Falls: The beginning

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Falls The beginning of the end.

• CDR Carol L. Blackwood, MD
• Naval Hospital Camp Lejeune
• Family Medicine and Geriatrics

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Falls Objectives

• Overview of incidence, mortality, and morbidity
• Evidence supporting risk factor screening
• Fall Preventative strategies.
• Medication Review
• Pharmacologic Interventions
• Cardiac or Neurologic Disorder Treatment
• Physical Interventions
• Visual Interventions
• Environmental Interventions
• Minimize Morbidity
• Treat osteoporosis
• Summon aid quickly
• Summary

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Fall A person comes to rest inadvertently on
the ground or a lower level (not associated with
LOC or trauma)
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Fall Prevalence
Morbid/Mortality Risk factor screening Fall
Preventative strategies. Medication Review
Pharm Interventions Cardiac/Neuro Tx
Physical Interventions Visual Interventions
Environ Interventions Minimize Fall Morbidity
Tx Osteoporosis Summon aid quickly Summary

• 30-40 of community dwelling, gt65yr old persons
  fall each year.
• In long term setting, 50 of all residents fall
  each year.
• Risk of death due to fall, increases with age and
  overall incidence of fall mortality is increasing!

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Morbid/Mortality Risk factor screening Fall
Preventative strategies. Medication Review
Pharm Interventions Cardiac/Neuro Tx
Physical Interventions Visual Interventions
Environ Interventions Minimize Fall Morbidity
Tx Osteoporosis Summon aid quickly Summary
Fatal Falls per 100,000 Population
Stevens, MMWR 200655(45)1221-1224
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Fatal Falls 2003/100,000 people U.S. by Race
Morbid/Mortality Risk factor screening Fall
Preventative strategies. Medication Review
Pharm Interventions Cardiac/Neuro Tx
Physical Interventions Visual Interventions
Environ Interventions Minimize Fall Morbidity
Tx Osteoporosis Summon aid quickly Summary
Stevens, MMWR 200655(45)1221-1224
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Morbid/MortalityRisk factor screeningFall
Preventative strategies. Medication Review
Pharm Interventions Cardiac/Neuro Tx
Physical Interventions Visual Interventions
Environ InterventionsMinimize Fall Morbidity
Tx Osteoporosis Summon aid quicklySummary
Falls Morbidity in Older Adults (50 and older)

• Most common cause of injury death (14,000 deaths
  in 2002)
• Most common cause of non-fatal injury (46 of
  injuries) 2.7 million in 2003.
• Women break bones more often when they fall, but
  men die from the fall more often

CDC NCIPC Injury FactBook2007
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Fall Morbidity in Older Adults (50 and older)
Morbid/Mortality Risk factor screening Fall
Preventative strategies. Medication Review
Pharm Interventions Cardiac/Neuro Tx
Physical Interventions Visual Interventions
Environ Interventions Minimize Fall Morbidity
Tx Osteoporosis Summon aid quickly Summary

• 20 to 30 of people who fall, suffer moderate to
  severe injuries such as bruises, hip fracture, or
  head trauma.
• Injury limits independent living and increase the
  risk of early death (Alexander et al. 1992
  Sterling et al. 2001).
• Falls are the most common cause of traumatic
  brain injuries, or TBI (Jager et al. 2000). In
  2000, TBI accounted for 46 of fatal falls among
  older adults (Stevens et al. 2006).

CDC Falls among older adults An overview Fact
sheet 2007
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Fall Morbidity
Morbid/Mortality Risk factor screening Fall
Preventative strategies. Medication Review
Pharm Interventions Cardiac/Neuro Tx
Physical Interventions Visual Interventions
Environ Interventions Minimize Fall Morbidity
Tx Osteoporosis Summon aid quickly Summary

• Most fractures among older adults are caused by
  falls (Bell et al. 2000).
• The most common fractures are of the spine, hip,
  forearm, leg, ankle, pelvis, upper arm, and hand
  (Scott 1990).
• Risk of serious injury from a fall is 5 times
  greater in a person 85yrs or older compared to a
  person age 65 to 74.

CDC Falls among older adults An overview Fact
sheet 2007
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Morbid/Mortality Risk factor screening Fall
Preventative strategies. Medication Review
Pharm Interventions Cardiac/Neuro Tx
Physical Interventions Visual Interventions
Environ Interventions Minimize Fall Morbidity
Tx Osteoporosis Summon aid quickly Summary
Hip Fractures per 100,000 U.S. population
Stevens, MMWR 200655(45)1221-1224
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Morbid/Mortality Risk factor screening Fall
Preventative strategies. Medication Review
Pharm Interventions Cardiac/Neuro Tx
Physical Interventions Visual Interventions
Environ Interventions Minimize Fall Morbidity
Tx Osteoporosis Summon aid quickly Summary
Incidence and Cost Comparison non-Fatal Fall
Injuries in U.S. in 2000
Stevens. Inj Prev 200612290-295
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Fall Morbidity and Cost
Morbid/Mortality Risk factor screening Fall
Preventative strategies. Medication Review
Pharm Interventions Cardiac/Neuro Tx
Physical Interventions Visual Interventions
Environ Interventions Minimize Fall Morbidity
Tx Osteoporosis Summon aid quickly Summary

• Many people who fall, even those who are not
  injured, develop a fear of falling. This fear may
  cause them to limit their activities, leading to
  reduced mobility and physical fitness, and
  increasing their actual risk of falling (Vellas
  et al. 1997).
• In 2000, direct medical costs totaled 0.2
  billion (179 million) for fatal falls and 19
  billion for nonfatal fall injuries (Stevens et
  al. 2006).

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Morbid/Mortality Risk factor screening Fall
Preventative strategies. Medication Review
Pharm Interventions Cardiac/Neuro Tx
Physical Interventions Visual Interventions
Environ Interventions Minimize Fall Morbidity
Tx Osteoporisis Summon aid quickly Summary
FALLS Volume Importance analysis American
Geriatric Society, 320 sightings within 6,051
documents!!!
of Sightings Dementia 390 Falls
320 Hearing 161 Vision 132 Driving
60
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What is the evidence?
Morbid/Mortality Risk factor screening Fall
Preventative strategies. Medication Review
Pharm Interventions Cardiac/Neuro Tx
Physical Interventions Visual Interventions
Environ Interventions Minimize Fall Morbidity
Tx Osteoporosis Summon aid quickly Summary

• Canadian Task Force on Preventative
  Healthcare-There is good evidence to support
  referral to a multi-disciplinary post fall
  assessment team (where service is available (A-I)

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Fall Prevention
Morbid/Mortality Risk factor screening Fall
Preventative strategies. Medication Review
Pharm Interventions Cardiac/Neuro Tx
Physical Interventions Visual Interventions
Environ Interventions Minimize Fall Morbidity
Tx Osteoporosis Summon aid quickly Summary

• Try to prevent fall
• Screening for risk factors
• Multi factoral assessment and targeted treatment,
  if have risk factors
• Minimize morbidity of a fall
• Bone health
• Social support systems

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American Geriatrics Society 2006 Recommendations
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(No Transcript)
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American Geriatric Society Evaluation of the
Evidence-supporting fall evaluation/treatment

• The categories of evidence for the guidelines
  were classified as followsClass I Evidence
  from At least one randomized controlled trial or
  meta-analysis of randomized controlled
  trials.Class II Evidence from at least one
  controlled study without randomization or
  evidence or evidence from at least one other type
  of quasi experimental study.Class III Evidence
  from non-experimental studies, such as
  comparative studies, correlation studies and
  case-controlled studies.Class IV Evidence from
  expert committee reports or opinions and/or
  clinical experience of respected authorities.
• The strength of the recommendations is classified
  as follows
• A. Directly based on Class I evidence.
• B. Directly based on Class II evidence or
  extrapolated recommendation from Class I evidence
  
• C. Directly based on Class III evidence or
  extrapolated recommendation from Class I or II
  evidence.
• D. Directly based on Class IV evidence or
  extrapolated recommendation from Class I, II, or
  III evidence

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Medications which contribute to Falls
Morbid/Mortality Risk factor screening Fall
Preventative strategies. Medication Review
Pharm Interventions Cardiac/Neuro Tx
Physical Interventions Visual Interventions
Environ Interventions Minimize Fall Morbidity
Tx Osteoporosis Summon aid quickly Summary
Medication Reduction Review for older persons
taking four or more medications and to those
taking psychotropic medications. (level C)
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Vitamin D
Morbid/Mortality Risk factor screening Fall
Preventative strategies. Medication Review
Pharm Interventions Cardiac/Neuro Tx
Physical Interventions Visual Interventions
Environ Interventions Minimize Fall Morbidity
Tx Osteoporosis Summon aid quickly Summary

• People who have low vit D, fall more often.
• Recommend 800-1000 IU daily.
• Common sources of Vit D
• Milk-30 IU/serving
• MVI-400 IU
• Calcium pill-200 IU

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Vit D Effect on Falls
Morbid/Mortality Risk factor screening Fall
Preventative strategies. Medication Review
Pharm Interventions Cardiac/Neuro Tx
Physical Interventions Visual Interventions
Environ Interventions Minimize Fall Morbidity
Tx Osteoporosis Summon aid quickly Summary

• Vitamin D reduced falls by 22
• 400-800 IU
• N1237
• Mean age 60
• Confidence interval (CI) 0.64-0.92
• Number needed to treat (NNT) 15
• Bischoff-Ferrari 2004 JAMA 291161999-2006
• 800 IU reduced falls by 49
• Bischoff et al. 2003 J Bone Miner Res
  18(2)343-51

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Vit D Effect on Falls
Morbid/Mortality Risk factor screening Fall
Preventative strategies. Medication Review
Pharm Interventions Cardiac/Neuro Tx
Physical Interventions Visual Interventions
Environ Interventions Minimize Fall Morbidity
Tx Osteoporosis Summon aid quickly Summary

• Doubling of vitamin D level reduced falls by 20
• Flicker et al. 2003 JAGS 51(11)1533-8
• 1 mcg alphacalcidol reduced falls in community
  elderly taking gt512 mg Ca
• Dukas et al. 2004 JAGS 52(2)230-6.
• 800 IU reduced falls by 72 compared to placebo
  in nursing homes
• Broe et al. 2007 JAGS 55234-9

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Hx suggestive of Cardiac or Neurologic Cause
Morbid/Mortality Risk factor screening Fall
Preventative strategies. Medication Review
Pharm Interventions Cardiac/Neuro Tx
Physical Interventions Visual Interventions
Environ Interventions Minimize Fall Morbidity
Tx Osteoporosis Summon aid quickly Summary

• Hypotention (treatment of postural hypotention is
  Level B)
• Arrythmia (treatment of cardiac arrythmia is
  level D)
• Other Causes- Appropriate referral for further
  evaluation

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Physical Interventions
Morbid/Mortality Risk factor screening Fall
Preventative strategies. Medication Review
Pharm Interventions Cardiac/Neuro Tx
Physical Interventions Visual Interventions
Environ Interventions Minimize Fall Morbidity
Tx Osteoporosis Summon aid quickly Summary

• Physical Training. Balance, strength, chair
  aerobics, etc. (Level B).
• Treat joint pain
• Scheduled Acetaminophen, first line
• Physical Therapy for arthritis improves mobility
  and decreases pain. (Level B)

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Vision and Falls
Morbid/Mortality Risk factor screening Fall
Preventative strategies. Medication Review
Pharm Interventions Cardiac/Neuro Tx
Physical Interventions Visual Interventions
Environ Interventions Minimize Fall Morbidity
Tx Osteoporosis Summon aid quickly Summary

• 3 fold association between poor lighting and
  falls.
• Visual impairment is directly related to falls,
  and tx reduces risk of falls (Level C).
• 4 major types of eye disease in elderly
• Cataracts
• Macular Degeneration
• Glaucoma
• Diabetic Retinopathy

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Major vision issues in Elderly
Morbid/Mortality Risk factor screening Fall
Preventative strategies. Medication Review
Pharm Interventions Cardiac/Neuro Tx
Physical Interventions Visual Interventions
Environ Interventions Minimize Fall Morbidity
Tx Osteoporosis Summon aid quickly Summary

• Cataracts
• 52 of patients 75yrs have visually significant
  cataracts
• Surgery is main modality of treatment
• 92 of patients report improved visual function
  after surgery.
• Macular Degeneration
• Dry form slowly progressive, less visual impact
• Wet form more acute, central vision loss
• Wet form can be slowed by ophthalmologist.
• 25 of patients 75yrs have dry macular
  degeneration, and 5 have wet.

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Morbid/Mortality Risk factor screening Fall
Preventative strategies. Medication Review
Pharm Interventions Cardiac/Neuro Tx
Physical Interventions Visual Interventions
Environ Interventions Minimize Fall Morbidity
Tx Osteoporosis Summon aid quickly Summary
Falls and Health Status in Elderly Women
following First eye Cataract Surgery
Harwood. B J Ophth 20058953-59.
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Major vision issues in Elderly
Morbid/Mortality Risk factor screening Fall
Preventative strategies. Medication Review
Pharm Interventions Cardiac/Neuro Tx
Physical Interventions Visual Interventions
Environ Interventions Minimize Fall Morbidity
Tx Osteoporosis Summon aid quickly Summary

• Glaucoma
• Usually chronic
• Bilateral, but asymmetric
• Primary open angle most common in elderly
• More common in blacks, increases in all races
  with age
• Lowering intraocular pressure, lessens visual
  loss
• Diabetic Retinopathy
• Incidence increases with duration of systemic
  disease
• Hypertention and hyperlipidemia can worsen
  diabetic retinopathy
• Laser treatment can reduce visual loss

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Environmental issues
Morbid/Mortality Risk factor screening Fall
Preventative strategies. Medication Review
Pharm Interventions Cardiac/Neuro Tx
Physical Interventions Visual Interventions
Environ Interventions Minimize Fall Morbidity
Tx Osteoporosis Summon aid quickly Summary

• Slippery surfaces, uneven floors, poor lighting,
  loose rugs, unstable furniture, and objects on
  floors.
• Remove tripping hazards and use non-slip mats in
  the bathtub and on shower floors.
• Have grab bars put in next to the toilet and in
  the tub or shower, and have
• Handrails put in on both sides of all stairs.
  (Level C)

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Reduce morbidity of a Fall
Morbid/Mortality Risk factor screening Fall
Preventative strategies. Medication Review
Pharm Interventions Cardiac/Neuro Tx
Physical Interventions Visual Interventions
Environ Interventions Minimize Fall Morbidity
Tx Osteoporosis Summon aid quickly Summary

• Treat Osteoporosis
• Minimize on the ground time.
• Hip protectors (class I evidence)

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Osteoporosis Risk Factors
Morbid/Mortality Risk factor screening Fall
Preventative strategies. Medication Review
Pharm Interventions Cardiac/Neuro Tx
Physical Interventions Visual Interventions
Environ Interventions Minimize Fall Morbidity
Tx Osteoporosis Summon aid quickly Summary

• Thin, white or Asian race
• Hx of unexplained bone fracture in past
• Caused by a pre-existing condition (secondary
  Dx).
• Chronic steroid use
• Excessive alcohol or tobacco use
• Treatment with dutaseride or finasteride for
  large prostate.
• Inflammatory bowel disease (Colitis, Crohns
  Disease, hypogonadism (low testosterone),
  hyper-parathyroid
• Lifestyle choices-physical inactivity

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Osteoporosis-News Flash!
Morbid/Mortality Risk factor screening Fall
Preventative strategies. Medication Review
Pharm Interventions Cardiac/Neuro Tx
Physical Interventions Visual Interventions
Environ Interventions Minimize Fall Morbidity
Tx Osteoporosis Summon aid quickly Summary

• Not just a womans disease!
• In 2004, 10 million Americans had osteoporosis
  (20 of them MEN!)
• 33 of hip fractures occur in men

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Male Osteoporosis
Morbid/Mortality Risk factor screening Fall
Preventative strategies. Medication Review
Pharm Interventions Cardiac/Neuro Tx
Physical Interventions Visual Interventions
Environ Interventions Minimize Fall Morbidity
Tx Osteoporosis Summon aid quickly Summary

• In 2004, 2 million of the total 10 million people
  with osteoporosis were male!!
• 1/5 to 1/3 of all hip fractures occur in males.
• Men are more likely to die or have chronic
  disability after a hip fracture.
• 24 of all people die within 1 yr of hip
  fracture!
• Men typically have either secondary (60) or
  idiopathic (40) osteoporosis.

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Osteoporosis Prevention
Morbid/Mortality Risk factor screening Fall
Preventative strategies. Medication Review
Pharm Interventions Cardiac/Neuro Tx
Physical Interventions Visual Interventions
Environ Interventions Minimize Fall Morbidity
Tx Osteoporosis Summon aid quickly Summary

• Calcium 1200-1500mg day (divided doses).
• Calcium citrate does not require low pH to be
  absorbed (use with patients taking PPI).
• Regular weight bearing exercise.
• Vitamin D 800iu or more a day.

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Vit D Effect on Fracture
Morbid/Mortality Risk factor screening Fall
Preventative strategies. Medication Review
Pharm Interventions Cardiac/Neuro Tx
Physical Interventions Visual Interventions
Environ Interventions Minimize Fall Morbidity
Tx Osteoporosis Summon aid quickly Summary

• Oral Vitamin D 700-800 IU daily reduces hip 26
  and non-vertebral fractures 23 in elderly gt60.
• N 5572
• CI (0.61-0.88) and (0.68-0.87)
• NNT 45
• No Fx reduction in group taking 400 IU
• Bischoff-Ferrari HA, et al. 2004 JAMA
  2911999-2006

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Vit D Effect on Fracture
Morbid/Mortality Risk factor screening Fall
Preventative strategies. Medication Review
Pharm Interventions Cardiac/Neuro Tx
Physical Interventions Visual Interventions
Environ Interventions Minimize Fall Morbidity
Tx Osteoporosis Summon aid quickly Summary

• Hip fracture reduction by 43 in elderly avg. age
  83
• Chapuy et al. NEJM 1992 327(23)1637-1642

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Help Ive fallen and cant get up
Morbid/Mortality Risk factor screening Fall
Preventative strategies. Medication Review
Pharm Interventions Cardiac/Neuro Tx
Physical Interventions Visual Interventions
Environ Interventions Minimize Fall Morbidity
Tx Osteoporosis Summon aid quickly Summary

• Of people who fall, only about 50 are able to
  get without help.
• Those who survive a long lie tend to have
  lasting declines in functional status.

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Social Support Systems
Morbid/Mortality Risk factor screening Fall
Preventative strategies. Medication Review
Pharm Interventions Cardiac/Neuro Tx
Physical Interventions Visual Interventions
Environ Interventions Minimize Fall Morbidity
Tx Osteoporosis Summon aid quickly Summary

• Bring aid more quickly in the case of a fall.
• Personal Alarm devices
• Institutional or building alarm systems
• Daily phone checks
• Assisted/Senior living apartments

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Falls Summary
Morbid/Mortality Risk factor screening Fall
Preventative strategies. Medication Review
Pharm Interventions Cardiac/Neuro Tx
Physical Interventions Visual Interventions
Environ Interventions Minimize Fall Morbidity
Tx Osteoporosis Summon aid quickly Summary

• A significant cause of morbidity and mortality.
• Evidence supports screening and multi factorial,
  targeted interventions.
• Medication review
• Strength Training
• Vision enhancement
• Environmental safety
• Tx Osteoporosis and minimize on the ground time