Current Research on Falls Prevention

1
Current Research on Falls Prevention

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

2
Scope of the Problem

• In 1999, accidents were the 8th 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.

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Falls in Wisconsin

• In 2002, there were 22,500 hospitalizations in
  Wisconsin for fall-related injuries.
• The states death rate due to falls has increased
  20 from 1992 to 2002
• The states death rate due to falls is almost
  twice the national average.

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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

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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

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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.

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Components of Postural Control
Sensory Input
Central Processing
Effector Output
Cognition CNS pathways Medications
Visual Vestibular Proprioceptive
Musculoskeletal Strength Biomechanical
Environ-ment
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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, Parkinsons, stroke

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Risk Factors are Additive Tinetti, NEJM, 1988
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2001 GuidelinesAmerican 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.

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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

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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

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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

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Randomized Trials of Group Exercise

• Outcome
• Risk 47
• Rate 22
• Rate 40
• Rate 18
• Risk 25 NS

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

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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

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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

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Post-hospital falls prevention - rationale

Musculoskeletal Output
Sensory
CNS Delirium
Environ-ment
Systemic Effects of Illness
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Acute Changes in Postural Control

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

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

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Risk of Falls after Hospitalization Mahoney,
JAGS, 1994

• Older adults discharged from St. Marys 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)

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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

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Falls After Hospital Discharge Mahoney, Arch Int
Med, 2000 - 311 older adults receiving home
nursing after discharge
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Rehospitalizations Due to Fall Injuries

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

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Risk Factors for Falling Pre-Hospital

• Pre-Hospital
• Prior dependence in ADLs
• Used standard walker
• gt 2 falls in yr prior
• hospitalizations
• in year prior

• Odds Ratio
• 2.3
• 3.2
• 1.7
• 1.1

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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

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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

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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

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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

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Results

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

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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

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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

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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.

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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.

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Methods

• Inclusion Criteria
• - Residing in Kenosha County, WI, age gt65.
• - 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

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

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Baseline Characteristics (n349)
DOMAIN MEASUREMENT BASELINE
Demographics Age 80.0 7.5
Demographics Female 78.5
Falls No. falls in past year 2.4 2.5
Health status Emergency Room visit(s) past 4 months 30.7
Mobility Assistive device use indoors 35.9
Function Barthel Index 88.1 16.6
Function No. of independent Instrumental Activities of Daily Living out of 7, (IADLs) 4.8 2.2
Cognition Mini-Mental State Exam (max 30) 27.1 4.4
Meds No. of prescription medications 5.7 3.3
Health Behaviors Any alcohol intake 37.3
Health Behaviors Frequency of exercise (days per week) , () lt1 34.7
Health Behaviors Frequency of exercise (days per week) , () 1-3 21.2
Health Behaviors Frequency of exercise (days per week) , () 4-7 44.1
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Differences in 2 fallers versus single fallers

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

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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.

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Enrollment by Falls History

• Comparison 2 falls past 12 mos. (n189) vs. 1
  fall in past 24 mos. (n160)
• Two-sample t-tests for continuous variables and
  Pearsons chi-square tests for categorical
  variables.

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Comparison of Baseline Characteristics
DOMAIN MEASUREMENT MEASUREMENT 2 FALLS PAST YEAR N189 1 FALL PAST 1-2 YEARS N160 P-VALUE
Demographics Age Age 79.9 80.0 0.94
Demographics Female Female 73.5 84.4 0.014
Falls No. falls in past yr No. falls in past yr 3.7 0.8 lt0.0001
Health status Hx of hip fx , Hx of hip fx , 11.2 7.6 0.25
Health status Hx of CVA , Hx of CVA , 31.2 18.8 0.008
Health status Health rated fair/poor , Health rated fair/poor , 38.1 21.3 0.007
Health status ER visits in past 4 mos, ER visits in past 4 mos, 38.1 21.9 0.001
Mobility Assistive device use indoors , Assistive device use indoors , 42.3 28.1 0.006
Mobility Walk outside, Without help 60.9 83.8 lt0.0001
Mobility Walk outside, Some help 26.5 11.9 lt0.0001
Mobility Walk outside, Unable 12.7 4.4 lt0.0001
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Comparison of Baseline Characteristics
DOMAIN MEASUREMENT MEASUREMENT 2 FALLS PAST 12 MOS N189 1 FALL PAST 24 MOS. WITH INJURY OR GAIT/BALANCE PROBLEMS N160 P-VALUE
Function No. IADLs No. IADLs 4.3 5.4 lt0.0001
Function Barthel Index score Barthel Index score 85.1 91.6 0.0002
Cognition MMSE score MMSE score 26.6 27.6 0.028
Depression GDS scpre GDS scpre 3.4 2.5 0.004
Medication No. prescription medications No. prescription medications 6.2 5. 0.0007
Medication No. Psychotropics No. Psychotropics 0.3 0.1 0.018
Vison Able to watch TV, Able to watch TV, 91.5 96.9 0.037
Health Behaviors Any intake alcohol , Any intake alcohol , 34.4 40.6 0.29
Health Behaviors Exercise program , Exercise program , 18 18.1 0.97
Health Behaviors Frequency of exercise, times per week , lt1 36 33.1 0.70
Health Behaviors Frequency of exercise, times per week , 1-3 19.5 23.1 0.70
Health Behaviors Frequency of exercise, times per week , 4-7 44.4 43.8 0.70
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Barthel Comparison
SELECTED BARTHEL ACTIVITY lower score indicating more impairment MEAN BARTHEL SCORE MEAN BARTHEL SCORE P-VALUE
SELECTED BARTHEL ACTIVITY lower score indicating more impairment 2 FALLS PAST YEAR 1 FALL PAST 1-2 YEARS P-VALUE
Bathing Self 3.6 4.4 0.0002
Dressing 8.8 9.3 0.036
Toileting 9.6 9.9 0.019
Transferrring 14.1 14.7 0.014
Walking on level surface 11.7 13.3 0.001
Climbing stairs 7.1 8.5 0.0002
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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.

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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

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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.

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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.

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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.

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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.

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Randomization
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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.

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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

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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

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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

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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.

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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

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Strategies for Recruitment

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

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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