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5/9/2012
1
FALL RISK AND PREVENTIONIN OLDER ADULTS
Josette Rivera, MDAssistant Professor of Medicine
Division of GeriatricsDepartment of MedicineUniversity of California
Ellen Corman, BS, MRASupervisor, Community Outreach
and Injury PreventionStanford University Medical Center
Trauma Service
Sponsored by
Stanford Geriatric Education Center
in conjunction with
American Geriatrics Society,
California Area Health Education Centers,University of California, San Francisco
Trauma Service
May 10 2012
This project is/was supported by funds from the Bureau of Health Professions (BHPr), Health Resources and Services Administration (HRSA), Department of Health and Human Services (DHHS) under UB4HP19049, grant title: Geriatric Education Centers, total award amount:
$384,525. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by the BHPr, HRSA, DHHS or the U.S. Government.
California Area Health ducation Centers,
and
Natividad Medical Center
Natividad Medical Center CME Committee Planner Disclosure Statements:
The following members of the CME Committee have indicated they have no conflicts of interest to disclose to the learners: Kathryn Rios, M.D.; Anthony Galicia, M.D.; SandraG. Raff, R.N.; Sue Lindeman; Janet Bruman; Jane Finney; Tami Robertson; Judy Hyle, CCMEP; Christina Mourad and Nobi Riley
“Fall Risk and Prevention in Older Adults”
Stanford Geriatric Education Center Webinar Series Planner Disclosure Statements:
The following members of the Stanford Geriatric Education Center Webinar Series Committee have indicated they have no conflicts of interest to disclose to the learners:Gwen Yeo, Ph.D. and Kala M. Mehta, DSc, MPH
Faculty Disclosure Statement:
As part of our commercial guidelines, we are required to disclose if faculty have any affiliations or financial arrangements with any corporate organization relating to thispresentation. Dr. Rivera and Miss. Corman have indicated they have no conflicts of interest to disclose to the learners, relative to this topic.
Dr. Rivera and Miss. Corman will inform you if they discuss anything off-label or currently under scientific research.
Josette Rivera is a clinician educator and an Assistant Professor of Medicine in the Division of Geriatrics. She is dedicated to providing primary and palliative care to homebound older adults throughout San Francisco through the UCSF Housecalls Program. Dr. Rivera’s educational focus is on training students and professionals how to collaborate within interdisciplinary teams to provide effective, patient-centered care for older adults. She recently received a Geriatric Academic Career Award with which she will create and expand interprofessional and geriatric education opportunities at UCSF.
Dr. Rivera received her medical degree from the University of Rochester and residency training in Primary Care Internal Medicine at Johns Hopkins Bayview. She then completed a three year clinical and research fellowship in the Division of Geriatric Medicine and Gerontology at Johns Hopkins. At the conclusion of fellowship, Dr. Rivera became a staff physician at On LokLifeways, a Program of All-Inclusive Care for the Elderly, which serves nursing home eligible seniors in the San Francisco area. She joined the Geriatrics faculty at UCSF in 2008.
Ellen Corman, MRA
Ellen Corman, Supervisor of Community Outreach and Injury Prevention for the Trauma Service at Stanford University Medical Center, has over 20 years experience working in the area of injury prevention. She has an undergraduate degree in Occupational Therapy and a Masters degree in Rehabilitation Administration. Ellen was a member of the state’s Injury Prevention Strategic Planning Committee and active in the state’s Stop Falls Network. Ellen currently co-chairs the San Mateo County Fall Prevention Task Force and developed and manages a fall prevention program for older adults called Farewell to Falls at Stanford’s Trauma Service. She has presented locally to seniors, caregivers and professionals and has presented at national conferences.
1
Fall Risk and Prevention in OlderPrevention in Older
Adults
Josette Rivera, MDDivision of Geriatrics
UCSF
2
3
2
Objectives
By the end of this discussion, participants should be able to:
1. Understand the personal and societal impact of falls
2. Identify risk factors for falls among older adults
3 Describe evidence based guidelines for screening and prevention3. Describe evidence based guidelines for screening and prevention
4. Discuss interventions that have been demonstrated to reduce falls in clinical trials
What is a Fall?
• Unintentionally coming to rest on the ground or other lower level
• Not due to a major intrinsic event or overwhelming environmental hazard
• No loss of consciousness
The Importance of Falls
3
Older Adult Falls Burden 2006
Fifth leading cause of death in
older adults
CDC’s Research Portfolio in Older Adult Fall PreventionSleet DA J Safety Res. 2008;39(3):259-67
Falls Cause Morbidity and Mortality
• Injuries are common:
– 40% of falls result in minor injuries
– 10% result in major injuries
• 2.2% of injurious falls result in death
• Cost of fall-related injuries for 65+
– Currently $19 billion -> $54.9 billion by 2020
Chang JT BMJ 2004Tinetti ME JAGS 1995
Tinetti ME JAMA 2010MMWR Morb Mortal Wkly Rep 2008
Falls Associated with Functional Decline
• Decline in function/loss of independence
• Fallers 3X more likely to enter SNF
• Fear -> isolation, further functional decline
– 60% fallers reported moderate activity restriction
15% reported severe restriction– 15% reported severe restriction
Deshpande N JAGS 2008Tinetti, ME N Engl J Med
1997MMWR Morb Mortal
Wkly Rep 2006; 55:1221Tinetti, ME J Gerontol A
Biol Sci Med Sci 1998
4
Epidemiology of Falls
Question
What % adults > 65 yrs old living in the community fall each year?
A. 5%
B. 10%
C 20%C. 20%
D. 30%
E. 50%
Incidence
• 30% of community-dwelling people over the age of 65 fall each year
• Increases to ~50% for those 80 years and older
• Half are repeat fallers
Chang JT BMJ 2004Tinetti ME N Engl J
Med 2003Rubenstein
LZ Clin Ger Med 2002
5
Question
Which ethnic groups are most likely to fall?
A. African Americans
B Asian AmericansB. Asian Americans
C. Latino Americans
D. European Americans
E. No difference between groups
Falls and Socio-demographic Factors
18.3%
11.3%
7.9%
15.3%
Latino AfricanAmerican
Asian White
Multiple falls past year, age 65+Source: 2007 California Health Interview Survey
Question
Which ethnic group is most likely to be hospitalized because of a fall?
A. African Americans
B. Asian Americans
C. Latino Americans
D. European Americans
E. No difference between groups
6
American Geriatrics Society Fall Prevention Guidelines
www.medcats.com/FALLS/frameset.htm
Screening
• AGS: All adults > 65 should be asked at least annually if they have fallen in the past year or whether they have difficulties in gait or balance
• Single fall: check balance/gait
• Recurrent falls or balance/gait disturbance: do multifactorial fall risk assessment
Tinetti ME JAMA 2010AGS Fall Prevention Clinical Practice Guidelines 2010
2010 AGS/BGS Clinical Practice Guideline
7
Evaluation of the Faller
Evaluation of Falls: History
• Rule out acute badness
– Syncope or fall?
– Injury?
– Acute illness?
• Any recent changes in health or environment?
Evaluation of Falls: History
• Relevant medical conditions
– Neurolgical, cardiac, ophtho, incontinence, osteoporosis
• Medications
– Psychoactive? Recent changes? Total # > 4?
• Substance/alcohol use
• Difficulty with walking or balance
• Ability to complete ADLs
• Fear of falling
8
Gait and Balance Evaluation
• You have not fully examined the nervous or musculoskeletal systems until you have analyzed gait
• Quick, validated, in office tests
Timed Up and Go– Timed Up and Go
• Physical Therapy Evaluation (insurance/$ dependent)
– Outpatient
– Adult Day Health Center
– Home Care
Mathias A Arch Phys Med Rehab 1986Podsiadlo D JAGS 1991Tinetti ME JAGS 1986
Evaluation of Falls: Physical Exam
• Supine and standing BP & CV exam
• Vision and hearing evaluation
• Neurological exam, including cognition
• Musculoskeletal exam
• Feet/footwear
• Formal gait and balance assessment
• Inappropriate assistive device use
Etiology and Risk Factors
9
Thinking About Fall Risk
Intrinsic Factors Extrinsic Factors
Medical Medications
FALLS
conditions
Impaired vision and hearing
Age- related changes
Improper use of assistive devices
Environment
Most Common Fall Risk Factors
Risk Factor Relative Risk # studies
Previous Falls 1.9 – 6.6 16
Balance Impairment 1.2 – 2.4 15
Decrease Muscle Strength 2.2 – 2.6 9
Vision Impairment 1.5 – 2.3 8
Meds: > 4 or psychotropic 1.1 – 2.4 8
Gait impairment 1.2 – 2.2 7
Depression 1.5 – 2.8 6
Orthostasis 2.0 5
Age >80 1.1 – 1.3 4
Female 2.1 – 3.9 3
Cognitive Impairment 2.8 – 3.0 3
Arthritis 1.2 – 1.9 2
Tinetti,JAMA. 2010;303(3):258-266
Thinking About Fall Risk
1 year follow up
Tinetti ME N Engl J Med 1988
10
Summary
• Falls are common and multifactorial
• Often lead to injuries, functional decline, nursing home placement, and death
• Screen older adults for falls at least annually
• Evaluation should included risk factor assessment, gaitEvaluation should included risk factor assessment, gait assessment, and home assessment
• Targeted multifactorial interventions most effective
• AGS Fall Prevention Guidelines available
• Interprofessional collaboration essential
Resources
• American Geriatrics Society Fall Prevention Clinical Practice Guideline
– http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2010/
• Centers for Disease Control Falls in Adults Publications and Resources
– http://www.cdc.gov/HomeandRecreationalSafety/Falls/index-pr.html
• NIH Senior Health: Falls and Older Adults for patients
http://nihseniorhealth gov/falls/toc html– http://nihseniorhealth.gov/falls/toc.html
• Tinetti M and Kumar C. The Patient Who Falls: It’s Always a Trade Off. JAMA. 2010;303(3):258-266
• Michael YL et al. Primary Care–Relevant Interventions to Prevent Falling in Older Adults: A Systematic Evidence Review for the U.S. Preventive Services Task Force. Ann Intern Med. 2010;153:815-825.
5/9/2012
1
ELLEN CORMAN OT MRA
Fall Risk Best Practice in
Prevention
ELLEN CORMAN, OT, MRAST AN FO RD HO SP IT AL AN D
CL IN ICST RAU MA S E RV IC E
Falls at Stanford Trauma
12%
5%
5%1%1% 1% 1%
0%0%
Cause of Injury > = 65 years old
FALL
MVC
PEDESTRIAN
74%
12% BICYCLE
OTHER BLUNT
MCC
ASSAULT
OTHER PENETRATING
STABBING
GSW
In 2006, there were 2,645
hospitalizations due to falls.
Santa Clara County Fall Facts
Average cost of hospitalization
estimated to be $38,563/person.
Average cost of ambulance ride
after 911 call in Santa Clara
County estimated to be $1,423.
5/9/2012
4
Best Practice in Fall Prevention
Causes of falls are due to multiple causes. Therefore,
the best intervention to prevent f ll i f d b l i f lfalls is found to be multi-factoral. (Tinetti, Baker, McAvay, Claus, Gareet, Gottschalk,
NJMed, 1994)
Interventions for Fall Prevention
Medication Review special attention to psychotropic drugs
Home Safety Assessment and Modification Most effective if can assure follow-through with recommendations
Exercise Exercise Type and frequency of exercise not conclusive
Balance and strength training seems to be most effective
Tai Chi – only exercise strategy that was significantly effective in isolation of other interventions.
Personal Habits Attention to surroundings and change in behaviors.
Farewell to Falls
Free home-based program offered by Trauma Service at Stanford Hospital and Clinics
Multi-faceted program Home Safety
di i Medication management
Strength/balance – exercise
Personal habits
5/9/2012
5
Program Implementation
Two home visits by Occupational Therapist
Health, ADL and activity interview
Medication review (meds listed by OT and reviewed by Stanford pharmacist with written report)
Sensory-Motor assessment
Home safety assessment
Exercise and Home Safety Intervention
Connection to community exercise program and/or home-based exercise program with DVD provided and/or written material.Home-based exercise is equally beneficial for
ti i t b d i (Ki H k ll t participants as group-based exercise (King, Haskell, et al, 1991:Vol266 No11)
Connection to home safety company to install grab bars, if necessary. Program covers those who need financial assistance.
Admission Criteria
65 years and older
Live in Santa Clara or San Mateo County in home or apartment
Ambulatoryy
Cognitively aware – can follow instructions and provide own health history
Willing to commit to exercise and program recommendations
5/9/2012
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Evidence-Based Fall Prevention Programs
A Matter of Balance – Volunteer Lay Leader Model www.mainhealth.org
Stepping On Wisconsin Institute of Healthy Aging – 608-243-5690
Tai Chi: Moving for Better Balance Oregon Research Institute, Eugene, Oregon
Otago [email protected]
Resources
National Council on Aging (NCOA) – Center for Healthy Aging, www.ncoa.org/improve-health/center-for-healthy-aging
Public Health Agency of Canada – Evidence for Best Practices on the Prevention of Falls and Fall-Related Injuries Among Seniors Living in the Community, www.phac-aspc.gc.ca/seniors-aines/publications/pro/injury-blessure/practices-pratiques/chap4-eng.php
King AC, Haskell WL, Taylor CB, Kraemer HC, DeBuskRF, Group- vs Home-Based Exercise Training in Healthy Older Men and Women: A Community-Based Clinical Trial, JAMA, 1991; 266(11):1535-1542.
For information about Farewell to Falls or a Matter of Balance, contact:
ELLEN CORMAN
SUPERVISOR, INJURY PREVENTION
STANFORD UNIVERSITY MEDICAL CENTER STANFORD UNIVERSITY MEDICAL CENTER
TRAUMA SERVICE
650-724-9369