Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J

Professor Keith Hill,

Head, School of Physiotherapy and Exercise Science,

Curtin University – Keith.Hill@urtin.edu.au

Falls prevention for people living with dementia:

Education session for HACC Assessment Officers

and District Nurses

Gippsland (Victoria): September 2014

Overview 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

Hospital separations due to injury and poisoning, Australia 2008-9

Australian Institute of Health and Welfare, 2012

Falls as a National IssueTransportation related hospitalisations – 55,457

Falls related hospitalisations – 153,170

Hospital separations due to injury and poisoning, Australia 2003-4

Falls as a National Issue

Australian Institute of Health and Welfare, 2007

Other factors

implicated in up to 40% of admissions to residential care

quality of life issues◦ independence◦ community living◦ active life-style◦ other

Falls are multi factorial

Intrinsic factors

Extrinsic factors

Medications

Healthproblems

Ageing

Environment

Activityrelatedrisks

eg.psychoactive meds

Factors commonly associated with fallers:previous fallslower extremity weaknessarthritis (hips / knees)gait / balance disorderscognitive disorders (depression / dementia /

poor judgement...)visual disorderspostural hypotensionbladder dysfunction (frequency / urgency /

nocturia / incontinence...)medications (psychotropics/ sedatives /

hypnotics / antihypertensives...)

Tideiksaar, 1995

Identifying who is at risk of falls…

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60

70

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0 1 2 3 4+

Number of risk factors

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Tinetti et al, 1988

Number of risk factors

Modifiable and non-modifiable risk factors

Falls risk assessment

Systematic process of identifying an individual’s intrinsic falls risk factors (...to tailor an intervention)

Falls risk screening

Systematic process of identifying an individual’s level of falls risk (eg low, medium, high)

Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J

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 TechnologyCRICOS 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 from-http://www.mednwh.unimelb.edu.au/nari_tools/nari_tools_falls.html

Environmental problems contributing to risk of falling

Poor lighting

Loose mat or slippery / uneven surface

Poor footwear

….. having had a recent fall

The biggest risk for having a future fall is …….

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

However many older people who fall do not tell a Doctor or other health professional

American Geriatrics Society / British Geriatrics Society guidelines:JAGS 2011, 59: 148-157

Case: Mary

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

Early identification of risk: Mary

Reduced awareness of environment and safety

Agitation

Wandering

Increased unsteadiness

What effect does dementia have on a person’s risk of falling?

Even greater risk of falling

But the person with dementia may also have other falls risk factors…

Poor eyesight

Arthritis in the legs

Incontinence

Dizziness

• Poor eyesight• Dizziness• Incontinence• Arthritis • etc

OFTEN THESE CAN BE TREATED• Poor eyesight• Dizziness• Incontinence• Arthritis • etc

Can the risk of falls among older people be

reduced?

YES!

What can help to reduce an older person’s risk of falls: 1. See the doctor or other health

professional

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

Commences using a different walking aid

If a person is reducing their activities

What can help an older person to reduce their risk of falls: 2. Exercise

What can an older person do to reduce their risk of falls: 2.

Exercise 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 interventionssignificantly reduced the risk of sustaining a fall-related fracture …….”.

Cochrane review: Gillespie et al, 2012

Exercise / physical activity

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 intensityNOTE: Exercise programs usually have a range

of other benefits as well as falls prevention

Usually under intermittent supervision of physiotherapist or accredited exercise physiologist

Often need for encouragement to maintain participation

Many older people have an exercise program to do at home

What can an older person do to reduce their risk of falls: 3.

Medication review 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

What can an older person do to reduce their risk of falls: 4. Vision

check

Regular vision review

Cataract surgery

◦ First eye effective

Bifocals and multi-focal glasses– can be a problem

What can an older person do to reduce their risk of falls: 5. Home

safety

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

What can an older person do to reduce their risk of falls and fall injuries: Vitamin D and calcium

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

Vitamin D and calcium together have been shown to reduce fractures and falls (in high risk samples)

Effect of vitamin D on falls

Cochrane review: Gillespie et al, 2012

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

What can an older person do to reduce their risk of falls injuries: Hip protectors

Useful if falling frequently, and / or if bones are weak

Will reduce risk of hip fracture substantially, if worn...

Several different types◦ Hard shields◦ Foam

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Factors influencing low adherence with hip protectors

Design and style

Fashion / concern about “extra width on hips”

Cost

Impact of:◦ Reduced dexterity◦ Incontinence (some come with continence pads)

Staff / family not reinforcing value of hip protectors

Other interventions from best practice guidelines

Safe footwear

Treat posturalhypotension

Education

Treat incontinence

Change walking aid

Case: Mary – how can her falls risk be reduced?

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

Use her personal alarm if a fall occurs and cannot get up

Discuss hip protectors / vitamin D / possibly antiresorptive medications

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

Case: if Mary also had dementia…

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

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 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 …..

Falls risk can change quickly◦ Acute health problems such as urinary tract /

chest infections

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

Additional considerations

Summary of what works: falls prevention interventions in the

community setting for people with dementia (randomised controlled

trials)

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)

Reasons for lack of research evidence …

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

An area with recent promising results

Suttanon et al, Clinical Rehabilitation, 2013

Curtin University is a trademark of Curtin University of TechnologyCRICOS Provider Code 00301J

The falls prevention pathway for people living with dementia in Gippsland

Curtin University is a trademark of Curtin University of TechnologyCRICOS 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

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/2857_SOYF.pdf)

Encourage:1. Medical review if falls, near falls, unsteadiness, change in

mobility2. Participation in recommended interventions (exercise, use of

gait aid, home modifications, etc)3. Home care workers to report changes in potential level of risk4. If provided with training, encourage home care workers to

observe and encourage participation in home exercise programs

Ways nursing or assessment staff can assist in reducing risk of falling for a client with dementia

Falls are common among older people and can cause serious injuries and loss of confidence

All falls should be reported to a doctor

There are a number of ways that falls risk can be reduced

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

Summary

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Falls prevention resources

National Falls Prevention Guidelines for Community setting (UPDATED – Nov 2009):http://www.safetyandquality.gov.au/our-work/falls-prevention/falls-

prevention-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