Disclosures Crash, Snap: Falls Cause “Osteoporosis- related” Fractures. � Research support � Novartis What Can a Clinician Do? � Viking NAMS Pre-meeting October 10, 2017 � Consultant Neil Binkley, M.D. � Amgen • Some of this talk University of Wisconsin School of Medicine and Public Health � Radius is my opinion • This is indicated Madison, WI, USA by orange text Definition and Prevalence Falls and Common Sense � “ Fall ” defined as an event which results in a � Walking is “controlled falling” person coming to rest inadvertently on the ground or floor or other lower level. � Falls are very common in older adults; � People are top-heavy incidence annually in those age and older: � 30-40% of community-dwelling � 50% of those in LTC facilities � 60% in those with fall in previous year � Our default position is on the ground � Falls risk increases with advancing age � Most falls are not associated with syncope WHO.int/mediacentre/factsheets/fs344/en/ Stel , et. al., Age Ageing. 2004 Jan; 33:58-65.
Why Are We Treating “ Osteoporosis? ” Why Are We Talking About Falls in An Osteoporosis Session?? Fracture is What’s Important Fracture Incidence and Morbidity Falls Cause “Osteporosis-related” Fracture � National Electronic Injury � Reports vary, but some find that 10-15% of falls Surveillance System All Injury result in fracture or other serious injury Program � ~95% of hip fractures are from falls � Generated national estimates � Usually from falling sideways of ED visits for fall related fracture in adults age 65+; Parkkari, et. al., Calcif Tissue Int, 1999; 65:183-187 Hayes, et. al., Calcif Tissue Int; 52: 192-198 2001-2008 � Preventing falls prevents fracture….. � Estimated 4.05 million fall-related fracture during the 8 yrs � Fracture rate increased ~24% during study period � 48% required hospitalization � Fracture rates increased with age; 2X higher in women Orces CH. BMJ Open 2013;3 e001772
Impaired Physical Performance Increases Hip Fracture Risk Risk Factors for Falls Mean relative risk or odds ratios from 16 studies Evaluated the • Muscle weakness 4.4 • Arthritis 2.4 association of • History of falls 3.0 • Impaired ADL 2.3 physical • Balance deficit 2.9 • Depression 2.2 performance and hip fracture risk in • Gait deficit 2.9 • Cognitive impairment 1.8 MrOS; • Assist device 2.6 • Age > 80 years 1.7 5995 men age • Visual deficit 2.5 65+ “Poor physical function is independently associated with an increased risk of hip fracture in older men.” Rubenstein & Josephsen, Clin Ger Med Adapted from Cawthon, et. al., J Bone Miner Res, 2008, 23:1037- 1044 Sarcopenia: the Age-related Gradual Loss Sarcopenia Pathogenesis is Multifactorial Osteoporosis of Muscle mass, Strength and Function � Hormonal declines Sarc for flesh (muscle), penia for deficiency � GH/IGF-1, testosterone, estrogen Are osteoporosis � Increased inflammation and sarcopenia Term coined in 1989; � IL-6, TNF-alpha, etc, etc. the same more recently defined as: “ The age- � Malnutrition process? associated loss of skeletal muscle � Protein, vitamin D mass and function…. a complex � Sedentariness/Diseases leading to decreased use syndrome associated with muscle With the disease � Toxin exposure mass loss alone or in conjunction being fracture? � Neuronal loss with increased fat mass. ” � Reduced muscle “ quality ” expressed ultimately as bone reduced function � Changes in structure, fat and connective tissue Fielding, et. al, J Am Med Dir Assoc 2011; 12: 249-256 Jensen, J Parenter Enteral Nutr, 32;656-659, 2008
We Need to Get Past Treating This Paradigm is Identical “Osteoporosis” and Treat People to Metabolic Syndrome Fractures result from a syndrome: treatment should be directed at various conditions to reduce fracture risk Metabolic Syndrome Dysmobility Syndrome Advancing age Hyperlipidemia Advancing age Reduced QOL Osteoporosis Hypertension Healthcare Cost Reduced QOL Heart Attack Sarcopenia Falls & Diabetes Death Healthcare Cost Diabetes Fractures Death Obesity Toxins, Obesity Family History e.g., tobacco Etc, etc Toxins, Family History e.g., tobacco Binkley, et. al., J Bone Miner Res. 2017 Jul;32(7):1391-1394 It’s My Bias That “We” Haven’t Done a Good Job in Conveying Information That Treating Osteoporosis Without “Fractures Are Bad” Considering Other Parts of the Syndrome Causing Fractures is Comparable to Treating Hyperlipidemia and Ignoring Hypertension and Diabetes in Patients With Metabolic Syndrome Personal opinion
Fractures Reduce Quantity and Fractures Cause Dependency Quality of Life Loss of Independence is a Huge Concern Telephone Survey of ~800 Older Adults in 2007 � What do you fear most? � Loss of independence: 26% � Moving out of home into nursing home: 13% � Giving up driving: 11% � Loss of family/friends: 11% � Death: 3% www.slideshare.net/clarityproducts/clarity-2007- www.share.iofbonehealth.org/WOD/2012 aginig-in-place-in-america-2836029 So, What Can a Clinician Do Maintaining Independence is THE Reason to Reduce Falls Risk? to Treat The Fracture Risk Syndrome
Recognize Conditions That Increase Falls Appreciate the Age-related Changes Risk Factors for Recurrent Falls That Increase Falls Risk � Age � Vision impairment � Visual system: acuity, depth perception, contrast � Female � Postural hypotension sensitivity, dark adaptation � History of falls � Depression � Fear of falling � Urinary incontinence � Proprioceptive system: lower extremities � Impaired mobility � Stroke � Sedentariness � CV disease � Vestibular system: loss of labyrinthine hair cells, � Arthritis/OA � Chronic pain vestibular ganglion cells, nerve fibers � Parkinson’s disease � Drug use Modified from De Jong, et. al., Ther Adv Drug Saf. 2013 Aug; 4(4): 147–154 A Couple of Concrete Examples of Chronic Conditions That Increase Review (and Reduce) the Medications Falls and Fracture Risk � Common fall risk factor; potentially easily modifiable � Parkinson’s disease � Certain classes associated with hip fracture � Rigidity of lower extremity musculature � Benzodiazepines � Slow movement initiation to correct body sway � Antidepressants (including SSRIs) � Hypotensive drug effects � Antipsychotic drugs � Cognitive impairment � Increased risk of fall… � Osteoarthritis, especially in knees � With recent change in dose � Can affect mobility � With increasing total number of prescriptions � Inability to step over objects � Avoid complete weight bearing on joint
“The exact number of falls caused by drugs or drug intoxication is not known because falls Post Hospitalization is a High-risk Time are not officially recognized as an ADR.” � After hospital discharge, falls rates are increased compared to community dwelling older adults 1 � 40+% fall within 6 months; over half are injurious falls 2 Drug Class Odds ratio for falls Antidepressants 1.68 � Hospitalization doubles the risk of hip fracture, notably in the month after discharge 3 Neuroleptics/antipsychotics 1.59 Benzodiazepines 1.57 � ~ one-third experience ADL functional decline Sedative/hypnotics 1.47 compared to their preadmission level of activities of daily living 4 Antihypertensives 1.24 NSAIDs 1.21 1Mahoney, et. al., Arch Intern Med 2000;160:2788–95 2Hill, et. al. . J Gerontol A Biol Sci Med Sci. 2011 Sep;66(9):1001-12 De Jong, et. al., Ther Adv Drug Saf. 2013 Aug; 4(4): 147–154 3Wolinsky, et. Al. J Gerontol A Biol Sci Med Sci. 2009 Feb;64(2):249-55 Woolcott , et. al. . 2009 Arch Intern Med 169: 1952–1960 4Kovinsky, et. al., J Am Geriatr Soc. 2003 Apr;51(4):451-8 Sarcopenia Medicaitons Might Ideally be Used Diagnostic Approach: History After Illnesses/Events to Get Back to Baseline The most important question is: When was the last time you fell down? � Among ~2800 older adults that reported fall within the last year � 50% of women and 60% of men did not talk with a healthcare provider about falls � Falls prevention was discussed with a healcare provider by 31% of women and 24% of men Stevens, et. al., Am J Prev Med 2012; 43:59-62
Diagnostic Approach: History Diagnostic Approach: Physical Exam � Circumstances at time of fall � Focus on risk factors � Activity � Assess for gait disturbance, postural stability � Prodromal symptoms � Integrated musculoskeletal assessment most important � Time of fall � TUG � Medication use � Rhomberg � Environmental factors (lighting, floor furniture, etc.) � Clinic walk � Loss of consciousness? � Increase index of suspicion for orthostatic hypotensions, CV event or neurologic etiology Laboratory and Diagnostic Tests � No specific lab evaluation; tailor to problems and risks � Modify home environment (multifactorial) � Vitamin deficiencies; B1, B6, B12 and D � Done by healthcare professional � Holter, spine radiographs, MRI, echocardiography only if � Effective for fallers with visual impairment indicted by exam or history � Minimize/taper medications; including OTC � Imaging studies if lumbar stenosis or cervical spondylosis � Sedtives, anxiolytics, antidepressants, antipsychotics suspected or hyperreflexia or spasticity on PE � Reduction in total # of meds should be pursued � Exercise; esp balance, strength and gait training � Tai Chi with balance and strength is effective Panel on Prevention of Falls in Older Persons, AGS and BGS, J Am Geriatr Soc. 2011 Jan;59:148-57
Recommend
More recommend
