Transcript Exercise approaches for the prevention of frailty

Professor Keith Hill,
Head, School of Physiotherapy and Exercise Science,
Curtin University – [email protected]
Curtin University is a trademark of Curtin University of Technology
CRICOS Provider Code 00301J
Gippsland (Victoria): September 2014
 How common are falls among older people
 What are the effects of falls on an older person
 Why do older people fall
 What effect does dementia have on falls
 What should an older person do if they have a fall
 Case study
 How can HACC Assessment Officers and District Nurses help clients (with
and without dementia) to avoid falls
 Introduction to the Gippsland Falls Prevention Pathway for People Living
With Dementia
 Resources to help older people who fall
Transportation related
hospitalisations – 55,457
Falls related
hospitalisations – 153,170
Australian Institute of
Health and Welfare, 2012
Hospital separations due to injury and
poisoning, Australia 2008-9
Australian Institute of
Health and Welfare, 2007
Hospital separations due to injury and
poisoning, Australia 2003-4
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implicated in up to 40% of admissions to
residential care
quality of life issues
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independence
community living
active life-style
other
Health
problems
Intrinsic factors
Ageing
Medications
eg.
psychoactive
meds
Environment
Activity
related
risks
Extrinsic
factors
Identifying who is at risk of falls…
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Factors commonly associated with fallers:
previous falls
lower extremity weakness
arthritis (hips / knees)
gait / balance disorders
cognitive disorders (depression / dementia /
poor judgement...)
visual disorders
postural hypotension
bladder dysfunction (frequency / urgency /
nocturia / incontinence...)
medications (psychotropics/ sedatives /
hypnotics / antihypertensives...)
Tideiksaar, 1995
Percentage who fell
80
70
60
50
40
30
20
10
0
0
1
2
3
Number of risk factors
Modifiable and non-modifiable risk factors
4+
Falls risk screening
Systematic process of identifying an
individual’s level of falls risk (eg low,
medium, high)
Systematic process of identifying an
individual’s intrinsic falls risk factors (...to
tailor an intervention)
The falls prevention pathway for people living
with dementia in Gippsland
 Tools:
Falls risk screening tool (FROP-Com* screen)
FROP-Com = Falls Risk for Older People: Community version:
Screen available from-http://www.mednwh.unimelb.edu.au/nari_tools/nari_tools_falls.html
Curtin University is a trademark of Curtin University of Technology
CRICOS Provider Code 00301J
The falls prevention pathway for people living
with dementia in Gippsland
 Tools:
Eg Falls risk assessment tool (FROP-Com*)
FROP-Com = Falls Risk for Older People: Community version:
Assessment tool available fromhttp://www.mednwh.unimelb.edu.au/nari_tools/nari_tools_falls.html
Curtin University is a trademark of Curtin University of Technology
CRICOS Provider Code 00301J
Poor lighting
Poor footwear
Loose mat or slippery / uneven surface
….. having had a recent fall
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Why is this important?
◦ The Doctor can
 assess the cause of the falls
 provide treatment to reduce
risk of a further fall
◦ But if the Doctor is not
aware of the fall
 there will be no actions put
in place to reduce ongoing
risk of falls
 another fall is likely to occur
American Geriatrics
Society / British Geriatrics
Society guidelines:
JAGS 2011, 59: 148-157
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85 yo lady
Lives at home alone, has a home care worker visit twice
weekly
Has a personal alarm
Has been falling for more than 10 years
Multiple fractures from falls
Medical past history includes osteoporosis, diabetes,
depression, osteoarthritis, cataracts
Medications include sleeping tablets, antidepressants,
and several others
Increasing unsteadiness in past few months
Had a recent fall, has not seen Doctor about falls
Environmental hazards
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Reduced awareness of environment and safety
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Agitation
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Wandering
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Increased unsteadiness
Even greater risk of falling
Poor eyesight
Dizziness
Incontinence
Arthritis in the legs
OFTEN THESE CAN
BE TREATED
Poor eyesight
eyesight
•• Poor
Dizziness
•• Dizziness
Incontinence
•• Incontinence
Arthritis
•• Arthritis
etc
•• etc
Can the risk of falls
among older people be
reduced?
YES!
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If a person has a fall even if they think it was
just an accident
If a person is feeling
more unsteady when
walking / turning
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Commences using a
different walking aid
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If a person is reducing
their activities
COCHRANE REVIEW: “Multiple-component group exercise significantly reduced rate of
falls …….. and risk of falling ….., as did multiple-component home-based exercise …...
For Tai Chi, the reduction in rate of falls bordered on statistical significance …… but
Tai Chi did significantly reduce risk of falling ……. Overall, exercise interventions
significantly reduced the risk of sustaining a fall-related fracture …….”.
Cochrane review: Gillespie et al, 2012
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Most researched single intervention in falls
prevention
Majority of research in the community setting
Meta-analysis of >50 RCTs identified key
elements for success in reducing falls
(Sherrington et al, (JAGS, 2011):
◦ Balance component
◦ Moderate intensity
NOTE: Exercise programs usually have a range
of other benefits as well as falls prevention
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Usually under
intermittent supervision
of physiotherapist or
accredited exercise
physiologist
Often need for
encouragement to
maintain participation
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Keep medications to the
minimum needed
Take medications as
prescribed
Have medications reviewed
by the doctor regularly
Try to avoid / minimise use
of sleeping tablets, anti
anxiety tablets etc
Largest effect of any falls prevention
study involved weaning people off
sleeping / anxiety medications
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Regular vision review
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Cataract surgery
◦ First eye effective
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Bifocals and multi-focal
glasses– can be a
problem
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Removing
environmental hazards
will reduce risk of falls
If having falls should
have an occupational
therapy home
assessment
Outcomes associated
with level of adherence
with recommendations
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Many older people have low
levels of vitamin D
Main sources of vitamin D
are:
◦ Sunlight (approx 20 min/day)
◦ Some foods (eg sardines)
◦ Supplements
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Vitamin D and calcium
together have been shown
to reduce fractures and falls
(in high risk samples)
COCHRANE REVIEW: “Overall, vitamin D did not reduce rate of falls ……. or risk of
falling ……, but may do so in people with lower vitamin D levels before treatment..”
Complex series of studies to interpret because of:
• different types of vitamin D (D2 and D3)
• different dosages
• different samples in terms of vit D deficiency
• supplementation of vitamin D with calcium
• outcomes of fractures as well as falls
Cochrane review: Gillespie et al, 2012
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Useful if falling frequently,
and / or if bones are weak
Will reduce risk of hip
fracture substantially, if
worn...
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Several different types
◦ Hard shields
◦ Foam
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Design and style
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Fashion / concern about “extra width on hips”
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Cost
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Impact of:
◦ Reduced dexterity
◦ Incontinence (some come with continence pads)
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Staff / family not reinforcing value of hip protectors
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Safe footwear
Education
Change walking
aid
Treat incontinence
Treat postural
hypotension
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85 yo lady
Lives at home alone, has a home care
worker visit twice weekly
Has a personal alarm
Has been falling for more than 10 years
Multiple fractures from falls
Medical past history includes
osteoporosis, diabetes, depression,
osteoarthritis, cataracts
Medications include sleeping tablets,
antidepressants, and several others
Increasing unsteadiness in past few
months
Had a recent fall, has not seen Doctor
about falls
Environmental hazards
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Use her personal alarm if a fall occurs
and cannot get up
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Discuss hip protectors / vitamin D /
possibly antiresorptive medications
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Review re cataracts-?surgery
Review medications, in particular
sleeping tablets
Physiotherapy assessment of balance
and mobility - ?exercise program
Have a medical review AND report the
fall
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Home safety assessment by
occupational therapist
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

85 yo lady
Lives at home alone, has a home care
worker visit twice weekly
Has a personal alarm
Has been falling for more than 10 years
Multiple fractures from falls
Medical past history includes osteoporosis,
diabetes, depression, osteoarthritis, cataracts
Medications include sleeping tablets,
antidepressants, and several others
Increasing unsteadiness in past few months
Had a recent fall, has not seen Doctor about
falls
Environmental hazards
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POSSIBLE OPTIONS TO REDUCE RISK OF
FALLS
 Use her personal alarm if a fall occurs and
cannot get up
 Discuss hip protectors / vitamin D / possibly
antiresorptive medications
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Review re cataracts-?surgery
Review medications, in particular sleeping
tablets
Physiotherapy assessment of balance and
mobility - ?exercise program
Have a medical review AND report the fall
Home safety assessment by occupational
therapist
Dementia friendly environment
Consider any additional carer burden in interventions
Ensure consideration of causes and management of agitation
Other …..
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Falls risk can change quickly
◦ Acute health problems such as urinary tract / chest
infections
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Transitions between settings appear to
increase risk of falls (eg home to hospital,
home to respite)
Greater level of care / falls risk management at
these times
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Exclusion criteria for most community falls
prevention randomised trials
Difficult area of research
Limitations in few randomised trials to date
(mainly replicating approaches found
successful for people who don’t have
dementia)
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Home based exercise for people with mild to
moderate dementia
◦ Prescribed by a physiotherapist
◦ Individualised exercise program, based on balance
and mobility assessment findings
◦ Key role of carer in supporting / encouraging
exercise participation by the person with dementia
(sometimes doing the exercises together)
◦ Regular review and update by physiotherapist (6
times in 6 months)
Improved balance, mobility and falls risk after 6
months
Suttanon et al, Clinical Rehabilitation, 2013
The falls prevention pathway for people living
with dementia in Gippsland
Curtin University is a trademark of Curtin University of Technology
CRICOS Provider Code 00301J
The falls prevention pathway for people living
with dementia in Gippsland
Identification of falls risk and referral / screen
• Many people accept falls as an inevitable part of ageing (irrespective of
cognitive impairment)
• Only a quarter of older people who fall report the fall to a Dr or health
professional
• Many falls risk factors are not identified or managed optimally (eg
guideline care in Emergency Departments)
• Need for multiple access / referring points
Timing
• Consider falls risk screening
• in early stages of dementia, and
• intermittent review, especially if increased unsteadiness, falls or near
falls
Curtin University is a trademark of Curtin University of Technology
CRICOS Provider Code 00301J
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Observe for signs of increased falls risk
Ask the client to complete a falls risk self assessment
(eg:
http://www.health.wa.gov.au/stayonyourfeet/docs/28
57_SOYF.pdf)
Encourage:
1. Medical review if falls, near falls, unsteadiness, change in
mobility
2. Participation in recommended interventions (exercise, use of
gait aid, home modifications, etc)
3. Home care workers to report changes in potential level of risk
4. If provided with training, encourage home care workers to
observe and encourage participation in home exercise
programs
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Falls are common among older people and can cause
serious injuries and loss of confidence
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All falls should be reported to a doctor
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There are a number of ways that falls risk can be
reduced
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Home care assessment staff, home nursing staff and
other health professionals can play an important role
in identifying potential risks for falling among their
clients
Consider the Gippsland falls prevention pathway for
people with dementia in assessment and
management of clients with dementia
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 National Falls Prevention Guidelines for Community setting
(UPDATED – Nov 2009):
http://www.safetyandquality.gov.au/our-work/falls-prevention/fallsprevention-community/
 Victorian Government Dept of Health– website of falls prevention
resources for community and residential aged care settings
(UPDATED 2009)
http://health.vic.gov.au/agedcare/maintaining/falls_dev/index.htm