Falling among older adults: Research from prediction and

prevention to practice and policy

University of North Carolina

April, 2010

Mary Tinetti MD

Falling…

Falls among older adults: research from prediction to policy

• First phase: acquiring the evidence

• Second phase: translating evidence into practice and policy

Early 1980s

• Falls considered inevitable part of aging

– Accidens: to happen, chance event

• Little was known about fall risk

• Nothing was known about prevention

• Not a focus of investigation

…T. Franklin Williams

First phase: Acquiring the evidence

• Epidemiology– Prevalence (of falls and consequences)– Prediction

• Clinical trial– Effective prevention strategies– Mechanisms of effect

Falls in the community: 1985 –1990

• #1: Substudy New Haven EPESE (N=350)

• Representative sample of persons 75+

• Interview and exam, monthly phone calls

• 1-year follow-up

• # 2: Project Safety

• Probability sample of 1103 persons

• Yearly interview / exam, daily calendars

• 3-year followup

Epidemiology: Frequency

• Community setting: – 30% of adults 70+ fall each year– with age (50% by 80+)

New Engl

J Med, 1988

Epidemiology: Morbidity

• 3 year f/u of Project Safety cohort

• 10% of falls → serious injury

(fracture, TBI, soft tissue )

• 8% persons 70+ → ED after fall; – ½ were admitted to hospital

J Am Geriatr Soc, 1995

Epidemiology: Morbidity

• ~1/2 of fallers unable to get up JAMA, 1995

• 1 in 5 fallers acknowledged avoiding activities because of fear of

fallingJ Gerontol,

1994

•

Extra $24,000/person

Med Care, 1998

Morbidity: Functional decline

• Non-injurious and injurious falls * ↓ in basic and instrumental ADLs, social

and physical activities

*Independent of demographic, medical, cognitive, and psychosocial factors

J Gerontol, 1998

Morbidity: Long term nursing home stay

* Independent of demographic, psychosocial, medical, functional, and cognitive status

1 fall w.o. injury

3.1 (1.9, 4.9)

2 falls w.o. injury

5.5 (2.1,14.2)

1+ fall with injury 10.2 (5.8,17.9)

New Engl J Med 1997

Epidemiology: Interpretation of study results

• Falls are common

• Falls are morbid

• Falls are $$$$$$$

Epidemiology: Predict risk

Fall prediction: Geriatric syndrome

Health condition that:– Results from accumulated effect of

multiple impairments / diseases

– Occurs when older adults who are predisposed are exposed to

precipitating challenges JAMA, 1995

Epidemiology: Predict risk

• Identify

– Predisposing risk factors: chronic health conditions that compromise stability or risk of injury

– Precipitating risk factors: transient factors within individual or environment that risk at time of event

Predisposing risk factors (EPESE)*

• ↓ Strength

• Impaired balance, gait

• Vision impairment

• Psychoactive meds

↑ risk ≥ 2-fold

• ↓ Postural BP

• Cognitive impairment

• Foot problems

• Depressive sxs

• 4+ Meds.

NEJM 1988; JAGS1995

Risk of falls by number of predisposing risk factors

0

20

40

60

80

100

Per

cen

t F

alli

ng

0 1 2 3 4+

Number of Risk Factors

8%

19%

32%

60%

78%

Risk factors for serious injury (Project Safety)

Cognitive impairment 2.2 (1.5, 3.2)

≥ 2 chronic conditions 2.0 (1.4, 2.9)

Balance / gait impairment 1.8 (1.3, 2.7)

Female 1.8 (1.1, 2.9)

Body mass index < 20 1.8 (1.2, 2.5)

J Am Geriatr Soc, 1995

Precipitating factors*

• 4+ medications

• Footwear

• Stairs

• Unsafe behaviors

* ≥ 2-fold risk of serious injury if falls

Precipitating factors

Falls on stairs…

risk of serious injury 10-fold

By 1990s…

• Much is known about epidemiology of falls (frequency, morbidity, risk

factors (~50 epidemiologic studies)

• Almost nothing is known about prevention

National Institute on Aging

Frailty and Injuries: Cooperative Studies of Intervention Techniques (FICSIT)

Yale FICSIT:1992 - 1996

Aim: Compare effectiveness of targeted multifactorial intervention (TI) and usual care + social visits (SV) at ↓ falls

• Hypothesis: Risk of falling with # risk factors → risk of falling ↓ by reducing risk factors

Yale FICSIT:1992 - 1996

• Design: RCT

• Population: 301 community living persons 70+ with ≥ 1 fall risk factor

• Intervention: Standardly-tailored multifactorial intervention targeted at each of 6 modifiable risk factors

Yale FICSIT: Targeted risk factors

TI (153) SV (148) Postural hypotension 46% 39%

Sedative use 19% 18%

4+ Prescriptions 42% 49%

Leg strength 37% 49%

Arm strength 22% 24%

Balance/gait impair 62% 69%

New Engl J Med 1994

Medications

• Assessment

– ≥ 4 medications

– High-risk medications

– Possible fall-related adverse medication effects

• Management

– Minimize medications

Medications: Minimize

• If:

– ≥4 medications and ≥ 1 high risk med. and ≥ 1 medication sign/symptom

• Then consider:

– What is the net benefit vs. harm of medications for patient’s overall

health

– What can be eliminated or reduced?

– Think total doses of all drugs

Balance, gait, muscle strenth management

Gait training Assistive device –right device used

correctly

Appropriate footwear - high box, thin sole, low heel

Strength training

Balance training

Yale FICSIT: Results

N Engl J Med, 1994

Yale FICSIT: Conclusions

Multifactorial, targeted intervention:

• Feasible - 85% enrolled; 80% adhered

• Safe - No injuries during 20,000 unsupervised exercise sessions

• Effective

– ↓ % who fell by 25%

– ↓ rate of falling by 31%

Yale FICSIT: Mechanism of effect

• RF reduction: ↓ no. of targeted risk factors

→ → → ↓ falls

Am J Epidem 1996

Yale FICSIT: Mechanism of effect

• Tl>SV improvements in 3/6 RF: – Postural BP (p=0.01)

– Gait / balance (p=0.004)

– No. of medications (p=0.003)

Am J Epidem 1996

By 2001…

• Much is known about fall risk and prevention, but…

•Falls largely neglected outside select settings

•Survey of primary care providers-≈30% ask about falls

J Am Geriatr Soc, 2003

Falls among older adults: research from prediction to policy

• First phase: acquiring the evidence– Falls common, predictable, preventable

• Second phase: translating evidence into practice and policy

Falls research: Translation

• Disconnect between evidence (>60

RCTS) and practice (ignored)

• Can fall risk assessment and

management be imbedded in care

• If so, is it effective?

38

Connecticut Collaboration For Fall Prevention (CCFP)

Funded by the Donaghue Foundation and the National

Institute on Aging

CCFP: Aims

• To encourage health care and community providers to incorporate evidence-based fall risk evaluation/ management into their practices

• To determine effect on serious fall injury and fall-related health utilization

• To identify barriers and facilitators to adopting fall-related practices

Recommended Practices: health careProvider/Facility

Assess/ Refer

Risk Factor Management

GaitBal.

Med. adjust

Post. BP

Vis./hear

Feet Env

ED / hospitals

X X X

PT/OT X X X X

Home care

X X X X X

1º MDsX X X X X X

Recommended Practices: CommunityProvider/Facility

Assess/ Refer

Risk Factor Management

GaitBal.

Med. adjust

Post. BP

Vis./hear

Feet Env

EMS X

Senior centers

X

Assisted living

X X X X X X

Senior housing, etc

X

CCFP Methods

Heighten awareness of falling as a preventable cause of morbidity: website, bus ads, posters, brochures, media…

CCFP Methods: Initial tasks• Determine core intervention to disseminate

• Develop practice materials (checklists; manuals; passbooks, website)

• Identify clinical (and community) sites/providers

• Establish referral patterns among ED, PT, homecare, 1° care

• Address Medicare reimbursement issues

CCFP Methods to translate research into practice

• Composite of professional change strategies → enhance knowledge, skills, fall-related practices

• No one strategy ideal or effective

• Evidence suggests multiple strategies most effective

Methods to increase fall- related practices

• Buy in from leaders; champions; early adopters

• Working groups; local participation in planning and implementation

• Patient-mediated (patients request fall management)

Methods to increase fall- related practices

• Outreach visits (academic detailing)

• Time consuming but

necessary…

10/2001 10/2002 10/2003 10/2004 10/2005 10/20060

10

20

30

40

50

60

70

80

90

100

Home Care Agencies

Outpatient Rehabilitation Offices

Primary Care Offices

Senior Centers

(n=26)

(n=133)

(n=212)

(n=41)

Year

Perc

enta

ge

% offices with ≥1 outreach visit

CCFP: Aims

• To encourage health care (and community) providers to incorporate evidence-based fall risk evaluation/ management into their practices

• To determine effect on serious fall injury and fall-related health utilization

• To identify barriers and facilitators to adopting fall-related practices

Aim 2

• To compare serious fall injury and fall-related utilization rates in a region in Connecticut exposed to CCFP interventions relative to a usual care region.

Pre-Intervention Intervention Evaluation

26

28

30

32

34

36Usual Care

Intervention

10/1999 - 9/2001 10/2001 - 9/2004 10/2004 - 9/2006

Rate

per 1

000

Pers

ons

70 Y

ears

and O

lder

Pre-Intervention Intervention Evaluation60

65

70

75

80

85

90Usual Care

Intervention

10/1999 - 9/2001 10/2001 - 9/2004 10/2004 - 9/2006

Rate

per 1

000

Pers

ons

70 Y

ears

and O

lder

Adj. serious fall injury / fall-related utilization rates in intervention vs. usual care regions.

New Engl J Med, 2008

CCFP: Aims

• To encourage health care (and community) providers to incorporate evidence-based fall risk evaluation/ management into their practices

• To determine effect on serious fall injury and fall-related health utilization

• To identify barriers and facilitators to adopting fall-related practices

Challenges / barriers to fall prevention

• Clinicians and seniors unaware of falling and fall prevention

• Perceived lack of expertise

• Lack of familiarity and fragmentation among multiple clinicians in multiple settings

J Am Geriatr Soc, 2005

Challenges / barriers to fall prevention

• Arcane Medicare coverage / payment

• Patients aren’t asking for it

• Competing demands (providers bombarded with guidelines, Q.I.)

• Coordination between health care and community facilities

Facilitators / incentives fall prevention• Medicare covers all (most) components• Provider-specific incentives

– fallers divert resources in E.D.s – evidence- based practice for PT/OT – new market for PT/OT, home care

• Mandates, incentives are emerging

Gerontologist, 2007

Fall prevention: ongoing activities

• New AGS guidelines (J Am Geriatr Soc)

• Work with CMS and CDC on coverage

• CMS and NQF- fall assessment as quality measure

• National Action Plan (NCOA)-Falls free coalition

• State legislation