小结
跌倒往往是多原因的。[1]Deandrea S. Risk factors for falls in community-dwelling older people: a systematic review and meta-analysis. Epidemiology. 2010 Sep;21(5):658-68. http://www.ncbi.nlm.nih.gov/pubmed/20585256?tool=bestpractice.com 以下因素的存在与未来跌倒更大可能性有关,[2]Rubenstein LZ, Josephson KR. Falls and their prevention in elderly people: what does the evidence show? Med Clin North Am. 2006 Sep;90(5):807-24. http://www.ncbi.nlm.nih.gov/pubmed/16962843?tool=bestpractice.com [3]McInnes L, Gibbons E, Chandler-Oatts J. Clinical practice guideline for the assessment and prevention of falls in older people. Worldviews Evid Based Nurs. 2005;2(1):33-6. http://www.ncbi.nlm.nih.gov/pubmed/17040554?tool=bestpractice.com 以及跌倒筛查指南建议识别高危人群的这些特征,这可能有助于实施跌倒预防策略:
运动问题:步态和平衡障碍;肌无力[2]Rubenstein LZ, Josephson KR. Falls and their prevention in elderly people: what does the evidence show? Med Clin North Am. 2006 Sep;90(5):807-24. http://www.ncbi.nlm.nih.gov/pubmed/16962843?tool=bestpractice.com [4]Ganz DA, Bao Y, Shekelle PG, et al. Will my patient fall? JAMA. 2007 Jan 3;297(1):77-86. http://www.ncbi.nlm.nih.gov/pubmed/17200478?tool=bestpractice.com [5]Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988 Dec 29;319(26):1701-7. http://www.ncbi.nlm.nih.gov/pubmed/3205267?tool=bestpractice.com [6]Campbell AJ, Borrie MJ, Spears GF. Risk factors for falls in a community-based prospective study of people 70 years and older. J Gerontol. 1989 Jul;44(4):M112-7. http://www.ncbi.nlm.nih.gov/pubmed/2738307?tool=bestpractice.com [7]Chu LW, Chi I, Chiu AY. Incidence and predictors of falls in the Chinese elderly. Ann Acad Med Singapore. 2005 Jan;34(1):60-72. http://www.annals.edu.sg/pdf200502/ChuW.pdf http://www.ncbi.nlm.nih.gov/pubmed/15726221?tool=bestpractice.com [8]Luukinen H, Koski K, Laippala P, et al. Predictors for recurrent falls among the home-dwelling elderly. Scand J Prim Health Care. 1995 Dec;13(4):294-9. http://www.ncbi.nlm.nih.gov/pubmed/8693215?tool=bestpractice.com
感觉障碍:周围神经病变、前庭功能障碍、视觉障碍[2]Rubenstein LZ, Josephson KR. Falls and their prevention in elderly people: what does the evidence show? Med Clin North Am. 2006 Sep;90(5):807-24. http://www.ncbi.nlm.nih.gov/pubmed/16962843?tool=bestpractice.com [4]Ganz DA, Bao Y, Shekelle PG, et al. Will my patient fall? JAMA. 2007 Jan 3;297(1):77-86. http://www.ncbi.nlm.nih.gov/pubmed/17200478?tool=bestpractice.com [9]Bergland A, Jarnlo GB, Laake K. Predictors of falls in the elderly by location. Aging Clin Exp Res. 2003 Feb;15(1):43-50. http://www.ncbi.nlm.nih.gov/pubmed/12841418?tool=bestpractice.com [10]Pfeiffer E. A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriatr Soc. 1975 Oct;23(10):433-41. http://www.ncbi.nlm.nih.gov/pubmed/1159263?tool=bestpractice.com [11]Coleman AL, Stone K, Ewing SK, et al. Higher risk of multiple falls among elderly women who lose visual acuity. Ophthalmology. 2004 May;111(5):857-62. http://www.ncbi.nlm.nih.gov/pubmed/15121359?tool=bestpractice.com
认知或情绪障碍:痴呆、抑郁、谵妄[5]Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988 Dec 29;319(26):1701-7. http://www.ncbi.nlm.nih.gov/pubmed/3205267?tool=bestpractice.com [7]Chu LW, Chi I, Chiu AY. Incidence and predictors of falls in the Chinese elderly. Ann Acad Med Singapore. 2005 Jan;34(1):60-72. http://www.annals.edu.sg/pdf200502/ChuW.pdf http://www.ncbi.nlm.nih.gov/pubmed/15726221?tool=bestpractice.com
体位性低血压[2]Rubenstein LZ, Josephson KR. Falls and their prevention in elderly people: what does the evidence show? Med Clin North Am. 2006 Sep;90(5):807-24. http://www.ncbi.nlm.nih.gov/pubmed/16962843?tool=bestpractice.com [4]Ganz DA, Bao Y, Shekelle PG, et al. Will my patient fall? JAMA. 2007 Jan 3;297(1):77-86. http://www.ncbi.nlm.nih.gov/pubmed/17200478?tool=bestpractice.com
多药联合或某些药物(尤其精神科药物)[12]Hartikainen S, Lonnroos E, Louhivuori K. Medication as a risk factor for falls: critical systematic review. J Gerontol A Biol Sci Med Sci. 2007 Oct;62(10):1172-81. http://www.ncbi.nlm.nih.gov/pubmed/17921433?tool=bestpractice.com
日常活动能力障碍[13]Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969 Autumn;9(3):179-86. http://www.ncbi.nlm.nih.gov/pubmed/5349366?tool=bestpractice.com
环境危害(如松动的地毯、光线不足、杂物堆砌)[2]Rubenstein LZ, Josephson KR. Falls and their prevention in elderly people: what does the evidence show? Med Clin North Am. 2006 Sep;90(5):807-24. http://www.ncbi.nlm.nih.gov/pubmed/16962843?tool=bestpractice.com
其他因素如年龄或伴发疾病。[2]Rubenstein LZ, Josephson KR. Falls and their prevention in elderly people: what does the evidence show? Med Clin North Am. 2006 Sep;90(5):807-24. http://www.ncbi.nlm.nih.gov/pubmed/16962843?tool=bestpractice.com
许多预防跌倒方案的关键内容包括:解除危险因素、提倡运动(包括力量和平衡训练)、审查用药情况、评估视力、评估居所安全性,必要时可进行调整。[14]Centers for Disease Control and Prevention. Home and recreational safety: older adult falls. Feb 2017 [internet publication]. http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html 例如,对于有跌倒高风险的≥65 岁社区居住成人,美国预防服务工作组推荐采用运动(如,成组运动、太极、多元运动)或物理治疗来预防跌倒。[15]US Preventive Services Task Force; Grossman DC, Curry SJ, Owens DK, et al. Interventions to prevent falls in community-dwelling older adults: US Preventive Services Task Force recommendation statement. JAMA. 2018 Apr 24;319(16):1696-704. https://jamanetwork.com/journals/jama/fullarticle/2678104 http://www.ncbi.nlm.nih.gov/pubmed/29710141?tool=bestpractice.com [16]Guirguis-Blake JM, Michael YL, Perdue LA, et al. Interventions to prevent falls in older adults: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2018 Apr 24;319(16):1705-16. https://jamanetwork.com/journals/jama/fullarticle/2678103 http://www.ncbi.nlm.nih.gov/pubmed/29710140?tool=bestpractice.com 关于补充维生素 D(单独或搭配钙补充)的荟萃分析显示,该治疗在减少跌倒方面没有益处。[17]Bolland MJ, Grey A, Gamble GD, et al. Vitamin D supplementation and falls: a trial sequential meta-analysis. Lancet Diabetes Endocrinol. 2014 Jul;2(7):573-80. http://www.ncbi.nlm.nih.gov/pubmed/24768505?tool=bestpractice.com
一项 Cochrane 系统评价发现,与常规治疗或注意力控制相比,多元干预措施(抛开所有对跌倒风险的评估,为所有人提供相同组分干预措施;其中大多数措施包括运动)可以减少生活在社区的老年人跌倒次数和摔倒风险。另外还发现,与常规治疗或注意力控制相比,多因素干预措施(根据对跌倒风险的评估,每个人之间的组分干预措施有所不同)可以减少社区老年人的跌倒次数。[18]Hopewell S, Adedire O, Copsey BJ, et al. Multifactorial and multiple component interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev. 2018 Jul 23;(7):CD012221.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012221.pub2/full
http://www.ncbi.nlm.nih.gov/pubmed/30035305?tool=bestpractice.com
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Can multifactorial interventions help prevent falls among older people living in the community?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.2296/full展示答案
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Can multicomponent interventions help prevent falls among older people living in the community?/cca.html?targetUrl=https://www.cochranelibrary.com/cca/doi/10.1002/cca.2295/full展示答案
一项网络荟萃分析发现,以下干预措施在预防导致损伤的跌倒方面比常规治疗更有效:[19]Tricco AC, Thomas SM, Veroniki AA, et al. Comparisons of Interventions for Preventing Falls in Older Adults: A Systematic Review and Meta-analysis. JAMA. 2017 Nov 7;318(17):1687-99 http://www.ncbi.nlm.nih.gov/pubmed/29114830?tool=bestpractice.com
体育锻炼
运动、视力评估联合治疗
运动、视力评估和治疗联合环境评估和调整
临床水平的质量改进策略(例如病例管理)、多因素评估和治疗联合钙和维生素 D补充。
若干指南已对采用此类干预措施预防跌倒进行评估:
NICE - falls in older people: assessing risk and prevention external link opens in a new window
NICE: falls in older people. Quality standard external link opens in a new window
跌倒是美国≥65 岁人群由意外伤害导致死亡的主要原因。[20]Burns E, Kakara R. Deaths from falls among persons aged ≥65 years - United States, 2007-2016. MMWR Morb Mortal Wkly Rep. 2018 May 11;67(18):509-14. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5944976/ http://www.ncbi.nlm.nih.gov/pubmed/29746456?tool=bestpractice.com 四分之一的老年人报告每年至少跌倒一次,导致大约 300 万次急诊就诊。从 2007 年到 2016 年收集的数据表明,这一发生率每年增加约 3%。[20]Burns E, Kakara R. Deaths from falls among persons aged ≥65 years - United States, 2007-2016. MMWR Morb Mortal Wkly Rep. 2018 May 11;67(18):509-14. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5944976/ http://www.ncbi.nlm.nih.gov/pubmed/29746456?tool=bestpractice.com 几乎所有年龄和人群的跌倒发生均在增加,但 85 岁及以上人群的增幅最大。该年龄组的跌倒致死率也较高。[20]Burns E, Kakara R. Deaths from falls among persons aged ≥65 years - United States, 2007-2016. MMWR Morb Mortal Wkly Rep. 2018 May 11;67(18):509-14. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5944976/ http://www.ncbi.nlm.nih.gov/pubmed/29746456?tool=bestpractice.com
对跌倒周围情况和相关症状的识别可以帮助确定潜在病因,而这些病因的发现又反过来强调了解跌倒细节的重要性。 病因的识别可以决定是否有必要进行更多的紧急的医学评价,以应对危及生命的病因及其后果。 这个调查也可以帮助识别最有可能导致跌倒的危险因素,实施适当的干预措施来减少再次跌倒的风险。
鉴别诊断
撰稿人
作者展开全部内容
Assistant Professor
Cleveland Clinic Lerner College of Medicine of Case Western Reserve University
Geriatric Medicine Fellowship Program Director
Center for Geriatric Medicine, Medicine Institute
Cleveland Clinic
Cleveland
OH
利益声明
RF is a Pfizer stockholder.
同行评议者展开全部内容
Professor of Medicine
Division of Geriatric Medicine
Saint Louis University
Saint Louis
MO
利益声明
DT declares that he has no competing interests.
Consultant Physician
Nuffield Department of Medicine
John Radcliffe Hospital
Oxford
UK
利益声明
AD declares that he has no competing interests.
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