#539 - Falls Prevention, Exercise for Depression, PRx90 – Springing Forward

From the Literature

1)  Falls Prevention in Older Adults

Falls are among the most common and preventable causes of morbidity and mortality for older adults and increase substantially after age 65.  In a 2018 survey, 28% of community dwelling adults aged > 65 reported falling in the last year.  Other data indicates one of 5 falls among older adults leads to fractures or head injury.  Health care expenditures related to falls in the account for 4.4% of Medicare hospital expenditures, 5.7% of physician and other health professional expenditures, and 11.8% of spending for home health services, long-term care facilities, and durable medical equipment.

In a sample of community-dwelling adults > 60, fear of falling and fall-related activity restriction were highly prevalent (69% for fear of falling and 38% for fall-related activity restriction).  Both concerns are associated with sarcopenia and depression.

Clinicians across specialties and settings of care are likely to encounter patients at risk of falls. The cause of falls may be multi- factorial, requiring careful assessment and intervention across multiple domains.  A recently published review was written with the intention of summarizing current understanding of best practices for risk stratification, clinical assessment, and selection of risk reduction interventions for falls prevention.

Risk factors for falls can be intrinsic or extrinsic to the patient.   Major intrinsic risk factors for 2 or more falls over 6-12 months are generally related to neurologic diseases (eg, Parkinson disease, stroke) and major neurocognitive disorders such as dementia, which may not be modifiable.  Factors defining the frailty phenotype (unintentional weight loss, self-reported exhaustion, muscle weakness, slow walking speed, and low physical activity) are associated with falls in an additive manner.  Other moderate risk factors, including visual and hearing impairment, pain, and orthostatic hypotension, are potentially modifiable.

Medications are the most common modifiable extrinsic risk factor for falls, particularly psychoactive, anticholinergic, cardiovascular (particularly loop diuretics), and analgesic medications.  High-quality studies suggest an association between environmental hazards and recurrent falls, particularly when the hazard interferes with function (eg, low seats).  Poor lighting and tripping hazards (eg, rugs) are other common environmental risk factors.  Walking barefoot or in stockings markedly increases the risk of falls while athletic shoes (sneakers) are associated with a lower risk compared with other shoes.

Most clinical practice guidelines suggest risk stratification for adults > 65 using a combination of fall history (eg, “Have you fallen in last 12 months?”), subjective fear of falling, and a mobility screening test such as Timed Up and Go (TUG) test or gait speed measurement.  For those with prior falls, fear of falling, and/or abnormal TUG or gait screening test, guidelines recommend a targeted clinical assessment to identify modifiable factors.  Recommended physical examination includes assessments for sensory impairment (eg, hearing, vision, neuropathy), orthostasis, foot deformities, and gait abnormalities.  A more detailed gait and balance evaluation to guide need for assistive devices such as canes and walkers and/or rehabilitation services can be completed in primary care using the Short Physical Performance Battery (SPPB) (gait speed measurement, 3-stage balance test, and chair stand test), or by referral to a physical therapist.  

General categories of interventions tested for fall prevention include exercise programs to improve leg strength and balance, vision interventions, home environmental modification, deprescribing programs, podiatry interventions, multifactorial interventions (ie, systematic risk factor assessment followed by tailored intervention targeting multiple modifiable factors), and multicomponent interventions (ie, fixed combinations of interventions provided to all patients).  Gait and balance training by physical therapy is generally covered by Medicare.  Durable medical equipment such as canes, walkers, and commode chairs are covered under Medicare Part B for specific diagnoses with a 20% co-pay, and some Medicare Advantage plans also cover additional home safety equipment such as tub chairs and grab bars, although plans vary widely.  

Many older adults are able to access balance and functional exercise classes through community- funded programs or Silver Sneakers, a fitness program for adults > 65 that provides access to gyms, community exercise classes, and exercise videos, and is fully covered by most Medicare Advantage and some other insurance plans.  Home safety checklists are available for patients and families to use to identify environmental hazards, although their effectiveness is unclear. The CDC offers a clinician toolkit and patient education materials, and many state or area councils on aging curate lists of local fall prevention community resources.

In December of 2023 the USPSTF published draft updated recommendations for interventions for falls prevention in community-dwelling older adults > 65.  The draft recommends exercise interventions to prevent falls for those who are at increased risk (B) and recommends that clinicians individualize the decision to offer multifactorial interventions to prevent falls based on individual patient context (C). 

Mark’s Comments:

Advising our patients to move more while moving safely is certainly something that we should be advising for practically all of our elderly patients.  This resource on exercises for falls prevention from the National Council on Aging comes with video links for each recommendation and is one of many resources that can help guide your advice.  Encouraging participation in community-funded exercise programs adds the element of socialization, which is preferred when possible.  And remember to take advantage of your time during Medicare Annual Wellness visits to both counsel and educate your patients to minimize their risk of falling.

References:

• Colon-Emeric C, et al. Risk Assessment and Prevention of Falls in Older Community-Dwelling Adults: A Review. JAMA published online March 27, 2024.  doi:10.1001/jama.2023.2694.  Link
• USPSTF. Falls Prevention in Community-Dwelling Older Adults: Interventions.  Draft Recommendation Statement.  December 5, 2023.  Link

From the Literature

2)  Exercise for Depression

Exercise, or at least physical activity, has shown up in many guidelines about the management of depression in primary care. The MacArthur Foundation Initiative on Primary Care and Depression at the nearest turn of the century included exercise as one of its key depression self-management recommendations. And yet, the evidence behind exercise for depression has been scant, low-quality, and lacking in detail about dose or intensity. A recent systematic review has attempted to create the most recent summary of the evidence. The authors used network meta-analysis to deal with the effect of different modalities of exercise to avoid having to combine them to facilitate the usual analyses.

The investigators searched multiple databases, had specific and realistic inclusion criteria (major depression either clinically diagnosed, or by validated self-report scale), assessed the included studies for their validity (using Cochrane’s risk of bias tool), and assessed the body of evidence for excessive heterogeneity (aided by a newer method that uses “prediction intervals” which works better with network meta-analyses). They did not report a search for unpublished data.

Two hundred and forty-six reports of 218 studies, including 14,170 participants were included. Because most studies did not blind either the participants or research staff, they were judged as at least low and most often very low quality, which ultimately affects the certainty of the conclusions of this review. Large effects in depression reduction were found with dance. Moderate effects were found with walking/jogging, yoga, strength training, mixed aerobic exercise, and tai chi/qigong. Cognitive behavioral therapy was in the middle of the moderate effect group, the combination of exercise + SSRI followed behind that.  SSRI therapy alone was the least effective intervention studied, with only a small effect. However, all these comparisons are somewhat tentative – studies sometimes studied effects in only one sex, or under-reported factors like age. The best evidence was associated with walking/jogging (though still at a “low” rating). All other comparisons were at a “very low” evidence rating.

There was a clear and consistent dose-response curve to exercise – the higher the intensity, the more the effect. The best exercise for women and for younger patients was strength training. For men and older patients, it was yoga/qigong. There was statistically significant publication bias in the evidence, but not enough to alter the findings.

John’s Comments:

The evidence about exercise and depression still feels slightly “soft” in places and its magnitude of effect might change in the future, but the association is definitely there. I try to discuss several self-management recommendations with my patients with depression, and exercise is always included – mainly because it has so many other benefits – if we’re wrong about its effect on depression, it’s still beneficial in many other ways! The benefit of exercise appears to be greater than SSRIs in this study, which ought to give us some pause…

Reference:

·         Noetel M, Sanders T, Gallardo-Gómez D, et al. Effect of exercise for depression: systematic review and network meta-analysis of randomised controlled trials. BMJ. 2024;384:e075847. Link

From PeerRxMed ( www.PeerRxMed.org )

3)  How Will You Spring Forward in the Coming Months?

"I have great faith in a seed.... Convince me that you have a seed there, and I am prepared to expect wonders." — Henry David Thoreau

I don’t know about you, but I’m quite grateful that spring has finally arrived.  This change of seasons provides a dramatic and symbolic contrast from the colder, dark and more monotone backdrop of winter to the warmer, lighter, burst-of-senses palette of spring, and with it, a chance to do some personal and professional reflection.

Recall that a vital component of the PeerRxMed process is the PRx90 quarterly check-in (“up to 90 minutes every 90 days”) intended to provide a deliberate space for reconnecting with yourself and your PeerRx partner.  Here’s a reminder of that Process.   It’s time to schedule that quarterly meeting once again.  To help guide your dialogue, consider these standard quarterly questions as well as a few others below:   

• What have you learned about yourself over the past 3 months?
• What are your top personal/professional goals and priorities over the next three months?  What is one that will cause disappointment if you have not accomplished it when we meet again in 3 months?
• When’s your next vacation / adventure / break?  What will you do that will be fun for you?

In the spirit of the season, here are some additional questions for personal reflection and sharing around two traditional activities of spring:

Spring Cleaning: 

Consider how some internal and external “spring cleaning” of your life might be useful as you begin to prepare for the next few months.  What needs to be cleaned up and what given or thrown away?  What habits or patterns have you accumulated that you no longer need or have outgrown?  What is “cluttering up” your life in terms of over-commitments or mindless activity?  What parts of you need some “sprucing up” through a change in pattern of diet, exercise, sleep, or even making an appointment for routine medical care?

Spring Planting: 

Consider what type of seeds you would like to plant in your personal and professional life that could lead to a bountiful harvest in the next 4-6 months.  Is there a specific “crop” you need to prioritize?   What tools and resources do you need to ensure your growth goes as planned?   What is your personal equivalent of water and sunlight that you will need?   How will you schedule regular “weeding”?

Don’t squander this incredible opportunity for spring cleaning and planting.  Schedule some personal reflection time as well as time with your PeerRx partner.  As you look back 3 months from now, you’ll be glad you did.

______________

Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org