Reducing Falls for Older People

Ngaire Kerse, FRNZCGP, PhDDepartment 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

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

<5 5-14 15-24 25-34 35-44 45-49 55-64 65-74 75-84 85+

age group

rate

pe

r 10

0,00

0 p

op

ula

tio

n

male

female

Mortality

Age specific mortality

0.00

500.00

1,000.00

1,500.00

65-74 75-84 85+

age group

rate

pe

r m

illio

n

po

pu

lati

on

male

female

Personal risk age, living alone, residential care

Psychotropics

Depression

Dementia

Multiple co-morbidity

Age & previous falls &

Wandering & gait 6x

Wandrng & environmt 5x

Environmt & depressn 3x

Frailty

Lower leg weakness

Balance problems

Visual problems

The mechanism

The person

risk factors

The place – environment

Other people, context

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 safetyGillespie 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;20:9541Gillespie 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

Close J et al. Lancet 1999;353:93-7

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

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

00.5

11.5

22.5

33.5

44.5

5

falls

/res

iden

t ye

arintervention

control

Kerse JAGS 2004

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 typeReview: Interventions for preventing falls in older people in nursing care facilities and hospitalsComparison: 02 Single exercise modalities vs usual care (nursing care facilities) Outcome: 01 Rate ratio (falls)

Study Intervention Usual care Rate ratio (fixed) Weight Rate ratio (fixed)or sub-category N N log[Rate ratio] (SE) 95% CI % 95% CI

01 3D exercisesFaber 2006 78 90 -0.0400 (0.1100) 89.27 0.96 [0.77, 1.19]

Subtotal (95% CI) 78 90 89.27 0.96 [0.77, 1.19]Test for heterogeneity: not applicableTest for overall effect: Z = 0.36 (P = 0.72)

02 Gait, balance and coordination exercises vs usual care (nursing care facilities)Shimada 2004 15 11 -0.6300 (0.4700) 4.89 0.53 [0.21, 1.34] Sihvonen 2004 20 7 -0.9200 (0.4300) 5.84 0.40 [0.17, 0.93]

Subtotal (95% CI) 35 18 10.73 0.45 [0.24, 0.85]Test for heterogeneity: Chi² = 0.21, df = 1 (P = 0.65), I² = 0%Test for overall effect: Z = 2.48 (P = 0.01)

Total (95% CI) 113 108 100.00 0.89 [0.72, 1.09]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 1 2 5 10

Favours intervention Favours usual care

Success in residential care

Multifaceted– Staff and resident

education– Balance and strength

exercises– Environmental

adaptations– Hip protectors– Resident choice

Falls – 0.55 (0.41 – 0.75)

Fallers & frequent fallers reduced

Time to first fall increased

(Becker 2004, Germany)

Becker; by cognition a)

Time (days)

Impaired cognition

Time (days)

Intact cognition

Pro

babi

lity

of s

urvi

val w

ithou

t fal

l

Pro

babi

lity

of s

urvi

val w

ithou

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l

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