Arch Osteoporos (2017) 12:96 https://doi.org/10.1007/s11657-017-0393-5

SHORT COMMUNICATION

Implementation of a fall screening program in a high risk of fracture population Katherine Ritchey 1 & Amanda Olney 2 & Jane Shofer 1 & Elizabeth A. Phelan 3 & Alvin M. Matsumoto 1

Received: 22 June 2017 / Accepted: 18 October 2017 # International Osteoporosis Foundation and National Osteoporosis Foundation 2017

Abstract Summary Fall prevention is an important way to prevent fractures in person with osteoporosis. We developed and implemented a fall screening program in the context of routine osteoporosis care. This program was found to be feasible and showed that a significant proportion of persons with osteoporosis are at risk of falling. Purpose Falls are the most common cause of fracture in persons with osteoporosis. However, osteoporosis care rarely includes assessment and prevention of falling. We thus sought to assess the feasibility of a fall screening and management program integrated into routine osteoporosis care. Methods The program was developed and offered to patients with osteoporosis or osteopenia seen at an outpatient clinic between May 2015 and May 2016. Feasibility was measured by physical therapist time required to conduct screening and ease of integrating the screening program into the usual clinic workflow. Self-report responses and mobility testing were conducted to describe the fall and fracture risk profile of osteoporosis patients screened. Effects on fall-related care processes were assessed via chart abstraction of patient participation in fall prevention exercise.

Results Of the 154 clinic patients who presented for a clinic visit, 68% met screening criteria and completed in two thirds of persons. Screening was completed in a third of the time typically allotted for traditional PT evaluations and did not interfere with clinic workflow. Forty percent of those screened reported falling in the last year, and over half had two or more falls in the past year. Over half reported a balance or lower extremity impairment, and over 40% were below norms on one or more performance tests. Most patients who selected a group exercise fall prevention program completed all sessions while only a quarter completed either supervised or independent home-based programs. Conclusions Implementation of a fall risk screening program in an outpatient osteoporosis clinic appears feasible. A substantial proportion of people with osteoporosis screened positive for being at risk of falling, justifying integration of fall prevention into routine osteoporosis care. Keywords Fall screening . Fracture prevention . Quality improvement . Fall prevention

Introduction * Katherine Ritchey [email protected]

1

Geriatric Research, Education, Clinical Center, Veteran’s Affairs Puget Sound Health Care System, 1660 S. Columbian Way, S-182-GRECC, Seattle, WA 98108, USA

2

Rehabilitation Care Services, Veteran’s Affairs Puget Sound Health Care System, 1660 S. Columbian Way, S-117-RCS, Seattle, WA 98108, USA

3

Division of Gerontology & Geriatric Medicine, University of Washington, 325 9th Avenue, Box 359755, Seattle, WA 98104, USA

Falls are a significant source of morbidity and mortality in older adults [1, 2]. Ten percent of falls result in serious injury, and falls are the leading cause of fatal and nonfatal injury in adults over the age of 65 years [2]. Persons with osteoporosis are at high risk of sustaining a fall-related fracture. A recent meta-analysis found that 90% of low-impact fractures in osteoporotic patients were attributable to falls [3]. Bone mineral density (BMD) alone underestimates fracture risk, especially in older adults. Factors such as lower extremity weakness, balance deficits, and fall circumstances (i.e., fall from standing height, fall to side) are better predictors

96

Page 2 of 7

of those who will fracture from falling and may confer a risk that is twice that of BMD [4]. Higher Fracture Risk Assessment Tool (FRAX) scores may also indicate those at risk of falling independent from BMD and prior history of falling [5]. Risk factors for falling such as postural instability and weak quadriceps are also common in persons with osteoporosis [6]. Since falling is preventable, it is imperative that fall prevention be included alongside medical management for osteoporosis [7]. Chart review conducted by some of us [KR, IC] revealed that only 14% of osteoporosis patients at our healthcare facility over the age of 65 years and seen over a 5-year period received a referral to physical therapy (PT) for fall risk assessments. Of those patients referred, 36% ultimately declined due to a lack of perceived need on the part of the patient, lack of consistent transportation, or inability to contact the patient. Therefore, we sought to improve fall screening rates and referral to evidence-based fall prevention exercise programs. Herein, we describe our evaluation of the feasibility of implementing fall screening in the context of a routine osteoporosis clinic visit, fall characteristics of patients screened, and effects on care processes to address fall risk.

Methods Setting The fall screening and management program was developed and piloted in an outpatient osteoporosis clinic of the Veteran’s Affairs (VA) Seattle Division of the Puget Sound Healthcare System (VAPSHCS). Veterans seen at the VAPSHCS are referred to the specialty clinic for evaluation and treatment of osteopenia or osteoporosis. The specialty clinic is held one half-day a week and serves mostly white male veterans with an average age of 65 and residing primarily in the Puget Sound region. Program development and screening procedures The intent was to develop a fall screening and management program that could be embedded within regularly scheduled osteoporosis clinic visits. A multidisciplinary team consisting of three physicians (an endocrinologist, physiatrist, and geriatrician), a registered nurse, and a PT developed and evaluated the program. The Center for Disease Control and Preventions (CDC) Guide to Program Evaluation for Public Health Programs was used to establish program goals, electronic health record (EHR) documentation, evaluation methods, and output measures [8]. Initial screening program processes were modified and improved over a 2-month period using rapid cycle, Plan-Do-Study-Act methods [9]. Final program processes were agreed upon and implemented beginning in May 2015.

Arch Osteoporos (2017) 12:96

A screening questionnaire was developed to identify those at risk of falling who would benefit from risk-reducing interventions. Screening questions were selected from the CDC’s Stopping Elderly Accidents, Deaths and Injuries (STEADI) BStay Independent^ fall risk self-assessment instrument along with demographic and selected STEADI self-report fall risk questions [10]. They assessed falls in the prior 12 months, injury-related falls, assistive device use, balance and lower extremity strength impairments, and fear of falling. The questionnaire also included the Falls Efficacy Scale International Short Form (FES-I), which elicits concerns about falling while performing daily activities [11]. FES-I short form scores range from 7 to 28, with higher scores indicating a greater concern about falling. The physician offered fall screening and the nurse administered a cognitive screen (Mini-Cog®) to persons who met the following screening program inclusion criteria: community-dwelling and history of osteopenia or osteoporosis. The PT reviewed the questionnaire and conducted four physical performance tests (Timed Up-and-Go [TUG], 30-s Sit to Stand [STS], Four-stage Balance Test, and 10-m Gait Speed Test) immediately following the clinician visit [12]. Information from the screening questionnaire and performance test results were entered into each participant’s electronic health record (EHR). One of three fall prevention exercise programs was offered if the screening questionnaire, performance testing, or the PT’s clinical judgment determined that a patient was at risk of falls. The three programs were the following: (1) independent home-based exercise program, (2) 8-week, group-based exercise program, and (3) traditional, one-on-one supervised PT sessions for those with more functional impairment. All programs included balance and lower extremity exercises adapted from the evidence-based Otago Exercise Program [13]. Exercise program recommendations were individualized based on patient needs and preferences. Funding in the amount of 0.1 full-time equivalent (FTE) was provided by the Veterans Integrated Service Network (VISN) and the VAPSHCS Geriatric Research, Education and Clinical Center (GRECC). The screening program was developed as a quality improvement project. Program purpose, methods, and evaluation were reviewed by the VAPSHCS IRB and determined to not require IRB approval. Methods of evaluation, data sources and statistical analysis We evaluated the following: (1) feasibility of program implementation in the context of routine outpatient osteoporosis clinic visits, (2) fall and fracture risk of patients screened, and (3) fall-related processes of care resultant from the program. Feasibility was measured by PT productivity (the number of patients seen per hour with the expectation of one patient/ hour), time spent screening each patient (with a goal of

Arch Osteoporos (2017) 12:96

< 25 min/patient), and ability for patients to complete the screening questionnaire independently. We also assessed barriers (e.g., inability to complete screening, disruption to the clinic visit) to program implementation. Fall and fracture risk profiles were assessed by responses to self-report fall risk questions and percentages of participants performing below norms on mobility testing (indicating increased risk of falling). Analyses were calculated on the number of persons with non-missing values which included 68 of the 70 patients screened for fall and fracture risk profiles and 30-s STS and 67 persons for the TUG and gait speed tests. Variability in means and percentages was estimated with 95% confidence intervals calculated using a bootstrap method [14]. Analyses were carried out using both IBM SPSS version 23 and R Core Team version R.3.2.3 statistical packages [15]. Demographics, chronic conditions, and medications were collected through review of the EHR. Fracture risk was measured by laboratory, bone mineral density (BMD), T score, and anthropomorphic values (height and weight) drawn from the most recent data available at the time of fall screening. Fracture Risk Assessment Tool (FRAX®) was calculated with information gathered during the clinical encounter and femoral neck BMD. Fall-related care processes were assessed via chart review conducted 12 months after the fall screening program start date. Completion of the recommended exercise program was defined as discharge from the group exercise class or from PT services (for the home-based and supervised PT options). Reasons for not initiating or finishing the program of choice were abstracted if documented in the EHR.

Results

Page 3 of 7 96

50% of participants responded BYes^ to one of the selfreport fall screening questions (Table 1). Forty percent (N = 28) of participants reported falling in the last year and over half of fallers were recurrent fallers (N = 26), and 67% of fallers had sustained an injury (N = 16) (Table 1). Over two thirds of those with a fear of falling reported that they were restricting their activity due to fear (N = 18). The average FESI short form score corresponded to a Bmoderate level of concern^ about falling when performing daily activities (10.3, SD ± 3.6). Prevalence of other fall risk factors (medications or disorders affecting gait, balance, or lower extremity strength) is shown in Table 1. A substantial proportion of persons performed below norms on the TUG (mean 12.7 s, SD 5.3; 37% below norm, 95% CI 24–46%), gait speed (mean 1.0 m/s, SD 0.3; 42% below norms, 95% CI 27–50%), or 30-s STS (mean 9.6, SD 5.3; 53% below norms, 95% CI 39–61%). Though nearly two thirds of persons could hold a tandem stance for > 10 s (33% below norms, 95% CI 21–43%), 57% (95% CI 41–66%) were unable to hold a single leg stance for at least 5 s, a more sensitive measure of risk for an injurious fall [16]. Only 8% (N = 5) of participants had seen a PT in the past 6 months for falls, balance, or gait training. The most frequent risk factors for fracture among patients screened for falls were low BMD/T score, prior history of vertebral fracture, or history of hypogonadism (Table 1). Less than 20% were currently smoking, and less than 10% were on glucocorticoids, had significant alcohol intake (> 3 drinks/day), or had personal history of hip fracture (Table 1). BMD and FRAX® scores suggested a high risk of fracture among those screened (Table 1). Most were on calcium and vitamin D supplementation, nearly half were prescribed medication for osteoporosis, and another quarter were on a treatment holiday (Table 1).

Feasibility of program implementation Delivery of fall prevention exercise training A total of 154 patients were evaluated by osteoporosis clinic providers (Fig. 1). Of those patients, 105 (68%) met screening program inclusion criteria, and 70 patients (67%) underwent screening. As shown in the figure, 25 (24%) declined and another 10 (10%) were unable to be screened due to time constraints. The screening questionnaire was completed independently by 91% of screened participants. On average, The PT assessed 2.5 (SD ± 0.5) participants/hour with an average of 22 (SD ± 4.4) minutes/participant. Clinic providers and staff reported that PT activities did not interfere with their usual workflow nor disrupt the osteoporosis evaluation. Fall and fracture risk profiles The average age of persons screened was 71 years. Those screened were predominately male and white and most did not show signs of cognitive dysfunction (Table 1). Over

A fall prevention-based exercise program was recommended to nearly 70% of the patients screened by the PT, and distribution into each exercise program is shown in Fig. 1. Four participants who were found to be at risk of falling declined recommended exercise. For a third of those screened (N = 23), no specific fall-based PT intervention was recommended. Three of these participants were enrolled in a home-based primary care program, which includes regular PT screenings and did not need additional PT services. The remaining (N = 20) were considered low risk of falling based on screening evaluation. None had a history of falling, balance impairments, or lower extremity weakness, and all completed the TUG below the at risk for falling cut-off and were able to hold a tandem stance. These low-risk participants were given basic fall prevention information and recommended communitybased fall prevention exercises programs.

96

Page 4 of 7

Arch Osteoporos (2017) 12:96

Fig. 1 Screening program inclusion criteria

Nine group exercise participants completed their program (75%); a three did not (25%), (Fig. 1). Within the supervised PT program, nine (23%) attended the first scheduled followup session, but only four (25%) completed all recommended sessions. Of the home exercise program participants, five (25%) finished their exercise program, nine (45%) were lost to follow-up, and the rest did not complete the program (N = 6; 30%). The most common reasons for not attending or completing a designated program were lack of consistent transportation, distance required to travel for follow-up sessions, change in health status, and loss of interest in the exercise program.

Discussion Falling is a strong independent risk factor for fracture in older adults, and fall prevention is as effective as medications for reducing the risk of fractures in the older osteoporotic patient

[4, 17]. Our screening results suggest that many patients with osteopenia/osteoporosis are at risk of falls. However, to our knowledge, few outpatient, integrated osteoporosis/fall prevention programs exist or have demonstrated feasibility [18, 19]. Our evaluation suggests that the implementation of a fall screening program in an outpatient osteoporosis clinic is feasible and can identify persons at high risk of falls and fractures. Our program surpassed our screening targets and anticipated provider productivity measures. Independent selfcompletion of the screening questionnaire by participants permitted a more streamlined screening process that cut the time allocated for PT consultations by two-thirds and did not interfere with normal clinic workflow. Embedding a screening program into clinic also captured persons who otherwise may not have been assessed for mobility impairments or fall risk, and delivery of exercise interventions increased among those who were found to be at fall risk. As stated previously, prior observational review suggested that persons undergoing

Arch Osteoporos (2017) 12:96 Table 1

Characteristics of persons screened (N = 68)a

Age (years), mean (SD) Male (%) White (%) BMI (kg/m2) (SD) Mini-Cog score ≥ 3 (%) Pain rating, mean (SD)b Medical conditions (%) Depression Osteoarthritis Spinal degenerative disease Stroke or transient ischemic attack Peripheral neuropathy Dementia Parkinson’s disease Vertigo Medications (%) Prescribed ≥ 4 medicationsc Opiate use (PRN or long acting) Antidepressants Antipsychcotics No prior treatment for osteoporosisd Self-report fall risk items, BYES^ response (%) BI have fallen in the past 12 months^ BI have fallen two or more times in past 12 months^e BI am worried about falling^ BI avoid certain activities due to a fear of falling^ BSometimes I feel unsteady with walking^ BI have fallen in the past year and sustained an injury^e BI steady myself by holding onto furniture or railings when walking at home or down stairs^ BI need to use my arms to stand from a chair^ Risk factors for fracture (%) Current glucocorticoid useg History of vertebral fracture History of hip fracture Current tobacco use Alcohol 3+ drinks/day Hypogonadism Rheumatoid arthritis Vitamin D deficiency Osteoporosis measures BMDh lumbar spine (SD); T score (SD) BMD total hip (SD); T score (SD) BMD femoral neck (SD); T score (SD) FRAX® score, 10-year risk for hip fracture (%) (SD) FRAX® score, 10-year risk for major fracture (%) (SD) Osteoporosis treatment (%) Calcium supplementation Vitamin D3 supplementation Current therapy for osteoporosisd a

Page 5 of 7 96

71 (10) 67 78 27 (6) 84 3 (3) 40 32 28 16 16 3 2 4 78 6 28 3 39 40 57 44 69 56 67 59 51 7 40 4 19 6 27 7 41 0.906 (0.2); − 1.6 (1.4) 0.772 (0.2); − 1.7 (0.9) 0.623 (0.8); − 2.2 (0.8) 5 (5) 14 (8) 75 85 87

Percentages were calculated on the number of persons with non-missing values which included 68 of the 70 patients screened

b

Pain level was self-rated on a 0–10 pain scale with 0 as a low and 10 as a high

c

Number of medications as listed in the patient medical record

d Osteoporosis treatment was defined as taking a bisphosphonate, RANKL monoclonal antibody, or recombinant human parathyroid hormone [1, 34] analog for any period of time e

Includes only those persons who had fallen in the past 12 months

f

Selected questions from the CDC’s Stopping Elderly Accidents, Deaths and Injuries (STEADI) BStay Independent^ fall risk self-assessment instrument

g

Glucocorticoid use was defined as ≥ 5 mg prednisone equivalent daily × 3 months

BMD bone mineral density

96

Arch Osteoporos (2017) 12:96

Page 6 of 7

evaluation for osteoporosis were rarely evaluated for fall risk or received fall-specific exercise recommendations. The screening program therefore increased the percentage of patients screened for risk of falling by nearly fivefold and overcame a key reason (i.e., visit cancelation) for patients not to follow through with routine PT referrals. Self-report measures and mobility testing confirmed the high prevalence of physical impairments in gait, balance, and lower extremity strength that increase fall (and fracture) risk. The findings of lower extremity weakness are not surprising as sarcopenia, like osteoporosis, is a consequence of aging. Prevalence of sarcopenia can be as high as 50% in persons over the age of 80 and contributes to disability, poor quality of life, and mortality [20]. Persons with sarcopenia are nearly twice as likely to have osteoporosis and are at increased risk of falling due to weaker quadriceps, postural changes, and increased postural sway impairing balance [6, 21]. Thus, proactive identification of strength and balance deficits should be included in every osteoporosis patient evaluation. Fear of falling, activity restriction, and concern about falling when performing usual daily activities were also prevalent in our population. A diagnosis of osteoporosis has been associated with a fear of falling which can result in more cautious behaviors, reduced gait speed, balance impairments, and ultimately a loss of independence [22]. By contrast, increasing awareness about osteoporosis and fall prevention has been shown to reduce fear related to falling, improve exercise self-efficacy, and promote confidence in ADL performance [23, 24]. Only one in four persons who fall discusses falling with their health care provider [24]. Eliciting these concerns during osteoporosis clinical encounters is therefore warranted, especially with older adults in whom falling is prevalent and adversely impacts quality of life. There are several limitations to our program evaluation. Since our goal was to determine the feasibility of a clinical demonstration project, an underpowered, convenience sample of persons was used and monitoring of fall and fracture rates was not conducted. Secondly, completion rates for supervised PT and home-based exercise options were low. Future plans will assess barriers to completion that were identified and investigate patient-centered delivery options to improve adherence to fall prevention exercise programs. Finally, even though the PT assessment did not disrupt clinic flow, 20% were missed due to time limitations in clinic and reliance on a highly skilled (PT) provider to conduct. Future analysis of the predictive ability self-report measures alone may suggest a more efficient screening process independent of inperson, time-intensive, provider-driven physical performance testing.

Conclusion Fall prevention is an essential element of fracture risk reduction in persons with osteoporosis. As demonstrated here, mobility impairments that increase the risk of falling are prevalent among these individuals, and assessment to detect these impairments can be incorporated into routine clinical osteoporosis care and increase receipt of exercise-based interventions to address deficits and reduce fall risk. Future studies are necessary to ascertain if screening and intervention for falls in osteoporosis populations will ultimately lead to improvement in clinical outcomes, including fall and fracture reduction. Acknowledgements The authors would like to thank the Rehabilitation Care Service and the Geriatric Research, Education, Clinical Center at VA Puget Sound and the Veteran’s Integrated Service Network 20 for administration support, funding, and collaboration making this program possible. We would additionally like to thank Dr. Ileana Howard, Dr. Kushang Patel, Dr. Isabela Cardim, Ms. Ruby Farinas, Ms. Magdalena Wojtowicz, and Ms. Nancy Lewis who provided additional program support, guidance, and manuscript review. Compliance with ethical standards Conflicts of interest None.

References 1.

2.

3.

4.

5.

6.

7.

8.

9.

Gribbin JHR, Smith C, Gladman J, Lewis S (1999) Incidence and mortality of falls amongst older people in primary care in the United Kingdom. J of General Intern Med 19(2):723–739 Centers for Disease Control and Prevention NCfIPaC (2010) Web-based Injury Statistics Query and Reporting System (WISQARS) 2014 Morrison A, Fan T, Sen S, Weisenfluh L (2013) Epidemiology of falls and osteoporotic fractures: a systematic review. Clinico Econ Outcome Res 5:9–18 Greenspan S, Myers E, Maitland L, Resnick N, Hayes W (1994) Fall severity and bone mineral density as risk factors for hip fracture in ambulatory elderly. JAMA 271(2):128–133 Harvey N, Johansson H, Oden A, Karlsson M, Rosengren B, Ljunggren O, Cooper C, McCloskey E, Kanis J, Ohlsson C, Mellstrom D (2016) FRAX predicts incident falls in elderly men: findings from MrOs Sweden. Osteoporos Int 27:267–274 Lui-Ambrose T, Eng J, Khan K, Carter N, McKay H (2003) Older women with osteoporosis have increased postural sway and waker quadraceps strength than counterparts with normal bone mass: overlooked determinants of fracture risk? J Gerontol: Med Sci 58A(9):862–866 Sugiyama T, Kim Y, Oda H (2015) Both falling and bone fragility should be targeted to prevent hip fracture in older adults. Osteoporosis International October:1–2 Introduction to program evaluation for public health programs: a self-study guide. (2011) Centers for Disease Control and Prevention, Atlanta, GA Institute for Health Care Improvement: The science of improvement: how to improve. http://www.ihi.org/resources/Page/ HowtoImprove/ScienceofImprovementhowtoimprove.aspx. Accessed March 28, 2015

Arch Osteoporos (2017) 12:96 10.

11.

12. 13.

14. 15.

16.

17.

18.

Rubenstein L, Vivrette R, Harkr J, Stevens J, Kramer B (2011) Validating an evidence-based, self-rated fall risk questionnaire (FRQ) for older adults. J Saf Res 42(6):493–499 Kempen G, Yardley L, Van Haastreg J, Zijlstra G, Beyer N, Hauer K, Todd C (2008) The Short FES-I: a shortened version of the falls efficacy scale-international to assess fear of falling. Age Ageing 37(1):45–50 Stevens J (2013) The STEADI tool kit: a fall prevention resource for healthcare providers. IHS Primary Care Provider 38(9):1–5 Campbell A, Robertson M, Gardner M, Norton R, Tilyard M, Buchner D (1997) Randomized controlled trial of a general practice programme of home based exercise to prevent falls in elderly women. BMJ 315:1065–1069 Davison A, Hinkley D (1997) Bootstrap methods and their applications. Cambridge University Press, Cambridge Team RC (2015) A language and environment for statistical computing. R Foundation for Statistical Computing RL https://www.R-project.org/. Accessed March 2016 2015 Vellas B, Wayne S, Romero L, Baumgartner R, Rubenstein L, Garry P (1997) One-leg balance is an important predictor of injurious falls in older persons. J Am Geriatr Soc 46(6):735–738 Robertson M, Campbell A, Gardner M, Devin N (2002) Preventing injuries in older people by preventing falls: a meta-analysis of individual-level data. J Am Geriatr Soc 50(5):905–911 Gomez F, Curcio C, Suriyaarachchi P, Demontiero O, Duque G (2013) Differing approaches to falls and fracture prevention between Australia and Colombia. Clin Interv Aging 8:61–67

Page 7 of 7 96 19.

Smulders E, Weerdesteyn V, Groen B, Duysens J, Eijsbouts A, Laan R, van Lankveld W (2010) Efficacy of a short multidisciplinary falls prevention program for elderly persons with osteoporosis and a fall history: a randomized controlled trial. Arch Phys Med Rehabil 91:1705–1711 20. Trombetti A, Reid K, Hars M, Herrmann F, Pasha E, Phillips E, Fielding R (2016) Age-associated declines in muscle mass, strength, power and physical performance: impact on fear of falling and quality of life. Osteoporos Int 27: 463–471 21. Bischoff-Ferrari H, Orav J, Kanis J, Rixxoli R, Schlogl M, HB S, Willett W, Dawson-Hughes B (2015) Comparative performance of current definitions of sarcopenia against the prospective incidence of falls among community-dwelling seniors age 65 and older. Osteoporos Int 26:2793–2802 22. Resnick B, Nahm E, Brown C, An M, Park B, Brown J (2014) The impact of osteoporosis, falls, fear of falling and efficacy expectations on exercise among community dwelling older adults. Orthop Nursing 33(5):277–286 23. Burk-Doe A, Hudson A, Werth H, D R (2008) Knowledge of osteoporosis risk factors and prevalence of risk factors for osteoporosis, falls, and fracture in functionally independent older adults. J Geriatr Phys Ther 31 (1):11–17 24. Stevens J, Ballesteros M, Mack K, Rudd R, DeCaro E, Adler G (2012) Gender differences in seeking care for falls in the aged Medicare population. Am J Prev Med 43(1):59–62