Falling among older adults: Research from prediction and
prevention to practice and policy
University of North Carolina
April, 2010
Mary Tinetti MD
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
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