Transcript Falls

Falling among older adults:
Research from prediction and
prevention to practice and policy
University of North Carolina
April, 2010
Mary Tinetti MD
Falling…
Falls among older adults: research
from prediction to policy
• First phase: acquiring the
evidence
• Second phase: translating evidence
into practice and policy
Early 1980s
• Falls considered inevitable part of aging
– Accidens: to happen, chance event
• Little was known about fall risk
• Nothing was known about prevention
• Not a focus of investigation
…T. Franklin Williams
First phase: Acquiring the evidence
• Epidemiology
– Prevalence (of falls and consequences)
– Prediction
• Clinical trial
– Effective prevention strategies
– Mechanisms of effect
Falls in the community: 1985 –1990
• #1: Substudy New Haven EPESE (N=350)
• Representative sample of persons 75+
• Interview and exam, monthly phone calls
• 1-year follow-up
• # 2: Project Safety
• Probability sample of 1103 persons
• Yearly interview / exam, daily calendars
• 3-year followup
Epidemiology: Frequency
• Community setting:
– 30% of adults 70+ fall each year
–   with age (50% by 80+)
New Engl J Med, 1988
Epidemiology: Morbidity
• 3 year f/u of Project Safety cohort
• 10% of falls → serious injury
(fracture, TBI, soft tissue )
• 8% persons 70+ → ED after fall;
– ½ were admitted to hospital
J Am Geriatr Soc, 1995
Epidemiology: Morbidity
• ~1/2 of fallers unable to get up
JAMA, 1995
• 1 in 5 fallers acknowledged avoiding
activities because of fear of falling
J Gerontol, 1994
• Extra $24,000/person
Med Care, 1998
Morbidity: Functional decline
• Non-injurious and injurious falls * ↓ in
basic and instrumental ADLs, social
and physical activities
*Independent of demographic, medical,
cognitive, and psychosocial factors
J Gerontol, 1998
Morbidity: Long term nursing
home stay
 1 fall w.o. injury
3.1 (1.9, 4.9)
 2 falls w.o. injury
5.5 (2.1,14.2)
 1+ fall
10.2 (5.8,17.9)
with
injury
* Independent of demographic, psychosocial,
medical, functional, and cognitive status
New Engl J Med 1997
Epidemiology: Interpretation of
study results
• Falls are common
• Falls are morbid
• Falls are $$$$$$$
Epidemiology: Predict risk
Fall prediction: Geriatric syndrome
 Health condition that:
– Results from accumulated effect of
multiple impairments / diseases
– Occurs when older adults who are
predisposed are exposed to
precipitating challenges
JAMA, 1995
Epidemiology: Predict risk
• Identify
– Predisposing risk factors: chronic health
conditions that compromise stability or 
risk of injury
– Precipitating risk factors: transient
factors within individual or environment
that  risk at time of event
Predisposing risk factors (EPESE)*
• ↓ Strength
• Impaired balance,
gait
• Vision impairment
• Psychoactive meds
• ↓ Postural BP
• Cognitive
impairment
• Foot problems
• Depressive sxs
• 4+ Meds.
↑ risk ≥ 2-fold
NEJM 1988; JAGS1995
Risk of falls by number of predisposing
risk factors
100
Percent Falling
78%
80
60%
60
32%
40
19%
20
0
8%
0
1
2
3
Number of Risk Factors
4+
Risk factors for serious injury
(Project Safety)
Cognitive impairment
2.2 (1.5, 3.2)
≥ 2 chronic conditions
2.0 (1.4, 2.9)
Balance / gait impairment
1.8 (1.3, 2.7)
Female
1.8 (1.1, 2.9)
Body mass index < 20
1.8 (1.2, 2.5)
J Am Geriatr Soc, 1995
Precipitating factors*
•
•
•
•
4+ medications
Footwear
Stairs
Unsafe behaviors
* ≥ 2-fold risk of serious injury if falls
Precipitating factors
Falls on stairs…
 risk of serious
injury 10-fold
By 1990s…
• Much is known about epidemiology of
falls (frequency, morbidity, risk
factors (~50 epidemiologic studies)
• Almost nothing is known about
prevention
National Institute on Aging
Frailty and Injuries:
Cooperative
Studies of
Intervention
Techniques
(FICSIT)
Yale FICSIT:1992 - 1996
Aim: Compare effectiveness of targeted
multifactorial intervention (TI) and usual
care + social visits (SV) at ↓ falls
• Hypothesis: Risk of falling  with # risk
factors → risk of falling ↓ by reducing
risk factors
Yale FICSIT:1992 - 1996
• Design: RCT
• Population: 301 community living persons
70+ with ≥ 1 fall risk factor
• Intervention: Standardly-tailored
multifactorial intervention targeted at
each of 6 modifiable risk factors
Yale FICSIT: Targeted risk factors

TI (153) SV (148)
Postural hypotension
46%
39%

Sedative use
19%
18%

4+ Prescriptions
42%
49%

 Leg strength
37%
49%

 Arm strength
22%
24%

Balance/gait impair
62%
69%
New Engl J Med 1994
Medications
• Assessment
– ≥ 4 medications
– High-risk medications
– Possible fall-related adverse
medication effects
• Management
– Minimize medications
Medications: Minimize
• If:
– ≥4 medications and ≥ 1 high risk med.
and ≥ 1 medication sign/symptom
• Then consider:
– What is the net benefit vs. harm of
medications for patient’s overall health
– What can be eliminated or reduced?
– Think total doses of all drugs
Balance, gait, muscle strenth
management
 Gait training
 Assistive device –right device used
correctly
 Appropriate footwear - high box, thin
sole, low heel
 Strength training
 Balance training
Yale FICSIT: Results
N Engl J Med, 1994
Yale FICSIT: Conclusions
Multifactorial, targeted intervention:
• Feasible - 85% enrolled; 80% adhered
• Safe - No injuries during 20,000
unsupervised exercise sessions
• Effective
– ↓ % who fell by 25%
– ↓ rate of falling by 31%
Yale FICSIT: Mechanism of effect
• RF reduction: ↓ no. of targeted risk factors
→→→
↓ falls
Am J Epidem 1996
Yale FICSIT: Mechanism of effect
• Tl>SV improvements in 3/6 RF:
– Postural BP (p=0.01)
– Gait / balance (p=0.004)
– No. of medications (p=0.003)
Am J Epidem 1996
By 2001…
• Much is known about fall risk and
prevention, but…
•Falls largely neglected outside select
settings
• Survey of primary care providers≈30% ask about falls
J Am Geriatr Soc, 2003
Falls among older adults: research
from prediction to policy
• First phase: acquiring the evidence
– Falls common, predictable, preventable
• Second phase: translating evidence
into practice and policy
Falls research: Translation
• Disconnect between evidence (>60
RCTS) and practice (ignored)
• Can fall risk assessment and
management be imbedded in care
• If so, is it effective?
Connecticut Collaboration For Fall
Prevention (CCFP)
Funded by the Donaghue
Foundation and the National
Institute on Aging
38
CCFP: Aims
• To encourage health care and
community providers to incorporate
evidence-based fall risk evaluation/
management into their practices
• To determine effect on serious fall
injury and fall-related health utilization
• To identify barriers and facilitators to
adopting fall-related practices
Recommended Practices: health care
Provider/
Facility
Assess/
Refer
Risk Factor Management
Gait Med. Post. Vis./
Bal. adjust BP hear
ED /
hospitals
X
PT/OT
X
X
Home
care
X
X
X
X
X
X
X
X
1º MDs
X
Feet
Env
X
X
X
X
X
X
Recommended Practices: Community
Provider/
Facility
Assess/
Refer
Risk Factor Management
Gait Med. Post. Vis./
Bal. adjust BP hear
EMS
X
Senior
centers
X
Assisted
living
Senior
housing,
etc
X
X
X
X
X
Feet
Env
X
X
CCFP Methods
Heighten awareness
of falling as a
preventable cause
of morbidity:
website, bus ads,
posters, brochures,
media…
CCFP Methods: Initial tasks
• Determine core intervention to disseminate
• Develop practice materials (checklists;
manuals; passbooks, website)
• Identify clinical (and community)
sites/providers
• Establish referral patterns among ED, PT,
homecare, 1° care
• Address Medicare reimbursement issues
CCFP Methods to translate
research into practice
• Composite of professional change
strategies → enhance knowledge,
skills, fall-related practices
• No one strategy ideal or effective
• Evidence suggests multiple strategies
most effective
Methods to increase fall- related
practices
• Buy in from leaders; champions; early
adopters
• Working groups; local participation in
planning and implementation
• Patient-mediated (patients request fall
management)
Methods to increase fall- related
practices
• Outreach visits
(academic
detailing)
• Time consuming
but necessary…
% offices with ≥1 outreach visit
100
90
80
Percentage
70
60
50
Home Care Agencies (n=26)
40
Outpatient Rehabilitation Offices (n=133)
30
20
Primary Care Offices (n=212)
10
Senior Centers (n=41)
0
10/2001 10/2002 10/2003 10/2004 10/2005 10/2006
Year
CCFP: Aims
• To encourage health care (and
community) providers to incorporate
evidence-based fall risk evaluation/
management into their practices
• To determine effect on serious fall
injury and fall-related health utilization
• To identify barriers and facilitators to
adopting fall-related practices
Aim 2
• To compare serious
fall injury and fallrelated utilization
rates in a region in
Connecticut
exposed to CCFP
interventions relative
to a usual care
region.
Adj. serious fall injury / fall-related utilization
rates in intervention vs. usual care regions.
Usual Care
36
90
Rate per 1000 Persons
70 Years and Older
Rate per 1000 Persons
70 Years and Older
Intervention
34
32
30
28
85
Usual Care
Intervention
80
75
70
65
26
60
Pre-Intervention
10/1999 - 9/2001
Intervention
Evaluation
10/2001 - 9/2004
10/2004 - 9/2006
Pre-Intervention
10/1999 - 9/2001
Intervention
Evaluation
10/2001 - 9/2004
10/2004 - 9/2006
New Engl J Med, 2008
CCFP: Aims
• To encourage health care (and
community) providers to incorporate
evidence-based fall risk evaluation/
management into their practices
• To determine effect on serious fall
injury and fall-related health utilization
• To identify barriers and facilitators to
adopting fall-related practices
Challenges / barriers to fall prevention
• Clinicians and seniors unaware of
falling and fall prevention
• Perceived lack of expertise
• Lack of familiarity and fragmentation
among multiple clinicians in multiple
settings
J Am Geriatr Soc, 2005
Challenges / barriers to fall prevention
• Arcane Medicare coverage / payment
• Patients aren’t asking for it
• Competing demands (providers
bombarded with guidelines, Q.I.)
• Coordination between health care and
community facilities
Facilitators / incentives fall prevention
• Medicare covers all (most) components
• Provider-specific incentives
– fallers divert resources in E.D.s
– evidence-based practice for PT/OT
– new market for PT/OT, home care
• Mandates, incentives are emerging
Gerontologist, 2007
Fall prevention: ongoing activities
• New AGS guidelines (J Am Geriatr Soc)
• Work with CMS and CDC on coverage
• CMS and NQF- fall assessment as
quality measure
• National Action Plan (NCOA)-Falls free
coalition
• State legislation