Transcript No Slide Title

Reducing Falls for Older People
Ngaire Kerse, FRNZCGP, PhD
Department of General Practice and Primary Health Care
University of Auckland
Presentation 2 to National Falls Programme Expert Advisory Group meeting
13 July 2012, HQSC
Definitions


An unexpected event in which the
participants come to rest on the ground,
floor, or lower level
“In the past month, have you had any
fall including a slip or trip in which you
lost your balance and landed on the
floor or ground or lower level?”
Lamb SE et al. J Am Geriatr Soc 2005;53:1618-22
Hospitalisation
Unintentional injury hospitalisation rates, Victoria, 1990
rate pe r 100,000 population
8,000
7,000
6,000
5,000
male
4,000
female
3,000
2,000
1,000
0
<5
5-14
15-24
25-34
35-44
45-49
age group
55-64
65-74
75-84
85+
Mortality
Age specific m ortality
rate per m illion
population
1 ,5 0 0 .0 0
1 ,0 0 0 .0 0
m a le
fe m a le
5 0 0 .0 0
0 .0 0
6 5 -7 4
7 5 -8 4
a g e g ro u p
85+
Personal risk
Frailty
Lower leg
weakness
Balance
problems
Visual
problems
age, living alone, residential care
Psychotropics
Depression
Dementia
Multiple comorbidity
Age & previous falls &
Wandering & gait
6x
Wandrng & environmt 5x
Environmt & depressn 3x
The mechanism
The place – environment
The person
Other people, context
risk factors
The exposure
Risky activity
Community




30% in 1 year
Injury common
Hip fracture tip of
the iceburg
Risk factors
–
–
–
–
Poor mobility
Lower limb, balance
Vision
Medication
Cochrane review
Community living older people aged ≥60 years
 111 RCTs, n = 55,303
 43 exercise alone
 31 multifactorial
 13 vitamin D
 10 multiple (8 with exercise)
 8 home safety
Gillespie LD et al. Cochrane Database Syst Rev 2009(2) Art. No.:
CD007146!
Exercise programmes
Effect of exercise programmes in reducing the rate and
risk of falling “should now be regarded as
established”
 Group exercise, multiple components
– Rate ratio 0.78 95%CI 0.71 – 0.86

Individual exercise at home – the Otago Exercise P
– Rate ratio 0.66 95%CI 0.53 – 0.82
– Life Programme Clemson 2010

Tai chi
– Rate ratio 0.63 95%CI 0.52 – 0.78

Effective when selected/not selected for risk of falling
Otago Exercise Programme http://www.acc.co.nz/oep
Balance training is key

44 RCTs community and residential care
– Rate ratio 0.83 95%CI 0.75 – 0.91

Challenging balance exercises, >50 hours over the
trial period, no walking programme
– Rate ratio 0.58 95%CI 0.48 – 0.69
– Lesser effect in higher risk participants (P=0.09)

One trial only with balance alone (Wolf 1996) NS
Sherrington C et al. J Am Geriatr Soc 2008;56:2234-43!
Effective single strategies

Home safety assessment and modification for those at high risk
only (6 trials)
– Risk of falling 21%

Vitamin D (only if lower levels, 2 trials), no reduction overall

Gradual withdrawal of psychotropic medication (1 trial)
– Rate of falls 66%

Medication review (GP one-on-one with pharmacist )
– Risk of falling 39%

Cataract surgery, pacemakers, single lens glasses
Clemson L et al. J Aging Health 2008;20:9541
Gillespie LD et al. Cochrane Database Syst Rev 2009(2) Art. No.:
CD007146!
Med review
Multifactorial intervention
Clinic based - ED
 Postural hypotension
 Visual acuity
 Balance
 Cognition
 Depression
 Carotid sinus studies
 Medication review
 Home safety assessment
and advice
Home based
 Postural hypotension
 Sedative medications
 Use of ≥4 medications
 Transfer skills, grab bars
 Environmental hazards
 Gait training, assistive
device
 Balance exercises, exercises
 against resistance
Close J et al. Lancet 1999;353:93-7
Tinetti ME et al. N Engl J Med
1994;331:821-7
Single interventions
Multifactorial interventions
Conclusions: falls and injury




common problem
disastrous consequences
identified risks
Interventions may maintain
independence, stop hip
fracture
Guidelines AGS UKSoc
Screen all >64
“have you fallen”
 Examine gait on all
 Full examination

– Fallen and frail
– Medications
medications
medications

Refer, Optimal
medical mngmt
Exercise, OT home
Residential care



Falls are 3 x the rate
of community
dwelling older
people
61% of all residents
fall
Hip fracture 10x rate
of community
dwellers.



Total cost of falls 41
mi yearly (1995)
187 mi spent on falls
in 2 years (ACC
only)
2/3 of these costs
are from residential
care residents
Hazards
Unsuccessful trial – Auckland 2004
Increased falls
–
–
–
–
1.34 (1.06-1.72)
?mobility
?staffing
?measurement
Fall rates
falls/resident year

5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
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Results
Trials
 41 trials – 25,442
 15 cluster RCT
 30 in nursing care
 11 hospitals, 1 acute, 6
subacute
 13 countries
– UK 10, USA 9, Australia 6

21 individual assessment
–
–
–
–
CGA 3, funcl 1,
falls risk 5 (NH) 4 (hosp)
Mobility 2, ex cap 3
Behav 1 meds 1
Participants
 Age 83, 73% female
 Conditions
– Cognition - 4 trials
specifically targetted
cognitively impaired
– Stroke – 1
– Hip fracture – 1



NH 20 trials, 10 rest home
1 acute hosptial
6 subacute
ProFaNE (Prevention of Falls
Network Europe)
http://www.profane.eu.org
Nursing care homes - Vitamin D
Exercises – overall
Exercises – combination exercise
modalities
Exercises – by type
Review:
Comparison:
Outcome:
Study
or sub-category
Interventions for preventing falls in older people in nursing care facilities and hospitals
02 Single exercise modalities vs usual care (nursing care facilities)
01 Rate ratio (falls)
Intervention
N
01 3D exercises
78
Faber 2006
78
Subtotal (95% CI)
Test for heterogeneity: not applicable
Test for overall effect: Z = 0.36 (P = 0.72)
Usual care
N
90
90
Rate ratio (fixed)
95% CI
log[Rate ratio] (SE)
Weight
%
-0.0400 (0.1100)
89.27
89.27
0.96 [0.77, 1.19]
0.96 [0.77, 1.19]
4.89
5.84
10.73
0.53 [0.21, 1.34]
0.40 [0.17, 0.93]
0.45 [0.24, 0.85]
100.00
0.89 [0.72, 1.09]
02 Gait, balance and coordination exercises vs usual care (nursing care facilities)
15
11
-0.6300 (0.4700)
Shimada 2004
20
7
-0.9200 (0.4300)
Sihvonen 2004
35
18
Subtotal (95% CI)
Test for heterogeneity: Chi² = 0.21, df = 1 (P = 0.65), I² = 0%
Test for overall effect: Z = 2.48 (P = 0.01)
113
108
Total (95% CI)
Test for heterogeneity: Chi² = 5.17, df = 2 (P = 0.08), I² = 61.3%
Test for overall effect: Z = 1.16 (P = 0.25)
0.1
0.2
0.5
Favours intervention
1
2
5
10
Favours usual care
Rate ratio (fixed)
95% CI
Success in residential care

Multifaceted

Falls – 0.55 (0.41 – 0.75)
Fallers & frequent
fallers reduced
Time to first fall
increased
– Staff and resident

education
– Balance and strength

exercises
– Environmental
adaptations
– Hip protectors
– Resident choice
(Becker 2004, Germany)
Becker; by cognition
a)
Impaired cognition
Probability of survival without fall
Probability of survival without fall
Intact cognition
Time (days)
Time (days)
Results
Nursing care homes
 Effect of exercise
inconsistent
 Multifactorial
interventions
– Team based > nurse
led


Vitamin D effective
Knowledge alone
ineffective
Hospitals

Overall success
– Exercise
– Orthogeriatrics
– AT&R

Less success
– Acute
Exercise - hospitals
Multifactorial – hospitals
Stenvall – ortho and geriatric ward Sweden
Stenvall
Healey elderly care wards UK
Cummings – acute & subacute Sydney
Hospitals

Multifactorial
– Success related to resources

Exercises promising