STEADI: Promoting Older Adult Health & Independence Through Fall PreventionRobin Cornell Creamer, DO, FAAFPMedical Director AdventHealth Family Medicine

Justin Hess, PT, DPT, OCSOrthopedic Research Manager, AdventHealth Sports Medicine & RehabWinter Park, Florida

Disclosure Statement

It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest. If conflicts are identified, they are resolved prior to confirmation of participation. Only participants who have no conflict of interest or who agree to an identified resolution process prior to their participation were involved in this CME activity.

All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose.

Learning Objectives1. Provide an overview of the recommendations contained within

the STEADI Initiative to prevent falls. 2. Implement a fall risk screening and prevention program within

your practice. 3. Review the following fall risk evaluation tests: The Timed Up

and Go (TUG) test, 30-second Chair Stand test, and 4-Stage Balance test

FallsDefinition: coming to rest unintentionally on the ground or at a

lower level, not due to an acute event. 1 in 3 adults ≥ age 65; 1 in 2 ≥ age 80, report falling each year Common threat to independenceNearly 60% had prior fall, only 1 in 4 disclose to physicianAssoc w/ decline in function, nursing home placement, fear of

falling Leading cause of fatal and nonfatal injury in older adultsDeath rate due to falls increases with age, injurious falls are more

common in women but mortality highest in men age ≥ 85.

Evidence suggests risk of falling can be reduced 20-40% Family physicians must be proactive in primary and secondary

screening and evidence-based recommendations Fall Screening is included in Medicare Wellness VisitsQuality Metrics The CDC’s STEADI is a coordinated approach to implementing

the American and British Geriatrics Societies’ clinical practice guideline STEADI algorithm includes Fall Risk Screening, Assessment

and Intervention and outlines how to implement these 3 elements

Case: Mr. T is an 81 yo man comes to the office for pre-op evaluation for knee

replacement. He and his wife live independently at home. Denies recent fall on intake sheet PMHx- atrial fibrillation, HTN, BPH, OA PSHx- pacemaker, cataract removal ou Meds: apixaban 5mg bid, metoprolol succinate100 mg, tamsulosin,

MVI with 800 iu Vit D Exam: BP 135/80, drops to 110/70 upon standing 1 min.

Pulse 70 sitting, 75 standing. Bruising noted on his outer forearm. Admits to catching himself from falling

last week heading to the bathroom at night You realize you need to address his fall risk and use the STEADI

algorithm.

AES Question

Question 1

Which is not one of the 3 key STEADI screening questions?

A. Have you fallen in the past year? B. Have you been advised to use a cane or walker to get

around safely? C. Do you feel unsteady when standing or walking? D. Are you worried about falling?

“It’s not the broken hip, it’s the nursing home I don’t want. I need to be independent, so I take Tai Chi.” Leonard Jones, age 74

People who use canes are brave. They can be more independent and enjoy their lives.” Shirley Warner, age 79

www.cdc.gov/steadi

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Fall Risk Screening Approaches

How often? AGS recommends person ≥ 65 be asked yearly if they have fallen 2 or more times, were injured in a fall, or have difficulties with walking or balance.

Screening for falls

Risk Factors Falls usually result from a combination of impairments,

modifiable and non-modifiable, intrinsic and extrinsic. Greatest risk factors: psychoactive meds, impaired gait, lack of

lower-extremity strength and balance and cognitive impairment Injurious falls most common in women, cognitive impairment,

several chronic conditions and low body wt. The greater the number of risk factors, the more likely to fall and

to fall with injury.

Timed Get Up and Go (TUG)Equipment: Stopwatch, Chair, distance of 10 ft marked on floorMay use a walking aid. Patient sits back in a standard arm chair. Instruct patient to stand, walk to line on floor, turn, walk back

and sit down again.Adult who takes ≥12 seconds is at risk for falling

Chair RiseEquipment: chair and stopwatch Instruct patient to sit in the middle of the chair. Place hands on the opposite shoulder,

arms against chest, feet flat on the floor. On “Go,” rise to a full standing position,

then sit back down again. Repeat this for 30 seconds.

4 Stage Balance If the patient can hold a

position for 10 seconds go on to the next position. If not, STOP the test. Not to use assistive

device Keep Eyes open

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Risk factors, assessment tools, and intervention strategies

Review for High Fall Risk Medications

Address orthostatic hypotensionOptimize BP meds including alpha blockers, ie: tamsulosinAvoid over diuresing including for non-HF edema

Avoid high risk meds:Benzodiazepines and non-benzo receptor agonist

(ie: zolpidem) antipsychotics, anticonvulsants, TCAs, SSRIs, Opioids

Avoid combining benzodiazepines, opioids, EtOH

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Role of Vit D and Calcium in Fall PreventionGuidelines conflict whether Vit D supplementation is effective for

fall preventionAGS and STEADI recommend Vit D 800-1000 iu/dayCochran review- Vit D supplementation not shown to reduce fallsUSPSTF- not recommend for adults without osteoporosis or Vit

D deficiency, due to a large trial showed Vit D 500,000 iuannually increased risk of falls and fractures among community dwelling older adults

STURDY(Study to Understand Fall Reduction and Vit D in You)NIH funded to determine whether Vit D supplementation

reduces falls in community-dwelling adults ≥ 70 who are at elevated risk for falls and have 25(OH)D levels 25-72.5 nmol/LControl group Vit D3 200 iu vs 1,000, 2000, and 4,000 iu/d 2,000 and 4,000 iu groups greater risk for hsop or death than

the 200 iu. 1,000 iu group few falls than the 2,000 and 4,000 iu groups No significant difference between 1,000 and 200 iu groups. No benefit from higher doses, concerns higher doses

deleteriousAppel,L; Michols,E, et al. The Effects of Four doses of Vitamin D Supplements

on Falls in Older Adutls. Ann Intern Med. 2021;174:145–156.

Lab and Diagnostic Testing Tests and procedures guided by H&P: Echo, brain imaging,

radiographic studies of spineConsider: Hgb, TSH, BUN, creatinine, glucose

25-hydroxy Vit D, Vit B12 DXAHolter Monitor: not proven for routine eval of fall

Communicating with patients using the Fall Prevention Stages of Change model

Back to case: Mr T Falls Risk testing: TUG 15 seconds Chair rise- unable to perform due to knee pain 4 Stage Balance- unable to tandem stand without holding on

Mr T attributes his fall to his “bad knee” and feels he will not be at risk of falling once he has his knee replaced. He welcomes your suggestion to decrease his metoprolol succ to 50 mg due to orthostatic BP.

AES Question

Question 2

Which of the following would most likely reduce Mr.T’s fall risk after his knee replacement?

A. Upper body strength training B. LE strength and balance training in Physical TherapyC. Increase Vit D dose to 2,000 iu/ dayD. Referral to a community exercise program

When to Refer to PT? If patient fails a fall risk screening:STEADI questions Mobility performance tests Unsteadiness? Pain? Orthopedic complaints?

If pass mobility tests: Refer to Community Exercise Program

How do I refer to PT?Write “Eval and Treat” on referral for physical therapyCommon ICD 10 Codes:R26.8 Other abnormalities of gait and mobilityR26.9 Unspecified abnormalities of gait and mobilityM62.81 Muscle weakness (generalized)M81.0 Age-related osteoporosis without current pathological

fractureM85.8 Other specified disorders of bone density and structure

(osteopenia)

The PT EvalOne-on-one session with patientReviews medical intake, including past medical history, meds,

co-morbidities with subjective questioning Motivational interviewing, assessing for yellow flags including

fear of falling & kinesiophobiaSystems-level screen & neuro-screen for red flags Differential MSK evaluation for addt’l ortho. complaintsHome environment & safe assistive device use

The PT Eval cont’d Repeat measures you performed in clinic Strength and power assessments: Upper quarter Lower quarter

Balance assessment: Static Dynamic

The Plan of Care (POC) Following PT evaluation, POC will be faxed to you for signature Must be signed for Medicare 2021 Medicare = $2,110 for PT, OT, and Speech combined Approx. > 25 sessions No longer a hard cap – but must be medically necessary

Typically 2x/week for 4-6 weeks ~45min to 1 hour Average of 10-12 visits for gait & balance patients More visits allowed for addt’l ortho complaints or more complex

PT InterventionsAgility & gait (re)training

PT Interventions cont’dBalance training

PT Interventions cont’dStrengthening

Discharging from PTRe-assessment of strength,

power & balance Meeting of goals?Personalized home exercise

program (MedBridge)Home Health/maintenance Transition to wellness

program

Lifelong Behavior ChangeEncourage physical activity in the older adult Strengthening, flexibility, and now balance trainingBalance training: Standing balance activities 3x/week, until >50hr

“Brushing teeth”

Andréasson K Hesselstrand R. Fall Prevention in Community-Dwelling Older Adults. N Engl J Med. 2020; 382 (26): 2579-2582. https://www.ncbi.nlm.nih.gov/pubmed/32579828. doi:10.1056/NEJMc2005662.

Evidence

20-60% reduction in falls following balance training

What is your patient doing to improve their balance?

AES Question

Question 3After being discharged from physical therapy, Mr. T returns to you for a future follow-up and expresses his concern of regressing to his old sedentary habits. He asks you: what should he do to focus on improving his balance now?

A. Tell him to do some flexibility exercises to improve his balance.B. Tell him to do a walking program and upper extremity

strengthening.C. Encourage patient to participate in exercise program given by

physical therapist, keep up with his balance training for ~3min/day and join a community wellness program.

D. Defer the question to your medical assistant to answer.

Establish patient goals for reducing fall risk: • List the patient’s (& family’s) priorities Checklist of recommended interventions:• include reason for the intervention (e.g., gait disturbance, low vision) • Phone numbers for referralsEstablish follow-up plans:• Phone calls from nurses, pharmacist/primary care provider appointments, etc.Identify red flags: • Know when to share & notify the primary care team (e.g., pain with exercise,

dizziness, adverse symptoms due to medication reduction). Use of the EHR problem list:• Briefly summarize the patient’s fall risk and recommended interventions

Summary: Practice Recommendations-Implement a fall risk screening and prevention program in your office-Screen patients age ≥ 65 for fall risk in your office using the 3 question survey or self-assessment fall survey-Assess patients at risk to identify their specific fall risk factors -Intervene to address modifiable risk factors including:

- Provide referrals to ophthalmology, podiatry- Prescribe Physical Therapy or community fall program for gait

and balance exercises

Summary: Practice RecommendationsReview for High Fall Risk Medications Address orthostatic hypotensionOptimize BP meds including alpha blockers, ie: tamsulosinAvoid over diuresing including for non-HF edema

Avoid high risk meds:Benzodiazepines and non-benzo receptor agonist

(ie: zolpidem) antipsychotics, anticonvulsants, TCAs, SSRIs, Opioids

Avoid combining benzodiazepines, opioids, EtOH

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References: Aartolahti E, Häkkinen A, et al. A. Long-term strength and balance training in

prevention of decline in muscle strength and mobility in older adults. Aging Clin Exp Res. 2020; 32 (1): 59-66. https://www.ncbi.nlm.nih.gov/pubmed/30830597. doi:10.1007/s40520-019-01155-0. Afridi A, Rathore FA Nazir SNB. Wii Fit for Balance Training in Elderly: A Systematic

Review.J Coll Physicians Surg Pak. 2021; 30 (5): 559-566. https://www.ncbi.nlm.nih.gov/pubmed/34027869. doi:10.29271/jcpsp.2021.05.559. American Geriatrics Society 2015 Beers Criteria Update. JAGS 63; 2227-2246 Andréasson, K Hesselstrand R. Fall Prevention in Community-Dwelling Older

Adults. N Engl J Med. 2020; 382 (26): 2579-2582. https://www.ncbi.nlm.nih.gov/pubmed/32579828. doi:10.1056/NEJMc2005662 Appel,L; Michols,E, et al. The Effects of Four doses of Vitamin D Supplements on

Falls in Older Adutls. Ann Intern Med. 2021;174:145–156. doi:10.7326/M20-3812 In the Clinic, Fall Prevention in Community Older Adults, Annals of Int Medicine, Dec

4, 2018.

References continued: Mohamed AA, Jan YK. Effect of Adding Proprioceptive Exercise to Balance

Training in Older Adults with Diabetes: A Systematic Review. Curr Diabetes Okubo Y, Sturnieks DL, et al. Effect of Reactive Balance Training Involving

Repeated Slips and Trips on Balance Recovery among Older Adults: A Blinded Randomized Controlled Trial. J. Gerontol. Ser. A Biol. Sci. Med. Sci. 2019; 74 (9): 1489-1496. http://biomedgerontology.oxfordjournals.org/. doi:10.1093/gerona/glz021. Papalia GF, Papalia R, et al. The Effects of Physical Exercise on Balance and

Prevention of Falls in Older People: A Systematic Review and Meta-Analysis. J Clin Med. 2020; 9 (8): 2595. https://www.ncbi.nlm.nih.gov/pubmed/32796528. doi:10.3390/jcm9082595. Phu S, Vogrin S, Al Saedi A, et al. Balance training using virtual reality improves

balance and physical performance in older adults at high risk of falls.Clin IntervAging. 2019; 14: 1567-1577. https://www.ncbi.nlm.nih.gov/pubmed/31695345. doi:10.2147/CIA.S220890.

References continued: Rev. 2020;16(4):327-339. doi:10.2174/1573399815666190712200147 Rogers MW, Creath RA, et al. Comparison of Lateral Perturbation-Induced Step

Training and Hip Muscle Strengthening Exercise on Balance and Falls in Community Dwelling Older Adults: A Blinded Randomized Controlled Trial.JGerontol A Biol Sci Med Sci. 2021;. doi:10.1093/gerona/glab017. Thomas E, Battaglia G, Patti A, et al. Physical activity programs for balance and

fall prevention in elderly - A systematic review. Medicine (Baltimore). 2019; 98 (27): e16218. https://www.ncbi.nlm.nih.gov/pubmed/31277132. doi:10.1097/MD.0000000000016218. Zouita S, Zouhal H, et al. Effects of Combined Balance and Strength Training on

Measures of Balance and Muscle Strength in Older Women With a History of Falls. Front Physiol. 2020; 11. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7786296/. doi:10.3389/fphys.2020.619016

Answers1. B2. B 3. C