Fall Prevention No disclosures School of Medicine and Management - PowerPoint PPT Presentation

Presenter Disclosure Information Louise Aronson Fall Prevention • No disclosures School of Medicine and Management Division of Geriatrics Osteoporosis CME 2013 Louise Aronson MD MFA Associate Professor UCSF Division of Geriatrics Director, NorCal Geriatric Education Center Why learn about falls? Fifteen seconds • The other half of the equation Osteoporosis + Fall = Outcomes we care about: fractures hospitalization End 12 15 14 11 10 13 7 9 8 4 6 5 3 2 1 disability death anxiety and fear institutionalization 1

Every 29 minutes Every 15 seconds an older American AN OLDER AMERICAN **DIES** is seen in an Emergency Department because of a fall BECAUSE OF A FALL NCOA NCOA 2012 2012 How many have died already today? Objectives Epidemiology By the end of this discussion, participants should be able to: • Discuss the epidemiology of older adult falls • Identify the essentials of a fall assessment • Describe interventions that have been demonstrated to reduce falls in clinical trials • Develop an exercise prescription for an older person at risk for falls 2

Question #1 Falls Are Common Fifth leading cause of What % adults > 65 yrs old living in the death in community fall each year? older adults A. 5% B. 10% 46% C. 20% D. 30% E. 50% 21% 21% 13% NEJM 348:42- MMWR. 49,2003 2006;55:1 0% Clin Ger Med 222-1224 18:141- % % % % % 158,2002 5 0 0 0 0 1 2 3 5 CDC’s Research Portfolio in Older Adult Fall Prevention Sleet DA J Safety Res. 2008;39(3):259-67 Falls Are Costly Falls Are Morbid • Hip fracture 55% – 1/5 will die within a year of the fracture • Non-hip fractures 21% • Traumatic Intracranial hemorrhage (10%) – More common in men, AfAm • Chest Injury (7%) Lawrence Conn Med et. Al, PIRE 2009 2011 Mar;73(3): 139-45. 3

Question #2 Falls Are Morbid What % of falls occur at home during normal • 60% fallers report moderate activity restriction activities? – 15% report severe restriction 44% A. 25% • 1/3 require help with ADLs B. 45% 31% C. 55% • 3x risk of nursing home placement D. 70% E. 85% • 1/3 develop fear of falling 13% 9% – ↓ physical and social activity 3% – ↓ self-reported health – depression Adv Data % % % % % 5 5 5 0 5 392; 2007 2 4 5 7 8 Assessing a Patient Who Falls CASE 1: Mrs. FF (First Fall) • 77 year old woman with HTN, hypothyroidism, osteoporosis, GERD – Meds: diltiazem, synthroid, PPI, fosamax • Fell in her apt, taken to ED, ok now • Has never fallen before What else do you want to know? What do you do? 4

Evaluation of Falls: History Evaluation of Falls: History • The fall history Mrs. FF • Rule out acute badness • Reaching – Location & circumstances – Syncope, i.e. not fall? • No – Associated symptoms – Injury? • No – Witness accounts – Acute illness? • No – Ability to get up • This should be done even if you are • Other falls or near falls? • First fall seeing the patient days/weeks later • Any recent changes in – Medication • No • Mrs. FF: No LOC, head lac, URI – Living situation/environment • No – Assistive device • No need Question #3 Evaluation of Falls: History What % of fallers experience moderate or severe • Relevant medical conditions functional decline as a result of their fall? • No – MS, neuro, card, ophtho, incont, osteoporosis A. 8% • Medications B. 15% • No, yes, 4 – Psychoactive? HTN? total # > 4? 41% C. 38% • Substance abuse/alcohol use D. 60% • No • Difficulty with walking or 27% E. 75% • No, walks, 23% balance incl hills • Ability to complete ADLs • Independent 9% • Fear of falling • Yes new 0% 8% 15% 38% 60% 75% 5

STEADI Falls Assessment Tool Mrs. FF • What is her risk for falling again? • What else do you need to do? CDC 2012 Fall Risk Most Common Fall Risk Factors Risk Factor Relative Risk # studies Previous Falls 1.9 – 6.6 16 Balance Impairment 1.2 – 2.4 15 Decrease Muscle Strength 2.2 – 2.6 9 Vision Impairment 1.5 – 2.3 8 Meds: 4+ or psychotropic 1.1 – 2.4 8 Gait impairment 1.2 – 2.2 7 Depression 1.5 – 2.8 6 Orthostasis 2.0 5 Age >80 1.1 – 1.3 4 Tinetti, JAMA. Female 2.1 – 3.9 3 2010;3 Tinetti ME Cognitive Impairment 2.8 – 3.0 3 03(3):2 N Engl J 58-266 Arthritis 1.2 – 1.9 2 1 year follow up Med 1988 6

Gait and Balance Evaluation Next Steps for Mrs. FF • Complete risk assessment • No perfect test; no adequate cut off score – Vision -- Gait and balance • Timed Up and Go (TUG) – Orthostatic BP -- Muscle strength – Cognition -- Mood – Quick, validated in-office test • Stand from chair � walk 10 feet � return � sit • Or • 20 seconds = grossly abnormal STEADI: • Time less important than clinical judgment – CDC video http://www.cdc.gov/homeandrecreationalsafety/Falls/steadi/videos.html Tinetti JAMA • Alternate: Physical Therapy Evaluation 2010; Wrisley, Phys Ther – Insurance/$ dependent 2010; Nevitt, JAMA 1989 – Outpatient v Home Care Question #4 CASE2: Mr. RF (Recurrent Faller) Who is more likely to (1) be injured and (2) die • 86 years old lying on exam table from a fall? • CAD/MI, CABG4, AD, HTN, L TKR A. Women • Bruised eye/cheek B. Men • R leg in brace, new walker beside table C. No gender difference What else do you want to know? What do you do? 7

Mr. RF The Assessment • R/o elder abuse • Ask about syncope, injury, illness • His history – Tripped on stair, had single pt cane in hand – No abuse or syncope, R quad tear, not ill when fell – He has fallen 3 times in the last year – 9 meds none new, some ETOH – Gait unsteady, not afraid of falling What’s next? Evaluation of Falls: PE Gait and Falls • You have not fully examined the nervous or • Ortho BP • Borderline musculoskeletal systems • Cognition • MOCA 20/30 until you have analysed the gait • Meds • 9, no psychoactive • Gait abnormalities • Feet/footwear • Good – 20-40% age >65 50% if >85 • Gait/balance • Slow, unsteady/poor – Speed predicts 10 year mortality • Assistive device use • Poor • Vision • Scratched trifocals • At least assess – Normal or abnormal • CV exam • NSR – Safe or unsafe • MSK • Atrophy, ROM Rt – Too slow, too fast UE, hip contractures 8

Mr. RF: Formulating a Care Plan Fall Prevention & Management • Address RF & findings from H & P – Today • D/c any meds? • PT/OT referral – Walker training – Exercise • Home safety evaluation • Vit D level/rx – Later visit • Assess ETOH • Ophtho f/u • Osteop eval/tx Question #3 Fall Prevention Community Elderly What are the three falls management strategies with the best supporting evidence? A. Exercise program, vitamin D, and multifactorial assessment B. Exercise, multifactorial patient 32% assessment, home assessment 28% C. Exercise, vitamin D, medication withdrawal/ minimization 16% 16% D. Medication 8% withdrawal/minimization, home assessment, exercise JAMA 2013; 309(13) . . . . . . . . . . . a . . . . E. Experts only agree on exercise r t t a g u l t w i o v i y r m l p , n n , e o e e s o s i t i s s i c a t c i c r r r r e c e e e x d i p x E x E e x E M E 9

Cochrane Review Cochrane Review: Other findings • Vision correction Intervention ↓ Rate of ↓ Risk of Falls Falling – One trial increased risk Multiple-component group exercise Yes Yes – Trifocal wearers who go outside a lot fell less with Multiple-component home exercise Yes Yes single lens glasses Tai Chi Almost Yes • First eye cataract surgery decreased falls Multifactorial intervention Yes No – Not second eye; only women in trial Vitamin D # No No • Multifaceted podiatry decreases falls if foot pain Home safety assessment* Yes Yes • Antislip shoe device in icy conditions Cognitive-behavioral interventions No No • Medication interventions Patient education No No – Psych med withdrawal lower rate Gillespie Gillespie et al et al # But prevents fractures – PCP prescribing program decreased risk 2012 2012 * Best if done by OT USPSTF Falls Recommendations Fall Prevention & Vitamin D • First Study: Systematic review • To prevent falls in community-dwelling adults aged 65 years or older who are at increased risk – Vit D reduced falls among older individuals by 19% for falls – Beneficial dose 700-1000 IU/day – Exercise or PT (Grade B rec) – Aim for serum 25-hydroxyvitamin D of >60 nmols/L • Group exercise classes or at-home PT • Second study: once yearly high dose • Intensity from very low ( ≤ 9 hours) to high (>75 hours) – Vitamin D supplementation (B) – RCT 2258 women, 500 000 IU of vitamin D3 • 600IU age 51-70 and 800IU >70 – INCREASED risk for falls and fractures Bischoff- Ferrari et al. BMJ 2009 & • Bottom line: – No automatic multifactorial risk assessment (C) N Engl J Med 2012; – Both too little and too much may be risky Ann Intern • Base on fall hx, comorbidities, patient goals 367:40-49; Med. – Insufficient evidence for other recommendations 339b3692 – ≥ 800 IU to decrease fx 2012;157. Sandars KM et.al JAMA. – Most helpful if baseline levels low 2010;303 10