Falling among older adults: Research from prediction and prevention to practice and policy

2. Falling among older adults: Research from prediction and prevention to practice and policy University of North Carolina April, 2010 Mary Tinetti MD

3. Falling…

4. Falls among older adults: research from prediction to policy • First phase: acquiring the evidence • Second phase: translating evidence into practice and policy

5. 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

6. …T. Franklin Williams

7. First phase: Acquiring the evidence • Epidemiology • Prevalence (of falls and consequences) • Prediction • Clinical trial • Effective prevention strategies • Mechanisms of effect

8. 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

9. Epidemiology: Frequency • Community setting: • 30% of adults 70+ fall each year •  with age (50% by 80+) New Engl J Med, 1988

10. 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

11. 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

12. 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

13. Morbidity: Long term nursing home stay * Independent of demographic, psychosocial, medical, functional, and cognitive status New Engl J Med 1997

14. Epidemiology: Interpretation of study results • Falls are common • Falls are morbid • Falls are $$$$$$$

15. Epidemiology: Predict risk

16. 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

17. 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

18. ↓ Strength Impaired balance, gait Vision impairment Psychoactive meds ↑ risk ≥ 2-fold ↓ Postural BP Cognitive impairment Foot problems Depressive sxs 4+ Meds. NEJM 1988; JAGS1995 Predisposing risk factors (EPESE)*

19. 78% 60% 32% 19% 8% Risk of falls by number of predisposing risk factors

20. Risk factors for serious injury (Project Safety)

21. Precipitating factors* • 4+ medications • Footwear • Stairs • Unsafe behaviors * ≥ 2-fold risk of serious injury if falls

22. Precipitating factors Falls on stairs…  risk of serious injury 10-fold

23. By 1990s… • Much is known about epidemiology of falls (frequency, morbidity, risk factors (~50 epidemiologic studies) • Almost nothing is known about prevention

24. National Institute on Aging Frailty and Injuries: Cooperative Studies of Intervention Techniques (FICSIT)

25. 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

26. 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

27. Yale FICSIT: Targeted risk factors New Engl J Med 1994

28. Medications • Assessment • ≥ 4 medications • High-risk medications • Possible fall-related adverse medication effects • Management • Minimize medications

29. 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

30. 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

31. Yale FICSIT: Results N Engl J Med, 1994

32. 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%

33. Yale FICSIT: Mechanism of effect • RF reduction: ↓ no. of targeted risk factors → → → ↓ falls Am J Epidem 1996

34. 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

35. 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

36. 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

37. 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?

38. Connecticut Collaboration For Fall Prevention (CCFP) Funded by the Donaghue Foundation and the National Institute on Aging

39. 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

41. Recommended Practices: health care

42. Recommended Practices: Community

43. CCFP Methods Heighten awareness of falling as a preventable cause of morbidity: website, bus ads, posters, brochures,media…

44. CCFP Methods: Initial tasks • Determine core intervention to disseminate • Developpractice materials (checklists; manuals; passbooks, website) • Identify clinical (and community) sites/providers • Establish referral patterns among ED, PT, homecare, 1° care • Address Medicare reimbursement issues

45. 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

46. 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)

47. Methods to increase fall- related practices • Outreach visits (academic detailing) • Time consuming but necessary…

48. % offices with ≥1 outreach visit

49. 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

50. Aim 2 • To compare serious fall injury and fall-related utilization rates in a region in Connecticut exposed to CCFP interventions relative to a usual care region.