Presenter Disclosure Information Louise Aronson

Fall Prevention and Management

School of Medicine Division of Geriatrics

• No disclosures

Osteoporosis CME 2012 Louise Aronson MD MFA Associate Professor UCSF Division of Geriatrics Director, NorCal Geriatric Education Center 2

Falls are • Common • Costly

Objectives By the end of this discussion, participants should be able to: 1. Discuss the morbidity and mortality associated with falls among older adults

• Morbid • Sometimes fatal

The other half of the equation:

2. Identify the essentials of a fall assessment 3. Describe interventions that have been demonstrated to reduce falls in clinical trials 4. Develop an exercise prescription for an older person at risk for falls

Fracture (often) = Osteoporosis + Fall

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Risk Factors and Consequences

Question #1 What % adults > 65 yrs old living in the community fall each year? A. 5% B. 10% 27%

C. 20%

29%

31%

D. 30% E. 50% NEJM 348:4249,2003 Clin Ger Med 18:141158,2002

14%

0% A.

B.

C.

D.

E.

Older Adult Falls Burden 2006 Fifth leading cause of death in older adults

MOST FALLS (85%) OCCUR IN THE HOME DURING NORMAL ACTIVITIES OF DAILY LIVING

MMWR. 2006;55: 12221224

CDC’s Research Portfolio in Older Adult Fall Prevention Sleet DA J Safety Res. 2008;39(3):259-67

2

Serious Falls-related Injuries

Question #2

• Hip fracture 55%

What % of fallers experience moderate or severe functional decline as a result of their fall?

– 1/5 will die within a year of the fracture

A. 8%

• Non-hip fractures 21%

B. 15%

35% 31%

C. 38%

• Traumatic Intracranial hemorrhage (10%) – More common in men, AfAm

D. 60% 19%

E. 75%

• Chest Injury (7%)

13%

Conn Med 2009 Mar;73(3): 139-45.

2% A.

B.

C.

D.

E.

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Functional Consequences

Evaluation of the Faller

• 60% fallers report moderate activity restriction – 15% report severe restriction

• 1/3 require help with ADLs • 3x risk of nursing home placement • 1/3 develop fear of falling – ↓ physical and social activity – ↓ self-reported health Adv Data 392; 2007

– depression

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CASE 1: Mrs. FF

Evaluation of Falls: History

• 78 year old woman with HTN, hypothyroidism, osteoporosis, GERD

• Rule out acute badness – Syncope, not fall?

– Meds: diltiazem, synthroid, PPI, fosamax

– Injury? • Fell in her apt, taken to ED, ok now • Has never fallen before

– Acute illness? • This should be done even if you are seeing the patient days/weeks after the fall

What else do you want to know? What do you do?

Evaluation of Falls: History • The fall history

Mrs. FF

– Location & circumstances

• Reaching

– Associated symptoms

• No

– Witness accounts

• No

– Ability to get up

• Other falls or near falls?

• No • First fall

• Any recent changes in – Medication

• No

– Living situation/environment

• No

– Assistive device

• No need

•

Mrs. FF: No LOC, head lac, URI

Evaluation of Falls: History • Relevant medical conditions • MS, neuro, card, ophtho, incont, osteoporosis

• Medications

• No, yes, 4

• Psychoactive? HTN? total # > 4?

• Substance abuse/alcohol use

• No

• Difficulty with walking or balance

• No, walks, incl hills

• Ability to complete ADLs

• Independent

• Fear of falling

• Yes new

4

Mrs. FF

Most Common Fall Risk Factors

• What else do you need to do?

Risk Factor

Relative Risk

# studies

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

Female

2.1 – 3.9

3

Cognitive Impairment

2.8 – 3.0

3

Arthritis

1.2 – 1.9

2

Previous Falls

• What is her risk for falling again?

Tinetti, JAMA. 2010;3 03(3):2 58-266

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Risk Factors for Falls Intrinsic Factors Medical conditions Sensory impairment Weakness & imbalance JAGS 49;664, 2001

Functional & cognitive impairment

Thinking About Fall Risk

Extrinsic Factors Medications

FALLS

Improper use of assistive devices Environmental hazards URI

Tinetti ME N Engl J Med 1988

1 year follow up

5

Risk Factors for Future Falls Risk factor

JAMA. 2007;297 :77-86

Likelihood Ratio

Previous fall in last year

2.8-3.8

Orthostatic hypotension

-

Visual acuity

~2

Gait and Balance

2

Medications

1.7

Assess basic and instrumental activities of daily living

2-4

Assess cognition

4-17

CASE2: Mr. RF • 83 years old lying on exam table • CAD/MI, CABG4, AD, HTN, L TKR • Bruised eye/cheek • R leg in brace, new walker beside table What else do you want to know? What do you do?

Mrs. FF is at low risk for a near term future fall

Mr. RF

Evaluation of Falls: PE

• R/o elder abuse

• Ortho BP

• Borderline

• Ask about syncope, injury, illness

• CV exam

• NSR

• Neuro

• Mild neurop

• Cognition

• MOCA 20/30

• MSK/jt ROM

• Atrophy, decr ROM R UE, hip contr

– 8 meds none new, some ETOH

• Vision & hearing

• Trifocals/ok

– Gait unsteady, not afraid of falling

• Feet/footwear

• Good

• Gait/balance

• Slow, wide/poor

• 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

What’s next?

• Assistive device use • Poor

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Gait and Falls

Gait and Balance Evaluation

• Gait abnormalities

• Quick, validated in-office test

–

20-40% over age 65; 50% if age 85 and over

–

Speed predicts 10 year mortality

– Timed Up and Go (TUG)

• Time to stand from chair
walk 10 feet
return
sit back down • 12 sec cutoff: sensitivity 83% and specificity 93%

• At least assess

• 20 seconds = grossly abnormal

– Normal or abnormal

• Physical Therapy Evaluation

– Safe or unsafe – Too slow, too fast

•

– Insurance/$ dependent Wrisley, Phys Ther 2010 Nevitt, JAMA 1989

You have not fully examined the nervous or musculoskeletal systems until you have analyzed the gait

– Outpatient – Home Care Mathias A Arch Phys Med Rehab 1986 Podsiadlo D JAGS 1991 Tinetti ME JAGS 1986

Mr. RF: Formulating a Care Plan

CASE 3: Ms. NF

• Address RF & findings from H & P

• 75 yo with COPD, HTN, THR, PVD, osteoporosis

Today

Later visit

– Med review/ d/c?

Assess ETOH

– PT/OT

Osteoporosis eval/tx

• Walker use training

• Has never fallen

Ophtho f/u

• She has a lot to say at clinic visits

• Exercise program

– Home safety eval – Vit D level/other as indicated medically

• Other key issues

Should you screen for fall risk?

– Goals of care: dz/med trade-offs; safety v. indep – Advance directives 27

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Screening

Ms. NF

• All adults > 65 should be asked annually about

• Admits to feeling unsteady

– Falls in the past year – Gait or balance difficulties

• TUG = 16 seconds – Leans forward to get up from chair

• Perform gait/balance test (TUG) if:

– Wobbles a bit when she first stands

– Single fall – Report of difficulty

• Perform multifactorial fall risk assessment if: 2010 AGS/BGS Clinical Practice Guideline

What do you do next?

– Report or display unsteady gait/balance – At least 1 injurious fall or 2+ non-injurious falls Tinetti ME JAMA 2010 AGS Fall Prevention Clinical Practice Guidelines 2010

Management of Falls

Question #3 What are the three falls management strategies with the best supporting evidence? A. Multifactorial patient assessment, vitamin D, home assessment B. Exercise program, vitamin D, and multifactorial assessment C. Vision correction, vitamin D, medication withdrawal/minimization D. Medication withdrawal/minimization, adapt home environment, exercise

44%

29%

15%

12%

A.

B.

C.

D.

8

USPSTF Falls Recommendations

Ann Intern Med. 2010;153:815825.

Intervention

RR (95% CI)

Comments

Multifactorial Intervention

0.89 (0.76–1.03)

Seems to reduce falls but not statistically significant

Exercise or PT

0.85 (0.78–0.92)

More extensive exercise is better

Vitamin D

0.83 (0.77–0.89)

No added benefit from calcium

Vision correction

No reduction

Single study raised ? more falls

• Studies too few or poor quality to assess - Medication review and withdrawal - Home safety modification - Clinical education - Footwear modification

USPSTF Recommendations • Vitamin D – 600IU age 51-70 – 800IU >70

• Exercise or physical therapy – Group exercise classes or at-home PT – Intensity from very low (≤9 hours) to high (>75 hours) Ann Intern Med. 2012;157.N Engl J Med 2012 Jul 5; 367:40

Fall Prevention & Vitamin D

Grade B recommendations But: Vit D NEJM metaanalysis

Exercise and Falls

• First Study: Systematic review

• Most widely studied single intervention

– Vit D reduced falls among older individuals by 19%

• Review of 19 trials of exercise interventions alone or in combination

– Need doses of 700-1000 IU/day for benefit – Aim for serum 25-hydroxyvitamin D of >60 nmols/L

– 9 of 14 combination trials reduced falls by 22- 46%

• Second study: once yearly high dose

– All positive trials included a balance component

– RCT 2258 women, 500 000 IU of vitamin D3

– Only 1 of 5 trials using a single exercise intervention reduced falls

– Mean serum levels >90 nmols/L for 3 months BischoffFerrari et al. BMJ 2009;; 339b3692 Sandars KM et.al JAMA. 2010;303

– INCREASED risk for falls and fractures

• Bottom line: – Both too little and too much may be risky – 800 IU to decrease fx; most helpful if Vit D levels low

Gillespie, Cochrane, 2007; Wolf JAGS 1996

• Tai Chi group exercise

– ↓falls ~30% (1 trial); ↓falls ~47% (1 trial)

• Individually prescribed home based exercises – ↓falls ~34% (3 trials)

Tinetti ME JAMA 2010

9

Exercise in Older Adults

Multi-factorial Interventions

• Many benefits, few risks

• Guidelines

– Maximal HR is the only immutable change with age

– USPSTF: No evidence for routine use but + indications

– Lung, muscle, jt, other cardiac all improve – ↓ CAD, DM, death, falls, OA, Dn, insomnia

– AGS: 2+ falls,1 injurious fall, gait/balance problems

• Helps at all ages and levels of frailty

• Evidence based components

– Study of100 SNF patients mean age 87

– Multiple risk factor assessment

• ↑↑strength ↑activity ↑gait; no ↑falls

– Balance/mobility evaluation

– FICSIT: 8 independent, prospective RCTs Fiatarone NEJM 1994; Province JAMA 1995

Intervention

Any exercise Balance

RR Falls

.90

.83

Ann Intern Med. 2012;157.N; AGS 2010

95% CI

(.81-.99)

(.70-.98)

– Med review withdrawal minimization – Orthostatics / vision / feet & footwear – Home safety evaluation – Critical to f/u and manage identified problems/risks

Treating our 3 patients

The Exercise Prescription: Ms. NF

• Vit D

• Rx improves compliance & time spent

– All 3 esp if deficiency

– Can gradually increase each component

• The Rx: FITTS

• Exercise – All 3 but different rx

– Frequency 3x per week (↑ to 5-7) – Intensity Comfortable, HR 60-79% MPHR

• Multifactorial assessment

– Time 5 min (↑ to 20 – 30)

– Maybe Mrs. FF – Mr. RF for sure

– Type

– Not needed by Ms. NF

– Specific precautions and modifications

walking + resistance + balance

use inhaler before, premedicate OA pain

39

10

Patient-Centered Exercise Rx

Exercise Rx: Mrs. FF and Mr. RF

• Convenience/feasibility

• Mrs. FF

• Social benefits/ peer group experience/ fun

– Already walking 4-5 times a week with good time and intensity – Add balance (tai chi/ exercise class) and resistance

• Safety – No treadmill necessary if start slowly – Neighborhood and home

• Cost

• Mr. RF – Home based PT • Supervised resistance and balance exercises 2/week • Supervised walking with assistive device daily

• Patient’s competence and confidence • Might be greater adherence to lower rather than greater intensity RX

– Precautions • Monitor HR initially • As directed by ortho/ leg brace

Hip Protectors • Designed to absorb and/or shunt away the impact toward the soft tissues to keep the force on the trochanter below the fracture threshold.

One Last Topic

11

Hip Protectors

Falls Summary

• Hip protector demonstrated superior capacity to reduce peak impact force in simulated experiments

• Falls are common in older adults and precipitate most fractures • Falls can be prevented/injuries can be minimized

• The HIP PRO RCT – 1042 SNF residents wore a hip protector on 1 hip only; each participant as own control

• Ask older adults about falls in the last year and observe gait and balance

– 20 month follow up; stopped b/c no efficacy • Evaluate/treat/refer patients at risk for future falls Protected hips

Unprotected hips

p

Hip Fracture (all subjects)

3.1% ; 1.8%4.4%

2.5% ;1.3%-3.7%

0.70

Hip Fracture (>80% adherence)

5.3% ; 2.6%8.8%

3.5% ; 1.3%-5.7%

0.42

• Hip protectors not proven to reduce fracture risk • Exercise rx increases exercise, decreases falls

Resources • American Geriatrics Society Fall Prevention Clinical Practice Guideline (AGS/BGS 2010) – http://www.americangeriatrics.org/health_care_professionals/clinic al_practice/clinical_guidelines_recommendations/2010/

• Centers for Disease Control Falls in Adults Publications and Resources – http://www.cdc.gov/HomeandRecreationalSafety/Falls/indexpr.html

Thank You!

• Tinetti M and Kumar C. The Patient Who Falls: It’s Always a Trade Off. JAMA. 2010;303(3):258-266. • Moyer V. Prevention of Falls in Community-Dwelling Older Adults: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2012;157. • NIH Senior Health: Falls and Older Adults for patients – http://nihseniorhealth.gov/falls/toc.html

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