1. FALLS PREVENTION for Seniors Miriam Klassen, MD, MPH Medical Officer of Health Perth District Health Unit September 27, 2012

2. Falls Prevention for Seniors It is estimated that one in three seniors will fall at least once per year (WHO, 2007) This is a complex problem that requires a complex solution

3. Health Canada

4. Overview Definitions Injury in Canada Unintentional injury in Canada Falls Falls in seniors Economic burden of falls in seniors Falls in seniors in Huron and Perth Risk factors for falls in seniors Prevention of falls in seniors (screening, assessment, intervention)

5. Definitions Injury: "unintentional or intentional damage to the body resulting from acute exposure to thermal, mechanical, electrical, or chemical energy or from the absence of such essentials as heat or oxygen." (CDC, m 2011 ) Predictable and preventable Intentional injury occurs as a result of intent to harm oneself or others - Includes murder, acts of interpersonal violence, and intentional self- inflicted injuries or suicides Unintentional injury (UI) occurs in the absence of any harmful intent - Includes falls, motor vehicle crashes, drowning and suffocation, poisoning and fires - Very responsive to prevention

6. Definitions Fall: “sudden, unintentional change in position resulting in an individual landing at a lower level such as an object, the floor or the ground, with or without injury” (PHAC, 2009) Seniors: “Canadians aged 65 years and older”

7. Definitions Direct costs: “all the goods and services used for the diagnosis, treatment, continuing care, rehabilitation, and terminal care of people experiencing a major illness or impairment” Indirect costs: “indirect costs are societal productivity losses, which account for the injured individual’s inability to perform his or her major activities” Intangible costs: pain and suffering, economic dependence and social isolation

8. Injury in Canada Injury is predictable and preventable Injury death rate in Canada fell by 10.9% from 1995 – 2004 (SMARTRISK, 2009) Image from CDC. Retrieved from:http://phil.cdc.gov/phil/details.asp

9. Injury prevention pays off (SMARTRISK, 2006) $1 invested in painting traffic lines on roads saves $61 $1 invested in front seat belts for vehicles saves $49 $1 invested in functional family therapy for at risk youth saves $32 $1 invested in smoke detectors saves $15 $1 invested in Big Brother/Big Sister mentoring for violence prevention saves $5 $1 invested in intensive sobriety checkpoint campaigns saves $3

10. Injury in Canada (SMARTRISK, 2009) Summary of findings, all injury, Canada, 2004 (SMARTRISK, 2009) Injury deaths Hospitalized Treatment Non- hospitalized treatment Permanent Partial disability Permanent Total Disability Total Cost $10.72 b direct health care = 54% $9.06 b indirect 13,667211,7683,134,02562,5635,023$19.8 billion

11. Unintentional injury UI is the 6 th leading cause of death in Canada UI is the #1 cause of death for those aged 1 to 34 yrs (PHAC, m 2008) UI accounts for 81% of all injury costs = $16.01 billion in 2004 (SMARTRISK, 2009)

12. Falls Falls are the third most common cause of all injury deaths Falls are the second most common cause of UI deaths Number of fall-related deaths, hospitalizations, non-hospitalizations and related disability cases, Canada, 2004 (SMARTRISK, 2009) Deaths Hospitalized treatment Non- hospitalized treatment Permanent Partial disability Permanent Total Disability 2,225105,565883,67629,5762,500

13. Falls (SMARTRISK, 2009) Falls accounted for 50% of all injuries resulting in hospitalization Falls were the leading cause of injuries resulting in permanent partial and total disability Falls were the leading cause of overall injury costs, accounting for 6.2 billion or 31% of total costs (4,457 b direct and 1.698 b indirect)

14. Falls in seniors Falls are the most common injury in seniors Cause of injury for emergency department visits and hospitalizations among seniors, Ontario 2004/5 (OIPRC, 2007) Emergency Department Visits Hospitalizations Number% % All UI146,23630,893 Falls86,8205924,64780 * Assumption that falls are unintentional

15. Falls in seniors (SMARTRISK, 2009) In Canada, among all falls, falls in those ≥ 65 yrs accounted for: 84% of deaths 59% of hospitalizations 53% of permanent partial disability 54% of permanent total disability

16. Falls in seniors (OIPRC, 2007) Every 10 minutes in Ontario, at least one senior visits an emergency department due to a fall. Every 30 minutes in Ontario, at least one senior is admitted to hospital due to a fall Rates of falls and fall-related injuries among seniors are higher for females Rates of fall-related injury among seniors increase with age, with the highest rates reported for those 90 years of age and older, for both emergency department visits and hospitalizations.

17. Falls in seniors (OIPRC, 2007) Among Ontario seniors who were hospitalized due to a fall in 2004/5: 38% were discharged to their place of residence (includes seniors who were discharged home with home care services) 26% were transferred to another inpatient facility 26% were transferred to a long-term care facility 7% of seniors died during their hospital stay.

18. Falls in seniors (OIPRC, 2007) Lower limb was the most common site of injury followed by injury to upper limb for both emergency room visits and hospitalizations Hip fracture was the leading cause of hospitalization Slips/trips on same level most common mechanism, followed by: stairs/steps, involving furniture, involving snow/ice

19. Falls in seniors (OIPRC, 2007) In 2007, 1.6 million Ontarians were 65 years or older (about 13% of the population) It is estimated that, by 2031, this will increase to 25% (or approximately 3.5 million seniors) Therefore, by 2031, there would need to be the equivalent of five new acute care hospitals built, each with 200 beds, solely to accommodate the additional seniors hospitalized with an injury.

20. Pattern of falls in seniors (PHAC 2005) Injurious falls: F > M Living alone > living with someone ↑ with income < $15,000 ↑ with higher education ↑ with age (fall-related injury rate is 9X higher for those aged ≥ 65 years than among those < 65 years) Falls cause > 90% hip fractures in seniors and 20% die within one year of hip fracture 40% of nursing home admissions are due to falls

21. Pattern of falls in seniors (PHAC 2005) Location of falls: Home (47%) Other (25%) Residential institution (21%); only 7.4% of seniors ≥ 65 yrs live in institutions Public Building (4%) Street (2%) Recreational (1%)

22. Economic analysis Economic analysis completed from a societal point of view Incidence costing Intangible costs not quantified The costs, both direct and indirect, were discounted to a present value in 1999 at 3% per annum. Indirect costs included only foregone earnings calculated as average earnings, adjusted by the participation rate and unemployment rate, over the relevant period within the working life of an individual from ages 15 to 64 years inclusive. A real wage growth rate of 1% per year was assumed

23. Economic burden of falls in ‘seniors’ in Ontario In Ontario, the estimated annual cost of falls is > $1.9 billion (SMARTRISK, 2006) Adults 55 years of age and older accounted for $962 million, or almost half that cost A review of programs and strategies have demonstrated effectiveness, reducing falls by 20% or more A 20% reduction of falls in those aged 55 years and older could prevent 1000 permanent disabilities and 4000 hospitalizations, saving $121 million in direct health care costs With regard to indirect costs, seniors contribute significantly via volunteering and family support

24. Perth and Huron County Demographics, 2011 (Statistics Canada) The Canadian Population 2011 (Statistics Canada, 2012) CanadaOntarioHuronPerth Median Age40.6 40.4 45.141.2 0-14 years23.317.0 17.118.3 15-64 years68.568.4 63.165.2 65+ years14.814.6 19.816.5

25. Fall-related hospitalizations among seniors Initial Report of Public Health 2009 * = mainly rural ** = urban centre other = urban/rural

26. Source: IntelliHEALTH, Ambulatory All Visit Problem Dx and External Cause (interim) (NACRS), MOHLTC, ONTARIO, extracted on: July 19, 2012 Figure 1. The rate of ER visits due to falls (per 100,000) by Perth County female and male seniors, 2007-2010

27. Figure 2. The rate of ER visits due to falls (per 100,000) by Huron County female and male seniors, 2007-2010 Source: IntelliHEALTH, Ambulatory All Visit Problem Dx and External Cause (interim) (NACRS), MOHLTC, ONTARIO, extracted on: July 19, 2012

28. Figure 3. The rate of ER visits due to falls (per 100,000) by Huron County and Perth County seniors, 2007-2010 Source: IntelliHEALTH, Ambulatory All Visit Problem Dx and External Cause (interim) (NACRS), MOHLTC, ONTARIO, extracted on: July 19, 2012

29. Figure 4. Rate of ER visits due to falls (per 100,000) by Huron County and Perth County seniors, 2007-2010 Source: IntelliHEALTH, Ambulatory All Visit Problem Dx and External Cause (interim) (NACRS), MOHLTC, ONTARIO, extracted on: July 19, 2012

30. Figure 5. Places of falls by Huron County and Perth County seniors Source: IntelliHEALTH, Ambulatory All Visit Problem Dx and External Cause (interim) (NACRS), MOHLTC, ONTARIO, extracted on: July 19, 2012

31. Risk Factors Personal/Environmental Modifiable/Non-modifiable > 400 Falls risk factors documented in the literature to date (LHINC, 2011) History of fall(s)

32. Risk factors for falls (LHINC, 2011)

33. Screening and assessment Depends on level of risk Numerous validated tools available (TUG, Morse Fall Scale, Berg Balance Scale) Can be administered in different settings by health care providers either independently or as part of a team (physicians, nurses, pharmacists etc) - Community setting: volunteers, primary care, fall clinics, teams - Home-based: CCAC

34. Interventions BEEEACH Model (CFPC = Canadian Falls Prevention Curriculum) Behavior Change (client and many others) Education Provision of Equipment Changing Environment Activity Clothing and Footwear Health Management (medications: Beer’s Criteria) Image from CDC. Retrieved from: http://phil.cdc.gov/phil/quicksearch.asp

35. Interventions: What does the evidence show? It is complicated! Exercise –based interventions for community (active aging) and in-patient settings, possibly LTCH Multifactorial interventions for residential (in one study) and community settings, and ? in-patient Home modification for some community groups (frail elderly, visually impaired) Vitamin D in LTCF and ? some community groups

36. Interventions Policy should provide the infrastructure and support essential to a comprehensive and integrated approach to falls prevention. (WHO, 2007) Co-ordinated, community wide, multi-strategy initiatives have been shown to reduce fall-related injuries in seniors by up to 33% (McClure, 2005) $1 invested in comprehensive community based fall prevention for high risk seniors saves $7 (SMARTRISK, 2009) “It takes a village”

37. Retrieved from: http://www.alphaweb.org/docs/lib_014321248.pdf Integrated Provincial Falls Prevention Framework & Toolkit July 2011

38. References Centres for Disease Control (CDC). (modified 2010). Healthy youth! Injury and violence (including suicide). Author. Retrieved from: http://www.cdc.gov/healthyyouth/injury/facts.htm Local Health Integration Network Collaborative (LHINC). (2011). Integrated falls prevention framework and toolkit. Government of Ontario. McClure, R. et al.. (2005). Population-based interventions for the prevention of fall-related injury in older people. Intervention Review Cochrane Library. Retrieved from: http://www.mrw.interscience.wiley.com.proxy.lib.uwaterloo.ca/cochrane/clsysrev/articles/CD004441/frame.htmlhttp://www.mrw.interscience.wiley.com.proxy.lib.uwaterloo.ca/cochrane/clsysrev/articles/CD004441/frame.html Ministry of Health and Long-Term Care (MOHLTC). (2009). Initial report on public health. Author. Public Health Division. Retrieved from: http://www.google.ca/search?sourceid=navclient&aq=0&oq=initial+repor&ie=UTF- 8&rlz=1T4ADRA_enCA467CA468&q=initial+report+on+public+health+2009&gs_upl=0l0l0l3359lllllllllll0&aqi=g4&pbx=1 Ontario Injury Prevention Resource Centre (OIPRC). (2007). Injuries in seniors in Ontario: A descriptive analysis of emergency department and hospitalization data. Author. Retrieved from: http://www.oninjuryresources.ca/downloads/seniors_report.pdf Public Health Agency of Canada (PHAC). (modified 2008). Leading causes of death and hospitalization in Canada: Table 1. Author. Retrieved from: http://www.phac-aspc.gc.ca/publicat/lcd-pcd97/table1-eng.php Public Health Agency of Canada (PHAC). (2005, modified 2009). Report of seniors’ falls in Canada. Author. Retrieved from: http://www.phac- aspc.gc.ca/seniors-aines/alt-formats/pdf/publications/pro/injury-blessure/seniors_falls/seniors-falls_e.pdf SMARTRISK. (2009) The economic burden of injury in Canada. Author. Retrieved from: http://www.smartrisk.ca/downloads/burden/Canada2009/EBI-Eng-Final.pdf http://www.smartrisk.ca/downloads/burden/Canada2009/EBI-Eng-Final.pdf SMARTRISK. (2006). The economic burden of injury in Ontario. Author. Retrieved from: http://www.smartrisk.ca/downloads/burden/EBI-Ont- 2006.pdfhttp://www.smartrisk.ca/downloads/burden/EBI-Ont- 2006.pdf Statistics Canada. (2012). Census Profile. 2011 Census. Statistics Canada Catalogue no. 98-316-XWE. Ottawa. Released February 8 2012. Retrieved from: http://www12.statcan.gc.ca/census-recensement/2011/dp-pd/prof/index.cfm?Lang=E World Health Organization (WHO). (2007). WHO global report on falls prevention in older age. Retrieved from: http://www.who.int/ageing/publications/Falls_prevention7March.pdf http://www.who.int/ageing/publications/Falls_prevention7March.pdf