Current Research on Falls Prevention

1. Current Research on Falls Prevention Jane Mahoney, MD University of Wisconsin Medical School Dec 15, 2004

2. Scope of the Problem • In 1999, accidents were the 8th leading cause of death for adults age 65 and older in the US, and the leading cause of accidental deaths was falls. • Fractures accounted for 531,000 hospitalizations in the over-65 age group.

3. Falls in Wisconsin • In 2002, there were 22,500 hospitalizations in Wisconsin for fall-related injuries. • The state’s death rate due to falls has increased 20% from 1992 to 2002 • The state’s death rate due to falls is almost twice the national average.

4. Fall-Injury Rates Are Increasing Over Time • Kannus et al, Lancet 1997 • Finnish data – national hospital discharge register • Age-adjusted incidence of fall-related injury for ages 60 and over

5. Purpose • Overview of current guidelines for fall prevention • Intervention research: multifactorial trials, exercise, group cognitive-behavioral classes • Prevention after hospital discharge • Preliminary data, Kenosha County Falls Prevention Study • Dane County SAFE Study: evaluating research findings in a community setting

6. Definition of Accidental Fall An accidental fall is an event which results in a person coming to rest inadvertently on the ground or other lower level not due to obvious loss of consciousness, stroke, seizure or sustaining a violent blow.

7. Components of Postural Control Sensory Input Central Processing Effector Output Cognition CNS pathways Medications Visual Vestibular Proprioceptive Musculoskeletal Strength Biomechanical Environ-ment

8. Previous hx of falls Balance or gait impairment Dementia Visual deficit Neuropathy Muscle weakness Psychotropic medications Depression Arthritis, Parkinson’s, stroke Risk Factors For Falls from Epidemiologic Studies

9. Risk Factors are AdditiveTinetti, NEJM, 1988

10. 2001 GuidelinesAmerican Geriatrics Society, British Geriatric Society, American Academy of Orthopedic Surgeons • All older adults should be asked at least once a year about falls. • All older adults who report a single fall should be observed rising from a chair and walking. • Older adults with 2 or more falls in the past year, 1 fall with injury, or 1 fall with gait and balance problems should receive a fall evaluation followed by multifactorial intervention.

11. 2001 Guidelines Multifactorial Intervention • Gait training including advice on assistive devices • Review/modify medications, especially psychotropics • Individualized, progressive exercise programs with balance training • Treat postural hypotension • Modify environmental hazards • Treat cardiovascular disorders including arrythmias

12. Study Tinetti, NEJM 1994 Wagner, AJPH, 1994 Close, Lancet, 1999 Day, BMJ, 2002 Outcome Rate 31% Risk 9% Risk 61% Rate 33% Randomized Trials of Multifactorial Interventions

13. Benefit of Exercise in Reducing Falls • Previous studies have shown that patients with a history of multiple previous falls will benefit from individualized physical therapy • Physical therapy should be progressive, last several months, and should include balance exercises

14. Study Wolf, JAGS, 1996 Tai Chi Lord, JAGS, 2003 standing Barnett, Age Ageing, 2003 standing Day, BMJ, 2002 standing Wolf, JAGS, 2003 Tai Chi Outcome Risk 47% Rate 22% Rate 40% Rate 18% Risk 25% NS Randomized Trials of Group Exercise

15. Group Exercise for Falls Prevention • Include standing exercises that challenge balance • Stepping, Tai Chi, change of direction, dance steps • Complexity and speed of exercises increase • Classes held 1-2 times per week, typically also with home exercises • Exercises are individualized as needed

16. Group classes: cognitive-behavioral learning • 7-week classes plus 1 home OT visit to improve self-efficacy, encourage behavioral change, reduce falls • Focus on improving balance and strength, improving home and community environamental and behavioral safety, encouraging vision screen and med review • Results = 31% reduction in falls

17. Post-hospital falls prevention - rationale Musculoskeletal Output Sensory CNS Delirium Environ-ment SystemicEffects of Illness

18. Acute Changes in Postural Control New Medications Musculoskeletal Output Sensory CNS changes Environ-ment Bedrest, Deconditioning

19. Effects of Bedrest • Loss of muscle mass and strength • Orthostasis, volume contraction • Increased body sway • Slower gait speed • Visual-spatial abnormalities • Impaired coordination

20. Risk of Falls after HospitalizationMahoney, JAGS, 1994 • Older adults discharged from St. Mary’s Hospital after acute illness - 14% fell in the month after hospital discharge. • Risk was higher among those receiving home nursing compared to those not (20% vs 8% fell, p=.01)

21. Not receiving home nursing Vision impairment Self-report of confusion Receiving home nursing Mobility imp pre-hosp Decline in mobility by discharge Use of anticholinergics or antihistamines Self-report of confusion Risk factors by home nursing use

22. Falls After Hospital DischargeMahoney, Arch Int Med, 2000- 311 older adults receiving home nursing after discharge

23. Rehospitalizations Due to Fall Injuries • 15% of all re-hospitalizations in the first month were due to fall injuries.

24. Pre-Hospital: Prior dependence in ADLs Used standard walker > 2 falls in yr prior # hospitalizations in year prior Odds Ratio 2.3 3.2 1.7 1.1 Risk Factors for Falling: Pre-Hospital

25. Post-Hospital: Admit for GI dx First generation tricyclic Uses cane indoors Middle tertile balance Lowest tertile balance Probable delirium Odds Ratio 2.5 3.2 0.3 2.2 3.3 6.7 Risk Factors Potentially Related to Hospitalization and Acute Illness

26. Post-Hospital Falls Prevention : Nikolaus, Bach: JAGS, 2003 • Home visit during hospitalization followed by 1+ visits after discharge • Typically OT and other member of interdisc team (RN, PT or SW) • Evaluate and modify home hazards, teach safe behaviors including use of mobility and functional aids

27. Results • 30% decrease in falls in 1-year follow-up compared to no home visits • Most effective in those with 2+ falls in year prior: IRR = 0.63 • Both groups got comprehensive geriatric assessment prior to discharge

28. Post-Hospital Fall Prevention: Cumming et al, JAGS 1999 • 1+ home OT visits, and 1 phone call 2 weeks post-first visit • Assess and modify home hazards, teach safe behaviors, evaluate and recommend safe footwear

29. Results • 19% reduction in fallers (p=.050) • 36% reduction in fallers among those with prior hx of falls (p=.001)

30. Approach to post-hospital falls prevention • Minimize bedrest during hospitalization • Observe patient doing functional tasks • walking, transferring, reaching, dressing • Educate older patients about post-hospital risk • Use mobility aid, caution with maneuvers • Eyeglasses, sturdy footwear, home safety check • Stratify post-hospital falls risk: • 2+ falls in year prior • significant decline in mobility with hosp

31. Reduce psychotropics Refer to home health for home OT (if qualifies) Evaluate transfers and ADL Assess need for home functional aids Assess and modify home hazards Teach safe behaviors Obtain PT in-hospital Evaluate for home assistive device Evaluate need for home PT Provide balance, strengthening exercises for home For high risk patients

32. Applying Multifactorial Interventions in the Community • Multifactorial falls prevention strategies have been successful in research studies • utilized specific exercise programs or physical therapists • utilized multiple specialists • It is unknown if a multifactorial intervention utilizing existing medical systems will decrease falls.

33. Randomized Trial of Community-Based Multifactorial Intervention • Kenosha County Falls Prevention Study • Funded by Wisc Resource Center Prevention Grant • Algorithm for falls assessment, recommendations, and monthly follow-up. • Recommendations to physician, referral to PT followed by exercise, other referrals as needed.

34. Methods • Inclusion Criteria: - Residing in Kenosha County, WI, age >65. - Two or more falls in past year, or one fall in past 1 to 2 years with injury or gait and balance problems • Exclusion Criteria: - Residence in Nursing home or CBRF - Diagnosis of dementia, no related caregiver in home. • Baseline information collected regarding: demographics, health status, mobility, function, cognition, depression, medications, vision, and health behaviors. • Followed monthly for falls for 1 year

35. Enrollment Characteristics 616 Referred 418 Eligible (68%) 349 Enrolled (83% of eligible)

36. Baseline Characteristics (n=349)

37. Differences in 2+ fallers versus single fallers Kenosha County Falls Prevention Study funded by the Wisconsin Department of Health and Human Services

38. Differences in recurrent fallers versus single fallers • The AGS recommends that older adults who have had 2+ falls in the past year, 1 fall with injury, or 1 fall with gait or balance problems receive a multifactorial falls evaluation. • Purpose: to examine baseline characteristics of those who have had 2+ falls in the past 12 months, compared to those with 1 fall in past 1-2 years. If there are differences, this could have implications for treatment.

39. Enrollment by Falls History • Comparison: 2+ falls past 12 mos. (n=189) vs. 1 fall in past 24 mos. (n=160) • Two-sample t-tests for continuous variables and Pearson’s chi-square tests for categorical variables.

40. Comparison of Baseline Characteristics

41. Comparison of Baseline Characteristics

42. Barthel Comparison

43. Conclusion • There are multiple significant differences in domains of: health status, mobility, function, cognition, depression, medications, and vision, comparing recurrent fallers and single fallers. Recurrent fallers are more likely to have risk factors in multiple domains. • The propensity for positive exercise behavior was similar in both groups.

44. Implications • Given the greater number of risk factors and impairments in the recurrent faller group, we may need to consider focusing a multifactorial approach toward this group. • Our data on exercise behavior suggests recurrent fallers may be equally likely to adhere to an exercise intervention as single fallers

45. Limitations • The sample was self selected by those interested in a falls prevention trial and may not be representative of all fallers. • This was primarily a white, middle-class population and may not be generalizable to other populations.

46. Dane County SAFE Study • Three-year RCT funded by CDC • Will randomize 420 older adults at high risk for falls to multifactorial intervention and follow-up or health information booklets. • Intervention similar to Kenosha County study. • But, supplemented by educational initiatives to increase physician and physical therapy utilization of recommendations.

47. Grant Overview • Two components • Goal 1: In-home multifactorial assessment randomized trial for high-risk older adults • Goal 2: Education of primary health care providers in Dane County.

48. Goal 1: Multifactorial intervention trial • Target group: • Community-residing adults age 65 and older at high risk for falls – AGS criteria • 2+ falls in the past year • 1 fall with injury • 1 fall with abnormal gait or balance • Exclusion criteria: • residence in NH or CBRF • Unable to give informed consent and no related caregiver in home.

49. Randomization

50. Outcomes • Primary outcome = falls • Hypothesized 40% reduction in rate of falls over 1 year compared to control group • Falls obtained via monthly calendar • Secondary outcomes • # hospitalizations and hospital days • # nursing home admissions and NH days • Change in function, mood, vision, medications, fear of falling, and physical performance at 12 months compared to baseline.