Molly Moncrieff Doctor of Pharmacy Candidate University of Georgia

1. Prevention of Falls in Community-Dwelling Older Adults: U.S. Preventative Services Task Force Recommendation Statement Molly Moncrieff Doctor of Pharmacy Candidate University of Georgia College of Pharmacy Class of 2013 Preceptor: Dr. Ali Rahimi

2. Background • Falls are the leading cause of injury in adults 65 years old or older • 30-40% of community-dwelling adults 65 years or older fall at least once per year • 5-10% of adults who fall will have a fracture, laceration or head injury • The burden of falls on patients and the health care system is large

3. Purpose • There are various approaches used to identify persons at increased risk for falls and no evidence-based instrument exists that can accurately identify older adults at an increased risk for falling • There are several reasonable and feasible preventative interventions available for older adults • Which one is best?

4. Risk Factors • Age • History of falls • Used most often to identify high risks patients • History of mobility factors • Poor performance on the times Get-Up-and-Go test • Time it takes a person to rise from an armchair, walk 10 feet, turn, walk back and sit down again • Average for a healthy adult >60 years old is 10 seconds

5. Prevention • Exercise and physical therapy • HHS recommends 150 minutes per week of moderate-intensity or 75 minutes per week of vigorous-intensity aerobic physical activity • Muscle-strengthening exercises twice per week • Balance training 3 or more days per week for patients at risk for falling due to recent fall or difficulty walking • Vitamin D supplementation • Institute of Medicine recommends daily allowance for vitamin D of 600 IU for patients aged 51 to 70 and 800 IU for patients older than 70 years old • AGS recommends 800 IU per day for persons at increased risk for falls

6. Prevention • Multifactorial risk assessment with comprehensive management • Evaluations of balance and mobility, vision, orthostatic and postural hypotension, review of medication use and home environment • Providing medical and social care to address factors identified during the assessment • Vision correction • Medication discontinuation • Protein supplementation • Education or counseling • Home hazard modification

7. Evidence • Exercise or physical therapy has a moderate net benefit in preventing falls in older adults • Reduce the risk of falls by 13% • Number needed to treat = 16 • Vitamin D supplementation has a moderate net benefit in preventing falls in older adults • Reduce the risk of falls by 17% • Number needed to treat = 10 • Multi-factorial risk assessment with comprehensive management has a small net benefit in preventing falls in older adults • Vision correction, medication discontinuation, protein supplementation, education or counseling and home hazard modification lack sufficient evidence

8. Harms • Harms of physical therapy or exercise are small • Paradoxical increase in falls • Increase in physician visits • Harms of vitamin D supplementation are no greater than small • Harms of multifactorial risk assessment with comprehensive management of identifies risks are no greater than small

9. USPSTF Recommendations • Exercise and Physical Therapy • B Recommendation • Vitamin D Supplementation • B Recommendation • Do not automatically perform an in-depth Multifactorial Risk Assessment in conjunction with comprehensive management of identified risks • Consider the balance of benefits and harms on the basis of the circumstance of previous falls, comorbid conditions and patient values • C Recommendation

10. USPSTF Recommendations

11. USPSTF Recommendations

12. Biological Understanding • Exercise and Physical Therapy • Improve strength and balance therefore resulting in fewer falls • Vitamin D Supplementation • Vitamin D receptors have been identified in various cell types including skeletal muscle and stimulation of these receptors promotes protein synthesis • Vitamin D receptors decline with age • Vitamin D and its metabolites have a beneficial effect on muscle strength and balance

13. References • Moyer V.A, et al. Prevention of Falls in Community-Dwelling Older Adults- U.S. Preventive Services Task Force Recommendation Statement. Annals of Internal Medicine. 2012 August 7;157(3):197-204.