Upper Extremity Fractures and Secondary Fall Prevention: Opportunities to Improve Management and Outcomes Across Disciplines Chris,ne McDonough, PhD, PT, CEEAA Health Outcomes Unit Department of Health Law Policy & Management Boston University School of Public Health Acknowledgements The Dartmouth Ins,tute for Health Policy & Clinical Prac,ce Na,onal Ins,tute of Arthri,s and Musculoskeletal and Skin Diseases at the Na,onal Ins,tutes of Health (P60-AR062799; Tosteson A, PI) APTA and the Academy of Geriatric Physical Therapy Boston University, TREAT, NEPDC 1
Objec,ves Present current evidence related to UE Fx through the lens of secondary preven,on Selected studies from TDI MCRC Research Fracture Care Project Study 1: Epidemiology of Second Fracture Study 2: Prescrip,on Drug Use Before and A[er Fx Study 3: Evalua,on and Treatment of Balance & Gait a[er UE Fx Study 4: Opioid Use a[er Fx Recommenda,ons based on American Physical Therapy Associa,on Fall Risk Management Guideline Systema,c Review of Measures Sample & Data Sources Fee-for-service Medicare beneficiaries age 66 99 years old who sustained a hip, shoulder, or wrist fragility fracture Enrolled in Medicare Without managed care enrollment for one year before and one year a[er the index fracture or un,l death Iden,fied fracture types using claims 2
Study 1: Fracture Epidemiology Individuals in cohort were followed for one year or un,l occurrence of another fracture or death Cohort Descrip,on 3
Results Hip fracture pa,ents: older, had higher comorbidity. Older more likely to die by 1 yr a[er index Fx Hip: 27% Shoulder: 13% Wrist: 7% Women more likely than men to sustain any Fx Gender imbalance > for UE than hip Fx Wrist: 14 % male Shoulder: 19 % male Hip: 26 % male Second Fracture Results Fig. 2 Distribu,on of second fracture type among beneficiaries who sustained a second fracture within 1 year of index hip, shoulder, or wrist fracture 4
Second Fracture Results & Conclusions Overall 11,885 people (4.3%) had second within one year Age and comorbidity have strong effects on risk of second fracture Ligle difference in risk by index fracture type or gender (hip: 7.3k; shoulder: 5.8k; wrist: 5.5k per 100k) Results reveal that fracture preven,on is as important a[er humerus and wrist facture as for hip and for men as much as women Study 2: Prescrip,on Drug Use 5
Ra,onale: Prescrip,on Drug Use Is Modifiable Risk Factor Fragility Fracture Increased Bone Density Decreased Second Fracture Bisphosphonates Fragility Fracture Deceased Bone Density Increased Second Fracture Proton Pump Inhibitors Fragility Fracture Opiates, SSRIs, seda,ves Increase Fall Risk Increased Second Fracture 6
Study 2: Prescrip,on Drug Use Background: Prescrip,on drugs are modifiable risk factor for second fracture Bisphosphonate use a[er fracture low Small study showing high rate of use of drugs associated with fall risk Aim: To characterize prescrip,on drug use and associated fracture risk before and a[er fragility fracture Study 2 Results & Conclusions There was very ligle reduc,on in exposure to prescrip,on drugs associated with fracture risk a[er fragility fracture some pa,ents discon,nued drugs associated with fracture an equal number started new risk-related drugs ~ 25% used bone-building drugs Post-fracture care is an opportunity to medica,on-related risk of second fracture risk 7
Study 3 Study 3 Methods Subjects: Fee-for-service beneficiaries age 66 to 99 treated as outpa,ents for proximal humerus or distal radius/ulna ("wrist") fragility fractures Outcomes % evaluated or treated for fall risk up to 6 months a[er proximal humerus or wrist fracture from 2007-2009 Predictors of receiving evalua,on or treatment (logis,c regression) 8
Percent Receiving Assessment or Treatment for Extremity Fracture Study Results 20 18 Proximal Humerus Wrist 16 14 14.2 12 Percent 10 8.8 8.5 9.0 8 6 6.0 5.0 4 2 0 Evalua,on Treatment Evalua,on or Treatment Percent of Medicare Beneficiaries who Received Evalua,on or Treatment up to 6 Months a[er Index Proximal Humerus or Wrist Fracture (n=309,947). Study 3 Results 10.7% received evalua,on or treatment for fall risk or gait issues Using the broader defini,on the percentage increased to 18.5% Higher likelihood of services a[er fracture were: evalua,on or treatment for falls or gait prior to fracture, more comorbidi,es, prior nursing home stay, older age, humerus fracture (versus wrist), female sex and white race 9
Study 3 Conclusions/Next Steps This low rate of assessment and treatment a[er an upper extremity fracture is the most important finding of this study, marking a large missed opportunity to reduce future falls and associated func,onal loss Next step Rerun the analysis from 2010-2013 to address more recent incen,ves and policies (AGS/BGS CPG, APTA CGS, PQRS, Medicare annual wellness visit, etc.) Opportuni,es to Improve Management and Outcomes Across Disciplines Fragility fractures should be sen,nel events triggering Assessment of medica,on-based risk & reduc,on Evalua,on & treatment of balance and mobility deficits Consider humerus, wrist, and hip fracture as equally predic,ve of second fracture Take appropriate ac,on as soon as possible a[er fracture 10
Methods: Iden,fica,on of Clinical Prac,ce Guidelines (CPGs) Systema,cally search (11 databases) Search terms: falls, geriatric, older adult Inclusion Published between 2000 and 2013 English and Adults over the age of 65 living in the community or in assisted-living seongs Exclusion Specific to a neurological condi,on (e.g., stroke, Parkinson disease, mul,ple sclerosis) Fracture management Clinical prac,ce statements excluded 11
Methods 4028 CPGs iden,fied 5 met inclusion criteria Cri,cally appraised by >=3 reviewers: AGREE II AGS/BGS (American & Bri,sh Geriatrics Socie,es) NICE (Na,onal Ins,tute for Health & Care Excellence) FSGG (French Society of Geriatrics & Gerontology ) AGILE (UK Society for PTs working with older adults) Moreland J et al. 2003 Recommenda,ons The recommenda,ons were wrigen for physical therapists Based on mul,-disciplinary CPGs, therefore may be relevant for other disciplines Levels of Evidence Level I: Strong (RCTs, SR) Level II: Moderate (small RCTS, quasiexperimental) Level III: Weak (observa,onal studies) 12
Screening [Physical therapists] should rou,nely ask older adult pa,ents if they have fallen in the previous 12 months (Strong Recommenda,on based on Level III evidence). Screening should include: History and context of falls over previous 12 months At least one ques,on about the pa,ent s percep,on of difficulty with balance or walking Screening For each pa,ent who reports a fall or falls or reports difficulty with balance or walking, [the physical therapist] should screen by observing for gait or balance disturbance (Strong Recommenda,on based on Level III Evidence). Posi,ve screening result is when either is found: Mul,ple falls One fall + balance or gait impairment 13
Assessment Evidence: Health Condi,ons Cardiac condi,ons Cardiac exam (NICE, AGS/BGS) HR, rhythm, postural pulse, BP, hypotension (AGS/ BGS) An,-arrhythmia medica,on (NICE) Cardiac drugs and postural hypotension (Moreland) Osteoporosis (NICE, AGS/BGS) Risk assessment or diagnosis Assessment Evidence: Health Condi,ons Depression (Moreland) Assess for risk Geriatric Depression Scale Medica,on review Number of meds with dosage Cardiac Psychotropic (benzodiazepines, hypno,cs, an,depressants, tranquilizers) 14
Assessment Evidence: Body Func,ons and Structures Strength of the extremi,es Lower extremity strength (AGS/BGS) Balance No specific procedures or methods for balance assessment are provided within the CPGs Frequently used tests: BBS, TUG, POMA Assessment Evidence: Body Func,ons and Structures Vision Visual acuity (AGS/BGS) Urinary func,on/ incon,nence Cogni,ve assessment/ neurologic func,on Cogni,ve evalua,on (AGS/BGS, NICE) Peripheral nerve func,on, propriocep,on, reflex tes,ng, and cor,cal, extrapyramidal, cerebellar func,on (AGS/BGS) 15
Assessment Evidence: Ac,vity and Par,cipa,on Gait (thorough and detailed) Gait deficits or abnormali,es are a risk factor for falls No specific procedures or methods were recommended Individual professional should iden,fy appropriate measures for the assessment of gait for each older adult (NICE) Use of walking aids (Moreland) Assessment Evidence: Ac,vity and Par,cipa,on Ac,vi,es of daily living and mobility ADL skill including use of adap,ve equipment Mobility aids (AGS/BGS) Transfers (Moreland) Physical ac,vity Given that moderate ac,vity levels may be protec,ve to balance and falls, assess levels of physical ac,vity (Moreland) 16
Assessment Evidence: Environmental and Personal Factors Since home safety and hazards are risk factors, assess the home for hazards Example: Tripping hazards: agen,on to loose rugs and mats Fear and health percep,on Assess perceived func,onal ability and fear of falling Assessment: Environmental and Personal Factors Social support Iden,fica,on of the older adult s social support network (Moreland) Alcohol use Assessment of consump,on and inappropriate alcohol use (Moreland) Feet and footwear Assess feet and footwear (AGS/BGS) 17
Interven,on Evidence: Health Condi,ons Conduct medica,on review; modify/ withdraw psychotropic meds if possible Treat cardioinhibitory caro,d sinus hypersensi,vity (NICE, AGS/BGS) Treat postural hypotension (AGS/BGS, Moreland) Treat vitamin D insufficiency (AGS/BGS) Treat impaired cogni,ve status (Moreland) Treat depression (Moreland) Interven,on Evidence: Body Func,ons and Structure Individualized balance training Individualized strength exercises (NICE, AGS/BGS) Monitored by appropriately trained health care professional (NICE, AGS/BGS) Coordina,on training (AGS/BGS) Flexibility and endurance should be offered; not as stand alone interven,on (AGS/BGS) 18
Interven,on Evidence: Body Func,ons and Structure For persons who have fallen, but with no specific findings on assessment Tai chi or other balance control ex (e.g. on foam surfaces) (Moreland) For women over 80 yrs, individualized home physical therapy program for strengthening, balance, and flexibility (Moreland) Interven,on Evidence: Body Func,ons and Structure Delivery Referral to physical therapy (Moreland) Tai chi or physical therapy (AGS/BGS) Group exercise or individual (AGS/BGS) 19
Interven,on Evidence: Body Func,ons and Structure Expedite first cataract surgery when indicated (AGS/BGS) χ Advise against mul,focal lenses for walking on level and stairs (AGS/BGS) Treat vision and hearing impairment (Moreland) Insufficient evidence to recommend vision correc,on as stand-alone falls interven,on (NICE, AGS/BGS) Interven,on Evidence: Ac,vity & Par,cipa,on Individualized gait training combined with balance and strength training (AGS/BGS, Moreland was specific to older women) χ Advise against brisk walking for postmenopausal women with fracture history (Moreland) Insufficient evidence for brisk walking (NICE) 20
Interven,on Evidence: Ac,vity & Par,cipa,on ADL training for those with difficulty performing ADL ac,vi,es. (AGS/BGS, Moreland) Interven,on Evidence: Educa,on Educa,on and informa,on giving Verbal and wrigen re: preven,on, effec,ve measures, mo,va,on to exercise, benefits of engagement in risk reduc,on ac,vi,es (NICE) Tailored educa,on within mul,-factorial interven,on (AGS/BGS) Insufficient evidence for targeted or untargeted educa,onal programs as stand-alone interven,ons (AGS/BGS) 21
Interven,on Evidence: Alcohol and Physical Ac,vity For those with inappropriate alcohol use Educate and refer for treatment (Moreland) For those with risky ac,vity level Educate and refer for treatment (Moreland) Interven,on Evidence: Environmental Factors Home hazard modifica,on Home hazard assessment combined with modifica,ons. Home hazard assessment should not be conducted without follow-up and modifica,ons 22
Interven,on Evidence: Personal Factors Footwear Treatment of foot and footwear problems iden,fied in mul,-factorial assessment (AGS/BGS) Advise low heels and high surface contact area (AGS/BGS) Interven,on Evidence: Personal Factors Hip protectors Insufficient evidence to recommend hip protectors for fall preven,on (NICE) ** Note that hip protectors may be effec,ve in preven,ng fractures associated with falls 23
Assessment Recommenda,ons [Physical therapists] should provide individualized assessment within scope of prac,ce that contributes to mul,-factorial assessment of falls and fall risk. Addi,onal risk factors may need to be addressed by the appropriate provider (Strong Recommenda,on based on Level II evidence). This assessment should include: Medica,on review Polypharmacy & psychoac,ve drugs Assessment Recommenda,ons Medical History Osteoporosis Depression Cardiac disease Signs & symptoms of cardioinhibitory caro,d sinus hypersensi,vity 24
Assessment Recommenda,ons Body func,ons and structure, ac,vity and par,cipa,on, environmental & personal factors Strength Balance Gait Ac,vi,es of Daily Living Footwear Environmental Hazards Cogni,on Neurological Func,on Cardiac func,on, including postural hypotension Vision Urinary incon,nence Interven,on Recommenda,ons Broadly, recommenda,ons were similar for older adults at risk of falls Individualized exercise program including: Balance training Strength training Referral to physical therapy (Moreland) There were differences 25
Interven,on Recommenda,ons [Physical therapists] should provide individualized interven,ons within the scope of prac,ce (Strong Recommenda,on based on Level I evidence). Components of the interven,on should include: Strength training that is individually prescribed, monitored, and adjusted (Strong recommenda,on based on Level I evidence) Interven,on Recommenda,ons Balance training that is individually prescribed, monitored, and adjusted (Strong recommenda,on based on Level I evidence) 26
Interven,on Recommenda,ons Gait training (Strong recommenda,on based on Level I evidence) Interven,on Recommenda,ons Correc,on of environmental hazards (Strong recommenda,on based on Level I evidence) 27
Interven,on Recommenda,ons Correc,on of footwear or structural impairments of the feet (Recommenda,on based on Level II evidence) Which tests to Use to Determine Fall Risk 28
Summary of Clinically Useful Indicators of Fall Risk Category Measure Medical History Ques,ons Any previous falls Psychoac,ve medica,on Requiring any ADL assistance Ambulatory assis,ve device use Self-report Measures Geriatric Depression Scale-15 Falls Efficacy Scale Interna,onal Performance-based Measures Timed Up & Go Test Single-limb stance eyes open Five Times Sit-to-Stand Test Self-selected walking speed More details Gillespie LD, Robertson MC, Gillespie WJ, et al. Interven,ons for preven,ng falls in older people living in the community. Cochrane Database of Systema,c Reviews 2012, Issue 9. Sherrington C, Whitney JC, Lord SR, et al. Effec,ve exercise for the preven,on of falls: A systema,c review and meta-analysis. J Amer Geriatr Soc. 2008; 56(12): 2234-43. Power V, Clifford AM. Characteris,cs of op,mum falls preven,on exercise programmes for community-dwelling older adults. Eur Rev Aging Phys Act 2013; 10:95-106. 29
Mode Must include balance training Strength training only has small effect Mul,factorial home or community-based interven,ons Walking programs alone have small effect Intensity of training Balance training demanding Intensity challenging appropriate and increasing levels of difficulty Highest possible level of difficulty without falling or near-falling Mastery of each exercise before progressing 30
Frequency Minimum effec,ve frequency twice per week Most consistently effec,ve frequency three,mes per week Higher frequencies reduce fall risk, but adherence was poor adherence frequency Time Total exercise volume? At least 40* or 50** hours over the course of the interven,on *Power et al ** Sherrington et al 31
Exercise components What works Leaning beyond BOS Shi[ing the COM Minimizing UE support Narrowing base of support Dual-task movement Altering sensory feedback Func,onal ac,vi,es TJQMBB What doesn t work Lack of balance training component Lack of func,onal relevance Lack of exercise progression Ques,ons? 32
Thank You! 33