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Chapter 33: Falls in Elderly Patients With KidneyDisease St. Louis University School of Medicine and GRECC, VA Medical Center, St. Louis, Missouri Falls and associated fragility fractures are a major brain, e.g., pulmonary embolus, myocardial infarc- cause of morbidity and mortality in older persons tion, anemia, stroke, seizures, dehydration, meta- with kidney disease. In a longitudinal study from bolic abnormalities, and subdural hematoma (Ta- one dialysis center for a median of 468 d, 47% fell.1 ble 4). Problems with lower limb strength and The fall incident rate was 1.60 falls per year. Overall balance disorders are common in older dialysis pa- studies suggest that the fall rate is much greater in tients and treatable with physical therapy. Drugs dialysis patients than in the general population. In associated with falling are listed in Table 6. Studies the general population over 75 yr of age, 30% of in older diabetics suggest that falls are reduced persons fall each year, with one in five having an injury. Hip fractures in persons on dialysis occurthree to four times more commonly than in thegeneral population. One-year mortality in dialysis patients who have a hip fracture is two to threetimes of that in older community-dwelling persons Postural hypotension is a major cause of falls. It can who have a fracture. A single fall in a dialysis patient occur without any dizziness. For this reason, BP over 65 yr increases the risk of death after adjust- needs to be regularly measured in the standing po- ment for comorbidities.2 In the first 2 yr after dial- sition. Orthostatic hypotension occurs more com- ysis, renal transplant patients have a higher risk of monly in the morning, and in an individual with fracture than patients on dialysis.3 Table 1 lists side severe orthostasis, it may only be present on one half of the BP measurements. In a group of 23 el- A community study of fall prevention in Con- derly on dialysis, orthostasis was present in 8 pa- necticut showed that a simple education program tients before dialysis and 16 of 23 after dialysis.5 (focused on medication reduction and balance and Besides falls, orthostatic hypotension can lead to gait training) could reduce falls and the need for syncope, myocardial infarction, stroke, and death.
fall-related medical services4 (www.fallsprevention.
Causes of orthostatic hypotension include anticho- org). Falls can be either caused by extrinsic (envi- linergic medications, anemia, prolonged recum- ronmental) or intrinsic factors. Environmental fac- bency, dehydration, inadequate salt intake, protein tors include wet, slippery floors, poor lighting, energy malnutrition, adrenal insufficiency, diabetic uneven surfaces, and stairs. Descending stairs is a autonomic neuropathy, Parkinson’s disease, and particular risk factor. There are multiple causes of multiple system atrophy (Shy-Drager syndrome).
falls caused by intrinsic factors as shown in Tables 2 Postprandial hypotension (a fall in BP of Ͼ20 and 3.4 Specific dialysis-related causes of delirium mmHg) occurs in up to 25% of older persons and include uremic encephalopathy, dialysis dementia, persons with diabetes. Its nadir is reached 1 to 2 h Wernicke’s encephalopathy, and dialysis dysequi- after a meal. It is not necessarily associated with orthostasis. It has also been shown to be present New onset falls are often caused by delirium. De- during dialysis in nondiabetic patients.6 Postpran- lirium can present as purely the inability to pay at-tention. Delirium should be considered as a causeof falling in any patient on dialysis who suddenly Correspondence: John E. Morley, MB, BCh, Division of GeriatricMedicine, St. Louis University School of Medicine, 1402 S. Grand starts falling. Delirium has multiple causes such as Boulevard, M238, St. Louis, MO 63104. E-mail: drugs, infection, active decrease in oxygenation to Copyright ᮊ 2009 by the American Society of Nephrology Table 3. Safe and sound mnemonic for renal disease–associated falls Decreased activity and functional decline Systolic blood pressure (low predialysis) dial hypotension is associated with falls, syncope, stroke, myo- No Vitamin D (Ͻ30 ng/ml)Dialysis disequilibrium or other causes of delirium cardial infarction, and death. Treatment can consist of multi-ple small meals with limited carbohydrate content. Because it iscaused by the release of a vasodilatory intestinal peptide, calci- Rarely is a diagnosis made when a person has a single syncopal tonin gene–related peptide, it can be treated with somatostatin event. If a person has multiple syncopal events, they should be analogs. Recent studies have shown that ␣-1-glucosidase in- given an event recorder that should be used.
hibitors, acarbose and miglitol, can markedly attenuate post-prandial hypotension.
Many persons who fall or have disequilibrium develop a “fearof falling.” Studies in older persons suggest that fear of falling Persons who fall with loss of consciousness either have seizures puts persons at a marked increased risk of falls and other ad- or syncope. More than one half of older persons with seizures have partial complex seizures (unusual behavior not necessar-ily associated with toxic clonic seizures) explaining why it cantake nearly 2 yr to diagnose seizures in older persons. Older persons with syncope need to undergo carotid sinus massagebecause those who develop bradycardia need a pacemaker.
A 25(OH) vitamin D (calcidiol) level Ͻ75 nmol/L (30 ng/ml)has been identified as a cause of falls that responds to treatment with a reduction in falls.7 25(OH) Vitamin D deficiency is verycommon in renal failure patients.8 There is some evidence sug- gesting calcidiol is more effective than calcetriol.9 Poor lightingNo grab bar in toiletStairs cluttered There is a paucity of studies examining factors associated with falls in dialysis patients. Cook et al.10 found that age, comor- bidity, lower predialysis systolic BP, and a history of falls rep- Table 4. DELIRIUMS mnemonic for multiple causes of Dementia (poor ability to “dual-task”) Low PO2 states (pulmonary embolus, myocardial infarction, anemia, Metabolic (vitamin B12 deficiency, hypothyroidism, thiamine associated with markedly increased morbidity and mortality in patients on dialysis. The causes of fragility fractures are falls or other trauma and bone disease. In the general population that Treat anemia (if present, with erythopoetin) usually means osteoporosis (Table 7). In renal failure, the pic- ture is complicated because of renal osteodystrophy. Osteodys- trophies include osteomalacia caused by vitamin D deficiency, osteitis fibrosa cystica caused by excess parathyroid hormone secretion, and adynamic bone disease caused by aluminum toxicity and/or parathyroid hormone oversuppression. Low bone mineral density may be seen in either osteoporosis or in Midodrine (alpha 1 adrenergic antagonist) osteodystrophy. Bone mineral loss in older men correlates with elevated cystatin C and lower estimated GFR.13 Bone mineral resented the major associated factors. Desmet et al.1 reported density may be abnormally elevated in the presence of aortic that age, diabetes, increased number of drugs, antidepressant calcification. In dialysis patients, the major risk factors for fra- drug use, and failing a walking test predicted falling in hemo- gility fracture are older age, female sex, diabetes mellitus, heart dialysis patients. Angalakudi et al.11 found the following co- disease, longer periods on dialysis, race other than African morbidities to be associated with an in-hospital fall in persons American, lower body mass index, and low parathyroid lev- with chronic kidney disease (Ͻ60 ml/min GFR): dementia, els.14 In the Dialysis Outcomes and Practice Patterns Study, pneumonia, gastrointestinal disease, diabetes, antidepressants, risk factors were older age, female gender, prior kidney trans- plant, low serum albumin, selective serotonin reuptake inhib-itors, narcotics, benzodiazepines, adrenal steroids, and veryhigh parathyroid hormone levels.15 Levels of PTH between 600 and 900 pg/ml seemed to have the lowest risk.
The use of bisphosphonates in this population is unclear. In The Cochrane Collaboration examined 62 trials on interven- persons who do not have adynamic bone disease or hyperpara- tions to reduce fall risk.12 Multidisciplinary, multifactorial thyroidism and normal 25(OH) vitamin D levels, bisphospho- programs reduced falls in community-dwelling older persons nates at lower doses can be considered. In most cases, a bone (RR ϭ 0.73; range ϭ 0.63 to 0.85) and residential care facilities biopsy with tetracycline labeling would be considered neces- (RR ϭ 0.60; range ϭ 0.50 to 0.73). Programs that had high sary before using bisphosphonates to not aggravate adynamic efficacy at reducing falls were muscle strengthening and bal- bone disease, although it is feasible that bone markers could be ance retraining; home hazard assessment and modifications; used in persons where no exposure to aluminum exists.16 Low withdrawal of psychotropic medications; Tai Chi exercise in- levels of osteocalcin and bone alkaline phosphatase suggest tervention; and cardiac pacing for falls with cardio-inhibitory carotid sinus hypersensitivity (Tables 5 and 6).
Hypogonadism is common in older males and in renal fail- All persons who fall should be enrolled in a home fall pre- ure patients. In males with a low free testosterone (either cal- vention program. This is reimbursed by Medicare Part A if culated or measured by dialysis) (see or bio- homebound and Medicare Part B if not.
available testosterone (albumin bound and free), the use oftestosterone, which should both increase osteoblastic activity and muscle strength, can be considered. Total testosteroneshould not be used in view of elevated levels of sex hormone Fragility fractures (fractures associated with minor trauma) are Table 6. Medications associated with falls Other relatives with osteoporosis/fractures (used for restless legs syndrome in dialysis) Raloxifene increases bone markers of osteoblastic activity in patients on hemodialysis and thus could be used to treat osteo- After renal transplantation, there is a rapid decrease in bone mineral density over the first year. This decrease in bone isassociated with increased risk of fractures. The causes of this increased loss of bone include renal osteodystrophy, glucocor- 1. Desmet C, Beguin C, Swine C, Jadoul M: Falls in hemodialysis pa- ticoids, immunotherapy, vitamin D deficiency, hypophos- tients: prospective study of incidence, risk factors, and complications.
phatemia, hypogonadism, and osteoporosis. Bisphosphonates Am J Kidney Dis 45: 148 –153, 2005 (oral and intravenous), vitamin D, and calcitonin have all been 2. Li M, Tomlinson G, Naglie G, Cook WL, Jassal SV: Geriatric comor- bidities, such as falls, confer an independent mortality risk to elderly shown to slow the rate of bone loss.17 There are inadequate dialysis patients. Nephrol Dial Transplant 23: 1396 –1400, 2008 data to conclude what are their effects on fracture prevention.
3. Ball AM, Gillen DL, Sherrard D, Weiss NS, Emerson SS, Seliger SL, After a hip fracture, a number of factors have been shown to Kestenbaum BR, Stehman-Breen C: Risk of hip fracture among dialysis improve outcome in older persons: surgery within 48 h de- and renal transplant recipients. JAMA 288: 3014 –3018, 2002* creases length of hospitalization and possibly mortality; sur- 4. Morley JE: Falls and fractures. J Am Med Dir Assoc 8: 276 –278, 2007*5. Roberts RG, Kenny RA, Brierley EJ: Are elderly hemodialysis patients gery delay for cardiology clearance may increase mortality; bet- at risk of falls and postural hypotension? Int Urol Nephrol 35: 415– 421, ter outcomes are obtained with spinal or epidural anesthesia; early mobilization enhances rehabilitation outcomes; delirium 6. Sherman RA, Torres F, Cody RP: Postprandial blood pressure changes reduces functional outcomes and it is reduced by a geriatric during hemodialysis. Am J Kidney Dis 12: 37–39, 1988* consult; vitamin D (calcidiol or calcitriol) will improve out- 7. Bischoff-Ferrari HA, Dawson-Hughes B, Willett WC, Staehelin HB, Bazemore MG, Zee RY, Wong JB: Effect of Vitamin D on falls: a comes; and the use of bisphosphonates depends on the type of meta-analysis. JAMA 291: 1999 –2006, 2004 8. Blair D, Byham-Gray L, Lewis E, McCaffrey S: Prevalence of vitamin D [25(OH)D] deficiency and effects of supplementation with ergocalcif-erol (vitamin D2) in stage 5 chronic kidney disease patients. J Ren Nutr18: 375–382, 2008 9. O’Donnell S, Moher D, Thomas K, Hanley DA, Cranney A: Systematic review of the benefits and harms of calcitriol and alfacalcidol forfractures and falls. J Bone Miner Metab 26: 531–542, 2008 Falls are extremely common in patients with end-stage renal 10. Cook WL, Tomlinson G, Donaldson M, Markowitz SN, Naglie G, failure on dialysis. Fall prevention programs that include a Sobolev B, Jassal SV: Falls and fall-related injuries in older dialysis medication review, prevention of orthostasis, cardiac pacing patients. Clin J Am Soc Nephrol 1: 1197–1204, 2006* 11. Angalakuditi MV, Gomes J, Coley KC: Impact of drug use and comor- where appropriate, home hazard assessment and modifica- bidities on in-hospital falls in patients with chronic kidney disease. Ann tions, and muscle strengthening and retraining are effective. In Pharmacother 41: 1638 –1643, 2007 addition, making sure the 25(OH) vitamin D level is Ͼ30 12. McClure R, Turner C, Peel N, Spinks A, Eakin E, Hughes K: Population- ng/ml has been found to be effective.
based interventions for the pr3evention of fall-related injuries in older Treatment of bone disease is complicated because of the people. Cochrane Data Sys Rev 1: CD004441, 2005 13. Ishani A, Paudel M, Taylor BC, Barrett-Connor E, Jamal S, Canales M, coexistence of osteoporosis and renal osteodystrophy. In per- Steffes M, Fink HA, Orwoll E, Cummings SR, Ensrud KE; Osteoporotic sons without adynamic bone disease, low-dose bisphospho- Fractures in Men (MrOS) Study Group: Renal function and rate of hip nates are possibly indicated. There may be a role for testoster- bone loss in older men: the Osteoporotic Fractures in Men Study.
one in males and raloxifene in females.
Osteoporos Int 19: 1549 –1556, 2008* 14. Kaneko TM, Foley RN, Gilbertson DT, Collins AJ: Clinical epidemiol- ogy of long-bone fractures in patients receiving hemodialysis. ClinOrthopeadics Rel Res 457: 188 –193, 2007 15. Jadoul M, Albert JM, Akiba T, Akizawa T, Arab L, Bragg-Gresham JL, Mason N, Prutz KG, Young EW, Pisoni RL: Incidence and risk factorsfor hip or other bone fractures among hemodialysis patients in the • Fall prevention programs should be instituted for all older dialysis Dialysis Outcomes and Practice Patterns Study. Kidney Int 70: 1358 – • All older kidney failure patients should have 25(OH) vitamin D levels 16. Miller PD: Is there a role for bisphosphonates in chronic kidney dis- ease? Semin Dial 20: 186 –190, 2007* • Bisphosphonates, testosterone in males, and raloxifene in females can 17. Palmer SC, McGregor DO, Strippoli GF: Intervention for preventing be used to treat bone disease as long as the type of disease is under- bone disease in kidney transplant recipients. Cochrane Database Syst REVIEW QUESTIONS: FALLS IN ELDERLY PATIENTS 1. To prevent falls, 25(OH) vitamin D levels should be greater 3. To determine if there is adynamic bone measure 2. Which of the following drugs can be used to treat postprandial



OPHTHALMIC OPHTHALMIC FORUM A relentless peripheral corneal ulcer Comments by: Chi-Cheong Wong, FRCS, FHKAM (Ophth), Jack A. Singer, MD, Peter G. Watson, FRCS, FRCOphth Case history A 64-year-old lady with good past health first presented 7 years previously with left eye limbal congestion and a small peripheral corneal guttering ulcer at the nasal region ( Figure 1 ) associated w

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