7/22/2015 OSTEOPOROSIS NEW INSIGHTS IN RESEARCH, DIAGNOSIS,AND CLINICAL CARE School of Medicine Division of Geriatrics The Other Half of the Fracture Equation: Fall Prevention and Edgar Pierluissi, MD Management Medical Director Acute Care for Elders Unit San Francisco General Hospital and Trauma Center epierluissi@medsfgh.ucsf.edu July 23, 2015 SECTION HEADING Presenter Disclosure Information Edgar Pierluissi • No relevant disclosures School of Medicine 2 1
7/22/2015 SECTION HEADING Presentation Outline • Case presentation • Incidence and Consequences • Risk factors • Screening and Evaluation • Prevention • Summary School of Medicine 3 SECTION HEADING 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. School of Medicine 4 2
7/22/2015 • Her falls have resulted in : – 1997: hip fracture – 2003: patellar fracture – 2006: metatarsal fracture – 2006: hip fracture – 2014: displaced rib fractures. She also has evidence of an age indeterminate L2 vertebral fracture. • She was treated with alendronate from 2003 to 2010. School of Medicine 5 • 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. School of Medicine 6 3
7/22/2015 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 School of Medicine Vitamin D3 1000 IU daily 7 SECTION HEADING Presentation Outline • Case presentation • Incidence and Consequences • Risk factors • Screening and Evaluation • Prevention • Summary School of Medicine 8 4
7/22/2015 SECTION HEADING Prevalence of Falls Falls are Common • ~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 NEJM 348:42 ‐ 49,2003 Clin Ger Med 18:141 ‐ 158,2002 School of Medicine Am J Prev Med 2012;43(1):59–62 9 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) School of Medicine Adv Data 392; 2007 Fall Injury Episodes Among Noninstitutionalized Older Adults: US, 2001–2003 10 5
7/22/2015 65+ Number Going to ED/Getting Hospitalized for Falls is Increasing 2.5 Millions 2 To Emergency Department 1.5 1 0.5 Hospitalized 0 2001 2003 2005 2007 2009 2011 2013 School of Medicine http://www.cdc.gov/injury/wisqars/ Accessed April 24, 2014 11 Fractures Due to Fall in Older Women ALL FRACTURES WRIST PROXIMAL HUMERUS ELBOW HIP PATELLA ANKLE FOOT/TOES PELVIS FACE HAND/FINGER TIBIA/FIBULA RIB School of Medicine 0 10 20 30 40 50 60 70 80 90 Nevitt et al. 1997 Percent 12 6
7/22/2015 Death from Falls 65+ 30000 25000 Number of Deaths 20000 15000 10000 5000 0 1999 2001 2003 2005 2007 2009 2011 2013 School of Medicine http://www.cdc.gov/injury/wisqars/ Accessed April 24, 2014 13 Costs – Direct medical costs: 30 billion dollars in 2010 – Indirect and direct est 68B by 2020 School of Medicine Inj Prev 2006; 12(5): 290-5 14 7
7/22/2015 Summary • Falls are common • Falls affect patient function and are a major mechanism of injury. School of Medicine 15 SECTION HEADING Presentation Outline • Case presentation • Incidence and Consequences • Risk factors • Screening and Evaluation • Prevention • Summary School of Medicine 16 8
7/22/2015 Independent Risk Factors for Falling Among Community-Living Older Adults Risk factor No. of Studies RR OR Significant 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 JAMA 2010;303:258 Cognitive impairment 3 2.8 1.9-2.1 School of Medicine Pain 2 1.7 17 Risk factors for future falls 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 2-4 activities of daily living Assess cognition 4-17 School of Medicine Will My Patient Fall? JAMA. 2007;297:77-86 18 9
7/22/2015 Using LRs • 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% School of Medicine 19 Novel risk factors • Hypoxia during sleep – Men with ≥ 10% of sleep time with SaO2 ≤ 90% had RR of 1.25, CI = 1.04-1.51 for one or more falls RR of 1.43, CI = 1.06-1.92 for two or more falls c/t men with ≤ 10% of sleep time with SaO2 ≤ 90% JAGS 62:1853, 2014. School of Medicine 20 10
7/22/2015 SECTION HEADING Presentation Outline • Case presentation • Incidence and Consequences • Risk factors • Screening and Evaluation • Prevention • Summary School of Medicine 21 Screening Guidelines for Fall Prevention • 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 • CDC Stopping Elderly Accidents, Death, and Injuries – July 2015 School of Medicine 22 11
7/22/2015 AGS/BGS Guideline Older person encounters health care provider 2 or more falls last year Screen for risk of falling Presents with acute fall Difficulty with walking or balance No Yes Single fall in past year? Falls Evaluation No Yes Yes Abnormalities in gait or unsteadiness? No Reassess annually School of Medicine 23 American Academy of Neurology Inquire about falls in Review risk factors for falling the past year Neurological: stroke AND dementia gait/mobility problem parkinsonism peripheral neuropathy assistive device LE sensorimotor loss General: (not rated) age >65 vision deficit arthritis, arthralgia depression polypharmacy restricted ADLs School of Medicine Neurology 2008;70;473-479 24 12
7/22/2015 • If A or B positive: Falls Evaluation School of Medicine 25 SECTION HEADING Slide Title. Arial Bold, 32pt Ask patients ≥ 75 years old about falls and balance or gait difficulties. No fall and no Observe getting into and out of a Recommend exercise balance or gait chair and walking. program with balance and difficulties strength training One fall and no Two or more falls balance or gait or balance or gait difficulties difficulties Assessment of predisposing and precipitating factors, followed by interventions suggested by the results of detailed assessment. A Falls Evaluation School of Medicine N Engl J Med.348 (1) 42. 2003 26 13
7/22/2015 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. Am J Prev Med 2012;43(1):59–62 School of Medicine 27 Other screening tests • Standing unassisted • Timed Up and Go • 325 community • Time to stand from elders, 60 or older chair, walk 3m, and sit back down • Time to stand from • Cutoff 12 sec had sitting, unaided, without use of arms sensitivity of 83% and specificity of 93% • Unable or >2 sec had an OR of 3.0 Nevitt, JAMA 1989 Wrisley, Phys Ther 2010 School of Medicine 28 14
7/22/2015 http://www.cdc.gov/injury/STEADI School of Medicine 29 School of Medicine 30 15
7/22/2015 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 School of Medicine 31 Falls Evaluation • Falls history and circumstances • Assessment of: – balance and gait – LE strength, sensation, coordination – perceived functional ability and fear relating to falling – visual impairment – cognitive impairment – home hazards – footwear and foot problems • Cardiovascular examination including orthostasis • Medication review NICE Clinical Guideline, Assessment and prevention of falls in older people 2004 JAMA The patient who falls. 303 (3) 2010 School of Medicine 32 16
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