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FALL PREVENTION: RESEARCH TO PRACTICE

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. Preventing Falls: What does the evidence show?. Background: Epidemiology, costs

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FALL PREVENTION: RESEARCH TO PRACTICE

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  1. 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

  2. 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

  3. Famous Fallers

  4. Fall Incidence in Older Adults[rate/person/yr] or [rate/bed/yr] Rubenstein LZ, Josephson KR. Clin Geriatr Med. 2002(May);18(2):141-158

  5. 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

  6. 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

  7. Causes of Falls: Summary of 12 Studies • Accident/environment31% • Gait/balance disorder17 • Dizziness/vertigo13 • Drop attack10 • Confusion 4 • Postural hypotension 3 • Vision problem 3 • Other specified15 • Unknown 5 Rubenstein LZ, Josephson KR. Clin Geriatr Med. 2002(May);18(2):141-158

  8. Risk Factors for Falls: 16 Multivariate Studies Rubenstein LZ, Josephson KR. Clin Geriatr Med. 2002(May);18(2):141-158

  9. Drugs & Falls: Meta-analysisLeipzig, 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 ψagents no better. --Hien, Cumming, Cameron, et al, JAGS 53:1290, 2005

  10. 12-Month Fall Rate in NH: Interacting Risk Factors Robbins AS, Rubenstein LZ, Josephson KR, et al. Arch Intern Med. 1989(July);149(7):1628-1633

  11. 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 • Outdoors • bad weather • poor sidewalks • traffic activity • street crossings • uneven steps • distractions • obstacles • ↑ activity levels • Institution • low lighting • new admission • poor furniture • slick hard floors • low supervision • ↓ # of nurses • meal times • no hand rails

  12. ri • Intrinsic Risk Factors • Gait & balance impairment • Peripheral neuropathy • Vestibular dysfunction • Muscle weakness • Vision impairment • Medical illness • Advanced age • Impaired ADL • Orthostasis • Dementia • Drugs • Extrinsic Risk Factors • Environmental hazards • Poor footwear • Restraints • Precipitating Causes • •Trips & slips • Drop attack • Syncope • Dizziness FALL

  13. Fall Risk Assessment MeasuresPerell 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)

  14. 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.”

  15. Fall Prevention Trials:>100 RCTs since 1984 • Assessment (preventive & post-fall) • Exercise & rehabilitation programs • Environmental modifications • Devices • Nursing interventions • Combined interventions

  16. Benefits of a Post-Fall AssessmentResults 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

  17. Benefits of a Post-Fall AssessmentPrevention 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):93-97

  18. 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)

  19. Tai Chi and Fall Reduction in Older AdultsLi 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-chiStretching Falls 3873 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

  20. Hip Protectors – Examples Safehip KPH CuraMedica HipGuard HIPS

  21. 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

  22. 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

  23. Anti-Slip Footwear – Examples Fashion Treads Care-Steps Pillow Paws Walk Alerts

  24. Bed & Chair Monitors – Examples Bed & Chair Alarm Chair Sentry Locator Alarm AirPro Alarm Safe-T Mate Alarmed Seatbelt Economy Pad Alarm Floor Mat Monitor Keep Safe QualCare Alarm

  25. Do Bedrails Prevent Falls? Pre-Post StudyAHC 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: before-89 after-106 • Serious fall injuries: before-33 after-18 • Minor fall injuries: before-43 after-60

  26. Bedside Mats – Fall Cushions CARE Pad bedside fall cushion Posey Floor Cushion NOA Floor Mat Roll-on bedside mat Soft Fall bedside mat Tri-fold bedside mat

  27. Fall Prevention Trials:RAND-CMS Meta-analysis • Lit review (1980-2002): 830 pubs, 41 RCTs Fall riskMonthly fall rate All RCTs:.88 [.82 - .95] .79 [.71 - .87] Meta-regression of intervention components: • Fall eval + f/u.82 [.72 - .94] .63 [.48 - .83] • Exercise.86 [.75 - .99] .84 [.71 - .98] • Environ mod.90 [n.s.] .85 [n.s.] • Education[n.s.] [n.s.]

  28. Exercise Type 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 Components

  29. 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

  30. Vitamin D Effect on Falls: Meta-analysisBischoff-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

  31. 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

  32. 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

  33. Vibrating Insoles may improve balance Priplata AA, et al. Vibrating insoles & balance in elderly people. Lancet 2003; 362:1123.

  34. Fall Prevention Strategies • COMMUNITY • Risk-factor screen & intervention • Post-fall assessment • Exercise program (strength, balance) • Environmental inspection & modification • INSTITUTION • Organized program • Risk-factor screen • Post-fall assessment • Nurse awareness • Targeted interventions (e.g., hip pads, low bed, bed/ chair alarms, monitors)

  35. 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

  36. No intervention No falls Single fall Recurrent falls Check for gait/balance problem Gait/balance problems No problems Patient presents to medical facility after a fall Fall Evaluation* Assessment History Medications Vision Gait and balance Lower limb joints Neurological Cardiovascular Multifactorial intervention (as appropriate) Gait, balance, exercise - programs Medication - modification Postural hypotension - treatment Environmental hazards - modification Cardiovascular disorders - treatment Assessment and Management of Falls Periodic case finding in Primary Care: Ask all patients about falls in past year

  37. 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)

  38. 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

  39. 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 community-dwelling population • To provide an educational venue for a variety of trainees

  40. 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

  41. Interdisciplinary Team Approach • Occupational Therapist • Physical Therapist • Physician (Geriatrician) • Referrals as needed for other resources or providers

  42. 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.

  43. 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

  44. Occurrence of Falls According to the Number of Risk Factors(Tinetti, 1988)

  45. 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

  46. 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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