Falls and Mobility Problems in Older Adults

1. Falls and Mobility Problems in Older Adults Shelley B. Bhattacharya, D.O., M.P.H. Department of Family Medicine Kansas Reynolds Program in Aging University of Kansas Medical Center

2. Epidemiology of falls in elderly Ageing Definitions Classifications Incidence

3. Epidemiology of falls in elderly Definitions: An event that results in a person inadvertently coming to rest on the ground or other lower level (not as a result of loss of consciousness, violent blow, sudden onset of paralysis or seizure) (Gibson et al., Kellogg International Work Group, 1987) An event which results in a person coming to rest unintentionally on the ground or other lower level, not as a result of major intrinsic event (such as stroke) or overwhelming hazard (Tinetti et al., 1988) Unintentionally coming to rest on the ground, floor or other lower level (Ory et al, FICSIT trials, 1993)

4. Epidemiology of falls in elderly Classifications: • Fallers • Non-fallers • Once-only fallers • Recurrent fallers Intrinsic Extrinsic Injurious Non-injurious • Falls • Trigger • Consequence

5. Epidemiology of falls in elderly Incidence: • Accidents are the 5th leading cause of death in older adults 1 • Falls account for 2/3 of these accidental deaths • 1/3 of adults over 65 living in the community fall at least once a year • This rises to ½ of adults over age 80 2,3 • 5% of these falls result in a fracture or hospitalization • Mobility abnormalities affect 20-40% of adults over 65 and 40-50% of adults over age 85 4,5

6. Epidemiology of falls in elderly Incidence: • Mortality 46 • Of those who are hospitalized, ~50% will not be alive a year later • Falls constitute 2/3rd of deaths associated with unintentional injuries • In 2000 traumatic brain injury (TBI) accounted for 46% of fatal falls. • Cost 47 • Fall-related injuries are among the most expensive health conditions • In 2000 $179 million were spent on fatal falls and $19 billion were spent on injuries from non-fatal falls

7. Epidemiology of falls in elderly Incidence: • Location 48 • Most falls occur outdoors • Women are more likely to report indoor falls • Indoor falls are associated with frailty • Outdoor falls are associated with compromised health status in more active elderly

8. Epidemiology of falls in elderly Incidence: The rate of falls and their associated complications are ~ twice over the age of 75 years. 10-25% falls induce fractures in this population Hip fractures are more common after the age of 75 years Those ≥75 years of age are more likely to report indoor falls Incidence is higher in certain populations (e.g. institutionalized elderly, diabetics, Parkinson’s disease, post-stroke etc.) 49

9. Fall prevention • The quality of falls care in older adults is suboptimal • If we can reduce the risk factors for falling, then we can reduce the incidence and the morbidity associated with falls • 3 studies have found that 65-100% of older adults with 3 or more risk factors fell in a 12 month period compared with 8-12% of older adults without any risk factors 1,6-8

10. ACOVE Indicators • ACOVE = Assessing Care Of Vulnerable Elders • The 12 new ACOVE indicators59 are designed to improve the clinical approach to falls and mobility in older adults • Evidence based focus: 182 articles were reviewed to obtain these indicators • Some have practice guidelines which will be shared

11. ACOVE Indicator 1 • ALL vulnerable elders should have ANNUAL documentation about the occurrence of recent falls …

12. Because… • Falls are common • Preventable • Frequently unreported • Often cause injury • Can restrict activity unnecessarily • A recent fall is a potent predictor of future falls • Need a multifactorial falls risk assessment for all of your vulnerable older adults

13. Multifactorial Falls Risk Assessment • Many studies show that a multifactorial falls risk assessment program is beneficial to assess and intervene on falls • In one meta-analysis, the risk ratio for a first fall in subjects enrolled in a risk assessment program was 0.82 (95% CI 0.72-0.94) compared to controls and was 0.63 (95% CI 0.49-0.83) for any fall 9 • In other words, 18% fewer 1st falls and 37% fewer of any falls with a falls risk assessment program!

14. Falls Risk Assessment Features • Medication review • ADL and IADL assessment • Orthostatic blood pressure measurement • Vision assessment • Gait and balance evaluation • Cognitive evaluation • Assessment of environmental hazards

15. ACOVE Indicator 2 • IF a vulnerable elder reports 2 or more falls in the previous year, THEN document a basic fall history within 3 weeks of the report … • Because a basic fall history provides the necessary information to implement an individualized multifactorial falls risk intervention strategy

16. What is a fall history? • Circumstances? • Medications? • Chronic conditions? • Mobility status? • Alcohol intake? • You can use the positives to tailor a fall prevention program specific for each of your older adults 10,11

17. ACOVE Indicator 3 • IF a vulnerable elder reports 2 or more falls (or 1 fall with injury) in the previous year, THEN there should be documentation of orthostatic vital signs within 3 months of the report… • Because detection of orthostasis decreases the risk of future falls • Is a part of the multifactorial falls prevention intervention

18. Evidence • Supported by 13 studies including cohort and RCT’s 12-18 • Some clinical guidelines that are recommended: • Correct postural hypotension 19 • Assess postural vitals in all older adults that have had a recent fall, report recurrent falls or demonstrate abnormalities in gait or balance 20 • Include a cardiovascular examination when doing a falls risk assessment 21

19. ACOVE Indicator 4 • IF a vulnerable elder reports a history of 2 or more falls in the last year, THEN there should be documentation of an eye examination in the previous year or visual acuity testing within 3 months of the report… • Because detection and treatment of some forms of visual impairment reduces the risk of falls.

20. Evidence • 11 studies examined visual acuity as a falls risk factor • One study looked at falls improvement after expedited (within 27 days) and routine (71-212 days) cataract surgery in women over age 70 22 • After 1 year, 49% of adults in expedited group fell at least once compared to 45% in routine group • 18% fell twice in expedited group compared to 25% in control group

21. ACOVE Indicator 5 and 6 • IF a vulnerable elder reports 2 or more falls in the last year, OR • IF a vulnerable elder has new or worsening difficulty with ambulation, balance or mobility, • THEN there should be documentation of basic gait, balance and strength evaluation within 3 months of the report…

22. Because… • Detection and treatment of gait and balance disorders reduces the risk of future falls as part of a multifactorial intervention

23. Evidence • 9 studies looked at gait and balance assessments in falls prevention • Cohort and RCT’s • In 3 studies, abnormal gait and balance alone were significant predictors of falls 6

24. Clinical Guidelines for Gait and Balance • Provide interventions to improve balance, transfers and gait 19 • Do a gait and balance assessment for those requiring medical attention because of a fall, report recurrent falls in the past year or demonstrate abnormalities of gait or balance 20 • Risk assessment includes assessment of gait, balance, mobility and muscle weakness 21

25. Screening and Examination of Gait and Balance Timed Get Up and Go Test Single Leg Stand Test Dynamic Gait Index Berg Balance Scale

26. Timed Get Up and Go Test Measures functional capacity rather than individual impairment – reflects multiple domains, useful in detecting mobility impairment . Time it takes to stand up from arm chair, walk 3 meters (10 feet), return to chair and sit down

27. Timed Get Up and Go Test Interpretation of Performance on the Timed Get Up And Go Test • < 10 sec. Low fall risk; clients are freely mobile; encourage regular exercise • < 20 sec. Moderate fall risk; clients are independent with basic transfers; most go outside alone and climb stairs, many are independence with tub and shower transfers. PT referral may be appropriate. • 20-29 sec. High fall risk; “Gray zone”; functional abilities vary. Physician or multidisciplinary team assessment recommended. • >30 sec. Very high fall risk; Many are dependent with chair and toilet transfers; most are dependent with tub and shower transfers; most cannot go outside alone; few, if any, can climb stairs independently. Physician or multidisciplinary team assessment recommended.

28. Timed Get Up and Go (TUG) Test Bischoff (2003) Community dwelling elderly women < 12 sec. on TUG normal Women in residential care – only 9% performed in <12 sec.; 42% were below 20 sec; 32% were between 20-30 sec. and 26% > 30sec. Suggests that community dwelling woman with TUG > 12 sec. should be referred for PT evaluation Over 50% of women in residential care at high or very high risk of falling

29. Timed Get Up and Go Test Nordin (2006) Individual variation in performance high in institutionalized elderly Variation increased with slower performance. Cognitive impairment or cuing did not increase variability Could use mean of three trials to obtain a more accurate score We do not know what this variability means in terms of falls risk prediction

30. Single Leg Stance Test A measure of static balance that relates to foot/ankle strategies Functional implications for gait, especially on uneven surfaces, and going up/down curbs or steps Marker of frailty in elderly persons Community dwelling older adults unable to stand for 5 sec. had a 2.1 times risk of injurious falls

31. Dynamic Gait Index Developed to quantify gait dysfunction in older adults during level surface walking as well as more complex functional tasks. Dual task demands relevant to falls risk in elderly Applicable to assessing balance in other groups of patients including those with vestibular disorders, multiple sclerosis, head injury, and Parkinson’s Scores of 19 or less out of 24 indicate increased risk of falling in older adults (Shumway-Cook 1997)

32. Berg Balance Scale • Measure of static and dynamic balance in movements common in everyday life on 14-item scale (56 points) • Useful for evaluating multiple falls risk in community living older adults • No longer recommends a dichotomous 45 point cut-off • Likelihood of multiple falls increases as score decreases • Reliable test of balance in elderly in residential care – change of 8 points required to reveal genuine change in function • Discriminates persons with Parkinson’s disease who fall vs. those who do not fall • Cut-off score of 44/56 recommended by Landers, 2008

33. Limitations of Balance Scales and Screening Tools Screening for falls may increase fear of falling Falls are multifactorial, no scale captures all aspects Scales and balance screening tools have not been well tested in a wide range of populations/settings Uncertainty regarding predictive scores Scales test different aspects of balance, sensitivity for prediction and examination may be best with multiple tests

34. ACOVE Indicator 7 • IF a vulnerable elder reports 2 or more falls in the past year, THEN there should be documentation of a cognitive assessment in the past 6 months… • Because, detection and management of cognitive impairment reduces the risk of falls as part of a multifactorial intervention

35. Evidence • 7 studies • 4 studies recommend using the MMSE 15-17,23 • Clinical Practice Guideline • Assess mental status as part of your fall evaluation for older adults who had a fall, report recurrent falls in the past year or show abnormal gait or balance 20

36. ACOVE Indicator 8 • IF a vulnerable elder reports a history of 2 or more falls in the past year, THEN there should be documentation of an assessment and modification of home hazards recommended in the previous year or within 3 months of the report…

37. Because… • Environmental factors can contribute to risk of falls and mobility problems • An assessment and modification of home hazards may decrease fall risk

38. Difficulty Moving Around at Home Hard to go up stairs 35% Difficulty walking 15% Use of cane/walker 8% Use of wheelchair/scooter 6% Difficulty bathing 3% Chair or bed transfers 3% (Source: Fixing to Stay, 2002)

39. Important Housing Features Main floor, bath Main floor, bedroom Accessible climate controls Non-slip flooring Bathroom aids No step entrance Covered parking (Source: These Four Walls…, May 2003)

40. Occupational Therapy considers the physical context During Assessment Understand obstacles/barrier to participation Understand supports to participation Consider individual, groups, populations who use the physical space During intervention Reduce activity demands from the environment Insure adequate supports Facilitate performance though the use of the environment Avoid further functional decline and excess disability caused by environmental factors

41. 3 Major Problem Areas of the Home: Outside Steps To The Entrance Inside Stairs To A Second Floor Unsafe Bathrooms Source: HUD (2001)

42. Other Alternatives to Entrance with Outside Steps Ramps Earth Berms/Walkways Lifts Zero Step entrance

43. Other Strategies for Getting Upstairs Chair lift Elevator Relocate rooms to main floor

44. Strategies for Bathing Bath bench/chair Bath lift Grab bars Visual contrast Non slip surface Hand held showerhead Shower/wet room Curbless shower

45. Evidence • Many RCT’s reviewed • One RCT of over 3000 older adults 24 • Intervention: in home safety mobility assessment • Control: no assessment • Results: Odds ratio of falling in the intervention group dropped from 1.0 to 0.85 • In other words, there was a 15% drop in falls in those receiving the in home safety mobility assessment

46. More Evidence • Environmental assessment and modification using an occupational therapist reduced 12 month relative risk of falling to 0.64 (95% CI 0.5-0.83) in older adults at higher risk of falling 25-28 • Another study compared a home safety program to a home exercise program in older adults with severe visual impairment 29 • Found fewer falls in the home safety program: 0.59 (95% CI 0.42-0.83) • No difference with the home exercise group

47. Review Study • A review study looking at 3 trials found that professionally prescribed home hazard assessment and modification in older adults with a history of falling reduced the risk of falling, RR of 0.66 (95% CI 0.54-0.81) 30

48. Checklists--Examples Home Safety Council www.homesafetycouncil.org/resource_center/rc_checklist_w001.aspxp Rebuilding Together --Checklist www.rebuildingtogether.org CDC Check for Safety www.cdc.gov/ncipc/pub-res/toolkit/checkforsafety.htm http://www.cdc.gov/ncipc/falls/FallPrev4.pdf http://www.cdc.gov/ncipc/duip/fallsmaterial.htm

49. ACOVE Indicator 9 • IF a vulnerable elder reports a history of 2 or more falls, or 1 fall with injury, in the past year, THEN there should be documentation of a discussion of related risks and assistance offered to reduce or discontinue benzodiazepine use… • Because, benzodiazepine use increases the risk of future falls

50. Evidence • 1 RCT: 93 ambulatory adults over age 65 on a benzodiazepine, any other hypnotic, antidepressant or tranquilizer 31 • Randomized to withdrawal plus exercise, withdrawal only, exercise only or no intervention • Over 44 weeks, medication withdrawal group had lower rate of falls (0.52 vs. 1.16 falls per person-year. Difference 0.64, 95% CI 0.07-1.35)…NOT significant • But, if adjusted for history of falls in past year and total number of meds taken, hazard for falls in the medication withdrawal group was 0.34 (0.16-0.74)