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Fall Prevention, Osteopenia & Osteoporosis Avoid the Pitfalls of A Fall Prevention, Osteopenia & Osteoporosis Avoid the Pitfalls of a Break David T Walsworth, MD, FAAFP Associate Chair for Clinical Affairs and Associate Chair Department of Family Medicine College of Human Medicine Michigan State University Saturday, August 3, 2019 Disclosures No financial relationships with pharmaceutical, biological, or device manufacturers Michigan Quality Improvement Consortium – Medical Directors Committee American Academy of Family Physicians Congress of Delegates, Delegate from Michigan Academy of Family Physicians Course director, content developer, presenter – Care of Chronic Conditions National Live Course (Atrial Fibrillation, Chronic Opioid Therapy Update, Dizziness and Vertigo, Osteoporosis & Osteopenia, Performance Improvement, Preventive Care: Immunizations, Preventive Care: LGBTQ) Content developer and presenter – FMX (Anticoagulation Management Update) Michigan Academy of Family Physicians – Board of Directors; Practice Management Committee Family Medicine Foundation of Michigan – Board of Trustees (Treasurer); Professional Development Cmte American Medical Association – House of Delegates, Delegate from Michigan State Medical Society Michigan State Medical Society House of Delegates, Delegate from Ingham County Medical Society Annual Scientific Meeting Planning Committee (Chair), CME Accreditation, Health Care Quality, Environment, and Efficiency Cmte Learning Objectives Summarize current guidelines for fall prevention Evaluate elderly patients or patients at risk for low bone mass/osteoporosis using the FRAX® algorithm, and consider the impact of fracture risk scores on patient management Advise patients on appropriate prophylactic strategies for patients with low bone mass/osteoporosis Compare and contrast management with RANKL inhibitor vs bisphosphonates; and the pros and cons between various bisphosphonates Determine the risks and benefits of maintaining bisphosphonate treatment for greater than 5 years Personal photograph taken by David T Walsworth on 5/6/16 Special Slide Icons Look up here for one of the following: Treatment or practice guideline(s) Choosing Wisely Performance measure(s) Overcoming barriers to change Practice tool(s) Monday morning “To Do List” Key practice recommendation(s) Best Practice Recommendations Fall Prevention CDC Fall Statistics 1/5 falls cause a broken bone or head injury 3 million emergency department visits annually 800,000 hospitalizations annually 300,000 hip fractures annually (95% from falls) Falls are the most common cause of traumatic brain injuries $50 billion spent in fall care in 2015 Fall death rates increased by 30% from 2007 – 2016 (46-61/100,000) CDC estimates that there will be 7 deaths per hour by 2030 CDC, 2019. Important Facts about Falls. Accessed on 6/30/19 from https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html Who is at an Increased Risk of Falls? According to CDC According to USPSTF Lower body weakness Age Vitamin D deficiency History of falls Difficulties with walking and/or balance Medications that affect balance Impaired gait Vision problems Impaired mobility Foot pain or poor footwear Impaired balance Broken or uneven steps or floors Abnormal “Timed Get Up & Go Test” (TUG) Throw rugs or clutter under foot 3 Key questions Have you fallen in the past year? Do you feel unsteady when standing or walking? Do you worry about falling? CDC, 2019. Important Facts about Falls. Accessed on 6/30/19 from https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html CDC, 2019. STEADI (Stopping Elderly Accidents, Injuries, and Deaths. Accessed on 6/30/19 from https://www.cdc.gov/steadi/ USPSTF, 2018. Fall Prevention in Community-Dwelling Older Adults: Interventions. Accessed on 6/30/19 from https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/falls-prevention-in-older-adults-interventions1#consider Timed Get Up and Go Test (TUG) Tool available from CDC: https://www.cdc.gov/steadi/pdf /TUG_Test-print.pdf STEADI (Stopping Elderly Accidents, Deaths, and Injuries) Toolkit available from CDC: https://www.cdc.gov/steadi/ Two Guidelines Somewhat Agree CDC Fall Prevention Guideline USPSTF Fall Prevention Guideline The USPSTF recommends exercise interventions to Professional fall risk evaluation prevent falls in community-dwelling adults 65 years or older who are at increased risk for falls. (B Professional medication review Recommendation) Vitamin D supplementation The USPSTF recommends that clinicians selectively offer multifactorial interventions to prevent falls to Strength and balance exercises (e.g. tai chi) community-dwelling adults 65 years or older who are at increased risk for falls. Existing evidence indicates that Professional vision assessment the overall net benefit of routinely offering multifactorial interventions to prevent falls is small. Consider prescription lenses with distance only When determining whether this service is appropriate for correction for walking or other outdoor exercises an individual, patients and clinicians should consider the balance of benefits and harms based on the Remove trip hazards circumstances of prior falls, presence of comorbid medical conditions, and the patient’s values and Grab bars inside and outside of tub or shower, preferences. (C Recommendation) and for toilet The USPSTF recommends against vitamin D supplementation to prevent falls in community-dwelling Railings on both sides of a stair adults 65 years or older. (D Recommendation) Increase light throughout home CDC, 2019. Important Facts about Falls. Accessed on 6/30/19 from https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html USPSTF, 2018. Fall Prevention in Community-Dwelling Older Adults: Interventions. Accessed on 6/30/19 from https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/falls-prevention-in-older-adults-interventions1 Key Practice Recommendations (AFP SORT) A Evidence A multifactorial intervention for falls in older persons should include exercise, particularly balance, strength, and gait training B Evidence Community-dwelling older persons at low to moderate risk of falls should participate in an exercise program or physical therapy and take vitamin D supplements Older persons at risk of falls who are hospitalized in an acute setting or for an extended time in a subacute setting should receive a multifactorial risk assessment and intervention tailored to their needs Nursing home residents at risk of falls should receive a multifactorial risk assessment and intervention tailored to their needs that are administered by a multidisciplinary team The following components should be included in multifactorial interventions for falls in older persons Vitamin D3 supplementation of at least 800 IU daily Withdrawal or minimization of psychoactive and other medications Adaptation or modification of the home environment for those who have fallen or have visual impairment Management of foot problems and footwear Management of postural hypotension Dual chamber cardiac pacing should be considered in patients with carotid sinus hypersensitivity who experience unexplained recurrent falls C Evidence Community-dwelling older persons at high risk of falls should receive a multifactorial risk assessment and intervention tailored to their needs Van Voast Moncado & Mire, 2017. Preventing Falls in Older Persons. Am Fam Physician. 2017 Aug 15’ 96(4):240-247. Accessed on 6/30/19 from https://www.aafp.org/afp/2017/0815/p240.html Choosing Wisely AMDA – The Society for Post-Acute and Long-Term Care Medicine (Last updated August 10, 2017) Don’t initiate antihypertensive treatment in individuals ≥60 years of age for systolic blood pressure (SBP) <150 mm Hg or diastolic blood pressure (DBP) <90 mm Hg. AMDA, 2017. Choosing Wisely. Accessed on 6/30/19 from http://www.choosingwisely.org/clinician-lists/amda-antihypertensive-treatment-in-individuals-sixty-and-over/ Performance Improvement Reporting Falls Risk Assessment - National Quality Strategy Domain: Patient Safety - Measure 154 (NQF: 0101) Definitions Fall – A sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor, or the ground, other than as a consequence of sudden onset of paralysis, epileptic seizure, or overwhelming external force. Risk Assessment – Comprised of balance/gait AND one or more of the following: postural blood pressure, vision, home fall hazards, and documentation on whether medications are a contributing factor or not to falls within the past 12 months. Balance/gait Assessment - Medical record must include documentation of observed transfer and walking or use of a standardized scale (e.g., Get Up & Go, Berg, Tinetti) or documentation of referral for assessment of balance/gait Postural blood pressure - Documentation of blood pressure values in supine and then standing positions Vision Assessment - Medical record must include documentation that patient is functioning well with vision or not functioning well with vision based on discussion with the patient or use of a standardized scale or assessment tool (e.g., Snellen) or documentation of referral for assessment of vision Home fall hazards Assessment - Medical record must include documentation of counseling on home falls hazards or documentation of inquiry of home fall hazards or referral for evaluation of home fall hazards Medications Assessment- Medical record must include documentation of whether the
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