Right Side Up-Falls Prevention Continuum

Transcription

1 Right Side Up-Falls Prevention Continuum

2 Falls in the Elderly The Scope - Each year 1 in 3 adults age 65 or older falls - Half of those are repeat fallers - Lead to significant morbidity and mortality - Fall related costs for those 65 or older total $19 billion in Projected to reach $55 billion by Fatal fall rates increased 42% between 2000 and Falls among older adults: Figures and maps. CDC. [Online] January 19, [Cited May 14, 2010].

3 A Long- Standing Problem Falls in the Elderly Figure 1. Age adjusted fall injury rates among men and women aged 65 years or older. (1)

4 An Increasing Problem Falls in the Elderly Figure 2. Percent of US population by age divided into five age groups. (1)

5 Falls in the Elderly Figure 3. Age adjusted fall injury rates among women aged 65 and older (1)

6 Falls in the Elderly Figure 4. Age adjusted fall injury rates among men aged 65 years and older (1)

7 Falls in the Elderly Otter Tail County, MN - 16% female pop. age 70 or older (state 10%) - 12% male pop. age 70 or older (state 7%) - Falls the leading cause of injury-related mortality in those 75 or older

8 Project funding from USDA Partners: University of Minnesota Extension Service & Nutrition Service, Center on Aging & Geriatric Education Center Minnesota Department of Health Minnesota Board on Aging Lake Region Healthcare Otter Tail County Public Health Central Minnesota Area Health Education Center Land of the Dancing Sky Area Agency on Aging.

9 Goal: To address the prevention and management of falls and falls risks in the elderly through the development of a comprehensive and coordinated continuum of care.

10 Gaps Identified Need for instructors for evidence-based programs to reach persons at risk for falls Providers assessing risk and making referrals Need for communication between provider organizations about persons falls risk when transferred from one setting to another.

11 Otter Tail County Falls Prevention Points of Intervention Continuum Community Based Falls Prevention in Older Adults Safety Promotion Risk Identification Minimize Risks Emergency Medical Services & Primary Care Rehabilitation Minimize Risks Living well with Chronic Conditions Classes. Falls risk assessment by clinicians. Exercise/ Therapy Program First Responder/ Ambulance Inpatient/ Outpatient Therapy Exercise/ Therapy Program Matter of Balance Classes Promote use of Calcium & Vitamin D Lifeline Systems Hospitalization Lifeline Systems Grab bars & Handrails. Interdisciplinary team Falls Assessments. Homecare Services Orthopedic Consultation Homecare Services Parish Nurse/LAH/BNP Homes Plus Homes Plus Assisted Living Assisted Living Nursing Home Nursing Home XGreen: Preventing Falls XOrange: Fallen With No Fractures XYellow: Risk Factors Exist XRed: Fractures/Rehab Has Occurred

12 Safety Promotion Target Population: Persons living in the community. Primary Risk Factors: Vision, Environment, Exercise, and Medication Management Interventions: Educational Classes, Adaptive devices such as grab bars and Handrails or referrals to Parish Nurse or LAH/BNP

13 Chronic Disease Management Educational Programs Usually 6-8 weeks of classes one time a week for hours Taught by trained peer leaders Living Well with Chronic Conditions or Matter of Balance or Arthritis Exercise Programs

14 Inter-Professional Team Falls Assessments Public Health/Home Health-home environment Medical Students-Medical conditions that can increase risk of falls Pharmacy Students-medication review and assessment

15 Assessment Process Referrals Who can refer? Anyone Who to refer? Individuals with history of falls Individuals at risk for falls When to refer? Home Visit & Reports

16 Assessment Tool Environmental assessment Medical history Medical systems review Mental status Physical assessment Orthostatic BPs, balance, strength Medication Review

17 Drug-Induced Falls Drugs causing orthostasis Drugs causing ataxia Drug causing lethargy, weakness Drugs causing pseudoparkinsonism

18 Drug-Induced CNS Depression Barbiturates Sedative/Hypnotics Antidepressants Antihistamines Muscle relaxants Narcotic analgesics Anxiolytics Antipsychotics Antihypertensives Etc.

19 Drug-Induced Orthostatic Hypotension Antihypertensives (atenolol, metoprolol, CoReg, ) Diuretics (HCTZ, furosemide, ) Nitrates (NTG, Isosorbide, ) Calcium Channel Blockers (Norvasc, Procardia, diltiazem, ) ACE Inhibitors (lisinopril, ) Antiparkinson (Sinemet, Requip, Parlodel, ) Antipsychotics (Risperdal, Seroquel, Zyprexa, ) Antidepressants (amitriptyline, imipramine, doxepin, ) Alpha Blockers (Minipress, Hytrin, Cardura, Flomax)

20 Orthostatic Drug YOUNG PERSON OLD PERSON Orthostatic Hypotension Orthostatic Hypotension + Balance/C.V. Problems Fall + Osteoporosis Hip Fracture Prolonged Healing/Incomplete Healing Minor Adverse Effect Permanent Disability (Death)

21 Case #1 A.B. is a 56 y.o. female with a complicated medical history including a long history of chronic pain, for which she was once prescribed gabapentin. She was taking a large dose of gabapentin (probably 800 mg tid) and during this time she developed a tremor and fell many times. She ended up in the ED after a fall and the gabapentin was discontinued. Since that hospitalization (some time in early 2009) she has moved into her current apartment and has not had any falls. Past medical history includes: Spinal Stenosis, Chronic pain, Fibromyalgia, Type 2 Diabetes, COPD, Chronic bronchitis, Depression, Dyslipidemia, Possible MS (some confusion about her diagnosis), Possible PTSD (nurse did not know about this diagnosis)

22 Case #1 Medications Effexor XR 300 mg qd Glipizide 5 mg qd Glucophage 500 mg bid Lantus 20 units qhs Novolin R sliding scale Spiriva 2 puffs qd DuoNeb qid Trazodone mg qhs Amitriptyline 75 mg bid Morphine sulfate ER 60 mg q 12 hours Diazepam 10 mg bid Simvastatin 80 mg qhs Zetia 10 mg qd Omeprazole 40 mg qd Fish oil 1000 mg bid Vitamin B Complex bid SennaS bid Miralax 17gm qd Vicodin 5/500 bid prn pain (uses ~2 tabs daily for breakthrough pain) Ibuprofen 800 mg prn pain (for breakthrough pain, sometimes uses before Vicodin) Lasix 20 mg prn qd for swelling (uses 3 or 4 times weekly) Propranolol 20 mg 1-2 tabs q 4-6 hours prn shakes (uses when needs to write) Albuterol MDI 2 puffs prn (uses 4-5 x daily) Bisacodyl 5 mg 1-2 tabs prn constipation (uses 2 every 3 days) MOM 30 ml prn DuoNeb prn Refresh eye gtts prn Erythromycin eye ung qhs prn

23 Recommendations Environmental Very little clutter, well maintained Level of Care Homemaker help with errands home health nurse consider PT/OT Medications Pain journal monitoring Reassess amitriptyline/effexor Trial decrease diazepam Calcium and Vitamin D Strength, gait, balance Encourage utilization of walker Chronic medical problems Low back and knee pain MS history? Improve diabetes control/diabetes educator

24 April 27, 2010 Dear A.B., Sharing Recommendations Thank you for visiting with us and participating in the Falls Program. We enjoyed meeting with you and we appreciate your willingness to help our students learn. Based on the visit by part of our team on April 7, 2010, our committee has developed the following recommendations for your consideration: 1. We noticed the following positive things to help decrease your risk of falls during our assessment. Your apartment was clean and free of clutter. Your bathroom had grab bars and a seat in the tub. 2. As we discussed during our visit, consider meeting with a Diabetes Educator to strategize ways to better control your diabetes. We are asking your physician for a possible referral. 3. We encourage you to use your walker whenever necessary, especially when leaving the apartment. 4. Meeting with an Occupational or Physical Therapist could be beneficial for you to reduce your risk of falls. We are asking your physician for a possible referral. 5. As we discussed during our visit, starting a pain journal could be a good way to understand how effective your pain medications are for you. Consider keeping a journal that includes a rating of how bad the pain is before you take your medication, what medication you take, how much medication you take, and a rating of your pain minutes after taking your pain medication. 6. The dose of Effexor XR you are on, 300 mg daily, is an effective dose for both depression and pain management. It works in much the same way as your amitriptyline and we will have your physician discuss with you if changes are appropriate or not. 7. Diazepam can cause marked drowsiness and increase your risk of falls. We will have your physician discuss with you if changes are appropriate or not. 8. Consider the addition of Calcium 600 mg twice daily and Vitamin D IU daily. Calcium and Vitamin D can help strengthen your bones and decrease your risk of falls. A letter has been mailed to your doctor with recommendations from the Lake Region Healthcare Corporation Falls Committee to help prevent future falls. If you have any questions, please feel free to contact Todd Johnson at or Mark Dewey at Sincerely, Patient: A.B. D.O.B Dear Dr., One of your patients, A.B., has recently participated in an Interprofessional Falls Prevention and Education Program. This program combines students from medicine, pharmacy, nursing, public health and/or physical therapy to collaboratively assess individuals at risk for falls in an effort to reduce the incidence of falls. Students then present the patient case to a team of professionals, the Lake Region Healthcare Corporation Falls Committee, for evaluation and recommendations for patient care. Attached is a report of the Falls Committee s findings from the patient visit, which occurred at A.B. s home, along with the corresponding recommendations from the Falls Committee meeting on April 25, Thank you for allowing us to participate in A.B. s case. If you have any questions or concerns, please contact Todd Johnson at Sincerely, Todd Johnson, PharmD LRHC Falls Committee Chairperson The Falls Committee

25 Case #2 C.D. is a 87 y.o. female and excellent historian but hesitant to report falls. She reports falling 1/16/2010, 4/09, and says fell and did a number on her back a year or so before. Home health nurse reveals patient experiences slides and near falls and patient agrees these occur more frequently. Patient denies dizziness and attributes falls to weakness and arthritis. Past Medical History: Arthritis, HTN, COPD, Restless Leg Syndrome, Insomnia, Diverticulosis, Urinary urgency, Hx of hypokalemia?

26 Case #2 Medications Diovan 320mg daily Aspirin 81mg daily Coumadin as directed monitored and adjusted monthly Triamterene-HCTZ 37.5/25mg daily KlorCon 20mEq ii qam, i qpm (dissolve in water) Trixaicin HP (capsaicin) topical cream to affected areas nightly Silver tonic daily Enablex 7.5mg daily (just started, was on Detrol LA) Tylenol 650mg ii bid Systane i gtt ou bid OTC Vitality Calcium Complete ii qam, i qam OTC B mcg daily OTC Vitamin Replenex for Joints daily OTC Vitality MVI w/ Minerals as directed (1 packet am, 1 packet pm) OTC NutraView Vitamins for Eyes daily Carbidopa-Levodopa 25/100mg prn for RLS... no longer taking Clonazepam 1mg prn for RLS Fiberwise qhs prn Discontinued Detrol LA 4mg daily, CranBarrier qhs

27 Recommendations Environmental House free of clutter and no notable fall risks Level of Care Appears appropriate with family and home health assistance Medication Recommendations Reassess Klonopin, Rule out iron deficiency, trial of Requip or Mirapex Reassess Enablex benefit Strength, gait, balance Patient gets fatigued/weak easily with no sleep Patient states good ambulation with wheeled walker when rested Chronic Medical Problems Ongoing insomnia and restless legs

28 Sharing Recommendations February 23, 2010 Dear C.D., Thank you for visiting with us and participating in the Falls Program. We enjoyed meeting with you and we appreciate your willingness to help our students learn. Based on the visit by part of our team on February 9, 2010, our committee has developed the following recommendations for your consideration: Restless Leg Syndrome and difficulty sleeping appear to have great impact on your strength and balance. Please continue to work with your doctor to improve your ability to sleep. As you were about to begin clonazepam 1mg as needed for RLS at the time of our visit, please ask yourself these questions to assess if the medication is safe and effective: Can I fall asleep when I take the medication? How long do I sleep when I take the medication? Do I feel rested the next day or do I feel groggy, tired, or dizzy? Please inform your doctor if clonazepam is not working well, stops working, or makes you feel groggy and tired the next day. You were also starting Enablex 7.5mg daily at the time of our visit. Is this working for you? Please update your physician if this medication is not working or if you experience troublesome side effects. You have made adjustments to your home and lifestyle that benefit your health and decrease your risk of falls. Continue to enlist the help of your family and home health agency as needs arise. Patient: C.D. DOB: Dear Dr., One of your patients, C.D., has recently participated in an Interprofessional Falls Prevention and Education Program. This program combines students from medicine, pharmacy, nursing, public health and/or physical therapy to collaboratively assess individuals at risk for falls in an effort to reduce the incidence of falls. Students then present the patient case to a team of professionals, the Lake Region Healthcare Corporation Falls Committee, for evaluation and recommendations for patient care. Attached is a report of the Falls Committee s findings from the patient visit, which occurred at C.D. s home, along with the corresponding recommendations from the Falls Committee meeting on February 22, Thank you for allowing us to participate in JK s case. If you have any questions or concerns, please contact Eric Christianson at Sincerely, Eric Christianson, PharmD LRHC Falls Committee Member A letter has been mailed to your doctor with recommendations from the Lake Region Healthcare Corporation Falls Committee to help prevent future falls. If you have any questions, please feel free to contact Eric Sincerely, The Falls Committee

29 Physical Therapy Services Balance testing 8 foot Up & Go Romberg Outpatient therapy Vestibular testing Strength testing Gait assessment Wii

30 Otter Tail County Falls Prevention Points of Intervention Continuum Community Based Falls Prevention in Older Adults Safety Promotion Risk Identification Minimize Risks Emergency Medical Services & Primary Care Rehabilitation Minimize Risks Living well with Chronic Conditions Classes. Falls risk assessment by clinicians. Exercise/ Therapy Program First Responder/ Ambulance Inpatient/ Outpatient Therapy Exercise/ Therapy Program Matter of Balance Classes Promote use of Calcium & Vitamin D Lifeline Systems Hospitalization Lifeline Systems Grab bars & Handrails. Interdisciplinary team Falls Assessments. Homecare Services Orthopedic Consultation Homecare Services Parish Nurse/LAH/BNP Homes Plus Homes Plus Assisted Living Assisted Living Nursing Home Nursing Home XGreen: Preventing Falls XOrange: Fallen With No Fractures XYellow: Risk Factors Exist XRed: Fractures/Rehab Has Occurred

31 Falls Risk Assessments: Short-term outcomes - Telephone Interview - 16 visits in last 6 months - Data collected from 11/16 visits - Data from 7 patients and 6 caregivers - Average time from visit 3.5 months

32 Falls Risk Assessments: Short-term outcomes Patient Questionnaire 1. Did you find the falls visit helpful? 2. Did you receive our recommendation letter following our visit? 3. Were the suggestions helpful? If so, what did you find the most helpful (med review, environment analysis, therapy suggestions, ect.) What wasn t helpful? 4. Are there things you are doing differently to reduce your risk of falls like exercising or using your walker more? 5. Have you discussed the suggestions with your doctor? 6. Have you had any falls since the visit? 7. Has the number of falls or near falls increased, decreased, or stayed the same since our visit? 8. Do you think this program would be helpful for others you know? 9. Do you have any suggestions to improve the program?

33 Falls Risk Assessments: Short-term outcomes Home Health/Community Services Provider Questionnaire 1. Were you present for the falls visit? 2. Did you find the visit helpful? 3. On a scale of 1-10, how beneficial was this program to your patient? 4. Has the number of falls or near falls increased, decreased or stayed the same since our visit? 5. Do you think this program would be helpful for others you know? 6. Do you have any suggestions for improvement?

34 Results: Patient Responses Falls Risk Assessments: Short-term outcomes Follow-up Question Mean (%) Found the visit to be helpful 100 Doing something differently to reduce falls 78 Recommendations were helpful 100 Discussed suggestions with doctor 57 Have had falls since the visit 17 The program would be helpful for others 86

35 Falls Risk Assessments: Results: Caregiver Responses Short-term outcomes Follow-up Question Mean % Present for visit 100 Found the visit helpful 100 Client s falls have decreased since visit 50 Visit would be helpful for other clients 100 Caregiver rated benefit of visit to patient (1-10): 7

36 Data Analysis: Limitations: - Sample size Falls Risk Assessments: - <100% response Short-term outcomes - Barriers to implementation of recommendations - Variable time intervals between visit and response Adverse Events: - 1 pt had fall requiring hospitalization - 1 pt admitted to NH for other reasons

37 Implications: Falls Risk Assessments: Short-term outcomes Decrease incidence of falls aging population NNT = 2? NNT for other common preventative measures NNT= 18 Number of pt >60 with HTN that need to be treated to prevent one coronary event over 5 years. Thrombolytic therapy in acute MI NNT=33 Blood pressure control after stroke to prevent over 8 years NNT=26

38 Falls Risk Assessments: Short-term outcomes Future Strategies: 1. Continue to spread awareness of program 2. Standardize data collection Questionnaire at 3 months and 6 months 3. Long-term follow-up Outcomes at >12 months Does prevention falls= prevention fall related injury?

39 Questions?

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