The evidence for the The evidence for the Otago Home Exercise Otago Home Exercise Programme to reduce Programme to reduce

falls falls

NSF for OP: Exercise NSF for OP: Exercise EvidenceEvidence

StandardsStandards 33 Intermediate CareIntermediate Care 55 StrokeStroke 66 FallsFalls 77 Mental HealthMental Health 88 Promotion of Health and Promotion of Health and

active life in old ageactive life in old age

Falls – a major problem Falls – a major problem in the UKin the UK

11 million people aged > 65 yrs11 million people aged > 65 yrs 28,000 women aged > 90 yrs28,000 women aged > 90 yrs

Fractures costs £1.6 billion paFractures costs £1.6 billion pa 1 Hip Fracture every 10 mins1 Hip Fracture every 10 mins

– Cost £12-15 kCost £12-15 k 1 Wrist Fracture every 9 mins1 Wrist Fracture every 9 mins

– Cost £480Cost £480 1 Spine Fracture every 3 mins1 Spine Fracture every 3 mins

500 admitted to Hospital every day500 admitted to Hospital every day 3333 never go home never go home Annual European Home and Leisure

Accident Surveillance Survey (EHLASS) Report UK 2000

How common are falls?How common are falls?

In In > 75s> 75s, falls are the leading cause of , falls are the leading cause of

deathdeath resulting from injury resulting from injury

75-80%75-80% of falls are not reported of falls are not reported

1 in 3 >651 in 3 >65’’s and 1 in 2 >80s and 1 in 2 >80’’s fall each s fall each

yearyear

10%10% of all call-outs for of all call-outs for UK Ambulance UK Ambulance

ServiceService are for people aged 65+ who are for people aged 65+ who

have ‘fallen’ but nearly have ‘fallen’ but nearly half half are not taken are not taken

to Hospital.to Hospital.

Time and Location of Time and Location of Reported FallsReported Falls

0

20

40

60

80

100

% fallen in last three

months

Day Night Indoors Outdoors

MenWomen

Cambridge City Over 75s Cohort Study, Fleming, 2002

Changing incidence of Changing incidence of fractures with increasing fractures with increasing ageage

• 50 to 65 yrs - wrist

• 55 to 85 yrs - spine

• 75 to 85 yrs - hip

(because of poor reaction, coordination and reflexes)

Incidence of Fractures Incidence of Fractures Compared with Other Compared with Other DiseasesDiseases

1. National Osteoporosis Foundation, 2002. Available at: http://www.nof.org.2. American Heart Association. Heart & Stroke Facts: 1999 Statistical Supplement.3. American Cancer Society. Breast Cancer Facts & Figures 1999-2000.

1,200,000

513,000

228,000 184,000

0

500,000

1,000,000

1,500,000

2,000,000

OsteoporoticFractures

Heart Attack Stroke BreastCancer

An

nu

al I

nci

den

ce 1

2

2 3

1-14

IMPACT – Cost to the IMPACT – Cost to the IndividualIndividual

InjuriesInjuries include: include: – Cuts and lacerations, Cuts and lacerations, – Deep bruises, Deep bruises, – Soft Tissue Injuries,Soft Tissue Injuries,– Dislocations,Dislocations,– SprainsSprains– Increase in joint painIncrease in joint pain

Less than Less than 5%5% of all falls result in a of all falls result in a fracturefracture

Long lieLong lie’’s & complications s & complications Post fall syndromePost fall syndrome Avoidance of activities and social Avoidance of activities and social

isolationisolation

IMPACT - Costs to the IMPACT - Costs to the NHSNHS

Hospital spending > £10 billion. Hospital spending > £10 billion.

Local authority, residential care > £3 billionLocal authority, residential care > £3 billion

– Non-residential care > £2 billion. Non-residential care > £2 billion.

– Half of L.A. social services spent on services for older Half of L.A. social services spent on services for older

peoplepeople

Formal and informal ‘care’Formal and informal ‘care’

Emergency call-outsEmergency call-outs

IMPACT- HospitalisationIMPACT- Hospitalisation

0

500

1000

1500

2000

2500

3000

3500

65-69 70-74 75-79 80-84 85+

MaleFemale

Age group- years

Rate / 100,00

Age-specific hospital admission rates for falls

[SE Thames

1991-2]

Cryer et al

IMPACT - Fear and IMPACT - Fear and avoiding activityavoiding activity

Present in >50% of fallers & up to 40% non-Present in >50% of fallers & up to 40% non-fallersfallers

Predicts Predicts

– decreases in physical and social decreases in physical and social activityactivity

– deterioration in physical functioningdeterioration in physical functioning

– higher risk of falling higher risk of falling

Particularly common in people who cannot get up Particularly common in people who cannot get up from the floorfrom the floor

Map of NZMap of NZ

Dept of Health Dept of Health Prevention Package Prevention Package 20092009

Hip fractures cost the NHS in England £1.8 billion a Hip fractures cost the NHS in England £1.8 billion a year.year.

The direct cost to commissioners of a hip fracture is The direct cost to commissioners of a hip fracture is estimated to be £10,000 – plus the cost of local estimated to be £10,000 – plus the cost of local authority social care.authority social care.

One-third of people who experience a hip fracture are One-third of people who experience a hip fracture are unable to continue to live independently afterwards.unable to continue to live independently afterwards.

An effective falls and fracture prevention service can An effective falls and fracture prevention service can make direct savings of £263,636 over five years for a make direct savings of £263,636 over five years for a primary care trust with a population of 320,000.primary care trust with a population of 320,000.

Every five hours in England, an older person Every five hours in England, an older person dies as a result of a fall. dies as a result of a fall.

For a primary care trust with a population of For a primary care trust with a population of around 300,000 this means:around 300,000 this means:

– 15,500 older people will fall each year• 15,500 older people will fall each year•

– 2,200 of those will attend an accident and • 2,200 of those will attend an accident and • emergency department or minor injuries clinic, and emergency department or minor injuries clinic, and a similar number will call an ambulancea similar number will call an ambulance

– 1,100 will sustain a fracture – 300 of which will • be 1,100 will sustain a fracture – 300 of which will • be of the hip.of the hip.

Dept of Health Prevention Dept of Health Prevention Package 2009Package 2009

An effective falls and fracture prevention An effective falls and fracture prevention service in a primary care trust with a service in a primary care trust with a population of around 320,000 can make population of around 320,000 can make NHS and social care direct savings of NHS and social care direct savings of £263,636 over five years.£263,636 over five years.

OEP is an important part of an effective OEP is an important part of an effective falls and fracture prevention servicefalls and fracture prevention service

Dept of Health Prevention Dept of Health Prevention Package 2009Package 2009

54% of sites had PSI trained staff

41% of sites had Otago trained staff

RCP Audit of exercise in falls services (2012)

OTAGOOTAGO

Map of NZMap of NZ

New Zealand RCTs - OTAGONew Zealand RCTs - OTAGOIndividually tailored programme: Campbell, BMJ 1997

-80+ years, n=233, home-based, physiotherapist -1 year, falls 32%, injuries 39%

Nurse delivered programme at home: Robertson, BMJ 2001-75+ years, n= 240, home-based, district nurse

-1 year, falls 46%, serious injuries and hospital costs

Nurse programme at GP centres: Robertson, BMJ 2001-80+ years, n=450, home-based, general practice nurse-1 year, falls 30%, injuries 28%

Visually Impaired Older People: Campbell, BMJ 2005-1 year, home-based. Only effective with full compliance, falls 28%

6 month programme: Liu-Ambrose, JAGS 2008

-70+ years, home-based, cognitive function improvements after 6 months and after 1 year falls 47%

New Zealand RCTs - OTAGONew Zealand RCTs - OTAGO

Delivering in Groups vs One to One at home: Kyrdalen, Physio Res Int, 2013

-mean age 82 years, n=125, home-based vs group based, physiotherapist led -12 weeks only. Group exercise is more effective for improving functional balance, muscle strength and physical health than home based. Falls not assessed.

Cost effectiveness of OEP: Davis, BJSM, 2010

- meta-analysis of 9 studies, showing that OEP is cost effective in 65+ adults and cost SAVING in over 80s.

OEP reduces risk of death and falls: Thomas, Age Ageing 2010

-Meta-analysis of 7 trials, N=1503 participants. Mean age 82 years. OEP participants had reduced risk of death (RR 0.45) and significantly less falls (IRR 0.68)

• Multicentre cluster-randomised controlled trial

• 1256 people aged 65 and over in primary care

• Randomised into:– home exercise (Otago OEP)– group exercise (FaME) or – control (usual care (UC))

• Primary outcome – continuation of exercise

• Falls – secondary outcome

OEP & Primary Falls Prevention

Iliffe et al. BMJ, in press 2014.

OEP & Primary Falls Prevention

• 6 month intervention

• FaME reduced falls compared to Usual Care in the 12 months following the intervention (IRR=0.66,

• The reduction in falls in the OEP group did not reach significance (IRR 0.71, p=0.14)

-Shorter duration (less than 12 months)-Support options not as intensive as original OEP trials-These were not fallers so perhaps strength and balance challenge not high enough?

OTAGO Exercise OTAGO Exercise ProgrammeProgramme

SummarySummary Designed to ↓ falls by ↑ strength and balanceDesigned to ↓ falls by ↑ strength and balance Effective in ↓ falls in community dwelling OPEffective in ↓ falls in community dwelling OP Effective when delivered by physiotherapist and Effective when delivered by physiotherapist and

trained, supervised nursestrained, supervised nurses Most effective for 80+ years with previous falls historyMost effective for 80+ years with previous falls history Only effective with good compliance in OP with visual Only effective with good compliance in OP with visual

impairmentimpairment Balance improvements better when delivered in a Balance improvements better when delivered in a

group than in unsupervised home exercise group than in unsupervised home exercise

What is the OEP?What is the OEP?

Components of the OEPComponents of the OEP How to deliver the OEPHow to deliver the OEP

Programme EssentialsProgramme Essentials

Delivered at home or in groups by a trained Delivered at home or in groups by a trained OEP leaderOEP leader

Lower limb muscle strength and balance Lower limb muscle strength and balance exercises individually tailored exercises individually tailored (by an (by an appropriate person)appropriate person) from a set programmefrom a set programme

Frequency - 3 x p/wFrequency - 3 x p/w Intensity - ModerateIntensity - Moderate Duration - 30 minsDuration - 30 mins ProgressiveProgressive + Walking (30 mins x 2 p/w)+ Walking (30 mins x 2 p/w)

OEP ScheduleOEP Schedule

X 4 home visits in first 2 monthsX 4 home visits in first 2 months Booster visit at 6 monthsBooster visit at 6 months 1 hour first visit, 30 mins subsequent visits1 hour first visit, 30 mins subsequent visits Telephone call x 1 p/m between visitsTelephone call x 1 p/m between visits Exercises (warm up, strength, balance, Exercises (warm up, strength, balance,

flexibility, cool down)flexibility, cool down)

OROR Delivered x1p/w in a group Delivered x1p/w in a group plusplus x 2p/w at home x 2p/w at home Walking Walking

OEP ScheduleOEP Schedule

MonthMonth 11 22 33 44 55 66 …………

1212

WeekWeek 11 22 44 88Home Home Exercise Exercise VisitsVisits

TelephoTelephone ne follow follow upup

OEP Exercise OEP Exercise ComponentsComponents

Warm Up – 5 exercisesWarm Up – 5 exercises Strength training – 5 exercisesStrength training – 5 exercises Balance training (dynamic & static) – 12 Balance training (dynamic & static) – 12

exercisesexercises (Cool down)(Cool down) Walking programmeWalking programme

Strength, balance and walkingStrength, balance and walking

Guidelines state addition of strength and balance Guidelines state addition of strength and balance

on top of moderate physical activityon top of moderate physical activity

BUT Brisk walking may increase risk of falls in BUT Brisk walking may increase risk of falls in

those who are frail or who do not walk regularlythose who are frail or who do not walk regularly

However, brisk walking in pre-frail older people However, brisk walking in pre-frail older people

increases bone density...dilemma?increases bone density...dilemma?

Strength and balance exercises should be Strength and balance exercises should be

incorporated into walking programmesincorporated into walking programmes

(Campbell 1997; Robertson 2001; Campbell 2005; Sherrington 2011; Ebrahim 1997)

Cue cards with walking advice plus 10 Strength and Balance exercises

Leaflet for older adults containing the same exercises and simplified information

Warm Up ExercisesWarm Up Exercises

5 exercises5 exercises

Strength Training Strength Training ExercisesExercises

5 exercises5 exercises

Balance Training Balance Training ExercisesExercises 12 exercises12 exercises

Walking PlanWalking Plan

Encourage person to include Encourage person to include walking for health benefitswalking for health benefits

Walk at usual pace with usual Walk at usual pace with usual walking aidwalking aid

Progress duration before intensityProgress duration before intensity Start with 10 minutes Start with 10 minutes ““walk-snackwalk-snack

ss”” Progress to 30 mins 2 x p/wProgress to 30 mins 2 x p/w

OEP EquipmentOEP Equipment

For OEP LeaderFor OEP Leader– OEP Manual and LLT Teaching Supplement OEP Manual and LLT Teaching Supplement

For OEP ParticipantFor OEP Participant– Stable chair / furnitureStable chair / furniture– Ankle cuff weights (1, 2, 3 kg)Ankle cuff weights (1, 2, 3 kg)– Activity BookletActivity Booklet– Calendar / DiaryCalendar / Diary