Current Research on Falls Prevention

Jane Mahoney, MD University of Wisconsin Medical School Dec 15, 2004

Scope of the Problem

• In 1999, accidents were the 8 th 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.

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.

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

2000 1600 1200 800 400 0 1970 1975 1980 1985 1990 1995 Women Men

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

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.

Components of Postural Control

Sensory Input Central Processing Effector Output Environ ment Visual Vestibular Proprioceptive Cognition CNS pathways Medications Musculoskeletal Strength Biomechanical

Risk Factors For Falls from Epidemiologic Studies

• Previous hx of falls • Balance or gait impairment • Dementia • Visual deficit • Neuropathy • Muscle weakness • Psychotropic medications • Depression • Arthritis, Parkinson’s, stroke

Risk Factors are Additive

Tinetti, NEJM, 1988

80 70 60 50 40 30 20 10 0 0 rf 1 2 % falling 3 4+

2001 Guidelines

American 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.

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

Randomized Trials of Multifactorial Interventions Study

• Tinetti, NEJM 1994 • Wagner, AJPH, 1994 • Close, Lancet, 1999 • Day, BMJ, 2002

Outcome

Rate 31% Risk 9% Risk 61% Rate 33%

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

Randomized Trials of Group Exercise Study

Wolf, JAGS, 1996 Tai Chi Lord, JAGS, 2003 standing Barnett, Age Ageing, 2003 standing Day, BMJ, 2002 Wolf, JAGS, 2003 standing Tai Chi

Outcome

Risk 47% Rate 22% Rate 40% Rate 18% Risk 25% NS

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

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

Post-hospital falls prevention rationale

Environ ment Sensory

CNS

Delirium Musculoskeletal Output Systemic Effects of Illness

Acute Changes in Postural Control

New Medications Environ ment Sensory CNS changes Musculoskeletal Output Bedrest, Deconditioning

Effects of Bedrest

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

Risk of Falls after Hospitalization

Mahoney, 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)

Risk factors by home nursing use

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

Falls After Hospital Discharge

Mahoney, Arch Int Med, 2000

-

311 older adults receiving home nursing after discharge

1 0 7 6 3 2 5 4 2 4 6 8 10 12 Weeks After Hospital Discharge 14

Rehospitalizations Due to Fall Injuries

• 15% of all re-hospitalizations in the first month were due to fall injuries.

Risk Factors for Falling: Pre-Hospital

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 Potentially Related to Hospitalization and Acute Illness

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

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

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

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

Results

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

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

For high risk patients • 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

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.

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.

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

Enrollment Characteristics

616 Referred 418 Eligible (68%) 349 Enrolled (83% of eligible)

Baseline Characteristics (n=349)

DOMAIN MEASUREMENT BASELINE

Age 80.0 ±7.5

Demographics Female 78.5% Falls Health status Mobility Function Cognition Meds Health Behaviors No. falls in past year Emergency Room visit(s) past 4 months Assistive device use indoors Barthel Index No. of independent Instrumental Activities of Daily Living out of 7, (IADLs) Mini-Mental State Exam (max 30) No. of prescription medications Any alcohol intake Frequency of exercise (days per week) , (%) 2.4 ± 2.5

30.7% 35.9% 88.1 ±16.6

4.8 ± 2.2

27.1 ± 4.4

5.7 ± 3.3

37.3% <1 34.7% 1-3 21.2% 4-7 44.1%

Differences in 2+ fallers versus single fallers

Kenosha County Falls Prevention Study funded by the Wisconsin Department of Health and Human Services

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.

Enrollment by Falls History

200 180 160 140 120 100 80 60 40 20 0 2+falls past 12 mos, n=189 1 fall past 12 mos. With injury, n=64 1 fall past 12 mos. with gait/balance problems, n=51 fall past 12-24 mos. With injury, n=30 fall past 12-24 mos. With gait/balance problems, n=15

•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.

Comparison of Baseline Characteristics

DOMAIN MEASUREMENT 2+ FALLS PAST YEAR 1 FALL PAST 1-2 YEARS N=160 P-VALUE

Demographics Falls Health status Mobility Walk Age Female No. falls in past yr Hx of hip fx , % Hx of CVA , % Health rated fair/poor , % ER visits in past 4 mos, % Assistive device use indoors , % outside, % Without help Some help Unable

N=189

79.9

73.5% 3.7

11.2% 31.2% 38.1% 38.1% 42.3% 60.9% 26.5% 80.0

84.4% 0.8

7.6% 18.8% 21.3% 21.9% 28.1% 83.8% 11.9% 0.94

0.014

<0.0001

0.25

0.008

0.007

0.001

0.006

<0.0001

12.7% 4.4%

Comparison of Baseline Characteristics

DOMAIN MEASUREMENT 2+ FALLS PAST 12 MOS 1 FALL PAST 24 MOS. WITH INJURY OR GAIT/BALANCE PROBLEMS N=160 P-VALUE N=189

Function Cognition Depression Medication Vison Health Behaviors No. IADLs Barthel Index score MMSE score GDS scpre No. prescription medications No. Psychotropics Able to watch TV, % Any intake alcohol , % Exercise program , % <1 Frequency of exercise, times per week , % 1-3 4-7 4.3

85.1

26.6

3.4

6.2

0.3

91.5% 34.4% 18% 36% 19.5% 44.4% 5.4

91.6 27.6

2.5

5.

0.1

96.9% 40.6% 18.1% 33.1% 23.1% 43.8$

<0.0001

0.0002

0.028

0.004

0.0007

0.018

0.037

0.29

0.97

0.70

SELECTED BARTHEL ACTIVITY

lower score indicating more impairment Bathing Self

Barthel Comparison

MEAN BARTHEL SCORE 2+ FALLS PAST YEAR

3.6

1 FALL PAST 1-2 YEARS

4.4

P-VALUE 0.0002

Dressing 8.8

9.3

0.036

Toileting Transferrring Walking on level surface Climbing stairs 9.6

14.1

11.7

9.9

14.7

13.3

0.019

0.014

0.001

7.1

8.5

0.0002

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.

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

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.

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.

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.

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.

Randomization

High risk older adults (n=420) informed consent baseline assessment I n-home multifactorial intervention (n=210) Educational booklets (n=210)

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.

Multifactorial assessment

• Follows principles of AGS guidelines • Can be performed by PT or RN with cross training • Requires about 2 hours to perform • Is performed in-home preferably with caregiver present

Algorithm assesses:

– History of falls, comorbidities, risk related to IADLs and ADLs, fear of falling, risky behaviors, footwear – depression, cognition – medications, alcohol intake – Exam: Orthostatics, vision, visual fields, vibration, Romberg – Gait and balance: Sensory integration, reactive balance, Berg balance, Tinetti Gait, Attention, Foot/ankle alignment

Outcome of assessment

• Algorithm generates recommendations to patient and physician, and referrals to PT, opthalmology, podiatry, OT, and other health provider and community resources • Assessor returns to the home within 2 weeks to provide recommendations and referrals

Intervention continues for 1 year

• Monthly phone call from assessor to encourage and assess compliance, help with problem-solving, etc.

• For most participants, the algorithm generates a referral to physical therapy. Physical therapy is followed by an ongoing, individualized exercise plan for community or home exercise, with an exercise “buddy” if needed.

Goal 2: Provider Education

• Target Groups – Primary care physicians – Physician Assistants and NPs – Physical Therapists, Paramedics • Purpose: Educate for falls prevention • Outcomes: Compare change in rate of hospitalizations for fall-related injuries in Dane County to other counties

Strategies for Recruitment • Direct to seniors • Community groups • Professional providers • Enrolled to date: 337 • Enrollment will continue through April 05

Referrals by Referral Type (N=729)

7% 2% 1% 13% 67% 3% 7% DCAAA Post Hosp/ER Home Care Primary MD/clinic Therapy OT/PT Other Indirect Self Referred

66%

Participants by Referral Type (N=290)

6% 1% 1% 14% 2% 10% DCAAA Post-Hosp/ER home care Primary MD/clinics Therapy (PT/OT) Other Indirect Self Referred

Thank-you

     Wisconsin Dept. of Health and Family Services Terry Shea, PT, Co-Principal Investigator Bob Przybelski, MD, Co-Investigator Ron Gangnon, Mari Palta, Biostatistics Nurses and physical therapists with the Dane County SAFE Study   Sheila Guilfoyle, Coordinator Community agencies, health care providers