Mohamad Sidani, MD, MS Professor BCM, School of Medicine Department of Family and Community Medicine 03/24/2018

Transcription

1 Mohamad Sidani, MD, MS Professor BCM, School of Medicine Department of Family and Community Medicine 03/24/2018

2 Financial Disclosure Nothing to disclose financially.

3 Learning Objectives By the end of the session, the audience will be able to: a. Recite the AGS screening guidelines for falls in older adults b. Identify 4 common causes of falls in older adults c. Identify the common medications increasing the risk of falls in older adults d. Feel comfortable at evaluation of older adults presenting with falls e. Name more than one preventive measure to decrease risk for falls in older adults

4 Definition Unintentionally coming to the ground or some lower level and other than as a consequence of sustaining a violent blow, loss of consciousness, sudden onset of paralysis as in stroke or an epileptic seizure A report of the kellog International Work group on the prevention of falls by the elderly. Danish Medical Bulletin 1987;34 (Suppl4):1-24. JAGS 1997;45:735-8 AGS/GBS Clinical Practice Guideline Prevention of Falls in Older Person. 2010

5 Epidemiology 1/3 older adults (> 65 years) living in the community fall every year. Rates increase with increasing age In 2014, older Americans reported 29 million falls. Almost a quarter of these or 7 million falls required medical treatment or restricted activity for at least one day. Women reported a higher percentage of falls (30%) compared with men (27%). GRS7;AGS

6 Epidemiology 50% of nursing home residents fall each year. Falls incidence is equal in men and women Falls are more likely to result in injury in women.

7

8 Every second in the US an older adult falls, making falls the number one cause of injuries and deaths from injury among older Americans.

9 Complications In 2013, 2.5 million nonfatal falls among older adults were treated in emergency departments Over 800,000 patients a year are hospitalized because of a fall injury, most often because of a broken hip or head injury.

10 Cost Treating fall injuries is very costly. In 2015, costs for falls to Medicare alone totaled over $31 billion. Both the number of falls and the costs to treat fall injuries are likely to rise. The costs of treating fall injuries goes up with age. Fall injuries are among the 20 most expensive medical conditions. The average hospital cost for a fall injury is over $30,000.

11

12 Falls Mortality Injuries are the Ninth leading cause of death among older adults. Among older adults, falls are the leading cause of both fatal and nonfatal injuries (Centers for Disease Control and Prevention, National Center for Injury Prevention and Control) Only 2.2 percent of falls in older adults result in death About one-half of fatal falls among older adults are due to TBI. MMWR Morb Mortal Wkly Rep Oct 24;52(42):

13 Falls Mortality The death rate from falls increases with age. White men ( 85 year old) have a death rate >180 deaths per 100,000 population).

14 Falls Morbidity Major injuries are sustained in 5-15% of falls Head trauma; Falls are the most common cause of traumatic brain injuries (TBI). Soft tissue damage Fractures/Dislocations These injuries Make it hard to get around or live independently. Increase the risk of early death. Decline in functional status. Increased likelihood of nursing home placement. Greater use of medical services. MMWR Morb Mortal Wkly Rep Oct 24;52(42):

15 Long-Term Outcomes Fractures accounted for 75% of serious injuries Hip fractures were reported in 1-2% of falls Many people, even if they are not injured, develop a fear of falling (Medical Journal of Australia 2000;173(4):176 7). causing decreased activities; reduced mobility; loss of physical fitness, which increases their risk of falling. N Engl J Med 1997 Oct 30;337(18):

16 Fear of Falling Post-fall anxiety syndrome Can happen in 33-46% of falls Can result in Restriction of activities (60 % moderate; 15 % severe) living alone cognitive impairment Depression balance and mobility impairments. J Am Geriatr Soc Oct;55(10):

17

18 SPSTF: May 2012 No single recommended tool or brief approach can reliably identify older adults at increased risk for falls, but several reasonable and feasible approaches are available for primary care clinicians. Grade B

19 One systematic review of risk factor assessments used in trials of effective falls interventions analyzed the prognostic value of risk factors and found that 3 risk factors provided independent prognostic value in most studies: history of falls, use of certain medications (for example, psychoactive medications), and gait and balance impairment. Annals of Internal Medicine. Prevention of Falls in Community-Dwelling Older Adults: U.S. Preventive Services Task Force Recommendation Statement.2012;157:

20 Why to ask about? less than half of elderly who fell talk to their healthcare providers about it

21 Screening for Falls 1. All older individuals living in the community should be asked whether they have fallen (in the past year). 2. An older person who reports a fall should be asked about the frequency and circumstances of the fall(s). 3. Older individuals should be asked if they experience difficulties with walking or balance AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons

22 AGS/BGS Older persons should have a multifactorial fall risk assessment if they present for medical attention because of a fall, They report recurrent falls in the past year They report difficulties in walking or balance (with or without activity curtailment) balance

23 History of One fall last Year Older adults reporting only a single fall require no fall risk assessment if: They report no difficulty or unsteadiness They Pass gait assessment tool (i.e. the Get Up and Go Test )

24 History of One Fall last Year Older adults reporting only a single fall require multifactorial fall risk assessment if: They report difficulty or unsteadiness They fail gait assessment tool (i.e. the Get Up and Go Test )

25

26 Causes Falls in older individuals are rarely due to a single cause. Falls occur when an insult occurs on the declined balance, ambulation, and cardiovascular function

27 Risk Factors The percentage of persons falling rose from 8% for those with no risk factor to 78% for those with four or more risk factors. N Engl J Med 2003;348(1):42-9.

28 Med Clin North Am March ; 99(2):

29 Intrinsic Factors Gait and Balance Impairment Recurrent falls Peripheral neuropathy Vestibular dysfunction Muscular weakness (Lower extremities) Visual impairment Reduced vision Acuity <20/60 Decreased depth perception Decreased contrast sensitivity Cataracts

30 Intrinsic Factors Female gender Impaired ADLs Medications Orthostatic Hypotension Cognitive impairment Arthritis Hospital Discharge: Risk is high during the first month. Acute medical Illness

31 Intrinsic Factors Medical illness especially neuromuscular disorders Advanced age Anemia Decreased hearing Use of cane or walker

32 Recurrent Falls The annual incidence of falls rises to 60% in people who fell during last year. History of a hip fractures increases the risk of having a second hip fracture^ Arch Intern Med Oct 8;167(18): ^

33 Medications CNS acting drugs (antidepressants, neuroleptics, and benzodiazepines) sedatives and hypnotics OR 1.47 (CI ) neuroleptics and antipsychotic*, OR 1.59 (CI, ); Antidepressants* OR 1.68 (CI, ); Benzodiazepines* OR 1.57 (95% CI, ); Narcotics, OR 0.96 (95% CI, );

34 Benzodiazepines Case-control studies have found that Long acting benzos (half-lives > 24 hrs.) are associated with higher risk of hip fractures than short acting benzos (halflives < 24 hrs.) Other studies suggested that the dose or recent use, and not the drug half-life of benzodiazepine, is the important risk factor No decrease in hip fracture incidence was noticed in states where use of benzos have been reduced by 60.3%.

35 Antidepressants Diagnosis of depression doubles the risk of falling. Treatment with SSRI or TCA doubles the risk of falling. No antidepressants have been has been proven to safe as far as fall risk in older adults. The way to reduce falls is by withdrawing antidepressant medications whenever not indicated. Drugs and aging.2009;2006: Arch Intern Med. 2009;169(21):

36 Antidepressants Health ABC study: Health Aging and Body Composition: The use of any antidepressant increased the probability of recurrent falls by 48% (OR: 1.48%; CI ) The use of any antidepressant increased the probability of recurrent falls by 83% in users with a history of falls at baseline (OR: 1.83; CI: ) The use of antidepressants did not increase the risk of recurrent falls in users with no history of falls at baseline The Brown University Psychopharmacology Update. August 2016

37 Antidepressant Use Nursing home residents are at high risk of falls during the first 2 days following a new prescription or increased dose of a non-ssri antidepressant (odds ratio: 4.7; 95%CI: ). The effect on falling was no longer significant at 5 days (odds ratio: 1.9; 95% CI: ) No association was found between SSRI changes and falls. J Gerontol A Biol Sci Med Sci Oct; 66A(10):

38 Cardiovascular Medications antihypertensive agents, OR 1.24 (95% CI, )^ Diuretics (OR: 1.07; 95% CI: )^ Beta-blockers (OR: 1.01; 95% CI: )^ Vasodilators* Type IA antiarrhythmic medications. ARCH INTERN MED/ VOL 169 (NO. 21), NOV 23, 2009^

39 Medications NSAIDs OR 1.21 (CI, )^. Anticonvulsants* Polypharmacy of prescription medications is associated with increased risk for falls. Patients taking > 4-5 drugs seem to be at increased risk N Engl J Med 2003;348(1):42-9.* Arch Intern Med Nov 23;169(21): ^

40 Clinician Response to Medications Exposure to prescription drugs associated with fracture risk (drugs that increase fall risk; drugs that decrease bone density; and drugs with unclear fracture risk mechanism) is infrequently reduced following fragility fracture occurrence. There is a missed opportunity to modify at least one factor contributing to secondary fractures. JAMA Intern Med. 2016;176(10):

41 Hypotension Underlying vascular disease compromising resting cerebral perfusion; Age-related decline in baroreflex (failure to increase the heart rate when blood pressure falls). Postprandial hypotension Age-related reduction in total body water (increased risk of hypovolemia with acute illness, diuretic use, or hot weather). Decline in renin/aldosterone levels.

42 Postprandial hypotension Blood pressure falls occur 1-2 hours after a meal. Optimal therapy: avoidance of volume depletion and certain drugs Avoidance of large and high carbohydrate meals Lying semi-recumbent for 90 minutes postprandially Taking a walk in between meals. Acarbose (a small trial in autonomic failure). Octreotide 50 mcg SQ, 30 Q AC Caffeine has also been thought to be effective Guar gum in healthy adults and in DM (9 gram).

43 Cardiovascular Disorders Cardiovascular disorders in older adults cause falls by: either because of balance instability in persons with background gait and balance disorders or because of amnesia for loss of consciousness during unwitnessed syncope The most common cardiovascular disorders associated with falls are carotid sinus hypersensitivity, vasovagal syndrome, bradyarrhythmia (e.g., sick sinus syndrome and atrioventricular block), and tachyarrhythmias. JAGS.2011;59: Clin Interv Aging. 2006; 1:

44 Hearing Loss and Falls Aa 25-dB hearing loss (equivalent from going from normal to mild hearing loss) being associated with a nearly 3-fold increased odds of reporting a fall over the preceding year. ARCH INTERN MED/ VOL 172 (NO. 4), FEB 27, 2012 J Gerontol A Biol Sci Med Sci. 2009;64(2): Arch Neurol. 2003;60(6):

45 Hearing Loss and Falls While worsening hearing was related to fall risk in univariate models, after adjusting for age and other risk factors for falling, no significant relationship was seen. Women with hearing loss may be more socially isolated and may not venture out to as great a degree as normally hearing women, which may have confounded test results. Ann Epidemiol 2004;14:

46 Visual problems Aging is often associated with changes in visual acuity, development of cataracts, macular degeneration, glaucoma, and other conditions that would suggest an effect on risk of falling. JAGS.2011;59:

47 Chronic Medical Conditions The risk for falls increases with increasing numbers of chronic diseases: Parkinson s disease Chronic musculoskeletal pain (Osteoarthritis of the knees, chronic pain) Diabetes Mellitus. Seizure Disorder Cardiovascular/cerebrovascular disease

48 Cognitive Impairment Mild to moderate cognitive impairment is associated with a higher risk of falls. Risk of hip fractures was doubled when MMSE was One study showed that the volume of white matter lesions in the cerebral cortex was directly associated with the risk for falls.

49 Foot Problems Serious foot problems (moderate or severe bunions, toe deformities, ulcers or deformed nails) predispose older adults to falls (OR: 1.8; 95%CI: ) N Engl J Med, 1988 Also, foot position awareness is significantly poorer in older persons. The type and condition of footwear may also contribute to the risk of falling. Footwear that fits poorly, has worn soles, has high heels, or is not laced or buckled when worn has been associated with a higher risk of falling. J Am Geriatr Soc, 1988

50 Vitamin D Deficiency Vitamin D deficiency is common in older people. it impairs muscle strength and neuromuscular function.

51 Alcohol Light drinking (< 14 drinks/week) has not been associated with increased risk of falls in men RR 0.77 (CI ) Problem drinking has been associated with increased risk of falls in men RR 1.59 (CI )

52 Extrinsic Factors Environmental hazards Poor footwear Restraints

53

54 History Ask about the activity at the time of the fall Look for the associated symptoms (lightheadedness, imbalance, dizziness, LOC) Ask about associated injuries Ask about frequency of falls Ask about Location and timing of fall. Check for chronic diseases Get information on previous falls

55 History: LOC Ask about loss of consciousness. Consider the diagnosis of syncope in elderly who report just going down, because some elderly persons are unaware of episodes of loss of consciousness N Engl J Med 2003;348(1):42-9.

56 History Take a complete medication history Assess alcohol use Identify environmental factors: Lighting Floor covering Door thresholds Railings Furniture.

57 Physical Exam Check for carotid sinus sensitivity by doing carotid sinus massage and looking for sinus pauses in unexplained or recurrent fallers Rule out postural hypotension: Check blood pressure and heart rate supine, and after one and three minutes of standing (Sitting BP and heart rate if the patient is unable to stand). JAGS.2011;59:

58 Physical Exam Check visual acuity Check for sensory neuropathies. Check proprioception Check cognition Check muscle strength Check extrapyramidal and cerebellar function Check for eighth cranial nerve deficits JAGS.2011;59:

59 Physical Exam Examine the extremities (joints and range of motion) Examine the feet for bunions, callouses, and arthritic deformities. JAGS.2011;59:

60 Gait and Balance Patient s report or observation of unsteadiness. Impairment on brief assessment (e.g., the Get-Up and Go test, or performance-oriented assessment of mobility)

61 The Timed "Get-Up and Go Test Task Get up out of a standard armchair (seat height of approximately 46 cm [18.4 in.]), walk a distance of 3 m (10 ft.), turn, walk back to the chair and sit down again. Requirement Ambulate with or without assistive device and follow a three-step command. Trials One practice trial and then three actual trials. The times from the three actual trials are averaged. Am Fam Physician 2000; 61: ,2173-4

62 The Timed "Get-Up and Go Test Time 1 to 2 minutes Equipment Armchair, stopwatch (or wristwatch with a second hand) and a measured path results <10 <20 20 to 29 >30 Freely mobile Mostly independent Variable mobility Am Fam Physician 2000; 61: , Impaired mobility

63 The Timed "Get-Up and Go test Sensitivity 88% Specificity 94% It is useful to follow patients over time for functional decline.

64

65 All living spaces Remove throw rugs. Secure carpet edges. Remove low furniture and objects on the floor. Reduce clutter. Remove cords and wires on the floor. Check lighting for adequate illumination at night (especially in the pathway to the bathroom). Secure carpet or treads on stairs. Install handrails on staircases. Eliminate chairs that are too low to sit in and get out of easily. Avoid floor wax (or use nonskid wax). Ensure that the telephone can be reached from the floor. Am Fam Physician 2000; 61: , ) Home Safety Checklist Bathrooms Install grab bars in the bathtub or shower and by the toilet. Use rubber mats in the bathtub or shower. Take up floor mats when the bathtub or shower is not in use. Install a raised toilet seat. Outdoors Repair cracked sidewalks. Install handrails on stairs and steps. Trim shrubbery along the pathway to the home. Install adequate lighting by doorways and along walkways leading to doors

66 Labs No routine diagnostic testing. Tests are indicated by findings in the history and physical examination. These tests could include thyroid-stimulating hormone, vitamin B12 level, complete blood count, and 25-hydroxy vitamin D level. CBC; BMP; TSH; vitamin B12; ECG can help identifying some causes Serum 25-hydroxyvitamin D levels may be done N Engl J Med 2003;348(1):42-9.

67 Tests Assessment for causes of syncope if there is strong suspicion (recurrent, unexplained falls.)^ ECG*: An abnormal ECG is a predictor of cardiac syncope and increased mortality. A normal ECG suggests low risk of cardiac syncope. Echocardiography has a low diagnostic yield in the absence of clinical, physical, or electrocardiographic findings*. Clin Interv Aging Mar; 1(1): * Med Clin North Am Mar; 99(2): ^

68 A dual-energy x-ray absorptiometry scan should be done if bone mineral density has not been assessed. No other radiographic imaging study is routinely necessary. However, based on signs and symptoms, such as evidence of head injury or a new focal neurologic deficit, computed tomography or MRI of the brain may be indicated. Med Clin North Am Mar; 99(2):

69 Labs No indication for routine Holter monitor; Echocardiography; brain imaging; or X-rays of the spine Consider echo if there is heart murmur Consider MRI if there is gait disorders, abnormalities on neurologic examination, lower extremity spasticity, or hyperreflexia

70 Older Adults in Community

71 Assessment and Intervention Multifactorial interventions assess an individual s risk of falling, and then carry out treatment or arrange referrals to reduce the identified risks. Overall, current evidence shows that this type of intervention reduces the number of falls in older people living in the community but not the number of people falling during follow-up. These are complex interventions, and their effectiveness may be dependent on factors yet to be determined. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD007146

72 Interventions Direct interventions customized to the identified risk factors, coupled with an appropriate exercise program should follow the multifactorial fall risk assessment.[a] A strategy to reduce the risk of falls should include multifactorial assessment of known fall risk factors and management of the risk factors identified. [A] JAGS.2011;59:

73 Medication use Gradual withdrawal of psychotropic medication reduced rate of falls (RaR 0.34, 95% CI 0.16 to 0.73), but not risk of falling. A prescribing modification program for primary care physicians significantly reduced risk of falling (RR 0.61, 95% CI 0.41 to 0.91). Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD007146

74 Medication Use: AGS/BGS Evidence is building that SSRIs increase fall risk as much as the older tricyclic antidepressants. AGS/BGS recommend: Withdrawal of psychotropic medications, as a single intervention or as a component of multifactorial intervention. [B] Reduction of psychoactive medications as a single intervention or as a component of multifactorial intervention [B] Withdrawal or minimization of other medications as a component of multifactorial intervention [C] JAGS.2011;59:

75 Exercise Multiple-component (balance and strength) group exercise significantly reduced rate of falls (RR 0.71, 95% CI 0.63 to 0.82) and risk of falling (RR 0.85, 95% CI 0.76 to 0.96) Multiple-component home-based exercise reduced ratee of falls (RR 0.68, 95% CI 0.58 to 0.80)and risk of falling (RR 0.78, 95% CI 0.64 to 0.94). Exercise programs significantly reduced the risk of sustaining a fall-related fracture (RR 0.34, 95% CI 0.18 to 0.63). Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD007146

76 Exercise: AGS/BGS Exercise should be included as a component of multifactorial interventions for fall prevention in community-residing older persons. [A] All older adults who are at risk of falling should be offered an exercise program incorporating balance, gait, coordination, and strength training. Flexibility and endurance training should also be offered, but not as sole components of the program. [A] Exercise may be considered as a single intervention. In most positive trials, the exercise program was longer than 12 weeks (1 3 times per week) with variable intensity JAGS.2011;59:

77 Exercise: AGS/BGS Exercise may be performed in groups or as individual(home) exercises because both are effective in preventing falls. [B] Exercise programs should take into account the physical capabilities and health profile of the older person(i.e., be customized) and be prescribed by qualified health professionals or fitness instructors. [I] The exercise program should include regular review, progression, and adjustment of the exercise prescription as appropriate. [I] JAGS.2011;59:

78 Physical Therapy Evidence from trials of single and multifactorial interventions suggests that all elderly persons who have any abnormalities on balance and gait testing should be referred to physical therapy for a comprehensive evaluation as well as rehabilitation. An exercise program that targets strength, gait, and balance, such as tai chi or physical therapy, is recommended as an effective intervention to reduce falls. [A] N Engl J Med 2003;348(1):42-9.

79 Tai Chi, Tai chi chuan, a Chinese martial art often shortened to "Tai Chi" or "Taiji" in everyday use Contains elements of strength and balance training Tai Chi significantly reduced risk of falling (RR 0.71; 95% CI 0.57 to 0.87). However, the reduction in rate of falls bordered on statistical significance (RR 0.72; 95% CI 0.52 to 1.00) J Am Geriatr Soc Aug;55(8): Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD007146

80 Tai Chi and PT: AGS/BGS 21. An exercise program that targets strength, gait, and balance, such as tai chi or physical therapy, is recommended as an effective intervention to reduce falls. [A] JAGS.2011;59:

81 Musculoskeletal Causes Treatment: Diagnosis and treatment of the underlying cause, if possible; N Engl J Med 2003;348(1):42-9.

82 Postural hypotension Diagnosis and treatment of underlying cause, if possible: Review and reduction of medications; Modification of salt restriction; Adequate hydration Compensatory strategies (e.g., elevation of head of bed, rising slowly, or dorsiflexion exercises) pressure stockings pharmacologic therapy if the above strategies fail(fludrocortisone and midodrine) N Engl J Med 2003;348(1):42-9. JAGS.2011;59:

83 Pace makers Pacemakers reduced rate of falls in people with carotid sinus hypersensitivity (RaR 0.73, 95% CI 0.57 to 0.93) but not risk of falling. J Am Coll Cardiol 2001 Nov 1;38(5): Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD007146

84 Foot Exercises Multifaceted podiatry including foot and ankle exercises with standard podiatry in people with disabling foot pain significantly reduced the rate of falls (RaR 0.64, 95% CI 0.45 to 0.91) but not the risk of falling. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD007146

85 Addressing feet AGS/BGS recommend: people should be advised that walking with shoes of low heel height and high surface contact area may reduce the risk of falls. Advise older adults that walking with shoes with low heel height and high surface contact area may reduce the risk for falling. [C] Identify foot problems and treat or refer for treatment as part of a multifactorial fall risk assessments and interventions. [C] JAGS.2004;52: JAGS.2011;59:

86 Address Postural Hypotension AGS/BGS recommend: Managing postural hypotension should be included as a component of multifactorial intervention in community-living older persons. [C] JAGS.2011;59:

87 Managing heart rate and Rhythm Abnormalities Consider Dual-chamber cardiac pacing for older persons with cardioinhibitory carotid sinus hypersensitivity who experience unexplained recurrent falls. [B] JAGS.2011;59:

88 Visual Abnormalities An intervention to treat vision problems resulted in a significant increase in the rate of falls (RaR 1.57, 95% CI 1.19 to 2.06) and risk of falling (RR 1.54, 95% CI 1.24 to 1.91). When regular wearers of multifocal glasses were given single lens glasses, all falls and outside falls were significantly reduced in the subgroup that regularly took part in outside activities. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD N Engl J Med 2003;348(1):42-9.

89 Visual Abnormalities First eye cataract surgery in women reduced rate of falls (RaR 0.66, 95% CI 0.45 to 0.95), but second eye cataract surgery did not. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD007146

90 Visual problems: AGS/BGS Vision should be formally assessed, and any remediable visual abnormalities should be treated, If patients report problems or concerns It remains unclear whether vision is an essential component of multifactorial intervention. [I] There is insufficient evidence to recommend vision assessment and intervention as a single intervention for the purpose of reducing falls. [D]. JAGS.2011;59:

91 Visual problems: AGS/BGS In older women cataract surgery should be expedited because it reduces the risk of falling.[b] An older person should be advised not to wear multifocal lenses while walking, particularly on stairs. [C] JAGS.2011;59:

92 Vitamin D Supplementation Vitamin D did not reduce falls in community-dwelling older people (RaR 1.00, 95% CI 0.90 to 1.11), but may do so in those who have lower vitamin D levels in the blood before treatment. In care facilities, the prescription of vitamin D reduced the number of falls, probably because residents have low vitamin D levels Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: CD005465

93 Vitamin D: USPSTF May 2012 The USPSTF 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. Grade B

94 AGS/BGS 2011; Vitamin D Vitamin D supplements of at least 800 IU per day should be provided to older persons with proven vitamin D deficiency to reduce fall risk. [A] Vitamin D supplements of at least 800 IU per day should be considered for people with suspected vitamin D deficiency(nnt 15; significant fall risk reduction; safe; cheap) or who are otherwise at increased risk for falls. [B] Moreover, vitamin D supplementation at appropriate levels should also be considered for all older adults. JAGS.2011;59:

95 Cognitive impairment There is insufficient evidence to recommend for or against multifactorial or single interventions to prevent falls in older persons with known dementia living in the community or in long-term care facilities. [I] JAGS.2011;59:

96 Home Environment AGS/BGS recommends adaptation or modification of home environment [A] JAGS.2011;59:

97 Environmental Risk Factors Home safety assessment and modification interventions were effective in reducing rate of falls (RaR 0.81, 95% CI 0.68 to 0.97) and risk of falling (RR 0.88, 95% CI 0.80 to 0.96). These interventions were more effective in people at higher risk of falling, including those with severe visual impairment. Home safety interventions appear to be more effective when delivered by an occupational therapist. RX: Removal of loose rugs use of nightlights nonslip bathmats, stair rails other interventions as necessary Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD007146

98 Preventing Slips An anti-slip shoe device reduced rate of falls in icy conditions (RaR 0.42, 95% CI 0.22 to 0.78;). Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD007146

99 Neurologic Abnormalities Treatment: Diagnosis and treatment of underlying cause, if possible; Increase in proprioceptive input (with an assistive device or appropriate footwear that encases the foot and has a low heel and thin sole) Reduction of medications that impede cognition Awareness on the part of caregivers of cognitive deficits Reduction of environmental risk factors Referral to physical therapist for gait, balance, and strength training. N Engl J Med 2003;348(1):42-9.

100

101 Hip Pads Most hip fractures are caused by sideways falls (impact directly on the side of the hip). External hip protectors made of special protective and shock-absorbing material rest directly on the hips over the most common impact points. Patient compliance is generally poor

102 Hip Pads Hip protectors probably reduce the risk of hip fractures if made available to older people in nursing care or residential care settings, without increasing the frequency of falls. However, hip protectors may slightly increase the small risk of pelvic fractures. Poor acceptance and adherence by older people offered hip protectors is a barrier to their use. Better understanding is needed of the personal and design factors that may influence acceptance and adherence.

103

104 Can t Get UP Discuss with patients and families what to do if the elderly fell and could not get up. A personal emergency-response system or a telephone that is accessible from the floor should be available. N Engl J Med 2003;348(1):42-9.

105 Medical Alert Service The standard Lifeline Service provides quick access to help at the push of a button. NEW! Medical Alert Service with AutoAlert Option All the benefits of our standard medical alert service plus the only medical alert pendant that can call for help if it detects a fall.