1. Caídas
Sandra Milena Acevedo Rueda
MD Residente Medicina Interna UNAB
Enero de 2013
Page 1

2. Clin Geriatr Med 29 (2013) 137–150 Page 2

3. Caídas
El individuo cae usualmente
Son comunes y son los
ocurren cuando
principales factores que
las deficiencias en varios dominios
amenazan su
ponen en peligro la capacidad de
independencia
compensación del individuo
JAMA. 1995;273(17):1348.
Page 3

4. Falta de atención clínica…
JAMA. 1995;273(17):1348. Page 4

5. “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 in
that would result in
nursing home admission”
nursing home admission”
BMJ. 2000;320(7231):341
Page 5

6. Epidemiología
12.6 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 Page 6

7. Epidemiología
Estudio en mujeres mayores de 70 a (2 años)
41 % trauma menor
6% trauma mayor
Pacientes institucionalizados tienen más
trauma mayor
5% serán hospitalizados
N Engl J Med. 2003;348(1):42 Page 7

8. “In an Australian study, 9.5 percent
“In an Australian study, 9.5 percent
of patients hospitalized for falls
of patients hospitalized for falls
became first-time residents of a
became first-time residents of a
long-term care facility at discharge”
long-term care facility at discharge”
Emerg Med J. 2012 Sep;29(9):742-7.
Page 8

9. Page 9

10. “ 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 death”
in death”
Am J Epidemiol. 1990;131(6):1028
Page 10

11. Miedo a caer
Después de una caída…
60% restricción moderada
15% restricción marcada
50% después de una fx de cadera
J Am Geriatr Soc. 2010;58(9):1739
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12. Page 12

13. Clin Geriatr Med 29 (2013) 137–150 Page 13

14. Órganos de los sentidos
Lentes multifocales aumentan el riesgo
Agudeza visual, percepción de profundidad,
adaptación a la oscuridad
Propiocepción alterada
Sistema vestibular alterado
J Am Geriatr Soc. 2002;50(11):1760 Page 14

15. Page 15

16. Activación y composición
muscular
Activación muscular proximal
Mayor activación de músculos antagónicos
Recuperación alterada
Infiltración grasa y riesgo de Fx cadera
J Am Geriatr Soc. 2002;50(11):1760 Page 16

17. Historia de caídas
Riesgo de segunda Fx de cadera
“Framingham Study”: 14.8%
tuvieron una segunda fractura en
los siguientes 4 años
J Am Geriatr Soc. 2002;50(11):1760 Page 17

18. Page 18

19. Presión arterial
Hipotensión ortostática
Menos % agua, diuréticos, climas
cálidos
J Am Geriatr Soc. 2002;50(11):1760 Page 19

20. Enfermedades crónicas
Enfermedad de Parkinson
Dolor musculo-esquelético crónico
Osteoartritis
Diabetes
J Am Geriatr Soc. 2002;50(11):1760 Page 20

21. Deterioro cognitivo
“ 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 impairment”
with no impairment”
J Am Geriatr Soc. 2002;50(11):1760 Page 21

22. Medicamentos
“ 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 sedatives and hypnotics (odds ratio [OR]
with the use of sedatives and hypnotics (odds ratio [OR]
1.47, 95% credible interval (CrI) 1.35-1.62), neuroleptics
1.47, 95% credible interval (CrI) 1.35-1.62), neuroleptics
and antipsychotics (OR 1.59, 95% CrI 1.37-1.83),
and antipsychotics (OR 1.59, 95% CrI 1.37-1.83),
antidepressants (OR 1.68, 95% CrI 1.47-1.91), and
antidepressants (OR 1.68, 95% CrI 1.47-1.91), and
benzodiazepines (OR 1.57, 95% CrI 1.43-1.72)”
benzodiazepines (OR 1.57, 95% CrI 1.43-1.72)”
Arch Intern Med. 2009;169(21):1952 Page 22

23. Alcohol, calzado, factores
medio-ambientales
A mayor consumo de alcohol, mayor riesgo
Suelas, tacones
Ayudas especiales
Pacientes institucionalizados
J Am Geriatr Soc. 2002;50(11):1760 Page 23

24. Reportar caídas recurrentes
Reportar alteración en la marcha o el balance
Buscar atención médica ó presentarse al
departamento de urgencias cuando haya una
caída
Page 24

25. Historia clínica completa, valoración funcional
y cognitiva
Función musculo-esquelética
Examen físico
Laboratorios e imágenes
Page 25

26. Short Physical Performance Battery (SPPB)
1. Repeated Chair Stands
2. Balance Testing
a. Semitandem Stand
b. Side-by-Side stand
c. Tandem Stand
3. 8’ Walk (2.44 meters)
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27. The "Get up and go" test for gait
The "Get up and go" test for gait
assessment in elderly patients
assessment in elderly patients
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. Page 27

28. Page 28

29. Tinetti Performance Oriented Mobility
Tinetti Performance Oriented Mobility
Assessment (POMA)*
Assessment (POMA)*
Tinetti ME. Performance-oriented assessment of mobility problems in
elderly patients. JAGS 1986; 34: 119-126. (Scoring description: PT Page 29
Bulletin Feb. 10, 1993)

30. Balance
Tinetti
Tinetti
Performance
Performance
Oriented
Oriented
Mobility
Mobility
Assessment
Assessment
(POMA)
(POMA)
Tinetti ME. Performance-oriented assessment of mobility problems in
elderly patients. JAGS 1986; 34: 119-126. (Scoring description: PT Page 30
Bulletin Feb. 10, 1993)

31. Marcha
Tinetti
Tinetti
Performance
Performance
Oriented
Oriented
Mobility
Mobility
Assessment
Assessment
(POMA)
(POMA)
Tinetti ME. Performance-oriented assessment of mobility problems in
elderly patients. JAGS 1986; 34: 119-126. (Scoring description: PT Page 31
Bulletin Feb. 10, 1993)

32. Diagram of
functional reach
test to assess
balance in
elderly persons
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.
Page 32

33. Page 33
N Engl J Med. 2003;348(1):42

34. 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.
Page 34

35. 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.
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36. N Engl J Med. 2003;348(1):42 Page 36

37. Ejercicio
• Marcha y balance
• Fuerza
• Flexibilidad
• Movimientos (TaiChi o baile)
• Actividad física general
• Resistencia
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38. Medicamentos
• Modificación de dosis y fármacos
• Vitamina D
• Evitar toxicidad
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39. Otras intervenciones
Hipersensibilidad 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
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40. Tiempo en el suelo
““ A study of 1100 individuals over age 72
A study of 1100 individuals over age 72
found that 47 percent of the 313 who
found that 47 percent of the 313 who
experienced non-injurious falls were unable
experienced non-injurious falls were unable
to get up for at least one hour after falling”
to get up for at least one hour after falling”
JAMA. 1993;269(1):65
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41. 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 rarely a contraindication to the use
trauma, is rarely 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)”
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42. Medio ambiente
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43. 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 Page 43

44. 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 Page 44

45. Guau!
Gracias!
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