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FALL RISK AND PREVENTIONIN OLDER ADULTS

Josette Rivera, MDAssistant Professor of Medicine

Division of GeriatricsDepartment of MedicineUniversity of California

Ellen Corman, BS, MRASupervisor, Community Outreach 

and Injury PreventionStanford University Medical Center 

Trauma Service

Sponsored by 

Stanford Geriatric Education Center 

in conjunction with

American Geriatrics Society,

California Area Health Education Centers,University of California, San Francisco

Trauma Service

May 10 2012

This project is/was supported by funds from the Bureau of Health Professions (BHPr), Health Resources and Services Administration (HRSA), Department of Health and Human Services (DHHS) under UB4HP19049, grant title: Geriatric Education Centers, total award amount: 

$384,525. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by the BHPr, HRSA, DHHS or the U.S. Government.

California Area Health ducation Centers,

and 

Natividad Medical Center

Natividad Medical Center CME Committee Planner Disclosure Statements:

The following members of the CME Committee have indicated they have no conflicts of interest to disclose to the learners: Kathryn Rios, M.D.; Anthony Galicia, M.D.; SandraG. Raff, R.N.; Sue Lindeman; Janet Bruman; Jane Finney; Tami Robertson; Judy Hyle, CCMEP; Christina Mourad and Nobi Riley

“Fall Risk and Prevention in Older Adults”

Stanford Geriatric Education Center Webinar Series Planner Disclosure Statements:

The following members of the Stanford Geriatric Education Center Webinar Series Committee have indicated they have no conflicts of interest to disclose to the learners:Gwen Yeo, Ph.D. and Kala M. Mehta, DSc, MPH

Faculty Disclosure Statement:

As part of our commercial guidelines, we are required to disclose if faculty have any affiliations or financial arrangements with any corporate organization relating to thispresentation. Dr. Rivera and Miss. Corman have indicated they have no conflicts of interest to disclose to the learners, relative to this topic.

Dr. Rivera and Miss. Corman will inform you if they discuss anything off-label or currently under scientific research.

Josette Rivera is a clinician educator and an Assistant Professor of Medicine in the Division of Geriatrics. She is dedicated to providing primary and palliative care to homebound older adults throughout San Francisco through the UCSF Housecalls Program. Dr. Rivera’s educational focus is on training students and professionals how to collaborate within interdisciplinary teams to provide effective, patient-centered care for older adults. She recently received a Geriatric Academic Career Award with which she will create and expand interprofessional and geriatric education opportunities at UCSF.

Dr. Rivera received her medical degree from the University of Rochester and residency training in Primary Care Internal Medicine at Johns Hopkins Bayview. She then completed a three year clinical and research fellowship in the Division of Geriatric Medicine and Gerontology at Johns Hopkins. At the conclusion of fellowship, Dr. Rivera became a staff physician at On LokLifeways, a Program of All-Inclusive Care for the Elderly, which serves nursing home eligible seniors in the San Francisco area. She joined the Geriatrics faculty at UCSF in 2008.

Ellen Corman, MRA

Ellen Corman, Supervisor of Community Outreach and Injury Prevention for the Trauma Service at Stanford University Medical Center, has over 20 years experience working in the area of injury prevention. She has an undergraduate degree in Occupational Therapy and a Masters degree in Rehabilitation Administration. Ellen was a member of the state’s Injury Prevention Strategic Planning Committee and active in the state’s Stop Falls Network. Ellen currently co-chairs the San Mateo County Fall Prevention Task Force and developed and manages a fall prevention program for older adults called Farewell to Falls at Stanford’s Trauma Service. She has presented locally to seniors, caregivers and professionals and has presented at national conferences.

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Fall Risk and Prevention in OlderPrevention in Older

Adults

Josette Rivera, MDDivision of Geriatrics

UCSF

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Objectives

By the end of this discussion, participants should be able to:

1. Understand the personal and societal impact of falls

2. Identify risk factors for falls among older adults

3 Describe evidence based guidelines for screening and prevention3. Describe evidence based guidelines for screening and prevention

4. Discuss interventions that have been demonstrated to reduce falls in clinical trials

What is a Fall?

• Unintentionally coming to rest on the ground or other lower level

• Not due to a major intrinsic event or overwhelming environmental hazard

• No loss of consciousness

The Importance of Falls

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Older Adult Falls Burden 2006

Fifth leading cause of death in

older adults

CDC’s Research Portfolio in Older Adult Fall PreventionSleet DA J Safety Res. 2008;39(3):259-67

Falls Cause Morbidity and Mortality

• Injuries are common:

– 40% of falls result in minor injuries

– 10% result in major injuries

• 2.2% of injurious falls result in death

• Cost of fall-related injuries for 65+

– Currently $19 billion -> $54.9 billion by 2020

Chang JT BMJ 2004Tinetti ME JAGS 1995

Tinetti ME JAMA 2010MMWR Morb Mortal Wkly Rep 2008

Falls Associated with Functional Decline

• Decline in function/loss of independence

• Fallers 3X more likely to enter SNF

• Fear -> isolation, further functional decline

– 60% fallers reported moderate activity restriction

15% reported severe restriction– 15% reported severe restriction

Deshpande N JAGS 2008Tinetti, ME N Engl J Med

1997MMWR Morb Mortal

Wkly Rep 2006; 55:1221Tinetti, ME J Gerontol A

Biol Sci Med Sci 1998

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Epidemiology of Falls

Question

What % adults > 65 yrs old living in the community fall each year?

A. 5%

B. 10%

C 20%C. 20%

D. 30%

E. 50%

Incidence

• 30% of community-dwelling people over the age of 65 fall each year

• Increases to ~50% for those 80 years and older

• Half are repeat fallers

Chang JT BMJ 2004Tinetti ME N Engl J

Med 2003Rubenstein

LZ Clin Ger Med 2002

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Question

Which ethnic groups are most likely to fall?

A. African Americans

B Asian AmericansB. Asian Americans

C. Latino Americans

D. European Americans

E. No difference between groups

Falls and Socio-demographic Factors

18.3%

11.3%

7.9%

15.3%

Latino AfricanAmerican

Asian White

Multiple falls past year, age 65+Source: 2007 California Health Interview Survey

Question

Which ethnic group is most likely to be hospitalized because of a fall?

A. African Americans

B. Asian Americans

C. Latino Americans

D. European Americans

E. No difference between groups

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American Geriatrics Society Fall Prevention Guidelines

www.medcats.com/FALLS/frameset.htm

Screening

• AGS: All adults > 65 should be asked at least annually if they have fallen in the past year or whether they have difficulties in gait or balance

• Single fall: check balance/gait

• Recurrent falls or balance/gait disturbance: do multifactorial fall risk assessment

Tinetti ME JAMA 2010AGS Fall Prevention Clinical Practice Guidelines 2010

2010 AGS/BGS Clinical Practice Guideline

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Evaluation of the Faller

Evaluation of Falls: History

• Rule out acute badness

– Syncope or fall?

– Injury?

– Acute illness?

• Any recent changes in health or environment?

Evaluation of Falls: History

• Relevant medical conditions

– Neurolgical, cardiac, ophtho, incontinence, osteoporosis

• Medications

– Psychoactive? Recent changes? Total # > 4?

• Substance/alcohol use

• Difficulty with walking or balance

• Ability to complete ADLs

• Fear of falling

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Gait and Balance Evaluation

• You have not fully examined the nervous or musculoskeletal systems until you have analyzed gait

• Quick, validated, in office tests

Timed Up and Go– Timed Up and Go

• Physical Therapy Evaluation (insurance/$ dependent)

– Outpatient

– Adult Day Health Center

– Home Care

Mathias A Arch Phys Med Rehab 1986Podsiadlo D JAGS 1991Tinetti ME JAGS 1986

Evaluation of Falls: Physical Exam

• Supine and standing BP & CV exam

• Vision and hearing evaluation

• Neurological exam, including cognition

• Musculoskeletal exam

• Feet/footwear

• Formal gait and balance assessment

• Inappropriate assistive device use

Etiology and Risk Factors

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Thinking About Fall Risk

Intrinsic Factors Extrinsic Factors

Medical Medications

FALLS

conditions

Impaired vision and hearing

Age- related changes

Improper use of assistive devices

Environment

Most Common Fall Risk Factors

Risk Factor Relative Risk # studies

Previous Falls 1.9 – 6.6 16

Balance Impairment 1.2 – 2.4 15

Decrease Muscle Strength 2.2 – 2.6 9

Vision Impairment 1.5 – 2.3 8

Meds: > 4 or psychotropic 1.1 – 2.4 8

Gait impairment 1.2 – 2.2 7

Depression 1.5 – 2.8 6

Orthostasis 2.0 5

Age >80 1.1 – 1.3 4

Female 2.1 – 3.9 3

Cognitive Impairment 2.8 – 3.0 3

Arthritis 1.2 – 1.9 2

Tinetti,JAMA. 2010;303(3):258-266

Thinking About Fall Risk

1 year follow up

Tinetti ME N Engl J Med 1988

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Summary

• Falls are common and multifactorial

• Often lead to injuries, functional decline, nursing home placement, and death

• Screen older adults for falls at least annually

• Evaluation should included risk factor assessment, gaitEvaluation should included risk factor assessment, gait assessment, and home assessment

• Targeted multifactorial interventions most effective

• AGS Fall Prevention Guidelines available

• Interprofessional collaboration essential

Resources

• American Geriatrics Society Fall Prevention Clinical Practice Guideline

– http://www.americangeriatrics.org/health_care_professionals/clinical_practice/clinical_guidelines_recommendations/2010/

• Centers for Disease Control Falls in Adults Publications and Resources

– http://www.cdc.gov/HomeandRecreationalSafety/Falls/index-pr.html

• NIH Senior Health: Falls and Older Adults for patients

http://nihseniorhealth gov/falls/toc html– http://nihseniorhealth.gov/falls/toc.html

• Tinetti M and Kumar C. The Patient Who Falls: It’s Always a Trade Off. JAMA. 2010;303(3):258-266

• Michael YL et al. Primary Care–Relevant Interventions to Prevent Falling in Older Adults: A Systematic Evidence Review for the U.S. Preventive Services Task Force. Ann Intern Med. 2010;153:815-825.

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ELLEN CORMAN OT MRA

Fall Risk Best Practice in

Prevention

ELLEN CORMAN, OT, MRAST AN FO RD HO SP IT AL AN D

CL IN ICST RAU MA S E RV IC E

Falls at Stanford Trauma

12%

5%

5%1%1% 1% 1%

0%0%

Cause of Injury > = 65 years old

FALL

MVC

PEDESTRIAN

74%

12% BICYCLE

OTHER BLUNT

MCC

ASSAULT

OTHER PENETRATING

STABBING

GSW

In 2006, there were 2,645

hospitalizations due to falls.

Santa Clara County Fall Facts

Average cost of hospitalization

estimated to be $38,563/person.

Average cost of ambulance ride

after 911 call in Santa Clara

County estimated to be $1,423.

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Why Do People Fall?

Health Issues

Medications

Personal Habits

Vision

Home Safety Issues

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Personal Habits

Multi-Tasking

Balance and Strength

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Best Practice in Fall Prevention

Causes of falls are due to multiple causes. Therefore,

the best intervention to prevent f ll i f d b l i f lfalls is found to be multi-factoral. (Tinetti, Baker, McAvay, Claus, Gareet, Gottschalk,

NJMed, 1994)

Interventions for Fall Prevention

Medication Review special attention to psychotropic drugs

Home Safety Assessment and Modification Most effective if can assure follow-through with recommendations

Exercise Exercise Type and frequency of exercise not conclusive

Balance and strength training seems to be most effective

Tai Chi – only exercise strategy that was significantly effective in isolation of other interventions.

Personal Habits Attention to surroundings and change in behaviors.

Farewell to Falls

Free home-based program offered by Trauma Service at Stanford Hospital and Clinics

Multi-faceted program Home Safety

di i Medication management

Strength/balance – exercise

Personal habits

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Program Implementation

Two home visits by Occupational Therapist

Health, ADL and activity interview

Medication review (meds listed by OT and reviewed by Stanford pharmacist with written report)

Sensory-Motor assessment

Home safety assessment

Exercise and Home Safety Intervention

Connection to community exercise program and/or home-based exercise program with DVD provided and/or written material.Home-based exercise is equally beneficial for

ti i t b d i (Ki H k ll t participants as group-based exercise (King, Haskell, et al, 1991:Vol266 No11)

Connection to home safety company to install grab bars, if necessary. Program covers those who need financial assistance.

Admission Criteria

65 years and older

Live in Santa Clara or San Mateo County in home or apartment

Ambulatoryy

Cognitively aware – can follow instructions and provide own health history

Willing to commit to exercise and program recommendations

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Evidence-Based Fall Prevention Programs

A Matter of Balance – Volunteer Lay Leader Model www.mainhealth.org

Stepping On Wisconsin Institute of Healthy Aging – 608-243-5690

Tai Chi: Moving for Better Balance Oregon Research Institute, Eugene, Oregon

fuzhongl@ori.org

Otago clare.robertson@otago.ac.nz

Resources

National Council on Aging (NCOA) – Center for Healthy Aging, www.ncoa.org/improve-health/center-for-healthy-aging

Public Health Agency of Canada – Evidence for Best Practices on the Prevention of Falls and Fall-Related Injuries Among Seniors Living in the Community, www.phac-aspc.gc.ca/seniors-aines/publications/pro/injury-blessure/practices-pratiques/chap4-eng.php

King AC, Haskell WL, Taylor CB, Kraemer HC, DeBuskRF, Group- vs Home-Based Exercise Training in Healthy Older Men and Women: A Community-Based Clinical Trial, JAMA, 1991; 266(11):1535-1542.

For information about Farewell to Falls or a Matter of Balance, contact:

ELLEN CORMAN

SUPERVISOR, INJURY PREVENTION

STANFORD UNIVERSITY MEDICAL CENTER STANFORD UNIVERSITY MEDICAL CENTER

TRAUMA SERVICE

650-724-9369

ECORMAN@STANFORDMED.ORG