Older Adult Falls Prevention Overview

1. Older Adult Falls Prevention Overview

2. NC Falls Prevention Coalition Goal - Reduce the number of falls & fall-related injuries for North Carolinians Members - Researchers, planners, health care providers, housing specialists, aging services providers, & many others Committees Infrastructure Development & Maintenance Surveillance & Evaluation Community Awareness & Education Provider Education Risk Assessment & Behavioral Intervention Advocacy for Supportive Policies & Environments While the goal of this group is to address ALL FALLS – the coalition, for now, is choosing to address the area of biggest concern – that of falls in our adult population. Members are from a diversity of disciplines, interests and geographic areas. They come together once a quarter for the coalition meetings and in-between for committee work The committees address six areas – with today clearly springing from community awareness & provider education, at a minimum. Funding, like many new ventures, has been almost non-existent! Lots of in-kind contributions and passion but minimal funding for start-up costs. There has been one-time Division of Public Health funding ($30,000), and we have had some other monetary assistance from the NC Dept. of Insurance, and the National Assoc. of Chronic Disease Directors around falls policy work. From the coalition was born the coalition’s tag line, “Stay Strong, Stay Active, Stay Standing”While the goal of this group is to address ALL FALLS – the coalition, for now, is choosing to address the area of biggest concern – that of falls in our adult population. Members are from a diversity of disciplines, interests and geographic areas. They come together once a quarter for the coalition meetings and in-between for committee work The committees address six areas – with today clearly springing from community awareness & provider education, at a minimum. Funding, like many new ventures, has been almost non-existent! Lots of in-kind contributions and passion but minimal funding for start-up costs. There has been one-time Division of Public Health funding ($30,000), and we have had some other monetary assistance from the NC Dept. of Insurance, and the National Assoc. of Chronic Disease Directors around falls policy work. From the coalition was born the coalition’s tag line, “Stay Strong, Stay Active, Stay Standing”

3. This Morning’s Agenda 3 This presentation was prepared by the NC Falls Prevention Coalition specifically to: make sure a number of individuals, such as each of you, has a common baseline of knowledge about a variety of subject content around falls and fall prevention – although, clearly, many of you may be experts in this arena; and to serve as a catalyst for falls action throughout the state so communities (so you today) can begin to formulate or expand upon plans to address falls prevention. Let’s continue by discussing the impact of older adult falls and the data related to falls prevention. Take questions at end… This presentation was prepared by the NC Falls Prevention Coalition specifically to: make sure a number of individuals, such as each of you, has a common baseline of knowledge about a variety of subject content around falls and fall prevention – although, clearly, many of you may be experts in this arena; and to serve as a catalyst for falls action throughout the state so communities (so you today) can begin to formulate or expand upon plans to address falls prevention. Let’s continue by discussing the impact of older adult falls and the data related to falls prevention. Take questions at end…

4. Our focus today is primarily UNINTENTIONAL FALLS, as defined here. We also want to stress that FALLING IS NOT A NORMAL PART OF AGING! While there may be more things that put you at risk for a fall as you grow older, FALLS ARE PREVENTABLE!Our focus today is primarily UNINTENTIONAL FALLS, as defined here. We also want to stress that FALLING IS NOT A NORMAL PART OF AGING! While there may be more things that put you at risk for a fall as you grow older, FALLS ARE PREVENTABLE!

5. Prevalence of Falls: US 30-35% of people 65+ fall each year1 Those who fall are 2-3 times more likely to fall again2 1 in 5 falls causes serious injuries3 Looking at the overall prevalence of falls, while 35% of people 65 and older fall each year, HALF of those 75+ fall once or more a year. Those who fall are predisposed to falling again. Looking at the overall prevalence of falls, while 35% of people 65 and older fall each year, HALF of those 75+ fall once or more a year. Those who fall are predisposed to falling again.

6. Falls-Related Deaths in North Carolina and the US So how does NC stack up with respect to the US and its number of falls? We have no less to worry about and, in fact, even more reason to be concerned for a couple of reasons. First, while the NC and US fall rates were not all that different for most of this 1999-2005 time period, note what clearly starts to happen around age 65: falls dramatically shoot up and NC gains, unfortunately, and passes the US numbers for this older age group. So how does NC stack up with respect to the US and its number of falls? We have no less to worry about and, in fact, even more reason to be concerned for a couple of reasons. First, while the NC and US fall rates were not all that different for most of this 1999-2005 time period, note what clearly starts to happen around age 65: falls dramatically shoot up and NC gains, unfortunately, and passes the US numbers for this older age group.

7. Percent of Population Age 65+ in North Carolina, 2000 But these next two maps lay the basis for why we really need to be concerned about older adult falls as a significant public health problem. Focus on the red and dark blue counties, as these are the ones that had the most individuals age 65 and older in 2000 In 2000, only 28 counties had more folks age 60 and over than age 17 and under Now look at this next map because….. But these next two maps lay the basis for why we really need to be concerned about older adult falls as a significant public health problem. Focus on the red and dark blue counties, as these are the ones that had the most individuals age 65 and older in 2000 In 2000, only 28 counties had more folks age 60 and over than age 17 and under Now look at this next map because…..

8. Percent of Population Age 65+ in North Carolina, 2030* By 2030, not 28 BUT 75 counties will have more people aged 60 and older than 17 and under. This map suggests that while we already have a significant problem with falls in the elderly, we are in for what we might term a SILVER TSUMANI when we couple this growth in older adults with the group that tends to experience the most falls! By 2030, not 28 BUT 75 counties will have more people aged 60 and older than 17 and under. This map suggests that while we already have a significant problem with falls in the elderly, we are in for what we might term a SILVER TSUMANI when we couple this growth in older adults with the group that tends to experience the most falls!

9. Falls Projections for Adults 65+ Just comparing our 2006/2007 death, hosp and ED data, you can see that the projections are somewhat alarming for NORTH CAROLINA if we don’t get interventions in place and address those at risk for falling. Numbers double for each group IF the RATE of falls remains the same, but we already know it is beginning to climb. Our hospitalization rate due to unintentional falls in older adults alone increased by 15% between 2000 and 2006. These numbers have major ramification for people’s lives and for our health care dollars unless we become more proactive. Just comparing our 2006/2007 death, hosp and ED data, you can see that the projections are somewhat alarming for NORTH CAROLINA if we don’t get interventions in place and address those at risk for falling. Numbers double for each group IF the RATE of falls remains the same, but we already know it is beginning to climb. Our hospitalization rate due to unintentional falls in older adults alone increased by 15% between 2000 and 2006. These numbers have major ramification for people’s lives and for our health care dollars unless we become more proactive.

10. Cost Projections for “Silver Tsunami” Hospitalizations We have extrapolated here on the cost implications for HOSPITALIZATIONS alone from falls. If the rate of falls/100,000 was simply to remain the same as today (which it won’t), the costs double. This is without all the other costs related to the ED, death, rehabilitation, suffering and loss of independence. Of particular concern is that Medicare is now refusing to compensate hospitals for some falls deemed preventable. We have extrapolated here on the cost implications for HOSPITALIZATIONS alone from falls. If the rate of falls/100,000 was simply to remain the same as today (which it won’t), the costs double. This is without all the other costs related to the ED, death, rehabilitation, suffering and loss of independence. Of particular concern is that Medicare is now refusing to compensate hospitals for some falls deemed preventable.

11. Impact on Quality of Life of Older Adults 20% - 36% fear falling1 Hip fracture patients are 2-3x more likely to die within a year2 25% in a nursing home one year later3 Older adults want to live independently and to age “in place”, but a fall is often the beginning of the end of independence. Fear of Falling leads people to decrease their activities, increasing their fall risk as they become weaker and less steady on their feet. Older adults want to live independently and to age “in place”, but a fall is often the beginning of the end of independence. Fear of Falling leads people to decrease their activities, increasing their fall risk as they become weaker and less steady on their feet.

12. A Complex Problem Over 60% of falls result from multiple interacting factors (Campbell, 2007) Effective interventions Multi-factor interventions 30% decrease in falls (Tinetti, 1994; Hogan. 2001; Niklaus, 2003) Single-factor community-based interventions 30-50% decrease in falls (Campbell, 2007) CDC says multi-factor interventions are more effective, but no matter what, INTERVENTIONS ARE MOST EFFECTIVE WHEN DESIGNED TO REACH THOSE MOST AT RISK OF FALLING CDC says multi-factor interventions are more effective, but no matter what, INTERVENTIONS ARE MOST EFFECTIVE WHEN DESIGNED TO REACH THOSE MOST AT RISK OF FALLING

13. Challenges Assumption on part of older adults and providers that falls are inevitable vs. preventable Older adults hesitant to mention a fall (stigma) Older adults not being assessed for fall risk Providers lack time, knowledge of effective interventions Challenge to preventing falls: DON’T ASK (on part of provider), DON’T TELL (on part of patient). Busy providers with little knowledge about availability of interventions for their patients. Challenge to preventing falls: DON’T ASK (on part of provider), DON’T TELL (on part of patient). Busy providers with little knowledge about availability of interventions for their patients.

14. Challenges (cont.) Limited interventions/programs at community level Problem must be addressed in a systematic, broad-based framework Lack of funding at both state and federal level (1) While some very specific interventions are evidence-based and available for duplication, not as many are “packaged” (w/manuals, etc.) and have all the pieces in place to train master trainers/lay leaders, ensure fidelity and evaluation components as in some other areas of prevention. (2) Problem needs to be addressed by a system-wide methodology, a socio-ecological model per se. Need to educate the provider to conduct risk assessments; Need to get the word out to older adults/care receivers and providers that falls are preventable; and Need to work with housing specialists and others about what can be put in place to prevent falls (1) While some very specific interventions are evidence-based and available for duplication, not as many are “packaged” (w/manuals, etc.) and have all the pieces in place to train master trainers/lay leaders, ensure fidelity and evaluation components as in some other areas of prevention. (2) Problem needs to be addressed by a system-wide methodology, a socio-ecological model per se. Need to educate the provider to conduct risk assessments; Need to get the word out to older adults/care receivers and providers that falls are preventable; and Need to work with housing specialists and others about what can be put in place to prevent falls

15. NC-Specific Falls Data: Putting the Numbers to Work for Prevention

16. Overview of Falls Data in NC Major data sources Death Data Hospitalization Data Emergency Department Data Know the basic falls facts For those 65+, unintentional falls are: • 1st leading cause of injury deaths & ED visits • 2nd leading cause of injury hospitalizations The death rate due to falls for people > 65 was 23 times the rate for those < 65 (2007) Death Data – comes from death file Hospitalization Data comes from Hospital Discharge Database Emergency Department Data comes from NC Detect database (Public Health has access, but housed at UNC) (As an aside: The deaths are for the period 2004-2007; ED visits for 2006-2007; Hospitalizations are for 2004-2007) It’s good to be familiar with your topic’s most basic facts: Mention: “Older Adult Injuries in North Carolina” document - published by NC Injury and Violence Prevention Branch and available on-line at www.injuryfreenc.ncdhhs.gov But nothing helps like seeing the numbers graphically so let’s take a look at some additional data specific to NC that can help make our case for falls prevention. Death Data – comes from death file Hospitalization Data comes from Hospital Discharge Database Emergency Department Data comes from NC Detect database (Public Health has access, but housed at UNC) (As an aside: The deaths are for the period 2004-2007; ED visits for 2006-2007; Hospitalizations are for 2004-2007) It’s good to be familiar with your topic’s most basic facts: Mention: “Older Adult Injuries in North Carolina” document - published by NC Injury and Violence Prevention Branch and available on-line at www.injuryfreenc.ncdhhs.gov But nothing helps like seeing the numbers graphically so let’s take a look at some additional data specific to NC that can help make our case for falls prevention.

17. Leading Causes of Unintentional Injury Death for People 65+, NC, 2006 This chart showing the leading causes of unintentional injury death among people 65 and older actually shows deaths from falls to be 38.5 vs. the US rate of 45% for this same period which is a bit of a surprise, and it will be interesting to see if this is a blip in the data.This chart showing the leading causes of unintentional injury death among people 65 and older actually shows deaths from falls to be 38.5 vs. the US rate of 45% for this same period which is a bit of a surprise, and it will be interesting to see if this is a blip in the data.

18. Looking at age and gender for those 65 and older… LOOK at how the fall-related injury death rate jumps for those 85 and older Adults 85 and older = 18x more likely to die from an unint. fall compared to adults age 65 to 69 (or 162 per 100,000 vs. 9 per 100,000). Note that we do not see that much difference between the male and female death rates/100,000Looking at age and gender for those 65 and older… LOOK at how the fall-related injury death rate jumps for those 85 and older Adults 85 and older = 18x more likely to die from an unint. fall compared to adults age 65 to 69 (or 162 per 100,000 vs. 9 per 100,000). Note that we do not see that much difference between the male and female death rates/100,000

19. Injury from an unintentional fall was significantly more likely to require hospitalization or an ED visit with advancing age. 4,550 hospitalizations for 85 and older vs 523 for those 65 to 69 Here, however, note that women were nearly twice as likely as men to be hospitalized with a fall injury.Injury from an unintentional fall was significantly more likely to require hospitalization or an ED visit with advancing age. 4,550 hospitalizations for 85 and older vs 523 for those 65 to 69 Here, however, note that women were nearly twice as likely as men to be hospitalized with a fall injury.

20. For unintentional falls, the injury rate per 100,000 was 8,957 ED visits for adults aged 85 and older in contrast with 1,705 ED visits for adults 65 to 69. And, again, we see that women were nearly twice as likely as men to visit an ED for a fall injury. For unintentional falls, the injury rate per 100,000 was 8,957 ED visits for adults aged 85 and older in contrast with 1,705 ED visits for adults 65 to 69. And, again, we see that women were nearly twice as likely as men to visit an ED for a fall injury.

21. Overview of Falls in NC (cont.) True total cost of falls hard to come by We normally report charges Health economists can come up with more accurate figure, calculating for: Work loss Quality of life Medical costs Difficulties calculating true costs – charges are much easier (in fact we find an astounding $1.4 billion in total hospital charges for older adult unint. fall-related injuries (2004-07)!; average charges of $21,000. Ted Miller has quality data but not current (from 2002 in 2004 dollars) Some costs still aren’t captured like: (1) all trips to private MD, urgent care center, costs of ambulance care, etc. or (2) family support losses (loss of job and change in life style to care for a loved one, for example)Difficulties calculating true costs – charges are much easier (in fact we find an astounding $1.4 billion in total hospital charges for older adult unint. fall-related injuries (2004-07)!; average charges of $21,000. Ted Miller has quality data but not current (from 2002 in 2004 dollars) Some costs still aren’t captured like: (1) all trips to private MD, urgent care center, costs of ambulance care, etc. or (2) family support losses (loss of job and change in life style to care for a loved one, for example)

22. This is only 2007 falls data, but, as you can see, this injury iceberg is a way of showing that fall deaths are only a tip of the iceberg and that far greater numbers become a reality as you move to the less severe injuries, and that we are totally lacking, in NC, pre-hospital data (EMS), urgent care, doctor’s offices, self-treatment numbers. This is only 2007 falls data, but, as you can see, this injury iceberg is a way of showing that fall deaths are only a tip of the iceberg and that far greater numbers become a reality as you move to the less severe injuries, and that we are totally lacking, in NC, pre-hospital data (EMS), urgent care, doctor’s offices, self-treatment numbers.

23. Data Limitations Missing e-codes E-codes that are too general/inaccurate Hospital discharge data allows only one mechanism/cause of injury to be recorded Inadequate/inaccurate coding by triage nurses and physicians Data is often coded for billing vs. surveillance purposes (with one exception) Missing e-codes in medical records are a major problem. (E-codes are a way of recording the external causes of injuries and poisonings as well as the adverse effects of drugs and substances.) E-codes that are too general or inaccurate are also a problem: a fall versus a fall from a 2nd story window vs. a fall from a wheelchair provide totally different clues as to the possible aim of an injury prevention program. Poor coders in hospitals can also be a problem. Emergency Department usually has 6 fields to capture and record e-code data while hospital discharge data may only allow for 1 field. As for inadequate/inaccurate coding: this can also be the result of nurse/physician haste, lack of attention to detail and to understanding the importance of the description. As a result, a head trauma may be incorrectly coded as “struck by” versus a “fall” That data is often coded for billing vs. surveillance purposes is also a challenge. The exception in NC is trauma registry data obtained from trauma centers who code for injury prevention (vs. for maximized reimbursement).Missing e-codes in medical records are a major problem. (E-codes are a way of recording the external causes of injuries and poisonings as well as the adverse effects of drugs and substances.) E-codes that are too general or inaccurate are also a problem: a fall versus a fall from a 2nd story window vs. a fall from a wheelchair provide totally different clues as to the possible aim of an injury prevention program. Poor coders in hospitals can also be a problem. Emergency Department usually has 6 fields to capture and record e-code data while hospital discharge data may only allow for 1 field. As for inadequate/inaccurate coding: this can also be the result of nurse/physician haste, lack of attention to detail and to understanding the importance of the description. As a result, a head trauma may be incorrectly coded as “struck by” versus a “fall” That data is often coded for billing vs. surveillance purposes is also a challenge. The exception in NC is trauma registry data obtained from trauma centers who code for injury prevention (vs. for maximized reimbursement).

24. A good case for injury prevention can be made if one looks at deaths, hospitalizations and ED visits for the counties in NC. We are going to look at some real detail on this when we look at each county’s specific data in just a few minutes. Interestingly, PITT COUNTY is shaded in the darkest blue This map for fall fatality rates is like the map we saw before, but for 2000-2008 data. Showing different time frames can provide insight. It is interesting to note in the “Older Adult Injuries” publication that when one looks at the 65 and older injury rates (vs. falls injuries) by region that: The West has the highest rates of injury deaths per 100,000; East has highest number of injury hospitalizations/100,000; the Central part of the state has the highest rate of injury-related emergency department visits/100,000. Let’s look closer at the picture at home - of fall rates in North Carolina’s specific counties. This is ALL FALLS, not just unintentional. ALL AGES, not just 65 and over. Specific counties in West and East seem to have higher rates of injury from falls than others, although there appears to be a band beginning to develop down the middle of the state as well. Earlier maps for unintentional fall death rates (vs. all falls) for 2002-2006 are a bit different (which likely reflects an increase in the unintentional since intentional falls are usually so small). This period shows an increase in the rate of deaths in the middle of the state, but with similar high death rates in the west (although the counties shift a little), as well as the east (although the counties also shift a bit). Looking at the other, related, maps specific to falls:A good case for injury prevention can be made if one looks at deaths, hospitalizations and ED visits for the counties in NC. We are going to look at some real detail on this when we look at each county’s specific data in just a few minutes. Interestingly, PITT COUNTY is shaded in the darkest blue This map for fall fatality rates is like the map we saw before, but for 2000-2008 data. Showing different time frames can provide insight. It is interesting to note in the “Older Adult Injuries” publication that when one looks at the 65 and older injury rates (vs. falls injuries) by region that: The West has the highest rates of injury deaths per 100,000; East has highest number of injury hospitalizations/100,000; the Central part of the state has the highest rate of injury-related emergency department visits/100,000. Let’s look closer at the picture at home - of fall rates in North Carolina’s specific counties. This is ALL FALLS, not just unintentional. ALL AGES, not just 65 and over. Specific counties in West and East seem to have higher rates of injury from falls than others, although there appears to be a band beginning to develop down the middle of the state as well. Earlier maps for unintentional fall death rates (vs. all falls) for 2002-2006 are a bit different (which likely reflects an increase in the unintentional since intentional falls are usually so small). This period shows an increase in the rate of deaths in the middle of the state, but with similar high death rates in the west (although the counties shift a little), as well as the east (although the counties also shift a bit). Looking at the other, related, maps specific to falls:

25. This is the county pictorial for Fall Hospitalization Rates for the older adult population.This is the county pictorial for Fall Hospitalization Rates for the older adult population.

26. This is the similar map for Emergency Dept. visits.This is the similar map for Emergency Dept. visits.

27. Making the Case for Prevention Using Data Know your Audience Look for outliers/astounding facts to use Use conversational language Appeal to personal or occupational interests/concerns Be an opportunist: call upon the new “mantra” of aging well, etc. Use social math when appropriate Consider what is important to audience, level of education (language), area of interest (state, regional, county, town) and what already know, what is expected (legislators want hard data). Look for interesting facts and use conversational language: Say “about half of men who fell ended up in the hospital” vs. 47.3% of males who suffered a fall injury were hospitalized in 2007. Appeal to personal interests/concerns: With young people, refer to grandparents; with policy makers refer to impact of boomer population; with hospital administrators refer to problems related to extended lengths of stay that can be costly (backs up admissions, etc.). Opportunist (call upon new mantras): eat smart, move more/safe and active communities; return on investment of prevention versus treatment; and aging well “in place’ are gaining in popularity. Social math can often better capture the audience’s attention and be remembered. For example, for 2007, instead of talking about NC’s 167,000 fall ED visits (includes all ages), point out these are 457 ED visits/day or 19 every hour. OR, taking an example from the CDC Injury Framing Guide, we could say that each year almost 1.8 million older Americans are seen in an ED for a fall when these folks could be practicing Tai Chi or swimming and would fill more than 3,600 senior and recreation centers. Consider what is important to audience, level of education (language), area of interest (state, regional, county, town) and what already know, what is expected (legislators want hard data). Look for interesting facts and use conversational language: Say “about half of men who fell ended up in the hospital” vs. 47.3% of males who suffered a fall injury were hospitalized in 2007. Appeal to personal interests/concerns: With young people, refer to grandparents; with policy makers refer to impact of boomer population; with hospital administrators refer to problems related to extended lengths of stay that can be costly (backs up admissions, etc.). Opportunist (call upon new mantras): eat smart, move more/safe and active communities; return on investment of prevention versus treatment; and aging well “in place’ are gaining in popularity. Social math can often better capture the audience’s attention and be remembered. For example, for 2007, instead of talking about NC’s 167,000 fall ED visits (includes all ages), point out these are 457 ED visits/day or 19 every hour. OR, taking an example from the CDC Injury Framing Guide, we could say that each year almost 1.8 million older Americans are seen in an ED for a fall when these folks could be practicing Tai Chi or swimming and would fill more than 3,600 senior and recreation centers.

28. Utilization of Data to FocusPrevention Efforts Double check your data Make sure the source of data is/was reliable/credible Look for trends in age groups, genders, geographic areas to identify and target disparate populations Make sure your data do not have errors and are not in conflict with other data (or know why there are differences). Document with trends NOT with isolated years or instances. Look for specific trends to ID and target disparate populations. Hospital data is now being collected for ethnicity and this will be helpful.Make sure your data do not have errors and are not in conflict with other data (or know why there are differences). Document with trends NOT with isolated years or instances. Look for specific trends to ID and target disparate populations. Hospital data is now being collected for ethnicity and this will be helpful.

29. Utilization of Data to Focus Prevention Efforts (cont.) Draw your data from groups that are truly representative of the focus population Maintain quality data so you can evaluate effectively and document effectiveness of your efforts With the increasing demand to do more with less, with ever decreasing resources, QUALITY data are vital to serve as evidence of successful interventions (evidence based practices/best practices).With the increasing demand to do more with less, with ever decreasing resources, QUALITY data are vital to serve as evidence of successful interventions (evidence based practices/best practices).

30. Discussion/Questions