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Presenter Disclosure Information

Edgar Pierluissi

Fall Prevention and hip

School of Medicine Division of Geriatrics

No relevant disclosures

protectors
Osteoporosis CME 2010

Edgar Pierluissi, MD Medical Director, Acute Care for Elders Unit, San Francisco General Hospital and Trauma Center
July 15, 2010

epierluissi@medsfgh.ucsf.edu

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Presentation Outline
Case presentation Prevalence and Consequences of Falls Risk factors Screening Prevention Hip protectors Summary

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School of Medicine

Best Practice and Res Clin Rheum 2009

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Case presentation
76 y/o woman seen in clinic.

Presentation Outline
Case presentation

A bone densitometry report indicates femoral neck osteoporosis. She is on HCTZ, ASA, glyburide, and temazepam prn for sleep. One fall in the last year.

Prevalence and Consequences of Falls Risk factors Screening Prevention Hip protectors Summary

Since falls are the major mechanism of hip fracture, what is her risk for falling and how can we mitigate this risk?
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Prevalence and Consequences of Falls

Falls, Fall-related Injuries and Death

15,800

Died 1.8 million persons 65 to ED/year with fall-related injuries

433,000
Hospitalized ~320,000 with hip fx

~1/3 of those over 65 will fall in the next year ~1/2 of those over 80 will fall in the next year

1,350,000 1,800,000
5.8 million persons 65 fell at least once in prior 3 months

Discharged from ED Injured

4,000,000

NEJM 348:42-49,2003 Clin Ger Med 18:141-158,2002

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CDC. Self-Reported Falls and Fall-Related Injuries Among Persons Aged 65 YearsUnited States, 2006 MMWR. 2008;57:225-229 Fatalities and injuries from falls among older adultsUnited States, 1993-2003 and 2001-2005. MMWR. 2006;55:1222-1224

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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
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Prevalence and Consequences of Falls

About one out of five hip fracture patients dies within a year of their injury. Up to 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.

Nevitt et al. 1997

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20

30

40

50

60

70

80

90

Percent

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Consequences of falls
Fear of Falling Decreased physical and social activity Decreased self-reported health Depression Costs 19 billion dollars in 2000 (12B-hosp, 4B-ED, 3B-Visit) Indirect and direct est 54B by 2020
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Presentation Outline
Case presentation Prevalence and Consequences Risk factors for falls Screening Prevention Hip protectors Summary

Age and Ageing 2008; 37: 1924 Inj Prev 2006; 12(5): 290-5

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Intrinsic Factors

Extrinsic Factors

Results of Univariate Analyses of Most Common Risk Factors Identified in 16 Studies That Examined Risk Factors Risk factor
Muscle weakness

Significant/ Total 10/11 12/13 10/12 8/11 8/8 6/12 3/7 8/9 3/6 4/11 5/8

Mean RR-OR 4.4 3.0 2.9 2.9 2.6 2.5 2.4 2.3 2.2 1.8 1.7

Range 1.5-10.3 1.7-7.0 1.3-5.6 1.6-5.4 1.2-4.6 1.6-3.5 1.9-2.9 1.5-3.1 1.7-2.5 1.0-2.3 1.1-2.5

Medical conditions Sensory impairment Weakness & imbalance Functional & cognitive impairment

FALLS

Medications Improper use of assistive devices Environmental hazards Risk taking behavior

History of falls Gait deficit Balance deficit Assistive device Visual deficit Arthritis Impaired ADL Depression Cognitive impairment Age >80

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JAGS 49;664, 2001

JAGS 49(5) 664-672, 2001

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Risk factors for future falls

Risk factor Previous fall in last year Orthostatic hypotension Visual acuity Gait and Balance Medications Assess basic and instrumental activities of daily living Assess cognition Likelihood Ratio 2.8-3.8 ~2 2 1.7 2-4 4-17

The More Risk Factors: The Higher the Fall Risk

Risk Factor Sedative use Cognitive impairment LE disability Palmomental reflex Gait/balance abnormality Foot problems

Adjusted OR 28.3 5.0 3.8 3.0 1.9

Fall risk increased linearly, from 8% with none to 78% in patients with 4 risk factors.

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Tinetti, M et al. N Engl J Med. 1988 Dec 29;319(26):1701-7

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

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Presentation Outline
Case presentation Prevalence and Consequences of Falls Risk factors Screening Prevention Hip protectors Summary

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 49:664672, 2001 Practice Parameter: Assessing patients in a neurology practice for risk of falls
American Academy of Neurology

Neurology 2008;70;473-479

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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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Slide Title. Arial Bold, 32pt Screening

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

Ask about falls in the prior year Observe for gait or balance problems in getting up from chair

Two or more falls or balance or gait difficulties

One fall and no balance or gait difficulties

If yes or problems ==>Falls Evaluation

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Assessment of predisposing and precipitating factors, followed by interventions suggested by the results of detailed assessment

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

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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 and neurological examination home hazards

Presentation Outline
Case presentation Incidence and Consequences Risk factors Screening Prevention Hip protectors Summary

Cardiovascular examination and medication review.

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NICE Clinical Guideline, Assessment and prevention of falls in older people 2004

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Prevention

Effective Interventions
Exercise: (reduced # falls and #fallers)

Multifactorial assessment, followed by interventions targeting the identified risk factors.

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

Several interventions have solid evidence to support their use.

Multifactorial risk factor program (reduced #falls) Home hazard assessment & modification in higher risk (only in those with visual impairment and high risk of falling)
Gillespie et al Cochrane 2009

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Effective Interventions
Medications: (reduced # falls, not fallers) Withdrawal of psychotropic medication; educational program for 1care MDs Cardiac pacing for fallers with cardioinhibitory carotid sinus hypersensitivity (reduced #falls) Vitamin D may reduce falls in those with low D levels

Interventions with Unknown Effectiveness

Vitamin D with or without calcium in those with adequate levels Home hazard modification in those without fall history Hormone replacement therapy Correction of visual deficiency

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Gillespie et al Cochrane 2009

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Gillespie et al Cochrane 2009

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Presentation Outline
Case presentation Incidence and Consequences Risk factors Screening Prevention and management Hip protectors for fracture prevention Summary

Hip Protectors

Designed to absorb and/or shunt away the impact toward the soft tissues to keep the force on the trochanter below the fracture threshold.

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Hip protectors for fracture prevention

Pooled data indicate a marginally significant effectiveness of hip protectors in frail older people in institutional care.

Provision of hip protectors does not reduce the incidence of hip fractures in older people who remain ambulant in the community.

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School of Medicine

JAMA, 2007Vol 298, No. 4

Parker et al Cochrane 2009

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Efficacy of a Hip Protector to Prevent Hip Fracture in Nursing Home Residents The HIP PRO Randomized Controlled Trial Unique design Hip protector demonstrated superior capacity to reduce peak impact force in simulated experiments Nursing home residents wore a hip protector on 1 hip only; each participant served as own control Better ascertainment of adherence with 3 unannounced visits to all participants
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Efficacy of a Hip Protector to Prevent Hip Fracture in Nursing Home Residents The HIP PRO Randomized Controlled Trial Unique design Hip protector demonstrated superior capacity to reduce peak impact force in simulated experiments Nursing home residents wore a hip protector on 1 hip only; each participant served as own control Better ascertainment of adherence with 3 unannounced visits to all participants

JAMA. 2007;298(4):413-422

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JAMA. 2007;298(4):413-422

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Efficacy of a Hip Protector to Prevent Hip Fracture in Nursing Home Residents The HIP PRO Randomized Controlled Trial 37 nursing homes, 1042 patients, 20 month followup Study stopped due to lack of efficacy Overall adherence was 73.8%.
Protected hips Hip Fracture (all subjects) Hip Fracture (>80% adherence) Unprotected hips p 0.70

3.1% ; 1.8%-4.4% 2.5% ;1.3%-3.7%

5.3% ; 2.6%-8.8% 3.5% ; 1.3%-5.7%

0.42

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JAMA. 2007;298(4):413-422

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Presentation Outline
Case presentation Incidence and Consequences Risk factors Screening Prevention and management Hip protectors for fracture prevention Summary

Falls-Summary
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 observe gait and balance. Refer patients at risk for future falls to effective fall prevention approaches. Hip protectors not proven to reduce fracture risk.

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Case Presentation
Patient is at high risk for future falls (probability at least 60%) Complete Falls evaluation Stop or taper benzodiazepine Refer for exercise program (multicomponent exercise, Tai Chi, or individually prescribed home based exercise program) Home evaluation for safety Measure vitamin D.
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