1. 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

2. 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

3. Famous Fallers

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

5. 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):

6. 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):

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

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

9. Drugs & Falls: Meta-analysis Leipzig, Cumming, Tinetti, JAGS, 1999
Psychotropics, any: RR 1.73 ( )
Neuroleptics: ( )
Sedative/hypnotics: ( )
Antidepressants: ( )
Benzodiazepines: ( )
Diuretics: ( )
Anti-arrhythmics (Ia) : ( )
Digoxin: ( )
Fall risk from newer ψ agents no better. --Hien, Cumming, Cameron, et al, JAGS 53:1290, 2005

10. 12-Month Fall Rate in NH: Interacting Risk Factors
Robbins AS, Rubenstein LZ, Josephson KR, et al. Arch Intern Med. 1989(July);149(7):

11. 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

13. •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

14. 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)

15. 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.”

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

17. 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

18. 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

19. 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)

21. 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 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

22. Hip Protectors – Examples
Safehip
KPH
CuraMedica
HipGuard
HIPS

23. 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

24. 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

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

26. 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

27. 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

29. 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

30. Fall Prevention Trials: RAND-CMS Meta-analysis
Lit review ( ): 830 pubs, 41 RCTs
Fall risk Monthly fall rate
All RCTs: [ ] [ ]
Meta-regression of intervention components:
• Fall eval + f/u .82 [ ] [ ]
• Exercise [ ] [ ]
• Environ mod [n.s.] [n.s.]
• Education [n.s.] [n.s.]

31. 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)

32. 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

33. 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 )
Effect independent of Ca+ supplement, duration of Rx, sex
Baseline Vit D levels not measured

34. 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

35. 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

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

37. 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)

38. 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

39. 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

40. 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)

41. 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

42. 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

43. 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

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

45. 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.

46. 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

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

48. 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

50. 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.

54. 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)

55. 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

56. 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

57. 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

59. 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

60. 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

63. 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!

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

65. Thanks to the patients who allowed themselves to be photographed