pierluissi osteoporosis cme 072116presentation outline • case presentation • incidence and...

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The Other Half of the Fracture Equation: Fall Prevention and

Management

OSTEOPOROSISNEW INSIGHTS IN RESEARCH, DIAGNOSIS,AND CLINICAL CARE

Edgar Pierluissi, MDAcute Care for Elders Unit Zuckerberg San Francisco

General Hospital

July 21, 2016

School of MedicineDivision of Geriatrics

[email protected] School of Medicine

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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 and Evaluation

• Prevention

• Summary

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• Prevalence and Consequences

• Risk factors


• Prevention

• Summary

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Why falls?

The odds of a fracture are 7–9 times higher among community-dwelling postmenopausal women with both a fall and osteoporosis or osteopenia, compared with women having a fall or osteoporosis/osteopenia only.

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Geusens P, et al. The relationship among history of falls, osteoporosis, and fractures in postmenopausal women. Arch Phys Med Rehabil. 2002;83(7):903–906.

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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

0 10 20 30 40 50 60 70 80 90PercentNevitt et al. 1997

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Prevalence

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

Falls are Common

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0.32

Clinicoecon Outcomes Res. 2013;5:9-18.

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Self-reported falls in US, ≥ 65 years

• In the past 3 months, how many times have you fallen? (16% fell)

• How many of these falls caused an injury?

9MMWR. 2008;57:225-229

1.8 Million with Injury

4 Million

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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)

• ~350,000 hip fractures annually

10Adv Data 392; 2007 Fall Injury Episodes Among Noninstitutionalized Older Adults: US, 2001–2003

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65+ Number Going to ED/Getting Hospitalized for Falls is Increasing

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To Emergency Department

Hospitalized

http://www.cdc.gov/injury/wisqars/ Accessed April 24, 2014

0

0.5

1

1.5

2

2.5

2001 2003 2005 2007 2009 2011 2013

Millions

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Death from Falls 65+

12http://www.cdc.gov/injury/wisqars/ Accessed April 24, 2014

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er

of D

ea

ths

0

5000

10000

15000

20000

25000

30000

1999 2001 2003 2005 2007 2009 2011 2013

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Costs

– Direct medical costs: 30 billion dollars in 2010

– Indirect and direct est 68B by 2020

14Inj Prev 2006; 12(5): 290-5

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Summary

• Falls are common among older adults

• Falls affect patient function and are a major mechanism of injury.

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• Incidence and Consequences

• Risk factors


• Prevention

• Summary

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Independent Risk Factors for Falling Among Community-Living Older Adults

Risk factor No. of StudiesSignificant

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;303:258School of Medicine

18Osteoporos Int. 2009 Dec; 20(12): 2025–2034.

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19Osteoporos Int. 2009 Dec; 20(12): 2025–2034.School of Medicine

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Risk factors for injurious falls

Previous injurious fall increases risk of falling ~ 3X

BMC Geriatr. 2014 Nov 18;14:120

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Trip

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Video Capture

• 2 Long-term facilities in British Columbia

• 38 months monitoring of common spaces

• 227 falls in 130 people

• Correlation between staff investigation and video

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Lancet. 2013 Jan 5;381(9860):47-54

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Incorrect weight shifting 41% (93 of 227) of falls

Trip or stumble 21% (48)

Hit or bump 11% (25)

Loss of support 11% (25)

Collapse 11% (24)

Slipping 3% (6)

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Other 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%

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JAGS 62:1853, 2014.

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Frailty

• Multiple definitions- all (CHS, SOF, WHI) associated with falls

• Women’s Health Initiative (3558 participants)

– Weight loss (≥10lbs or 5% over 1 year)

– Exhaustion

– Low Physical Activity score

• Average follow-up of 12 years

• Women with high frailty scores had elevated risk for falls and fractures

25J Am Geriatr Soc. 2016 Jun 16. doi: 10.1111/jgs.14233. [Epub ahead of print]

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• Risk factors


• 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

• CDC Stopping Elderly Accidents, Death, and Injuries

– July 2015School of Medicine

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Older person encounters health care provider

Single fall in past year?

Falls Evaluation

2 or more falls last yearPresents with acute fallDifficulty with walking or balance

Screen for risk of falling

Abnormalities in gait or unsteadiness?

No Yes

YesYes

Reassess annually

No

No

AGS/BGS Guideline

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American Academy of Neurology

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Inquire about falls in the past year

AND

Review risk factors for falling Neurological: strokedementiagait/mobility problemparkinsonismperipheral neuropathyassistive deviceLE sensorimotor loss

Neurology 2008;70;473-479

General: (not rated)age >65vision deficitarthritis, arthralgiadepressionpolypharmacyrestricted ADLs

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• If A or B positive:

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Falls Evaluation

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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 School of Medicine

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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http://www.cdc.gov/injury/STEADI

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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:

– 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

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

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Medications

• Benzodiazepines

• Anti-depressants

• Anti-psychotics

• Anti-epileptics

• Anti-hypertensives*

• Polypharmacy (14% higher risk for each med added above 4)

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

What about SPRINT?

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2-arm, multi-center RCT comparing treating HTN to a target of < SBP 120 mm Hg vs <140 mmHg.

Study stopped early due to 25% lower relative risk of major CV events and death, and a 27% lower relative risk of death from any cause

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SPRINT-SENIOR

• Enrolled 2636 patients ≥75 years

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Exclusions:

• Standing SBP <110

• Excluded patients with dementia

JAMA. 2016 Jun 28;315(24):2673-82

Results:

• Death at ~3 years, 8.1% vs 5.5% NNT ~39

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Adverse events

• Syncope 3% vs 2.4% (ns)

• Injurious falls 4.9% vs 5.5% (ns)

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• Risk factors


• Prevention

• Summary

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Independent Risk Factors for Falling Among Community-Living Older Adults

Risk factor No. of StudiesSignificant

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 fallsAge

GenderBMI

ADL Disabilities

Things you can’t change

BalanceStrengthVision

Gait ImpairmentDepression

Urinary incontinenceCognitive impairment

Dizziness or orthostasisMedications

Pain

Things you might 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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• 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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• Medications: (↓ # falls) Gradual withdrawal of psychotropic medication; educational program for 1° care MDs

• Cardiac pacing for fallers with cardioinhibitorycarotid sinus hypersensitivity (↓ #falls)

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

46Gillespie 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 trainingGillespie 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.” 48

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What I Recommend

• Offer cholecalciferol to all older adults at risk for falls.

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What about perturbation-based training?

• RCT 212 patients

• 24 slip session vs 1 slip session

• Self-reported falls in the year after the intervention:

– 25% in control vs 13% in intervention

53J Gerontol A Biol Sci Med Sci (2014) 69 (12): 1586-1594School of Medicine

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Perturbation-based training

• 8 RCTs

• 404 participants

• Fewer fallers 29%

• Fewer falls 46% reduction

55Phys Ther. 2015 May;95(5):700-9

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• Risk factors


• Prevention

• Summary

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• Risk factors

• Screening

• Prevention and management

• Summary

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• Falls are common in older adults.

• Falls cause significant ADL deficits and most fractures and 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.

Falls-Summary

What Questions Do You Have?

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• Landing on the floor or other lower level, including stairs, by accident• An unintentional change in position resulting in coming to rest on the

ground or another lower level, and not as a result of a major intrinsic event (eg, stroke, syncope) or overwhelming hazard (eg, car accident)

• Unintentionally coming down on the floor or to a lower level• An unintentional change in position to the floor or ground• Losing your balance such that your hands, arms, knees, buttocks or

body touch or hit the ground or floor• An unexpected event when the person fell to the ground on the same

or from an upper level, taking the falls on stairs and those onto a piece of furniture into account.

• An event in which the participant unintentionally comes to rest on the ground or at a lower level.

• Unintentionally coming to rest on the ground floor, or other lower level for reasons other than sudden onset of acute illness or overwhelming external force.

• An event which results in a person coming to rest unintentionally on the ground or other lower level, not due to any intentional movement, a major intrinsic event (eg, stroke) or extrinsic force (eg, forcefully

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pierluissi osteoporosis cme 072116presentation outline • case presentation • incidence and...

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