David Ganz, MD, PhD Staff Physician, VA Greater Los Angeles Assistant Professor of Medicine, UCLA Preven&on of Falls in Older Adults No conflicts of interest to disclose
Objectives Detail the evidence-based strategies available to reduce falls in independently living older people Describe the basic components of an officebased fall evaluation Understand organizational changes needed to reduce falls in nursing homes and hospitals 2
Common and Costly Age 65 years, 1/3 fall each year 5-10% of fallers have serious injuries fractures, head trauma, lacerations most common (62%) mechanism of nonfatal injury treated in ER in 2001 Nursing home/hospital: 150 falls/100 beds/year Fall injuries cost $19 billion in 2000 Rubenstein LZ. Clin Geriatr Med 2002;18:141 MMWR Morb Mortal Wkly Rep 2003;52:1019 Stevens JA et al. Inj Prev 2006;12(5):290 3
Why Are Falls Important? Marker for underlying functional decline May be reversible Serious injury after a fall may mean the end of independent living Fear of falling may cause older adults to restrict their activities 4
Why Are Falls Important? In hospital and nursing home, may lead to length of stay Non-reimbursement (hospital) Litigation Wong CA. Joint Commission Journal 2011;37:81 5
I: POPULATION HEALTH STRATEGIES TO PREVENT FALLS 6
Fall Risk Pyramid 7
USPSTF Recommendations Recommended (Grade B) for at-risk older patients: Exercise or physical therapy Vitamin D supplementation Moyer VA. Ann Intern Med 2012;157:197-204 8
Systematic Reviews: Exercise Group exercise, Tai Chi, and home based exercise ALL effective Fall rate reduction: 28% to 32%, significant Effective in lower and higher risk patients Gillespie LD. Cochrane Library Systematic Reviews 2012 9
Exercise: Key Findings PCP plays important role in recruitment Most common forms: Gait/balance/functional training Strength/resistance training 3x/week in most successful programs Shier V et al., submitted for publication 10
Exercise: Options Group programs (see AoA website): http://eldercare.gov/eldercare.net/public/index.aspx Outpatient physical therapy prescription Home physical therapy via home health Make community exercise handout, e.g., http://www.geronet.ucla.edu/images/stories/docs/professionals/ falls_community_resources.pdf 11
Exercise Prescription to Patient Frequency -- times per week Intensity e.g., moderate (= brisk walk) Duration minutes/session Type e.g., balance training http://www.usuhs.mil/fap/resources/eptp/exerciserxbasics.ppt 12
Exercise Prescription to Patient Tailor to individual conditions, level of motivation Exercise handouts -- http://www.geronet.ucla.edu/professionals/ patient-education If safety concern, refer to physical therapy 13
Systematic reviews: Vitamin D Did not reduce falls overall Benefit in subgroup with low vitamin D levels Current recommendations for older adults Age 51-70: 600 IU daily Age > 70: 800 IU daily Gillespie LD. Cochrane Database Systematic Reviews 2012; CD007146 Moyer VA. Ann Intern Med 2012;157:197-204 14
Vitamin D: Clinical Strategies Public health approach Empiric Vitamin D to those with limited sun exposure Medical approach Check 25-hydroxy-D levels and treat those who are low Contraindication: hypercalcemia 15
Vitamin D: Harms Toxic in overdose Safe upper limit: 4000 IU/day Slight increased risk of kidney stones with 400 IU Vitamin D3/Calcium 1000 mg in Women s Health Initiative 16 http://www.iom.edu/reports/2010/dietary-reference-intakes-for-calcium-and-vitamin-d/dri-values.aspx Moyer VA. Ann Intern Med 2012;157:197-204
II: FALL EVALUATION FOR VULNERABLE BUT INDEPENDENTLY LIVING ELDERS 17
Fall Risk Pyramid 18
Systematic reviews Multifactorial fall assessment/intervention Reduced rate of falls by 24% (95% CI 14% to 33%) Did not reduce number of people who fell But components have benefit Exercise, home modifications, first-eye cataract surgery, medication withdrawal Gillespie LD. Cochrane Library Systematic Reviews 2012 19
USPSTF Recommendations Do not automatically perform multifactorial assessment consider individual patients risks, benefits, preferences (grade C recommendation) Moyer VA. Ann Intern Med 2012;157:197-204 20
Causes of Falls Multiple interacting causes no magic bullet However, intervening on these causes decreases the rate of future falls 21
Evaluation Seven Elements Orthostatic vital signs Visual acuity Gait/balance Functional status Cognitive Medications Home hazards Chang JT et al. BMJ 2004;328:680 22
Orthostasis Orthostatic hypotension dizziness or loss of consciousness fall Check orthostatic vital signs Interventions Discontinue or dose causative medicines Support stockings In severe cases, treat orthostatic hypotension 23
Vision Visual impairment inability to see hazards puts patients at risk Check for eye exam in the past year If not, perform visual acuity examination Intervention Referral to eye care May lead to cataract extraction Single-lens distance glasses for outdoors Harwood RH. Br J Ophthalmol 2005;89:53-59 Haran MJ. BMJ 2010; 340: c2265 24
Gait/balance/strength Gait/balance/strength impairment likelihood of losing balance or tripping Observe gait Side-by-side/semi-tandem/full tandem (balance) Watch patient arise from chair without using his/her arms to push off (strength) Interventions Physical therapy Assistive device Exercises for balance 25
Function Functional impairments inability to complete tasks safely Ask patient or caregiver about basic/ instrumental activities of daily living (ADL s) Interventions Occupational therapy Equipment to support ADL s 26
Cognition Cognitive impairment Poor insight, judgment, awareness of surroundings unsafe decisions Cognitive evaluation (e.g., 3-item recall) Impairment evaluate for reversible causes Interventions Treat reversible causes (e.g., depression) Develop a plan with caregiver for supervising patient 27
Medications Medications (particularly CNS-active medications) confusion or drowsiness Assessment/Intervention Identify and discontinue medicines without a clear indication Discontinue or benzodiazepines, antidepressants, and antipsychotic agents after weighing risks and benefits 28
Environment Environmental hazards inciting factor that initiates a fall Order home safety evaluation Through home health Intervention Remove hazards Improve lighting 29
Evaluation Seven Elements Orthostatic vital signs Visual acuity Gait/balance Functional status Cognitive Medications Home hazards Chang JT et al. BMJ 2004;328:680 30
Resources American Geriatrics Society guidelines http://www.americangeriatrics.org/health_care_professionals/ clinical_practice/clinical_guidelines_recommendations/2010/ CDC STEADI toolkit http://www.cdc.gov/homeandrecreationalsafety/falls/steadi/index.html 31
III: FALLS AND SAFE MOBILITY IN HOSPITALS AND NURSING HOMES 32
Systematic Reviews: Fall Prevention Hospitals: possibly effective strategies include Multifactorial interventions Exercise (in subacute settings) Nursing homes: possibly effective strategies include Multifactorial interventions Vitamin D supplementation Cameron ID. Cochrane Database Systematic Reviews 2012; CD005465 33
Systematic Reviews: Exercise As part of multidisciplinary intervention: Reduce hospital length of stay by about one day Save $278 per hospital stay Six additional patients discharged to home per 100 treated De Morton N. Cochrane Datab Syst Rev 2009, Issue 1 34
Falls in hospitals: risk factors Recent fall Muscle weakness Behavioral disturbance Urinary frequency/incontinence Medications Orthostatic hypotension/syncope Oliver D. Clin Geriatr Med 2010;26:645 35
Falls in hospitals Affected by staff supervision Physicians responsible for treatment plan Medications Multifactorial interventions target patient risk factors for falls and environmental hazards See AHRQ Falls Toolkit for specific guidance www.ahrq.gov/research/ltc/fallpxtoolkit/ Kolla BP. J Hosp Med 2013;8;1 36
Problems with Bedrest Loss of muscle strength of 5% per day Loss of function Among older medical inpatients, 17% of those who enter the hospital able to ambulate leave the hospital needing help to walk Increased risk of complications Pressure ulcers, venous thromboembolism, aspiration, falls De Morton N. Cochrane Datab Syst Rev 2009, Issue 1 Creditor MC. Ann Intern Med 1993;118:219-223 Anderson FA. Circulation 2003;107:I-9-I-16 37
Hospital Mobility Program Can be run by nursing staff Specially trained nursing assistants Range of motion (in bed) Transfer from bed to chair Walking Complementary to physical therapy for more complex patients 38
Other Strategies Volunteer walking program Example: Hospital Elder Life Program http://www.hospitalelderlifeprogram.org/public/ public-main.php 39
Fall prevention in nursing homes Leadership involvement, interdisciplinary team are key Hybrid between hospital and independentliving approach Falls Management Program website: http://www.ahrq.gov/research/ltc/fallspx/fallspxmanual.htm Becker C. Clin Geriatr Med 2010;26:693 40
Key Points on Falls and Mobility For high-functioning older people, offer exercise For vulnerable community-dwelling elders, consider seven-point fall evaluation, and then act on results Hospitals and nursing homes require multifaceted organizational change strategy 41
THANK YOU! 42