AMDA Clinical Practice Guidelines CPGs For Falls And Osteoporosis

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AMDA Clinical Practice Guidelines(CPGs)
ForFalls And Osteoporosis
For Medical Directors, attending physicians and
advanced practitioners
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Why Consider Falls And Osteoporosis Together?

• Both are common in long-term care (LTC) patients
• Both may have a common outcome fracture
• Both may result in high health care expenditures
• Both are associated with mortality, morbidity,
  reduced functioning, and premature placement in
  LTC facilities

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Introduction To Falls In LTC

• Definition Falling is a problem characterized by
  the failure to maintain an appropriate lying,
  sitting, or standing position, resulting in an
  individuals sudden, unintentional relocation
  either to the ground or into contact with another
  object below his or her starting point.
• Significant cause of injury and death in frail
  elderly
• Often the triggering event resulting in LTC
  placement
• Fall are not inevitable in LTC facilities
• Increasing fall rates in LTC facilities

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Introduction To Osteoporosis In LTC

• Progressive, systemic skeletal disease
  characterized by
• Brittle bones
• Decreased bone density and strength
• Structural deterioration of bone tissue
• Fragility of remaining bone
• Silent Disease
• Significant public health problem, associated
  with significant disability, mortality, and cost

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OsteoporosisPrevalence

• Prevalence of osteoporosis in LTC patients aged
  65 to 7410
• White women 63.5
• Black women 27.3
• White men 34.4
• Black men 25.0

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OsteoporosisPrevalence

• Prevalence of osteoporosis in LTC patients aged
  75 to 8410
• White women 71.1
• Black women 54.7
• White men 66.7
• Black men 48.8

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OsteoporosisPrevalence

• Prevalence of osteoporosis in LTC patients aged
  gt8510
• White women 85.8
• Black women 56.0
• White men 79.6
• Black men 47.1

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Osteoporosis

• Bone Remodeling
• Osteoporosis a complex endocrinologic disorder
  of bone and mineral metabolism
• Processes of bone resorption and bone formation
  becomes uncoupled (bone resorption exceeds
  formation)

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AMDA Falls And Osteoporosis CPGs

• CPG Steps
• Recognition
• Assessment
• Treatment
• Monitoring

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Falls And Fall Risk Recognition

• Recognition
• History of falls
• Risk factors for falls
• Risks of falling increases dramatically as number
  of risk factors increase
• Falls are result of multiple coexisting risk
  factors

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Falls And Fall Risk Recognition

• Intrinsic Risk Factors
• History of falls
• Age and physiological changes with age
• Acute febrile illnesses, e.g., urinary tract
  infections (UTI) or pneumonia
• Balance and gait deficits
• Chronic illnesses, e.g., congestive heart failure
  (CHF) or diabetes
• Diseases/conditions that impair sensory,
  cognitive, neurological or musculoskeletal
  function
• Weakness in lower extremities
• History of stroke
• Anemia
• (Continued on next slide)

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Falls And Fall Risk Recognition

• Intrinsic Risk Factors
• (Continued from last slide)
• Dementia
• Fear of falling
• Foot disorders
• Impaired ability to perform activities of daily
  living (ADLs)
• Medications (e.g., antipsychotics,
  sedative-hypnotics, antidepressants,
  antiarrhythmics, anticonvulsants, narcotics,
  diuretics, and any medication with
  anticholinergic side effects)
• Reduced hearing or vision
• Urinary or fecal urgency
• Use of assistive devices

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Falls And Fall Risk Recognition

• Extrinsic Risk Factors
• Clutter in rooms
• Inadequate assistive devices
• Inappropriate footwear
• Incorrect bed height
• Irregular or loose floor coverings
• Lack of grab bars
• Malfunctioning emergency call systems
• Poor lighting
• Slippery floors
• Use of full-length side rails
• Other environmental hazards

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Osteoporosis Recognition

• Risk Factors
• History of fracture(s) after age 50
• Low bone mass
• Advanced age
• Female gender
• Early menarche
• Estrogen deficiency
• Ethnicity (Caucasian or Asian)
• Family history of osteoporosis
• History of excessive exercise resulting in
  amenorrhea
• History of smoking and excessive alcohol use
• Low lifetime calcium intake
• Small body frame and low weight
• Vitamin D deficiency
• Low testosterone in men
• (Continued on next slide)

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Osteoporosis Recognition

• Risk Factors
• (Continued from last slide)
• Use of certain medications, e.g.,
  glucocorticoids, chemotherapy, anticonvulsants,
  lithium, antacids, excess thyroid replacement,
  excess vitamin A, GnRH agonists/ antagonists, and
  heparin
• Conditions, e.g., chronic liver failure, chronic
  obstructive lung disease, chronic renal failure,
  Cushings syndrome, type 1 diabetes, vitamin D
  deficiency, multiple myeloma, lymphoma,
  hyperthyroidism or excess thyroid hormone
  replacement, disuse or immobilization,
  hypogonadism, malabsorption syndrome, cirrhosis,
  and inflammatory bowel disease.

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Osteoporosis Recognition

• Men and Osteoporosis
• Under diagnosed, under-reported, and inadequately
  researched
• Causes
• Decreased testosterone levels
• Lifestyle
• Chronic disease
• Use of certain medications
• Race

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Falls And Fall Risk Assessment

• Routine Assessment of Fall Risk
• Assess fall risk in all new admissions
• Ask about fall history at least annually
• Balance and gait screenings for patients with
  fall risk
• Referral to physical and/or occupational therapy
  for further assessment if indicated

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Falls And Fall Risk Assessment

• Complications From Falls
• Fractures
• Other injuries
• Psychological trauma and fear of falling
• Decreased activity and exercise

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Falls And Fall Risk Assessment

• Fractures Complications of Falls and
  Osteoporosis
• Linked to increased mortality and morbidity
• High rate of fractures and associated morbidity
  in LTC patients

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Falls And Fall Risk Assessment

• Postfall Assessment
• History of recent or recurrent falls
• Associated symptoms (precipitating factors) at
  time of fall
• Circumstances of fall including time and location
  of fall
• Comorbid/underlying conditions
• Medication review
• Neurological status
• Psychological status
• Labs and diagnosis
• Functional assessment, mobility, gait, use of
  assistive devices, appropriateness of restraints,
  changes in activity tolerance, footwear
  appropriateness
• Environmental issues related to fall

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Osteoporosis Assessment

• Types Of Osteoporosis (Associated With Causes)
• Primary osteoporosis
• Type 1 osteoporosis or postmenopausal
• Type 2 osteoporosis associated with normal
  aging processes
• Secondary osteoporosis
• Associated with endocrine disease,
  medications, and other diseases or conditions.
  e.g., liver disease, malignancy.

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Osteoporosis Assessment

• Medical history
• Physical exam
• Family history
• Height loss
• Change in posture
• Presence of risk factors
• Laboratory values
• Bone mineral density testing

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Osteoporosis Assessment

• Work-up For Osteoporosis
• Assess risk factors
• Decide whether to do a work-up for osteoporosis
• Perform DXA, if feasible, to assess severity and
  to monitor response to treatment
• Consider individual patients wishes, clinical
  condition, goals of treatment, prognosis, and
  willingness to accept interventions, and life
  expectancy

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Osteoporosis Assessment

• Diagnosis
• Labs
• X-ray
• DXA

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Osteoporosis Assessment

• Complications Of Osteoporosis
• Risks of falls and osteoporosis related fractures
• Increased morbidity and mortality
• Decreased social functioning and decreased
  physical activity
• Decreased quality of life
• Pain
• Deformity
• Problems with self-esteem/self-image

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Falls And Fall Risk Treatment

• Prevention Of Falls
• Develop individualized plan to manage falls and
  fall risk
• Assess patient after a fall
• Exercise/activity programs to improve strength
  and endurance
• Programs for patients who wander
• Gait training
• Environmental assessment and modification if
  necessary
• Review of prescribed medications and
  modifications if needed
• Treat medical conditions, e.g., as postural
  hypotension, anemia, dementia
• Alarm systems, assistive devices, and hip
  protectors
• Educate staff (and patient and family) to
  identify fall risks
• Reduction in use of physical restraints
• Toileting and continence programs

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Falls And Fall Risk Treatment

• Exercise
• Resistance strength training
• Flexibility training
• Aerobic exercise

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Falls And Fall Risk Treatment

• Environmental Factors
• Slippery floors
• Irregular or loose floor surfaces
• Bad lighting
• Clutter in room
• Furniture repositioning
• Bed height/design
• Loose shoes
• Trip hazards, (e.g., cords, loose carpet)
• Other extrinsic risk factors (see Falls and Fall
  Risk Recognition)

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Falls And Fall Risk Treatment

• Medication review and modification if necessary
• Number of medications prescribed
• Types of medications

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Falls And Fall Risks Treatment

• Falls and Anemia
• Anemia is common in older people
• Fatigue is a debilitating symptom of anemia
• Anemia associated with physical decline in older
  persons
• Anemia linked to risk of falls in patients
  sustaining hip fractures

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Falls And Fall Risk Treatment

• Assistive Devices
• Canes
• Walkers
• Hip protectors

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Falls And Fall Risk Treatment

• Fall Risk Education
• Provide Education and In-Services
• Nursing home staff
• Patients and patients families
• Physicians
• Interdisciplinary care team

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Osteoporosis Treatment

• Barriers to providing osteoporosis care
• Patient comorbidities
• Reimbursement issues
• Length of stay
• Medication related adverse events

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Osteoporosis Treatment

• Goals of treatment
• Prevent further bone loss
• Increase or at least stabilize bone density
• Prevent fractures
• Relieve deformity (e.g., kyphoplasty)
• Relieve pain
• Increase level of physical functioning
• Increase quality of life

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Osteoporosis Treatment

• Prevention strategies
• Good general nutrition
• Diet including adequate calcium and vitamin D
• Weight-bearing exercise
• Stop smoking and stop excessive alcohol intake
• Bone density testing and medications where
  appropriate
• Monitor patients on thyroid hormone to ensure
  adequate replacement

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Osteoporosis Treatment

• Nutritional supplements
• Calcium and vitamin D supplementation
• Low Salt
• Low caffeine
• Avoid excessive cigarette smoking
• Avoid excessive alcohol consumption

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Osteoporosis Treatment

• Weight-bearing exercise
• Walking
• Low-impact aerobics
• Strength training
• Balance training
• Agility exercises

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Osteoporosis Treatment

• Medications
• Bisphosphonates
• Calcitonin
• Estrogen receptor modulators
• Parathyroid hormone

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Falls And Fall Risks Monitoring

• Monitor falling in patients with fall risk or
  fall history
• Monitor and document patients response to
  interventions
• Re-evaluate interventions and reconsider current
  interventions
• Amend the care plan as necessary
• Document presence of irreversible risk factors
• Respond to late consequences of falling

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Falls And Fall Risk Monitoring

• Conduct quality improvement activities related to
  falls
• Track falls by time, location, and cause
• Review quality indicators related to falls
• Evaluate and adjust the prevention and management
  program

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Osteoporosis Monitoring

• Monitor/document progress of patients
• Consider additional DXA scans
• Monitor post-acute care patients undergoing
  short-term rehabilitation
• Identify quality indicators related to
  osteoporosis
• Monitor patient for side effects of medications
  used to treat osteoporosis