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2018: Falls evidence based prevention gwep
- 1. I WONT FALL FOR THAT AGAIN! EVIDENCE BASED FALL PREVENTION IN THE ELDERLY Neila Shumaker M.D. Associate Professor Internal Medicine/Geriatrics/Palliative Medicine Program Director, Geriatric Medicine Fellowship
- 2. LEARNING OBJECTIVES 1. Explain the significance of falls to elders and society 2. Identify fall risk factors 3. Assess elderly fallers 4. Apply evidence based fall interventions
- 3. DEFINITION OF A FALL • A fall is an event which results in a person coming to rest inadvertently on the ground • Not a consequence of loss of consciousness, seizure or sudden paralysis • ICD-10 codes • E880-E888.9 Accidental fall • R29.6 Repeated falls
- 4. ETIOLOGY OF FALLS IN OLDER ADULTS • Result from the cumulative effects of • Impaired gait and balance • Aging changes • Polypharmacy • Cognitive impairment • Acute illness • Environmental factors
- 5. FREQUENCY OF FALLS IN ADULTS OVER 65 • Community dwelling elders – 30 to 40% per year • Nursing home residents – over 50% fall during stay • Hospitalized elders – 3 times outpatient rate
- 6. MORBIDITY AND MORTALITY FROM FALLS • Falls are the leading cause of fatal injuries over age 65 • Over 800,000 hospital admissions per year for falls • 70% of accidental deaths over age 75 are due to a fall • Mortality from a fall is highest among older white men • “1/3 of older adults fall per year, 1/3 of falls cause injury, 1/3 of injuries are serious” • Serious injuries – fractures, head injuries, lacerations • Falls are a common cause of immobility, ADL dependence, downward spiral and institutionalization
- 7. ECONOMIC COSTS OF FALLS • About 10% of ED visits among the elderly • 1/3 of these were admitted to the hospital • Mean length of stay 5.5 days • Total cost of older adult fall injuries was $31 billion in 2014
- 8. FALL RISK FACTORS IN ELDERS • Intrinsic • Acute illness • Vestibular (balance) dysfunction • Cardiovascular (arrhythmias, orthostatic hypotension, cardiac syncope) • Neurologic (Parkinson’s disease, neuropathies, myelopathies, stroke, cognitive impairment, “senile” gait) • Musculoskeletal (foot, knee and leg disorders affecting strength, mobility and gait) • MEDICATIONS!
- 9. MEDICATIONS AND FALL RISK • Use of more than 4 medications may increase fall risk. • Many drug classes are linked to falls • Antihypertensives • Diabetes meds • Anxiety/mood/sleep medications • Antipsychotics • ETC! Any medication that alters alertness, concentration, judgment, gait/balance
- 10. EXTRINSIC FALL RISK FACTORS • Environmental hazards • Contribute to 50% of falls in elders • 70% of these falls happen at home • Kitchen, bathroom, stairs are most common sites • Slippery surfaces, loose rugs, uneven/unmarked steps, clutter etc.
- 11. SCREENING FOR FALL RISK • Ask all adults over 65 if they have • Fallen 2 or more times in the past year • Sought medical attention after a fall, or • Feel unsteady when walking • Refer for further assessment for any positive response • Gait/balance evaluation if elder had one fall without injury – refer if abnormal • Fall risk assessment is part of Welcome to Medicare and Medicare Annual Wellness visits
- 12. FALL RISK ASSESSMENT • Falls history • Number, circumstances, warning symptoms, location, time of day, activity, footwear, assistive device, glasses • Injuries, any treatment • Is the elder able to get up after a fall? • Medications • Psychoactive drugs, diuretics, blood pressure and diabetes meds • Any drug causing sedation, confusion, altered gait, balance, alertness and judgment.
- 13. FALLS RISK ASSESSMENT – PHYSICAL, LAB • Physical Exam • Orthostatics, cardiovascular, neurologic, legs/feet/shoes • Gait/balance tests – on STEADI site – can be done by team member • Timed Up and Go (TUG) • 30 second chair stand test • 4 stage balance test • Functional assessment – ADLs, IADLs • Cognitive screen – Mini-Cog • Lab, imaging – not always indicated • Consider acute illness as a cause of a fall • CBC, Chem panel, TSH, B12 level, vitamin D level • Xrays, head CT if indicated by presentation, injuries • Bone density study when stable
- 14. APPROACH TO MANAGING FALL RISK • Ask what elder thinks causes their falls • Ask about fear of falling • Educate – many falls can be prevented • Beware overprotective caregivers! • Nursing home placement is not the answer to falls! • Focus on quality of life, independence, values, goals of care • STEADI toolkit has many patient/caregiver resources • http://www.cdc.gov/injury/STEADI
- 15. EVIDENCE BASED FALL PREVENTION INTERVENTIONS • Strength and balance exercise interventions are the most effective • Both individual and group exercises • Walking alone has not been shown to prevent falls • Home environmental assessment by OT or other trained clinician • Effective alone or as part of multifactorial intervention by a team • Covered by Medicare if elder qualifies as homebound • Assesses ADLs, cognition, vision, footwear, lighting, clutter , outside hazards • Teaches adaptive safety behaviors in the home • Physical therapy • Gait/balance assessments • Exercise programs • Mobility aids • Anti-slip shoe devices for ice
- 16. MORE INTERVENTIONS • Community fall prevention programs • Otago home exercise program • Group tai chi classes • What do you have in your community? AOA endorsed programs • Reduce doses and numbers of prescription medicines • Calcium and vitamin D supplementation • 1200 mg calcium from diet and supplements • 1000 to 2000 iu vitamin D • First eye cataract surgery shown to decrease falls • Carry cell phone or wear medical alert device
- 17. HOSPITAL FALL PREVENTION BEST PRACTICES • Universal fall precautions • Standardized assessment of fall risk factors • Similar risks PLUS acute illness, tethers (eg IV poles), delirium, new medications, sleep deprivation, etc. • Beware Alarm and Risk Score fatigue! targeted to risk factors • Care planning and interventions – mobility algorithm • ACE unit and HELP studies – ambulation does not increase falls • Postfall procedures • AHRQ: Preventing Falls in Hospitals - A Toolkit for Improving Quality of Care • HELP website – includes mobility program information
- 18. BARRIERS TO AMBULATION OF OLDER HOSPITALIZED PATIENTS • Pain, fatigue, weakness • Lines, catheters • Nurse staffing, training • Medical focus • Environmental obstacles • Patient, family reluctance • Bedrest orders!
- 19. FALL INJURY PREVENTION IN NURSING FACILITIES • Alarms don’t prevent falls • Restraints increase falls and cause many other harms • Evidence based interventions • Comfort rounds, fall prevention rounds • Bed height appropriate to resident, functional status • Fall pads when in bed • Hip protectors • Restorative nursing • Activities, exercise
- 20. SUMMARY • Balance, medications and home safety should be addressed in all high risk fallers • Leg strength, vision, footwear, calcium, vitamin D and carrying a cell phone are other evidence based interventions • Refer to effective fall prevention programs endorsed by public health departments and Area Agencies on Aging • Monitor repeat fallers • Clinical Modification (ICD-10-CM) code R29.6 for repeated falls
- 21. KEY POINTS • Ask about falls at least annually • Falls are multifactorial • Use evidence based assessments and interventions, targeted to risk factors and setting • Many falls can be prevented!
- 22. ANY QUESTIONS BEFORE WE PRACTICE? ???
- 23. BEFORE YOU GO…..LET’S PRACTICE! • LINKS TO CDC STEADI FUNCTIONAL ASSESSMENTS: • 30 second chair test: https://www.cdc.gov/steadi/pdf/30_Second_Chair_S tand_Test-a.pdf • 4 Stage balance test: https://www.cdc.gov/steadi/pdf/4- Stage_Balance_Test-a.pdf • Timed Up and Go test: https://www.cdc.gov/steadi/pdf/TUG_Test-a.pdf
- 24. REFERENCES General fall and fall injury prevention • http://www.cdc.gov/injury/STEADI Preventing Falls in Hospitals A Toolkit for Improving Quality of Care • https://www.ahrq.gov/sites/default/files/publications/files/fallpxtoolkit.pdf
Editor's Notes
- Thank you for your interest in a very important topic, falls and fall prevention in the elderly. I hope you will each take away something you can use in your setting.
- Here are my objectives for todays presentation.
- Here is the official definition of a fall. Research studies usually exclude those falls that are due to sudden loss of consciousness from a cardiac event, seizure or massive stroke.
- Falls in older adults are usually due to multiple contributing factors, shown on this slide.
- Prevalence: 1 in 4 Americans over 65 falls each year Every 11 seconds an older adult is treated in the ED for a fall – over 2.8 million injuries are treated in ED annually.
- Every 19 minutes an older adult dies from a fall in the U.S. – over 27000 deaths per year, the leading cause of fatal injuries amongst older adults. There are over 800,000 hospital admissions for falls – the leading cause of admissions for trauma over 65. Why do you suppose mortality is highest amongst older white males? Rule of thumb “1/3 1/3 1/3” Falls lead to loss of independence, even placement. There are many hidden impacts from falls, such as fear of falling, social isolation and depression.
- Cost of falls are direct and indirect, including medical, emergency and trauma care, acute hospital and post acute facility costs, lost productivity of caregivers etc. Anticipated to reach as much as $67.7 billion by 2020.
- We can look at the risk factors for falls as being either specific or “intrinsic” to the individual elder, or environmental (extrinsic). While different people age differently, these are some of the common categories of aging and disease that are associated with increased risk of falling. Most of these are easily diagnosed, but I want to mention a few specifically. Parkinson’s disease should be differentiated from Parkinsonism, which can be medication induced (antipsychotics, metoclopramide). Senile gait refers to a short stepped, hesitant gait which is easily confused with Parkinson’s disease but is due to factors such as weakness, gait instability, fear of falling and vision impairment.
- In my setting I don’t see any patients on fewer than four medications! The total number of drugs, the numbers of doses, and the drug categories can all contribute to falls.
- “Contribute to” is the key point here. Although fall events are usually attributed to a trip or a slip such as on a wet surface or over the family dog, it is important to recognize that falls are rarely due to a single cause. Ask yourself if a younger adult could have avoided falling under the same circumstances. “I’ll be more careful” is not an effective fall prevention strategy!
- Older adults don’t always tell their health care team that they have fallen. You should ask about falls at least annually in the OP setting. Screening consists of asking patients whether they have fallen 2 or more times in the past year or sought medical attention for a fall, or, if they have not fallen, whether they feel unsteady when walking. Patients who answer positively to any of these questions are at increased risk for falls and should receive further assessment, which we will review. Those who have fallen once without injury should have their balance and gait evaluated; those with gait or balance abnormalities should receive additional assessment. A history of 1 fall without injury and without gait or balance problems does not warrant further assessment beyond continued annual fall risk screening.
- Assessment of risk: A history of falls is the single strongest risk factor for future falls. The proportion of older people who fell in one year increased from 19% for those with one risk factor to 78% for 4 or more risk factors. In 2010 The AGS/BGS published a clinical practice guideline to promote fall risk assessment and management. It recommends that health care providers ask all older adults if they have fallen in the past year. People who have fallen two or more times or who are experiencing difficulties with walking or balance should receive a multifactorial fall risk assessment. The history is as listed on the slide; be sure to ask about fear of falling, ADL function, mobility aids and medications. Higher ADL function correlates with falls on stairs, away from home, bending over, reaching. Lower ADL function correlates with falls at home during routine activities. Many drugs increase the risk of falls. Deprescribing, or eliminating inappropriate medications, is a key tenet of Geriatric Medicine. Cognitive Behavioral Therapy for Insomnia (CBT-I), proven to be effective for chronic insomnia, is one example of options for deprescribing. Psychoactive drugs and the inability to get up after a fall, or “fall with long lie” are both independent risk factors for further falls.
- Physical Exam and Lab: The physical exam should be targeted but should include orthostatic blood pressure check, gait, balance, neurological function, lower extremity muscle strength, cardiovascular status, visual acuity, cognitive screen and evaluation of the feet and usual footwear. Gait, balance and LE strength can be assessed with several commonly used tests. In the Timed Up and Go (TUG) test you ask the elder to stand up, walk about 10 feet using usual assistive device if any, turn, walk back at usual pace, then sit down. Greater than 12 seconds suggests high fall risk. The 30 second chair stand uses a knee height chair, don’t use the arms. There is an age and gender specific normal range. You can also use this to teach simple quadriceps strengthening. The 4 stage balance tests parallel, semi-tandem, tandem (heel toe – 10 seconds) and one-leg stances (5 seconds). Lab and imaging depends on the presentation. It is important to note that a fall may be a marker for an acute illness; pneumonia, heart failure, dehydration, stroke and fracture can all present with a fall.
- Approach to managing fall risk: The goals of fall risk management are to reduce the chance of falling, reduce the risk of injury, maintain the highest possible mobility, and ensure follow-up. Elders and caregivers often have inaccurate perceptions of what causes falls and will decrease activities after a fall, leading to deconditioning. You need to explore this and also fear of falling, since that can lead to self-limitation of mobility and socialization.
- Evidence Based Fall Prevention and Interventions: Here are some interventions that have been shown in high quality clinical trials to be effective. This information is all available on the CDC STEADI site (Stopping Elderly Deaths and Accidents). A meta-analysis of randomized controlled trials of fall interventions concluded that assessing and addressing an older person’s fall risk factors, in addition to identifying and treating symptoms of chronic conditions, can reduce falls (Gillespie et al., 2012; American Geriatrics Society/British Geriatrics Society [AGS/BGS], 2010). A Cochrane Systematic Review reported that clinical assessment by a health care provider combined with individualized treatment of identified risk factors, referral if needed, and follow-up, reduced the rate of falls by 24%. Even individuals at low risk (no history of falls, no problems with gait or balance) can benefit from a primary prevention approach, namely education about fall risk factors, strength and balance exercises, and vitamin D supplementation. To be effective, exercise must (1) focus on improving balance, (2) be of moderate to high challenge and progress in difficulty, and (3) be practiced a minimum of 50 hours, which equates to 2 hours weekly for 25 weeks. The CDC STEADI tool kit based on this guideline and other sources has tools for patients, providers and community agencies and programs. The CDC site is a wealth of information on fall screening, assessment and prevention, including patient handouts and provider instructions.
- More evidence based recommendations: Tai chi has been shown to reduce fall risk by 29%. Vitamin D was shown effective in elders with low levels. The recommended dose of vitamin D for fall prevention is 1000 IU of cholecalciferol daily. Calcium from diet and supplements should be around 1200 mg daily. First eye cataract surgery is effective but there may be a temporary increase in fall risk during adjustment. Podiatrist can help with footwear recommendations, orthoses. Support hose can sometimes help with orthostatic hypotension. Dementia impairs gait, balance and safety awareness. Recent evidence suggests that the mobility and balance deficits seen in dementia may be improved through exercise.
- Hospital fall prevention best practices: I want to briefly touch upon hospital and nursing home falls. How are falls in these settings different from home and community falls? Studies have shown that 23 to 65% of older inpatients lose independent ambulation in the first 2 days of hospitalization and sadly only a third have regained lost function by 1 year post discharge. Even healthy volunteers lose strength and lean body mass when kept in bed and sick patients also typically have anorexia and are in a catabolic state (negative energy balance). Hospital care and environments result in additional risk factors as shown. Incentives to use IV and psychoactive medications are a problem. Many best practices have been studied, such as individualized care planning and mobility algorithms. ACE units combine multidisciplinary geriatric assessments with acute hospital services and have shown decreased mortality vs usual care. Interventions include early mobilization and rehab, less sleep disruption, fewer meds etc. Walking patients does not increase falls! The Agency for Healthcare Research and Quality (AHRQ) toolkit is a comprehensive document addressing hospital falls and fall prevention programs and interventions. HELP – the Hospital Elder Life Program – is focused on delirium prevention but many of the interventions also help prevent falls.
- Barriers to ambulation: There are many barriers to mobilization of older hospitalized adults. Unit and hospital culture is key. Even intubated patients can be assisted to stand and transfer. Bed rest orders are common but most do not have a clearly documented indication. I recently watched a Webinar on a high resolution real time locating system (hr-RTLS) similar to a GPS system. It can be used for tracking when patients are out of bed and can generate a report showing a trail of a patients movements on the unit, time in bed etc.
- Fall injury prevention in NFs: In the nursing home setting the focus is as much or more on injury prevention as on fall prevention. Cardiovascular causes are somewhat more common, but most falls are still mainly associated with ADL activities such as transferring and toileting. Virtually all residents are at moderate or high fall risk, so risk scales are not that helpful. Bed and chair alarms are disruptive and can lead to alarm fatigue. Other alarms such as programmed talking alarms are being trialed. Restraints cause deconditioning so the residents are ultimately more likely to fall. Restraints also cause pressure sores, agitation, depression, delirium etc. and should not be used. Evidence based interventions in the nursing home include anticipating resident needs, adjusting bed heights, correct use of fall pads, hip protectors, but MOST OF ALL trying to maintain and improve function.
- Summary: So in summary we have reviewed fall risk assessment and evidence based interventions in home, hospital and nursing facility settings. Balance and strength, medications, vision, footwear and environmental hazards should be assessed and corrected if possible in all settings. The CDC STEADI site is replete with tools for providers, patients, caregivers and community programs. Every elder and every setting is unique, but the resources in STEADI are rich and adaptable to your needs.
- Key Points: I hope I have been able to convince you that Falls have multiple causes There are evidence based interventions you can apply to decrease falls and fall injuries Many falls can be prevented!
- Questions?
- Practice!!
- Here are the STEADI and AHRQ .gov sites for your reading pleasure!