Minnesota Falls Prevention Initiative: State of the Art in Practice. MN Falls Prevention Initiative. MN Falls Prevention Initiative.

Transcription

1 Minnesota Falls Prevention Initiative: State of the Art in Practice Statewide Videoconference Thursday, March 8, 2007 Kari Benson, Pam Van Zyl York, Lyle Felsch, Jean Wyman, and Suzanne Wiebusch MN Falls Prevention Initiative MN Board on Aging & Dept of Health October 2005: grant from U.S. Administration on Aging Convening a broad range of public and private partners at the state, regional and local levels to implement a statewide coordinated evidence-based falls prevention initiative. MN Falls Prevention Initiative The Vision Older Minnesotans will have fewer falls and fall-related injuries, maximizing their independence and quality of life. 1

2 MN Falls Prevention Initiative Objectives 1. Increase awareness of prevalence and risk factors for falls. 2. Increase assessment of fall risk. 3. Increase availability of evidencebased interventions statewide. 4. Increase access to these interventions. 5. Enhance quality assurance efforts related to falls prevention. Key Elements of a Falls Prevention Intervention Exercise to increase lower body strength and balance Home assessment and modification Medication review Support for self-management of risk factors and fear Falls The Evidence Pam Van Zyl York MN Department of Health 2

3 Falls The Evidence Every hour an older adult dies as the result of a fall Falls are the leading cause of injury death among older adults Hip fractures are among the most serious fall-related injuries Half never regain their previous level of functioning Many are unable to live independently after their injury Falls in Minnesota Leading cause of hospitalized injury Leading cause of ER-treated injury Fourth highest unintentional fall death rate in the country The problem is not getting better Unintentional Fall Death Rates, United States and Minnesota, Rate per 100, Rates are Age-Adjusted to US Year United States Minnesota 3

4 Fall Risk Factors Physical strength and balance Medication use Vision impairment Home environment Outside environment And, having already fallen at least once fear of falling, restricted activity Falls Prevention and Chronic Disease Management Keys to chronic disease management include regular physical activity and medication management 80% of those over 65 years have 1 or more chronic condition 65% have multiple chronic conditions Those with impaired strength, mobility, balance and endurance are twice as likely to fall as healthier persons Those with more chronic conditions are more likely to die or sustain more serious injury when they fall Chronic Disease in MN Age related macular degeneration - Approx. 25% of those over 65 years (nationally) Alzheimers Disease - 10% (nationally) Arthritis - 53% Diabetes - 13 % Stroke - 3% Osteoporosis - 45% 4

5 Effective intervention to prevent falls includes evidence-based intervention programs addressing falls and chronic disease management Regular physical activity that addresses strength, balance and endurance is particularly key to quality of life across risk conditions Rochester-Olmsted County Fall Prevention Coalition Lyle Felsch Deputy Fire Chief Rochester Fire Department Rochester-Olmsted County Fall Prevention Coalition Mission: network of services for citizens over 65 to decrease number and severity of falls in order to maintain a high level of independence in the home Vision: the coalition will be the multiinterventional link of fall prevention efforts in Olmsted County 5

6 Rochester-Olmsted County Fall Prevention Coalition Objectives: Provide fall prevention education to seniors over 65 Provide home safety checks Identify individuals at risk for additional falls Collaborate with and educate other community health agencies Rochester Fire Dept. Fall Prevention Decision Tree For those individuals who fall but are not injured Permission form to authorize In-home safety visit Send a copy of letter to physician that details fall incident Rochester Fire Dept. Fall Prevention Decision Tree For those individuals who fall but are not injured Permission form to authorize In-home safety visit Send a copy of letter to physician that details fall incident 6

7 Jean Wyman s ppt Jean Wyman U of M School of Nursing Jean Wyman s ppt Keeping In Balance Suzanne Wiebusch Fairview Ridges Hospital 7

8 Keeping In Balance Community health program initiated in 2000 by Fairview Ridges Hospital and community partners after e-codes identified falls as the leading injuryrelated reason for hospital admission Focus on primary and secondary prevention of falls Keeping In Balance Targets independent community-dwelling older adults of MN Valley Strengthens knowledge of and promotes action to address modifiable risk factors Reaches at-risk seniors who might not otherwise access health care or community resources until after an injurious fall has already occurred Keeping in Balance: Evidence-Based Most effective strategy for reducing risk in community-dwelling older adults is multi-factorial risk assessments and management interventions (Cochrane Database of Systematic Review 2003) Follow-up to track falls and followthrough with recommended interventions 8

9 Program Components Community Education for seniors Caregiver Education Provider Education Written material and videos *Caregivers and providers are often best at identifying at-risk seniors. Seniors will often not recognize or admit that they are risk until they actually fall!! Program Components Home Fall Risk Assessments conducted on high-risk seniors upon referral Comprehensive fall risk factor assessment Education on risk factor and home hazard reduction, exercise and physical activity Referrals to health care and community resources as appropriate Written recommendations provided to senior Program Components Community Fall Risk Screens Conducted at community events, health fairs, senior centers, senior housing facilities Annual large-scale community event that combines health fair, speakers and offers multi-disciplinary fall risk assessments Focus of DHS CCSD grant is fall risk assessments with PHN in Dakota Co subsidized senior housing Screening for risk factors by physical therapist in collaboration with other health care professionals when possible Seniors assisted in the development of an action plan to address risk factors 9

10 Exercise Has been shown to be one of the most effective stand-alone strategies for decreasing fall risk in community-dwelling elders Addressed with each senior in 1:1 assessments Goal: 30 minutes 5X per week Resources given re: community programs Walking programs Targeted exercise instruction at time of assessment Referrals to formal PT as indicated Affirmation of what senior is already doing Program Components Consultation and Partnership Senior service providers Community events Physical activity programs in the community Outcome Measurement Follow up calls to program participants to track number of falls and follow-through with recommendations Referrals Seniors themselves Caregivers Senior service providers e.g. senior housing, senior centers, parish nurses MN Valley clinics Program partners Fairview Ridges ED, Rehab, Lifeline, pharmacy DARTS service coordinators MN Valley EMS personnel 10

11 Fall Risk Assessment Components Fall risk Factor Checklist Medical History Review Fall History How many times have you fallen in the last year? Where you injured? Are you afraid that you might fall? Assessment Components Medication Review Four or more prescription or OTC meds (polypharmacy) Side effects (SE) Drug interactions Multiple pharmacies Multiple prescribing physicians Non-compliance Alcohol use Medication Review Meds associated with falls Diuretics IA antiarrhythmics Digoxin Tricyclic antidepressants Sedatives Antipsychotics Leipzig et al JAGS 1999 Benzodiazepines (ativan, valium) 11

12 Fall Risk Assessment Components Sensory Screen Vision Hearing Touch sensation and position sense Footwear Cognition/ Depression Screen MMSE (< 23/30 in significant) Depression may mask as dementia Assessment Components Vital signs New onset of irregular heartbeat Postural hypotension Systolic drops > 20 or to <90 or diastolic drops > 10 mm Hg upon standing Most common causes are dehydration and overmedication Three BP readings taken After resting 5 min in lying or sitting Immediately upon standing 2 minutes later in standing Assessment Components Muscle strength/flexibility screen Decreased muscle strength in hips, thighs, knees or ankles Tightness in hips, knees or ankles with increase in flexion posture Difficulty rising from chair without use of arms to assist Drop sitting 12

13 Components Gait evaluation Short or unequal steps Decreased speed Decreased foot clearance Use of walls or furniture for support Use of cane or walker Unsafe use Improper fit/repair Components Balance Screen Often progressive subtle changes Leans off center Increased sway Unable to stand unsupported Difficulty with single leg stance Decreased score on balance/functional ability test Balance Tests Berg Balance Test (Berg et al,can J Pub Health, 1992) Most studies have used as score of < 46/56 as a cut-off for increased fall risk Recent study indicates < 50/56 may be more sensitive for predicting falls Recommended when assessing lower-functioning communitydwelling elders Fullerton Advance Balance Test (Rose, FallProof!, 2003) A newer test that may be helpful when assessing higher functioning community-dwelling elders 13

14 Functional Ability Screens Timed Sit to Stand (Rikli and Jones, Senior Fitness Test Manual, 2001) Count number of times in 30 seconds to rise from standard chair with arms folded across chest and return to a complete sitting position Less than 8 indicates lower extremity weakness that can be associated with falling Timed Up and Go (Bohannon RW, J Ger Phys Ther, 2006) Time recorded to rise from standard arm chair, walk 3 meters, turn around, walk back and sit down again > 9 sec is associated with increased fall risk Assessment Components Home Safety assessment Room-by-room if in the home Barrier-free pathway Lighting Stairways Flooring Bathroom Safety Home Safety Checklist Fall Risk Screening Should be done in every setting and at all points on the care continuum for older adults Three essential questions to be asked in any setting Have you fallen in the last year? Are you afraid that you might fall? Are you able to rise from a chair without using your arms to assist? 14

15 Fall Risk Screening Items from Keeping in Balance Fall Risk Screen can be incorporated into any assessment/screen of older adults: Three essential questions Use of multiple meds that have SE for falls Use of assistive devices for gait Recent decline in strength; functional, sensory or cognitive ability Lack of regular physical activity/exercise Balance/functional ability screen Program Outcomes Follow-up at 4-8 months on 60 seniors in Dakota Co housing facilities assessed by program coordinator (a PT) and PHN 63% identified as high risk have followed through on at least one recommendation to decrease fall risk 56% of those assessed had a history of falls but only 11% reported a fall at time of follow-up Case Study #1 81-year-old male assessed in senior housing with following risk factors: History of 2+ falls in last year Fear of falling Orthostatic hypotension Dizzy spells Decreased balance with Berg score of 47/56 15

16 Case Study #1 Recommendations to decrease fall risk Follow-up with MD regarding blood pressure and dizziness Use of cane to improve balance especially when ambulating outdoors Increase physical activity by working up to 30 min/day of walking Case Study #1 5 month follow-up No falls since assessment No further issues with dizziness-senior diagnosed with sleep apnea by MD Using cane with improved balance noted Senior expresses gratitude for fall risk assessment Case Study #2 89-year-old male living independently in his own home Referred by Burnsville paramedics after three emergency calls due to falls Numerous home safety concerns identified Significant balance deficits (32/56 on the Berg Balance Test) Significant lower extremity weakness (unable to rise from chair without use of arms) 16

17 Case Study #2 Client instructed in two home exercise to begin addressing lower extremity weakness MD contacted about referral to physical therapy Granddaughter contacted about home safety modifications and to assist with setting up outpatient PT Contact Information Kari Benson State Project Manager MN Board on Aging Pam Van Zyl York Division of Health Promotion and Chronic Disease MN Department of Health Contact Information, contd. Lyle Felsch Deputy Fire Chief Rochester Fire Department Jean Wyman School of Nursing University of Minnesota

18 Contact Information, contd. Suzanne Wiebusch Program Coordinator Preventing Falls in Older Adults Fairview Ridges Hospital