FALL PREVENTION: RESEARCH TO PRACTICE Laurence Rubenstein, MD, MPH Director, Sepulveda Division Greater Los Angeles VA GRECC Professor of Medicine, UCLA VA GRECC Audio Conference October 26, 2006

Preventing Falls: What does the evidence show? Background: Epidemiology, costs Causes & risk factors Prevention approaches--evidence RAND meta-analysis New studies since the meta-analysis AGS/BGS practice guidelines--update

Famous Fallers

Fall Incidence in Older Adults [rate/person/yr] or [rate/bed/yr] Rubenstein LZ, Josephson KR. Clin Geriatr Med. 2002(May);18(2):141-158

Falls Mortality Accidents: the 5th leading cause of death in older adults Deaths from falls: 2/3 of accidental deaths 72% of U.S. fall-related deaths occur in the 13% of population age 65+ Rubenstein LZ, Josephson KR. Clin Geriatr Med. 2002(May);18(2):141-158

Costs of Falls 8% of pop 70 visit ERs for falls yearly 1/3 of these are hospitalized 5.3% of hosp patients 65 are due to falls U.S. cost est. 2000$20 B. (2020$32 B) 18% restricted activity initiated by falls Precipitate NH entry # 1 cause of NH litigation Rubenstein LZ, Josephson KR. Clin Geriatr Med. 2002(May);18(2):141-158

Causes of Falls: Summary of 12 Studies Accident/environment 31% Gait/balance disorder 17 Dizziness/vertigo 13 Drop attack 10 Confusion 4 Postural hypotension 3 Vision problem 3 Other specified 15 Unknown 5 Rubenstein LZ, Josephson KR. Clin Geriatr Med. 2002(May);18(2):141-158

Risk Factors for Falls: 16 Multivariate Studies Rubenstein LZ, Josephson KR. Clin Geriatr Med. 2002(May);18(2):141-158

Drugs & Falls: Meta-analysis Leipzig, Cumming, Tinetti, JAGS, 1999 Psychotropics, any: RR 1.73 (1.52-1.97) Neuroleptics: 1.50 (1.25-1.79) Sedative/hypnotics: 1.54 (1.40-1.70) Antidepressants: 1.66 (1.40-1.95) Benzodiazepines: 1.48 (1.23-1.77) Diuretics: 1.08 (1.02-1.16) Anti-arrhythmics (Ia) : 1.59 (1.02-2.48) Digoxin: 1.22 (1.05-1.42) Fall risk from newer ψ agents no better. --Hien, Cumming, Cameron, et al, JAGS 53:1290, 2005

12-Month Fall Rate in NH: Interacting Risk Factors Robbins AS, Rubenstein LZ, Josephson KR, et al. Arch Intern Med. 1989(July);149(7):1628-1633

Environmental Fall Risk Factors Home low lighting poor stairs & rails unstable furniture rug/carpet hazards low beds & toilets no grab bars slick floors obstacles pets medications Outdoors bad weather poor sidewalks traffic activity street crossings uneven steps distractions obstacles ↑ activity levels Institution low lighting new admission poor furniture slick hard floors low supervision ↓ # of nurses meal times no hand rails

•Trips & slips Drop attack Syncope Dizziness Gait & balance impairment Intrinsic Risk Factors Gait & balance impairment Peripheral neuropathy Vestibular dysfunction Muscle weakness Vision impairment Medical illness Advanced age Impaired ADL Orthostasis Dementia Drugs Extrinsic Risk Factors Environmental hazards Poor footwear Restraints Precipitating Causes •Trips & slips Drop attack Syncope Dizziness FALL

Fall Risk Assessment Measures Perell K, et al J Gerontol Med Sci 2001. Review of 20 fall risk measures 14 nursing tools, 6 functional tools Common items for nursing tools: mental status (13), fall hx (10), mobility (10), other dx (8), incontinence (8), drugs (7), sensory deficits (7), balance (5), age (4), ADLs (4), assistive device (4), weakness (4), gender (3), acuity (3), restraint use (1) Best measures overall Hospital: Oliver ‘97, Schmid ‘90, Morse ‘89, Hendrick ‘95, Rapport ‘93 Outpatient: Shumway-Cook ‘00, Cwikel ‘98, Tinetti ‘86, Berg ‘89 NH: “universal precautions” (or Morse ‘89, Shumway-Cook ‘00)

Fall Risk Assessment Measures: The Reality Most can accurately identify patients at higher risk of falls Probably helpful to sensitize community living elders of their fall risk & what to do Important for medico-legal purposes in hospitals & NHs: You need to show you’re doing something that is organized and current. But …virtually all patients in hospital and NHs come out as “high risk.”

Fall Prevention Trials: >100 RCTs since 1984 Assessment (preventive & post-fall) Exercise & rehabilitation programs Environmental modifications Devices Nursing interventions Combined interventions

Rubenstein et al, Ann Intern Med, 113: 308, 1990 Benefits of a Post-Fall Assessment Results of a Randomized Controlled Trial in NH Intervention: 1-2 hr post-fall assessment protocol by GNP (H&P, gait/bal, envir, lab); Feedback to PCP (dx, risk factors, recs) Setting/sample: 700-bed LTC facility, 2/3 F, age x=88, 160 fallers randomized, 2 yr f/u. Results: 3-4 treatable fall risks found per person 9% falls in assessed group (n.s.) 17% mortality (n.s.) 52% hosp days (p<.01) Rubenstein et al, Ann Intern Med, 113: 308, 1990

Close J, Ellis M, Hooper R, et al. Lancet. 1999(Jan 9);353(9147):93-97 Benefits of a Post-Fall Assessment Prevention of Falls in the Elderly Trial (PROFET) Randomized trial of post-fall assessment of fallers seen in ED & assessed by 7 days. N=397, 65 (mean age 78); London Assessment revealed many causes and risk factors and generated many referrals. 12-month follow-up: Intervention group had reduced risk of falls (OR=.39) & hospital admissions (OR=.61). Controls had greater decline in function. Close J, Ellis M, Hooper R, et al. Lancet. 1999(Jan 9);353(9147):93-97

Clinical Approach to the Faller Assess & treat any injury Determine likely precipitating cause(s) history, physical , lab (limited) Prevent recurrence treat underlying cause/illness identify & reduce risk factors (e.g., weakness, gait/bal prob, visual prob, polypharm) reduce environmental hazards teach adaptive behavior (e.g., slow rise, cane)

Tai Chi and Fall Reduction in Older Adults Li F et al, J Gerontol Med Sci, 2005 6-month RCT of 3x/wk Tai-chi vs. stretching in Oregon N=256 inactive, home-living elders (age 72-92) 6 month results: Tai-chi Stretching Falls 38 73 p<.01 Fallers 28% 46% p=.01 Inj. falls 7% 18% p=.03 Tai-chi group also signif better in: balance, physical performance & fear of falling

Hip Protectors – Examples Safehip KPH CuraMedica HipGuard HIPS

Do Hip Protectors Work? Initial studies, cluster randomized by facility, showed high effectiveness  50-70% intent to treat  80-95% among those wearing them More recent studies, randomized by person, equivocal Hard to get compliance Likely contribution from overall program Patient selection & education crucial

Nursing Interventions Risk assessments (Morse, Hendrich, MDS) Treat identified risks Universal fall precautions: call light & assist devices close bed wheels & w/c brakes locked adequate lighting clean spills immediately patient orientation & staff educ For high-risk patients: move closer to nursing station increased observation / sitter bed-chair alarms low beds non-skid slippers rails & grab bars clutter-free rooms clear signage floor mats special careplans hip protectors

Anti-Slip Footwear – Examples Fashion Treads Care-Steps Pillow Paws Walk Alerts

Safe-T Mate Alarmed Seatbelt Bed & Chair Monitors – Examples Bed & Chair Alarm Chair Sentry Locator Alarm AirPro Alarm Safe-T Mate Alarmed Seatbelt Economy Pad Alarm Floor Mat Monitor Keep Safe QualCare Alarm

Do Bedrails Prevent Falls Do Bedrails Prevent Falls? Pre-Post Study AHC Hanger et al, J Am Geriatr Soc, 47:529, 1999 Study of falls in New Zealand hospital 6-mo before & 6-mo after bedrail restriction program. After policy, fewer beds w/ rails (29.6%  13.7%). Total falls/10,000 bed-days: before-165 after-192 Falls around bed/10,000 b-d: before-89 after-106 Serious fall injuries: before-33 after-18 Minor fall injuries: before-43 after-60

Bedside Mats – Fall Cushions CARE Pad bedside fall cushion Posey Floor Cushion NOA Floor Mat Roll-on bedside mat Soft Fall bedside mat Tri-fold bedside mat

Fall Prevention Trials: RAND-CMS Meta-analysis Lit review (1980-2002): 830 pubs, 41 RCTs Fall risk Monthly fall rate All RCTs: .88 [.82 - .95] .79 [.71 - .87] Meta-regression of intervention components: • Fall eval + f/u .82 [.72 - .94] .63 [.48 - .83] • Exercise .86 [.75 - .99] .84 [.71 - .98] • Environ mod .90 [n.s.] .85 [n.s.] • Education [n.s.] [n.s.]

Exercise Components 7 (8) 0.94 (074, 1.19) 13 (14) 0.73 (0.61, 0.86) Exercise Type Subjects who fell at least once Mean number of falls Number of Studies (Arms) Adjusted Risk Ratio (95% CI) Adjusted Incident Rate Ratio Balance 7 (8) 0.94 (074, 1.19) 13 (14) 0.73 (0.61, 0.86) Endurance 7 (7) 0.80 (0.66, 0.98) 4 (4) 1.19 (0.77, 1.84) Flexibility 0.72 (0.41, 1.25) 5 (5) 0.90 (0.60, 1.34) Strength 8 (9) (0.54, 1.20) 13 (13) 0.91 (0.67, 1.23)

Since the 2003 Meta-analysis, what’s new? > 35 new published RCTs New studies of existing models: Risk assessment + intervention (8), Exercise (14), Multifactorial (8), Hip protectors (3) New interventions Visual mods, Vit D + Ca++, Footwear, Vibration Multifactorial interventions seem best RF assessment + abatement, exercise, envir mod Organized, consistent, population-based programs

Vitamin D Effect on Falls: Meta-analysis Bischoff-Ferrari JAMA 291:1999-06, 2004. Pooled 5 RCTs, N=1237 Vit D reduced OR for falls by 22% (Corrected OR 0.78; 95% CI 0.64-0.96) Effect independent of Ca+ supplement, duration of Rx, sex Baseline Vit D levels not measured

Can Cataract Surgery Reduce Falls Can Cataract Surgery Reduce Falls? Harwood et al, Br J Ophthalmol 2005:89:53-9 RCT of women age 70+ w/ cataracts randomized to surgery or 12-mo wait list Falls measured by diary + q3mo f/u 12 mo results: 34% lower fall rate in surg group (p=.03) 3% vs 8% had fractures (p=.03) Surg assoc w/ better activity, anxiety, depression, confidence & visual disability

The “Yaktrax” gait stabilizing device – RCT: • ↓58% RR outdoor falls on snow & ice (p<.03) • ↓87% RR injurious falls on snow & ice (p<.02) • most intervention group falls occurred w/o device McKiernan FE, JAGS 53:943, 2005

Vibrating Insoles may improve balance Priplata AA, et al. Vibrating insoles & balance in elderly people. Lancet 2003; 362:1123.

Fall Prevention Strategies COMMUNITY Risk-factor screen & intervention Post-fall assessment Exercise program (strength, balance) Environmental inspection & modification INSTITUTION Organized program Risk-factor screen Post-fall assessment Nurse awareness Targeted interventions (e.g., hip pads, low bed, bed/ chair alarms, monitors)

Evidence Based Guideline for Fall Prevention (AGS-BGS-AAOS Task Force, 2001) SUMMARY Assessment Inquire about falls, gait, balance at routine visits (at least annually). Screen persons reporting a problem (e.g., “get up & go” test). Assess persons failing screen, or w/ >1 fall: Hx of fall circumstances, meds, chronic illness, mobility level Examine gait, balance, orthostasis, vision, neuro, cardiovascular Management of Fallers Multi-component interventions: assessment & f/u, exercise, gait training, med review, treatment (e.g., visual, cardiac, orthostasis) LTC setting interventions: assessment & f/u, staff education, gait training & assistive devices, medication review & adjustment Single interventions: assessment & f/u, exercise (esp balance), environmental assm’t/mod, medication review & adjustment

Assessment and Management of Falls Periodic case finding in Primary Care: Ask all patients about falls in past year No intervention No falls No problems Gait/balance problems Patient presents to medical facility after a fall Fall Evaluation* Check for gait/balance problem Single fall Recurrent falls Assessment History Medications Vision Gait and balance Lower limb joints Neurological Cardiovascular Multifactorial intervention (as appropriate) Gait, balance, exercise - programs Medication - modification Postural hypotension - treatment Environmental hazards - modification Cardiovascular disorders - treatment

Conclusions Falls: Common, debilitating, expensive Preventable w/ existing technology Assessment+f/u, exercise, environment mod System needed to mobilize evidence-based preventive approaches Likely cost-effective (multiple direct & indirect savings offset program costs)

Fall Prevention Principles in Action: The Birmingham/Atlanta GRECC Fall Prevention Clinic Cynthia J. Brown, MD, MSPH Investigator, Birmingham/Atlanta VA GRECC Medical Director, Birmingham/Atlanta GRECC Fall Prevention and Mobility Clinic Associate Professor, UAB

GRECC Fall Prevention and Mobility Clinic Objectives of the clinic To provide care to veterans with a history of falls, near falls or other mobility problems To develop a program which can be exported to other VA facilities To allow research into the area of falls, fall prevention and mobility disability in a community-dwelling population To provide an educational venue for a variety of trainees

Patient Population Served by the Clinic Referrals from several sources including primary care, neurology, and rehabilitation A variety of ages, functional status abilities and medical diagnoses are represented All have a history of falls or near falls

Interdisciplinary Team Approach Occupational Therapist Physical Therapist Physician (Geriatrician) Referrals as needed for other resources or providers

Methods Adaptable for All Healthcare Providers Fall prevention strategies can be employed by all healthcare providers within the VA. Key is multicomponent, interdisciplinary interventions. Having this type of clinic is not essential.

Risk Factors Targeted by the Team Muscle weakness Mobility and balance impairments Foot and footwear problems Sensory and perceptive deficits Cognitive impairments Multiple medications Postural hypotension and dizziness Environmental hazards

Occurrence of Falls According to the Number of Risk Factors (Tinetti, 1988)

Muscle Weakness Evaluation: Treatment: strength testing of the upper and lower extremities functional tests like timed chair stands Treatment: referral for strength training either as an outpatient or at home, depending on severity of mobility problems

Mobility and Balance Impairments Mobility (gait and transfers) Evaluation: timed chair stands, and timed 8 foot walk (Short Physical Performance Battery); or Get Up and Go test Treatment: Physical Therapy for gait and transfer training, provision of an assistive device Balance Evaluation: progressive static balance tests (feet together, semi-tandem, and tandem) Treatment: referral to PT or community exercise programs (Tai Chi) for instruction in balance exercises.

Foot and Footwear Problems We dare to take the patients shoes off ! Evaluation: watching gait with shoes on examining shoes for wear patterns examining feet without shoes Treatment: Podiatry referral for nail care orthotics/prosthetics for shoe inserts, special shoes or ankle-foot orthosis (AFO)

Sensory and Perceptive Deficits Vision Ask if any problems and refer as needed Hearing Ask if problems and refer as needed Sensation/ Proprioception Problems Check sensation to light touch and proprioception Referral to podiatry, foot clinic

Cognitive Impairments Screen for depression Geriatric Depression Scale (GDS) Work with PMD or Mental Health, treat as needed Screen for dementia Mini Mental State Exam (MMSE) Referral to Geriatric Assessment Clinic Assist family in understanding why the patient falls and target other interventions which may lower risk

Multiple Medications Physician review of medications Attempt to adjust or eliminate as able Focus on those known to be associated with high fall risk Benzodiazepines Anticholinergic medications Psychoactive medications

Postural Hypotension and Dizziness Evaluate by taking orthostatic blood pressures on ALL patients Check after supine for five minutes, then standing for one and three minutes Treatment: Review medications and adjust as able Instruct patients to change positions slowly

Environmental Hazards Occupational Therapist reviews home environment with patient Handouts of hazards given and discussed Adaptive equipment provided as needed (raised toilet seats, shower chairs, grab bars) Home health can evaluate for home safety

Benefits of an Interdisciplinary Team Approach Research shows a multicomponent approach most likely to be successful Allows a variety of targeted interventions to be done simultaneously Educational opportunity Fun!

The Birmingham/Atlanta GRECC Fall Prevention and Mobility Team J. Dennis Hughes, OTR/L Claire Peel, PhD, PT Cynthia J. Brown, MD, MSPH

Thanks to the patients who allowed themselves to be photographed