Applying the evidence in falls prevention

Dr Emma Stanmore, University of Manchester

Professor Chris Todd, University of Manchester

www.profound.eu.com

www.fallsprevention.eu

• Epidemiology – the size of the problem

• Implementation - what works to reduce falls

• The issues - uptake and adherence

• How can we address the problems?

ProFouNDCluster RCT of Exergames

Overview

• Falls are the leading cause of injury, injury related disability & death in older people

• 1 in 3 >65’s and 1 in 2 >80’s fall p.a.• 50% hospital admissions for injury due to falls

• Falls costs £2.3 billion in 20131 Hip Fracture every 10 mins1 Wrist Fracture every 9 mins1 Spine Fracture every 3 mins

Risk of falls

Viera et al., BMJ 2016; CDC 2014; WHO 2007; NICE 2013; Masud, Morris Age & Ageing 2001; 30-S4 3-7

Rubenstein. Age & Ageing; 2006; 35-S2; ii37-41

Hip Fractures

• 95% hip fractures due to falls

• 10% die within 30 days, 30% die within 1 yr

• 95% discharged to care homes (40% of all care home admissions)

• 50% never regain previous levels of mobility

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NHFD, 2015

EU28 Falls amongst community dwelling 60+ year olds 2015-2040 (estimate; 95% CIs)

Total

0

10,000,000

20,000,000

30,000,000

40,000,000

50,000,000

2005 2010 2015 2020 2025 2030 2035 2040 2045

Todd et al 2016 unpublished EC report data

RISK FACTORS EXAMPLES

Previous falls During the previous 12 months

Fear of falling Low falls efficacy scale scores

Balance problems Increased postural swayGait and mobility problems timed up and go test time >12s

Pain Lower limb and foot painDrugs Polypharmacy (≥4), psychotropics,

antidepressants, benzodiazepine

Cardiovascular conditions and syncope

Orthostatic hypotension, arrhythmias

Cognitive impairment Processing speed Urinary incontinence Rushing to the bathroom at night

Stroke Decreased balance control, increased variability of step length

Diabetes Peripheral neuropathy, visual decline

Falls can be prevented!

• Multiple-component group exercise– RaR 0.71 [0.63-0.82] RR 0.85 [0.76-0.96]

• Multiple-component home-based exercise

– RaR 0.68 [0.58-0.80] RR 0.78 [0.64-0.94]

• Tai Chi– RaR 0.72 [0.52-1.00] RR 0.71 [0.57-0.87]

• Multifactorial intervention individual risk assessment

– RaR 0.76 [0.67-0.86] RR 0.93 [0.86-1.02]

• Vitamin D – RaR 1.00 [0.90-1.11] RR 0.96 [0.89-1.03] NB low Vit D

• Home safety interventions by OT – RaR 0.69 [0.55-0.86] RR 0.79 [0.69-0.90]

RR=0.83 (95%CI 0.75-0.91)(High Dose & Challenging RR=0.58 (95%CI0.48–0.69)

Sherrington et al 2008, 2016

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Gillespie et al 2012 159 trials 79193 participants

So, what’s the problem?

Prevention programmes are efficacious

BUT - Implementation gap

– Falls prevention not a priority

– Services not available

– Evidence not used or modified

• Training needs to be challenging, progressive & regular

• Programmes often too short term

– Refusal/non-adherence=50-90%; prevention not effective?

21 partners in 12 countries –disseminate best practice in falls prevention

UK Manchester GlasgowBelfast London

D StuttgartNL Amsterdam LeidenFIN JyväskyläS UmeåI Empoli AnconaE Madrid Barcelona

ValenciaEL Athens LamiaNO TrondheimCH BernÖ ViennaH Budapest

Website V2 www.profound.eu.org

www.profound.eu.com

Downloads• ProFouND Fall

Prevention Awareness Campaign Pack

• Flyer

www.profound.eu.com

Resources

Otago Home Exercise Booklets

13 languages

• Evidence based home exercise programme shown to reduce falls with regular use and progression (Campbell &

Robertson, 1997, 2001)• 7 RCTs in community

dwelling older people

Exercise

• What works

• What does not work

• Cautions

• Who can help

• Where to find resources

• Assessmt. Instruments

• Summaryhttp

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Falls prevention fact sheets

Cascade Training• Train the trainers of future

strength & balance instructors across EU

• Face to face training (5 days)– Practical Workshops– Become an OEP Leader– Become a Cascade Trainer– Assessments (do themselves

and how to run them– follow up training &

accreditation. Dawn Skelton Bex Townley

Find out more about ProFouND on our website:www.profound.eu.com

Follow us on Twitter:@ProFouNDEU

Find us on Facebook and ‘Like’ our Page to receive updates:profound.eu.com

Not all video games are bad for you……!

EXERGAMES Project

WHY?

Current system untenable with increasing incidence of falls

Robust evidence that specific strength/balance exercises reduce falls

but……..

Low uptake and adherence

Barriers to exercise – health problems, slow return, low motivation,

other priorities

Evidence based exergames for Falls Prevention 2012 -

FUNDING

MICRA

CMFT

SBRI NHS England

TEAM

ACADEMIC

CLINICAL

HOUSING

AGE UK

PENNINE CARE NHS

TRUST

COMMERCIAL

USERS

PRE AND POST FOCUS

GROUPS

COMMUNITY EVENTS

FEASABILITY PILOT

CLUSTER RCT STUDY

Gamification in healthcare is the application of design principles of computer games to healthcare solutions that work to change patient

behaviour in order to attain better health.

This makes healthcare personalised and user centred, providing motivation and creating engaging experience.

Gamification in healthcare

Project plan

PRE DESIGN USER CENTERED DESIGN TESTING

- 3 PHASE PROJECT -

12EXERGAMES

(14 exercises)

FOCUS GROUPS

with feedback

PILOT FEASIBILITYn=24

CLUSTER RCT n=120

10 Sheltered Housing facilities in Manchester & 4 Glasgow

TALK AND EXERGAME DEMONSTRATION

QUESTIONS AND FEEDBACK

USER CENTERED DEVELOPMENT-

MIRA REHAB DESIGNED SOFTWARE -- 12 GAMES, 14 EXERCISES

Liked the concept

Enjoyed the exergames

Wanted to be able to tailor to their

health needs & level

Wanted exergames to be slower & simpler

Slower music or more suitable music

Didn’t like the young perfect avatar! Your

Shap

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olve

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Based on OTAGO/FaME strength & balance exercises

Input from 2 Falls prevention teams (geriatrician, physios, OTs, rehab nurse)

Input from patients & healthy older people

Motivators and awards

Controlled movements

Can be played with balance support (chair/person)

MIRA platform – captures patient stats in real time

MIRA exergames APPROVED

By measuring certain parameters, MIRA can easily track the patient's progress through rehab

INFORMATION GATHERING

Pilot & Cluster RCT

CLINICAL ASSESSMENT QUESTIONNAIRE

Lower limb muscle strength & balance (Berg)

Cognition (ACEIII)Medication

PMH (surgery, joint replacements, fractures & co-

morbidities)

History of falls/injuriesFRAT

Short FES-I (fear of falling)VAS pain & fatigue

Health status (EQ-5D)Vision

Usability (SUS)Physical activity (PASE)

Demographics

• Pre and post-study Interviews, focus groups & observation in sheltered homes

• 6 weeks Exergame group vs. usual activities – 2 sheltered housing facilities

• Randomised 14 sheltered housing facilities - 12 weeks Exergames vs. usual

activities (Manchester & Glasgow)

n=7

n=12

n=5

Pilot results

BALANCE

Pilot results FEAR OF FALLING

n=5

n=7

n=12

Need to be flexible about use

Need reminding about sessions & training

Having fun is important, social component

Frail older people interested and those with multi-morbidities but need more

support

Mean usability and acceptability scores good

Mean balance, pain, fatigue, cognition & global health scores all increased after 6 weeks

Pilot results

• Falls are a common problem but can be prevented

• Use the evidence and keep to it

• Collaborate &

• Implement what works to reduce falls

KEY MESSAGES

“The measure of intelligence is the ability to change.”

Any Questions?

Albert Einstein

How to test your balance and lower limb strength

• Four test balance scale

• Chair stand test

All but 1 person noted physical and mental improvements after 6 weeks

Found the exergames fun, motivating and enjoyed the challenge

Personal goal setting & feedback important

Some concerns about use of technology but ok if shown

Some wanted as social activity, others privacy

Concerns about use when have health issues

Some users had not participated in any exercise or activities previously

Good that they don’t have to go outside

Costs – who pays?

Focus GP results – older people (n=26) & Managers (n=2)

PHASE I BASELINE CHARACTERISTICS