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Falls Prevention January 13, 2010 Objectives • Understand the seriousness of falls in adults, particularly older adults • Identify Evidence-based Practice Fall Prevention/Reduction interventions • Demonstrate competency in Fall Risk Screening and Documentation Number of older adults in 2005: 18.6 million seniors age 65 to 74 almost 19 million adults age 74-84 the oldest sector, people age 85 and older, grew to 5 million These numbers do not include members of the baby boom generation; the oldest of the 78.2 million baby boomers that begin turning age 65 in 2011 • YOU will PROVIDE health care for this group!! • From 2000 to 2030, the population of those over age 65 will double Erie County • Most counties in Western New York (WNY) have a higher percentage of older adults than that of the state and nation. • Western and Central New York’s elderly comprise 17.7% of the population Erie County • Those requiring the most assistance with daily living, those 85 years and older, constitute the fastest growing segment of the Erie County population • From 1990-2000, there was a 35.5% increase in citizens over age 85, this age group is projected to increase by an additional 28% from 2000 to 2015 Erie County Senior Services, 2009 Falls: A National Problem Definition of a fall: No common definition used For our purposes: An unintentional event that results in the older adult coming to rest on the ground or on another lower level. HEROS© Program, Temple University, Philadelphia PA Falls: A National Problem • Falls: * 1/3 of ALL older adults fall at least one time each year *Falls are ranked as the #1 cause of injury related death for those over the age of 65 *Of those who fall, 20% to 30% suffer moderate to severe injuries such as hip fractures or head traumas that reduce mobility and independence, and increase the risk of premature death (Sterling 2001) Fall severity scale • • • • • • • • • • • 1=No injury 2=Minor abrasion contusion 3= Moderate to Serious laceration tissue tear hematoma impaired mobility due to injury fear of subsequent fall and fall injury 4. Serious fracture multiple fracture subdural hematoma head injury VHA, 2004 • The most common fractures are of the vertebrae, hip, forearm, leg, ankle, pelvis, upper arm, and hand (Scott 1990) • Many experience long term disability Fall related costs: • 1997-$19 billion dollars in fall related medical care • Estimates of the yearly costs for acute care associated with fall-related fractures have soared to more than $10 billion **Costs are anticipated to rise to over $55 billion dollars by 2020 Fall related costs: • The cost associated with falls includes 3 million hospital days per year for hip fractures • Long term care is required for half of hip fracture survivors Local Facts on Falls! Reasons for falls…….. • • • • • • • • • Accident/environment=31% Gait/balance disorder=17% Dizziness/vertigo=13% Drop attack=10% Confusion=4% Postural hypotension=3% Vision problem=3% Other specified=15% Unknown=5% • Rubenstein LZ, Josephson KR. ClinGeriatrMed. 2002(May);18(2):141-158 Concerns: • Medications • Environment • Intrinsic factors Medications •Affects alertness, judgment, coordination (increase risk of delirium) • •Postural Hypotension-significant drop in blood pressure with change in position (sit to stand) • •Altered balance mechanism, ability to recognize and adapt to obstacles • •Cause impaired mobility through stiffness, weakness, uncontrolled pain ©S Castle 2004 Drugs & Falls: Meta-analysis Leipzig, Cumming, Tinetti, JAGS, 1999 -Psychotropics -Neuroleptics -Sedatives/hypnotics -Antidepressants -Benzodiazepines -Diuretics -Anti-arrhythmics -Digoxin Fall risk from newer ψ agents no better. -Hien, Cumming, Cameron, et al, JAGS 53:1290, 2005 Medication issues: • four or more prescription medications • side effects • do not fill all prescriptions at the same pharmacy • No pharmacist consult about their current medication usage • Over-the-counters Rebenstein, 2002: • Evaluate by taking orthostatic blood pressures on ALL patients – Check after supine for five minutes, then standing for one and three minutes – Review medications and adjust as able – Instruct patients to change positions slowly Environmental Fall Risk Factors Home •low lighting •poor stairs & rails •unstable furniture •rug/carpet •low beds & toilets •no grab bars •slick floors •obstacles Outdoors •bad weather •poor sidewalks •traffic activity •street crossings •uneven steps •distractions •obstacles •↑ activity levels Clothing and Shoes that Pose a Fall Risk • Loose clothing that wraps around the legs or ankles. • Clothing and belts that hang to the floor. • Shoes without backs. • Shoes that are too big for the feet. • Shoes that have a large ‘bumper’ in the front of the toes. • Shoes that have slippery soles or too grippy soles. (Newton, 1998) Intrinsic Risk Factors Gait & balance impairment Peripheral neuropathy Vestibular dysfunction Muscle weakness Vision impairment Medical illness Advanced age Impaired ADL Orthostasis Intrinsic Risk Factors Gait & balance impairment Peripheral neuropathy Vestibular dysfunction Muscle weakness Vision impairment Medical illness Advanced age Impaired ADL Orthostasis Precipitating Causes •Trips & slips Drop attack Syncope Dizziness FALL Outcomes: • 18% restricted activity initiated by falls • The fear of falling is one of the best predictors of later functional decline • Falls account for 30 – 40% of admissions to long-term care facilities • Reduced independence Falls Risk Reduction Table If she/he has The chance she/he will suffer a serious fall in the next year is Treating risk factors reduces this risk to about Fallen in past year 50% 30% No falls in past year but even minor problems with walking or movements 30% 20% Any 1 of 6 the risk factors below 20% 10% Any 2 of the 6 risk factors below 30% 20% Any 3 of the 6 risk factors below 60% 40% 4 or more of the 6 risk factors 80% 50% Tinetti 2005 Known treatable risk factors include: • any problems with walking or movements • postural hypotension • use of 4 or more medications or any psychoactive medications • unsafe footwear or foot problems • visual problems • environmental hazards Mary E. Tinetti, M.D. (2008) • Research has shown that treating and correcting these specific health problems reduces the rate of falling by more than 30%. Tinetti, M.E., Speechley, M. and Ginter, S.F. (1988). a treatable health problem Occurrence of falls according to the number of risks. Tinetti, M.E., Speechley, M. and Ginter, S.F. (1988). • Patient as partner!! Stages of change: • Precontemplation: Participant has little or no intention to perform the behavior/activity every day in the future. • Contemplation: Participant does not perform the behavior/activity but intends to begin to perform the behavior/activity in the near future (usually the next week or month). • Preparation: Sometimes performs the behavior/activity and intends to perform the behavior/activity every day in the future. • Action: Performs the behavior/activity every day but has done so for less than 6 months. • Maintenance: Performs the behavior/activity every day and has done so for more than 6 months. Janz and Becker, 1984 Evidence Based Resources for Fall Prevention USE OF EVIDENCE BASED PRACTICE Screening to identify risks Assessment Interventions Medication Home environment Exercise Tai chi Communication with M.D./team Fall reduction/prevention through Evidence Based Practice: Simple, clinical screening tests can accurately identify seniors who are more likely to fall Shumway-Cook 1997). ( Fall reduction/prevention through Evidence Based Practice: Ellen Costello, PT, PhD., & Joan E. Edelstein, MA, PT, FISPO, CPed2 Update on falls prevention for communitydwelling older adults: Review of single and multifactorial intervention programs Fall reduction/prevention through Evidence Based Practice: Costello & Edelstein types of intervention programs: • home hazard assessment with modification only • exercise and/or physical therapy only • programs that offered multifactorial intervention programs Fall reduction/prevention through Evidence Based Practice: Conclusions: Costello & Edelstein Community-based multidisciplinary health and risk assessment programs with targeted treatment strategies were effective in reducing the number of falls sustained by community-dwelling older adults. Multifactorial programs were effective for both an unselected population of older people and a population of older people with a history of falls or known fall-risk factors. Medication and vision assessment appropriate health practitioner referral should be included as part of a falls screening examination. Fall reduction/prevention through Evidence Based Practice: Costello, PT, & Edelstein Exercise alone is effective in reducing the number of falls. It should include a comprehensive program combining strengthening, balance, and/or endurance training for a minimum of 12 weeks. Home hazard assessment with modifications may be beneficial in reducing falls, especially with those targeted individuals. Additional benefits may be obtained if an OT or a PT conducts the assessment. Fall reduction/prevention through Evidence Based Practice: Effective Exercise for the Prevention of Falls: A Systematic Review and MetaAnalysis Journal of the American Geriatrics Society Catherine Sherrington, PhD; Julie C. Whitney, MSc; Stephen R. Lord, DSc; Robert D. Herbert, PhD; Robert G. Cumming, PhD; Jacqueline C. T. Close, MD (2008) Fall reduction/prevention through Evidence Based Practice: Effective Exercise for the Prevention of Falls: A Systematic Review and Meta-Analysis Catherine Sherrington, et al. • confirmed that exercise can reduce fall rates in older people • identified important components of effective exercise intervention strategies • confirmed the importance of balance training in falls prevention and the need for exercise to be sustained over time. Supports Home exercise program! Fall reduction/prevention through Evidence Based Practice: Shumway-Cook Physical Therapy . Volume 77 . Number 1 . January 1997 Age was not associated with the adherence to exercise and with the reduction of fall risk. Those over age 80 were just as likely to follow their exercise program as those in their 60’s Balance and gait retraining programs can be beneficial to very old individuals Fall reduction/prevention through Evidence Based Practice: Tai Chi and Fall Reduction in Older Adults Li , F., et al, J Gerontol Med Sci, 2005 6-month Randomized Control Trial of 3x/wk Tai-chi vs. Stretching exercises 6 month results: Tai-chi Falls 38 Fallers 28% Inj. falls 7% Stretching 73 46% 18% p<.01 p=.01 p=.03 Tai-chi group also significantly better in: balance, physical performance & fear of falling Fall reduction/prevention through Evidence Based Practice: Tai Chi versus brisk walking in elderly women Audette et al. (2006) Tai Chi 1 hr. x three days per week for 12 weeks. found to be an effective way to improve many fitness measures in elderly women found to be significantly better than brisk walking in enhancing certain measures of fitness including • lower extremity • strength, balance • Flexibility. Li and colleagues (2005) Tai Chi and Fall Reductions in Older Adults: A Randomized Controlled Trial sample of 256 physically inactive, community-dwelling adults aged 70 to 92 randomized to participate in a threetimes-per-week Tai Chi group or to a stretching control group for 6 months. Measurement: (Berg Balance Scale, Dynamic Gait Index, Functional Reach, and single-leg standing), physical performance (50-foot speed walk, Up&Go), and fear of falling, assessed at baseline, 3 months, 6 months (intervention termination), and at a 6-month postintervention follow-up. Li, et al • Findings: • At the end of the 6-month intervention, significantly fewer falls in Tai Chi group • Decreased # of fallers and less injury in those that did fall • significant improvements in all measures of functional balance, physical performance, and reduced fear of falling ( p< .001) • multiple falls in the Tai Chi group was 55% lower than that of the stretching (control) group Li, et al. • Tai Chi group measures were maintained at a 6-month postintervention follow-up in the Tai Chi group Benefits of a Post-Fall Assessment Prevention of Falls in the Elderly Trial Assessment revealed: • many causes and risk factors and generated many referrals. • 12-month follow-up: Intervention group had reduced risk of falls (.39) & hospital admissions (.61) • Controls had greater decline in function. Close J, Ellis M, Hooper R, et al. Lancet. 1999 Home assessment/modification Ledford, 1996; AMDA, 1998; Mosley et al., 1998. • Variety of home modification strategies supported for reducing falls • Lord & Dayhew (2001) identified impaired vision as an important risk factor in community dwelling seniors Fall rates may be reduced by 30-40% through coordinated efforts by Patients, family, and healthcare providers • Taylor, et al. (2007) Journal of the American Medical Association, vol. 297, no. 1, 2007 Moreland, et al. (2003) • Strong evidence supporting a community-dwelling older adults to partake in multi-factorial risk assessment and intervention programming for fall reduction • Balance exercises included for all fallers and those over 80 years of age Fall Programming: • AHRQ (2007) funded research has shown that implementation of a falls prevention program: -is feasible way to address falls -improves care and documentation *-in nursing homes, may reduce falls even in the face of substantial reduction in the use of restraints, a major emphasis of the Federal Government. AHRQ: continued • Identified a lack of education among staff and primary care providers on risk factors for patient injuries. • Lack of effective tools that facilitate documentation and communication. Cochrane Review of 62 studies Gillespie, et al. (2009) “Healthcare purchasers and providers contemplating fall prevention programs should consider interventions which target both intrinsic and environmental risk factors of individual patients” Implementing best practices in fall risk identification, intervention, communication with other providers using the evidence GOOD PRACTICE! Probe!! – Ask about falls or near-falls, gait, balance, feelings about falling (at least initial eval) Hx of fall circumstances, meds, chronic illness, mobility level GOOD PRACTICE! Quick screen/assessments: “Timed up & go” test One-legged stance Tinnetti GOOD PRACTICE! Examine intrinsic factors Gait Balance Orthostasis Vision Neuro Cardiovascular Addressing the home environment Addressing the community/environment Home environment: • Safety-proofing the living environment has been shown to decrease the risk of falls for older adults. GOOD PRACTICE! • Management of Fallers – Multi-component interventions: assessment & f/u, *exercise, *gait training, *med review, *specific treatment (e.g., visual, cardiac, orthostasis) – Single interventions: assessment & f/u, exercise (esp balance), *environmental assm’t/mod, *medication review & recommendations for possible adjustment Greenfield fall specifics Focus Group: asked about experiences and feeling regarding falls • 3 gentlemen (2 residents of the Manor, 1 rehab out-patient) • 4 women (all residents of the manor) Fallers: 2/3 men had experienced at least one fall ½ of the women had experienced at least one fall Reports: • Most reported falling because of an environmental hazard or lower extremity weakness • All fallers reported multiple falls • Reported fairly substantial injuries • Of those non-fallers, did not report fear nor even real concern over falling upon initial inquiry • Once they heard the brief presentation and reports by fallers, they reported they realized falls were something to be aware of Reports of fallers: • Did not always “tell” that they had fallen • Expressed feeling embarrassed that they fell • Acknowledged others found out because they noticed bruising, etc. Reports: • • • • All did not report “Fear” – BUT one reported “scared to death” Did report ‘think about it while I am walking/doing” Report they walk and do tasks at a slower pace Stated that activities were not reduced nor affected, or avoided BUTreported they do things differently Of interest?? • Of all the out-patients asked to participate in the Falls Focus group, only one accepted the invitation to participate. • Manor residents seemed interested in follow-up fall prevention programming • Suggested inviting not only residents, but their family members to any fall prevention programming or activities because “they should know too” Reports: • When asked “Who Knew”-regarding health professionals who ask about falling OR • Whether health professionals asked about their exercise habits………… Reports were that Doctors do not ask! about falls, they were unaware of any exercise engagement, and did not recommend any! Data collected Identifying Greenfield falls risks Findings: Of 100 Falls Risk Screenings completed: • 48 reported they had fallen in the last 12 months • 38 reported they were afraid they would fall • 47 reported they used an assistive device to help them walk Falls Prevention Project GOAL: • To help reduce the number of falls in community dwelling adults in WNY Why Greenfield? The mission of Niagara Lutheran Health System states: “We place the needs of the individual above all else and seek innovative approaches to care for each person regardless of age, condition, or disability. We believe that every person should be able to live with dignity, respect and in comfort." Greenfield Fall Reduction Program Goal: • To reduce the number of risks and incidence of falling within the out-patient population Will you be our fall prevention partner? Step 1: Continue with outpatient Falls Risk Screening form Step 2: Standardized falls risk assessment: Quick testing: • Timed up and Go Test (TUG) (EBP: Following slide) • One legged stance • (EBP: Following slide) • SCREEN ALL Out-Patients to determine further assessment and intervention needs! Falls Prevention Screening Falls Prevention Screening Patient Name: ____________________ Date: __________________________ Patient Age: _________ Clinician: ________________________ Section A: Screening Questions to Patient: Falls Screening Form: 1.) Have youPrevention fallen in the past year? Yes No 2.) Are you afraid of falling? Yes No 3.) Do you use adaptive equipment to ambulate? Yes No 4.) Do you ever feel dizzy or lightheaded? Yes No 5.) Do you have trouble getting up from a chair? Yes No 6.) Do you have trouble stepping up or down curbs or steps? Yes No 7.) Do you need to steady yourself by leaning on someone/something? (i.e. walls, grocery cart, furniture) Yes No 8.) Do you see well: during the day? Yes No at night? Yes No 9.) Do you have any of the following falls risks in or around your house: •Throw rugs Yes No •Pets: Yes No (if yes, indicate type(s): __________________________________) •Poor lighting: Yes No •Cluttered pathways: Yes No •Improper footwear: Yes No •Tripping hazards (i.e. O² tubes; electrical cords): Yes No •Other: _______________________________________________________ 10.) If you have fallen in the past year, what were the circumstances:[if no falls in past year: N/A] a.) What were you doing when you fell: __________________________________ b.) Did you loose consciousness? Yes No c.) Were you lightheaded/dizzy prior to fall? Yes No d.) Did you need help to get up from the fall? Yes No **How many “yes” answers in #10: (0-3) _______ (the more the higher the risk for falls). Section B: Screening Plan to Address Falls Risk: If the patient is at risk for fall:, 1.) Discuss this risk with the patient.:______________ Date discussed ______________ 2.) Communicate this risk with the patient’s M.D: _____Date M.D.informed __________ 3.) Ask the patient if s/he would like to pursue further testing/treatment that may reduce this risk: Date discussed_____________; Outcome: ______________________________. 4.) If the patient declines, please circle best choice below that indicates reason a.) Unable to address at this time._____________________________________ b.) Patient is non weight bearing /non ambulatory c.) No reason given. •Provided patient with Home Safety Check List:________________ Date provided. Section C: Clinician Assessment/Intervention of Falls Risk (indicate standardized test used) ______Timed-Up-and Go (TUG) ______Tai Chi Walking ______One-leg Stance ______Tinetti • Comments: ________________________________________________________________ TUG • Results indicated that the TUG is a simple screening test that is a sensitive and specific measure of probability for falls among older adults. Normative Values for the Unipedal Stance Test with Eyes Open and Closed COL Barbara A. Springer, PT, PhD, OCS, SCS¹; COL Raul Marin, MD¹; Tamara Cyhan, RN, BSN¹; CPT Holly Roberts, MPT, GCS¹; MAJ Norman W. Gill, PT, DSc, OCS, FAAOMPT¹ One-legged stance test: performance values support the unipedal stance test (eyes open and eyes closed) a reliable, readily available and easy to perform examination tool for balance testing. Step 3: Interventions for fall prevention! Use evidence based practice, which will support your use of interventions Interventions • Address the specific intrinsic factors • Falls Strategy Patient Education Sheet • Adaptive equipment/home modification suggestions • Home exercises: Tai Chi/other • Communication: Doctor/other team members Use of Tai Chi Walk as an intervention Falls Strategy education FALLS PREVENTION STRATEGIES What can you do to reduce your risk of falls? 1.) Be screened to determine your risk - Note: 1/3 of all older adults fall each year & 60% of all falls occur in and around the home 2.) Discuss options to reduce your risk with your doctor Note: Your doctor/health care provider may not bring it up, but YOU can! Discuss with your doctor/health care provider about: a). your medications, b.) your strength, balance & daily activity-level, c.) your home safety, d.) your need for assessing your risk for falls 3.) Exercise daily: this should be discussed with your doctor. Note: Walking is good exercise: it helps maintain/improve balance and independence. 4.) Make your home safer: Use this Home Safety Improvement Checklist: ___Remove any throw rugs & make sure all large area-rugs lie flat. ___Make sure you have night lights where you need them (especially the path from the bedroom to the bathroom). ___Keep areas clear of clutter, make sure they are well lit & stairs have railings ___Clearly mark any changes in floor levels with brightly colored paint or secure tape (i.e. small step to family room or threshold in garage). ___Install grab bars in bathroom(s) & use a bath seat in shower/tub. ___Move frequently-used kitchen & household items within easy reach. ___Make sure kitchen has a working smoke detector & fire extinguisher. ___Make sure emergency phone numbers are posted by each phone. ___Make sure you have an emergency exit plan in case of fire. ___Evaluate your need for/benefits from a medical alert device (and/or a cell phone). ___Wear well-fitting, rubber-soled shoes (avoid heels & open backed shoes & slippers). ___If using adaptive equipment (i.e. walker, cane), make sure they are adjusted for you, are in proper working order, & that you use them correctly. If you have any questions or would like help in assessing your risk for falls, please contact The Greenfield Health & Rehabilitation Center Outpatient Clinic at (716) 684-3000, ext. 320. We are your Partners in Falls Prevention! Step 4: Documentation of interventions Reimbursement V Code for History of Falls The Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) have developed a V code to identify older adults who have fallen and are predisposed to recurrent falls. The code, V15.88, indicates that the older adult may benefit from a fall risk evaluation and management of fall risk(s). Qualification of the Medicare V code 15.88 is based upon the presence and documentation of at least one of the following: •Recent history of falls in last 6-12 months* •Health-related falls risk factors* •Health behaviors related to falls* •*Documentation qualifies for use of Medicare V code 15.88, which is a secondary ICD10 code to be used with primary ICD10 codes. CMS Occupational and Physical Therapists who successfully participate in the PQRI program will receive a bonus payment equal to 2% of the estimated total allowed charges for all services in 2010. • • Definitions: Fall - A sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor, or the ground, other than as a consequence of sudden onset of paralysis, epileptic seizure, or overwhelming external force. • Risk Assessment - Comprised of balance/gait AND one or more of the following: postural blood pressure, vision, home fall hazards, and documentation on whether medications are a contributing factor or not to falls within the past 12 months. CLINICAL RECOMMENDATION STATEMENTS: CMS, 2009 • Older people who present for medical attention because of a fall, or report recurrent falls in the past year, or demonstrate abnormalities of gait and/or balance should be offered a multifactorial falls risk assessment. • This assessment should be performed by a health care professional with appropriate skills and experience, normally in the setting of a specialist falls service. This assessment should be part of an individualized, multifactorial intervention. (NICE) (Grade C) CMS Multifactorial assessment may include the following: • identification of falls history • assessment of gait, balance and mobility, and muscle weakness • assessment of osteoporosis risk • assessment of the older person's perceived functional ability and fear relating to falling • assessment of visual impairment • assessment of cognitive impairment and neurological examination • assessment of urinary incontinence • assessment of home hazards • cardiovascular examination and medication review CMS • • • • • • • • RECOMMENDATION STATEMENTS: Among community-dwelling older persons (Le., those living in their own homes), multifactorial interventions should include: • gait training and advice on the appropriate use of assistive devices • review and modification of medication, especially psychotropic medication • exercise programs, with balance training as one of the components • treatment of postural hypotension • modification of environmental hazards • treatment for cardiovascular disorders Case study learning: Ed and Rita Quick screening tools: Intervention Greenfield Policy & Procedure Competency Testing • Post-test • TUG • One legged stance • Tai Chi Walk Questions???