Stay Strong. Stay Active. Stay Standing. Falls Prevention in Older Adults

1. Stay Strong. Stay Active. Stay Standing.Falls Prevention in Older Adults

2. NC Falls Prevention Coalition Goal - Reduce the number of falls & fall-related injuries for North Carolinians Members - Researchers, planners, health care providers, housing specialists, aging services providers, & many others Committees Infrastructure Development & Maintenance Surveillance & Evaluation Community Awareness & Education Provider Education Risk Assessment & Behavioral Intervention Advocacy for Supportive Policies & Environments The North Carolina Falls Prevention Coalition is dedicated to reducing the number of falls, fall-related injuries and the seriousness of injuries resulting from falls for North Carolinians. The founding partners of the NC Falls Prevention Coalition are the North Carolina Division of Public Health, North Carolina Division of Aging and Adult Services, the UNC Institute on Aging, and the Carolina Geriatric Education Center. Since its formation in 2008, the Coalition has grown to become a multi-disciplinary, multi-network group comprised of key leaders from over 60 organizations across the state. The North Carolina Falls Prevention Coalition is one of 23 falls prevention coalitions in the United States. It was established in April 2008 and has 40+ partner organizations (and growing). These are the six focus areas of the coalition. (1.) Infrastructure development: Regional Coalitions, Communication of Work, 5 year plan (2.) Community Awareness: Environmental Scan; Target Populations; Toolkits (3.) Provider Education: Customize information (4.) Risk Assessment: ID entry points for those at risk (senior centers, parks, health fairs (5.) Surveillance: Keep falls data up to date, evaluate efforts (6.) Advocacy: Falls Prevention Awareness Day- need personal stories, Info on needs for senior livable communities and homes The North Carolina Falls Prevention Coalition is dedicated to reducing the number of falls, fall-related injuries and the seriousness of injuries resulting from falls for North Carolinians. The founding partners of the NC Falls Prevention Coalition are the North Carolina Division of Public Health, North Carolina Division of Aging and Adult Services, the UNC Institute on Aging, and the Carolina Geriatric Education Center. Since its formation in 2008, the Coalition has grown to become a multi-disciplinary, multi-network group comprised of key leaders from over 60 organizations across the state. The North Carolina Falls Prevention Coalition is one of 23 falls prevention coalitions in the United States. It was established in April 2008 and has 40+ partner organizations (and growing). These are the six focus areas of the coalition. (1.) Infrastructure development: Regional Coalitions, Communication of Work, 5 year plan (2.) Community Awareness: Environmental Scan; Target Populations; Toolkits (3.) Provider Education: Customize information (4.) Risk Assessment: ID entry points for those at risk (senior centers, parks, health fairs (5.) Surveillance: Keep falls data up to date, evaluate efforts (6.) Advocacy: Falls Prevention Awareness Day- need personal stories, Info on needs for senior livable communities and homes

3. Presentation Outline Overview: Why falls prevention? scope of the issue complexity of falls challenges & misconceptions Successful strategies evidence based programs Role of a PCP Resources The first thing I�m going to do in this presentation is give you an overview of why falls prevention is important- the scope of the issue, the complexity of falls and the challenges associated with falls prevention. After I convince you of the importance and complexity of this issues, we�ll discuss successful intervention strategies and evidence based programs to address falls in North Carolina as well as the role of a primary care provider in addressing falls in older adults. The first thing I�m going to do in this presentation is give you an overview of why falls prevention is important- the scope of the issue, the complexity of falls and the challenges associated with falls prevention. After I convince you of the importance and complexity of this issues, we�ll discuss successful intervention strategies and evidence based programs to address falls in North Carolina as well as the role of a primary care provider in addressing falls in older adults.

4. Why Falls Prevention?

5. While 35% of people 65 and older fall each year, HALF of seniors 75+ fall ?once a year. A previous fall is predictive of a future fall as those who fall are two to three times more likely to fall again. For older adults, falls and fall-related injuries are a major threat to their health, independence and quality of life. 10% to 20% of falls cause serious injuries. 1. Hornbrook, Gerontologist, 1994; Hausdorff, Arch Phys Med & Rehab, 2001 and NC BRFSS. 2006. 2. Tinetti, New Eng J Med, 1988; Teno, JAGS,1990 3. Sterling, J Trauma-Inj Infection & Critical Care, 2001 While 35% of people 65 and older fall each year, HALF of seniors 75+ fall ?once a year. A previous fall is predictive of a future fall as those who fall are two to three times more likely to fall again. For older adults, falls and fall-related injuries are a major threat to their health, independence and quality of life. 10% to 20% of falls cause serious injuries. 1. Hornbrook, Gerontologist, 1994; Hausdorff, Arch Phys Med & Rehab, 2001 and NC BRFSS. 2006. 2. Tinetti, New Eng J Med, 1988; Teno, JAGS,1990 3. Sterling, J Trauma-Inj Infection & Critical Care, 2001

6. Falls in North Carolina1 Leading cause of fatal injuries In adults 65+� 2nd leading cause of nonfatal injuries death rate from falls increased 34% from 1999 to 2006 Adults > 65 are only 12% of population but account for 76% of fall-related deaths In North Carolina, falls are the leading cause of fatal injuries and the second leading cause of nonfatal injuries for people ages 65 and older. Moreover, the death rate resulting from falls increased from 28% from 1999 to 2006 for all age groups and 34% in that same time interval for adults ages 65 and older. Given the prevalence of falls, the Center for Disease Control�s National Injury Prevention and Control Center listed falls as one of their three current priorities along with child maltreatment and residential fires. 1. NC BRFSS, 2006 In North Carolina, falls are the leading cause of fatal injuries and the second leading cause of nonfatal injuries for people ages 65 and older. Moreover, the death rate resulting from falls increased from 28% from 1999 to 2006 for all age groups and 34% in that same time interval for adults ages 65 and older. Given the prevalence of falls, the Center for Disease Control�s National Injury Prevention and Control Center listed falls as one of their three current priorities along with child maltreatment and residential fires. 1. NC BRFSS, 2006

7. Falls in North Carolina This map depicts the death rates due to unintentional falls for all the counties in North Carolina between 2002-2006. You�ll notice that the East and West seem to have higher rates when compared to the rest of the state but there is a band down the middle as well. This map depicts the death rates due to unintentional falls for all the counties in North Carolina between 2002-2006. You�ll notice that the East and West seem to have higher rates when compared to the rest of the state but there is a band down the middle as well.

8. This graphically depicts the death rates related to falls in North Carolina by age group and compares this to the rates in the US. They�re very similar to the national rates but you�ll notice at the age of 65, that these rates increase greatly and even more significantly at the age of 75. This graphically depicts the death rates related to falls in North Carolina by age group and compares this to the rates in the US. They�re very similar to the national rates but you�ll notice at the age of 65, that these rates increase greatly and even more significantly at the age of 75.

9. In older adults, hospitalization rates for injuries from falls is 16 times that of those rates from motor vehicle related injuries. And from 2000 to 2006, the rate had increased by 15%. 1. NC BRFSS, 2006In older adults, hospitalization rates for injuries from falls is 16 times that of those rates from motor vehicle related injuries. And from 2000 to 2006, the rate had increased by 15%. 1. NC BRFSS, 2006

10. In 2007, falls were the number one cause of injury-related ED visits in 2007. In 2007, falls were the number one cause of injury-related ED visits in 2007.

11. I�m going to show you why preventing falls in older adults is a public health priority. Focus your attention on the red and dark blue counties, as these are the ones that had the most individuals 65 and older in 2000. In 2000, only 28 COUNTIES had more folks age 60 and over than age 17 and under. Now, we�re going to compare this map to one with projections of the future.I�m going to show you why preventing falls in older adults is a public health priority. Focus your attention on the red and dark blue counties, as these are the ones that had the most individuals 65 and older in 2000. In 2000, only 28 COUNTIES had more folks age 60 and over than age 17 and under. Now, we�re going to compare this map to one with projections of the future.

12. Now compare the red and dark blue areas to those observed in the previous map. By 2030, not 28 BUT 75 counties - more people aged 60 and older than 17 and under. For the majority of the counties in the state, more than 16% of the population will be ages 65 and older, with an average of 17.7% for the entire state. So the bottom line is that this shift in the percentage of older adults will result in a falls epidemic if this issue isn�t addressed. (Click back one slide to compare this to the 2000 proportions again.) Now compare the red and dark blue areas to those observed in the previous map. By 2030, not 28 BUT 75 counties - more people aged 60 and older than 17 and under. For the majority of the counties in the state, more than 16% of the population will be ages 65 and older, with an average of 17.7% for the entire state. So the bottom line is that this shift in the percentage of older adults will result in a falls epidemic if this issue isn�t addressed. (Click back one slide to compare this to the 2000 proportions again.)

13. If you compare the North Carolina�s 2006/2007 death, hospital and ED data to those projected values, it is quite alarming. This makes falls a sort of epidemic. The numbers will double for each group is the rate of falls remains the same. However, the rate of falls per 100,000 is actually climbing. The HOSPITALIZATION RATE due to unintentional falls in older adults alone increased by 15% between 2000 and 2006. These numbers have serious ramifications for: (1.) people�s lives and (2.) our health care dollars unless we become more proactive. MEDICARE is refusing to compensate hospitals for some falls deemed preventable. In light of the increasing proportion of older adults, the cost implications from falls alone due to hospitalizations, when you extrapolate the data, if the rate of falls/100,000 was simply to remain the same as today, the costs double, because of the increasing older population. This doesn�t take into account perhaps the even greater costs of falling, that of suffering and loss of independence. If you compare the North Carolina�s 2006/2007 death, hospital and ED data to those projected values, it is quite alarming. This makes falls a sort of epidemic. The numbers will double for each group is the rate of falls remains the same. However, the rate of falls per 100,000 is actually climbing. The HOSPITALIZATION RATE due to unintentional falls in older adults alone increased by 15% between 2000 and 2006. These numbers have serious ramifications for: (1.) people�s lives and (2.) our health care dollars unless we become more proactive. MEDICARE is refusing to compensate hospitals for some falls deemed preventable. In light of the increasing proportion of older adults, the cost implications from falls alone due to hospitalizations, when you extrapolate the data, if the rate of falls/100,000 was simply to remain the same as today, the costs double, because of the increasing older population. This doesn�t take into account perhaps the even greater costs of falling, that of suffering and loss of independence.

14. 35% of these people fall annually � 400,253 people ages 65+ will fall this year alone! Compare this to population of Raleigh: 388,9261 Falls in North Carolina I�m going to attempt to make the scope of this issue in North Carolina a bit more real. The 2008 NC population estimate is 9,222,4141. 12.4% of these people are 65+1 so we have approximately 1,143,579 people ages 65 and older in this sate. Given that 35% of people ages 65 and older fall every year, this means that approximately 400,252 people ages 65 and older will fall this year alone. The number of older adults that fall every year in NC is larger than the 2009 population of Raleigh. [1] Raleigh Department of City Planning Communications Group I�m going to attempt to make the scope of this issue in North Carolina a bit more real. The 2008 NC population estimate is 9,222,4141. 12.4% of these people are 65+1 so we have approximately 1,143,579 people ages 65 and older in this sate. Given that 35% of people ages 65 and older fall every year, this means that approximately 400,252 people ages 65 and older will fall this year alone. The number of older adults that fall every year in NC is larger than the 2009 population of Raleigh. [1] Raleigh Department of City Planning Communications Group

15. This means that over the course of a year, every person in Raleigh would fall, with one fall occurring every minute! Falls in North Carolina Picture yourself walking around downtown Raleigh. If you divide the number of people who will fall in NC this year over the age of 65 by the number of days in a year and then the minutes in a day, that means approximately one person will fall every minute and over the course of a year, every single person in this city would have fallen. [1] Raleigh Department of City Planning Communications GroupPicture yourself walking around downtown Raleigh. If you divide the number of people who will fall in NC this year over the age of 65 by the number of days in a year and then the minutes in a day, that means approximately one person will fall every minute and over the course of a year, every single person in this city would have fallen. [1] Raleigh Department of City Planning Communications Group

16. Fear of falling leads people to decrease their activities, which increases their fall risk, because they become weaker, and also impacts their quality of life. 25% in a nursing home after a hip fracture � one year later. Older adults want to live independently, to age �in place� but a fall is often the beginning of the end of independence. 20% die within a year of a hip fracture.2 1. Vellas BJ, Age & Aging, 1997; Friedman SM, JAGS, 2002 2. Lu-Yao GL, AJPH, 1994 3. Magaziner, J Gerontology: Medical Sciences, 2000 Fear of falling leads people to decrease their activities, which increases their fall risk, because they become weaker, and also impacts their quality of life. 25% in a nursing home after a hip fracture � one year later. Older adults want to live independently, to age �in place� but a fall is often the beginning of the end of independence. 20% die within a year of a hip fracture.2 1. Vellas BJ, Age & Aging, 1997; Friedman SM, JAGS, 2002 2. Lu-Yao GL, AJPH, 1994 3. Magaziner, J Gerontology: Medical Sciences, 2000

17. Associated with depression Decreased mobility and social activity Increased frailty Increased risk for falling as a result of deconditioning The Fear of Falling 1 Fear of falling is associated with depression, decreased mobility and social activity, increased frailty and increased risk for falls as a result of deconditioning. 1. Haynes, P. and Pelaez, M. (2007, June 24.) A Matter of Balance: Volunteer Lay Leader Model, MaineHealth Partnership for Healthy Aging. Available online at: http://www.doh.state.fl.us/Injury/PDF/AMatterofBalance-AProgramReview.pdf. Accessed March 28, 2010. Fear of falling is associated with depression, decreased mobility and social activity, increased frailty and increased risk for falls as a result of deconditioning. 1. Haynes, P. and Pelaez, M. (2007, June 24.) A Matter of Balance: Volunteer Lay Leader Model, MaineHealth Partnership for Healthy Aging. Available online at: http://www.doh.state.fl.us/Injury/PDF/AMatterofBalance-AProgramReview.pdf. Accessed March 28, 2010.

18. What puts someone at risk for a fall? There are good tools that exist that will tell you who is more at risk for a fall. There are some non-modifiable risk factors, like age, race, sex, prior fall). Risk of falling increases with age. Older people are at higher risk, more whites than blacks fall, more women than men, but more men die. Other personal risk factors that can�t be modified include certain chronic disease, stroke, Parkinson�s Diseases and mental impairment. However, research has verified that many of the factors that put someone at risk for a fall ARE modifiable and THESE are the ones we are most interested in. Muscle weakness is the biggest risk factor and this can be addressed through exercise, as can gait and balance problems. There are also many issues to medications such as, psychoactive medications, those that alter brain function and change mood. Examples of these include morphine and codeine for pain control and anti-depressants (psychiatric meds). Other modifiable risk factors include environmental factors including uneven sidewalks, lack of curb cuts etc. At home (where � to 2/3 of falls occur): poor lighting, throw rugs, lack of grab bars in the tub, obstacles in hallways, lack of handrails on stairs, etc. However, it is interesting to note that there is no evidence that modifying the home environment alone will reduce the risk of a fall. What puts someone at risk for a fall? There are good tools that exist that will tell you who is more at risk for a fall. There are some non-modifiable risk factors, like age, race, sex, prior fall). Risk of falling increases with age. Older people are at higher risk, more whites than blacks fall, more women than men, but more men die. Other personal risk factors that can�t be modified include certain chronic disease, stroke, Parkinson�s Diseases and mental impairment. However, research has verified that many of the factors that put someone at risk for a fall ARE modifiable and THESE are the ones we are most interested in. Muscle weakness is the biggest risk factor and this can be addressed through exercise, as can gait and balance problems. There are also many issues to medications such as, psychoactive medications, those that alter brain function and change mood. Examples of these include morphine and codeine for pain control and anti-depressants (psychiatric meds). Other modifiable risk factors include environmental factors including uneven sidewalks, lack of curb cuts etc. At home (where � to 2/3 of falls occur): poor lighting, throw rugs, lack of grab bars in the tub, obstacles in hallways, lack of handrails on stairs, etc. However, it is interesting to note that there is no evidence that modifying the home environment alone will reduce the risk of a fall.

19. Here are some of the things that contribute to or increase the risk of falling which can be targeted with individual level interventions. In a study produced by the American Geriatrics Society, the relative risk of falls is greatest due to muscle weakness, which increases the risk of falling 4.4 times and then gait and balance problems. These can be addressed with exercise programs and personalized physical therapy. Vision problems and psychoactive medications increase the risk of falling 2.5 times and 1.7 times respectively. 1. American Geriatrics Society, JAGS, 2001 Here are some of the things that contribute to or increase the risk of falling which can be targeted with individual level interventions. In a study produced by the American Geriatrics Society, the relative risk of falls is greatest due to muscle weakness, which increases the risk of falling 4.4 times and then gait and balance problems. These can be addressed with exercise programs and personalized physical therapy. Vision problems and psychoactive medications increase the risk of falling 2.5 times and 1.7 times respectively. 1. American Geriatrics Society, JAGS, 2001

20. Myths of Aging1 All older people fall Changes that occur with age are uncontrollable and irreversible Older adults don�t want to change Exercise does more harm than good There are several common misconceptions about aging among older adults AND their providers. This is not and exhaustive list. Many believe that once you get older, everyone falls and that the changes that occur with age are both uncontrollable and irreversible. Another misconception is that the motivation for change is low, that older adults don�t want to make the behavioral changes that can decrease their risk for falling. Finally, many assume that exercise will do no good and may even be harmful. 1. Haynes, P. and Pelaez, M. (2007, June 24.) A Matter of Balance: Volunteer Lay Leader Model, MaineHealth Partnership for Healthy Aging. Available online at: http://www.doh.state.fl.us/Injury/PDF/AMatterofBalance-AProgramReview.pdf. Accessed March 28, 2010. There are several common misconceptions about aging among older adults AND their providers. This is not and exhaustive list. Many believe that once you get older, everyone falls and that the changes that occur with age are both uncontrollable and irreversible. Another misconception is that the motivation for change is low, that older adults don�t want to make the behavioral changes that can decrease their risk for falling. Finally, many assume that exercise will do no good and may even be harmful. 1. Haynes, P. and Pelaez, M. (2007, June 24.) A Matter of Balance: Volunteer Lay Leader Model, MaineHealth Partnership for Healthy Aging. Available online at: http://www.doh.state.fl.us/Injury/PDF/AMatterofBalance-AProgramReview.pdf. Accessed March 28, 2010.

21. Talking about falls and falls prevention takes time. There often is a DON�T ASK mentality on part of provider and a DON�T TELL (on part of patient). Many older adults assume that falls are a natural part of the aging process and that they are inevitable and not necessarily preventable. There is a certain stigma associated with falling. People are hesitant to mention the fact that they�ve experienced a fall or even that they are fearful of one. As of now, falls risk assessments are not a standard part of practice in primary care, although we are moving in that direction. Not only that, but there are limited evidenced based programs in North Carolina addressing this issue, which, as you�ll see in the next slide is a very complex one as over 60% of falls result from multiple interacting factors. 1 Campbell, 2007Talking about falls and falls prevention takes time. There often is a DON�T ASK mentality on part of provider and a DON�T TELL (on part of patient). Many older adults assume that falls are a natural part of the aging process and that they are inevitable and not necessarily preventable. There is a certain stigma associated with falling. People are hesitant to mention the fact that they�ve experienced a fall or even that they are fearful of one. As of now, falls risk assessments are not a standard part of practice in primary care, although we are moving in that direction. Not only that, but there are limited evidenced based programs in North Carolina addressing this issue, which, as you�ll see in the next slide is a very complex one as over 60% of falls result from multiple interacting factors. 1 Campbell, 2007

22. Successful Falls Prevention Strategies and Evidence-Based Programs Now that we�ve discussed how the magnitude and complexity of this issue, as well as the challenges and misconceptions surrounding falls and falls prevention, let�s move on to strategies and programs which have proven successful in addressing the problem. Now that we�ve discussed how the magnitude and complexity of this issue, as well as the challenges and misconceptions surrounding falls and falls prevention, let�s move on to strategies and programs which have proven successful in addressing the problem.

23. It makes sense since 60% of falls are the result of a complex interaction of risk factors, that multifactorial risk factor reduction interventions have been found to be an extremely effective approach. There are also several single-factor community based interventions that have also been shown to decrease the risk of falls. Tinetta, 1995; Hogan, 2001; Niklaus, 2003 Campbell, 2007 It makes sense since 60% of falls are the result of a complex interaction of risk factors, that multifactorial risk factor reduction interventions have been found to be an extremely effective approach. There are also several single-factor community based interventions that have also been shown to decrease the risk of falls. Tinetta, 1995; Hogan, 2001; Niklaus, 2003 Campbell, 2007

24. These intervention strategies all target some of those extrinsic and intrinsic factors which contribute to falls. According to a study conducted by the RAND corporation for the Centers for Medicare & Medicaid Services, while multifactorial risk factor reduction is the most effective approach, regular physical activity most important single intervention. Exercise includes gait retraining, leg strengthening and balance exercises). Successful interventions also include comprehensive clinical exams, vision exams and the discontinuation of medications that increase the risk of falls. 1. American Geriatrics Society, JAGS, 2001 2. Lord SR, JAGS, 2001 3. Cumming RG, Drugs & Aging, 1998 4. Ray W, Topics in Geriatric R Rehab,1990 These intervention strategies all target some of those extrinsic and intrinsic factors which contribute to falls. According to a study conducted by the RAND corporation for the Centers for Medicare & Medicaid Services, while multifactorial risk factor reduction is the most effective approach, regular physical activity most important single intervention. Exercise includes gait retraining, leg strengthening and balance exercises). Successful interventions also include comprehensive clinical exams, vision exams and the discontinuation of medications that increase the risk of falls. 1. American Geriatrics Society, JAGS, 2001 2. Lord SR, JAGS, 2001 3. Cumming RG, Drugs & Aging, 1998 4. Ray W, Topics in Geriatric R Rehab,1990

25. Here are some more single interventions falls prevention strategies for community dwelling older adults. In regard to counseling regarding alcohol consumption, the NIAAA website recommends < 2 glasses of alcohol a day for older men and < glass for older women if there are no contraindications. 2 There is also modification of the environment, footwear and assistive devices, replacement of vitamin D if deficient and treatment of osteoporosis. It is important to note that, with respect to the discontinuation of medications that increase the risk of a fall, this may not always be possible but it is vital to at least review medication lists of be aware of the issues that may be present. 1. Day L, BMJ 2002; Gill TM, JAGS, 1999 2. National Institute on Alcohol Abuse and Alcoholism website. Available at: http://www.niaaa.nih.gov/. Accessed on March 28, 2010. Here are some more single interventions falls prevention strategies for community dwelling older adults. In regard to counseling regarding alcohol consumption, the NIAAA website recommends < 2 glasses of alcohol a day for older men and < glass for older women if there are no contraindications. 2 There is also modification of the environment, footwear and assistive devices, replacement of vitamin D if deficient and treatment of osteoporosis. It is important to note that, with respect to the discontinuation of medications that increase the risk of a fall, this may not always be possible but it is vital to at least review medication lists of be aware of the issues that may be present. 1. Day L, BMJ 2002; Gill TM, JAGS, 1999 2. National Institute on Alcohol Abuse and Alcoholism website. Available at: http://www.niaaa.nih.gov/. Accessed on March 28, 2010.

26. Evidence-Based Programs (EBPs) �interventions for which there is scientific evidence consistently showing that they improve client outcomes.� 1 Clearly, the need for fall prevention services is growing in importance. In order to meet the increasing demand, the number of programs has grown. There are several programs shown to decrease falls in older adults which have been deemed evidence based that I�m going to talk about in the next few slides. Evidence-based programs are �interventions for which there is scientific evidence consistently showing that they improve client outcomes.1 1. Drake RE, Goldman HH, Leff HS, Lehman AF, Dixon L, Mueser KT, Torrey WC. Implementing evidence-based practices in routine mental health service settings. Psychiatr Serv. 2001 Feb;52(2):179-82. Clearly, the need for fall prevention services is growing in importance. In order to meet the increasing demand, the number of programs has grown. There are several programs shown to decrease falls in older adults which have been deemed evidence based that I�m going to talk about in the next few slides. Evidence-based programs are �interventions for which there is scientific evidence consistently showing that they improve client outcomes.1 1. Drake RE, Goldman HH, Leff HS, Lehman AF, Dixon L, Mueser KT, Torrey WC. Implementing evidence-based practices in routine mental health service settings. Psychiatr Serv. 2001 Feb;52(2):179-82.

27. EBPs: CDC �s Community Based Falls Interventions1 Exercise-based Stay Safe, Stay Active The Otago Exercise Programme Tai Chi: Moving for Better Balance Australian Group Exercise Program Veterans Affairs Group Exercise Program Simplified Tai Chi The Center for Disease Control and Prevention developed the Compendium of Effective Community-based Interventions, which is a great resource as a starting point to see what types of programs are available to address the issues of falls. You can download this compendium for free on the CDC website. This compendium includes specific interventions that have rigorous scientific evidence of effectiveness. The inclusion criteria were science-based prevention intervention studies that included community-dwelling adults aged 65 and older, used a randomized controlled study design, measured falls as a primary outcome (not balance improvement or reduced fear of falling) and demonstrated statistically significant positive results reducing older adult falls.(1) They include 14 programs but these are broken into different categories, the first of which is exercise based interventions. The exercise based interventions include: Stay Safe, Stay Active The Otago Exercise Programme Tai Chi: Moving for Better Balance Australian Group Exercise Program Veterans Affairs Group Exercise Program and Simplified Tai Chi 1. Stevens JA, Sogolow ED. Preventing Falls: What Works. A CDC Compendium of Effective Community-Based Interventions from Around the World. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2008. The Center for Disease Control and Prevention developed the Compendium of Effective Community-based Interventions, which is a great resource as a starting point to see what types of programs are available to address the issues of falls. You can download this compendium for free on the CDC website. This compendium includes specific interventions that have rigorous scientific evidence of effectiveness. The inclusion criteria were science-based prevention intervention studies that included community-dwelling adults aged 65 and older, used a randomized controlled study design, measured falls as a primary outcome (not balance improvement or reduced fear of falling) and demonstrated statistically significant positive results reducing older adult falls.(1) They include 14 programs but these are broken into different categories, the first of which is exercise based interventions. The exercise based interventions include: Stay Safe, Stay Active The Otago Exercise Programme Tai Chi: Moving for Better Balance Australian Group Exercise Program Veterans Affairs Group Exercise Program and Simplified Tai Chi 1. Stevens JA, Sogolow ED. Preventing Falls: What Works. A CDC Compendium of Effective Community-Based Interventions from Around the World. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2008.

28. EBPs: CDC �s Community Based Falls Interventions1 Home Modification Home visits by an occupational therapist Falls-HIT (home intervention team) The next category is home modification interventions. This includes home visits by an occupational therapist and Falls Home Intervention Team. 1. Stevens JA, Sogolow ED. Preventing Falls: What Works. A CDC Compendium of Effective Community-Based Interventions from Around the World. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2008. The next category is home modification interventions. This includes home visits by an occupational therapist and Falls Home Intervention Team. 1. Stevens JA, Sogolow ED. Preventing Falls: What Works. A CDC Compendium of Effective Community-Based Interventions from Around the World. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2008.

29. EBPs: CDC �s Community Based Falls Interventions1 Multifaceted Interventions Stepping On PROFET (Prevention of Falls in the Elderly Trial) The NoFalls Intervention The SAFE Health Behavior Exercise Intervention Yale FICSIT A Multifactorial Program Finally we have �multifaceted interventions� a category where they lumped together all the interventions which target two or more of the risk factors contributing to a fall. These programs include: Stepping On PROFET (Prevention of Falls in the Elderly Trial) The NoFalls Intervention The SAFE Health Behavior Exercise Intervention Yale FICSIT and A Multifactorial Program 1. Stevens JA, Sogolow ED. Preventing Falls: What Works. A CDC Compendium of Effective Community-Based Interventions from Around the World. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2008. Finally we have �multifaceted interventions� a category where they lumped together all the interventions which target two or more of the risk factors contributing to a fall. These programs include: Stepping On PROFET (Prevention of Falls in the Elderly Trial) The NoFalls Intervention The SAFE Health Behavior Exercise Intervention Yale FICSIT and A Multifactorial Program 1. Stevens JA, Sogolow ED. Preventing Falls: What Works. A CDC Compendium of Effective Community-Based Interventions from Around the World. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, 2008.

30. More Evidence-Based Programs (www.stopfalls.org)1  EnhanceFitness FallProof! FaME (Falls Management Exercise) OsteoFit SAIL (Strategies and Action for Independent Living) A Matter of Balance There is another program review that you can download for free from www.stopfalls.org which includes 10 evidence-based programs, some of which were already listed in the preview slides and the remainder of which are listed here: EnhanceFitness, FallProof!, FaME, OsteoFit, SAIL and A Matter of Balance. In the next couple of slides I�m going to elaborate more on this last program because it is one of the only ones presently available in North Carolina. 1. Rose D, Rubenstein L, Nguyen A, Cicero C, Steinman B. Multi-factorial and Physical Activity Programs for Fall Prevention. (online PDF) Available at: www.stopfalls.org. Accessed on: April 8, 2010. There is another program review that you can download for free from www.stopfalls.org which includes 10 evidence-based programs, some of which were already listed in the preview slides and the remainder of which are listed here: EnhanceFitness, FallProof!, FaME, OsteoFit, SAIL and A Matter of Balance. In the next couple of slides I�m going to elaborate more on this last program because it is one of the only ones presently available in North Carolina. 1. Rose D, Rubenstein L, Nguyen A, Cicero C, Steinman B. Multi-factorial and Physical Activity Programs for Fall Prevention. (online PDF) Available at: www.stopfalls.org. Accessed on: April 8, 2010.

31. Evidence-Based Programs in North Carolina Matter of Balance1 Again, one of the programs mentioned in the �Multi-factorial and Physical Activity Programs for Fall Prevention� program review at www.stopfalls.org is Matter of Balance. Matter of Balance, an evidence based program which addresses the fear of falling, is one of the only, if not the only fairly widely utilized EBPs in North Carolina. It utilizes practical strategies to reduce fear and increase activity levels which helps participants view reducing falls as controllable, uses exercise to increase strength/balance, change in environment to reduce fall risk factors. I�m going to go into more detail in the next slide but it is important to note that NC has about 25 MOB master trainers and we need to train lay trainers and begin to roll out this program. 1. Haynes, P. and Pelaez, M. (2007, June 24.) A Matter of Balance: Volunteer Lay Leader Model, MaineHealth Partnership for Healthy Aging. Available online at: http://www.doh.state.fl.us/Injury/PDF/AMatterofBalance-AProgramReview.pdf. Accessed March 28, 2010. Again, one of the programs mentioned in the �Multi-factorial and Physical Activity Programs for Fall Prevention� program review at www.stopfalls.org is Matter of Balance. Matter of Balance, an evidence based program which addresses the fear of falling, is one of the only, if not the only fairly widely utilized EBPs in North Carolina. It utilizes practical strategies to reduce fear and increase activity levels which helps participants view reducing falls as controllable, uses exercise to increase strength/balance, change in environment to reduce fall risk factors. I�m going to go into more detail in the next slide but it is important to note that NC has about 25 MOB master trainers and we need to train lay trainers and begin to roll out this program. 1. Haynes, P. and Pelaez, M. (2007, June 24.) A Matter of Balance: Volunteer Lay Leader Model, MaineHealth Partnership for Healthy Aging. Available online at: http://www.doh.state.fl.us/Injury/PDF/AMatterofBalance-AProgramReview.pdf. Accessed March 28, 2010.

32. A Matter of Balance1 8 two hour sessions Group discussion, problem-solving, skill building, assertiveness training, sharing practical solutions, videotapes, exercise training Participants learn: To view falls and fear of falling as controllable To set realistic goals for increasing activity To change their environment to reduce all risk factors To promote exercise to increase strength and balance Matter of Balance is designed to benefit community-dwelling older adults who are concerned about falls, have sustained falls in the past, restrict their activities because of fear of falling and who are interested in improving flexibility, balance and strength. It consists of eight two hour sessions which include group discussion, problem-solving, skill building, assertiveness training, sharing practical solutions, videotapes and exercise training. Participants learn: To view falls and fear of falling as controllable To set realistic goals for increasing activity To change their environment to reduce all risk factors To promote exercise to increase strength and balance 1. Haynes, P. and Pelaez, M. (2007, June 24.) A Matter of Balance: Volunteer Lay Leader Model, MaineHealth Partnership for Healthy Aging. Available online at: http://www.doh.state.fl.us/Injury/PDF/AMatterofBalance-AProgramReview.pdf. Accessed March 28, 2010. Matter of Balance is designed to benefit community-dwelling older adults who are concerned about falls, have sustained falls in the past, restrict their activities because of fear of falling and who are interested in improving flexibility, balance and strength. It consists of eight two hour sessions which include group discussion, problem-solving, skill building, assertiveness training, sharing practical solutions, videotapes and exercise training. Participants learn: To view falls and fear of falling as controllable To set realistic goals for increasing activity To change their environment to reduce all risk factors To promote exercise to increase strength and balance 1. Haynes, P. and Pelaez, M. (2007, June 24.) A Matter of Balance: Volunteer Lay Leader Model, MaineHealth Partnership for Healthy Aging. Available online at: http://www.doh.state.fl.us/Injury/PDF/AMatterofBalance-AProgramReview.pdf. Accessed March 28, 2010.

33. The Role of a Primary Care Provider

34. Simple Clinical Falls Risk Assessment Ask your patient about falling Assess medications Add the timed get up and go test to H&P Refer those who fail to physical therapy; recommend exercise to those who pass It is really important that primary care providers screen for falls. Currently, falls risk assessments are not mandated in this state but we are moving in that direction. Fortunately, a clinical assessment for falls risk is quick and relatively simple so it is feasible to do for all older patients. These are the steps included in this simple assessment. First, ask your patient about falling, assess medications to determine if there are any that may be contributing to a patient�s risk of falling, perform a timed up and go test, which we will review on the next slide, and finally, refer those who fail the test to physical therapy and recommend exercise to all patients, even if they pass.It is really important that primary care providers screen for falls. Currently, falls risk assessments are not mandated in this state but we are moving in that direction. Fortunately, a clinical assessment for falls risk is quick and relatively simple so it is feasible to do for all older patients. These are the steps included in this simple assessment. First, ask your patient about falling, assess medications to determine if there are any that may be contributing to a patient�s risk of falling, perform a timed up and go test, which we will review on the next slide, and finally, refer those who fail the test to physical therapy and recommend exercise to all patients, even if they pass.

35. Get Up and Go Test All older persons who report a single fall should be observed as they� stand from a sitting position walk 10 feet, turn, and return to the chair sit back in the chair [If not completed in 10 seconds or less or demonstrate unsteadiness, further assessment is required!] This is just a review of the get up and go test. All older persons who report even a single falls should be observed as they: from a sitting position, stand without using their arms for support walk 10 feet, turn, and return to the chair sit back in the chair without using their arms for support Again, if they �fail� the falls assessment, further assessment may be required and referral to physical therapy important. This is just a review of the get up and go test. All older persons who report even a single falls should be observed as they: from a sitting position, stand without using their arms for support walk 10 feet, turn, and return to the chair sit back in the chair without using their arms for support Again, if they �fail� the falls assessment, further assessment may be required and referral to physical therapy important.

36. The American Geriatrics Society updated their clinical falls prevention guidelines in 2010. These guidelines are available at http://www.americangeriatrics.org/education/prevention_of_falls.shtml. This link is listed in the resources section at the end of this presentation. This is an algorithm summarizing the assessment and management of falls. The American Geriatrics Society updated their clinical falls prevention guidelines in 2010. These guidelines are available at http://www.americangeriatrics.org/education/prevention_of_falls.shtml. This link is listed in the resources section at the end of this presentation. This is an algorithm summarizing the assessment and management of falls.

37. Additional Resources

38. North Carolina Falls Prevention Website: www.ncfallsprevention.org AGS/BGS Clinical Practice Guidelines: Prevention of Falls in Older Persons: http://www.americangeriatrics.org/education/prevention_of_falls.shtml Evidence-based Programs: www.stopfalls.org CDC�s Preventing Falls: What Works: http://www.cdc.gov/HomeandRecreationalSafety/Falls/preventfalls.html The NC Falls prevention coalition website contains resources for individuals and families, providers, researches and educators. The NC Falls prevention coalition website contains resources for individuals and families, providers, researches and educators.