Transcript FALLS IN OLD PEOPLE - GRECC Audio Conferences

FALL PREVENTION:
RESEARCH TO PRACTICE
Laurence Rubenstein, MD, MPH
Director, Sepulveda Division
Greater Los Angeles VA GRECC
Professor of Medicine, UCLA
VA GRECC Audio Conference
October 26, 2006
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Preventing Falls:
What does the evidence show?
 Background: Epidemiology, costs
 Causes & risk factors
 Prevention approaches--evidence
 RAND meta-analysis
 New studies since the meta-analysis
 AGS/BGS practice guidelines--update
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Famous Fallers
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Fall Incidence in Older Adults
[rate/person/yr] or [rate/bed/yr]
Home
Any fall
Hospital Nsg Home
.3
1.5
1.7
.03(10%)
.3
.35(20%)
Fracture
.01
.05
.07
Hip fx
.003
Severe fall
Rubenstein LZ, Josephson KR. Clin Geriatr Med. 2002(May);18(2):141-158
.02
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Falls Mortality
 Accidents: the 5th leading cause of
death in older adults
 Deaths from falls: 2/3 of accidental
deaths
 72% of U.S. fall-related deaths occur
in the 13% of population age 65+
Rubenstein LZ, Josephson KR. Clin Geriatr Med. 2002(May);18(2):141-158
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Costs of Falls
 8% of pop 70 visit ERs for falls yearly
 1/3 of these are hospitalized
 5.3% of hosp patients 65 are due to falls
 U.S. cost est. 2000$20 B. (2020$32 B)
 18% restricted activity initiated by falls
 Precipitate NH entry
 # 1 cause of NH litigation
Rubenstein LZ, Josephson KR. Clin Geriatr Med. 2002(May);18(2):141-158
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Causes of Falls: Summary of 12 Studies
 Accident/environment
 Gait/balance disorder
 Dizziness/vertigo
 Drop attack
 Confusion
 Postural hypotension
 Vision problem
 Other specified
 Unknown
31%
17
13
10
4
3
3
15
5
Rubenstein LZ, Josephson KR. Clin Geriatr Med. 2002(May);18(2):141-158
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Risk Factors for Falls: 16 Multivariate Studies
Factor
Weakness
Prior fall
Balance deficit
Gait deficit
Assistive device
Vision deficit
Arthritis
ADL deficit
Depression
Cognitive deficit
Age >80
Signif/All Mean RR
10/11
12/13
8/11
10/12
8/8
6/12
3/7
8/9
3/6
4/11
5/8
4.4
3.0
2.9
2.9
2.6
2.5
2.4
2.3
2.2
1.8
1.7
Rubenstein LZ, Josephson KR. Clin Geriatr Med. 2002(May);18(2):141-158
Range
1.5 - 10.3
1.7 - 7.0
1.6 - 5.4
1.3 - 5.6
1.2 – 4.6
1.6 – 3.5
1.9 –2.9
1.5 – 3.1
1.7 – 2.3
1.0 – 2.3
1.1 – 2.5
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Drugs & Falls: Meta-analysis
Leipzig, Cumming, Tinetti, JAGS, 1999
Psychotropics, any: RR 1.73 (1.52-1.97)
–
–
–
–
Neuroleptics: 1.50 (1.25-1.79)
Sedative/hypnotics: 1.54 (1.40-1.70)
Antidepressants: 1.66 (1.40-1.95)
Benzodiazepines: 1.48 (1.23-1.77)
Diuretics: 1.08 (1.02-1.16)
Anti-arrhythmics (Ia) : 1.59 (1.02-2.48)
Digoxin: 1.22 (1.05-1.42)
 Fall risk from newer ψ agents no better.
--Hien, Cumming, Cameron, et al, JAGS 53:1290, 2005
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12-Month Fall Rate in NH: Interacting Risk Factors
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Robbins AS, Rubenstein LZ, Josephson KR, et al. Arch Intern Med. 1989(July);149(7):1628-1633
Environmental Fall Risk Factors
Home
•low lighting
•poor stairs & rails
•unstable furniture
•rug/carpet hazards
•low beds & toilets
•no grab bars
•slick floors
•obstacles
•pets
•medications
Institution
•low lighting
•new admission
•poor furniture
•slick hard floors
•low supervision
•↓ # of nurses
•meal times
•no hand rails
Outdoors
•bad weather
•poor sidewalks
•traffic activity
•street crossings
•uneven steps
•distractions
•obstacles
•↑ activity levels
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riGait
Intrinsic Risk
Factors
& balance impairment
Peripheral neuropathy
Vestibular dysfunction
Muscle weakness
Vision impairment
Medical illness
Advanced age
Impaired ADL
Orthostasis
Dementia
Drugs
Precipitating
Causes
•Trips & slips
FALL
Drop attack
Syncope
Dizziness
Extrinsic Risk
Factors
Environmental hazards
Poor footwear
Restraints
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Fall Risk Assessment Measures
Perell K, et al J Gerontol Med Sci 2001.
 Review of 20 fall risk measures
 14 nursing tools, 6 functional tools
 Common items for nursing tools:
 mental status (13), fall hx (10), mobility (10), other dx (8),
incontinence (8), drugs (7), sensory deficits (7), balance (5),
age (4), ADLs (4), assistive device (4), weakness (4), gender (3),
acuity (3), restraint use (1)
 Best measures overall
 Hospital: Oliver ‘97, Schmid ‘90, Morse ‘89, Hendrick ‘95, Rapport ‘93
 Outpatient: Shumway-Cook ‘00, Cwikel ‘98, Tinetti ‘86, Berg ‘89
 NH: “universal precautions” (or Morse ‘89, Shumway-Cook ‘00)
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Fall Risk Assessment Measures:
The Reality
 Most can accurately identify patients at
higher risk of falls
 Probably helpful to sensitize community
living elders of their fall risk & what to do
 Important for medico-legal purposes in
hospitals & NHs: You need to show you’re
doing something that is organized and current.
 But …virtually all patients in hospital
and NHs come out as “high risk.”
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Fall Prevention Trials:
>100 RCTs since 1984
 Assessment (preventive & post-fall)
 Exercise & rehabilitation programs
 Environmental modifications
 Devices
 Nursing interventions
 Combined interventions
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Benefits of a Post-Fall Assessment
Results of a Randomized Controlled Trial in NH
Intervention: 1-2 hr post-fall assessment
protocol by GNP (H&P, gait/bal, envir, lab);
Feedback to PCP (dx, risk factors, recs)
Setting/sample: 700-bed LTC facility, 2/3 F,
age x=88, 160 fallers randomized, 2 yr f/u.
Results: 3-4 treatable fall risks found per person
– 9% falls in assessed group (n.s.)
– 17% mortality (n.s.)
– 52% hosp days (p<.01)
Rubenstein et al, Ann Intern Med, 113: 308, 1990
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Benefits of a Post-Fall Assessment
Prevention of Falls in the Elderly Trial (PROFET)
Randomized trial of post-fall assessment of
fallers seen in ED & assessed by 7 days.
– N=397, 65 (mean age 78); London
Assessment revealed many causes and risk
factors and generated many referrals.
12-month follow-up: Intervention group had
reduced risk of falls (OR=.39) & hospital
admissions (OR=.61). Controls had greater
decline in function.
Close J, Ellis M, Hooper R, et al. Lancet. 1999(Jan 9);353(9147):93-9718
Clinical Approach to the Faller
 Assess & treat any injury
 Determine likely precipitating cause(s)
history, physical , lab (limited)
 Prevent recurrence
treat underlying cause/illness
identify & reduce risk factors (e.g.,
weakness, gait/bal prob, visual prob,
polypharm)
reduce environmental hazards
teach adaptive behavior (e.g., slow rise,
cane)
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Tai Chi and Fall Reduction in Older Adults
Li F et al, J Gerontol Med Sci, 2005
6-month RCT of 3x/wk Tai-chi
vs. stretching in Oregon
N=256 inactive, home-living
elders (age 72-92)
6 month results:
Tai-chi Stretching
Falls
38
73
p<.01
Fallers 28%
46%
p=.01
Inj. falls 7%
18%
p=.03
Tai-chi group also signif better in: balance, physical
performance & fear of falling
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Hip Protectors – Examples
Safehip
CuraMedica
KPH
HipGuard
HIPS
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Do Hip Protectors Work?
Initial studies, cluster randomized by facility,
showed high effectiveness
 50-70% intent to treat
 80-95% among those wearing them
More recent studies, randomized by person,
equivocal
– Hard to get compliance
– Likely contribution from overall program
– Patient selection & education crucial
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Nursing Interventions
Risk assessments (Morse, Hendrich, MDS)
Treat identified risks
Universal fall precautions:
–
–
–
–
–
call light & assist devices close
bed wheels & w/c brakes locked
adequate lighting
clean spills immediately
patient orientation & staff educ
For high-risk patients:
– move closer to nursing station
– increased observation / sitter
– bed-chair alarms
low beds
non-skid slippers
rails & grab bars
clutter-free rooms
clear signage
floor mats
special careplans
hip protectors 24
Anti-Slip Footwear – Examples
Care-Steps
Pillow Paws
Fashion Treads
Walk Alerts
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Bed & Chair Monitors – Examples
AirPro Alarm
Economy Pad
Alarm
Locator Alarm
Floor Mat
Monitor
Bed & Chair Alarm
Keep Safe
QualCare Alarm
Chair Sentry
Safe-T Mate
Alarmed Seatbelt
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Do Bedrails Prevent Falls? Pre-Post Study
AHC Hanger et al, J Am Geriatr Soc, 47:529, 1999
Study of falls in New Zealand hospital
– 6-mo before & 6-mo after bedrail restriction program.
After policy, fewer beds w/ rails (29.6%  13.7%).
Total falls/10,000 bed-days: before-165 after-192
– Falls around bed/10,000 b-d:
– Serious fall injuries:
– Minor fall injuries:
before-89 after-106
before-33 after-18
before-43 after-60
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Bedside Mats – Fall Cushions
CARE Pad
bedside fall cushion
NOA Floor Mat
Roll-on bedside mat
Tri-fold bedside mat
Posey Floor Cushion
Soft Fall bedside mat
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Fall Prevention Trials:
RAND-CMS Meta-analysis
 Lit review (1980-2002): 830 pubs, 41 RCTs
Fall risk
All RCTs:
.88 [.82 - .95]
Monthly fall rate
.79 [.71 - .87]
Meta-regression of intervention components:
• Fall eval + f/u
• Exercise
• Environ mod
• Education
.82 [.72 - .94]
.86 [.75 - .99]
.90 [n.s.]
[n.s.]
.63 [.48 - .83]
.84 [.71 - .98]
.85 [n.s.]
[n.s.]
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Exercise Components
Subjects who fell at least once
Mean number of falls
Number of
Studies
(Arms)
Adjusted Risk
Ratio
(95% CI)
Number
of Studies
(Arms)
Adjusted Incident
Rate Ratio
(95% CI)
Balance
7 (8)
0.94
(074, 1.19)
13 (14)
0.73
(0.61, 0.86)
Endurance
7 (7)
0.80
(0.66, 0.98)
4 (4)
1.19
(0.77, 1.84)
Flexibility
4 (4)
0.72
(0.41, 1.25)
5 (5)
0.90
(0.60, 1.34)
Strength
8 (9)
0.80
(0.54, 1.20)
13 (13)
0.91
(0.67, 1.23)
Exercise
Type
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Since the 2003 Meta-analysis,
what’s new?
 > 35 new published RCTs
 New studies of existing models:
Risk assessment + intervention (8), Exercise
(14), Multifactorial (8), Hip protectors (3)
 New interventions
Visual mods, Vit D + Ca++, Footwear, Vibration
 Multifactorial interventions seem best
RF assessment + abatement, exercise, envir mod
Organized, consistent, population-based
programs
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Vitamin D Effect on Falls: Meta-analysis
Bischoff-Ferrari JAMA 291:1999-06, 2004.
 Pooled 5 RCTs, N=1237
 Vit D reduced OR for falls by 22%
(Corrected OR 0.78; 95% CI 0.64-0.96)
 Effect independent of Ca+ supplement,
duration of Rx, sex
 Baseline Vit D levels not measured
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Can Cataract Surgery Reduce Falls?
Harwood et al, Br J Ophthalmol 2005:89:53-9
RCT of women age 70+ w/ cataracts
randomized to surgery or 12-mo wait list
Falls measured by diary + q3mo f/u
12 mo results:
– 34% lower fall rate in surg group (p=.03)
– 3% vs 8% had fractures (p=.03)
– Surg assoc w/ better activity, anxiety,
depression, confidence & visual disability
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The “Yaktrax” gait stabilizing device – RCT:
• ↓58% RR outdoor falls on snow & ice (p<.03)
• ↓87% RR injurious falls on snow & ice (p<.02)
• most intervention group falls occurred w/o device
McKiernan FE, JAGS 53:943, 2005
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Vibrating Insoles may improve balance
Priplata AA, et al. Vibrating insoles & balance in elderly people. Lancet 2003; 362:1123.
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Fall Prevention Strategies
COMMUNITY
INSTITUTION
– Risk-factor screen
& intervention
– Organized program
– Risk-factor screen
– Post-fall assessment
– Post-fall assessment
– Exercise program
(strength, balance)
– Environmental
inspection &
modification
– Nurse awareness
– Targeted interventions
(e.g., hip pads, low
bed, bed/ chair alarms,
monitors)
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Evidence Based Guideline for Fall Prevention
(AGS-BGS-AAOS Task Force, 2001)
SUMMARY
Assessment
– Inquire about falls, gait, balance at routine visits (at least annually).
– Screen persons reporting a problem (e.g., “get up & go” test).
– Assess persons failing screen, or w/ >1 fall:
 Hx of fall circumstances, meds, chronic illness, mobility level
 Examine gait, balance, orthostasis, vision, neuro, cardiovascular
Management of Fallers
– Multi-component interventions: assessment & f/u, exercise, gait
training, med review, treatment (e.g., visual, cardiac, orthostasis)
– LTC setting interventions: assessment & f/u, staff education,
gait training & assistive devices, medication review & adjustment
– Single interventions: assessment & f/u, exercise (esp balance),
environmental assm’t/mod, medication review & adjustment
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Assessment and
Management of Falls
Periodic case finding in
Primary Care:
Ask all patients about
falls in past year
Recurrent
falls
Gait/balance
problems
Patient presents to
medical facility
after a fall
No falls
No
intervention
Single fall
Check for
gait/balance
problem
No
problems
Fall Evaluation*
Assessment
Multifactorial intervention
History
Medications
Vision
Gait and balance
Lower limb joints
Neurological
Cardiovascular
(as appropriate)
Gait, balance, exercise - programs
Medication - modification
Postural hypotension - treatment
Environmental hazards - modification
Cardiovascular disorders - treatment
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Conclusions
 Falls: Common, debilitating, expensive
 Preventable w/ existing technology
Assessment+f/u, exercise, environment mod
 System needed to mobilize evidence-
based preventive approaches
 Likely cost-effective (multiple direct &
indirect savings offset program costs)
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Fall Prevention Principles in Action:
The Birmingham/Atlanta GRECC Fall
Prevention Clinic
Cynthia J. Brown, MD, MSPH
Investigator, Birmingham/Atlanta VA GRECC
Medical Director, Birmingham/Atlanta GRECC
Fall Prevention and Mobility Clinic
Associate Professor, UAB
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GRECC Fall Prevention
and Mobility Clinic
Objectives of the clinic
– To provide care to veterans with a history of falls,
near falls or other mobility problems
– To develop a program which can be exported to
other VA facilities
– To allow research into the area of falls, fall
prevention and mobility disability in a communitydwelling population
– To provide an educational venue for a variety of
trainees
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Patient Population Served
by the Clinic
• Referrals from several sources including
primary care, neurology, and rehabilitation
• A variety of ages, functional status
abilities and medical diagnoses are
represented
• All have a history of falls or near falls
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Interdisciplinary Team Approach
• Occupational Therapist
• Physical Therapist
• Physician (Geriatrician)
• Referrals as needed for other resources
or providers
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Methods Adaptable for All
Healthcare Providers
• Fall prevention strategies can be
employed by all healthcare providers
within the VA.
• Key is multicomponent, interdisciplinary
interventions.
• Having this type of clinic is not essential.
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Risk Factors Targeted by the Team
–
–
–
–
–
–
–
–
Muscle weakness
Mobility and balance impairments
Foot and footwear problems
Sensory and perceptive deficits
Cognitive impairments
Multiple medications
Postural hypotension and dizziness
Environmental hazards
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Occurrence of Falls According
to the Number of Risk Factors
(Tinetti, 1988)
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
0
1
2
3
4+
# risk factors
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Muscle Weakness
• Evaluation:
strength testing of the upper and lower extremities
functional tests like timed chair stands
• Treatment:
• referral for strength training either as an outpatient
or at home, depending on severity of mobility
problems
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Mobility and Balance
Impairments
• Mobility (gait and transfers)
– Evaluation: timed chair stands, and timed 8 foot
walk (Short Physical Performance Battery); or Get
Up and Go test
– Treatment: Physical Therapy for gait and transfer
training, provision of an assistive device
• Balance
– Evaluation: progressive static balance tests
(feet together, semi-tandem, and tandem)
– Treatment: referral to PT or community exercise
programs (Tai Chi) for instruction in balance
exercises.
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Foot and Footwear Problems
We dare to take the patients shoes off !
– Evaluation:
watching gait with shoes on
examining shoes for wear patterns
examining feet without shoes
– Treatment:
• Podiatry referral for nail care
• orthotics/prosthetics for shoe inserts, special
shoes or ankle-foot orthosis (AFO)
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Sensory and Perceptive Deficits
• Vision
– Ask if any problems and refer as needed
• Hearing
– Ask if problems and refer as needed
• Sensation/ Proprioception Problems
– Check sensation to light touch and
proprioception
– Referral to podiatry, foot clinic
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Cognitive Impairments
• Screen for depression
– Geriatric Depression Scale (GDS)
– Work with PMD or Mental Health, treat as needed
• Screen for dementia
– Mini Mental State Exam (MMSE)
– Referral to Geriatric Assessment Clinic
– Assist family in understanding why the patient falls
and target other interventions which may lower
risk
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Multiple Medications
• Physician review of medications
– Attempt to adjust or eliminate as able
– Focus on those known to be associated
with high fall risk
• Benzodiazepines
• Anticholinergic medications
• Psychoactive medications
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Postural Hypotension and
Dizziness
• Evaluate by taking orthostatic blood
pressures on ALL patients
– Check after supine for five minutes, then
standing for one and three minutes
Treatment:
– Review medications and adjust as able
– Instruct patients to change positions
slowly
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Environmental Hazards
• Occupational Therapist reviews home
environment with patient
• Handouts of hazards given and
discussed
• Adaptive equipment provided as
needed
(raised toilet seats, shower chairs, grab
bars)
• Home health can evaluate for home
safety
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Benefits of an Interdisciplinary
Team Approach
• Research shows a multicomponent
approach most likely to be successful
• Allows a variety of targeted
interventions to be done
simultaneously
• Educational opportunity
• Fun!
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The Birmingham/Atlanta GRECC
Fall Prevention and Mobility Team
• J. Dennis Hughes, OTR/L
• Claire Peel, PhD, PT
• Cynthia J. Brown, MD, MSPH
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Thanks to the patients who allowed
themselves to be photographed
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