Preventing Falls in Older Adults: State of the Science · Preventing Falls in Older Adults: State of the Science Preventing Falls in Older Adults: Laurence Rubenstein, MD, MPH ...

Preventing Falls in Older Adults: State of the Science

Preventing Falls in Older Adults: State of the Science

Laurence Rubenstein, MD, MPHGreater Los Angeles VA GRECC

Professor of Medicine, UCLA

British Columbia Injury Prevention ConferenceNovember 19-20, 2008

Preventing Falls: What does the evidence show?

Preventing Falls: What does the evidence show?

Background: Epidemiology, costsCauses & risk factorsPrevention approaches--evidence

Studies & meta-analysesAGS/BGS practice guidelines--update

Famous Fallers

Case ReportCase Report

78 year old gentlemanGood general healthGave a 1-hour graduation speech on October 20, 2004…

AP/Wide World Photos

What happened?What happened?

Broke left knee & right armNever fully recoveredCould his fall have been prevented?

Fall Incidence in Older Adults[rate/person/yr] or [rate/bed/yr]

Fall Incidence in Older Adults[rate/person/yr] or [rate/bed/yr]

Home Hospital Nsg Home

Any fall .3 1.5 1.7

Severe fall .03(10%) .3 .35(20%)

Fracture .01 .05 .07

Hip fx .003 .02

Rubenstein LZ, Josephson KR. Clin Geriatr Med. 2002(May);18(2):141-158

Falls MortalityFalls Mortality

Accidents: the 5th leading cause of death in older adultsDeaths from falls: 2/3 of accidental deaths72% of U.S. fall-related deaths occur in the 13% of population age 65+


Costs of FallsCosts of Falls

8% of pop ≥70 visit ERs for falls yearly 1/3 of these are hospitalized5.3% of hosp patients ≥65 are due to fallsU.S. cost est. 2000→$20 B. (2020→$32 B)42% of fallers reduce activity after fall18% restricted activity initiated by fallsPrecipitate NH entry


Falls are #1 cause of NH litigation

Causes of Falls: Summary of 12 StudiesCauses of Falls: Summary of 12 Studies

Accident/environment 31%Gait/balance disorder 17Dizziness/vertigo 13Drop attack 10Confusion 4Postural hypotension 3Vision problem 3Other specified 15Unknown 5


Risk Factors for Falls: 16 Multivariate StudiesRisk Factors for Falls: 16 Multivariate Studies

Factor Signif/All Mean RR Range Weakness 10/11 4.4 1.5 - 10.3 Prior fall 12/13 3.0 1.7 - 7.0 Balance deficit 8/11 2.9 1.6 - 5.4 Gait deficit 10/12 2.9 1.3 - 5.6 Assistive device 8/8 2.6 1.2 – 4.6 Vision deficit 6/12 2.5 1.6 – 3.5 Arthritis 3/7 2.4 1.9 –2.9 ADL deficit 8/9 2.3 1.5 – 3.1 Depression 3/6 2.2 1.7 – 2.3 Cognitive deficit 4/11 1.8 1.0 – 2.3 Age >80 5/8 1.7 1.1 – 2.5


Drugs & Falls: Meta-analysisLeipzig, Cumming, Tinetti, JAGS, 1999

Drugs & Falls: Meta-analysisLeipzig, Cumming, Tinetti, JAGS, 1999

Psychotropics, any: 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)

Leipzig RM, Cumming RG, Tinetti ME. J Am Geriatr Soc. 1999(Jan);47(1):40-50

Atypical Anti-psychotics & FallsHien, Cumming, Cameron, et al, JAGS 53:1290, 2005

Atypical Anti-psychotics & FallsHien, Cumming, Cameron, et al, JAGS 53:1290, 2005

Prospective LTC cohort study, AustraliaN=2005, age 65-104 (mean 86)

1.19 (.15)1.90Sedative/anxiolyt1.45 (.01)1.96Antidepressants1.32 (.54)1.0/3.1Risperidone1.74 (.04)2.5/3.3Olanzapine1.35 (.19)1.6/2.6Typical anti-Ψ1.01.0No psychotropicAdj RR (p)RR (alone/+)

Fall Incidence ↑ as Risk Factors ↑(Tinetti, 1988)

00.10.20.30.40.50.60.70.8

0 1 2 3 4+

# risk factors

Risk Factors for Hip FractureRisk Factors for Hip Fracture

05

1015202530

Hip fx/1000 woman yrs

Low3rd

Mid3rd

High3rd

Bone Density

0-23 to 45+

Cummings et al, NEJM 332:767, 1995.

Fall RFs

Environmental Fall Risk FactorsEnvironmental Fall Risk FactorsHome

•low lighting •poor stairs & rails•unstable furniture•rug/carpet hazards•low beds & toilets•no grab bars•slick floors•obstacles•pets•medications

Institution•low lighting •new admission•poor furniture•slick hard floors•low supervision•↓ # of nurses•meal times•no hand rails

Outdoors•bad weather•poor sidewalks•traffic activity•street crossings•uneven steps•distractions•obstacles•↑ activity levels

ri

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 Injury Risk FactorsFall Injury Risk FactorsRisk Factors Signif/AllGait/balance deficit 3/6Cognitive deficit 3/6Female sex 3/6Vision deficit 2/6Medications 2/6Weakness 2/5ADL deficit 2/6Low body mass 2/6Higher activity 1/6


Fall Risk Assessment MeasuresScott V, et al Age Ageing 2007; 36:130-9

Fall Risk Assessment MeasuresScott V, et al Age Ageing 2007; 36:130-9

Review of 38 validated fall risk measures 23 community tools, 10 NH tools, 8 hospital tools 27 functional mobility tools, 11 multi-factorial tools

Common items includedmental status, fall hx, mobility, other dx, incontinence, drugs, sensory deficits, balance, ADLs, assistive device, weakness, age, gender, acuity, restraint use, functional reach,

Best measures overallHospital: Oliver ‘97, Schmid ‘90, Morse ‘89, Hendrick ‘95, Conley ‘99Outpatient: Shumway ‘00, Tinetti ‘86, Berg ’89, Alessi ’03, Murphy ‘03NH: “universal precautions” (or Morse ‘89, Downton index ‘03)

Fall Risk Assessment Measures: The Reality

Fall Risk Assessment Measures: The Reality

Most can accurately identify patients at higher risk of fallsProbably helpful to sensitize community living elders of their fall risk & what to doImportant 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: Growth of RCTsFall Prevention: Growth of RCTs

0

20

40

60

80

100

120

140

'90-91

'92-93

'94-95

'96-97

'98-99

'00-02

'03-04

'05-06

'07-08

BiannualCumulative

Fall Prevention TrialsFall Prevention Trials

Assessment (preventive & post-fall)Exercise & rehabilitation programsEnvironmental modificationsDevicesNursing interventionsCombined interventions

Benefits of a Post-Fall AssessmentResults of a Randomized Controlled Trial in NH

Benefits of a Post-Fall AssessmentResults 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, ↓17% mort in treatment group (n.s. trends)↓52% hosp days (p<.01)

Rubenstein et al, Ann Intern Med, 113: 308, 1990

Prevention of Falls in the Elderly Trial (PROFET)

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); LondonAssessment 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 Clinical Approach to the Faller

Assess & treat any injuryDetermine likely precipitating cause(s)

history, physical , lab (limited)Prevent recurrence

treat underlying cause/illnessidentify & reduce risk factors (e.g., weakness, gait/bal prob, visual prob, polypharmacy)reduce environmental hazardsteach adaptive behavior (e.g., slow rise, cane)

“Falls History”“Falls History”Circumstances & prodrome of fall

sudden LOC, sudden leg weakness, tripped/slipped/hazard, position change, head back, tight collar, cough/urination, palpitations/angina, dizziness/giddiness

Major medical problemsesp. cardiovascular, neurologic

Drugs esp. psychoactive, cardiac, diuretic

Physical Exam: Key AspectsPhysical Exam: Key AspectsVital signs: postural pulse/BP, tempHEENT: vision, hearing, nystagmus Neck: ROM, motion-induced vertigo, bruitCard/Pulm: CHF, arrhythmia, murmurExtrems: arthritis, ROM, deformities, feetNeuro: altered MS, gait/balance deficit, weakness, focal findings, tremor, rigidity, peripheral neuropathy, divided attention

Lab/Diagnostic TestsLab/Diagnostic Tests

CBCBlood glucose, Na+, K+, Ca++, BUNX-ray of injuriesECGHolter monitor &/or CSM (if syncope, arrhythmia, or cardiac cause suspected)Formal gait & balance testing

Tinetti Balance & Gait Scale: Tinetti Balance & Gait Scale:

Sitting balance (1)Rising from chair (4)Standing balance (4)Nudge (2)Eyes closed (1)Turning 360º (2)Sitting down (2)

Initiation (1)Step length (2)Step height (2)Continuity (1)Symmetry (1)Stance/sway (3)Path deviation (2)

Balance (16 pts) Gait (12 pts)

Trueblood PR, Rubenstein LZ. Compr Ther. 1991(Aug);17(8):20-29

Pathologic Gait: CausesPathologic Gait: Causes

Decreased ROM (eg, arthritis, contractures)

Weakness (eg, deconditioning, neuropathy)

Sensory/balance deficit (eg, stroke, neuropathy)

Spasticiy (eg, stroke, cord lesion)

Pain (eg, arthritis, injury)

Impaired central processing (eg, dementia, delirium, stroke, drugs)

The “Aging Home ”Often An Obstacle CourseThe “Aging Home ”

Often An Obstacle Course

Old & rickety furniture & appliancesUnsafe stairs with poor handrailsThrow rugs, frayed carpetsElectrical cords, objects on floorPoor lightingSub-optimal height of bed, toilet, chairsAccumulated clutter of a lifetime

14 dangerous things in this picture

• Stairs without handrail• Deactivated fire alarm• Cloth on space heater• Overloaded outlets• Loose extension cords in pathways• Smoking. Cigarettes unattended• No automatic shut-off on coffee pot• Open bottles of medicine• Old medications in cabinet• Loose rugs• Flip-flop slippers• Clutter on staircase• Newspapers too close to lamp• No handle & no deadbolt on door

From Public Health Canada

The FICSIT Trials:Frailty & Injuries: Coop Studies of Intervention Techniques

The FICSIT Trials:Frailty & Injuries: Coop Studies of Intervention Techniques

7 independent randomized controlled trialsN: Total = 2328, Mean = 333, Range = 100-1323Sites: Atlanta, Boston, Farmington, New Haven, Portland, San Antonio, Seattle

Variety of interventions to reduce falls & frailty, all included exerciseExercise lasted 10-36 weeks, ≥2 year follow-upPooled effects on falls: .90 (95% CI, .81-.99) ▪ Effect for balance exercises: .83 (.70-.98)

Province, MA, Hadley EC, Hornbrook MC, et al. JAMA. 1995; 273(17):1341-1347

Tai Chi and Fall Reduction in Older AdultsLi F et al, J Gerontol Med Sci, 2005

Tai Chi and Fall Reduction in Older AdultsLi F et al, J Gerontol Med Sci, 2005

6-month RCT of 3x/wk Tai-chi vs. stretching in OregonN=256 inactive, home-living elders (age 72-92)6 month results:

Tai-chi StretchingFalls 38 73 p<.01 Fallers 28% 46% p=.01Inj. falls 7% 18% p=.03

Tai-chi group also signif better in: balance, physical performance & fear of falling

Finnish Hip Protector TrialKannus P, N Engl J Med 343: 1506-13, 2000

Finnish Hip Protector TrialKannus P, N Engl J Med 343: 1506-13, 2000

Randomized trial in 22 Finnish geriatric care programs

n=653 subjects, 1148 controls; age 70+; 2/3 NH, 1/3 home care; ≥1 hip fx risk factor

2-yr f/u↓Hip fx at f/u: 21/1000 vs. 46/1000 pers-yr

(RR=.4, 0.2-0.8)↓84% hip fx among fallers wearing protectors Trend toward lower pelvic fx, no effect other fxNNT to prevent one hip fx / yr = 41 (25-115)

Safehip

HipGuard

KPH

CuraMedica

Hip Protectors – Examples

HIPS

Do Hip Protectors Work?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

Minns, R. J. et al. Age Ageing 2007 36:140-144; doi:10.1093/ageing/afl186

Hip Protectors are Often Above the Greater TrochanterTop (hard shell): Remploys Caresse, FallGuard, KPH, SafeHip;

Bottom (pads): HipShield, HipSaver, PoseyHipsters, Lyds, Sanavida

Oliver, D. et al. BMJ 2007;334:82

Meta-analysis for hip protectors as a single intervention in care homes--hip fractures

Nursing InterventionsNursing InterventionsRisk assessments (Morse, Hendrich, MDS)Treat identified risksUniversal fall precautions:

call light & assist devices close bed wheels & w/c brakes lockedadequate lightingclean spills immediatelypatient orientation & staff educ

For high-risk patients:move closer to nursing stationincreased observation / sitterprompted toileting

low bedsnon-skid slippers rails & grab barsclutter-free roomsclear signage

bed-chair alarmsspecial careplanship protectors

Care-Steps Fashion Treads

Pillow Paws Walk Alerts

Anti-Slip Footwear – Examples

AirPro AlarmBed & Chair Alarm Chair Sentry

Economy Pad Alarm

Floor Mat Monitor Keep Safe

Bed & Chair Monitors – Examples

QualCare AlarmSafe-T Mate

Alarmed Seatbelt

Locator Alarm

NOCwatch system Patient Down fall detector

Tip Over alarm

Tunstall fall detector

iLife fall detector

Fall Alarms – Accelerometers & Position Sensors

Ambularm

Do Bedrails Prevent Falls? Systematic review. Healy et al, Age Ageing 2008; 37:368-78.

Do Bedrails Prevent Falls? Systematic review. Healy et al, Age Ageing 2008; 37:368-78.

Review of 24 pre-post studies.Most showed some falls after d/c railsSome had small # injuries assoc w/ railsRecs:

Rail use should be individualized Most injuries due to obsolete designs or use in pts likely to climb over themPremature to stop them globally

NOA Floor MatCARE Pad

bedside fall cushion Posey Floor Cushion

Soft Fall bedside matTri-fold bedside mat

Roll-on bedside mat

Bedside Mats – Fall Cushions

Fall Prevention Trials:RAND-CMS Meta-analysisFall Prevention Trials:RAND-CMS Meta-analysis

• Lit review (1980-2002): 830 pubs, 41 RCTsFall 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

Exercise Type

Subjects who fell at least once Mean number of falls

Number of Studies (Arms)

Adjusted Risk Ratio(95% CI)

Number of Studies (Arms)

Adjusted Incident Rate Ratio

(95% CI)

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 4 (4) 0.72(0.41, 1.25)

5 (5) 0.90(0.60, 1.34)

Strength 8 (9) 0.80(0.54, 1.20)

13 (13) 0.91(0.67, 1.23)

Since the 2003 Meta-analysis, what’s new?

Since the 2003 Meta-analysis, what’s new?

> 35 new published RCTsNew studies of existing models:

Risk assessment + intervention (8), Exercise (14), Multifactorial (8), Hip protectors (3)

New interventionsVisual mods, Vit D + Ca++, Footwear, Vibration

Multifactorial interventions seem bestRF assessment + abatement, exercise, envir modOrganized, consistent, population-based programs

Vitamin D Effect on Falls: Meta-analysisBischoff-Ferrari JAMA 291:1999-06, 2004.

Vitamin D Effect on Falls: Meta-analysisBischoff-Ferrari JAMA 291:1999-06, 2004.

Pooled 5 RCTs, N=1237Vit 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, sexBaseline Vit D levels not measured

Can Cataract Surgery Reduce Falls? Harwood et al, Br J Ophthalmol 2005:89:53-9

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 listFalls measured by diary + q3mo f/u12 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

Tinetti M et al. Effect of evidence dissemination in reducing injuries from falls. N Engl J Med 2008;359:252-261

Connecticut Collaboration for Fall Prevention:Systematic Outreach Education to Physicians, Senior

Centers, Homecare Agencies, & Outpt Rehab Programs

Tinetti M et al. N Engl J Med 2008;359:252-261

Connecticut Collaboration: Adjusted Annual Rates of Serious Fall-Related Injuries and Use of Medical Services per 1000 Persons 70 Years of Age or

Older during the Preintervention, Intervention, and Evaluation Periods

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 balancePriplata AA, et al. Vibrating insoles & balance in elderly people. Lancet 2003; 362:1123.

1-year double-blind RCT of 70 postmenopausal women showed that brief periods (<20 minutes) of low-level (0.2g, 30 Hz) vibration applied during quiet standing can inhibit bone loss in the spine and femur. Efficacy increased with greater compliance, particularly in subjects with lower body mass (3.45% gain, p<.01).

Rubin C, et al. Prevention of postmenopausal bone loss by low-magnitude, high-frequency mechanical stimuli: J Bone Miner Res 19:343-351, 2004

Vibrating platform improves bone density

Controlled whole body vibration to decrease fall risk in NH residents Bruyere, et al, Arch Phys Med Rehab 86:303,2005

Controlled whole body vibration to decrease fall risk in NH residents Bruyere, et al, Arch Phys Med Rehab 86:303,2005


Meta-analysis for multifaceted interventions in hospital--falls (random effects model)


Meta-analysis for multifaceted interventions in care homes for falls (random effects model)

Fall Prevention StrategiesFall Prevention Strategies

COMMUNITY– Ask about falls– Risk-factor screen

& intervention– Post-fall assessment– Exercise program

(strength, balance)– Environmental

inspection & modification

INSTITUTIONOrganized program

– Risk-factor screen– Post-fall assessment– Nurse awareness– Targeted interventions

(e.g., hip pads, sitter, low bed, bed alarms, monitors, prompted toileting)

Evidence Based Guideline for Fall Prevention (AGS-BGS-AAOS Task Force, 2001) SUMMARY

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 levelExamine 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

AssessmentHistory

MedicationsVision

Gait and balanceLower limb joints

NeurologicalCardiovascular

Multifactorial intervention (as appropriate)

Gait, balance, exercise - programsMedication - modification

Postural hypotension - treatmentEnvironmental hazards - modificationCardiovascular disorders - treatment

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 fallFall Evaluation*

Check for gait/balance

problem

Single fallRecurrent falls

ConclusionsConclusionsFalls: Common, debilitating, expensivePreventable w/ existing technology

Assessment+f/u, exercise, environment modSystem needed to mobilize evidence-based preventive approachesLikely cost-effective (multiple direct & indirect savings offset program costs)

Preventing Falls in Older Adults: State of the Science · Preventing Falls in Older Adults: State of the Science Preventing Falls in Older Adults: Laurence Rubenstein, MD, MPH ...

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