7/12/2016. Presenter Disclosure Information. The Other Half of the Fracture Equation: Fall Prevention and Management. Presentation Outline

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1 Presenter Disclosure Information Edgar Pierluissi Division of Geriatrics Edgar Pierluissi, MD Acute Care for Elders Unit Zuckerberg San Francisco General Hospital July 21, 2016 OSTEOPOROSIS NEW INSIGHTS IN RESEARCH, DIAGNOSIS,AND CLINICAL CARE The Other Half of the Fracture Equation: Fall Prevention and Management No relevant disclosures 2 Presentation Outline Presentation Outline Case presentation Prevalence and Consequences Risk factors Screening and Evaluation Prevention Summary Case presentation Prevalence and Consequences Risk factors Screening and Evaluation Prevention Summary 3 4 1

2 Why falls? Fractures Due to Fall in Older Women The odds of a fracture are 7 9 times higher among community-dwelling postmenopausal women with both a fall and osteoporosis or osteopenia, compared with women having a fall or osteoporosis/osteopenia only. Geusens P, et al. The relationship among history of falls, osteoporosis, and fractures in postmenopausal women. Arch Phys Med Rehabil. 2002;83(7): ALL FRACTURES WRIST PROXIMAL HUMERUS ELBOW HIP PATELLA ANKLE FOOT/TOES PELVIS FACE HAND/FINGER TIBIA/FIBULA RIB Nevitt et al Percent 6 Prevalence Falls are Common ~1/3 of those over 65 will fall in the next year ~1/2 of those over 80 will fall in the next year In 2010, ~7 million Medicare beneficiaries fell 0.32 NEJM 348:42 49,2003 Clin Ger Med 18: ,2002 Am J Prev Med 2012;43(1): Clinicoecon Outcomes Res. 2013;5:

3 Self-reported falls in US, 65 years In the past 3 months, how many times have you fallen? (16% fell) How many of these falls caused an injury? 1.8 Million with Injury Consequences 1/3 fallers with injuries reported needing help with ADLs as result of fall injury 1/2 of these expected to need help with ADLs for at least six months 4 Million ~10% result in a major injury (fracture, TBI, serious soft tissue injury) ~350,000 hip fractures annually MMWR. 2008;57: Adv Data 392; 2007 Fall Injury Episodes Among Noninstitutionalized Older Adults: US, Number Going to ED/Getting Hospitalized for Falls is Increasing Death from Falls 65+ Millions To Emergency Department Number of Deaths Hospitalized Accessed April 24, Accessed April 24,

4 Costs Direct medical costs: 30 billion dollars in 2010 Indirect and direct est 68B by Inj Prev 2006; 12(5): Summary Falls are common among older adults Falls affect patient function and are a major mechanism of injury. Presentation Outline Case presentation Incidence and Consequences Risk factors Screening and Evaluation Prevention Summary

5 Independent Risk Factors for Falling Among Community-Living Older Adults Risk factor No. of Studies Significant Previous falls RR OR Balance impairment Decreased muscle strength Visual impairment Meds: >4 or psychoactive Gait impairment Depression Dizziness or orthostasis ADL disabilities Age > Female Low BMI Urinary Incontinence JAMA 2010;303:258 Cognitive impairment Pain Osteoporos Int Dec; 20(12): Risk factors for injurious falls Osteoporos Int Dec; 20(12): Previous injurious fall increases risk of falling ~ 3X BMC Geriatr Nov 18;14:

6 Trip Video Capture 2 Long-term facilities in British Columbia 38 months monitoring of common spaces 227 falls in 130 people Correlation between staff investigation and video Lancet Jan 5;381(9860): Other risk factors Incorrect weight shifting 41% (93 of 227) of falls Trip or stumble 21% (48) Hit or bump 11% (25) Loss of support 11% (25) Collapse 11% (24) Slipping 3% (6) Hypoxia during sleep Men with 10% of sleep time with SaO2 90% had RR of 1.25, CI = for one or more falls RR of 1.43, CI = for two or more falls c/t men with 10% of sleep time with SaO2 90% JAGS 62:1853,

7 Frailty Multiple definitions- all (CHS, SOF, WHI) associated with falls Women s Health Initiative (3558 participants) Weight loss ( 10lbs or 5% over 1 year) Exhaustion Low Physical Activity score Average follow-up of 12 years Presentation Outline Case presentation Incidence and Consequences Risk factors Screening and Evaluation Prevention Summary Women with high frailty scores had elevated risk for falls and fractures J Am Geriatr Soc Jun 16. doi: /jgs [Epub ahead of print] Screening Guidelines for Fall Prevention AGS/BGS Guideline Guideline for the Prevention of Falls in Older Persons American Geriatrics Society British Geriatrics Society American Academy of Orthopaedic Surgeons JAGS 49: , 2001, updated 2010 Practice Parameter: Assessing patients in a neurology practice for risk of falls American Academy of Neurology Neurology 2008;70; CDC Stopping Elderly Accidents, Death, and Injuries Older person encounters health care provider Screen for risk of falling No Single fall in past year? No Abnormalities in gait or unsteadiness? No Yes Reassess annually Yes 2 or more falls last year Presents with acute fall Difficulty with walking or balance Yes Falls Evaluation July

8 American Academy of Neurology Inquire about falls in the past year AND Review risk factors for falling Neurological: stroke dementia gait/mobility problem parkinsonism peripheral neuropathy assistive device LE sensorimotor loss If A or B positive: Falls Evaluation General: (not rated) age >65 vision deficit arthritis, arthralgia depression polypharmacy restricted ADLs Neurology 2008;70; Fallers unlikely to discuss falls Less than half of Medicare beneficiaries who fall discuss falls with a healthcare provider (women>men). Only a third to a quarter who have fallen, discuss fall prevention strategies. Other screening tests Standing unassisted 325 community elders, 60 or older Time to stand from sitting, unaided, without use of arms Unable or >2 sec had an OR of 3.0 Timed Up and Go Time to stand from chair, walk 3m, and sit back down Cutoff 12 sec had sensitivity of 83% and specificity of 93% Am J Prev Med 2012;43(1):59 62 Nevitt, JAMA 1989 Wrisley, Phys Ther

9 Screening Ask about falls in the prior year Observe for gait or balance problems in getting up from chair If yes or problems ==>Falls Evaluation Falls Evaluation Falls history and circumstances Assessment of: balance and gait LE strength, sensation, coordination perceived functional ability and fear relating to falling visual impairment cognitive impairment home hazards footwear and foot problems Cardiovascular examination including orthostasis Medication review 35 NICE School Clinical of Medicine Guideline, Assessment and prevention of falls in older people 2004 JAMA The patient who falls. 303 (3)

10 Medications What about SPRINT? Benzodiazepines Anti-depressants Anti-psychotics Anti-epileptics Anti-hypertensives* Polypharmacy (14% higher risk for each med added above 4) 2-arm, multi-center RCT comparing treating HTN to a target of < SBP 120 mm Hg vs <140 mmhg. Study stopped early due to 25% lower relative risk of major CV events and death, and a 27% lower relative risk of death from any cause J Gerontol A Biol Sci Med Sci. 2007;62: SPRINT-SENIOR Adverse events Enrolled 2636 patients 75 years Exclusions: Standing SBP <110 Excluded patients with dementia Syncope 3% vs 2.4% (ns) Injurious falls 4.9% vs 5.5% (ns) Results: Death at ~3 years, 8.1% vs 5.5% NNT ~39 JAMA Jun 28;315(24):

11 Presentation Outline Independent Risk Factors for Falling Among Community-Living Older Adults Risk factor No. of Studies Significant RR OR Previous falls Case presentation Incidence and Consequences Risk factors Screening and Evaluation Prevention Summary Balance impairment Decreased muscle strength Visual impairment Meds: >4 or psychoactive Gait impairment Depression Dizziness or orthostasis ADL disabilities Age > Female Low BMI Urinary Incontinence JAMA 2010;303:258 Cognitive impairment Pain Effective Interventions Things you can t change Previous falls Age Gender BMI ADL Disabilities Things you might change Balance Strength Vision Gait Impairment Depression Urinary incontinence Cognitive impairment Dizziness or orthostasis Medications Pain Exercise: # falls and #fallers and risk for fracture Multiple component group exercise Individually prescribed, multiple component, home-based program Tai Chi group exercise 43 Gillespie et al Cochrane

12 Effective Interventions Effective Interventions Multifactorial risk factor program ( #falls) Medications: ( # falls) Gradual withdrawal of psychotropic medication; educational program for 1 care MDs Home hazard assessment & modification in higher risk in those with visual impairment and high risk of falling ( # falls and #fallers) Cardiac pacing for fallers with cardioinhibitory carotid sinus hypersensitivity ( #falls) Expedited cataract surgery for first eye( #falls) 45 Gillespie et al Cochrane Interventions that are Ineffective What about Vitamin D supplementation? Vitamin D with or without calcium in those with adequate Vitamin D levels Home hazard modification in those without fall history Hormone replacement therapy Correction of visual deficiency (alone) Patient education or cognitive behavioral training Gillespie et al Cochrane 2012 IOM 2009 Supplemental vitamin D in a dose of IU a day reduced the risk of falling among older individuals by 19%... IOM 2011 no significant reduction in fall risk related to vitamin D intake or achieved level in blood. USPSTF 2012 recommends exercise or physical therapy and vitamin D supplementation to prevent falls in community-dwelling adults aged 65 years or older who are at increased risk for falls. AGS 2013 Clinicians are strongly advised to recommend vitamin D supplementation of at least 1,000 international units (IU)/d, to reduce the risk of fractures and falls. BMJ 2014 In pooled analyses, supplementation with vitamin D, with or without calcium, does not reduce falls by 15% or more

13 What I Recommend Offer cholecalciferol to all older adults at risk for falls

14 What about perturbation-based training? RCT 212 patients 24 slip session vs 1 slip session Self-reported falls in the year after the intervention: 25% in control vs 13% in intervention J Gerontol A Biol Sci Med Sci (2014) 69 (12): Perturbation-based training 8 RCTs 404 participants Fewer fallers 29% Fewer falls 46% reduction Presentation Outline Case presentation Incidence and Consequences Risk factors Screening and Evaluation Prevention Summary Phys Ther May;95(5):

15 Presentation Outline Case presentation Incidence and Consequences Risk factors Screening Prevention and management Summary Falls-Summary Falls are common in older adults. Falls cause significant ADL deficits and most fractures and in older adults. Falls can be prevented. Ask older adults about falls in the last year and observe gait and balance. Refer patients at risk for future falls to effective fall prevention approaches What Questions Do You Have? Landing on the floor or other lower level, including stairs, by accident An unintentional change in position resulting in coming to rest on the ground or another lower level, and not as a result of a major intrinsic event (eg, stroke, syncope) or overwhelming hazard (eg, car accident) Unintentionally coming down on the floor or to a lower level An unintentional change in position to the floor or ground Losing your balance such that your hands, arms, knees, buttocks or body touch or hit the ground or floor An unexpected event when the person fell to the ground on the same or from an upper level, taking the falls on stairs and those onto a piece of furniture into account. An event in which the participant unintentionally comes to rest on the ground or at a lower level. Unintentionally coming to rest on the ground floor, or other lower level for reasons other than sudden onset of acute illness or overwhelming external force. An event which results in a person coming to rest unintentionally on the ground or other lower level, not due to any intentional movement, a major intrinsic event (eg, stroke) or extrinsic force (eg, forcefully 60 h d d k k d d b ) 15