Falls are Fatal Tan Maw Pin Division of

  • Slides: 20
Download presentation
Falls are Fatal Tan Maw Pin Division of Geriatric Medicine Department of Medicine Faculty

Falls are Fatal Tan Maw Pin Division of Geriatric Medicine Department of Medicine Faculty of Medicine University of Malaya

CONTENTS n Falls in Malaysia n Epidemiology n Risk factors n Prevention strategies n

CONTENTS n Falls in Malaysia n Epidemiology n Risk factors n Prevention strategies n My. FAIT study

FALLS IN OLDER MALAYSIANS (MELo. R) (n=1520) 30% 26% 18% 22% 10% 0% Malays

FALLS IN OLDER MALAYSIANS (MELo. R) (n=1520) 30% 26% 18% 22% 10% 0% Malays Indians Chinese Alex D et al. in progress

Tan MP et al. Publication pending

Tan MP et al. Publication pending

Tan MP et al. Publication pending

Tan MP et al. Publication pending

is k e H n io su az al ar Im ds Va pa

is k e H n io su az al ar Im ds Va pa so irm va ga en l. S t yn Po co pe or fo ot w O ea st eo r ar Fo th rit o H t is P ea r ob rin le g m im Si s pa tu at irm io Pe na en rip l t sy he nc ra op ln e e Sp ur op in al at hy co rd le si on St ro Pa ke rk in so n' s Vi om nc e 60% te ns yp o 70% H H g ru D 80% Ba la ng %total 90% tic ai t& G ea si In cr os ta R rth O lls Fa My. FAIT (Malaysian Falls Assessment and intervention Trial) n=264 78% 60% 59% 50% 40% 31% 30% 20% 10% 25% 23% 17% 18% 10% 8% 7% 4% 3% 2% 0% Tan PJ et al. BMC Geriatrics 2014; 14 (1): 1

Antihypertensives do not increase FALLS *Odds ratios adjusted for age and comorbidites Zia et

Antihypertensives do not increase FALLS *Odds ratios adjusted for age and comorbidites Zia et al. Eur J Clin Investigations 2015; 45 (10), 10691076

≥ 2 FRIDS ACCOUNT FOR FALLS in Polypharmacy n n n *adjusted for age,

≥ 2 FRIDS ACCOUNT FOR FALLS in Polypharmacy n n n *adjusted for age, gender, BMI, Comorbidities (Diabetes, Hypertension , Depression, Thyroid diseases, Eye diseases Vascular diseases; **adjusted for age, gender, BMI, Comorbidities (Diabetes, Hypertension , Depression, Thyroid diseases, Eye diseases , Circulatory diseases), Supine blood pressure, Timed up and go, Functional reach and Grip strength. Fallers (n=202): recurrent or injurious falls in past 12 months Controls (n=156) Polypharmacy no longer associated with falls postadjustment for all confounders ≥ 2 FRIDs is an independent risk factor falls If individuals with ≥ 2 FRIDs were excluded, polypharmacy no longer associated with falls. Zia et al. Geriatr Gerontol Int. 2016 Early online publication

ANTICHOLINERGIC COGNITIVE BURDEN IS associated with falls Score 1 (n=112) Medications Number Atenolol 33

ANTICHOLINERGIC COGNITIVE BURDEN IS associated with falls Score 1 (n=112) Medications Number Atenolol 33 Captopril 1 Colchicine 8 Dipyridamole 1 Digoxin 2 Furosemide 10 Fluvoxamine Hydrocortisone 2 2 Score 2 (n=2) Medications Number Carbamazepine 2 Score 3 (n=17) Medications Number Amitriptyline 5 Chlorpheniramin 5 e Dimenhydrinate 2 Orphenidrine 3 Metoprolol Nifedipine Prednisolone Ranitidine Theophylline 26 10 4 9 4 Olanzapine Prophenazine 1 1 • n=428 (cases=263; controls=165) • ACB ≥ 1: OR(95%CI)=1. 8(1. 1 -3. 0) ACB≥ 1 30% 28% 25% 18% 20% 15% 10% 5% 0% Fallers Non-fallers Zia et al. Maturitas. 2016; 84: 3237

potentially Inappropriate Prescriptions are associated with falls * 59% n n n=428 (fallers=263; non-fallers=165)

potentially Inappropriate Prescriptions are associated with falls * 59% n n n=428 (fallers=263; non-fallers=165) STOPP/START 2 criteria 37% Fallers 22% 23% Controls 19% 18% 8% 1 *p<0. 001 2 6% ≥ 3 ≥ 1 Zia et al. 2016 (under review)

SBP drop Among Fallers 90 80 SBP* (mm. Hg) 70 60 50 40 30

SBP drop Among Fallers 90 80 SBP* (mm. Hg) 70 60 50 40 30 20 10 0 *continuous BP measurements Fallers (n=117) Non-Fallers (n=89) Saedon et al. Clin Autonomic Research 2017

Minimal Standing SBP Fallers (n=202) Non-fallers P-value (n=156) Min SBP*, mean (SD) 128(27. 3)

Minimal Standing SBP Fallers (n=202) Non-fallers P-value (n=156) Min SBP*, mean (SD) 128(27. 3) 135. 7(24. 7) 0. 01 b Min DBP, mean (SD) 67(16. 7) 69. 8(17. 3) 0. 13 OH, n(%) 52(25. 7) 28(17. 9) 0. 08 *Manual SBP measurements Zia et al. Eu J Clin Inv 2015.

ECG changes and Falls ECG Fallers paramet er PR 179 (32) interval, mean (SD)

ECG changes and Falls ECG Fallers paramet er PR 179 (32) interval, mean (SD) QTc 449 (41) interval *adjusted for dizziness Nonfallers P-value Adjuste d Pvalue* 168 (27) 0. 013 0. 941 443 (39) 0. 008 0. 063 Izzati et al. CAR 2017

My. FAIT (Malaysian Falls Assessment and Intervention Trial) Age ≥ 65 yrs 2 falls

My. FAIT (Malaysian Falls Assessment and Intervention Trial) Age ≥ 65 yrs 2 falls or 1 injurious fall Individually-Tailored 6 component intervention: Otago, HOMEFAST Cardiovascular, Vision, Medications, Education Tan PJ et al. Under Review Control: Conventional Treatment + Health Advice Fall Recurrence (Monthly Diaries + Follow-Up Visit)

Changes in TUG, Functional Reach and Grip Strength with 6 months of Otago among

Changes in TUG, Functional Reach and Grip Strength with 6 months of Otago among Older Fallers in My. FAIT Improved 6 5 4 3 2 Intervention 1 Control Worsened 0 -1 -2 -3 -4 TUG *p<0. 05 FR* Right Hand Grip* Left Hand Grip* Liew et al. JGPT 2017 publication pending

Barriers to Implementation of Falls Prevention Research Prioritie s Not serious Accessibility of Referrals

Barriers to Implementation of Falls Prevention Research Prioritie s Not serious Accessibility of Referrals Old age Patient s Loganathan et al. BMJ Open 2015; 5: e 008460. Loganathan et al. BMC Geriatrics 2016; 16: 97 Reject Home Modification s Syste m Skills HCP Traditional Healers Caregi ver support Comm unicati on

Survey of Family Physicians in Malaysia (n=112) Falls Practice Response Barriers Respons e Routinely

Survey of Family Physicians in Malaysia (n=112) Falls Practice Response Barriers Respons e Routinely ask about falls 46% Time constraints 70% Unfamiliar with guidelines 70% 57% BP medications screening 71% More immediate demands TUG test screening 12% No training 53% No educational material 49% 41% Screening Knowledge Jaafar et al. under review Gait/Balance important 94% Too many other diagnoses Footwear important 36% Too many other patients 38% Management Advise/Family Support 57% No nurse to delegate to 31% Patient denial 20% Payment too low 16%

Falls and Syncope Service, UMMC Published with permission. n n Started in July 2015,

Falls and Syncope Service, UMMC Published with permission. n n Started in July 2015, 200 new patients to date Referral via ED, Primary Care, Outpatients, Orthopaedics, Medical Wards Gan et al. MJM 2017

Summary Falls are potentially fatal n Falls are multifactorial n Drugs have become the

Summary Falls are potentially fatal n Falls are multifactorial n Drugs have become the most common risk factor falls n Falls risk increasing drugs and anticholinergic burden n Lower standing blood pressure is associated with falls n Otago exercises improve functional outcomes in fallers n Multifactorial intervention for falls is inhibited by systemic issues in Malaysia n

acknowledgements My. FAIT investigators: Philip Poi Imran Zainal Abidin Shahrul B Kamaruzzaman Chee Kok

acknowledgements My. FAIT investigators: Philip Poi Imran Zainal Abidin Shahrul B Kamaruzzaman Chee Kok Han Chin Ai-Vyrn Mazlina Mazlan Khoo Ee Ming Keith Hill (Curtin) Idzwan Zakaria Lynette Mac. Kenzie Nurliza Khalidin (Sydney) Norlina Ramli Karen Morgan (RSCI) Norlisah Ramli Ng Chin Teck Our community partners: Special Thanks to: Dr Anam Zia, Ph. D student, UM 20132016 Miss Tan Pey June, Ph. D student, UM Ms Sumaiyah Mat, Ph. D student, UM Miss Nemala Nalathamby, Masters student, UM Miss Puvaneswary Subramaniam, Masters student, UM Mr Hasif Jaafar, Ph. D student, UM Miss Syazwana, Research Assistant UM Ms Teh Inn Lim, part-time data manager Miss Lee Siew Inn, part-time administrator Dr Anita Codati, psychiatrist Dr Izzati Saedon, lecturer, UM Dr Khor Hui Min, senior lecturer, UM Puan Norfazilah Khannas, OT, UMMC En Lokman Abd Majid, Physio, SS 20 Residents’ Association Life Chapel Seniors Heritage Centre Subang Jaya Buddhist Association Funding: University of Malaya Research Programme Grant (RP-010 -2012) MOSTE Sciencefund (SF 017 -2013) Grand Challenge Fund (GC 002 -14 HTM)