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FALL RISK AND PREVENTION IN OLDER ADULTS Josette Rivera, MD Assistant Professor of Medicine Division of Geriatrics Department of Medicine University of California,  University of California San Francisco

Ellen Corman, BS, MRA Supervisor, Community Outreach  and Injury Prevention Stanford University Medical Center  Trauma Service Trauma Service

Sponsored by 

Stanford Geriatric Education Center  in conjunction with American Geriatrics Society,

California Area Health Education ducation Centers, and  Natividad Medical Center

May 10 2012 This project is/was supported by funds from the Bureau of Health Professions (BHPr), Health Resources and Services Administration (HRSA), Department of Health and Human Services (DHHS) under UB4HP19049, grant title: Geriatric Education Centers, total award amount: 

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$384,525. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by the BHPr, HRSA, DHHS or the U.S. Government

“Fall Risk and Prevention in Older Adults” Natividad Medical Center CME Committee Planner Disclosure Statements: The following members of the CME Committee have indicated they have no conflicts of interest to disclose to the learners: Kathryn Rios, M.D.; Anthony Galicia, M.D.; Sandra G. Raff, R.N.; Sue Lindeman; Janet Bruman; Jane Finney; Tami Robertson; Judy Hyle, CCMEP; Christina Mourad and Nobi Riley Stanford Geriatric Education Center Webinar Series Planner Disclosure Statements: The following members of the Stanford Geriatric Education Center Webinar Series Committee have indicated they have no conflicts of interest to disclose to the learners: Gwen Yeo, Ph.D. and Kala M. Mehta, DSc, MPH Faculty Disclosure Statement: As part of our commercial guidelines, we are required to disclose if faculty have any affiliations or financial arrangements with any corporate organization relating to this presentation. Dr. Rivera and Miss. Corman have indicated they have no conflicts of interest to disclose to the learners, relative to this topic. Dr. Rivera and Miss. Corman will inform you if they discuss anything off-label or currently under scientific research.

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Josette Rivera is a clinician educator and an Assistant Professor of Medicine in the Division of Geriatrics. She is dedicated to providing primary and palliative care to homebound older adults throughout San Francisco through the UCSF Housecalls Program. Dr. Rivera’s educational focus is on training students and professionals how to collaborate within interdisciplinary teams to provide effective, patient-centered care for older adults. She recently received a Geriatric Academic Career Award with which she will create and expand interprofessional and geriatric education opportunities at UCSF. Dr. Rivera received her medical degree from the University of Rochester and residency training in Primary Care Internal Medicine at Johns Hopkins Bayview. She then completed a three year clinical and research fellowship in the Division of Geriatric Medicine and Gerontology at Johns Hopkins. At the conclusion of fellowship, Dr. Rivera became a staff physician at On LokLifeways, a Program of All-Inclusive Care for the Elderly, which serves nursing home eligible seniors in the San Francisco area. She joined the Geriatrics faculty at UCSF in 2008.

Ellen Corman, MRA

Ellen Corman, Supervisor of Community Outreach and Injury Prevention for the Trauma Service at Stanford University Medical Center, has over 20 years experience working in the area of injury prevention. She has an undergraduate degree in Occupational Therapy and a Masters degree in Rehabilitation Administration. Ellen was a member of the state’s Injury Prevention Strategic Planning Committee and active in the state’s Stop Falls Network. Ellen currently co-chairs the San Mateo County Fall Prevention Task Force and developed and manages a fall prevention program for older adults called Farewell to Falls at Stanford’s Trauma Service. She has presented locally to seniors, caregivers and professionals and has presented at national conferences.

Fall Risk and Prevention in Older Adults Josette Rivera, MD Division of Geriatrics UCSF

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Objectives By the end of this discussion, participants should be able to: 1. Understand the personal and societal impact of falls 2. Identify risk factors for falls among older adults 3 Describe evidence based guidelines for screening and prevention 3. 4. Discuss interventions that have been demonstrated to reduce falls in clinical trials

What is a Fall? • Unintentionally coming to rest on the ground or other lower level • Not due to a major intrinsic event or overwhelming environmental hazard • No loss of consciousness

The Importance of Falls

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

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

Falls Cause Morbidity and Mortality • Injuries are common: – 40% of falls result in minor injuries – 10% result in major injuries

• 2.2% of injurious falls result in death • Cost of fall-related injuries for 65+ – Currently $19 billion -> $54.9 billion by 2020 Chang JT BMJ 2004 Tinetti ME JAGS 1995 Tinetti ME JAMA 2010 MMWR Morb Mortal Wkly Rep 2008

Falls Associated with Functional Decline • Decline in function/loss of independence • Fallers 3X more likely to enter SNF • Fear -> isolation, further functional decline – 60% fallers reported moderate activity restriction – 15% reported severe restriction

Deshpande N JAGS 2008 Tinetti, ME N Engl J Med 1997 MMWR Morb Mortal Wkly Rep 2006; 55:1221 Tinetti, ME J Gerontol A Biol Sci Med Sci 1998

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Epidemiology of Falls

Question What % adults > 65 yrs old living in the community fall each year? A. 5% B. 10% C 20% C. D. 30% E. 50%

Incidence • 30% of community-dwelling people over the age of 65 fall each year • Increases to ~50% for those 80 years and older • Half are repeat fallers

Chang JT BMJ 2004 Tinetti ME N Engl J Med 2003 Rubenstein LZ Clin Ger Med 2002

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Question Which ethnic groups are most likely to fall? A. African Americans B Asian Americans B. C. Latino Americans D. European Americans E. No difference between groups

Falls and Socio-demographic Factors 18.3% 15.3% 11.3% 7.9%

Latino

African American

Asian

White

Multiple falls past year, age 65+ Source: 2007 California Health Interview Survey

Question Which ethnic group is most likely to be hospitalized because of a fall? A. African Americans B. Asian Americans C. Latino Americans D. European Americans E. No difference between groups

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American Geriatrics Society Fall Prevention Guidelines www.medcats.com/FALLS/frameset.htm

Screening • AGS: All adults > 65 should be asked at least annually if they have fallen in the past year or whether they have difficulties in gait or balance • Single fall: check balance/gait • Recurrent falls or balance/gait disturbance: do multifactorial fall risk assessment

2010 AGS/BGS Clinical Practice Guideline

Tinetti ME JAMA 2010 AGS Fall Prevention Clinical Practice Guidelines 2010

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Evaluation of the Faller

Evaluation of Falls: History • Rule out acute badness – Syncope or fall? – Injury? – Acute illness? • Any recent changes in health or environment?

Evaluation of Falls: History • Relevant medical conditions – Neurolgical, cardiac, ophtho, incontinence, osteoporosis

• Medications – Psychoactive? Recent changes? Total # > 4?

• Substance/alcohol use • Difficulty with walking or balance • Ability to complete ADLs • Fear of falling

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Gait and Balance Evaluation • You have not fully examined the nervous or musculoskeletal systems until you have analyzed gait • Quick, validated, in office tests – Timed Up and Go

• Physical Therapy Evaluation (insurance/$ dependent) – Outpatient – Adult Day Health Center – Home Care Mathias A Arch Phys Med Rehab 1986 Podsiadlo D JAGS 1991 Tinetti ME JAGS 1986

Evaluation of Falls: Physical Exam • Supine and standing BP & CV exam • Vision and hearing evaluation • Neurological exam, including cognition • Musculoskeletal exam • Feet/footwear • Formal gait and balance assessment • Inappropriate assistive device use

Etiology and Risk Factors

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Thinking About Fall Risk

Extrinsic Factors

Intrinsic Factors Medical conditions

Medications

Impaired vision and hearing

Improper use of assistive devices

FALLS

Environment

Age- related changes

Most Common Fall Risk Factors Risk Factor

Relative Risk 1.9 – 6.6

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Balance Impairment

1.2 – 2.4

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Decrease Muscle Strength

2.2 – 2.6

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Vision Impairment

1.5 – 2.3

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Meds: > 4 or psychotropic

1.1 – 2.4

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Gait impairment

1.2 – 2.2

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Depression

1.5 – 2.8

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2.0

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Orthostasis Tinetti, JAMA. 2010;303(3): 258-266

# studies

Previous Falls

Age >80

1.1 – 1.3

4

Female

2.1 – 3.9

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Cognitive Impairment

2.8 – 3.0

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Arthritis

1.2 – 1.9

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Thinking About Fall Risk

Tinetti ME N Engl J Med 1988 1 year follow up

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Summary • Falls are common and multifactorial • Often lead to injuries, functional decline, nursing home placement, and death • Screen older adults for falls at least annually • Evaluation should included risk factor assessment, gait assessment, and home assessment • Targeted multifactorial interventions most effective • AGS Fall Prevention Guidelines available • Interprofessional collaboration essential

Resources • American Geriatrics Society Fall Prevention Clinical Practice Guideline – http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guideli nes_recommendations/2010/

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

• NIH Senior Health: Falls and Older Adults for patients http://nihseniorhealth gov/falls/toc html – http://nihseniorhealth.gov/falls/toc.html

• Tinetti M and Kumar C. The Patient Who Falls: It’s Always a Trade Off. JAMA. 2010;303(3):258-266 • Michael YL et al. Primary Care–Relevant Interventions to Prevent Falling in Older Adults: A Systematic Evidence Review for the U.S. Preventive Services Task Force. Ann Intern Med. 2010;153:815-825.

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5/9/2012

Fall Risk Best Practice in Prevention ELLEN CORMAN, CORMAN OT, OT MRA STANFORD HOSPITAL AND CLINICS TRAUMA SERVICE

Falls at Stanford Trauma 5%

1% 1% 1% 0% 1% 0%

Cause of Injury > = 65 years old

5% FALL MVC PEDESTRIAN 12%

BICYCLE OTHER BLUNT MCC ASSAULT OTHER PENETRATING STABBING GSW

74%

Santa Clara County Fall Facts

 In 2006, there were 2,645

hospitalizations due to falls.  Average cost of hospitalization

estimated to be $38,563/person.  Average cost of ambulance ride

after 911 call in Santa Clara County estimated to be $1,423.

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Why Do People Fall? Health Issues

Personal Habits

Medications

Vision

Home Safety Issues

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Personal Habits

Multi-Tasking

Balance and Strength

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Best Practice in Fall Prevention Causes of falls are due to multiple causes. Therefore, the best intervention to prevent f ll iis ffound falls d to b be multi-factoral. lif l (Tinetti, Baker, McAvay, Claus, Gareet, Gottschalk, NJMed, 1994)

Interventions for Fall Prevention  Medication Review 

special attention to psychotropic drugs

 Home Safety Assessment and Modification 

Most effective if can assure follow-through with recommendations

 Exercise   

Type and frequency of exercise not conclusive Balance and strength training seems to be most effective Tai Chi – only exercise strategy that was significantly effective in isolation of other interventions.

 Personal Habits 

Attention to surroundings and change in behaviors.

Farewell to Falls  Free home-based program offered by Trauma

Service at Stanford Hospital and Clinics  Multi-faceted program  Home Safety  Medication di i management  Strength/balance – exercise  Personal habits

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Program Implementation  Two home visits by Occupational Therapist 

Health, ADL and activity interview



Medication review (meds listed by OT and reviewed by Stanford pharmacist with written report) Sensory-Motor assessment Home safety assessment

 

Exercise and Home Safety Intervention  Connection

to community exercise program and/or home-based exercise program with DVD provided and/or written material.  Home-based

exercise is equally beneficial for participants ti i t as group-based b d exercise i (King, (Ki H Haskell, k ll ett al, 1991:Vol266 No11)

 Connection

to home safety company to install grab bars, if necessary. Program covers those who need financial assistance.

Admission Criteria  65 years and older  Live in Santa Clara or San Mateo County in

home or apartment  Ambulatory y  Cognitively aware – can follow instructions and provide own health history  Willing to commit to exercise and program recommendations

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Evidence-Based Fall Prevention Programs  A Matter of Balance – Volunteer Lay Leader Model  www.mainhealth.org  Stepping On  Wisconsin Institute of Healthy Aging – 608-243-5690  Tai Chi: Moving for Better Balance  Oregon Research Institute, Eugene, Oregon  [email protected]  Otago  [email protected]

Resources  National Council on Aging (NCOA) – Center for Healthy

Aging, www.ncoa.org/improve-health/center-for-healthyaging  Public Health Agency of Canada – Evidence for Best Practices on the Prevention of Falls and Fall-Related Injuries Among Seniors Living in the Community, www.phacaspc.gc.ca/seniors-aines/publications/pro/injuryblessure/practices-pratiques/chap4-eng.php  King AC, Haskell WL, Taylor CB, Kraemer HC, DeBusk RF, Group- vs Home-Based Exercise Training in Healthy Older Men and Women: A Community-Based Clinical Trial, JAMA, 1991; 266(11):1535-1542.

 For information about Farewell to Falls or a Matter

of Balance, contact: ELLEN CORMAN SUPERVISOR, INJURY PREVENTION STANFORD UNIVERSITY MEDICAL CENTER TRAUMA SERVICE 650-724-9369 [email protected]

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