Interprofessional Population Health Session: Fall Prevention in Older Populations Kim Oosterhouse PhD, RN, CCRN-K, CNE Kimi Suh MD, MPH, FAAFP Jessica McIntyre MD, FAAFP GNUR: 290 CONCEPTS IN OLDER ADULT HEALTH PATIENT CENTERED MEDICINE - 1  

Learning Objectives 1) Describe the public health and individual significance of falls in older patients 2) Discuss risk factors for falls 3) Understand how fall risk is assessed, using evidence-based screening strategies (Stay Independent Brochure, Timed Up and Go, The 30 second chair stand, and the 4 Stage balance test) 4) Collaborate interprofessionally to identify strategies and create an evidence-based falls prevention plan

Why are we here together? Population Health - The health outcomes of a group of individuals, including the distribution of such outcomes within the group". It is an approach to health that aims to improve the health of an entire human population. Interprofessional Learning - When two or more professions learn with, from and about each other to improve collaboration and the quality of care of patients PCM-1: Focus on USPSTF recommendations (health promotion), understanding screening and prevention of important public health topics, evidence-based tools GNUR: Curriculum on falls, focus on evidence-based screening tools

Interprofessional Working Groups   Take 10-15 minutes as a small group to discuss 1. Names and school – after everyone is introduced, someone from each school (nursing, medicine, dietetics) share what training is/will be like  What are important qualities for an interprofessional health care team to have in order to provide the best patient care? What may be barriers to effective interprofessional care? Medical students – what is your understanding of the nursing/dietician role and value to the healthcare team? Nursing students – what is your understanding of the dietician/physician role and value to the healthcare team? Dietetic students – what is your understanding of the nursing/physician role and value to the healthcare team? Clarification of roles?

Population Health C. Kimi Suh, MD, MPH, FAAFP

Population Health Population health can be defined as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” -multiple definitions -social determinants of health, health equity and multi-level interventions Kindig D, Stoddart G (March 2003). "What is population health?" (PDF). American Journal of Public Health. 93 (3): 380–3.

Falls: A significant preventable public health concern One of the most important geriatric syndromes and the leading cause of morbidity and mortality for people older than 65 years of age Leading cause of both fatal and nonfatal injuries Falls are a significant public health problem In 2010, over 20,000 people 65 and older died from injuries related to unintentional falls

Falls are Costly In 2015, total medical costs for falls totaled more than $50 billion.

U.S Census Bureau Adults >65: Baby boomers are aging U.S Census Bureau Adults >65: 2000: 34.8 million 2020: 54 million 2040: 77 million Starting in 2011 baby boomers began turning 65 at a rate of 10,000 a day and will continue to do so until 2029.

Those who fall once are 2-3 times more likely to fall again

USPSTF Recommendation

The Elderly- A Critical and Vulnerable Population Often overlooked population Current elder-support services are not adequate Hospital Systems driven towards value-based care of populations rather than fee-for-service care for individuals Hospital acquired conditions (HACs) not covered under Medicare Need for evidence- based tools and interventions for fall prevention

What can be done? Two-thirds of falls may be preventable CDC’s STEADI: Stopping Elderly Accidental Deaths and Injuries Screen patients for fall risk Assess modifiable risk factors Intervene using clinical and community strategies

Evidence Based Interventions CDC Compendium, 2015 Multifaceted Exercise Tai Chi, balance/strengthening exercise programs Home Environmental evaluation for safety Clinical Polypharmacy, Neuropathy, Vision, Vitamin D

Kim Oosterhouse PhD, RN, CCRN-K, CNE Determining Risk for Falls: Understanding Evidence-Based Fall Risk Assessments Kim Oosterhouse PhD, RN, CCRN-K, CNE

Normal Changes with Aging Musculoskeletal Slower reflexes Bone resorption > formation Joint & ligament stiffness Decreased muscle fibers Cardiovascular Decreased baroreceptor sensitivity Auditory Decline in vestibular function Visual Decreased accommodation Changes in visual acuity Decreased contrast sensitivity

Fall Risk Factors Environmental Disease Medications Psychosocial (lifestyle)

High Risk Prior falls* Fear of falling Number of chronic condition pain sites* Parkinson’s disease* Pain (any)* Use of walking aid* Gait deficit* Vertigo Anticonvulsants Fall Risk Increasing Drugs (FRIDs) *Risk more than doubled Reuben, D. B., Herr, K. A., Pacala, J. T., Pollock, B. G., Potter, J. F., & Semla, T. P. (2018). Geriatrics at your fingertips. New York: American Geriatrics Society.

Assessment History of falls Medications Muscle strength Gait, balance, mobility Visual acuity Neurologic impairment Heart rate and rhythm Orthostatic hypotension Feet and footwear Environmental hazards Recommendations from 2011 American Geriatric Society and British Geriatric Society

Orthostatic & Postprandial Hypotension Take BP and HR after 5 minutes in supine position Move to sitting position; assess for dizziness. Take BP and HR after 1 minute Move to standing; assess for dizziness. Take BP and HR after 1 and 3 minutes Drop in SBP>=20 mmHg and or DBP>=10 mmHg is considered orthostatic hypotension Take BP and HR prior to eating a meal Take BP and HR in the same position every 10 minutes until 60 minutes after the meal Drop in SBP>20 mmHg is considered postprandial hypotension https://www.ahrq.gov/professionals/systems/hospital/fallpxtoolkit/fallpxtk-tool3f.html https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2989753/

Consequences of Falls Hip Fractures Traumatic Brain Injury (TBI) 95% of hip fractures are caused by falls Hip fractures are associated with considerable morbidity and mortality Traumatic Brain Injury (TBI) Persons over the age of 75 years have the highest rates of TBI-related hospitalization and death Falls are the leading cause of TBI for older adults Fallophobia Fear of falling is an important predictor of general functional decline and risk factor for future falls Disability Functional decline

DEMONSTRATING FALL RISK ASSESSMENT TOOLS Stay Independent Brochure The 30-Second Chair Stand 4-Stage Balance Test Timed Up and Go https://www.cdc.gov/steadi/materials.html

Fall Risk Assessment Tools in the EHR Morse Fall Scale The Hendrich II Fall Risk Model Others used as well Identify the tool used and become familiar with it

SnapShot: Patient Overview

Ambulatory Setting, Fall Risk

Inpatient, Fall Risk

Fall Risk Score

Fall Risk Score

Communicate Risk, Decision Support

Post-Fall Assessment Purpose Components of a post-fall assessment Determine underlying fall etiologies so that appropriate plans of care can be instituted Identify the clinical status of the person, verify and treat injuries, identify underlying causes, and assist with risk reduction interventions Components of a post-fall assessment Fall-focused history, fall circumstances, medical problems, medication review, mobility assessment, vision and hearing assessment, neurological examination, and cardiovascular examination

Group Case Discussion Mrs. Parker Mr. Ying What fall risk factors do you identify for this patient? What are fall prevention strategies that you recommend? (medical and community based) Based on your (future) professional role, what prevention strategies might you emphasize or take responsibility for? How might these recommendations overlap between professions? What other members of the healthcare team may be involved in fall prevention? How? https://www.cdc.gov/steadi/materials.html

Fall Prevention Programs A Matter of Balance CAPABLE EnhanceFitness FallsTalk / FallScape Fit & Strong! Healthy Steps in Motion Healthy Steps for Older Adults Otago Exercise Program Stay Active and Independent for Life (SAIL) Stepping On Stay Safe, Stay Active Tai Chi for Arthritis Tai Ji Quan : Moving for Better Balance YMCA Moving for Better Balance

Take home points (for the exam )