INTRODUCTION:
The physiological walking requires the smooth functioning of afférentiels sensory systems, vestibular, visual, peripheral nerves, muscles, and the integrity of the motor structures, extrapyramidal and cerebellar.
Despite its complexity, it is an essentially automatic activity involving a vast system of controls and checks.
Too common in the elderly, falls should always be considered a serious event. Past 65 years, a fall should prompt the physician to determine the cause of its occurrence, to seek its direct and indirect complications, and very likely to prevent recurrences. Being older does not oblige to fall. The management of the causes and consequences of the fall in the elderly must remain an ongoing priority. Their complications can mechanical beings, traumatic, metabolic, psychomotor, psychological or social fostering a loss of independence in activities of daily life, a source of institutionalization of those involved. They involve the physician never to trivialize the loss in the elderly.
The sometimes associated clinical review some simple additional tests often allows to specify the causative mechanisms differentiating factors intrinsic to the individual (impaired balance and walking, sensory deficits, diseases or iatropathologies, sources of discomfort ) and extrinsic environmental factors related to the living environment (unsuitability of habitat). Preventing recurrence through a patient’s awareness and collaboration among care teams, physiotherapists, occupational therapists, nutritionists and doctors. In all the circumstances of occurrence of a fall, the patient should be approached as a whole and in its environment.
EPIDEMIOLOGICAL REMINDERS:
Falls are a common cause of hospitalization among the elderly over 65 years. They are responsible for 30% of hospitalizations after the age of 65. They concern in 70-75% of cases of older healthy people, 15 to 20% of the frail elderly, and only in 5% of cases of dependent elderly persons living in institutions or at home. Nearly a fall on two occurs at home.
Extremely common in the elderly, falls affect at least once a year a third of people over 65 and half of those over 80 years, nearly two million people. Indeed, gait and balance may lead to falls that are strongly related to age, with 90% of falls involve patients over 65 years. Observing a delirium associated with the occurrence of a fall occurred in 10% of cases.
Half serious falls, that is to say, complicated at least one fracture, is mechanical cause. An obstacle hooking the foot during walking as a mat or a wire, a slippery, especially at night, poorly put slippers or inappropriate or insufficient or missing lighting are all contributing factors. The falls are complicated in 15% of cases of bone trauma. In France, they cause 50 000 fractures of the femoral neck, and nearly 10 000 deaths each year.
They represent a common factor in admission institution. Among patients hospitalized for a fall of ground, 40% are referred to a specialized facility. The short-term mortality increases with age to over 10% of the population after 80 years.
Even in the absence of immediate traumatic complication, some situations such as the inability for the elderly to rise, history of falls and an extended ground station of over an hour are factors of gravity and poor prognosis. Indeed, the risk of death within one year was 50% during prolonged bed rest and land quadrupled in the subject who experienced drop from the non-faller.
DISORDERS AND MARKET EQUILIBRIUM:
The history and physical examination are fundamental tools for establishing an accurate diagnosis, but they are sometimes difficult to use in geriatric medicine. Indeed, accountability of clinical signs in a given pathology is not always obvious, and a little pathology hide another. Similarly, the history is sometimes difficult reconstitution during the existence of cognitive disorders, for example.
The review of the inspection posture and walking are key elements in establishing the diagnosis. the patient standing static position is observed, eyes open then closed with carrying out a test of Romberg seeking equilibration disorders.
The dynamic test is to ask the patient to walk a few meters, to make a U-turn and come back to the examiner.
The functions of walking and balance require the integrity of the perception of visual, vestibular, proprioceptive and plantar tactile, their integration with the central nervous system and an adaptation of posture by musculoskeletal effectors. The failure of one of these stakeholders can cause trouble. Unfortunately, in the very elderly, balance disorders are often multifactorial.
Walking is an activity involving equilibration systems antigravitic and production steps. The equilibration system maintains the body’s center of gravity within the support base. It is based on the vestibular system, vision exposed to the onset of cataracts or macular degeneration, hearing and proprioception involved in conscious perception of movement and assessment positions related segments of the limbs in space. A decline in these sensory and proprioceptive abilities naturally observed during aging, thus coming disrupt an equilibrium situation.
Antigravitic the system opposes the effect of gravity and allows the maintenance of standing by regulating muscle tone. Not the production system consists of the sequence of postural imbalances leading to walking. Observed with physiological aging an increase in the reaction time, a shortening of the pitch by decreasing the basin and rotation amount of the excursion of the hip, an increase in the dependence of the double support feet, a decrease in speed walking, physical exercise and increased muscle weakness of the legs.
Examination of walking assesses both motor skills, sensory and cerebellar of the person.
Finally, walking can be disrupted by numerous clinical situations particularly frequent in this population as the occurrence of attention disorders or memory, depressed mood, or a fragile nutritional balance.
walking disorders and represent a real diagnostic challenge.
ETIOLOGICAL BALANCE BEFORE A FALL:
Any fall in the elderly must be seen as a warning signal. In these people, the fall is rarely attributable to a single cause but is often multifactorial. The clinical approach must be to search for possible etiologies or precipitating factors, but also the identification of predisposing factors to the fall, true risk factors due to aging of organs, diseases related to age or to iatrogenesis. Falls most often the result of a combination of several of these factors, the majority of them have no easily identifiable cause.
Precipitating factors:
Intrinsic precipitating factors:
We must seek the causes of malaise, loss of consciousness and more generally all the diseases that can cause a sudden drop in cerebral perfusion or acute impairment of cognitive abilities, especially during a delirium.
These causes are related to physiological aging, drug outlet or various pathological processes, including cardiovascular and neurological. The notion of discomfort or even a brief loss of consciousness, during a fall must be carefully sought for interrogation.
Extrinsic or environmental precipitating factors:
These are the factors mainly related to habitat and to the subject’s environment. They are directly responsible for 30 to 50% of the falls.
The search for environmental factors inappropriate to the patient’s degree of functional autonomy is best performed at home
the elderly by the occupational therapist. Some factors are found particularly frequently as too polished floor, rug or carpet poorly or not set, a chair or too low armchair, a floor or slippery bath, the presence of a march during the passage of one room to another, insufficient lighting, the existence of a pet, too long garment or ill-fitting footwear, or finally a change in environment such as during a hospitalization for example. The combination of several causes easily lead to cross the threshold of failure causing the fall.
Main causes of falls in the elderly:
Iatrogenic:
Drugs are one of the risk factors most frequently encountered falls in older people.
They may act by different mechanisms. A sedative effect is observed when taking barbiturates, benzodiazepine hypnotics or not, or anticonvulsants. The iatrogenic can manifest as the occurrence of extrapyramidal syndrome when prescribing of neuroleptics.
Orthostatic hypotension is frequently observed particularly during the administration of antihypertensive drugs, beta-blockers and diuretics, treatment with L-DOPA and dopamine agonists, or administration of molecules with antidepressant targeted. Some conduction disorders or heart rate are observed when antiarrhythmic taken as digitalis, diuretics kaliuretic causing torsades de pointes or beta blockers.
Cardiovascular causes:
Cardiovascular causes include atrioventricular conduction disorders and cardiac rhythm disorders (tachycardia, bradycardia), sometimes secondary to hyperthyroidism or myocardial necrosis. Similarly, the effort syncope in a patient with aortic stenosis or blood pressure changes are frequent observation. Orthostatic hypotension can occur in older people up after lunch or after prolonged bed rest due to drug intake, anemia, dehydration or internal bleeding.
Hypotension may be a manifestation from the forefront of some myocardial necrosis and pulmonary embolism.
Neurological:
Most neurological conditions resulting in gait and balance may be the cause of falls.
The semiotic examination of walking looking for a deficit approach evoking a challenge cit engine during an attack of the pyramidal system, peripheral neurological or muscular disorder. Ataxic gait directs the practitioner towards a sensory ataxia, cerebellar and labyrinthine. A walk slowly, a trend retropulsion or kinetic jamming characterized by the sudden interruption of walking evoke a parkinsonian syndrome. The astasia-abasia is defined as instability to standing with spontaneous retropulsion (astasia) and an inability to walk outside the presence of any pyramid or parkinsonism (abasia). Neurological etiologies include proprioceptive disorders in peripheral neuropathy, cerebellar syndrome, vestibular disorders, Parkinson’s disease and diseases accompanied by extrapyramidal syndrome like disease Steele Richardson Olszewski, the normal pressure hydrocephalus, the primary or secondary astasia-abasia, vertebrobasilar insufficiency and frontal expansive processes. Finally, Alzheimer’s disease has also recently been recognized as a fall risk factor.
Mechanical causes:
Gather under this designation falls occurring in patients with disorders or sequelae of orthopedic and rheumatological diseases. Osteoarthritis broadcasts including violations of the spinal canal, the prosthetic hip or knee harbor, the existence of inflammatory joint symptoms are purveyors of gait and balance. They are also frequently responsible for disrupting pain walking. It must not be forgotten in these cases violations podiatric. Moreover, under this term are grouped falls occur when the person slips or hits an obstacle.
Aches:
Malay is defined as the painful sensation of a disorder in physiological functions.
They include syncope, the faintness and dizziness. Paradoxically, 9 malaise of 10 are isolated, do not accompanying drop. Similarly, 99% of falls occur without discomfort. The only logical prevention is screening and etiological treatment of malaise, with particular emphasis on the search for a iatropathologie.
Other etiologies:
Some metabolic disorders such as hypoglycemia, dyskaliémies, hyponatremia, disturbance of serum calcium levels or anemia can beings accountable for falls in the elderly. These causes are all too frequently iatrogenic in this population.Syncope vasovagal, instrumental cause, including voiding the night, sometimes syncope closed glottis, as realizes stroke laryngeal after coughing, can complicate falls.
Finally, disorders of psychogenic origin walks are sometimes encountered in the elderly. Walking is so cautious and characterized by a slight imbalance, a discrete widening the support polygon, not a shorter and slower walking. This march is frequently encountered during an anxiety appeared as a result of falls and can lead to a real stasobasophobie (post-fall syndrome).
ATTITUDE CLINIC FACE DROP IN THE ELDERLY:
Examination:
When it is contributory, interrogation tries to find as accurately as possible the history of the episode and the risk factors and intrinsic precipitating factors.
The environment must be the subject of special attention. It allows to identify the risk factors extrinsic drop.
The history should emphasize the mode of early troubles and its insidious nature, brutal or progressive. the existence of a triggering event Wanted or aggravating the disorder as taking medication, and the concept of previous falls, the number is accurate, frequency, any traumatic consequences, difficulties to get up and time spent on the ground.
The collection of background research of diseases of the musculoskeletal system, podiatric ailments, neurological and cardiovascular disorders, and medication such as psychotropic drugs (neuroleptics, benzodiazepines, sedatives, tranquilizers) and antihypertensives sources of orthostatic hypotension.
Physical examination:
After a fall, the clinical examination in the elderly should try to find a cause. There must be systematic and comprehensive. It explores the passive and active mobility of the joints of the lower limbs and especially cervical spine disorders static looking for deformities or spinal stiffness, unequal leg length, deformation in varus, podiatric anomalies (feet valgus flat, varus, claw toe deformities). Neurological examination Research superficial and deep sensitivity disorders, tone, impaired muscle strength (quadriceps, tibialis anterior, levator toes, gluteus medius), a vestibular syndrome, a pyramidal or extrapyramidal syndrome, dysmetria, oculomotor disturbances, peripheral neuropathic damage, sequelae of stroke or observing cognitive and sensory disorders. The review also includes research of cardiovascular diseases including at least that of postural hypotension, arterial cervical breaths and performing an electrocardiogram to detect an arrhythmia or cardiac conduction.
The gait analysis and the balance of the subject is a key element in the etiological disorder.
Finally, it is necessary to look for functional symptoms associated as joint pain, exertional dyspnea, the notion of dizziness or discomfort, the existence of associated disorders including cognitive and psychological.
Additional tests:
The selection and implementation of additional tests directly dependent on information provided by the history of the falls and clinical examination of observations.
Most often, this review shall include at least the completion of an electrocardiogram, blood samples with blood glucose, serum calcium, blood count and chemistry panel, and the completion of standard radiography images centered contused or painful areas. Other tests such as brain CT scan, an electroencephalogram, electrocardiogram (ECG), Holter-ECG or ultrasound of the supra-aortic trunks can be requested depending on the clinical context.
CONSEQUENCES OF FALLS:
Immediate consequences:
Traumatic:
Nearly 8% of falls are causing fractures.
Among these, a third relates to the proximal femur. Fractures of the humeral head, the type of wrist Colles, rib or skull with the risk of subdural hematoma are the main locations to search. These injuries are regularly associated with deep or superficial bruises that surveillance should be careful when the patient is taking anticoagulants. Monitoring the state of consciousness during the days after the fall, especially when it is complicated with a brain injury, must be systematic to eliminate the possible occurrence of cérébroméningés bleeding.
The risk of fracture after a fall is highly correlated with bone mineral deficit.
Osteoporosis and osteomalacia are more common in women, the risk of fracture is therefore higher among them than among men.
Skin wounds can cause breakthrough bleeding and require tetanus vaccination up to date in these subjects.
Decubitus complications:
For prolonged ground station with inability to stand up, the patient is exposed to the occurrence of decubitus complications as the occurrence of bedsores, the onset of dehydration or pulmonary disease or even observation a delirium. These complications are sometimes associated with metabolic disorders such as disorders of the blood sodium or rhabdomyolysis.
They can engage the functional and vital prognosis.
Psychomotor consequences, post-fall syndrome:
They represent the most frequently observed effects. Too slow management may be the cause of heavy dependence of the subject concerned, with rapid progression to grabatisation. In the elderly, the fall can be complicated apprehension walking.
The occurrence of post-fall syndrome is the main risk of falling, it concerns more than 30% of patients. It results in a stunning achievements automation, loss of postural adaptation difficulties to keep standing, a trend retropulsion an impossible antepulsion due to fear of the subject when it comes to project forward to start walking. While standing, one can observe a talonnante walking in small steps with increased support polygon and knee flexion, the trunk is thrown backwards. Clinical and radiographic examinations found no organic cause for this phenomenon. The rapid psychomotor regression and risk of severe addiction requires aggressive management, responsive and fast. We must prevent the fear of falling again.
The gait joins a psychological component that results in a major anxiety with fear of heights, leading the patient to real stasobasophobie. The patient with fear of heights and refused to go vertical, even with help. He is aware of the fragility of his condition and lose confidence. These consequences result in autodévalorisation, the appearance of a depressive syndrome and the evolution towards a true loss of autonomy.
This psychomotor regression syndrome can appear suddenly or more gradually at the waning of the fall performing a genuine inability to walking and standing.
In addition, falls can promote a loss of independence in activities of daily living, frequent source of institutionalization of the elderly.
Psychosocial consequences:
The emergency hospital admission is stressful and may precipitate the patient to loss of independence and a move towards institutionalization. After a fall in the medium term, the loss of autonomy is seen in almost a third of patients who did not have fractures. The loss of autonomy is the culmination of psychomotor effects of the fall, that is to say, the post-fall syndrome, because of the fear of falling, loss of mobility or walking difficulties. The fall in the elderly then reveals a factor that causes a reduction of the scope of the social space, family and even body. The fear of a recurrence often leads to referral to an institution. The psychological consequences can install more insidiously in a very old suddenly lost confidence in him patient, feeling devalued in the eyes of his entourage, who, thinking to do well, sometimes reacts by excessive overprotection, installing more person in addiction and restriction of activity.
Delayed consequences:
Delayed consequences are dependent on the speed of relief originally procured and severity of the immediate consequences. They are mainly represented by the loss of independence due to the repetition of falls and trauma, fear of falling and loss of confidence. then observed a reduction in the space of wandering and the appearance of a phobia of walking that can be promoted through the use of various restraints. These complications include increased risk of further falls, entrance in institutions and mortality.
RATINGS FALL HAZARD:
This assessment is based on the identification of risk factors predictive of falls and performing simple clinical tests.
Risk factors :
These factors can be deduced from the intrinsic and extrinsic factors favoring impaired balance and walking behind falls in the elderly. Other factors add as female gender, advanced age, lack of physical activity, polypharmacy and living alone or reside in institutions. Similarly, the number of previous falls in the current episode, the greater the risk of recurrence is high. A fall in the previous 3 months exposes the person to a higher risk of recurrence. A ground station extended with difficulty or an inability to stand, also a predictor of recurrence of further falls, but also a prognostic factor. Indeed, nearly 40% of the remaining more than 3 hours on the ground subjects die within 6 months after the fall.
Clinical:
In the elderly, the physiological aging of the organs of balance and the existence of multiple pathologies often render illusory the identification of a unique cause and precise with gait and balance. A more functional approach was therefore adopted by geriatricians and clinical tests have been developed to help identify people at high risk of falling.
Unipodal Station:
The duration of maintaining the balance unipodal early declines and is increased when removes visual input. After 75 years, only 75% of people can maintain a support unipodal eyes open longer than 30 seconds and no more than 13 seconds with eyes closed. This first test is to ask the subject to stand in foot support more than 5 seconds. If the patient is unstable or if it is not able to hold support the required time, then there is a risk of traumatic loss.
“Get up and Go test”:
It is to ask the patient to get up a seat with armrest, walk 3 meters forward and then turn around and come back to sit.The patient should wear his regular shoes and can use walking aids which he is accustomed. After a first test, the second is timed. If it exceeds 20 seconds, there is a postural fragility and the subject may drop later. A time more than 16 seconds multiplies the risk of falling by 2.7 within 5 years.
Tinetti test:
It includes the assessment of balance and walking 10 items each. It assesses the sitting balance, the rising of the chair, trying to get up from the ground, the balance while standing, at a push, eyes closed, in 360 ° of rotation, or when the subject sits.
Thus, a first balance score on 16. The second part of the test analysis walking and allows obtaining a second score on 12. The sum of two evaluations provide an overall score of 28. A score below 19 indicates a fall risk increased 5 times.
FALLS PREVENTION:
A number of measures can be put in place to fight against postural instability that characterizes a large proportion of the elderly population.
Maintaining a healthy lifestyle:
Some rules of healthy living as the preservation of a good state, respect for balanced nutrition with particular emphasis on preventing food shortages, the fight against osteopenia and sarcopenia, the administration of a calcium and vitamin D supplementation in osteoporosis and maintaining adequate exercise with a particular maintenance of the strength of the lower limbs allow better coordination of movements, breathing capacity, endurance and muscle strength. Similarly, maintaining a regular intellectual activity promotes the preservation of attention skills, reflection and anticipation.Regarding the social life of the subject, it is important to break the isolation of people living alone.
Medical and medico means:
One of the priorities in the management of patients with a fall or being in a fall risk situation is the monitoring of drug prescriptions, removing unnecessary molecules and respect for indications of prescription drugs.
Regular assessment of the clinical situation and needs is required, thereby better adjust therapy to the clinical situation of the subject, as in the treatment of a pain syndrome.
When repeated falls or significant risk of falls, hip protectors of the prescription can find its place. A number of devices are available to correct the better the patient’s sensory disturbances, whether prescription glasses or a hearing aid.
A support in physiotherapy, where the gait or balance could be identified, reduces the risk of further falls. This activity is relearning to walk, education to optimize compliance postures and reinsurance. The patient must regain his confidence to cover a proper autonomy and a stroll safely. It is sometimes necessary to help a walker, a cane or even to use a wheelchair.
The patient environment is extrinsic risk factors for the development of a fall. Wearing clothes and appropriate shoes can significantly reduce the number of falls. Similarly, a habitat management is usually required. It may include the establishment of support bars, removing unnecessary electrical cables or too long, their attachment to the floor, or removing carpets.
Finally, the person may benefit from external assistance as a housekeeper, a carer, a home guard, wearing meals at home, remote support or home care services.
TREATMENT AFTER THE FALL:
The management of a patient who fall should be early, active and comprehensive. However, she has no interest if it does not deal in advance to minimize the risk factors for onset of fall in this population.
Medical and surgical treatment:
There is a direct function of the causes and consequences of this event. Particular attention regarding the iatrogenic.Indeed, the clinician must in this situation Check prescriptions to try to minimize medication that the fall can be attributed.
Treatment is based on the surgical management of fractures, suturing wounds with any verifi cation vaccination status against tetanus, prescription painkillers and monitoring of vigilance during complicated Falls head injury. In addition, supportive psychotherapy is always necessary in these patients. It is based primarily on the time listening and speaking with caregivers, families, doctors or psychologists. Patient care, the waning of his fall, also includes research and correction of intrinsic precipitating factors (etiological treatment discomfort or loss of consciousness) but extrinsic (environmental adaptation).
The use of physical restraint should be the maximum proscribed. These restraints promote physical deconditioning and often mental confusion. The risk of subsequent fall would then be even higher.
Functional treatment:
The main objective is to limit the secondary sensorimotor mismatch in the fall and bed rest. For this, we must use a multidisciplinary geriatric speech where physiotherapists and occupational therapists have a privileged place. These early begun treatment can help correct gait and balance secondary to the fall or responsible for it.
Support in physiotherapy include active work and education of the subject. The objectives of the management are a gait training, the work of various transfers, relearning postural reactions and parachutes and a strength of the lower limbs. The patient also receives tips as learning methods enabling it to be able to rise from the ground. It should also advise people to get up in two stages to limit the adverse effects of orthostatic hypotension. A stand-up work should be done as early as possible.
Medical and social assessment:
It should improve communication between the various stakeholders. It is also involved in the adaptation and development of the place where the patient lives, thanks to the help of an occupational therapist.
CONCLUSION:
Real public health problem, falls of seniors have too long been neglected.
Their prevention is based on the detection and treatment of pathologies responsible, and research and correction factors favoring mechanical Falls. The experience of falling weakens the elderly, even in the absence of result traumatic, and may be in many cases an input mode institution. The falls are not inevitable with aging. This is a serious event and often serious consequences, which is a real geriatric emergency regardless of its immediate consequences.Falls impose early care, active, fast and efficient multidisciplinary in order to prevent progression to a psychomotor regression.
