Wednesday, February 6, 2013 2-3p

1. Falls Program Virtual Breakthrough Series 2: (BTS 2)  Reducing Preventable Falls and Fall Related Injuries National Center for Patient Safety & VISN 8 Patient Safety Center of InquirySession 3 Wednesday, February 6, 2013 2-3p

2. BTS2 Program Goals: Improve your organization’s infrastructure and capacity to reduce fall-related injures. Enhance environmental safety. Mitigate or eliminate modifiable fall risk factors. Assure reliable handoff communication about patients’ fall and injury risk. Integrate patient (family) as a partner in their fall prevention program. Reduce rate of repeat falls. a Quantify impact of program changes.

3. Looking Ahead Ten Sessions of Learning and Sharing • Jan 9th: Improved Organizational Infrastructure and Capacity for Fall Prevention Programs • Jan 23rd : Ensuring a Safe Environment • Feb 6th: Mitigate or Eliminate Modifiable Fall Risk Factors, Part 1 • Feb 20th : Mitigate or Eliminate Modifiable Fall Risk Factors, Part 2 • Mar 6th: Reduce Moderate to Serious Injuries for Vulnerable Populations • Mar 20th: Clinically Relevant and Reliable Handoff Communication: Let’s Talk about Falls and Fall-related Injuries • Apr 3rd: Patients/Families as Full Partners in Fall Prevention • Apr 17th: Post Fall Management: Reducing Repeat Falls • May 1st: Fall Program Evaluation • May 15th: Sharing Program Successes

4. Session 3: Mitigate or Eliminate Modifiable Fall Risk Factors - Part 1 Objectives: • Differentiate fall risk screening from fall risk assessment. • Review modifiable vs. non-modifiable fall risk factors in multifactorial fall risk assessment. • Examine AGS/BGS fall risk assessment guidelines as framework for general fall risk assessment, while using clinical expertise to identify population-specific fall risk factors. • Evaluate clinical warning systems if patient has history of falls and fall-related injury.

5. Before we get started, let’s hear from you, about your homework assignments What did you learn when you: Completed environmental safety assessment specific to risk for falls and risk for injury, on one unit, including patient room and bathroom? Did you discover at least two environmental/equipment safety changes that could reduce fall risk? What are they? Did you discover at least two environmental/equipment safety changes that could reduce injuries should a fall occur? What are you key strategic actions to implement the proposed environmental safety changes and integrate hip protectors and floor mats into patient care? Did you have a chance to review the last 10 falls from one unit, classify the fall by type of falls? For those falls that are accidental falls, what were the immedicate causes for accidental falls?

6. Overview of Session • Roles of risk screening vs. comprehensive fall risk assessment. • In-depth review of the AGS/BGS guidelines. • Use of clinical judgment to identify additional fall risk factors for special populations (amputees, diabetics, Parkinson's Disease, Stroke (right vs. left brain). • Learn a framework for individualized care planning that links the specific fall risk factor to a treatment intervention required to mitigate or eliminate specific fall and injury risk factors. • Open discussion about clinical warning systems within current EMRs to alert others about patients’ fall and injury history.

7. Tatjana Bulat, MD Dr. Bulat is a Board certified internist/geriatrician, Director of the VISN 8 Patient Safety Center of Inquiry (a translational research center), Co-Director of the Interdisciplinary Fellowship in Patient Safety, Medical Director of the Falls clinic at JAH VA Hospital, as well as Associate Professor at the USF-COM Department of Internal Medicine, Division of Geriatrics. Her research interests are in the area of falls and fall injury prevention, medication management to prevent falls, and hazardous wandering. Over the years she participated in a number of research and implementation projects including VA National Falls Toolkit, developing standardized fall risk assessment for outpatients, evaluation of barriers and facilitators to hip protector use, biomechanical properties of hip protectors after multiple impacts and launderings, medication algorithms to decrease fall risk in older individuals, evaluation of biomechanical properties of bedside floor mats, and others.

8. Mitigate or eliminate modifiable fall risk factors: PART I

9. Normal balance • complex process that depends on three major components: • (1) sensory systems for accurate information about one’s position relative to environment; • (2) brain's ability to process this information; • (3) muscles and joints for coordinating the movements required to maintain balance

10. Normal balance • Balance-need to maintain our Center of Gravity over a narrow Base Of Support (area of contact between the support surface and feet); once the COG deviates beyond the perimeter of the BOS, a rapid step, stumble or external support is required to prevent a fall • A variety of ankle, knee and hip movements are used to actively control COG and keep it in BOS-hip, ankle movement strategies, stepping, grasping • The integration of postural control with movement is necessary for all locomotion, including initiation, turning, stopping and stepping

11. Normal Aging • Increased postural instability due to vestibular dysfunction (increased sway) • Proprioceptive feedback decreases and interferes with proper foot placement • Decline of central integration of visual, vestibular and proprioceptive senses • Vision-Greater sensitivity of aging eye to glare, slower adaptation to changes in environmental lightning

12. Normal Aging cont. • Decline in depth perception (step edges, curbs) • Baroreflex activity-progressive decline-blunted heart rate response to postural change resulting in transient hypotension • Musculoskeletal- relative decrease in muscle mass-muscle strength (proximal muscles), rapid deconditioning

13. Risk factors • Intrinsic • Extrinsic

14. Risk Factors-intrinsic • Cognitive impairment (delirium, dementia, depression) • previous falls, • fear of falling • cardiac arrhythmias, transient ischemic attacks, stroke • Parkinson’s disease • acute and subacute medical illness • orthostatic hypotension, dehydration, hypoglycemia

15. Intrinsic Risk Factors, Cont. • Musculoskeletal conditions, problems with gait and mobility, ADL impairment • incontinence (bowel or bladder) • Vision (both contrast sensitivity and acuity) or auditory impairment • Sensory impairments (proprioception) • vestibular dysfunction • Foot problems, ankle dorsiflexion

16. Extrinsic Risk Factors • Polypharmacy vs. polymedicine- more then 4 medications • “No risk factor for falls is as potentially preventable or reversible as medication use” (Leipzig RM et al. JAGS, 47:30-39, 1999.) • benzodiazepines, psychotropics, antihypertensives

17. Adverse medication effects • POSTURAL or ORTHOSTATIC HYPOTENSION-decrease in systolic BP >20mmHg 1 min after standing • Tricyclic antidepressants • Antipsychotics • L-dopa • Antihypertensives • Diuretics • Nitrates

18. Orthostatic hypotension • Altered systems in frail/elderly: • decreased arterial compliance • blunted response of volume/BP regulation (lower renin, angiotensin, aldosterone) • Decr B receptor response • Decr sympathetic response (less tachy with dehydration) • Can reduce OH by 50% with med adjustment (Fotherby M, Postgraduate Med J 70:878-81,1994)

19. Cont. • ATAXIA-toxic effect on cerebellum, vestibulosensory, or proprioceptive control systems-increased body sway, loss of balance • PSYCHOMOTOR SLOWING-difficult to measure clinically; lack of attention or a distraction from gait and balance problems, effect on judgment and reflexes • Benzodiazepines • Anticonvulsants-phenytoin, carbamazepine, phenobarbital

20. Cont. • DRUG-INDUCED PARKINSOMISM-increased muscle tone, rigidity, resting tremor, impaired postural responses to change in position • Antipsychotics • Metoclopramide • Reserpine

21. Cont. • MYOPATHIES-muscle wasting, weakness • Long-term steroid use • HMG CoA reductase inhibitors

22. Cont. • PERIPHERAL NEUROPATHIES-gait dysfunction • Amiodarone • Hydralazine • Phenytoin

23. Drugs associated with reduced bone mass in adults • Anticonvulsants (phenytoin, phenobarbital), carbamazepine, sodium valproate • Cytotoxic drugs • Glucocorticoids (and ACTH) • GnRH agonists • Immunosupressants-cyclosporin, tacrolimus, methotrexate • Lithium • Long-term heparin use • Supraphysiologic thyroxine doses • TPN

24. Drugs associated with increased fracture risk- new additions • SSRIs • Antipsychotics • TZDs • PPIs

25. Extrinsic Risk Factors, cont. • Use of restraints • Environmental factors-dim lighting, glare, inappropriate footwear, uneven flooring, loose rugs, wet, slippery floor, old and unstable furniture, etc. • Imperative that health care providers routinely assess risk factors and inquire about falls

26. Environmental Considerations

27. Etiology of falls • Accident/environment-37% • weakness, balance /gait-12% • dizziness/vertigo-8% • orthostatic hypotension-5% • other (acute illness, confusion, poor eyesight, drugs) -18% • combination of environmental hazards and increased susceptibility to falls related to aging and disease

28. Evidence based guideline for fall prevention (AGS/BGS/AAOS Task Force, 2001) • Ask patient annually about falls, if no falls-no intervention, screen persons reporting a problem (e.g Get up and go) • if failed screen or recurrent falls do assessment (hx of fall circumstances, meds, chronic illness, mobility level, examine gait/balance, orthostasis, vision, neuro, cardiovascular)

29. Updated guideline 2011 • http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2010

30. Fall Risk Assessment • Vital Signs with orthostatic BP measurements (0,1, and 3 min), visual acuity, depth perception • Cognitive screening (MoCA, Mini-COG) • Fall History (SPLATT) • Medication Review • Physical Examination

31. Functional Assessment (functional strength and endurance, SOT-mCTSIB, 8 foot up and go, gait description, backwards release) • Environmental Review + current assistive device use

32. 8 feet Up and Go Test (adapted from Senior Fitness Test) • A cone is placed 8 feet away from a chair • Patient rises, walks around cone, returns and sits as quickly as possible • > 8.5 seconds is associated with a high fall risk in community dwelling seniors • 10 feet up and go- >14 sec (line)

33. Team Evaluation of Findings • Recommendations and Plan- whole team • Why is this patient falling or at risk for continued falls? • Risk for injury? • What interventions are indicated? • Are assistive devices or exercise programs appropriate? • Should medications be changed, stopped or started? • Findings and recommendations discussed with the patient

34. Falls prevention • Interventions are usually multifactorial and include adjustments of medications, behavioral instructions, exercise programs (balance exercises, tai-chi, gait training and low-impact resistive exercises), assistive devices and equipment (grab bars, shower chair, etc.)

35. Anticoagulation and fall risk • study looking at the risk of developing a subdural hematoma (SDH) after a fall in anticoagulated individuals with chronic a. fib. (Man-Son-Hing M,1999) • Risk of embolic CVA with a.fib. 5%>65, incr’d >75, CHF,HTN, DM, Hx CVA (8%) • Reduced risk of CVA: warfarin 68%, ASA 21% • Risk of falling >65: 33%/yr;Subdural hematomas are rare • Persons taking warfarin must fall 295 times in 1 yr for warfarin not to be the optimal therapy (risk of SDH outweighs the benefit)

36. Anticoagulation with falls risk • Did not account for adverse outcomes other then SDH (increased morbidity or mortality with injury);Risk of bleeding increased if ETOH use, NSAID’s, hx GI bleed, noncompliance with med or lab monitoring • patients at high risk for falls with a. fib are at substantially increased risk of intracranial hemorrhage (ICH) (2.8 vs. 0.34), c but ischemic stroke rates/100 patient-years were 13.7 in patient at high risk for falls and 6.9 in other patients • Patients at high risk for falls with a. fib. because of their high stroke rate, appear to still benefit from anticoagulant therapy, if they have multiple stroke risk factors(Gage et al., 2005).

37. Are major bleeding events from falls more likely on warfarin? • www.fponline.com • summary of evidence with the same conclusion (Garvin and Howard, 2006) “There is no evidence of increased risk for major bleeding as result of falls in hospitalized patients taking warfarin (strength of recommendation B). “In the average patient taking warfarin for atrial fibrillation, the risk of intracranial hemorrhage from a fall is much smaller than the benefit gained from reducing risk of stroke” ( SOR A)

38. Discussion • The decision to start or continue anticoagulation in patients with a.fib at risk for falls requires clinical judgment and should be made after a complete risk benefit assessment including patient preferences(Somerfield, Barber, Anderson et al, 2006).

39. Amanda Olney, DPTSeattle VAMC Amanda Olney, DPT, Graduating from University of Puget Sound with Doctor of Physical Therapy Degree, in 2010 and has worked at the Seattle VA for two and a half years as Outpatient Physical Therapist, with Eight month rotation in Inpatient Rehab. Shortly after arriving at the VA, she became greatly involved in fall prevention at many different levels of administration. Working on Rehabilitation Care Services Fall Prevention Team, recently conducted first ever Fall Also she sits on the Facility Fall committee looking at fall prevention from a broader perspective. In December 2011 started pilot program of Interdisciplinary post fall huddles, which continues to date. Also very recently started an outpatient group balance program, which has shown to be very popular with Veterans.

40. Fall Screening Event • Broad based, large target Audience • Multi-Disciplinary • OT, PT, Pharmacy, Vision, MD • Education presentation • Screening Tests • Handouts • Follow Up

41. Comprehensive PT Screen • Patient history of falls (SPLATTT) • Special questions focused on type of fall, activity, fear of fall and confidence. • Systems screen • Vision, Hearing, Vestibular, Proprioception • Medication Changes, Orthostatic, Sleep • Appetite: Gain/Loss in 6 months • Social: Smoke/ Alcohol • Shoe Assessment

42. Reducing Risk Factors for Special Populations • Risk factors may include: • Musculoskeletal • Neuromuscular • Phantom limb Sensation • Cognitive • Pain

43. Interdisciplinary Post Fall Huddle • Started Jan 2012 Pilot program on 1E inpatient Rehab ward. • Logistics: Make it efficient/ Effective for all Members involved. • Timing: Quick huddle after rounds • Who: Specialist involved in patient care • Attending Physician/Resident • Nursing • OT, PT, RT, SP • Psychology • SW

46. Findings • Team approach • Increases Awareness of entire Team • Creative Interventions • Collaborative Effort • Outline provides structure to fall review • Systems and Individual interventions

47. PT TREATMENT • Individualized patient care plan • Safety, Equipment needs, Specific exercise • Balance exercise group

48. Otago Exercise ProgrammeCampbell 2002 • Founded at the University of Otago Medical School, New Zealand, led by Professor John Campbell • Home-based, individual based strength and balance retraining program • Establish 30 minute home program based on evaluation and progress with phone call monthly • Follow-up home visits recommended every six months • Educate Patients exercises must be maintained • Population: Home and Nursing Home dwelling • Ages 65-97

49. Research • Evidence Based Program: • 4 Randomized Controlled Trials • Tested as a stand-alone intervention • Participants age 65-97 home dwelling/SNF, 1016 total. • Meta Analysis Findings: • 35% decrease in number of falls and injuries from falls in Men and Women equally. • Improved Strength helped to improve Confidence • Greatest benefit from high risk patients: • >80 yo with history of fall.

50. Group Balance Class • Based On Otago Exercise Program (Campbell) • Implemented as part of a multi-factorial falls prevention program • 6 veterans per group, 2 therapists PT/PTA supervision • Strength, ROM, Balance, cardiopulmonary • 30 minutes 5 days per week • Booklet provided for education and exercises with tracking log • 6-8 week program with progression of home exercise program. • 2 weeks per level average • Develop sense of community/ camaraderie among Veterans • Post test BERG and ABC scale