7/25/2014 SECTION HEADING Presenter Disclosure Information Edgar - PowerPoint PPT Presentation

7/25/2014 SECTION HEADING Presenter Disclosure Information Edgar Pierluissi OSTEOPOROSIS NEW INSIGHTS IN RESEARCH, DIAGNOSIS,AND CLINICAL CARE • No relevant disclosures School of Medicine Division of Geriatrics The Other Half of the Fracture Edgar Pierluissi, MD Equation: Fall Prevention and Medical Director Management Acute Care for Elders Unit San Francisco General Hospital and Trauma Center School of Medicine epierluissi@medsfgh.ucsf.edu July 24, 2014 2 SECTION HEADING SECTION HEADING Presentation Outline Case presentation • Ms. L is a 69 y/o woman with a history of HIV (CD4-750), chronic hepatitis C, • Case presentation COPD, Bipolar affective disorder, • Prevalence and Consequences tobacco and cocaine abuse, • Risk factors hypothyroidism, and osteoporosis, • Screening complicated by multiple falls and fractures. • Prevention • Summary School of Medicine School of Medicine 3 4 1

7/25/2014 • Her falls have resulted in : – 1997: hip fracture • She has been referred to and completed – 2003 a patellar fracture in 2003 evaluations and rehabilitation with PT and – 2006 a metatarsal fracture bone in April OT, both at home and during several SNF stays. She has had home safety – 2006 hip fracture in November 2006 evaluations, and has a bathroom equipped – 2014 slipped on a bath mat, with displaced rib with grab bars and shower rails. fractures. She also has evidence of an age indeterminate L2 vertebral fracture. • She was treated with alendronate from 2003 to 2010. School of Medicine School of Medicine 5 6 Medications: SECTION HEADING Abacavir-lamivudine 600-300 mg daily Presentation Outline Efavirenz 600 mg daily Ipratropium/albuterol 2 puffs BID Advair 1 puff BID Aspirin 81 g daily • Case presentation Divalproex 125 mg BID Doxepin 10 mg qhs • Prevalence and Consequences of Falls Duloxetine 60 mg PO daily • Risk factors Olanzapine 2.5 mg qhs • Screening Ferrous sulfate 325 mg daily • Prevention Synthroid 50 mcg daily • Summary MVI Pravastatin 80 mg qhs Senna/Docusate Calcium gluconate 500 mg PO BID School of Medicine School of Medicine Vitamin D3 1000 IU daily 7 8 2

7/25/2014 SECTION HEADING Consequences Prevalence of Falls Falls are Common • 1/3 fallers with injuries reported needing help with ADLs as result of fall injury • ~1/3 of those over 65 will fall in the next year • 1/2 of these expected to need help with ADLs for at least six months • ~1/2 of those over 80 will fall in the next year • ~10% result in a major injury (fracture, TBI, serious • In 2010, ~7 million Medicare beneficiaries fell soft tissue injury) NEJM 348:42-49,2003 Clin Ger Med 18:141-158,2002 School of Medicine School of Medicine Am J Prev Med 2012;43(1):59–62 Adv Data 392; 2007 Fall Injury Episodes Among Noninstitutionalized Older Adults: US, 2001–2003 9 10 Number Going to ED/Getting Death from Falls 65+ Hospitalized for Falls is Increasing 25000 20000 2.5 Number of Deaths 2 15000 To Emergency Department Millions 1.5 10000 1 5000 0.5 Hospitalized 0 0 1999 2001 2003 2005 2007 2009 2001 2003 2005 2007 2009 2011 School of Medicine School of Medicine http://www.cdc.gov/injury/wisqars/ Accessed April 24, 2014 http://www.cdc.gov/injury/wisqars/ Accessed April 24, 2014 11 12 3

7/25/2014 Fractures Due to Fall in Older Women Consequences of Falls ALL FRACTURES • About one out of five hip fracture WRIST patients dies within a year of their injury. PROXIMAL HUMERUS ELBOW HIP PATELLA • About one in four adults who lived ANKLE independently before their hip fracture FOOT/TOES needs to stay in a nursing home for at PELVIS least a year after their injury. FACE HAND/FINGER TIBIA/FIBULA RIB Mortality, disability, and nursing home use for persons with and without hip fracture: a School of Medicine School of Medicine 0 10 20 30 40 50 60 70 80 90 population-based study. JAGS 2002;50:1644 Nevitt et al. 1997 Recovery from hip fracture in eight areas of function. J Geront: Med Sci 2000;55A(9):M498 Percent 13 14 Consequences of falls Costs • Fear of falling – ~1/3 without FOF before falling will – Direct medical costs: 30 billion dollars in develop FOF after falling 2010 – FOF associated with • ↓ physical and social ac�vity – Indirect and direct est 68B by 2020 • ↓ self-reported health • ↑ depression symptoms • ↑ risk of falling School of Medicine School of Medicine Age and Ageing 2008; 37: 19–24 Inj Prev 2006; 12(5): 290-5 15 16 4

7/25/2014 Summary Fallers unlikely to discuss falls • Falls are common • Falls affect patient function and are a • Less than half of Medicare beneficiaries who fall major mechanism of injury. discuss falls with a healthcare provider (women>men). • Only a third to a quarter who have fallen, discuss fall • Patients report infrequently discussing prevention strategies. falls and falls prevention with providers. School of Medicine School of Medicine Am J Prev Med 2012;43(1):59–62 17 18 Independent Risk Factors for Falling Among Community-Living SECTION HEADING Older Adults Risk factor No. of Studies RR OR Presentation Outline Significant Previous falls 16 1.9-6.6 1.5-6.7 Balance impairment 15 1.2-2.4 1.8-3.5 Decreased muscle strength 9 2.2-2.6 1.2-1.9 • Case presentation Visual impairment 8 1.5-2.3 1.7-2.3 • Prevalence and Consequences Meds: >4 or psychoactive 8 1.1-2.4 1.7-2.7 • Risk factors for falls Gait impairment 7 1.2-2.2 2.7 Depression 6 1.5-2.8 1.9-2.9 • Screening Dizziness or orthostasis 5 2.0 1.5-3.1 • Prevention ADL disabilities 5 1.5-6.2 1.7-2.5 • Summary Age >80 4 1.1-1.3 1.1 Female 3 2.1-3.9 2.3 Low BMI 3 1.5-1.8 3.1 Urinary Incontinence 3 1.3-1.8 JAMA 2010;303:258 Cognitive impairment 3 2.8 1.9-2.1 School of Medicine School of Medicine Pain 2 1.7 19 20 5

7/25/2014 Risk factors for future falls • Ex: Patient over 65 Risk factor Likelihood Ratio • Pre-test probability 33% Previous fall in last year 2.8-3.8 • Odds of falling in the next year 1:2 Orthostatic hypotension - Visual acuity ~2 Have they fallen in the previous year? Gait and Balance 2 • Previous fall has LR of ~3 Medications 1.7 Assess basic and instrumental 2-4 • Post test fall odds = LR x pre-test falls odds activities of daily living = 3 x 1:2 Assess cognition 4-17 = 3:2 • Post test probability 60% School of Medicine School of Medicine Will My Patient Fall? JAMA. 2007;297:77-86 22 23 SECTION HEADING Screening Guidelines for Fall Prevention Presentation Outline • Guideline for the Prevention of Falls in Older Persons – American Geriatrics Society • Case presentation – British Geriatrics Society • Prevalence and Consequences of Falls – American Academy of Orthopaedic Surgeons JAGS 49:664–672, 2001, updated 2010 • Risk factors • Practice Parameter: Assessing patients in a • Screening neurology practice for risk of falls • Prevention – American Academy of Neurology • Summary Neurology 2008;70;473-479 • Tinetti, ME N Engl J Med.348 (1) 42. 2003 JAMA. 2010;303(3):258-266 School of Medicine School of Medicine 24 25 6

7/25/2014 AGS/BGS Guideline American Academy of Neurology Older person encounters health care provider 2 or more falls last year Screen for risk of falling Presents with acute fall Difficulty with walking or balance No Yes A. Inquire about falls B. Review history for risk factors in the past year for falling Single fall in past year? (Level A) Neurological: (Levels A & B) Falls Evaluation AND No Yes stroke Yes dementia Abnormalities in gait gait/mobility problem or unsteadiness? parkinsonism peripheral neuropathy assistive device No LE sensorimotor loss Reassess annually Neurology 2008;70;473-479 School of Medicine School of Medicine 26 27 SECTION HEADING Slide Title. Arial Bold, 32pt Ask patients ≥75 years old about • If A or B positive: falls and balance or gait difficulties. No fall and no Observe getting into and out of a Recommend exercise balance or gait chair and walking. program with balance and difficulties strength training Falls Evaluation One fall and no Two or more falls balance or gait or balance or gait difficulties difficulties Assessment of predisposing and precipitating factors, followed by interventions suggested by the results of detailed assessment. A Falls Evaluation School of Medicine School of Medicine N Engl J Med.348 (1) 42. 2003 28 29 7