Recent developments in falls prevention research

Falls Clinic Coalition

March 2006

Associate Professor Keith Hill,

Physiotherapist & Researcher,

National Ageing Research Institute

k.hill@nari.unimelb.edu.au

Research review: what works?

• Funded by Commonwealth Dept Health & Aged Care

• Randomised controlled trials

• Community, residential aged care, and hospital settings

• Published in 2000, updated by NARI and re-published in 2004

Cochrane Systematic reviews

2000 2004

Falls Falls

Hip protectors Hip protectors

Vitamin D

Environmental mods

Evidence of intervention effectiveness: Community (2000)

Risk factorChronic medical conditionsEnvironmental hazardsReduced activityReduced balanceReduced strengthPoor visionCognitive impairmentPolypharmacyOsteoporosisLow body mass index DepressionOther

Education

Multiple strat

Injury min

Sensory

Environment

Medication

Medical screen

Exercise-gen

Exercise-bal

Exercise-str

Level II

Evidence of intervention effectiveness: Community (2004)

Risk factorChronic medical conditionsEnvironmental hazardsReduced activityReduced balanceReduced strengthPoor visionCognitive impairmentPolypharmacyOsteoporosisLow body mass index DepressionOther

Education

Multiple strat

Injury min

Sensory

Environment

Medication

Medical screen

Exercise-gen

Exercise-bal

Exercise-str

Level II (2000)

Post-hosp

Level II (2004)

Randomised controlled trials with significant outcomes

1314

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4

8

12

16

2000 2004

num

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of publis

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stu

die

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commonly used

One RCT identifying significant reduction in falls rates for an OT home visit / environmental assessment / behaviour risk modification IN AT RISK GROUP ONLY (Cumming et al, 1999)NB: equally as effective at home and away

from home : issues of compliance

Environmental safety: Home falls risk assessment & modification

Post hospitalisation

15% of older people fall at least once within 1 month of discharge home from hospital, with 11% experiencing serious injuries (Mahoney et al, 2000)

Nikolaus and Bach 2003 older people admitted to hospital with functional

decline post discharge, usual care vs additional home

intervention including follow-up visits, instructions on use of aids and home modifications, support for compliance

significant reduction in falls at 12 months differential outcome based on compliance

various forms of exercise balance strength cardiovascular fitness flexibility

specificity of training

other health benefits of exercise programs

strong evidence of effectiveness

of training in older people to

improve specific risk factor

Exercise

Exercise

tai chi (Wolf et al, 1996; Li et al, 2005)physiotherapy prescribed home program

(Campbell et al, 1997; Robertson et al, 2001)

group exercise program (Day et al, 2002, Barnett et al, 2003; Lord et al, 2003)

no published RCT’s evaluating medical screen with falls rate as an outcome

Campbell et al (1999) - RCT - psychotropic medication withdrawal 66% reduction in falls rates in intervention group 47% had resumed psychotropics after one month

Clinical screen: Medical (including medication)

Critical role of vision in balance and obstacle avoidance

Melbourne study identified identified that a third of people over 65 have inadequate visual correction

Cataract surgery has been shown to reduce falls (RCT – Harwood et al, 2004)

?? Effectiveness of visual assessment and correction

?? Effectiveness of changing bifocals to separate distance and reading glasses (current Sydney study)

Vision correction

Tinetti et al (1994) - RCT - subjects with one or more falls risk factors, all provided with 3 interventions (home mods, home exercise, medication review)sig difference in time to first fall, number of falls

and fear of fallingRizzo et al (1996) - cost benefit analysis of

Tinetti’s program

Clinical screen: Multiple strategy (restricted)

incorporates assessment and tailored management

Close et al (1999) - RCT - assessment by medical and occupational therapy staff significant reduction in falls rates

Cochrane meta-analysis (Gillespie et al, 2004)

Current NARI study nearing completion (700 older fallers presenting to Emergency Departments after a fall)

Clinical screen: Multiple strategy (unrestricted)

Injury minimisation

Alternative strategies may be indicated if: falls risk is high intervention has not been successfulother factors limit likelihood of successful

intervention (eg poor cognition)Osteoporotic / high fracture risk

Hip protectors

Limited studies in community settingshown to be effective in residential care

settings (though less so with recent studies) issues of limited compliance

Injury minimisation

Vitamin D & calcium supplementation RCT of older people in community / residential

aged care settings identified significant reduction in falls fracture rates (Chapuy et al, 1992)

Mechanism of slowing normal bone loss

Recent evidence of effect on reducing falls

Research gaps: Community setting

Some risk factors poorly understood and managed dizziness

Some interventions have good clinical basis, but limited research evidence use of walking aids footwear

Effect of early identification of falls risk All interventions are only as good as the adherence to the

intervention regime - issues to improve uptake and compliance need further exploration

Almost all interventions that have been shown to be effective have not included subjects with an important falls risk factor - cognitive impairment (NB- Shaw et al 2003)

Current and new NARI projects

Falls prevention for people presenting to Emergency Departments after a fall

Large study, in its 4th year Recruited 700 participants Evaluating effectiveness of a

comprehensive assessment (using a NARI developed tool-the FROP-Com) in reducing falls and falls injuries

Also evaluating cost effectiveness Will be one of the few studies to

evaluate outcomes on injuries and costs

Melissa Russell undertaking her PhD

Dr Irene Blackberry

Early balance screening & exercise

Using Neurocom force platform to detect mild levels of balance dysfunction

Participants with mild balance dysfunction will be randomised to receive Otago home exercise program or info booklet

12 month followup, to determine effectiveness in improving balance and mobility

2.5 year project

Funded by the Dept Veterans’ Affairs; Xaio Jing Yang undertaking her PhD

Keith Hill, Kirsten Black, Xiao Jing Yang, Sarah Tarquinio

Falls prevention for stroke patients after in-patient discharge

High falls risk stroke patients recruited at discharge

Randomised to information booklet, or risk assessment and targeted management program

12 month follow-up (falls, balance, QoL, etc)

Sub-studies: Temporal changes in fear of falling after a fall Obstacle negotiation skills at 12 months, and

association with falls

Funded by NHMRC; Frances Batchelor commencing her PhD

Keith Hill, Cathy Said, Shylie Mackintosh, Craig Whitehead, Sarah Tarquinio, Frances Batchelor

Balance problems and exercise response in clinical populations

Neurocom and clinical measures of balance in OA and RA patients

Identify any differences in balance abilities

Determine responsiveness to Otago home exercise program

Funded by JO & JR Wicking Trust

Keith Hill, Sue Williams, Sue Hunt, Caroline Brand

Funded by Haemophilia Foundation (Aust)

Keith Hill, Marcia Fearn

Neurocom and clinical measures of balance in patients with haemophilia

Identify falls history, level of balance dysfunction (relative to joint pathology)

Determine responsiveness to Otago home exercise program

Resources

VQC Guidelines: http://www.health.vic.gov.au/qualitycouncil/plans/falls_5d.htm

National Falls Prevention Guidelines for Hospital and Residential Care settings:http://www.health.qld.gov.au/fallsprevention/project/default.asp