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WHO IS MANAGING AGING PATIENTS & THEIR
RISK FOR FALLS ? No ONE - Jules Levin, NATAP
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Download the PDF here
"40% reported falls in the previous year/HIV+ in VA Aging
Cohort"....http://www.natap.org/2014/IDSA/IDSA_42.htm
HIV bone researchers where they predict an epidemic of bone fractures in HIV+......Falls are the main cause of injury, injury related disability, and death in older people.....We found that the fall rate in middle-aged adults (mean age 52.0 years) with HIV-1 infection is as common as in uninfected persons aged 65 years.....http://www.natap.org/2016/HIV/081216_04.htm
HIV-infected persons have low bone density, increased fracture risk, and premature frailty.5,6,13,14,24,25 Thus, in addition to increased risk of falls, aging HIV-infected persons are likely to be at increased risk of morbidity when falls occur.....Providers caring for HIV-infected persons should routinely inquire about falls; assess fall risk factors in those at risk for falling; and when high fall risk is identified, intervene to reduce risk. Interventions such as discontinuation of psychotropic or other high-risk medications, balance training, home safety evaluations, and exercise programs decrease fall risk in elderly, non-HIV-infected persons.2,22,23 Future research is needed to investigate the effectiveness of interventions to reduce fall risk in middle-aged and older HIV-infected persons.
From BMJ
cognitive impairment not only increases the risk of falls but may also adversely affect adherence to interventions and the effectiveness of such interventions
Multifactorial interventions are interventions that target multiple risk factors using multiple approaches. For example, a multifactorial intervention may address the risk of falls by delivering a group exercise program, a drug review, vitamin D supplementation, and home risk assessment and modifications.
Multifactorial, exercise based, tailored interventions are the most effective way to reduce falls and the resulting healthcare costs in community dwelling older people.19 93 Thus, healthcare providers need to identify those at risk of falls and refer them for comprehensive assessment and evidence based multifactorial interventions including exercises.
The AGS/BGS guidelines recommend that healthcare providers ask all older people or their caregivers at least once a year about falls, frequency of falling, and difficulties in gait and balance.44 A gait and balance evaluation should be conducted in those with a history of falls in the past 12 months.44 Examinations should include:
•A detailed assessment of gait, balance, mobility, and the function and muscle strength of the lower extremity joints
•Evaluation of neurological and cognitive function
•Assessment of lower extremity peripheral nerves, proprioception, reflexes, cortical, extrapyramidal and cerebellar function, and cardiovascular status
•Assessment of visual acuity
•Examination of the feet and footwear
•Assessment of activities of daily living including use of adaptive equipment and mobility aids
•Assessment of current activity levels, perceived functional ability, and fear of falls.44
The severity of resulting injuries varies, and 40-60% of falls result in major lacerations, fractures, or traumatic brain injuries.3 A longitudinal study found that 68% of people who fell reported some injury; healthcare was needed in 24% of cases, functional decline was reported by 35%, and social and physical activities were impaired for more than 15%.4 Close to 95% of all hip fractures are caused by falls; 95% of patients with a hip fracture are discharged to nursing homes (about 40% of nursing home admissions are related to falls), and 20% of patients with a hip fracture die within a year.
Falls and the fear of falls also seriously reduce quality of life.10 More than 60% of family care givers are afraid that their older relative will fall again.11 Low falls self efficacy (a measure of fear of falls) is associated with an increased risk of subsequent falls, a decline in activities of daily living, and reduced quality of life.12 Falls can trigger a cycle of fear of falls (>25% of cases), reduced physical activity, deconditioning, functional decline, impaired ability to perform daily activities, social isolation, reduced quality of life, depression, increased risk of subsequent falls, and institutionalization.13 14 15 16 17 After a first fall, people have a 66% chance of having another fall within a year.
This review summarizes the best available evidence on risk factors for falls in older people living in the community and how to assess the risk of falls. It discusses how to manage these risks, which interventions are most effective in reducing falls, and future directions in research and implementation.
Gait and balance
Gait and balance impairments are modifiable causes of falls; interventions to enhance musculoskeletal function are effective in preventing falls among older people in the community.35 36 Slower gait is an indicator of fear of falls and disability; it is a risk factor for falls and is used to classify people as frail (gait speed <0.8 m/s and not able to walk more than 350 m in six minutes). People who are afraid of falling increase their level of co-contraction (activation of agonist and antagonist muscles such as the quadriceps and hamstrings). Increased co-contraction increases rigidness, which may reduce the risk of falls during low speed disturbances such as being pushed lightly. However, it also increases the risk of falls during high velocity disruptions such as tripping because it takes longer to replace the feet and the person may not be able to recover balance in time.37
Frailty and disability
Falls are related to other problems in older people such as frailty, disability, incontinence, and visual and cognitive impairment.31 38 39 40 Markers of frailty, disability, and falls risk include not being able to complete more than seven chair rises in 30 seconds without using the hands, taking more than 50 seconds to climb 10 steps, and taking more than 30 seconds to get up from the floor.41 Community ambulation cut-off points include being able to walk 50 m independently and safely within a reasonable time period, and to be able to walk 365 m independently and at least 30 m at 1.3 m/s.41
Other frailty indicators include the loss of 4.5 kg or more during the past year, exhaustion for three or more days a week, grip strength of less than 10.4 kg force for women and 14.5 kg force for men, and sitting quietly or lying down during most of the day.42
The association of falls with frailty and disability is bidirectional, and they have risk factors in common.31 Falls can cause injuries that result in disability and lead to deconditioning and ultimately frailty. In the other direction, frail or disabled older adults may fall because of lack of balance or strength. In addition, disabilities (such as amputations) may predispose older people to falls. Thus, screening for and reducing the risk of falls affects the risk of frailty and disability and vice versa. Falls among frail older people are particularly worrying because the reduced physiologic capacities may increase complications and compromise recovery.43
Comorbid conditions
Acute or chronic medical problems such as osteoporosis, diabetes, urinary incontinence, and cardiovascular disease are also risk factors for falls.44 Carotid sinus syndrome, vasovagal syncope, orthostatic and postprandial hypotension, arrhythmias (bradyarrhythmias and tachyarrhythmias) are common causes of syncope related falls in older people.29 Orthostatic hypotension can cause older people to faint. A systolic drop of 20 mm Hg after one minute of standing may be particularly informative about the risk of falling in community dwelling older people with uncontrolled hypertension.45
Vitamin D deficiency is another suspected risk factor for falls in older people. Vitamin D is a regulator of calcium and phosphorus metabolism; its importance for bone health is well established and there has been increasing interest in the association between vitamin D and falls, but the results are controversial.46 47 Some studies found an association between falls and vitamin D deficiency, but others that controlled for physical activity levels found no such association.33
Polypharmacy
Drugs are often prescribed for patients who fall, but polypharmacy, often defined as use of four or more prescription drugs, as well as use of specific drugs-including antidepressants, sedatives and hypnotics, neuroleptics and antipsychotics, antihypertensives, and anticonvulsants-have been linked to an increased risk of falls.48 49 50
Vitamin D and calcium supplementation
Supplementation with vitamin D and calcium is another strategy for reducing the risk of falls. In 2009 a meta-analysis of seven randomized controlled trials with about 1900 participants linked 700-1000 IU of vitamin D supplementation to a lower risk of falls compared with those who did not take vitamin D (pooled relative risk 0.81, 0.71 to 0.92).
The USPSTF reviewed nine vitamin D supplementation randomized trials and found that a median oral daily dose of 800 IU of vitamin D with or without calcium was associated with a 17% (11% to 23%) reduced risk of falling in the intervention group (6-36 months of follow-up), and the USPSTF recommended vitamin D supplementation to prevent falls in community dwelling older adults.96
By contrast, a systematic review and meta-analysis in 2012 reported that in general vitamin D supplementation was not associated with lower fall rates in community dwelling older people (rate ratio 1.0, 0.90 to 1.11), but it reduced the rate of falls and risk of falling in subgroups with low vitamin D levels at baseline compared with those who did not receive vitamin D supplementation.36 Analyses of 804 participants with low vitamin D levels at baseline from four trials showed that fewer people fell in the group who received vitamin D supplements than in the group who did not received vitamin D supplements (relative risk 0.70, 0.56 to 0.87).120 121 122 123 The review concluded that vitamin D supplementation reduced falls only in people with lower vitamin D levels.36
The American Geriatrics Society workgroup on vitamin D supplementation for older adults graded the quality of evidence from clinical trials and meta-analyses of vitamin D supplementation to reduce falls and fractures in older people.124 The workgroup recommended minimum daily supplementation with 1000 IU of vitamin D plus 1000-1200 mg of calcium to prevent falls and fractures in older people in the community or institutional settings.124. Similarly, a meta-analysis conducted for the USPSTF to evaluate vitamin D supplementation with or without calcium for preventing cancer and fractures found that combined vitamin D and calcium supplementation reduced the risk of fractures in older people in the community (relative risk, 0.89, 0.76 to 1.04) 125 However, one of the trials reported adverse effects of supplementation including renal and urinary tract stones.125 The Institute of Medicine's dietary reference intake for calcium and vitamin D to maintain bone health and calcium metabolism is 600 IU for people aged 51-70 years and 800 IU for those aged 70 years or more.126 These are the same values as those proposed by the 2012 USPSTF for falls prevention,96 but the 2014 AGS recommendation for older adults is for at least 1000 IU per day and the AGS concluded that there are currently insufficient data to support vitamin D supplementation without calcium.124
The Institute of Medicine (IOM) recommended dietary allowance for calcium is 1000 mg for people aged 51-70 years and 1200 mg for those 70 years or more.126A meta-analysis found that combined vitamin D and calcium supplementation of institutionalized older people was associated with reduced risk of fractures (relative risk 0.71, 0.57 to 0.89), but results in community dwelling people did not reach statistical significance (0.89, 0.76 to 1.04).125 A dose dependent benefit of vitamin D supplementation has been found for hip and non-vertebral fractures in older adults, with a median vitamin D intake of 800 IU/day in community dwelling older people being associated with a reduction in hip fracture risk (relative risk 0.68, 0.48 to 0.96).127
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