FALLS IN OLD PEOPLE - PowerPoint PPT Presentation

Loading...

PPT – FALLS IN OLD PEOPLE PowerPoint presentation | free to download - id: 40e77-NGQwO



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

FALLS IN OLD PEOPLE

Description:

Famous Fallers. 4. Fall Incidence in Older Adults [rate/person/yr] ... Visual mods, Vit D Ca , Footwear, Vibration. Multifactorial interventions seem best ... – PowerPoint PPT presentation

Number of Views:259
Avg rating:3.0/5.0
Slides: 66
Provided by: drl6
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: FALLS IN OLD PEOPLE


1
FALL PREVENTION RESEARCH TO PRACTICE
Laurence Rubenstein, MD, MPH Director, Sepulveda
Division Greater Los Angeles VA GRECC Professor
of Medicine, UCLA
VA GRECC Audio Conference October 26, 2006
2
Preventing Falls What does the evidence show?
  • Background Epidemiology, costs
  • Causes risk factors
  • Prevention approaches--evidence
  • RAND meta-analysis
  • New studies since the meta-analysis
  • AGS/BGS practice guidelines--update

3
Famous Fallers
4
Fall Incidence in Older Adultsrate/person/yr
or rate/bed/yr
Rubenstein LZ, Josephson KR. Clin Geriatr Med.
2002(May)18(2)141-158
5
Falls Mortality
  • Accidents the 5th leading cause of death in
    older adults
  • Deaths from falls 2/3 of accidental deaths
  • 72 of U.S. fall-related deaths occur in the 13
    of population age 65

Rubenstein LZ, Josephson KR. Clin Geriatr Med.
2002(May)18(2)141-158
6
Costs of Falls
  • 8 of pop ?70 visit ERs for falls yearly
  • 1/3 of these are hospitalized
  • 5.3 of hosp patients ?65 are due to falls
  • U.S. cost est. 2000?20 B. (2020?32 B)
  • 18 restricted activity initiated by falls
  • Precipitate NH entry
  • 1 cause of NH litigation

Rubenstein LZ, Josephson KR. Clin Geriatr Med.
2002(May)18(2)141-158
7
Causes of Falls Summary of 12 Studies
  • Accident/environment 31
  • Gait/balance disorder 17
  • Dizziness/vertigo 13
  • Drop attack 10
  • Confusion 4
  • Postural hypotension 3
  • Vision problem 3
  • Other specified 15
  • Unknown 5

Rubenstein LZ, Josephson KR. Clin Geriatr Med.
2002(May)18(2)141-158
8
Risk Factors for Falls 16 Multivariate Studies
Rubenstein LZ, Josephson KR. Clin Geriatr Med.
2002(May)18(2)141-158
9
Drugs Falls Meta-analysisLeipzig, Cumming,
Tinetti, JAGS, 1999
  • Psychotropics, any RR 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)
  • Fall risk from newer ? agents no better. --Hien,
    Cumming, Cameron, et al, JAGS 531290, 2005

10
12-Month Fall Rate in NH Interacting Risk
Factors
Robbins AS, Rubenstein LZ, Josephson KR, et al.
Arch Intern Med. 1989(July)149(7)1628-1633
11
Environmental Fall Risk Factors
  • Home
  • low lighting
  • poor stairs rails
  • unstable furniture
  • rug/carpet hazards
  • low beds toilets
  • no grab bars
  • slick floors
  • obstacles
  • pets
  • medications
  • Outdoors
  • bad weather
  • poor sidewalks
  • traffic activity
  • street crossings
  • uneven steps
  • distractions
  • obstacles
  • ? activity levels
  • Institution
  • low lighting
  • new admission
  • poor furniture
  • slick hard floors
  • low supervision
  • ? of nurses
  • meal times
  • no hand rails

12
(No Transcript)
13
(No Transcript)
14
Fall Risk Assessment MeasuresPerell K, et al J
Gerontol Med Sci 2001.
  • Review of 20 fall risk measures
  • 14 nursing tools, 6 functional tools
  • Common items for nursing tools
  • mental status (13), fall hx (10), mobility (10),
    other dx (8), incontinence (8), drugs (7),
    sensory deficits (7), balance (5), age (4), ADLs
    (4), assistive device (4), weakness (4), gender
    (3), acuity (3), restraint use (1)
  • Best measures overall
  • Hospital Oliver 97, Schmid 90, Morse 89,
    Hendrick 95, Rapport 93
  • Outpatient Shumway-Cook 00, Cwikel 98, Tinetti
    86, Berg 89
  • NH universal precautions (or Morse 89,
    Shumway-Cook 00)

15
Fall Risk Assessment Measures The Reality
  • Most can accurately identify patients at higher
    risk of falls
  • Probably helpful to sensitize community living
    elders of their fall risk what to do
  • Important for medico-legal purposes in hospitals
    NHs You need to show youre doing something
    that is organized and current.
  • But virtually all patients in hospital and NHs
    come out as high risk.

16
Fall Prevention Trials gt100 RCTs since 1984
  • Assessment (preventive post-fall)
  • Exercise rehabilitation programs
  • Environmental modifications
  • Devices
  • Nursing interventions
  • Combined interventions

17
Benefits of a Post-Fall AssessmentResults of a
Randomized Controlled Trial in NH
  • Intervention 1-2 hr post-fall assessment
    protocol by GNP (HP, gait/bal, envir, lab)
    Feedback to PCP (dx, risk factors, recs)
  • Setting/sample 700-bed LTC facility, 2/3 F, age
    x88, 160 fallers randomized, 2 yr f/u.
  • Results 3-4 treatable fall risks found per
    person
  • ?9 falls in assessed group (n.s.)
  • ?17 mortality (n.s.)
  • ?52 hosp days (plt.01)

Rubenstein et al, Ann Intern Med, 113 308, 1990
18
Benefits of a Post-Fall Assessment Prevention of
Falls in the Elderly Trial (PROFET)
  • Randomized trial of post-fall assessment of
    fallers seen in ED assessed by 7 days.
  • N397, ?65 (mean age 78) London
  • Assessment 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
19
Clinical Approach to the Faller
  • Assess treat any injury
  • Determine likely precipitating cause(s)
  • history, physical , lab (limited)
  • Prevent recurrence
  • treat underlying cause/illness
  • identify reduce risk factors (e.g., weakness,
    gait/bal prob, visual prob, polypharm)
  • reduce environmental hazards
  • teach adaptive behavior (e.g., slow rise, cane)

20
(No Transcript)
21
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
    Oregon
  • N256 inactive, home-living elders (age 72-92)
  • 6 month results Tai-chi
    Stretching
  • Falls 38 73 plt.01
  • Fallers 28 46 p.01
  • Inj. falls 7 18 p.03

Tai-chi group also signif better in balance,
physical performance fear of falling
22
Hip Protectors Examples
Safehip
KPH
HipGuard
CuraMedica
HIPS
23
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

24
Nursing Interventions
  • Risk assessments (Morse, Hendrich, MDS)
  • Treat identified risks
  • Universal fall precautions
  • call light assist devices close
  • bed wheels w/c brakes locked
  • adequate lighting
  • clean spills immediately
  • patient orientation staff educ
  • For high-risk patients
  • move closer to nursing station
  • increased observation / sitter
  • bed-chair alarms
  • low beds
  • non-skid slippers
  • rails grab bars
  • clutter-free rooms
  • clear signage
  • floor mats
  • special careplans
  • hip protectors

25
Anti-Slip Footwear Examples
Fashion Treads
Care-Steps
Pillow Paws
Walk Alerts
26
Bed Chair Monitors Examples
Bed Chair Alarm
Chair Sentry
Locator Alarm
AirPro Alarm
Safe-T Mate Alarmed Seatbelt
Economy Pad Alarm
Floor Mat Monitor
Keep Safe
QualCare Alarm
27
Do Bedrails Prevent Falls? Pre-Post StudyAHC
Hanger et al, J Am Geriatr Soc, 47529, 1999
  • Study of falls in New Zealand hospital
  • 6-mo before 6-mo after bedrail restriction
    program.
  • After policy, fewer beds w/ rails (29.6 ?
    13.7).
  • Total falls/10,000 bed-days before-165
    after-192
  • Falls around bed/10,000 b-d before-89
    after-106
  • Serious fall injuries before-33 after-18
  • Minor fall injuries before-43 after-60

28
(No Transcript)
29
Bedside Mats Fall Cushions
CARE Pad bedside fall cushion
Posey Floor Cushion
NOA Floor Mat
Roll-on bedside mat
Soft Fall bedside mat
Tri-fold bedside mat
30
Fall Prevention Trials RAND-CMS Meta-analysis
  • Lit review (1980-2002) 830 pubs, 41 RCTs

Fall 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.
31
Exercise Components
32
Since the 2003 Meta-analysis, whats new?
  • gt 35 new published RCTs
  • New studies of existing models
  • Risk assessment intervention (8), Exercise
    (14), Multifactorial (8), Hip protectors (3)
  • New interventions
  • Visual mods, Vit D Ca, Footwear, Vibration
  • Multifactorial interventions seem best
  • RF assessment abatement, exercise, envir mod
  • Organized, consistent, population-based programs

33
Vitamin D Effect on Falls Meta-analysisBischoff-
Ferrari JAMA 2911999-06, 2004.
  • Pooled 5 RCTs, N1237
  • Vit 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, sex
  • Baseline Vit D levels not measured

34
Can Cataract Surgery Reduce Falls? Harwood et al,
Br J Ophthalmol 20058953-9
  • RCT of women age 70 w/ cataracts randomized to
    surgery or 12-mo wait list
  • Falls measured by diary q3mo f/u
  • 12 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

35
The Yaktrax gait stabilizing device RCT
?58 RR outdoor falls on snow ice (plt.03)
?87 RR injurious falls on snow ice (plt.02)
most intervention group falls occurred w/o device
McKiernan FE, JAGS 53943, 2005
36
Vibrating Insoles may improve balance
Priplata AA, et al. Vibrating insoles balance
in elderly people. Lancet 2003 3621123.
37
Fall Prevention Strategies
  • COMMUNITY
  • Risk-factor screen intervention
  • Post-fall assessment
  • Exercise program (strength, balance)
  • Environmental inspection modification
  • INSTITUTION
  • Organized program
  • Risk-factor screen
  • Post-fall assessment
  • Nurse awareness
  • Targeted interventions (e.g., hip pads, low bed,
    bed/ chair alarms, monitors)

38
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/ gt1 fall
  • Hx of fall circumstances, meds, chronic illness,
    mobility level
  • Examine 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 assmt/mod,
    medication review adjustment

39
Assessment and Management of Falls
Periodic case finding in Primary Care Ask all
patients about falls in past year
40
Conclusions
  • Falls Common, debilitating, expensive
  • Preventable w/ existing technology
  • Assessmentf/u, exercise, environment mod
  • System needed to mobilize evidence-based
    preventive approaches
  • Likely cost-effective (multiple direct indirect
    savings offset program costs)

41
Fall Prevention Principles in Action The
Birmingham/Atlanta GRECC Fall Prevention Clinic
  • Cynthia J. Brown, MD, MSPH
  • Investigator, Birmingham/Atlanta VA GRECC
  • Medical Director, Birmingham/Atlanta GRECC
  • Fall Prevention and Mobility Clinic
  • Associate Professor, UAB

42
GRECC Fall Prevention and Mobility Clinic
  • Objectives of the clinic
  • To provide care to veterans with a history of
    falls, near falls or other mobility problems
  • To develop a program which can be exported to
    other VA facilities
  • To allow research into the area of falls, fall
    prevention and mobility disability in a
    community-dwelling population
  • To provide an educational venue for a variety of
    trainees

43
Patient Population Served by the Clinic
  • Referrals from several sources including primary
    care, neurology, and rehabilitation
  • A variety of ages, functional status abilities
    and medical diagnoses are represented
  • All have a history of falls or near falls

44
Interdisciplinary Team Approach
  • Occupational Therapist
  • Physical Therapist
  • Physician (Geriatrician)
  • Referrals as needed for other resources or
    providers

45
Methods Adaptable for All Healthcare Providers
  • Fall prevention strategies can be employed by all
    healthcare providers within the VA.
  • Key is multicomponent, interdisciplinary
    interventions.
  • Having this type of clinic is not essential.

46
Risk Factors Targeted by the Team
  • Muscle weakness
  • Mobility and balance impairments
  • Foot and footwear problems
  • Sensory and perceptive deficits
  • Cognitive impairments
  • Multiple medications
  • Postural hypotension and dizziness
  • Environmental hazards

47
Occurrence of Falls According to the Number of
Risk Factors(Tinetti, 1988)
48
Muscle Weakness
  • Evaluation
  • strength testing of the upper and lower
    extremities
  • functional tests like timed chair stands
  • Treatment
  • referral for strength training either as an
    outpatient or at home, depending on severity of
    mobility problems

49
(No Transcript)
50
Mobility and Balance Impairments
  • Mobility (gait and transfers)
  • Evaluation timed chair stands, and timed 8 foot
    walk (Short Physical Performance Battery) or Get
    Up and Go test
  • Treatment Physical Therapy for gait and transfer
    training, provision of an assistive device
  • Balance
  • Evaluation progressive static balance tests
  • (feet together, semi-tandem, and tandem)
  • Treatment referral to PT or community exercise
    programs (Tai Chi) for instruction in balance
    exercises.

51
(No Transcript)
52
(No Transcript)
53
(No Transcript)
54
Foot and Footwear Problems
  • We dare to take the patients shoes off !
  • Evaluation
  • watching gait with shoes on
  • examining shoes for wear patterns
  • examining feet without shoes
  • Treatment
  • Podiatry referral for nail care
  • orthotics/prosthetics for shoe inserts, special
    shoes or ankle-foot orthosis (AFO)

55
Sensory and Perceptive Deficits
  • Vision
  • Ask if any problems and refer as needed
  • Hearing
  • Ask if problems and refer as needed
  • Sensation/ Proprioception Problems
  • Check sensation to light touch and proprioception
  • Referral to podiatry, foot clinic

56
Cognitive Impairments
  • Screen for depression
  • Geriatric Depression Scale (GDS)
  • Work with PMD or Mental Health, treat as needed
  • Screen for dementia
  • Mini Mental State Exam (MMSE)
  • Referral to Geriatric Assessment Clinic
  • Assist family in understanding why the patient
    falls and target other interventions which may
    lower risk

57
Multiple Medications
  • Physician review of medications
  • Attempt to adjust or eliminate as able
  • Focus on those known to be associated with high
    fall risk
  • Benzodiazepines
  • Anticholinergic medications
  • Psychoactive medications

58
(No Transcript)
59
Postural Hypotension and Dizziness
  • Evaluate by taking orthostatic blood pressures on
    ALL patients
  • Check after supine for five minutes, then
    standing for one and three minutes
  • Treatment
  • Review medications and adjust as able
  • Instruct patients to change positions slowly

60
Environmental Hazards
  • Occupational Therapist reviews home environment
    with patient
  • Handouts of hazards given and discussed
  • Adaptive equipment provided as needed
  • (raised toilet seats, shower chairs, grab bars)
  • Home health can evaluate for home safety

61
(No Transcript)
62
(No Transcript)
63
Benefits of an Interdisciplinary Team Approach
  • Research shows a multicomponent approach most
    likely to be successful
  • Allows a variety of targeted interventions to be
    done simultaneously
  • Educational opportunity
  • Fun!

64
The Birmingham/Atlanta GRECC Fall Prevention and
Mobility Team
  • J. Dennis Hughes, OTR/L
  • Claire Peel, PhD, PT
  • Cynthia J. Brown, MD, MSPH

65
Thanks to the patients who allowed themselves to
be photographed
About PowerShow.com