Fall Prevention in Practice

1. Fall Prevention in Practice Mary Spivey, MD April 18, 2018

2. Objectives • Define falls • Understand risks associated with falling • Recognize falls as a syndrome • Learn how to perform and interpret a simple clinical fall assessment • Know how to implement at least 3 interventions in fall prevention

3. Fall • Definition • Coming to rest inadvertently on the ground or at a lower level • Excludes Syncope • Costs • $19 Billion in 2000 • Est. at $54.9 billion by 2020 Annals IM 2012, Chen 2014, Eekhof 2001, Lee 2013

4. Fall Frequency and Outcome • Fall Risk per age • Age > 65- 28-35% • Age > 70 – 32-42% • Age > 80- > 50% • Injury • Complications from Falls are the leading cause of DEATH in adults > 65 y/o • Serious injury seen in 24% • Fracture seen in 6% Annals IM 2012, Chen 2014, Eekhof 2001, Lee 2013

5. Etiology of Falls • Intrinsic • Balance, weakness, chronic illness or cog impairment • Extrinsic • Polypharmacy, FRID’s • Environmental • Poor lighting, weather, equipment, carpet Geriatrics at your Fingertips

6. Risk Assessment • Unfortunately no evidence based instrument that accurately identifies high-risk persons for falls • Factor most often used is History of Fall • Additional factors are commonly used in people to consider them higher risk Annals IM 2012

7. 2010 AGS/BGS Guidelines(sweetened/condensed/paraphrased version) • All older adults need to be asked about falls • If they have fallen ask about circumstance/frequency • Anyone with fall problems need to be assessed • Including people reporting problems with balance or walking • A Multifactorial Fall Risk Assessment should be completed if: • Assessment is positive for gait/balance problems, or • Assessment is unable to be performed due to safety Otherwise, the ONLY people who don’t need a multi-factorial assessment are people who have fallen only once and have a normal gait and balance exam.

8. Multifactorial Fall Risk Assessment Focused History Physical Exam Functional Assessment Environmental Assessment

9. History • Fall history • Describe circumstances, frequency, symptoms, injuries • Medications • All meds including OTC and Rx need reviewed • Risk Factors • Acute and chronic medical problems

10. Physical Examination • ORTHOSTATICS! • Neurologic evaluation • Cognitive status, proprioception/neuropathy • Gait, balance and mobility assessment (*TUG) • Muscle strength • Visual acuity and hearing assessment • Foot examination and footwear

11. Functional Assessment • Assessment of ADL’s • Include use of adaptive equipment or mobility aids • Assessment of perceived functional ability and any fear of falling • Which fears are appropriate? • Which fears are contributing to deconditioning or compromised QOL?

12. Environmental Assessment • Home Safety Evaluation • Caregivers or Family members in home

13. Interventions!

14. Fall Prevention • USPTF evidence shows moderate benefit • Physical therapy or Exercise • Vitamin D supplementation • USPTF shows at least small benefit with • Interventions identified and managed in multifactorial assessment Annals IM 2012

15. Fall Prevention AGS Guidelines • Outline more specific interventions for different groups • Community Dwellings • Long-term Care Facilities • People with cognitive disorders

16. Community Based • Interventions need to be tailored to specific identified risk factors, coupled with PT!! • Most efficacious interventions included • Adaption of home environment * • Exercise with balance, strength and gait training * • Withdrawal/Minimize psychoactive meds * • Manage postural hypotension * • Withdrawal/Minimize all meds * • Manage Foot problems and footwear

17. Community Based • Psychoactive medications are the Devil * • Antipsychotics • Sedative hypnotics • Anxiolytics • Anti-depressants • Expedite cataract surgery if indicated * (women) • Risk with wearing multifocal lenses with walking Vitamin D supplements of at least 800 IU’s should be given to persons with low or suspected low serum levels **

18. Community Based • Assessment and treatment of postural hypotension* • Age appropriate hypertension goals • Cardiovascular devices may be needed • Reminders! • * Identifying the problems or risk factors without intervening on them does not help • * Education as a single modality, without intervention does not help and can be harmful

19. Older Persons in LTC’s • Vitamin D supplements of at least800 IU/day should be given to peoplewith proven or suspected Vit D deficiency or gait/balance abnormalities ** • Multifactorial interventions should be considered • Exercise programs should be considered, with particular caution in frail persons

20. Older Persons with Cognitive Impairment • There are no datathat either supportor refutemultifactorial or single agent interventions to prevent falls in older persons with known dementia living in either the community or long term care facilities.

21. Medications • FRIDS • Elimination and Metabolism • Types of Medications • How Medications are taken • Timing of Medication use

22. Fall Risk Increasing Drugs (FRIDs) • CNS acting agents • Anti-Alzheimer’s agents • Neurotoxic chemotherapeutic agents • Pharmacokinetic and pharmacodynamics properties • FRIDs may also include patterns of use of medications Chen 2014

23. Elimination Half Life and Metabolic Pathway • Studies show benzodiazepines with very short orshort half-life have a positive association with falls during hospitalizations • OR 1.9 and 1.8 Oxidative vs. Non-Oxidative benzodiazepines show different risk profiles for hip fracture • Oxidative show age related curve with fracture • Non-Oxidative show same curve regardless of age Chen 2014

24. Risk Rating of Medicationsin same therapeutic class • Antihypertensives • Positive association with falls will all antihypertensive classes in study by Gribbin et al in 2010 • One study in 2013 suggested a protective effect of ACE’s and ARB’s • Analgesics • Study published 2013 showed higher risk falls with narcotics vs. COX-2 or NSAID (OR 3.3 and 4.1) • NSAID exposure associated with higher risk falls Chen 2014

25. Characteristics of Med Use • Number of medications and drug-drug interactions • DDI particularly with benzodiazepines/Micromedex • Dose Strength • Main association with CNS altering drugs • HR for falls in nursing home study of demented patients from 2012 • Antipsychotics 2.78 • Anxiolytics 1.6, hypnotics / sedatives 2.58 • antidepressants 2.84 (2012 study) • A high dose-response curve with “Recurrent” falls • OR 2.89, 1.8, 1.42 for recurrent falls with higher, moderate and lowest doses from 2009 study Chen 2014

26. Prescribing Practice and Drug Adherence • PIM’s associated with increased fall risk per study of Beers meds 2009 • Low adherence associated with increased fall risk in community study Chen 2014

27. Timing of Medication Use • Psychotropics • Use in 3 months prior to fall >doubled odds • Antipsychotics • Use >90 days associated with increased risk of fall/fracture compared with <30 days • Antidepressants • Highest risk in 28 days after starting AND stopping the medication Chen 2014

28. Withdrawal of FRIDs • Netherland study showed removal of FRIDs decreased falls significantly • 2010 retrospective study demonstrated patient compliance was best when asked to discontinue drugs (benzo/Z drugs) rather than to reduce or taper off drug • Clinical Pharm reviews associated with more medication changes but no change in falls Chen 2014

29. Orthostatic/Postural Hypotension • Yowzers ! Inspector Gadget

30. Postural Hypotension • Orthostatic hypotension is a risk factor for falls, cardiovascular events and all cause mortality • Orthostasis may be related to • Medications • Systemic diseases involving peripheral autonomic nerves • Primary neurodegenerative disorders Arnold 2013

31. Treatment Postural Hypotension • Initial Non-Pharmacologic options • Avoiding or withdrawing offending medications • Devices to decrease pooling • Physical counter maneuvers to decrease pooling • Increase volume

32. Pharmacologic Treatment OH • Volume expansion • Fludricortisone 0.1-0.3mg q/day * • Vasoconstriction • Midodrine 2.5-10 mg * • Pyridostigmine 60mg * • Others include yohimbine, pseudophedrine, octreotide, atomoxetine, droxidopa Combination • Fludricort and midodrine or pseudophedrine and volume Arnold 2013, Lanier 2011

33. Summary • Falls are a leading cause of death in seniors • Evaluation of falls should be multifactorial • History, Physical, and Functional/Environmental assessments need to be done • Treatment and prevention of falls shouldbe multifactorial and interdisciplinary • Multimodality treatments are most effective • Clinicians can focus on medication reduction and treatment of postural hypotension as part of their role in fall prevention

34. Objectives • Define falls • Understand risks associated with falling • Recognize falls as a syndrome • Learn how to perform and interpret a simple clinical fall assessment • Know how to implement at least 3 interventions in fall prevention

35. References • 2010 AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons (largely from the Summary of Recommendations). • Summary of the Updated American Geriatric Society/British Geriatric Society Clinical Practice Guidelines for Prevention of Falls in Older Persons. JAGS 2010. • Current Concepts in Orthostatic Hypotension Management. Arnold et al. 2013. NIH author manuscript (published in Curr Hypertension Resp. 2013. Aug) • Evaluation and Management of Orthostatic Hypotension. Lanier et al. American Family Physician. 2011 • Prevention of Falls in Community Dwelling Older Adults. Moyer et al. Annals of Internal Medicine. 2012: 157. • The Patient Who Falls “It’s Always a Trade Off”. Tinetti et al. JAMA. NIH 2010 author manuscript. • Effects of Drug Pharmakinetic/Pharmacodynamic properties, characteristics of medications and relevant pharmacological interventions on fall risk in elderly patients. Chen et al. Therapeutics and Clinical Risk Management. 2014: 10, 437-448 • Preventing falls in the Geriatric Population. Lee et al. 2013. The Permanente Journal. • Short report: Functional Mobility Assessment at Home. Timed Up and Go Test Using Three Different Chairs. Eekhof 2001. Canadian Family Physician. • CDC- timed up and go. Retrieved 4/17/18. https://www.cdc.gov/steadi/pdf/TUG_Test-print.pdf