictive ability in the area of
fracture and all-cause mortality for residents of aged
care facilities. It is a simple and rapid indicator of nutritional status rendering it a
useful nutrition screen and goal for nutrition intervention
The relationship between specific cognitive functions and
falls in the aging
Holtzer R, et al.
Neuropsychology 2007 Sep ;21 (5):540-8.
The current study examined the relationship between cognitive function and
falls in older people who did not meet criteria for dementia or mild cognitive
impairment (N = 172). To address limitations of previous research, the
authors controlled for the confounding effects of gait measures and other
risk factors by means of associations between cognitive function and falls. A
neuropsychological test battery was submitted to factor analysis, yielding 3
orthogonal factors (Verbal IQ, Speed/Executive Attention, Memory). Single
and recurrent falls within the last 12 months were evaluated.
Multivariate logistic regressions showed that lower scores on
Speed/Executive Attention were associated with increased risk of single and
recurrent falls. Lower scores on Verbal IQ were related only to increased
risk of recurrent falls. Memory was not associated with either single or
recurrent falls. These findings are relevant to risk assessment and
prevention of falls and point to possible shared neural substrates of
cognitive and motor function.
Psychol Neuropsychiatr Vieil. 2005 Dec;3(4):271-9.
[Dementia and falls: two related syndromes in old age]
Puisieux F, Pardessus V, Bombois S.
Dementia and cognitive impairment are known as a major risk for falls and
subsequent adverse events in the elderly. In addition to result in serious injury,
including fractures, falls lead to functional decline due to fear of falling again and
self limitation of activity in older adults. All types of dementia and all degrees
of severity are involved. Rather than resulting from a single cause,
falls are the result of a combination of intrinsic, situational, and
environmental factors. The most common risk factors for falls in patients with
cognitive impairment and dementia are gait and balance disturbances,
behavioral disorders, visual problems, malnutrition, adverse effects of
drugs, fear of falling, neurocardiovascular instability (particularly
orthostatic hypotension), and environmental hazards. Based on data
from studies in cognitively normal people who fall, a multifaceted intervention,
including a physical exercise programme and modification of the risk factors may
prevent falls in older people with cognitive impairment and dementia. Preliminary
research suggests that physiotherapy may have a role for falls prevention in these
patients. However, randomized studies need to be performed.
Am J Geriatr Psychiatry. 2005 Jun;13(6):501-9.
Factors associated with falls among older, cognitively impaired people in
geriatric care settings: a population-based study.
Kallin K, Gustafson Y, Sandman PO, Karlsson S.
OBJECTIVE: The authors studied factors associated with falls among cognitively
impaired older people in geriatric care settings. Method: This was a study using all
geriatric care settings in a county in northern Sweden. Residents were assessed by
means of the Multi-Dimensional Dementia Assessment Scale, supplemented with
questions concerning the use of physical restraints, pain, previous falls during the
stay, and falls and injuries during the preceding week. Data about both falls and
cognition were collected in 3,323 residents age 65 and older. Of these residents
2,008 (60.4%) were cognitively impaired, and they became the study population. Of
the participants, 69% were women; mean age: 83.5 years.
RESULTS: Of 2,008 cognitively impaired residents, 189 (9.4%) had fallen at least
once during the preceding week. Being able to get up from a chair, previous falls,
needing a helper when walking, and hyperactive symptoms were the factors most
strongly associated with falls.
CONCLUSION: Preventing falls in cognitively impaired older people is
particularly difficult. An intervention strategy would probably have to
include treatment of psychiatric and behavioral symptoms,
improvement of gait and balance, and adjustment of drug treatment,
as well as careful staff supervision.
Educazione dei caregiver
La Formazione
Al personale per aumentare la consapevolezza del rischio dei pazienti e le
strategie di prevenzione,(Grado D)
(Meyer G, Warnke A, Bender R, Mùhlhauser I, BMJ 2003)
MATERIALI E METODI:
459 residenti di nursing home come caso
483 residenti nel gruppo controllo
OBIETTIVO: Ridurre l’incidenza di fratture di femore attraverso un
programma strutturato di formazione del personale
RISULTATO
21 fratture nel gruppo caso
42 fratture nel gruppo controllo
CONCLUSIONI:
l’introduzione di un programma di educazione del personale e
l’approvvigionamento di protettori d’anca riduce il numero delle fratture
di femore.
Educazione del paziente
AUSILI PER PROTEGGERE IL FEMORE
Trial clinico randomizzato che ha coinvolto 1801 anziani fragili finlandesi
- pazienti fragili in casa di riposo o a domicilio
- età media 81 anni
78% donne
- 63% assistite nella deambulazione
(Kammus 2003)
Inj Prev. 2008 Oct;14(5):306-10.
Risk of hip fractures in soft protected, hard protected, and unprotected falls.
Bentzen H, Bergland A, Forsén L.
OBJECTIVE: To compare hip fracture risk in soft and hard protected falls with the risk in
unprotected falls and to compare the incidence of hip fractures in nursing homes providing soft
and hard hip protectors.
METHODS: An observational study conducted within the framework of a cluster randomized
trial in 18 nursing homes. Nursing homes were randomized to offer either soft or hard hip
protectors. Individual participants were followed for falls for 18 months.
RESULTS: Of 1236 participating residents, 607 suffered 2926 falls; 590 of the 2926 falls were
categorized as soft protected, 852 as hard protected, and 1388 as unprotected falls. Sixty-six
verified hip fractures occurred: eight in soft protected falls, 11 in hard protected falls, and 45 in
unprotected falls. The hip fracture risk in soft and hard protected falls was almost 60% lower
than in unprotected falls (OR (soft) 0.36, 95% CI 0.17 to 0.77; OR (hard) 0.41, 95% CI 0.19 to
0.89). The incidence of hip fracture was 4.6 and 6.2 per 100 person-years in nursing homes
providing soft and hard hip protectors, respectively (p = 0.212).
CONCLUSION: Both
types of hip protector have the potential,
when worn correctly, to reduce the risk of a hip fracture in
falls by nearly 60%. Both can be recommended to nursinghome residents as a means of preventing hip fractures.
Br J Nurs. 2004 Nov 25-Dec 8;13(21):1242-8.
Preventing hip fracture in care homes 1: views of residents and staff.
Doherty D, Glover J, Davies S, Johnson T.
Hip protectors have been shown to be effective in reducing the incidence of
hip fracture among older people living in care homes (Parker et al, 2004).
However, there are problems with compliance. This article reports findings
from a survey of 138 staff from 23 care homes about experiences and
perceptions of using hip protectors. The survey was complemented by
qualitative case studies involving staff, to be linked to compliance with
wearing hip protectors including comfort, acceptability to the resident and
appearance. Few practical difficulties in using hip protectors were identified.
Staff and residents' perceptions and experiences of using
hip protectors vary and are likely to influence compliance.
il 2,1% vs. 4.6% all’anno di fratture con l’uso di protettore d’anca
Devono essere applicati per un anno a 40 pazienti per prevenire 1 frattura
di femore
2.4% di cadute determina fratture di femore quando non vengono usati
ausili
0.4% di cadute dermina frattura di femore quando vengono usati ausili
il livello di accettazione da parte dei pazienti è basso
(Kammus 2003)
Esercizio fisico
Cochrane Database Syst Rev. 2007 Oct 17;(4):CD004963.
Exercise for improving balance in older people.
Howe TE, Rochester L, Jackson A, Banks PM, Blair VA.
BACKGROUND: Diminished ability to maintain balance may be associated with an increased risk of falling.
In older adults, falls commonly lead to injury, loss of independence, associated illness and early death.
Although some exercise interventions with balance and muscle strengthening components have been
shown to reduce falls it is not known which elements, or combination of elements, of exercise interventions
are most effective for improving balance in older people.
OBJECTIVES: To present the best evidence for effectiveness of exercise interventions designed to improve
balance in older people living in the community or in institutional care.
MAIN RESULTS: For the 34 included studies there were 2883 participants at entry. Statistically significant
improvements in balance ability were observed for exercise interventions compared to usual activity.
Interventions involving gait; balance; co-ordination and functional exercises; muscle strengthening; and
multiple exercise types appear to have the greatest impact on indirect measures of balance. There was
trend towards an improvement in balance with cycling on a static cycle. However, there was limited
evidence that effects were long-lasting.
Exercise appears to have statistically
significant beneficial effects on balance ability in the short
term but the strength of evidence contained within these
trials is limited. Many of these mainly small studies demonstrated a range of methodological
AUTHORS' CONCLUSIONS:
weaknesses. The failure across the included studies to apply a core set of standardised outcome measures
to determine balance ability restricts the capacity to compare or pool different trials from which firm
conclusions regarding efficacy can be made. Further standardisation in timing of outcome assessment is
also required as is longer term follow-up of outcomes to determine any lasting effects.
J Gerontol A Biol Sci Med Sci. 2004 Oct;59(10):1062-7.
Low-intensity exercise and reduction of the risk for falls among at-risk elders.
Morgan RO, Virnig BA, Duque M, Abdel-Moty E, Devito CA.
BACKGROUND: Among elderly persons, falls account for 87% of all fractures and are
contributing factors in many nursing home admissions. This study evaluated the effect of an
easily implemented, low-intensity exercise program on the incidence of falls and the time to
first fall among a clinically defined population of elderly men and women.
METHODS: This community-based, randomized trial compared the exercise intervention with
a no-intervention control. The participants were 294 men and women, aged 60 years or older,
who had either a hospital admission or bed rest for 2 days or more within the previous month.
Exercise participants were scheduled to attend exercise sessions lasting 45
minutes, including warm-up and cool-down, 3 times a week for 8 weeks (24
sessions). Assessments included gait and balance measures, self-reported physical
function, the number of medications being taking at baseline, participant age, sex, and history
of falling. Falls were tracked for 1 year after each participant's baseline assessment.
RESULTS: 29% of the study participants reported a fall during the study period. The effect of
exercise in preventing falls varied significantly by baseline physical function level (p < or
=.002). The risk for falls decreased for exercise participants with low baseline physical
functioning (hazard ratio,.51) but increased for exercise participants with high baseline
physical functioning (hazard ratio, 3.51).
CONCLUSIONS: This easily implemented, low-intensity exercise program
appears to reduce the risk for falls among elderly men and women
recovering from recent hospitalizations, bed rest, or both who have
low levels of physical functioning.
Thai Chi and Falling
Atlanta FICSIT Trial
200 community dwelling elders > 70
Interventions: 15 week of education, balance training or Thai Chi
Outcome at 4 months: strength, flexibility, IADL
Falls reduced by 47% in Tai Chi group
(Wolf 1996)
TAI CHI
Alcuni ricercatori americani (Università del Minnesota)
affermano che il Tai Chi può essere utilizzato:
• Per aumentare l’equilibrio e la stabilità con
conseguente riduzione delle cadute;
• Per favorire le funzioni cardio-respiratorie;
• Per la riabilitazione di pazienti affetti da esiti di infarto
miocardico;
• Per la riabilitazione dell’artrite reumatoide;
• Per ridurre il dolore, l’insonnia e l’ansia.
J. Holist Nurs 1999
INTERVENTI MULTIFATTORIALI
J Gerontol Nurs. 2000 Mar;26(3):43-51.
A fall prevention program for elderly individuals. Exercise in long-term care settings.
Schoenfelder DP.
University of Iowa College of Nursing, Iowa City 52242, USA.
The purpose of this research was to explore the role of exercise in preventing falls, specifically assessing
the effectiveness of an ankle strengthening and walking program to improve balance, ankle strength,
walking speed, and falls efficacy and to decrease falls and subjects' fear of falling. Sixteen individuals
participated in the study which was conducted at two nursing homes. Subjects were assigned randomly to
an intervention or control group. The participants in the intervention group completed a 3-month supervised
program of ankle strengthening exercises and walking. Descriptive statistics were used to characterize the
sample, and differences in the least square means were used to assess the outcome variables (i.e.,
balance, ankle strength, walking speed, falls, fear of falling, falls efficacy) before the exercise program, and
again at 3 months and 6 months after the program for the intervention and control subjects. Findings for the
intervention group from pretest to 3-month posttest were, for the most part, maintained or in the predicted
direction, suggesting that regular exercise shows promise for preventing
deterioration and improving fall-related outcomes for elderly nursing home
residents.
ESERCIZIO FISICO
•
•
•
•
•
•
•
•
Le proposte operative volte a ridurre il rischio di
cadute sono molteplici:
corpo a terra
equilibrio statico e dinamico
esercizi di coordinazione
rinforzo segmentario
esercizi di propriocezione
massoterapia
esercizi di presa di coscienza
training autogeno
ESERCIZIO FISICO
Equilibrio statico e dinamico
• si può definire “equilibrio” la capacità di un individuo
di mantenere una posizione stabile del corpo sia in
condizioni di staticità che di movimento.
Molto spesso gli anziani presentano una diminuzione
dell’equilibrio anche quando non esiste compromissione
degli organi vestibolari.
EQUILIBRIO E CONTROLLO DELLA POSTURA
• L’equilibrio è una precondizione indispensabile per
una normale prestazione in tutte le attività della vita
quotidiana.
• Tutte le nostre prestazioni (ad esempio il camminare,
lo scendere le scale) sono delle situazioni di squilibrio
controllato: spostiamo la nostra massa al di fuori della
base di supporto (centro di pressione) per alzarci da
una sedia e camminare.
• Il controllo posturale sia in condizioni statiche (la
stazione eretta) sia in condizioni dinamiche (l’equilibrio)
può essere definito come la capacità di mantenere il
centro di massa corporea (normalmente localizzato in
stazione eretta al davanti delle prime vertebre sacrali)
nella base di supporto o nei limiti di stabilità.
SWAY NORMALE
•Nel soggetto normale la stazione eretta rilassata è
caratterizzata da una piccola oscillazione continua: il body
sway di Sheldon.
La costante e piccola deviazione dalla verticalità, e la sua
susseguente correzione, implica una continua risposta
muscolare riflessa costante, soprattutto dei muscoli del
polpaccio, ad un input sensoriale visivo, vestibolare e
somatosensoriale.
CONTROLLO POSTURALE
Visione
Campo visivo.Visione periferica. Acuità
visiva. Percezione di profondità.
Sensibilità di contrasto.
Sensazione
somatosensoriale
Sensibilità propriocettiva, tattile, senso
di posizione
Vestibolare
Orientamento del capo, accelerazione.
Riferimento
Outpout muscolare
ROM, stifness
Forza muscolare
Potenza muscolare
Integrazione cerebrale Tempo di reazione, scelta multipla
POSTUROSTABILOMETRO
RINFORZO SEGMENTARIO
• L’esercizio fisico può minimizzare i cambiamenti
fisiologici associati all’invecchiamento e contribuire al
benessere fisico e psicologico.
• Ci sono molte similitudini tra i cambiamenti determinati
dal mancato esercizio e quelli tipici dell’invecchiamento.
Nella maggior parte dei sistemi fisiologici tuttavia il
normale processo di invecchiamento non si manifesta
necessariamente con una disabilità in assenza di
malattia.
• Le linee guida stese in seguito a tali studi hanno
identificato specifiche modalità di esercizio appropriate
per la popolazione anziana. In particolare sono state
individuate 4 categorie di trattamento:
• Esercizi aerobici
• Esercizi di resistenza
• Esercizi di equilibrio
• Esercizi di allungamento muscolare
• Tali evidenze si sono dimostrate valide anche in caso di
pazienti affetti da disturbi cognitivi od affettivi (demenza
e depressione), che pertanto non rappresentano un
fattore di esclusione dal trattamento.
Suola Elettronica
L’iShoe è:
- un dispositivo elettronico di allarme istantaneo,
- dispositivo di raccolta dati che possono essere analizzati per attivare
procedure di correzione dei dati anomali,
- un dispositivo elettronico in grado di produrre stimoli tattili nel
momento che si verificano problemi di equilibrio per prevenire
un’eventuale caduta.
Terapia Occupazionale in Rsa
• Si definisce Terapia Occupazionale la
tecnica terapeutica che utilizza attività
finalizzate e selezionate, individuali e di
gruppo, al fine di promuovere nella
persona con disabilità (fisica, psichica,
sensoriale) il massimo livello di autonomia
fisica, sociale, psicologica.
• Progetto terapeutico
• L’osservazione e la conoscenza dei dati
permettono di definire gli obiettivi proponibili.
• Le attività della terapia occupazionale sono
rivolte alle attività della vita quotidiana, di lavoro,
di gioco, di artigianato, ecc.
• Le proposte, non casuali, devono sempre far
riferimento alle caratteristiche della personalità,
l’autonomia motoria, capacità intellettive ed
affettive.
• Gli Ausili:
“Qualsiasi prodotto, strumento, attrezzatura o
sistema tecnologico di produzione specializzata o
di comune commercio, utilizzato da una persona
disabile per prevenire, compensare, alleviare o
eliminare una menomazione, disabilità o
handicap”
Standard internazionale ISO 99/EN29999 ausili.
• Ausili per la mobilità:
Bastoni: una punta, tre punte, quattro punte
Stampelle: ascellari, antibrachiali, canadesi,
Deambulatori: quattro punte, due ruote e due punte,
quattro ruote,
Carrozzine: da transito, comode, elettriche.
• Funzione degli Ausili per la mobilità:
Aumentare stabilità e sicurezza, migliorare l’equilibrio,
fornire supporto (Jeka 1997)
Eliminare del tutto o in parte il carico da uno o entrambi gli
arti inferiori (Deathe 1993)
Diminuire o rimuovere il dolore durante il carico (Deathe 1993)
Aumentare la velocità di marcia
Migliorare l’estetica della deambulazione
• I deambulatori: Criteri di scelta
E stato condotto uno studio per valutare gli effetti di
deambulatori sulla: capacità di esercizio e ossigenazione
del sangue.
Metodi: Misurazione della saturazione di ossigeno durante
il cammino con e senza ausilio in un gruppo di anziani di
età compresa tra 70 e 92 anni affetti da bronchite
cronica.
Risultati: il deambulatore ascellare aumenta la capacità di
esercizio e di ossigenazione mentre il deambulatore
senza ruote ha effetti peggiori. (Roomy J 1998)
Arch Phys Med Rehabil. 2004 Dec;85(12):2067-9.
The WalkAbout: A new solution for preventing falls in the elderly and disabled.
Wolfe RR, Jordan D, Wolfe ML.
OBJECTIVE: To evaluate the performance of a new walking aid, the WalkAbout, for severely
disabled and elderly persons.
DESIGN: Crossover design.
SETTING: Laboratory and nursing home.
PARTICIPANTS: Sixty-five patients who could not walk independently.
INTERVENTIONS: The top rail of the WalkAbout completely encircles the user and is
approximately waist high to provide user stability. The footprint of the base is larger in
circumference than the top rail, with the legs angled outward to give the device maximum
stability. The caster wheels roll easily along the floor as the user walks. Foot brakes on 2
wheels provide stability for entering and exiting the device by walking through the gate. A
safety seat prevents falling but does not impede normal gait.
MAIN OUTCOME MEASURES: Distance walked, a questionnaire used to assess function of
the WalkAbout, and laboratory tests of safety in preventing falls.
RESULTS: Seventeen subjects could walk only with the WalkAbout. Ninety-seven percent of
subjects who could walk with another assistive device walked further with the WalkAbout.
Ninety-five percent of subjects said they felt safe while using the device and 92% reported that
the WalkAbout safety seat was comfortable.
CONCLUSIONS: The
WalkAbout prevents falls and subjects
walked further using the WalkAbout than with any other
assistive device tested.
• Servizio igienico per
disabile
• Illuminazione con luce no
abbaglianti e che non
formano ombre,interrutori
accessibili e posti
all’ingresso della camera
• Pavimento con fondo
antisdrucciolo
• Doccia per disabili
• Sedia comoda
•
•
•
•
•
Tripode e Quadripode
Bastone da passeggio
Canadesi
Deambulatore a quattro ruote
Deambulatore a due ruote e
due puntali
• Deambulatore con supporto
antibrachiale
• Deambulatore a quattro
puntali.
• Calzature con plantari
• la calzatura deve essere
adatta alle caratteristiche del
piede, comoda, sicura;
– chiuse,
– con punta e pianta larghe,
– tomaia soffice senza rilievi e
cuciture sporgenti.
– devono aderire bene al piede
e quindi essere
preferibilmente allacciate o
chiusura con velcro;
– la suola antiscivolo con tacco
di 2,5-3,5 cm in modo da
fornire un sostegno posteriore
e facilitare il passo.
Age Ageing. 2003 May;32(3):310-4.
An evaluation of footwear worn at the time of fall-related hip fracture.
Sherrington C, Menz HB.
BACKGROUND: a range of footwear features have been shown to influence balance in
older people, however, little is known about the relationships between inappropriate
footwear, falls and hip fracture.
METHODS: 95 older people (average age 78.3 years, SD 7.9) who had suffered a fallrelated hip fracture were asked to identify the footwear they were wearing when they fell.
Footwear characteristics were then evaluated using a standardised assessment form.
RESULTS: the most common type of footwear worn at the time of the fall was
slippers (22%), followed by walking shoes (17%) and sandals (8%).
The majority of subjects (75%)
wore shoes with at least one
theoretically sub-optimal feature, such as absent fixation (63%),
excessively flexible heel counters (43%) and excessively flexible soles (43%). Subjects
who tripped were more likely to be wearing shoes with no fixation compared to those who
reported other types of falls [chi(2)=4.21, df=1, P=0.033; OR=2.93 (95%CI 1.03-8.38)].
CONCLUSIONS: many older people who have had a fall-related hip fracture were
wearing potentially hazardous footwear when they fell. The
wearing of
slippers or shoes without fixation may be associated
with increased risk of tripping. Prospective studies into this proposed
association appear warranted.
• Sollevatore passivo
• Corsetto per
movimentazione
• Corsetto per sedia
comoda e WC
• Corsetto a rete
• Sedia per doccia
• Sollevatore attivo con
cinghia di sicurezza.
• Bagno assistito con
idromassaggio e
barella da trasporto.
• Doccia assistita con
WC incorporato.
• Carrozzina con ruote
anteriori
• Carrozzina con ruote
medie
• Carrozzina con
sistema basculante.
• Deambulatore con
supporto ascellare.
Falls in the nursing home: Are they preventable?
Vu MO, Weintraub N, Rubenstein LZ.
J Am Med Dir Assoc. 2005 May-Jun;6(3 Suppl):S82-7
CONCLUSION: Based on the current literature, an effective
multifaceted fall prevention program for nursing home residents
should include risk factor assessment and modification, staff
education, gait assessment and intervention, assistive device
assessment and optimization, as well as environmental
assessment and modification. Although there is no association
between the use of hip protectors and fall rates, their use should be
encouraged because the ultimate goal of any fall prevention
program is to prevent fall-related morbidity.
Istitutional falls: quality non quantity
M. McMurdo, J. Haper Age and Ageing Vol 33, N. 4 pp. 399-400, 2004.
We Know all falls cannot be prevented.
How should institutional falls be interpreted?
Undoubtedly falls do reflect the quality of care provided.
Falls need to be interpreted at the istitutional level – by examining
staffing levels, the environment and circumstances in which
residents are falling.
Falls also need to be addressed at the individual level, by
examining factors such prescriptions, reversible visual
impairment, and use of walking aids.
Istitutional falls: quality non quantity
M. McMurdo, J. Haper Age and Ageing Vol 33, N. 4 pp. 399-400, 2004.
In care setting for older people it is time now to
developed criteria wich will allow us to move on from
recording fall quantity to fall quality.
A risk-free life is no life at all.

La prevenzione delle cadute in casa di riposo

Transcription

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