Episode 56 - Elderly Falls - a podcast by Rio Bravo Family Medicine Residency Program

Introduction about Wegovy as a new treatment for obesity. Dr Amodio discusses fall prevention in older adults. 

News: Semaglutide for the treatment of obesity
By Hector Arreaza, MD, and Daniela Amodio, MD. 

About 70% of Americans suffer from overweight or obesity. It has been 7 years since a medication was approved by FDA for chronic weight management. 

As a reminder, Saxenda® (liraglutide, daily SQ injection) was approved in 2014 for the treatment of obesity in adults (7 years ago), and remarkably, in December 2020, Saxenda® was also approved for the treatment of obesity in children older than 12 years old (good to know). Saxenda® is a GLP-1 receptor agonist.

On June 4, 2021 (7 years later), Novo Nordisk® did it again and got approval for a new medication for the treatment of obesity (disclaimer, I do not receive any money from Novo Nordisk®)

After extensive trials (drum rolls), Wegovy® (pronounced wee-GOH'-vee) has been approved by the FDA for chronic weight management. The component is semaglutide, yes, you heard me right, this is the same component of Ozempic®, an injected medication FDA-approved for diabetes treatment, and it is the same component in Rybelsus® (pronounced reb-EL-sus), which is the same semaglutide but in oral form. 

-Wegovy® is a synthetic version of a hormone called glucagon-like peptide 1 (GLP-1). GLP is an incretin, and as such, it reduces glucose levels by optimizing the secretion of insulin and decreasing the secretion of glucagon during digestion. 

Wegovy® exerts its action in areas of the brain to curb appetite and increase satiety. 

The use of Wegovy is approved in adults with a BMI above 30 kg/m2, or above 27 kg/m2 who have at least one weight-related condition. As with other medications for obesity, Wegovy is an adjunct therapy which can be added to intensive lifestyle modifications.

This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. 

 

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Elderly Falls.   
By Daniela Amodio, MD, and Hector Arreaza, MD

 

Patients who are older than 65 are normally called “older patients”, but sometimes it’s confusing, older than who? What does it really mean? There are many euphemisms: seniors, older adults, elderly, “prolonged youth”, or old-timers.

“Aging experts… have tried calling people young old (65 to 74), old old (75-84) and oldest old (85+). Age-based categories at this stage of life often aren't helpful because there is so much variability in how people age.” (Tracey Gendron, gerontologist at Virginia Commonwealth University)[2]

Key points: 

1. A fall is one of the most common events that may make older adults lose their independence.

2. Complications from falls are the leading cause of death from injury in adults older than 65 years old.

3. A multifactorial risk assessments should be done in older adults with >2 falls in the past 12 months. 

 

Interventions that have shown to be effective in reducing falls: 

Medication review

Exercise programs for muscle strengthening and balance training

Vitamin D supplementation in vitamin D deficiency 

Use appropriate footwear 

Home hazardous assessment 

Comment: Deprescribing is an essential activity during your geriatric visits. Avoid unnecessary medications. Use the AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults to determine which medications you should either discontinue or change to minimize risk of falls. Some examples include: benzodiazepines, some antidepressants and dextromethorphan/quinidine. 

Prevalence and morbidity of falls in older adults:

According to CDC, one out of three adults older than 65 years old reports falling in the previous year. The incidence of falls is higher with advanced age, which means one half of individuals older than 80 years old or those living in nursing homes will fall each year. 

Most falls result in soft tissue injury and 5-10% result in fracture or head trauma. Women and nursing facility residents are more prone to non-fatal injury than men. Death rate due to falls is more common in white men older than 85 years old. 

Risk factors: 

Multiple studies indicate that falls are multifactorial. Risk factors include: old age, cognitive impairment, female gender, history of falls, gait/balance problems, low vitamin D, pain, psychotropic medications, Parkinson's disease, stroke and arthritis. 

Physiologic changes expected with aging: With aging visual acuity is affected as well as inability for dark adaptation. Loss of sensitivity in the legs is expected as well as loss of balance. Also, there may be other changes in the CNS that affect postural control, including loss of neurons and dendrites and depletion of neurotransmitters such as dopamine in basal ganglia. There is inability to keep an upright posture due to decline in baroreflex sensitivity, resulting in hypotension.  Elderly patients are prone to dehydration due to decreased body water percentage and decreased renin and aldosterone levels, these factors can lead to orthostatic hypotension and falls.

Prevention: 

The most modifiable risk factor is medication use. Of note, there is no difference in the risk of falling with the use of older antidepressant or antipsychotics compared with the newer SSRIs. Same thing applies with newer nonbenzodiazepine hypnotics to treat insomnia versus using benzodiazepine. So, the risk is the same.

The risk of falls increases with older adults taking more than one psychotropic medication, and among adults taking >3 medications of any type. 

Other medications that affect the risk of falls are antihypertensive medications. Meta-analysis studies have shown an increase of risk in those elderly patients taking medications such as:  digoxin, diuretics, class Ia antiarrhythmics and NSAIDs. As a reminder, class Ia antiarrhythmics are sodium channel blockers. Drugs in this group include quinidine, procainamide, and disopyramide. They cause QT prolongation, that’s why they are used, for example, in patients with short QT syndrome and recurrent ventricular arrhythmias (VA). 

Medications for dementia such as acetylcholinesterase inhibitors, have been associated with increased risk of syncope. Examples on this group: donepezil and memantine for Alzheimer’s disease.

Hypoglycemia is a risk factor for falls, so be cautious if you decide to use medications that cause hypoglycemia, including insulin. What do we do when we see a patient who reports frequent falls? 

Evaluation of the Elderly Patient Who Falls:

The most important point in the history is asking if there has been a previous fall because this is a strong risk factor for future falls. 

For patients presenting with a fall, it is important to include the activity at the time of the fall, the occurrence of prodromal symptoms (lightheadedness, dizziness and imbalance) and the location and time of the fall. Medication history should focus on newly added medication or recent dosage changes as well as the use of medications mentioned before. 

We need to identify potential factors in the environment such as lighting, floor covering, railings, furniture.  

Physical Exam/Screening tests:

The most important part of the physical examination is evaluation of musculoskeletal function that can be accomplished by performing stability tests.  

A useful test that evaluates strength and balance is the Up and Go test: patient stands up from a chair without using their arms to push against the chair, walks across the room (10 feet), turns around, walks back and sits down without using their arms. This test can evaluate muscle weakness, balance problems, gait abnormalities. 

Timed up and go test (TUG): An elderly patient who takes ≥12 seconds to complete this test is at risk for falling. This should be done routinely in geriatric visits. 

POMA test (performance-oriented Mobility assessment) It evaluates balancing gait through a number of items including ability to sit and stand from an armless chair, ability to maintain standing balance when pulled by an examiner and ability to walk normally, and maneuver obstacles. 

Treatment and Prevention:

In 2011 the AGS and BGS updated clinical practice guidelines for prevention of falls in older adults. All older adults in the community at risk of falling should be offered an exercise program incorporating balance, gait, and strength training. The interventions should be tailored to the individual's cognitive ability and language. The interventions considered to be effective are the following:

1. Home environment assessment and intervention should be performed by a healthcare professional in older adults who have fallen or have risk factors for falling. 

2. Discontinue or minimize psychoactive medications. Tapering medication is associated with a decreased rate of falls.

3. A prescribing modification program for PCP that includes medication review checklist, education and feedback from pharmacists. 

4. Manage foot problems: Clinicians should advise their patients to use walking shoes with high contact surface area. In elderly patients with disabling foot pain, falls may be reduced by intervention such as: customized insoles, foot/ankle exercise and falls prevention education. 

The USPSTF recommends exercise interventions to prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls (Grade B). The USPSTF recommends against vitamin D supplementation to prevent falls in community-dwelling adults 65 years or older (Grade D).

Fall is a common cause of morbidity, disability and mortality. Let’s remember to screen and intervene to prevent falls.

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Conclusion: Now we conclude our episode number 56, “Elderly Falls.” Dr Amodio gave us a summary of effective strategies to prevent falls in elderly patients. She described how to perform the “Timed-Up-and-go” test, a useful tool to screen for fall risk. She explained that exercise, home safety inspection, and medication reconciliation are useful strategies to prevent falls. Even without trying, every night you go to bed being a little wiser.

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Daniela Amodio, and Cecilia Covenas. Audio edition: Suraj Amrutia. See you next week! 

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References:

FDA Approves New Drug Treatment for Chronic Weight Management, First Since 2014, FDA (online), June 4, 2021. https://www.fda.gov/news-events/press-announcements/fda-approves-new-drug-treatment-chronic-weight-management-first-2014

 

Burling Stacey, “If we can't call old people 'old,' what's the right word?” The Philadelphia Inquirer (online), July 20, 2017. https://www.inquirer.com/philly/health/health-news/if-its-rude-to-call-old-people-old-whats-the-right-word-20170723.html

 

Berry, Sarah D and Douglas P Kiel, Chapter 34: Falls. Geriatrics Review Syllabus, 9th edition. Editors: Barbara Resnick, 2016.

 

Reuben, David B. Falls Prevention and Falls. Geriatrics At Your Fingertips, 22nd edition. American Geriatrics Society, 2020.

 

 

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