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7/25/2014 SECTION HEADING Presenter Disclosure Information Edgar Pierluissi OSTEOPOROSIS NEW INSIGHTS IN RESEARCH, DIAGNOSIS,AND CLINICAL CARE No relevant disclosures School of Medicine Division of Geriatrics The Other Half of the

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7/25/2014 1 The Other Half of the Fracture Equation: Fall Prevention and Management

OSTEOPOROSIS NEW INSIGHTS IN RESEARCH, DIAGNOSIS,AND CLINICAL CARE

Edgar Pierluissi, MD

Medical Director Acute Care for Elders Unit San Francisco General Hospital and Trauma Center

July 24, 2014

School of Medicine Division of Geriatrics

epierluissi@medsfgh.ucsf.edu

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Presenter Disclosure Information

  • No relevant disclosures

Edgar Pierluissi

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Presentation Outline

  • Case presentation
  • Prevalence and Consequences
  • Risk factors
  • Screening
  • Prevention
  • Summary

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Case presentation

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  • Ms. L is a 69 y/o woman with a history of

HIV (CD4-750), chronic hepatitis C, COPD, Bipolar affective disorder, tobacco and cocaine abuse, hypothyroidism, and osteoporosis, complicated by multiple falls and fractures.

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  • Her falls have resulted in :

– 1997: hip fracture – 2003 a patellar fracture in 2003 – 2006 a metatarsal fracture bone in April – 2006 hip fracture in November 2006 – 2014 slipped on a bath mat, with displaced rib

  • fractures. She also has evidence of an age

indeterminate L2 vertebral fracture.

  • She was treated with alendronate from

2003 to 2010.

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  • She has been referred to and completed

evaluations and rehabilitation with PT and OT, both at home and during several SNF

  • stays. She has had home safety

evaluations, and has a bathroom equipped with grab bars and shower rails.

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Medications:

Abacavir-lamivudine 600-300 mg daily Efavirenz 600 mg daily Ipratropium/albuterol 2 puffs BID Advair 1 puff BID Aspirin 81 g daily Divalproex 125 mg BID Doxepin 10 mg qhs Duloxetine 60 mg PO daily Olanzapine 2.5 mg qhs Ferrous sulfate 325 mg daily Synthroid 50 mcg daily MVI Pravastatin 80 mg qhs Senna/Docusate Calcium gluconate 500 mg PO BID Vitamin D3 1000 IU daily

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Presentation Outline

  • Case presentation
  • Prevalence and Consequences of Falls
  • Risk factors
  • Screening
  • Prevention
  • Summary

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Prevalence of Falls

  • ~1/3 of those over 65 will fall in the next year
  • ~1/2 of those over 80 will fall in the next year
  • In 2010, ~7 million Medicare beneficiaries fell

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NEJM 348:42-49,2003 Clin Ger Med 18:141-158,2002 Am J Prev Med 2012;43(1):59–62

Falls are Common

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Consequences

  • 1/3 fallers with injuries reported needing help with

ADLs as result of fall injury

  • 1/2 of these expected to need help with ADLs for at

least six months

  • ~10% result in a major injury (fracture, TBI, serious

soft tissue injury)

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Adv Data 392; 2007 Fall Injury Episodes Among Noninstitutionalized Older Adults: US, 2001–2003

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Number Going to ED/Getting Hospitalized for Falls is Increasing

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0.5 1 1.5 2 2.5 2001 2003 2005 2007 2009 2011

Millions

To Emergency Department Hospitalized http://www.cdc.gov/injury/wisqars/ Accessed April 24, 2014

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Death from Falls 65+

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http://www.cdc.gov/injury/wisqars/ Accessed April 24, 2014 5000 10000 15000 20000 25000 1999 2001 2003 2005 2007 2009 Number of Deaths

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Fractures Due to Fall in Older Women

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ALL FRACTURES WRIST PROXIMAL HUMERUS ELBOW HIP PATELLA ANKLE FOOT/TOES PELVIS FACE HAND/FINGER TIBIA/FIBULA RIB 10 20 30 40 50 60 70 80 90

Percent Nevitt et al. 1997

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Consequences of Falls

  • About one out of five hip fracture

patients dies within a year of their injury.

  • About one in four adults who lived

independently before their hip fracture needs to stay in a nursing home for at least a year after their injury.

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Mortality, disability, and nursing home use for persons with and without hip fracture: a population-based study. JAGS 2002;50:1644 Recovery from hip fracture in eight areas of function. J Geront: Med Sci 2000;55A(9):M498

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Consequences of falls

  • Fear of falling

– ~1/3 without FOF before falling will develop FOF after falling – FOF associated with

  • ↓ physical and social acvity
  • ↓ self-reported health
  • ↑ depression symptoms
  • ↑ risk of falling

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Age and Ageing 2008; 37: 19–24

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Costs – Direct medical costs: 30 billion dollars in 2010 – Indirect and direct est 68B by 2020

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Inj Prev 2006; 12(5): 290-5

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Fallers unlikely to discuss falls

  • Less than half of Medicare beneficiaries who fall

discuss falls with a healthcare provider (women>men).

  • Only a third to a quarter who have fallen, discuss fall

prevention strategies.

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Am J Prev Med 2012;43(1):59–62

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Summary

  • Falls are common
  • Falls affect patient function and are a

major mechanism of injury.

  • Patients report infrequently discussing

falls and falls prevention with providers.

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Presentation Outline

  • Case presentation
  • Prevalence and Consequences
  • Risk factors for falls
  • Screening
  • Prevention
  • Summary

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Independent Risk Factors for Falling Among Community-Living Older Adults Risk factor

  • No. of Studies

Significant RR OR

Previous falls

16 1.9-6.6 1.5-6.7

Balance impairment

15 1.2-2.4 1.8-3.5

Decreased muscle strength

9 2.2-2.6 1.2-1.9

Visual impairment

8 1.5-2.3 1.7-2.3

Meds: >4 or psychoactive

8 1.1-2.4 1.7-2.7

Gait impairment

7 1.2-2.2 2.7

Depression

6 1.5-2.8 1.9-2.9

Dizziness or orthostasis

5 2.0 1.5-3.1

ADL disabilities

5 1.5-6.2 1.7-2.5

Age >80

4 1.1-1.3 1.1

Female

3 2.1-3.9 2.3

Low BMI

3 1.5-1.8 3.1

Urinary Incontinence

3 1.3-1.8

Cognitive impairment

3 2.8 1.9-2.1

Pain

2 1.7

JAMA 2010;303:258

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Risk factors for future falls

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Will My Patient Fall? JAMA. 2007;297:77-86

Risk factor Likelihood Ratio Previous fall in last year 2.8-3.8 Orthostatic hypotension

  • Visual acuity

~2 Gait and Balance 2 Medications 1.7 Assess basic and instrumental activities of daily living 2-4 Assess cognition 4-17

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  • Ex: Patient over 65
  • Pre-test probability 33%
  • Odds of falling in the next year 1:2

Have they fallen in the previous year?

  • Previous fall has LR of ~3
  • Post test fall odds = LR x pre-test falls odds

= 3 x 1:2 = 3:2

  • Post test probability 60%

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Presentation Outline

  • Case presentation
  • Prevalence and Consequences of Falls
  • Risk factors
  • Screening
  • Prevention
  • Summary

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Screening Guidelines for Fall Prevention

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  • Guideline for the Prevention of Falls in Older Persons

– American Geriatrics Society – British Geriatrics Society – American Academy of Orthopaedic Surgeons

JAGS 49:664–672, 2001, updated 2010

  • Practice Parameter: Assessing patients in a

neurology practice for risk of falls

– American Academy of Neurology

Neurology 2008;70;473-479

  • Tinetti, ME N Engl J Med.348 (1) 42. 2003
  • JAMA. 2010;303(3):258-266
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Older person encounters health care provider Single fall in past year? Falls Evaluation 2 or more falls last year Presents with acute fall Difficulty with walking or balance Screen for risk of falling Abnormalities in gait

  • r unsteadiness?

No Yes Yes Yes

Reassess annually

No No

AGS/BGS Guideline

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American Academy of Neurology

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  • A. Inquire about falls

in the past year (Level A) AND

  • B. Review history for risk factors

for falling Neurological: (Levels A & B) stroke dementia gait/mobility problem parkinsonism peripheral neuropathy assistive device LE sensorimotor loss Neurology 2008;70;473-479

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  • If A or B positive:

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Falls Evaluation

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Slide Title. Arial Bold, 32pt

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Ask patients ≥75 years old about falls and balance or gait difficulties. Observe getting into and out of a chair and walking. Recommend exercise program with balance and strength training No fall and no balance or gait difficulties Two or more falls

  • r balance or gait

difficulties One fall and no balance or gait difficulties Assessment of predisposing and precipitating factors, followed by interventions suggested by the results of detailed assessment. A Falls Evaluation

N Engl J Med.348 (1) 42. 2003

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Other screening tests

  • Standing unassisted
  • 325 community

elders, 60 or older

  • Time to stand from

sitting, unaided, without use of arms

  • Unable or >2 sec had

an OR of 3.0

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  • Timed Up and Go
  • Time to stand from

chair, walk 3m, and sit back down

  • Cutoff 12 sec had

sensitivity of 83% and specificity of 93%

Nevitt, JAMA 1989 Wrisley, Phys Ther 2010

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Screening

  • Ask about falls in the prior year
  • Observe for gait or balance problems in getting

up from chair

  • If yes or problems ==>Falls Evaluation

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Falls Evaluation

  • Falls history and circumstances
  • Assessment of:

– gait, balance and mobility, and muscle weakness – perceived functional ability and fear relating to falling – visual impairment – cognitive impairment – home hazards – footwear and foot problems

  • Cardiovascular examination including orthostasis
  • Medication review

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NICE Clinical Guideline, Assessment and prevention of falls in older people 2004 JAMA The patient who falls. 303 (3) 2010

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Physical exam pearls

  • Difficulty getting up without arms suggests proximal

muscle weakness

  • Difficulty with gait initiation suggests fronto-

subcortical disorders such as Parkinson disease or normal-pressure hydrocephalus (NPH)

  • Worse performance with eyes closed than open

suggests peripheral neuropathy or vestibular problem

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Medications

  • Benzodiazepines
  • Anti-depressants
  • Anti-psychotics
  • Anti-epileptics anti-hypertensives*
  • Polypharmacy (4 or more or 14% higher

risk for each med added above 4)

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J Gerontol A Biol Sci Med Sci. 2007;62:1172

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Presentation Outline

  • Case presentation
  • Incidence and Consequences
  • Risk factors
  • Screening
  • Prevention
  • Summary

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Independent Risk Factors for Falling Among Community-Living Older Adults Risk factor

  • No. of Studies

Significant RR OR

Previous falls

16 1.9-6.6 1.5-6.7

Balance impairment

15 1.2-2.4 1.8-3.5

Decreased muscle strength

9 2.2-2.6 1.2-1.9

Visual impairment

8 1.5-2.3 1.7-2.3

Meds: >4 or psychoactive

8 1.1-2.4 1.7-2.7

Gait impairment

7 1.2-2.2 2.7

Depression

6 1.5-2.8 1.9-2.9

Dizziness or orthostasis

5 2.0 1.5-3.1

ADL disabilities

5 1.5-6.2 1.7-2.5

Age >80

4 1.1-1.3 1.1

Female

3 2.1-3.9 2.3

Low BMI

3 1.5-1.8 3.1

Urinary Incontinence

3 1.3-1.8

Cognitive impairment

3 2.8 1.9-2.1

Pain

2 1.7

JAMA 2010;303:258

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Previous falls Age Gender BMI ADL Disabilities Medications Pain Dizziness or orthostasis Balance Strength Vision Gait Impairment Depression Urinary incontinence Cognitive impairment Things you can’t change Things you probably can change Things you might be able to change

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Effective Interventions

  • Exercise: ↓ # falls and #fallers and risk for fracture

– Multiple component group exercise – Individually prescribed, multiple component, home-based program – Tai Chi group exercise

Gillespie et al Cochrane 2012

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Effective Interventions

  • Multifactorial risk factor program (↓ #falls)
  • Home hazard assessment & modification in

higher risk in those with visual impairment and high risk of falling (↓ # falls and #fallers)

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Effective Interventions

  • Medications: (↓ # falls) Gradual withdrawal of

psychotropic medication; educational program for 1°care MDs

  • Cardiac pacing for fallers with cardioinhibitory

carotid sinus hypersensitivity (↓ #falls)

  • Expedited cataract surgery for first eye(↓ #falls)

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Gillespie et al Cochrane 2012

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Interventions that are Ineffective

  • Vitamin D with or without calcium in those with

adequate Vitamin D levels

  • Home hazard modification in those without fall

history

  • Hormone replacement therapy
  • Correction of visual deficiency (alone)
  • Patient education or cognitive behavioral training

Gillespie et al Cochrane 2012

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What about Vitamin D supplementation?

  • IOM 2009 “Supplemental vitamin D in a dose of 700-

1000 IU a day reduced the risk of falling among older individuals by 19%...”

  • IOM 2011 “…no significant reduction in fall risk related

to vitamin D intake or achieved level in blood.”

  • USPSTF 2012 recommends exercise or physical

therapy and vitamin D supplementation to prevent falls in community-dwelling adults aged 65 years or older who are at increased risk for falls.

  • AGS 2013 “Clinicians are strongly advised to

recommend vitamin D supplementation of at least 1,000 international units (IU)/d, …to reduce the risk of fractures and falls.”

  • BMJ 2014 “In pooled analyses, supplementation with

vitamin D, with or without calcium, does not reduce falls by 15% or more.”

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What I Recommend

  • Offer cholecalciferol to all older adults at risk for

falls.

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Presentation Outline

  • Case presentation
  • Incidence and Consequences
  • Risk factors
  • Screening
  • Prevention and management
  • Summary

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  • Falls are common in older adults.
  • Falls precipitate most fractures in older adults.
  • Falls can be prevented.
  • Ask older adults about falls in the last year and
  • bserve gait and balance.
  • Refer patients at risk for future falls to effective fall

prevention approaches.

Falls-Summary

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Case Presentation

  • Ms. L is a 69 y/o woman with a history of HIV

(CD4-750), chronic hepatitis C, COPD, Bipolar affective disorder, tobacco and cocaine abuse, hypothyroidism, and osteoporosis, complicated by multiple falls and fractures.

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  • Offer counseling for cocaine use
  • Medication review with a focus on

psychotropic medication reduction

  • Exercise, including balance and strength

training

  • Repeat home safety evaluation and

evaluation for assistive device

Case Presentation - Our recommendations

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Medications:

Abacavir-lamivudine 600-300 mg daily Efavirenz 600 mg daily Ipratropium/albuterol 2 puffs BID Advair 1 puff BID Aspirin 81 g daily Divalproex 125 mg BID Doxepin 10 mg qhs Duloxetine 60 mg PO daily Olanzapine 2.5 mg qhs Ferrous sulfate 325 mg daily Synthroid 50 mcg daily MVI Pravastatin 80 mg qhs Senna/Docusate Calcium gluconate 500 mg PO BID Vitamin D3 1000 IU daily

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What Questions Do You Have?