Donald Doell Suzanne Morin Joanne Creager Gary Inglis Danièle Benoit Anita Tonet

1. Donald Doell Suzanne Morin Joanne Creager Gary Inglis Danièle Benoit Anita Tonet Montreal General Hospital CATCHFallersCritical Assessment in a Teaching Clinic for High-risk Fallers http://www.CATCHFallers.com

2. Objective Implement a simple decision Tool for residents Identify, Assess, Intervene in cases of individuals at Risk of falls We believe this will improve Case-identification of patients at risk for falls, Medical interventions for fall risk reduction and increased number of Referrals to specialized services

3. Overview • 1. Significance of falls in the elderly • 2. Identification of High-risk Fallers • 3. Assessment for patients at high-risk for falls • 4. Intervention can make a difference

4. 1. Significance of falls in the elderly • One out of every three individuals living in the community and over the age of 65 will fall • This rate will increase with more advanced age and among institutionalized individuals • Unintentional injuries are the fifth leading cause of death in older adults with falls accounting for two thirds of these deaths

5. Falls result in significant morbidity and mortality • 6% of falls will result in a fracture • Of all fallers approximately 1% will sustain a hip fracture • The incidence of mortality after one year is 20-30% for hip fractures • 60% will be left with restricted mobility • Other falls will result in significant soft tissue injury, head injury, subdural hematoma • Falls lead to significant fear of falling • Falls lead to increased incidence of nursing home placement and loss of autonomy

6. 2. Identification of High-risk Fallers • History of falls is most predictive • In particular history of recurrent falls • Functional testing is useful in stratifying those who may be at risk

7. The Timed-up-and-go (TUG) >35s = High risk 15-35s = Indeterminate risk <15s = Low risk

8. Recommendations • All persons over the age of 65 should be questioned once per year about falls • Any individual with a history of recurrent falls should have further assessment • If there is a history of a single fall in the last year, then further functional testing (i.e. TUG) should be used to risk stratify

9. Other Risk factors of Particular Note • Muscle weakness • Gait deficit • Balance deficit • Use of assist device • Visual deficit • Arthritis • Limitation in > 1 ADL (activity of daily living) • Depression • Polypharmacy (greater than 4 medications)

10. 3. Assessment for patients at high-risk for falls • Falls are multifactorial • Approach to assessment and treatment must also be multifactorial

11. Fall history and assessment • History of the fall circumstances • Review of medications • Number of medications • Cardiovascular medications • Psychotropic medications (neuroleptics, benzodiazepines, and antidepressants) • Review of acute or chronic medical problems • Review of mobility status

12. Approach to exam for fallers • Exam of vision • Exam of gait & balance • Exam of lower extremity joint function • Exam of basic neurological function • Mental status • Muscle strength • Lower extremity peripheral nerves • Proprioception • Reflexes • Tests of cortical, extrapyramidal, and cerebellar function • Exam of basic cardiovascular status • Heart rate and rhythm • Postural pulse and blood pressure • If appropriate, heart rate and blood pressure responses to carotid sinus stimulation

13. 4. Intervention can make a difference • Multifactorial approach is most effective (can reduce falls as much as 43%) and includes: • 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 of cardiovascular disorders, including cardiac arrhythmias

14. Single most important interventions • Exercise – Most effective strategy (fall reduction 19%) • Environmental Modification • Medication review, reduction and modification for psychotropic medications

15. Summary

16. The CATCHFallers Concept Again Implement a simple decisionTool for residents Identify, Assess, Intervene in cases of individuals at Risk of falls We believe this will improve Case-identification of patients at risk for falls, Medical interventions for fall risk reduction and increased number of Referrals to specialized services

17. About the tool An online survey for residents to complete that will guide them through the proper assessment for high-risk fallers http://www.CATCHFallers.com

18. The pre-study survey CATCHFallers - Pre Study Questions Critical Assessment in a Teaching Clinic for High-risk Fallers - A pre-study survey for residents Pre-study questions 1 Approximately how many patients over the age of 75 have you specifically asked for a history of falls in the last three months? Please write your answer here: ____________________ 2 Approximately how many patients have you treated or investigated for an underlying medical condition because of a possibly increased risk for falls in the last three months? Please write your answer here: ____________________ 3 Approximately for how many patients have you changed or reduced the number of their medications because of a possibly increased risk for falls in the last three months? Please write your answer here: ____________________ 4 How many patients have you referred for outpatient specialized or mulitdisciplanary assessment because of risk of falls (i.e. physiotherapy, CLSC services, occupational therapy, geriatric consultation) in the last three months? Please write your answer here: ____________________ 5 Approximately how many patients would you have liked to refer for outpatient services but were were unable to because you were not aware how to or if these services were available in the last three months? Please write your answer here: ____________________

19. The CATCHFallers survey • Part I - Evaluation of risk Evaluation of risk Age What is the patient's age? About one out of every three individuals living in the community and over the age of 65 will fall. This rate will increase with more advanced age. Plese write your answer here: ____________________ Fall history Is there a history of a fall in the past year? All older persons should be asked at least once a year about falls. All older persons who report a single fall should have a TUG. Please choose *only one* of the following: o Yes o No Multiple falls Is there a history of recurrent falls in the past year? Older persons who present for medical attention because of a fall or report recurrent falls in the past year should have a fall evaluation performed. Please choose *only one* of the following: o Yes o No TUG How long did it take the patient to perform a TUG (timed-up-and-go)? The time it takes for an individiual to stand up from a chair, walk to a line 3 meters away on the floor using usual aids at a usual pace, turn around and walk back to the chair and sit down. TUG < 15s = low risk TUG 15s-35s = indeterminate risk TUG > 35s = high risk Please write your answer here: ____________________ Risk Do you think this patient might be at risk for falls? Please choose *only one* of the following: o Yes o No

20. The CATCHFallers survey • Part II - Evaluation of modifiable risk factors Evaluation of modifiable risk factors Number of meds How many medications does this patient take? Increased risk of falls has been demonstrated with greater than four medications. Please write your answer here: ____________________ Barthel What is the Patient's Barthel Score? link to an online calculator here: www.patient.co.uk/showdoc/40001654/ Please write your answer here: ____________________ History findings Have you identified a predisposing risk factor for falls in your history? Should include a history of fall circumstances, acute or chronic medical problems, and mobility levels. Pay particular attention to muscle weakness, gait deficit, balance deficit, use of an assistive device, visual deficit, arthritis, depression, cognitive impairment, cardiovascular causes as risk factors. Please choose *only one* of the following: o Yes o No Exam findings Have you identified a predisposing risk factor for falls in your exam? Should include examination of vision, gait and balance, and lower extremity joint function; an examination of basic neurological function, including mental status, muscle strength, lower extremity peripheral nerves, proprioception, reflexes, tests of cortical, extrapyramidal, and cerebellar function; and assessment of basic cardiovascular status including heart rate and rhythm, postural pulse and blood pressure. Please choose *only one* of the following: o Yes o No Medication Have you identified a predisposing risk factor in this patient's medications? Pay particular attention to any psychotropic medication (neuroleptics, benzodiazepines, and antidepressants) Please choose *only one* of the following: o Yes o No

21. The CATCHFallers survey • Part III - Documentation of Intervention Documentation of Intervention Medication change I have changed or modified this patient's medications, because of risk of falls. Reduction in total number of medications if greater than four, or modification of medications especially psychotropic medications. Please choose *only one* of the following: o Yes o No Medical condition I will investigate or treat an underlying medical condition that may be implicated in this patient's risk for falls. Pay particular attention to cardiovascular intervention, treatment and investigation of postural hypotension and visual impairment. Please choose *only one* of the following: o Yes o No Outpatient I have referred this patient for outpatient multidisciplinary assessment. Exercise programs are extremely effective in preventing falls and may be one of the single most effective preventative strategies, particularly when combined as part of a multifactorial intervention. Please choose *only one* of the following: o Yes o No

22. Bottom Line • Bottom Line In the universe some things are constant • Exercise – Single most effective strategy • Environmental Modification • Medication review, reduction and modification for psychotropic medications Gravitational constant = 6.67300 × 10-11 m3 kg-1 s-2 The elderly will continue to fall Falls can be prevented

23. Bottom Line • References • Laurence Z Rubenstein and Karen R Josephson Falls and their prevention in elderly people: what does the evidence show? 2006 • Guideline for the prevention of falls in older persons. American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopedic Surgeons Panel on Falls Prevention. 2001 • Kerri M Clough-Gorr and Thomas Erpen and Gerhard Gillmann and Wolfgang von Renteln-Kruse and Steve Iliffe and John C Beck and Andreas E Stuck Preclinical disability as a risk factor for falls in community-dwelling older adults. 2008 • Ellinor Nordin and Nina Lindelöf and Erik Rosendahl and Jane Jensen and Lillemor Lundin-Olsson Prognostic validity of the Timed Up-and-Go test, a modified Get-Up-and-Go test, staff's global judgement and fall history in evaluating fall risk in residential care facilities. 2008 • Anne Tiedemann and Hiroyuki Shimada and Catherine Sherrington and Susan Murray and Stephen Lord The comparative ability of eight functional mobility tests for predicting falls in community-dwelling older people. 2008 • Cameron G Swift The role of medical assessment and intervention in the prevention of falls. 2006 • Theodore Speroff and Gerald T O'Connor Study designs for PDSA quality improvement research. 2004 • www.aafp.org/afp//AFPprinter/20000401/2159_f1.jpg • 1to3.livedoor.biz/archives/50358915.html • Exercise – Single most effective strategy • Environmental Modification • Medication review, reduction and modification for psychotropic medications