Seminario Caídas en el anciano

Caídas

Sandra Milena Acevedo RuedaMD Residente Medicina Interna UNAB

Enero de 2013

Clin Geriatr Med 29 (2013) 137–150

Caídas

Son comunes y son los principales factores que

amenazan su independencia

El individuo cae usualmente ocurren cuando

las deficiencias en varios dominios ponen en peligro la capacidad de

compensación del individuo

JAMA. 1995;273(17):1348.

Falta de atención clínica…

JAMA. 1995;273(17):1348.

““80 percent of older women 80 percent of older women preferred death to a "bad" hip preferred death to a "bad" hip

fracture fracture that would result inthat would result in

nursing home admission”nursing home admission”

““80 percent of older women 80 percent of older women preferred death to a "bad" hip preferred death to a "bad" hip

fracture fracture that would result inthat would result in

nursing home admission”nursing home admission”

BMJ. 2000;320(7231):341

Epidemiología12.6 billones de dolares (1995)

30 – 40% > 65 años (comunidad) se caen cada año (50% para mayores de 80ª)

En una encuesta de EE.UU. de más de 90.000 personas > 65 años, las caídas se registraron

en los tres meses anteriores en un 16%

N Engl J Med. 2003;348(1):42

EpidemiologíaEstudio en mujeres mayores de 70 a (2 años)

41 % trauma menor41 % trauma menor

6% trauma mayor6% trauma mayor

Pacientes institucionalizados tienen más trauma mayor

5% serán hospitalizados

N Engl J Med. 2003;348(1):42

““In an Australian study, 9.5 percent of patients hospitalized for falls became first-time residents of a

long-term care facility at discharge””

““In an Australian study, 9.5 percent of patients hospitalized for falls became first-time residents of a

long-term care facility at discharge””

Emerg Med J. 2012 Sep;29(9):742-7.

““ In a large study of elderly persons In a large study of elderly persons seeking emergency care after a fall, seeking emergency care after a fall, 2.2 percent of injurious falls resulted 2.2 percent of injurious falls resulted

in deathin death””

““ In a large study of elderly persons In a large study of elderly persons seeking emergency care after a fall, seeking emergency care after a fall, 2.2 percent of injurious falls resulted 2.2 percent of injurious falls resulted

in deathin death””

Am J Epidemiol. 1990;131(6):1028

Miedo a caerDespués de una caída…

60% restricción moderada60% restricción moderada

15% restricción marcada15% restricción marcada

50% después de una fx de cadera50% después de una fx de cadera

J Am Geriatr Soc. 2010;58(9):1739

Clin Geriatr Med 29 (2013) 137–150

Órganos de los sentidos

Lentes multifocales aumentan el riesgoLentes multifocales aumentan el riesgo

Agudeza visual, percepción de profundidad, Agudeza visual, percepción de profundidad, adaptación a la oscuridadadaptación a la oscuridad

Propiocepción alteradaPropiocepción alterada

Sistema vestibular alteradoSistema vestibular alterado

J Am Geriatr Soc. 2002;50(11):1760

Activación y composición muscular

Activación muscular proximalActivación muscular proximal

Mayor activación de músculos antagónicosMayor activación de músculos antagónicos

Recuperación alteradaRecuperación alterada

Infiltración grasa y riesgo de Fx caderaInfiltración grasa y riesgo de Fx cadera

J Am Geriatr Soc. 2002;50(11):1760

Historia de caídas

Riesgo de segunda Fx de caderaRiesgo de segunda Fx de cadera

““Framingham Study”: 14.8% Framingham Study”: 14.8% tuvieron una segunda fractura en tuvieron una segunda fractura en

los siguientes 4 años los siguientes 4 años

J Am Geriatr Soc. 2002;50(11):1760

Presión arterial

Hipotensión ortostáticaHipotensión ortostática

Menos % agua, diuréticos, climas Menos % agua, diuréticos, climas cálidoscálidos

J Am Geriatr Soc. 2002;50(11):1760

Enfermedades crónicas

Enfermedad de ParkinsonEnfermedad de Parkinson

Dolor musculo-esquelético crónicoDolor musculo-esquelético crónico

OsteoartritisOsteoartritis

DiabetesDiabetes

J Am Geriatr Soc. 2002;50(11):1760

Deterioro cognitivo

J Am Geriatr Soc. 2002;50(11):1760

““ In one study of 1600 persons aged 75 years and In one study of 1600 persons aged 75 years and above, the risk of hip fracture over six year follow-up above, the risk of hip fracture over six year follow-up

was twice as high when the score on the mini-was twice as high when the score on the mini-mental status examination was suggestive of mild mental status examination was suggestive of mild impairment (score 18 to 23) compared with those impairment (score 18 to 23) compared with those

with no impairmentwith no impairment””

““ In one study of 1600 persons aged 75 years and In one study of 1600 persons aged 75 years and above, the risk of hip fracture over six year follow-up above, the risk of hip fracture over six year follow-up

was twice as high when the score on the mini-was twice as high when the score on the mini-mental status examination was suggestive of mild mental status examination was suggestive of mild impairment (score 18 to 23) compared with those impairment (score 18 to 23) compared with those

with no impairmentwith no impairment””

Medicamentos

Arch Intern Med. 2009;169(21):1952

“ “ In a meta-analysis of 22 studies involving multiple In a meta-analysis of 22 studies involving multiple classes of drugs, the likelihood of falling was increased classes of drugs, the likelihood of falling was increased with the use of with the use of sedatives and hypnotics sedatives and hypnotics (odds ratio [OR] (odds ratio [OR] 1.47, 95% credible interval (CrI) 1.35-1.62), 1.47, 95% credible interval (CrI) 1.35-1.62), neurolepticsneuroleptics

and and antipsychoticsantipsychotics (OR 1.59, 95% CrI 1.37-1.83), (OR 1.59, 95% CrI 1.37-1.83), antidepressantsantidepressants (OR 1.68, 95% CrI 1.47-1.91), and (OR 1.68, 95% CrI 1.47-1.91), and

benzodiazepinesbenzodiazepines (OR 1.57, 95% CrI 1.43-1.72)” (OR 1.57, 95% CrI 1.43-1.72)”

“ “ In a meta-analysis of 22 studies involving multiple In a meta-analysis of 22 studies involving multiple classes of drugs, the likelihood of falling was increased classes of drugs, the likelihood of falling was increased with the use of with the use of sedatives and hypnotics sedatives and hypnotics (odds ratio [OR] (odds ratio [OR] 1.47, 95% credible interval (CrI) 1.35-1.62), 1.47, 95% credible interval (CrI) 1.35-1.62), neurolepticsneuroleptics

and and antipsychoticsantipsychotics (OR 1.59, 95% CrI 1.37-1.83), (OR 1.59, 95% CrI 1.37-1.83), antidepressantsantidepressants (OR 1.68, 95% CrI 1.47-1.91), and (OR 1.68, 95% CrI 1.47-1.91), and

benzodiazepinesbenzodiazepines (OR 1.57, 95% CrI 1.43-1.72)” (OR 1.57, 95% CrI 1.43-1.72)”

Alcohol, calzado, factores medio-ambientales

A mayor consumo de alcohol, mayor riesgoA mayor consumo de alcohol, mayor riesgo

Suelas, taconesSuelas, tacones

Ayudas especialesAyudas especiales

Pacientes institucionalizadosPacientes institucionalizados

J Am Geriatr Soc. 2002;50(11):1760

Reportar caídas recurrentes

Reportar alteración en la marcha o el balance

Buscar atención médica ó presentarse al departamento de urgencias cuando haya una

caída

Historia clínica completa, valoración funcional y cognitiva

Función musculo-esquelética

Examen físico

Laboratorios e imágenes

1. Repeated Chair Stands

2. Balance Testing

a. Semitandem Standb. Side-by-Side stand

c. Tandem Stand

3. 8’ Walk (2.44 meters)

Short Physical Performance Battery (SPPB)

Fleming KC, Evand JM, Weber DC, Chutka DS. Practical Functional Assessment of Elderly Persons: A Primary-Care Approach [Symposium on Geriatrics-Part III]. Mayo Clinic Proceedings 1995; 70:890. Copyright © 1995 Mayo Foundation.

The "Get up and go" test for gait assessment in elderly patients

The "Get up and go" test for gait assessment in elderly patients

Tinetti ME. Performance-oriented assessment of mobility problems in

elderly patients. JAGS 1986; 34: 119-126. (Scoring description: PT Bulletin Feb. 10, 1993)

Tinetti Performance Oriented Mobility Assessment (POMA)*

Tinetti Performance Oriented Mobility Assessment (POMA)*



Tinetti Performance Oriented Mobility Assessment (POMA)


Balance





Marcha

Fleming KC, Evand JM, Weber DC, Chutka DS. Practical Functional Assessment of Elderly

Persons: A Primary-Care Approach [Symposium on Geriatrics-Part III]. Mayo Clinic Proceedings 1995; 70:890. Copyright © 1995 Mayo Foundation.

Diagram of functional reach test to assess balance in elderly persons

N Engl J Med. 2003;348(1):42

The Prevention of Falls in Older Persons: Clinical Practice Guideline

(http://www.medcats.com/FALLS/frameset.htm) from the American Geriatrics Society. For more information visit the AGS online at www.americangeriatrics.org.

N Engl J Med. 2003;348(1):42

• Marcha y balance

• Fuerza

• Flexibilidad

• Movimientos (TaiChi o baile)

• Actividad física general

• Resistencia

Ejercicio

• Modificación de dosis y fármacos

• Vitamina D

• Evitar toxicidad

Medicamentos

Otras intervencionesOtras intervencionesHipersensibilidad seno carotídeo y marcapasos (RaR 0.42, 95% CI 0.23-0.75)

Cataratas (RaR 0.66, 0.45-0.95)

Suplemento nutricional

Hipotensión ortostática: medias elásticas, líquidos, fludrocortisona,

Intervención en podiatría

Protectores de cadera

Caminador ó bastón

Tiempo en el suelo

JAMA. 1993;269(1):65

“ A study of 1100 individuals over age 72 found that 47 percent of the 313 who

experienced non-injurious falls were unable to get up for at least one hour after falling”

“ A study of 1100 individuals over age 72 found that 47 percent of the 313 who

experienced non-injurious falls were unable to get up for at least one hour after falling”

Anticoagulación

“ “ A decision analysis has concluded that a A decision analysis has concluded that a predisposition to falls, with potential head predisposition to falls, with potential head

trauma, is trauma, is rarelyrarely a contraindication to the use a contraindication to the use of anticoagulants in older adult patients with of anticoagulants in older adult patients with

atrial fibrillation (AF)”atrial fibrillation (AF)”

“ “ A decision analysis has concluded that a A decision analysis has concluded that a predisposition to falls, with potential head predisposition to falls, with potential head

trauma, is trauma, is rarelyrarely a contraindication to the use a contraindication to the use of anticoagulants in older adult patients with of anticoagulants in older adult patients with

atrial fibrillation (AF)”atrial fibrillation (AF)”

Medio ambiente

Recommended Components of Clinical Assessment and Management for Older Persons Living in the Community Who Are at Risk for Falling

N Engl J Med. 2003;348(1):42

Gracias!

Guau!

Seminario Caídas en el anciano

Documents

Transcript of Seminario Caídas en el anciano