Transcript Physical activity and the prevention of falls among older

Active for Later Life
Physical activity and
the prevention of falls
among older people
Evidence into practice

Why are falls important?
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How active are older people?
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Physical activity in falls prevention.
Does it work?
Evidence of effectiveness
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Putting it into practice:
Recommendations and guidelines
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Putting it into practice:
Education and training
Why are falls important?
Why are falls important?
Why are falls important?
 The human costs of falls
 Large numbers of older people are falling
 Impact on local services
 Costs to the health services
Why are falls important?
The human costs of falls
A downward spiral?
 Further loss of function
 Loss of mobility, independence, dignity and
confidence
 Fear of another fall and further loss of function
 Increased isolation and loneliness
 Frequent fallers have poor outcomes
Why are falls important?
90-day outcome after hip fracture
 24% return to pre-fracture level of function
 42% of survivors require extra help with half their
daily activities
 21% require an increased level of residential or
hospital care
 35% receive increased community health and social
service care at home
(Bandolier, 1998)
Why are falls important?
Large numbers of older people are falling
Each year…
 One-third of people aged 65+ and 50% of over-80s
living in the community will fall.
 Over 60% of those living in nursing homes will fall
repeatedly.
 75% of falls-related deaths occur in the home.
 75% of falls are not reported.
(Cryer and Patel, 2001)
Why are falls important?
Are certain groups more at risk?
 Men and women fall at the same rate but men are far
less likely to injure themselves.
 There is no evidence of higher rates of falls among
minority ethnic groups.
 Older people over 80
 Older people living in nursing homes
Why are falls important?
Estimated incidence of hip fracture
in England and Wales
120
100
80
People
(000)
60
40
20
0
1985
1994 1996
2006
2016
Source: Grimley-Evans et al, 1997
Why are falls important?
Impact on local services
 Over 10% of the London ambulance service workload
(Halter et al, 2000)
 Contributes to local authority care costs of £3 billion
residential and £2 billion non-residential
 Long-term nursing care £19,000 per year for older
person affected by a fall
 Social care costs caused by falls of £2.5 million per
year for an urban primary care trust (population
260,000+)
(Department of Health, 2001)
Why are falls important?
Costs to the health services
The financial costs of hip fractures
 Estimated acute hospital costs for
fractured neck of femur
 Long stay/social cost
 Primary care costs
 Total cost
£4,808
£7,125
£164
£12,097
The annual cost of treatment of fractures among
women is now in excess of £1.8 billion.
(Dolan and Torgerson, 2000)
Physical activity in falls prevention.
Does it work?
Evidence of effectiveness
Physical activity in falls prevention. Does it work?
Modifying risk factors for falls
Extrinsic – Social or
physical environment e.g.
 Poor housing and lighting
 Baths without handles
 Ill-fitting shoes
 Unsafe walking areas
(More important in under-70s)
Intrinsic – States or traits
of an individual e.g.
 Sensory decline
 Medical conditions
 Strength, balance,
gait and physical
performance
 Four or more
medications
(More important in over-70s)
Physical activity in falls prevention. Does it work?
Intrinsic vs extrinsic risk factors
“We are all trippers.”
 Over half of falls experienced in the home are due
to environmental hazards – e.g. trips, slips, unsafe
or unlit stairs.
 A decline in a person’s intrinsic risk factors
(declining function and balance) means that the
extrinsic risk factors (loose mat, slippery floor)
no longer cause a correctable trip; they cause an
injurious fall.
Physical activity in falls prevention. Does it work?
Risk factors for falls that cannot
be modified
 Age
 Gender
 Social class
 Chronic medical conditions
 Irreversible vision problems
 Osteoporosis
Physical activity in falls prevention. Does it work?
Targeting the modifiable risk factors
for falling
 Low strength and
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
power
Medical condition
Medications
Incontinence
Cognitive impairment
Balance/gait
Postural hypotension
Vision/hearing
 Foot care
 Poor housing
 Depression
 Previous falls
 Fear of falling
 Functional capacity
 Poor heating
 Poor diet
Physical activity in falls prevention. Does it work?
Improving risk factors –
duration vs outcome
 Gait (8 weeks)
 Balance (Static 8 weeks + Dynamic 8 weeks)
 Muscle strength (8-12 weeks)
 Muscle power (12 weeks)
 Endurance (26 weeks)
 Transfer (6 months)
 Postural hypotension (24 weeks)
 Bone strength (1 year for femur and lumbar spine)
(Skelton and McLaughlin, 1996)
Physical activity in falls prevention. Does it work?
Reviews of effectiveness in falls
prevention
 Guidelines for the prevention of falls in older people
(Clinical Effectiveness Group, 1998)
 Gardner et al (2000)
 National Service Framework for Older People –
Standard 6: Falls (Department of Health, 2001)
Physical activity in falls prevention. Does it work?
Effective interventions
 Tinetti et al, 1994
 FICSIT Trials: Province et al, 1995
 Wolf et al, 1996
 Campbell et al, 1997
 PROFET: Close et al, 1999
 FaME Project: Skelton, 2001
 Day et al, 2002
Physical activity in falls prevention. Does it work?
Tinetti et al, 1994
 Community-dwelling older women 70+
 More than one risk factor
 Multi-factorial intervention
 Included transfer training, gait
30% reduction in falls
Physical activity in falls prevention. Does it work?
FICSIT Trials
(Province et al, 1995)
 7 sites (balance, strength, endurance and other
multi-disciplinary interventions)
10% lower risk of falling
 4 sites (balance training)
25% lower risk of falling
 1 site (Tai Chi only – 10 moves)
47% lower risk of falling
Physical activity in falls prevention. Does it work?
Wolf et al, 1996
 Community-dwelling population (n=200) with no
debilitating conditions
 Intervention based on Tai Chi
 A synthesis of 108 existing forms into 10 exercise
moves
 2 sessions a week for 15 weeks
Falls rate cut by half
Physical activity in falls prevention. Does it work?
Campbell et al, 1997
 Women aged 80+, community dwelling
 Physical activity prescribed by a physiotherapist
 4 home visits over 2 months
 Strength, balance and gait training
20%-30% reduction in falls
Physical activity in falls prevention. Does it work?
PROFET Trial
(Close et al, 1999)
 Community-dwelling, aged 65+
 Multi-factorial intervention
 Medical assessment
 Physiotherapy and occupational therapy
60% reduction of risk
Physical activity in falls prevention. Does it work?
FaME Project
(Falls Management Exercise trial)
 Independent, community-dwelling women with history
of 3 or more falls in previous year (high risk)
 9-month intervention – exercise only
 Weekly exercise class and home exercise with
trained seniors exercise instructor
 After 3 years, 10% of those in exercise group had
died or were in hospital or in a nursing home,
compared with 33% of those not exercising
60% reduction in falls and 75% reduction in injuries
(Skelton, 2001)
Physical activity in falls prevention. Does it work?
Day et al, 2002
 1,000+ aged 70 years +, living at home
 Interventions included group-based exercise, home
hazard management and vision improvement.
 Exercise (including balance training) comprised a
weekly supervised group session together with 2 x
weekly home exercise sessions.
14% reduction in annual rate of falls.
Group-based exercise was the most potent single
intervention tested.
Physical activity in falls prevention. Does it work?
Evidence of effectiveness
A critical review of 29 physical activity interventions
reported:
 Increased activity levels over a longer period of time
 Group/class-based and home-based activity were
effective
 Tailored to individual needs
 Cognitive-behavioural strategies and goal-setting
 Telephone support and continued contact
(King et al, 1998)
How active are older people?
How active are older people?
Overview
 Low levels of physical activity among older people
 Thresholds for quality of life and functional capacity
 Physical activity and frailty
 Environmental factors assisting the ‘spiral of decline’
How active are older people?
Levels of sedentary behaviour among
MEN aged 50+, England
5 kcal/min including brisk/fast walks 2 miles
4 kcal/min including all walks 2 miles
80%
4 kcal/min plus all walks 1 mile
60%
% participating
less than once
40%
a week
20%
0%
50-54
55-59
60-64
65-69
Age
70-74
75-79
80+
(Skelton, Young et al, 1999)
How active are older people?
Levels of sedentary behaviour among
WOMEN aged 50+, England
5 kcal/min including brisk/fast walks 2 miles
4 kcal/min including all walks 2 miles
80%
4 kcal/min plus all walks 1 mile
60%
% participating
less than once
40%
a week
20%
0%
50-54
55-59
60-64
65-69
Age
70-74
75-79
80+
(Skelton, Young et al, 1999)
How active are older people?
Levels of sedentary behaviour among
minority ethnic groups aged 55+, England
Those participating less than once a week
African-Caribbean
Indian
Pakistani
Bangladeshi
Chinese
Men
Women
57%
67%
73%
85%
68%
59%
78%
85%
92%
64%
(Erens et al, 2001)
How active are older people?
Older people living in care and
residential settings
 86% of women and 78% of men in care homes are
sedentary.
 Sedentary behaviour in care homes is double that in
private households (at age 65+).
 Half of all men and women in local authority
residential homes never or very occasionally take
trips outside the home.
(Department of Health, 2002)
How active are older people?
The physical activity paradox
 39% of men and 42% of women aged 50+ are
sedentary.
 YET over half of sedentary men and women aged
50+ believe they take part in enough activity to
keep fit.
 26% of men and 34% of women aged over 70 are
unable to walk a quarter of a mile on their own.
How active are older people?
Thresholds for quality of life
Physically active
Physically inactive
Exercise
performance
‘Threshold’ value
necessary for
performance of an
everyday task
Age
Adapted from Young (1986)
How active are older people?
Aerobic capacity in
MEN and WOMEN aged 50-74
(mean ± 2sd)
60
Men
Women
50
40
Maximum
oxygen
uptake
(ml/kg/min)
30
20
10
VO2 max to walk comfortably at 3mph
0
50-54 55-59 60-64 65-69 70-74
50-54 55-59 60-64 65-69 70-74
Age
(Skelton, Young et al, 1999)
How active are older people?
Knee extension strength in
MEN and WOMEN aged 50-74
12
(mean ± 2sd)
Men
Women
10
8
Isometric knee
extension
6
strength (N/kg)
4
2
0
Strength to be confident of rising from
low chair without using one’s arms
50-54 55-59 60-64 65-69 70-74
50-54 55-59 60-64 65-69 70-74
Age
(Skelton, Young et al, 1999)
How active are older people?
Shoulder flexibility in
MEN and WOMEN aged 50+
(mean ± 2sd)
200
160
Shoulder
abduction
(degrees)
120
80
Men
40
Women
Requirement to wash hair without difficulty
0
50-54 55-59 60-64 65-69 70-74 75-79 80+
50-54 55-59 60-64 65-69 70-74 75-79 80+
Age
(Skelton, Young et al, 1999)
How active are older people?
Functional capacity
Even healthy older people lose functional capacity.
 Muscle strength ‘lost’ at 1%-2% per year
 Muscle power ‘lost’ at 3%-4% per year
 Aerobic capacity ‘lost’ at 1% per year
 Bone density ‘lost’ at 1% in men and 2%-3% in
women after menopause
 Flexibility and balance
 Proprioception and kinesthetic awareness
 Co-ordination and reaction
 Thermo-regulation
Sedentary behaviour increases loss of performance.
(Skelton and Dinan, 1999)
How active are older people?
Functional decline and frailty
(Spirduso, 1995)
Time
Human
frailty
Disease
Disuse
How active are older people?
Inactivity-related disease?
Disuse rather than disease?
 One week’s bed rest reduces:
– strength by up to 20%
– spine bone mineral content by 1%.
 86% of women and 78% of men in residential homes
in England are sedentary.
 Nursing home residents spend 80%-90% of their
time seated or lying down – leading to inactivityrelated disability.
 Those who are less active and weaker will enter
nursing homes earlier than those who maintain their
fitness.
How active are older people?
Environmental factors assisting the
‘spiral of decline’
Following a fall
 Further loss of function
 Loss of mobility and independence
 Further loss of function
 Increased isolation and institutionalisation
 Loss of dignity and confidence and fear of a further fall
 Fear of using stairs
 Concerns for personal safety out of the house
 Poorly designed pavements/kerbs
 Concerns of family, friends and carers
Putting it into practice
Recommendations and guidelines
Putting it into practice: Recommendations and guidelines
What do we mean by physical activity?
 Physical activity “Any bodily movement produced
by skeletal muscles that results in energy
expenditure.”
‘Physical activity’ is a broad term covering all
types of movement (including leisure, work,
chores and movement).
 Exercise “Any leisure time physical activity which is
planned and structured, and repetitive bodily
movement undertaken to improve or maintain one or
more components of physiological fitness.”
(Bouchard et al, 1990)
Putting it into practice: Recommendations and guidelines
Specificity of intervention –
older people (Simey et al, 1999)
 To improve health and modify certain risk factors for
falling (e.g. strength), moderate physical activity is
appropriate.
 To reduce injurious falls, exercise should include
training in balance, strength, co-ordination and
reaction times.
 To reduce fractures, exercise should include boneloading in addition to the elements outlined for
reducing falls.
Putting it into practice: Recommendations and guidelines
Recent recommendations and
guidelines
 American Geriatrics Society, British Geriatrics Society
and the American Academy of Orthopaedic Surgeons
Panel on Falls Prevention (2001)
 Guidelines for the collaborative, rehabilitative
management of older people who have fallen
(Simpson, 1996)
Summarised in Falls, Fragility and Fractures
(Cryer and Patel, 2001)
Putting it into practice: Recommendations and guidelines
Specific recommendations:
multi-factorial interventions
Community-dwelling older people
 Gait training and appropriate use of assistive devices
 Review and modification of medication (especially
psychotropics)
 Exercise programmes, balance training
 Treatment of postural hypotension
 Modification of environmental hazards
 Treatment of cardiovascular disorders (including
arrhythmias)
(Cryer and Patel, 2001)
Putting it into practice: Recommendations and guidelines
Specific recommendations:
multi-factorial interventions
Long-term care and assisted living settings
 Staff education
 Gait training and appropriate use of assistive devices
 Review and modification of medications (especially
psychotropics)
Acute hospital settings
 No recommendations
Older people who have recurrent falls
 Long-term exercise and balance training
(Cryer and Patel, 2001)
Putting it into practice: Recommendations and guidelines
Recommendations and guidelines for
falls prevention for those aged 65+
 Individually tailored exercise programmes
administered by a qualified professional reduce the
incidence of falls in a selected high-risk group living in
the community.
 Exercise programmes reduce the risk of falls in a
selected group of older people with mild deficits of
strength and balance living in the community.
 Tai Chi classes with individual tuition can reduce the
risk of falls in older adults.
 Programmes that combine interventions (multifaceted – mostly including exercise) reduce falls.
(Feder et al, 2000)
Putting it into practice
Education and training
Putting it into practice: Education and training
Professional education and training –
generic areas
 Health and physical activity needs of older people
 Skills of key workers
 Principles of health promotion
 Specificity of exercise recommendations
 Safety issues
 Local opportunities and expertise
 Policy contexts
 Skills in exercise and sport services
(Simey et al, 1999)
Putting it into practice: Education and training
Training opportunities to support local
programmes
 ‘Making activity choices’ – Senior peer mentoring
programme
Peer mentoring to motivate inactive older people to
become active
 ‘Supervised targeted exercise’
Chair-based activity and assisted walking for frailer
older people
 Postural stability
A specialist exercise falls prevention and
management course designed for experienced
exercise professionals including physiotherapists
(Department of Health, 1999)
Putting it into practice: Education and training
‘Making Activity Choices’
Senior peer mentor programme
 Training senior peer mentors to promote physical
activity
 Flexible education and training programme with no
formal assessment
 Communication skills, assessing readiness to
exercise, overcoming barriers to activity, posture
check and initiating activities
 Built on the experience and skills of Age Concern’s
Ageing Well programme
(BHF National Centre for Physical Activity and Health, 2002)
Putting it into practice: Education and training
‘Making Activity Choices’
Community Healthy Activities Model Programme for Seniors (CHAMPS)
 Those enrolled in CHAMPS are twice as likely to take
part in physical activity.
 Effectiveness based on:
- attention from CHAMPS staff (peers)
- belonging to a group
- written materials
- goal-setting/self-monitoring
- range of accessible activities.
(Stewart, 2001)
Putting it into practice: Education and training
‘Supervised targeted exercise’
Chair-based activity and assisted walking
 Exercise leadership training for health professionals
 Total of four days’ training (including assessment)
 17 specific and targeted exercises designed to
improve mobility, strength, flexibility and co-ordination
 Includes assisted walking and games activities
(Department of Health, 1999)
Putting it into practice: Education and training
Chair-based exercise –
effective at targeting risk factors
Improvements in:
 strength (Fiatarone et al 1990; McMurdo et al 1993; Skelton et al 1995, 1996)
 power (Skelton et al, 1995)
 flexibility (McMurdo et al, 1993; Mills, 1994; Skelton et al, 1996)
 functional ability (McMurdo et al, 1993, 1994; Skelton et al, 1995, 1996)
 static balance (Skelton et al, 1996)
 rehabilitation following hip fracture (Nicholson et al, 1997)
 the performance of everyday tasks
(McMurdo et al, 1994; Skelton et al, 1995, 1996)
Putting it into practice: Education and training
Chair-based exercise –
effective at targeting risk factors
Also reductions in:
 depression (McMurdo et al, 1993)
 arthritic pain (Hochberg et al, 1995)
 postural hypotension (Millar et al, 1999)
 body fat (Nicholson et al, 1997)
 risk of future falls (Allen et al, 1999)
Particularly valuable for frailer older people
 Stabilises lower spine.
 Greater range of movement.
 Minimises load-bearing.
 Reduces balance problems.
 Increases confidence.
Putting it into practice: Education and training
Physical stability –
Specialist falls prevention and management course
 Specialist training for experienced exercise
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professionals (exercise teachers, physiotherapists,
occupational therapists, rehabilitation assistants)
Multi-factorial nature of falls
Exercise and assessment in care management plans
Improve postural instability, functional capacity
Medical conditions and medication
(Department of Health, 1999)
Putting it into practice: Education and training
Evidence for tailored exercise in
the prevention of falls
Exercise programmes can decrease the number of
falls and fall risk but certain conditions need to be met
including:
 Tailoring to meet the needs of vulnerable fallers
 Static and dynamic balance, low impact aerobics and
strength components
 Safely adapted Tai Chi
 Targeted home exercise
 Education and coping strategies
 Programme must be regular, sustained and
progressive.
(Gardner et al, 2000; Skelton and Dinan, 1999)
Physical activity and the prevention of
falls among older people – Summary
 Qualified and experienced teachers
 Effectiveness is achieved through appropriate
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programming which is:
– of sufficient intensity and duration
– is specific, progressive, tailored and adapted
to meet the needs of the individual participant
Include home-based (independent) exercise
Encourage socialisation
Build confidence
Fall coping strategies
Telephone support
(Skelton and Dinan, 1999)
Physical activity and the prevention of
falls among older people
“Physical activity, including muscle strengthening
(resistance) exercise, appears to be protective
against falling and fractures among the elderly,
probably by increasing muscle strength and
balance.”
From Physical Activity and Health: A Report of the
US Surgeon General
(US Department of Health and Human Services, 1996)
Physical activity and the prevention of
falls among older people
“Additional benefits from regular exercise include
improved bone health and, thus, reduction of
osteoporosis; improved postural stability, thereby
reducing the risk of falling and associated injuries
and fractures; and increased flexibility and range of
motion.”
American College of Sports Medicine, 1998
Physical activity and the prevention of
falls among older people
“Regular physical activity helps to preserve
independent living … Regular activity helps prevent
and/or postpone the age associated declines in
balance and co-ordination that are a major risk factor
for falls.”
World Health Organization, 1996