Multifactorial risk assessments and evidence-based interventions to address falls in primary care Sarah Ross, DO, MS Assistant Professor Internal Medicine, Geriatrics Nicoleta Bugnariu, PT, PhD Associate Professor Physical Therapy Objectives Discuss the importance of falls and fall prevention List modifiable risk factors for falls Name 3 assessments for gait & balance and how they are performed. Identify appropriate and evidenced based interventions to decrease fall risk Importance Among older adults, falls are the leading cause of both fatal and nonfatal injuries. Falls are the leading cause of death from injuries in people 65+ (i.e. more likely to die from an injury as a result of a fall than from an injury as a result of a car accident) Falls are the leading cause of Nonfatal Injuries in people 65+ (i.e. injury is most likely to have been caused by a fall than from other trauma) 10-15% of falls by older adults result in fracture or other serious injury Both the incidence of falls and the death rate attributable to falls increase with increasing age 1
Cost In 2000, the direct medical costs of falls were estimated to be $179 million for fatal falls and $19 billion for non-fatal falls. In 2015, the direct medical costs of falls are $637.2 million for fatal falls and $31.3 billion for non-fatal falls. In 2015, the average cost of a fatal fall was $26,340 while the average cost of a nonfatal fall was $9780. Morbidity and Mortality Possible Consequences of Falls Severe injury or death Minor injury Decline in functional status Nursing home placement Increased use of medical services Fear of falling Vicious Circle of fear of falls Experiencing a fall Increased risk of falls Fear of falling Decreased physical condition and balance skills Reduction in level and type of physical activity 2
Who is at risk of falling? Most falls are caused by the interaction of multiple risk factors. More risk factors -> greater chances of falling Complex interaction of Intrinsic and Extrinsic factors, some of which are modifiable Intrinsic Risk Factors for Falling Advanced age Poor vision Muscle weakness Mobility Impairment Gait & balance problems Sensory Impairment (Proprioceptive & vestibular systems) Postural hypotension Fear of falling Previous fall Acute Illness Chronic conditions: arthritis, Parkinson's, neuropathy, diabetes, stroke, incontinence, dementia Extrinsic Risk Factors for Falling Lack of handrails on stairs Poor stair design Lack of grab bars in bathrooms Dim lighting or glare Obstacles or tripping hazards Slippery or uneven surfaces Improper use of assistive device Psychoactive & other medications 3
Modifiable Risk Factors Biological Leg weakness Mobility Problems Balance Problems Poor Vision Behavioral Psychoactive medications Polypharmacy Risky behaviors Inactivity Environmental Clutter & tripping hazards Absences of stair railings or grab bars Poor lighting www.americangeriatrics.org Screening for Fall Risk American Geriatrics Society Recommendations (2010): Ask if any fall in the last year? If yes, then detailed history about the fall(s) Ask if any difficulties with walking or balance? If history of fall -> assess gait & balance If recurrent falls or if does poorly on gait & balance assessment then -> Multifactorial Falls Risk Assessment If only 1 fall reported and patient has no difficulty on evaluation of gait and balance, the full fall risk assessment is not needed 4
https://www.cdc.gov/steadi/ https://www.cdc.gov/steadi/ Risk Assessment (primary prevention) Brief Fall Risk Assessment Questions Have you fallen in the last 6-12 months? Do you have difficulty with walking or balance? 5
Gait & Balance Assessment Physical Assessments Timed Up and Go Test (mobility) 30-Second Chair Stand (strength and endurance) 4-Stage Balance Test (balance) Timed Up and Go Test Record the time it takes a person to: 1. Rise from a hard-backed chair with arms 2. Walk 10 feet (3 meters) 3. Turn 4. Return to the chair 5. Sit down Interpreting Timed Up and Go Comparison of Timed Up and Go Values Age (yrs) 20-29 30-39 40-49 50-59 60-69 70+ Mean (sec) 5.3 5.4 6.2 6.4 7.2 8.5 Most older adults can complete in 10 sec Most frail elderly adults can complete in 11-20 sec 14 sec increased falls risk >20 sec comprehensive evaluation Results are strongly associated with functional independence in ADLs 6
30-Second Chair Stand Have patient sit in a straight back chair without arm rests Instruct patient to cross arms across chest, sit in the middle of the chair, with feet flat on the floor. Patient must keep arms against chest & keep back straight Instruct the patient to rise to a full standing position and then sit back down Count the number of times patient comes to a full standing positions in 30 sec Interpreting 30-sec Chair Stand Age Men Women years Minimum number of times patient able to stand (i.e. fewer times is abnormal) 60-64 14 12 65-69 12 11 70-74 12 10 75-79 11 10 80-84 10 9 85-89 8 8 90-94 7 4 The 4-Stage Balance Test The 4 positions are progressively more difficulty. Eye remain open No assistive device Stand next to the patient for safety and to observe footing If the patient can hold the position for 10 seconds go to the next position If the patient cannot hold the position for 10 seconds stop the test 7
The 4-Stage Balance Test Risk Assessment (primary prevention) Assessment & Intervention (secondary prevention) 8
Multifactorial Fall Risk Assessment 1. Focused History 2. Physical Exam 3. Functional Assessment 4. Environmental Assessment 1. Focused History Detailed History of Falls Medication Review History of relevant risk factors (acute or chronic illness that could contribute) Inquire about environmental hazards Medication review Classes of medications associated with increased fall risk Benzodiazepines Antipsychotics Antidepressants Cardiac medications Hypoglycemic agents Recent medication adjustments Total number of medications 9
2. Physical Exam Balance & gait disturbance Muscle strength & mobility Neurologic Peripheral Neuropathy Other neurologic impairments Cardiovascular Assess for Orthostatic Hypotension Heart rate and rhythm Visual acuity Feet and foot wear Physical Exam Tools Romberg test Dix-Hallpike test (motion-induced imbalance) Monofilament exam Orthostatic Blood Pressure Mental status exam (eg, Mini-Cog) Measuring Orthostatic Blood Pressure Have the patient lie down for 5 minutes Measure Blood Pressure and Heart Rate Have the patient stand Measure Blood pressure and Heart Rate at 1 min and then 3 min after standing A drop in Systolic Blood Pressure of 20mm Hg is considered abnormal 10
3. Functional Assessment Assessment of skill in performing activities of daily living, including appropriate use of assistive devices Assessment of the individual s perceived functional ability and fear related to falling Cognitive assessment 4. Environmental Assessment Physical Therapy can assist Request Home Health Physical Therapist to perform a home safety evaluation Assessment & Intervention (secondary prevention) 11
Strength of Recommendations for Interventions A B C D I A strong recommendation that the clinicians provide the intervention to eligible patients (good evidences that intervention improves health outcomes and that benefits outweigh harm) A recommendation that clinicians provide this intervention to eligible patients (at least fair evidence that intervention improves health outcomes & benefits outweigh harm) No recommendation for or against (at least fair evidence that intervention can improve health outcomes, but balance of risk/benefit too close for a general recommendation) Recommendation is made against routinely providing the intervention to asymptomatic patients (at least fair evidence that ineffective or harm outweighs benefits) Evidence is insufficient to recommend for or against Practice Interventions to Reduce Falls 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] Targeted interventions based on what is found on assessment Goal is to reduce intrinsic and environmental risk factors. Practice Interventions to Reduce Falls Adapt / modify home environment [A] Withdraw /minimize psychoactive medications [B] Withdraw /minimize other medications [C] Manage postural hypotension [B/C] Manage foot problems and foot wear [C] Exercise: balance, strength, and gait training [A] Cataract Surgery [B] Avoidance of multifocal lenses [C] Vitamin D replacement in those w/ deficiency [A] 12
Practice Interventions to Reduce Falls Older persons with 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]. Implementing Fall Risk Assessment Screen all older patients for falls Medical Assistant or Provider can inquire about falls Evaluation of gait, strength, & balance choose one of the assessments discussed for your office can be done by MA, LVN, or by PT referral Multifactorial Fall Risk Assessment for those who have fallen and do poorly on assessment of gait & balance Identify modifiable fall risk factors provider to review medications & perform PE office staff can assist w/ orthostatic pressure measurement, vision check Reduce fall risk by tailoring interventions to patient s risks Educate all patients on falls prevention and community programs Community Programs for Fall Prevention Fort Worth Safe Communities Fall Prevention Task Force Collaboration between multiple groups Area hospitals Area Agency on Aging Senior Citizens Services United Way Tarrant County Public Health Meals on Wheels Med Star (EMS) Fort Worth Fire Department UNTHSC 13
Community Programs: Tarrant Co. A Matter of Balance (AMOB) Free Evidenced Based Program provided through Senior Citizen Services, Tarrant County Public Health 8-session workshop designed to decrease fear of falling and increase physical activity reduces risk of falls that lead to unnecessary or premature hospitalization or nursing home placement Tarrant County has largest AMOB program in Texas Community Programs: Tarrant Co. Home Meds Evidence Based medication management program endorsed by NCOA An in-home, medication review and intervention that includes a computerized risk assessment and alert process, plus a pharmacist review and recommendation for improvement A complement to other programs that address patient readmission reduction, health self-management, care transitions or caregiver support, it reduces medication errors and adverse drug affects preventing nursing home admissions and hospitalizations. Meals on Wheels (grantee) has largest program in U.S. Community Programs: Fort Worth Home Safety Evaluations by FW Fire Department Free for residents of Fort Worth Standardized checklist for environmental fall risk factors home safety hazards and recommendations performed by trained fire fighters Prescription pads with phone number to enroll patients in community programs available for providers 14
Summary Ask about falls! Assess Gait & Balance Complete evaluation for those who have fallen Reduce fall risk by tailoring interventions Use community resources Internet Resources For Primary Care Providers Stopping Elderly Accidents, Deaths, & Injuries (STEADI) Tool Kit for Health Care providers: https://www.cdc.gov/steadi/ American Geriatrics Society, Falls Prevention Guidelines: www.americangeriatrics.org For patients www.cdc.gov/injury www.stopfalls.org Fort Worth Safe Communities Like us on Facebook! https://www.facebook.com/fwscc?fref=ts THANK YOU!!!! Questions? Comments? 15