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Evidence for EffectiveFall Prevention
Strategies. . . Yes, the evidence is hard to find/understand – it’s a jungle out there!
The information is behind the lion
What I planned to end with but didn’t get to and should have
begun with! – the main message follows:
Best bet . . . 1.Search lit, look in meta analyses/systematic reviews/OTCATs, scan favorite journals.
2. Locate a few good articles you can implement – keeping in mind your population; Stay away from (don’t do!) what was done in studies that didn’t decrease falls!
3. Study the articles that report success and recreate the program.
What works?
What doesn’t?
• Strengthening program• increase in safety devices and reduction in hazards (installed
hand-rails, removed rugs, increased lighting, repaired floors) in a “one-time intervention
• decrease in internal risk factors including improved visual acuity, improved sit-to-stand time and improved knee flexion strength
• reducing risk factors: gait/balance training, medicine review, optometry and podiatry visits
• “low impact” individually prescribed fall risk management (individually prescribed: strength/balance training, ADL devices, caregiver instructions for supervision, medication review, accompany resident to toilet, ID as fall risk, vision/hearing eval & tx)
Making a list: Interventions NOT! Supported by Evidence
Search with • OTCATS, OTDBASE, AOTA Evidence-Based Practice Abstracts (for other than
falls); Ageline, CINAHL & PsychINFO for full text
Intervene with
• Some programs using multifactorial and interdisciplinary risk assessment with reduction in home hazards and behavioral hazards (maybe most effective with a history of falling)
• Some programs for balance or strength exercise
• Tai Chi (certain programs)
• Individually tailored program of exercise (consult PT)
• Specific strength training WITH flexibility WITH endurance training
• The “Stepping on” program to improve mobility efficacy and protective behaviors
• Individually prescribed multidisciplinary evaluation and recommendations in residential settings
FINAL: Interventions Supported by Evidence
The “Stepping on” program to improve mobility efficacy and protective behaviors (Clemson & friends)
Individually prescribed multidisciplinary evaluation and recommendations in residential settings (Eakman & friends)
• Improve mobility efficacy and protective behaviors as in the “Stepping on” program – 7-sewssion course in hazard identification, adopting safety strategies, etc. (described in Appendix of Clemson, Cumming, Kendig, Swann, Heard, & Taylor. Journal of the American Gerontological Society, 52: 1487-1494, 2004)
• Reduce environmental hazards and behavioral hazards. There was no difference in strength in fall vs no-fall group; but no-fall group benefitted from hazard reduction, so hazard reduction seems more important than strengthening. (Diener & Mitchell, Topics in Geriatric Rehab, 21 (3): 247-252, 2005)
Interventions Supported by Evidence
• Individually prescribed multidisciplinary recommendations ( as per OT / Speech / PT / Nursing / Pharmacy / Social Services evals): scheduled toileting program, ambulate with CNA when restless, clear pathways/clutter, wc modifications and minimal unsupervised use of adaptive mobility aids, restraint-free alarms, role-relevant activities to visit/engage. (Eakman et al. Topics in Geriatric Rehabilitation, 17 (3): 29-39, 2002)
Interventions Supported by Evidence
. . . Back to the beginning – slowly building lists of what works and what doesn’t . . .
Evidence: T
he Many W
ays of K
nowing!
•In
divid
ua
l article
s–
AJO
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Critica
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AO
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Evid
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ce-B
ase
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Brie
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Evi
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he M
any
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and
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sica
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jour
nal o
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AP
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ubsc
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Evidence: The Many Ways of Knowing!• Individual articles– AJOT and Physical Therapy (official journal of
APTA) subscriptions and journal club discussions
– Various journal articles found through database searches
• Systematic reviews• Meta analyses• Critically Appraised Topics (www.otcats.com) • AOTA Evidence-Based Practice Briefs & Abstracts (
www.aota.org)
Evidence: The Many Ways of Knowing!
• Individual articles– AJOT and Physical Therapy (official journal of
APTA) subscriptions and journal club discussions
– Various journal articles found through database searches
• Systematic reviews• Meta analyses• Critically Appraised Topics (www.otcats.com) • AOTA Evidence-Based Practice Briefs & Abstracts
(www.aota.org)
Practitioner-Friendly Sites
Introduction of practitioner-focused sites
• www.aota.org Evidence-Based Practice Resources
• www.otseeker.com Set up like traditional database
• www.OTCATS.com Critically Appraised Topics
FREE Sites for Searching:
• OT CATS - Critically Appraised Topics in OT: http://www.otcats.com
• Physiotherapy Evidence Database (PEDro): http://www.pedro.fhs.usyd.edu.au/index.html
• OTSeeker: http://www.otseeker.com/• Pub Med:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed
• Ageline through AARP: http://www.aarp.org/research/ageline/
• Psychbite - a free evidence database for cognitive and behavioral interventions in cases of acquired brain injury: http://www.psycbite.com/
• New England Journal of Medicine: http://content.nejm.org/search.dtl
• Google Scholar: http://scholar.google.com/
FREE Sites for Searching:
Characteristics of Search Engines/Databases
Characteristics of Search Engines/Databases
Search Engines: Yield in Full-Text Articles
Mean of full articles
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Agelin
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Cinahl
EBPRERIC
Med
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OT CATS
OTdBas
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OT See
ker
OTSerac
h
Psych
Info
PubM
ed
SportD
is
Web
Sci
Courtesy CSU Spring 2007 Research Group
Variation of Experience
Variation of full text articles
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Agelin
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ERIC
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OTSerac
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Psych
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PubM
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SportD
is
Web
Sci
Courtesy CSU Spring 2007 Research Group
Yield in Citations with Abstracts
Means of abstracts
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10.00
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Agelin
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Cinahl
EBPRERIC
Med
line
OT CATS
OTdBas
e
OT See
ker
OTSerac
h
Psych
Info
PubM
ed
SportD
is
Web
Sci
Courtesy CSU Spring 2007 Research Group
Variation of Experience
0
10
20
30
40
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Agelin
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Cinahl
ERIC
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OT CATS
OTdBas
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OT See
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OTSerac
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Psych
Info
PubM
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SportD
is
Web
Sci
• Citations: OT Seeker (low in variability -of experience – same yield regardless of who’s doing the search)
• Abstracts: Ageline, OTCATS, OTDBASE (all low variability); OT Search (high variability though & subscription separate from AOTA membership!)
• Abstracts & full-text articles: Ageline, CINAHL & PsychINFO (all three very low in variability)
Making a list: Where to Search??
Gathering Evidence from Meta Analyses/Systematic Reviews and the Articles
Cited Within
Strategies Shown in Randomized Clinical Trials to Be Effective in Reducing the Occurrence of Falls among Elderly Persons Living in the Community.
Strategy No. of Trials with + Results
Balance and gait training and 2 of 3strengthening exercise Reduction in home hazards after 1 of 1hospitalization Discontinuation of psychotropic medication 1 of 1Multifactorial risk assessment with targeted 3 of 3 management Specific balance or strength exercise 2 of 2programs
Tinetti. n engl j med 348;1 www.nejm.org january 2, 2003
Risk factor for falling Relative Risk for Falls (range between studies)
Lower limb strength
Upper limb strength
Lower limb range of motion
Sensation
Vestibular function
Vision
Cognition
Static Balance
Dynamic Balance/Gait
.5 - 10.3
1.5 – 4.3
1.9
0.6 – 5.0
4.0
1.3 – 1.6
1.2 – 5.0
1.5 – 4.1
1.6 – 3.3
Impairments and disabilities as risks for falls
Carter, Kannus, Khan. Sports Med 2001; 31 (6): 427-438
Intervention studies which have used exercise to modify intrinsic risk factors for falls
Risk factor for falling Average improvement (%)
[range between studies]
Muscle strength
Range of motion
Balance
Gait
Reaction time
6-174
0.5-18
–7-53
12-48
0-4
Sports Med 2001; 31 (6): 427-438
Type of Exercise Activity: Number of Effective and Ineffective Studies
0
1
2
3
4
5
6
7
8
Endurance Strength Balance Flexibility
# of EffectiveStudies
# of IneffectiveStudies
Duration of Exercise found Effective and Ineffective
0
0.5
1
1.5
2
2.5
3
3.5
15min
30min
40min
45min
60min
90min
# of Effective Studies
# of Ineffective Studies
Frequency (times/week) of Exercise found Effective and Ineffective
0
1
2
3
4
5
6
Twice Three times 4-7 times 14 times
# of Effective Studies
# of Ineffective Studies
Lehtola et al.,2000• Intervention of exercise
class including Tai Chi once weekly plus walking with sticks, and home exercises each at least 3× weekly for 6 months; Control usual activities
• Relative hazard for falls for the
exercise group in 10mo = 0.60
Sports Med 2001; 31 (6): 427-438
N = 131; (n = 92)
(n = 39)
[95% CI for (Intervention) compared with (Control) 0.43, 0.84]
Out of 13 intervention studies, four reported success in preventing falls; for example:
Lehtola et al.,2000
N= 131; Intervention (n=92) an exercise class including Tai Chi once weekly plus walking with sticks, and home exercises each at least 3× weekly for 6 months; Control (n=39) usual activities
Sports Med 2001; 31 (6): 427-438
Lehtola et al.,2000
An exercise class including Tai Chi once weekly plus walking with sticks, and home exercises each at least 3× weekly for 6 months
Sports Med 2001; 31 (6): 427-438
“. . . a programme of Tai Chi resulted in a 48% reduction of falls in participants (mean age 76 years) compared with controls. Such a reduction was not seen in the individuals who followed a computerised balance-training programme. It is of interest that whilst the computerised balance-training group developed greater stability on balance platform measures there was little change in this parameter in the Tai Chi group.”
Wolf et al., 1996
Meta Analysis:
Fall-prevention programs for the elderly: a Bayesian secondary meta-analysis. (includes abstract) Lucke JF; Canadian Journal of Nursing Research, 2004 Sep; 36 (3): 49-64. (journal article - equations & formulas, tables/charts) PMID: 15551662 CINAHL AN: 2005015262
• Fall-prevention programs for the elderly: a Bayesian secondary meta-analysis. 2004
• A secondary meta-analysis of programs to reduce falls in the elderly is undertaken to demonstrate a Bayesian analysis. The Bayesian statistical tradition is carefully distinguished from the standard Neyman-Pearson-Wald (NPW) statistical tradition. In the 12 studies, the logit effect size is used to compare treatment groups using a prevention program to control groups without a program. To contrast the Bayesian analysis, independent-effects and fixed-effect meta-analyses are first conducted in the NPW tradition. This is followed by Bayesian independent-effects and fixed-effect meta-analyses that numerically replicate the NPW results but have conceptually different interpretations. The final analyses comprise Bayesian random-effects and predictive meta-analyses. These results differ numerically from all the previous meta-analyses and conceptually from the NPW meta-analyses. The random-effects analysis allows for heterogeneity in the effect sizes. The predictive analysis yields the distribution of 5a ne%^$w, out%^^^%^^-of-sample effect size, which accommodates &*%$(*%^$#not only the heterogeneity of the effects $*(%^)%(*$%*($#$ but also the imprecision in the %^&*%($(*&%parameter estimates. This last analysis shows that the effectiveness of new fall-prevention programs is less definitive than that found in the sample. Bayesian statistical methods are particularly well-suited for #@!&%$^%&$#&$&^%%%*&$*&$ %*&% %*&%*&$$&$&$()(*&%% %)(^%)(^___%)(%)%($$&*%#$&*#($ 467437376449 $(*$(*##)$$(* $(*$ (* $$(*$$* !@#$%&^*%($%)$(%*$&^#$&#&^@#*#$$(*#$(*$$of nursing science studies. !@#$#$&*%$(*&%%
Bayesian statistical methods are particularly well-suited for #@!&%$^%&$#&$&^%%%*&$*&$ %*&% %*&%*&$$&$&$()(*&%% %)(^%)(^___%)(%)%($$&*%#$&*#($ 467437376449 $(*$(*##)$$(* $(*$ (* $$(*$$* !@#$%&^*%($%)$(%*$&^#$&#&^@#*#$$(*#$(*$$of nursing science studies. !@#$#$&*%$(*&%%
A meta-analysis of fall prevention programs for the elderly: how effective are they?
• RESULTS: The overall mean weighted effect size for the 12 studies included in the meta-analysis was .0779 (Z = 5.03, p < .001).
• Exercise alone had a mean weighted effect size of .0220 (Z = .5303, p > .5)
• Exercise and risk modification had a mean weighted effect size of .0687 (Z = 3.41, p < .001)
• Comprehensive risk assessment intervention studies had an effect size of .1231 (Z = 3.97, p < .001)
• Mean weighted effect size for community-based studies was .0972 (Z = 5.37, p < .001) and for institution-based studies was .0237 (Z = .7822, p = .22).
• CONCLUSIONS: There was a 4% decrease in the rate of falls for individuals who were in the treatment groups receiving various fall prevention interventions.
Hill-Westmoreland EE; Nursing Research, 2002 Jan-Feb; 51 (1): 1-8.
Effect Size (ES) – What is it?• In a way – a “magic number”: it is an index
of what can be seen/observed clinically as an improvement – removed from numbers or “statistical findings”
• There are many effect size measures; the most common are r and Cohen’s d effect sizes
• Cohen compared various statistical findings to clinical observations in the behavioral sciences and came up with a chart of equivalences
Effect Size (ES) – What is it?• In general, a positive ES indicates the
intervention group improved visibly/functionally; ES = 0 indicates no effect of therapy or “the intervention”; a negative ES indicates the intervention was harmful or had a negative effect on the group (and should not be repeated!)
• A Cohen’s d of .5 and an r of .3 is considered a “medium effect”; d = .8 or r = .5 considered “large or larger than typical effect”
A meta-analysis of fall prevention programs for the elderly: how effective are they?
• RESULTS: The overall mean weighted effect size for the 12 studies included in the meta-analysis was .0779 (Z = 5.03, p < .001).
• Exercise alone had a mean weighted effect size of .0220 (Z = .5303, p > .5)
• Exercise and risk modification had a mean weighted effect size of .0687 (Z = 3.41, p < .001)
• Comprehensive risk assessment intervention studies had an effect size of .1231 (Z = 3.97, p < .001)
• Mean weighted effect size for community-based studies was .0972 (Z = 5.37, p < .001) and for institution-based studies was .0237 (Z = .7822, p = .22).
• CONCLUSIONS: There was a 4% decrease in the rate of falls for individuals who were in the treatment groups receiving various fall prevention interventions.
Hill-Westmoreland EE; Nursing Research, 2002 Jan-Feb; 51 (1): 1-8.
One more look at meta analysis results:
Exercise in the prevention of falls in older people: a systematic literature review examining the rationale and the evidence.
• RESULTS: On the basis of 9 randomized controlled studies conducted since 1996, exercise appears to be a useful tool in fall prevention in older adults, significantly reducing the incidence of falls compared with control groups. However, current limitations such as inconsistencies in the measurement of key dependent and independent variables do not, at present, permit a meta-analysis of intervention trials.
Carter ND; Sports Medicine, 2001; 31 (6): 427-38.
Do hospital fall prevention programs work? A systematic review.
• RESULTS: Individual components of interventions showed no significant benefit. The pooled effect of about 25% reduction in the fall rate may be a result of intervention but may also be biased. Studies did not analyze compliance with the intervention or opportunity costs resulting from the intervention. Research and clinical programs in hospital fall prevention should pay more attention to study design and the nature of interventions.
Oliver D; Journal of the American Geriatrics Society, 2000
Dec; 48 (12): 1679-89.
• Reduction in home hazards after hospitalization
• Multifactorial risk assessment with targeted management
• Discontinuation of psychotropic medication
• Specific balance or strength exercise programs (But not computerized balance in Wolf, et al. 1996 study!)
• Exercise class including Tai Chi once weekly plus walking with sticks, and home exercises each at least 3× weekly for 6 months
Interventions Supported by Evidence
• Tai Chi 15 min twice daily at home for 4mo
• Individually tailored program of exercise. Physiotherapist visited 4× in first 2mo. Exercises 3× per wk, 30 min each, lower limb strength and balance plus encouraged walking outside 3×/wk
• For individuals with at least mild deficits in strength or balance: Strength training: upper and lower limb; 3 sessions per wk for 60 min. PLUS flexibility PLUS endurance training: stationary cycle 75% max. heart rate
Interventions Supported by Evidence
• Strengthening exercise/balance found to “work” but not always: – NOT computerized balance (as described in
Wolf, et al. 1996 study)!– NOT Exercise: 60 min, 3× per wk, 12mo. Stand-
up, step-up, stretching and movement to music– NOT Cognition/behavioral: health and safety
curriculum to prevent falls, relaxation, video games.
– NOT Exercise/cognition: 2× per wk exercise, once per wk cognition
– NOT stand-up/step-up routine progressing to 4 sets of 10 repetitions. 60 min 3× per wk
Interventions NOT! Supported by Evidence
– NOT individually tailored one-one physiotherapy sessions 3× per wk for 4mo, including range of motion, strength, balance, transfer and mobility. Each session 30-40 min
– NOT 60-min exercise sessions, twice weekly in 4 terms of 10-12wk. 4 sections per session: warm-up, conditioning (aerobic, strength, balance and flexibility), stretching and relaxation
– NOT 45 min weight-bearing exercise to music, 3× per wk for 3× 10wk terms for 2y (although worked for 18 months)
– NOT strength, endurance, mobility and balance training for 90 min, 3× per wk for 12wk
Interventions NOT! Supported by Evidence
Some hazards are pretty obvious . . .
Some happen involving objects you cannot get rid of . . .
www.vch.ca/abi/img/braincompanypicture.JPG© 2002-2007 Vancouver Coastal Health
ST
RE
NG
TH
BA
LA
NC
E
Would you use exercises to teach a
chicken to fly? Which exercises?
Consider the barnyard exercise class in Chicken Run©
Gathering Evidence from Cochrane Collaboration Systematic Reviews and the Articles Cited Within
Interventions in Preventing Falls in the Elderly (Cochrane Review)Gillespie, Gillespie, Robertson, Lamb, Cumming & Rowe
Go to: http://www.cochrane.org/reviews/
And search “Falls in the elderly”
The Cochrane Database of Systematic Reviews 2007 Issue 1Copyright © 2007 The Cochrane Collaboration. Published by John Wiley and Sons, Ltd.
Background: Approximately 30 per cent of people over 65 years of age and living in the community fall each year; the number is higher in institutions. Although less than one fall in 10 results in a fracture, a fifth of fall incidents require medical attention.
Objectives: To assess the effects of interventions designed to reduce the incidence of falls in elderly people (living in the community, or in institutional or hospital care).
Main results: Sixty two trials involving 21,668 people were included. Interventions likely to be beneficial: Multidisciplinary, multifactorial, health/environmental risk factor screening/ intervention programmes in the community both for an unselected population of older people (4 trials, 1651 participants, pooled RR 0.73, 95%CI 0.63 to 0.85), and for older people with a history of falling or selected because of known risk factors (5 trials, 1176 participants, pooled RR 0.86, 95%CI 0.76 to 0.98),
Cochrane Review Summary
• 62 trials 21,668 people included in the review
• Studies judged according to whether they were “likely to be beneficial” or “of unknown effectiveness” or “unlikely to be effective”
Risk Ratios (RR) of “Beneficial Interventions”
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
M.Diss/M.Fac.Fall Risk
Screening
RiskScreening-Hx
of Falls
NH Res.Settings
Mus. Str. &Balance
Home Haz.Eval & Mod. w/
Fall Hx.
Tai Chi Gp.*
*Incidence Rate
• Exercise may prevent falls?????? (Carter – problem with measurement of dependent variables)
• Hospital-based fall prevention????? (Oliver – Compliance, costs, inconsistent study designs all a problem; no significant findings per study, but a possible pooled effect across studies)
• Multi disciplinary/factorial risk screening
Interventions Supported by Evidence(Cochrane Collaboration reviews)
• Risk screening (for individuals with a history of falls)
• Programs in nursing home settings
• Strength and balance programs?
• Home hazard evaluation and modification (for individuals with a history of falls)
• Tai Chi group
Interventions Supported by Evidence(meta analyses/systematic reviews)
ST
RE
NG
TH
BA
LA
NC
E
Interventions NOT! Supported
• Group-Delivered Exercise• Individual LE Strengthening• Home Hazard Mod. w/ Medication
Suggestions• Home Hazard Mod. w/ education packet
on exercise and reducing falls• Cognitive/Behavioral Approach Alone• Hm. Haz. Mod. when no Hx of falling• Brisk walking in older women with UE
fracture
ST
RE
NG
TH
EN
ING
NO
T H
ome
Haz
ard
Mod
. w/
Med
icat
ion
Sug
gest
ions
NO
T H
ome
Haz
ard
Mod
. w/
educ
atio
n pa
cket
on
exer
cise
and
redu
cing
falls
NO
T H
ome
Haz
ard
mod
ifica
tion
whe
n
no h
isto
ry o
f fal
ling
Gathering Evidence from Critically
Analyzed Topics (CATs)
http://www.otcats.com
Another CAT . . .
• Interdisciplinary/multifactorial assessment and intervention (including OT) for cognitively intact in-patients, ≥65 years, whose primary diagnosis in A and E was a fall, reduced the falls rate in the year following their fall. This was also true for those with a history of falls who present as above. Number and length of subsequent hospital admissions may also be reduced and independence in ADL may be improved.
• Multifactorial intervention (including OT) had no effect on falls reduction within the following year for people ≥65 years, with cognitive impairment and dementia whose primary diagnosis in A and E was a fall.
Prepared by S. Patterson and M.Williams 2005. Available at www.otcats.com
One more CAT – look at the entire review
BEST EVIDENCE
• The review by Chang and colleagues (2004) was identified as the ‘best’ evidence and selected for critical appraisal. Reasons for selecting this article were: Most current available evidence; highest level of evidence; addressed both multifactorial falls assessment and management plans as an intervention, and compared this intervention to other commonly used falls prevention interventions
• Data from 26 intervention groups in 22 studies was used for the meta-analysis of participants who fell at least once. The combined data from these intervention groups showed a significant reduction in the risk of falling
• A multifactorial falls risk assessment and management programme had a statistically significant beneficial effect on both risk of falling and monthly rate of falling
• Relative effectiveness of major components of a multifactorial falls risk assessment and management programme not identified
• Exercise . . . also had a statistically significant beneficial effect on the risk of falls . . . [but] not able to detect statistically significant differences or consistent trends in the efficacy of different types of exercises
• Environmental modification and education were primary components of some studies . . . did not show statistically significant effects on the reduction of monthly fall rates or reduction in falls risk
Evidence Brief
Structured Abstract
• Home hazard assessment and modification/Risk awareness or advice
– But which one is more effective??
• Interdisciplinary/multifactorial assessment and intervention for those with a history of falls
– NOT if cognitive impairment/dementia was present!!
• multifactorial falls risk assessment and management program
– But which components?: Exercise effective – but which type of exercise?
– !!Environmental modification and education not necessarily effective!!
Interventions Supported by Evidence (from CATs)
Gathering Evidence from Individual Articles
You found in a Database Search
Effectiveness of a Community-Based Program for Reducing the Incidence of Falls in the Elderly: A Randomized Trial• Intervention group showed 31% reduction in
falls; this was a significant difference compared to control group, p = .025.
• Intervention gp sig. > in mobility efficacy and number of protective behaviors adopted
• 70% participants followed 50% of recommendations
• “Stepping on” program in Appendix and a reference to its full description
Clemson, Cumming, Kendig, Swann, Heard, & Taylor. Journal of the American Gerontological Society, 52: 1487-1494, 2004
What is “significantly different”??
• We are all different on just about anything you measure about us – height, weight, how far we throw a ball, etc.
• Randomly select 2 groups from this room and get average weight of each group. The two averages will be slightly different – based on CHANCE of a few more people with more weight being in one group compared to the other.
• Now I want to try an intervention – a diet for one gp, and the other is the control – “ eat as usual” gp. - and we do this experiment for 2 months.
“significantly different”?? cont. . .• How much different do the average weights of
the two gps need to be to feel confident the diet worked? – as they were different to begin with!
• Statistical tests give us an answer – the averages must be different enough that the chances of finding a difference that great would be rare (a low probability) in any two groups selected and weighed WITHOUT either getting the diet.
What is “p”??
• p tells us how low the probability is
• Magic value for p (which stands for “probability of finding a difference this large between groups”) is .05
• Example: An intervention to prevent falls showed a significant difference between fall-prevention gp. and usual treatment gp, p = .05
What is “p”?? cont. . .
• p = .05 means the chances of having a difference in number of falls this great WITHOUT the fall-prevention intervention is only 5 times in 100.
• So, a p of < .001 means the amount of difference was so great, it would happen only 1 time in 1000 of making two gps, having no intervention, and counting the number of falls in each group
Impact of a Multifactorial Fall Prevention Program Upon Falls of Frail Adults Attending an Adult Health Day Care Center
• Significantly greater % fallers in control gp compared to fall prevention gp, p<.001
• Significantly fewer environmental hazards and behavioral hazards in fall prevention gp, p<.001
• Strength NOT significantly different, p>.05, between two groups @ 6 months
Diener & Mitchell, Topics in Geriatric Rehab, 21 (3): 247-252, 2005
Preventing Falls in Older People: Outcome Evaluation of a Randomized Controlled Trial
• No significant difference between fall-prevention gp and control gp even though fall-prevention group showed significant increase in safety devices and significant reduction in hazards: installed hand-rails, removed rugs, increased lighting, repaired floors
• Concluded a “one-time intervention not enough” to impact falling in this population
Stevens, Holman, Benet, Klerk. Journal of the American Gerontological Society, 49: 1448-1455, 2001
The Effect of an Individualized Fall Prevention Program on Fall Risks and Falls in Older People: A Randomized, Controlled Trial
• No significant difference in the number of falls comparing the fall-prevention group to the usual-care group
• No difference in falls – even though there was a significant decrease in internal risk factors resulting from the program including improved visual acuity, improved sit-to-stand time and improved knee flexion strength
Lord, Tiedemann, Chapman, Munro, Murray, Remed, & Sherington. Journal of the American Gerontological Society, 53: 1296-1304, 2005
Fall Prevention in Residential Care Homes: A Randomized Controlled Trial
• No significant difference in the number of falls comparing the fall-prevention group (2.2 falls/resident/year) versus the usual-care group (4 falls/resident/year)
• No difference in falls – even though gait/balance training, medicine review, optometry and podiatry visits resulted in reduced risk factors in the fall-prevention group
Dyer, Taylor, Reed, Dyer, Robertson, & Harrington. Age and Aging, 33 (6): 596-602, 2004
Fall Prevention in Residential Care Homes: A Cluster Randomized Controlled Trial
• No significant difference in the number of falls comparing the fall-prevention group (2.2 falls/resident/year) versus the usual-care group (4 falls/resident/year)
• This “low impact” individually prescribed fall risk management resulted in 56% of the fall prevention participants falling compared to only 43% of the usual care group – this is a negative effect size = the intervention actually resulted in significantly more falls, p=.018!!
Kerse, Butler, Robinson, & Todd. Journal of the American Gerontological Society, 52: 524-531, 2004
Finally . . .the two best studies I found – both usable!
• The first is a repeat of one already presented – employs the “stepping on” program – described in the appendix of the article – for your use!
• The second is for institutional settings, is well described, and mostly measures what we typically do – individual assessments and prescribed programs!
Effectiveness of a Community-Based Program for Reducing the Incidence of Falls in the Elderly: A Randomized Trial• Intervention group showed 31% reduction in
falls; this was a significant difference compared to control group, p = .025.
• Intervention gp sig. > in mobility efficacy and number of protective behaviors adopted
• 70% participants followed 50% of recommendations
• “Stepping on” program in Appendix and a reference to its full description
Clemson, Cumming, Kendig, Swann, Heard, & Taylor. Journal of the American Gerontological Society, 52: 1487-1494, 2004
Fall Prevention in Long-Term Care: An In-House Interdisciplinary Team Approach
• Pretest/Posttest design – found significantly fewer falls (3.2 falls) after the fall prevention program compared to before (5.52 falls; p<.001)
• Also significantly fewer injuries from falls
• Study outlines the 20 most frequently given recommendations; 274 interventions given overall with range of 5 to 17 per resident
Eakman et al. Topics in Geriatric Rehabilitation, 17 (3): 29-39, 2002
• Improve mobility efficacy and protective behaviors as in the “Stepping on” program – 7-sewssion course in hazard identification, adopting safety strategies, etc. (described in Appendix of Clemson, Cumming, Kendig, Swann, Heard, & Taylor. Journal of the American Gerontological Society, 52: 1487-1494, 2004)
• Reduce environmental hazards and behavioral hazards. There was no difference in strength in fall vs no-fall group; but no-fall group benefitted from hazard reduction, so hazard reduction seems more important than strengthening. (Diener & Mitchell, Topics in Geriatric Rehab, 21 (3): 247-252, 2005)
Interventions Supported by Evidence
• Individually prescribed multidisciplinary recommendations ( as per OT / Speech / PT / Nursing / Pharmacy / Social Services evals): scheduled toileting program, ambulate with CNA when restless, clear pathways/clutter, wc modifications and minimal unsupervised use of adaptive mobility aids, restraint-free alarms, role-relevant activities to visit/engage. (Eakman et al. Topics in Geriatric Rehabilitation, 17 (3): 29-39, 2002)
Interventions Supported by Evidence
• Strengthening program• increase in safety devices and reduction in hazards (installed
hand-rails, removed rugs, increased lighting, repaired floors) in a “one-time intervention
• decrease in internal risk factors including improved visual acuity, improved sit-to-stand time and improved knee flexion strength
• reducing risk factors: gait/balance training, medicine review, optometry and podiatry visits
• “low impact” individually prescribed fall risk management (individually prescribed: strength/balance training, ADL devices, caregiver instructions for supervision, medication review, accompany resident to toilet, ID as fall risk, vision/hearing eval & tx)
Making a list: Interventions NOT! Supported by Evidence
Lighting Conditions of Falls in Three Settings
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Light Dark
NF
AL
Com
Location of Falls in Three Settings
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Bathr
oom
Bedro
om
Dinning
Roo
m
Hallway
Living
Roo
m
Outsid
e_ H
ome
Basem
ent
Insid
e_ho
me
Insid
e_pu
blic
Outsid
e_pu
blic
NF
AL
Com
Comparing Recommendations to Falls
Recommendations and Falls cont.
Solutions?:Skyhook and harness:
For men too!
Padded outfit!
Signage?
Well
-mea
ning
reco
mm
enda
tions
and
mod
ificat
ions?
CDC Resources
• Publications help older adults prevent falls
• CDC, in partnership with the CDC
Foundation and MetLife Foundation, has produced four posters and redesigned two of its popular brochures to help older adults—and those who care for them—prevent falls and the injuries and deaths that result. These materials are important resources to protect the health and independence of older adults.
CDC• What YOU Can Do to Prevent Falls outlines
four key fall prevention strategies. Strategies include exercising regularly, having medicines reviewed to reduce side effects and interactions, having yearly eye exams, and reducing fall hazards in the home.
• Check for Safety: A Home Fall Prevention Checklist for Older Adults guides readers in a room-by-room check of their home to find and fix hazards that can increase the risk of falling.
• Four posters, designed for use in health care facilities, senior centers, and other community organizations, highlight the messages in the brochures.
CDC Resources• In 2003, more than 13,700 people
65 and older died from falls; 1.8 million older adults were treated in emergency departments for nonfatal injuries from falls, and more than 460,000 of these patients were hospitalized. Free Resources:
• www.cdc.gov/ncipc/duip/fallsmaterial.htm.• www.cdc.gov/ncipc/duip/preventadultfalls.htm.
Guidance for gathering information as we work:
Development of a Common Outcome Data Set for Fall Injury Prevention Trials: The Prevention of Falls Network Europe Consensus
Sarah E. Lamb, Ellen C. Jorstad-Stein, Klaus Hauer, and Clemens Becker on behalf of the Prevention of Falls Network Europe and Outcomes Consensus Group
JAGS 53:1618–1622, 2005© 2005 by the American Geriatrics Society
Recommendation 2: Falls
1.A fall should be defined as ‘‘an unexpected event in which the participants come to rest on the ground, floor, or lower level.’’
2. Ascertainment must consider the lay perspective of falls. Participants should be asked, ‘‘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?’’
3. Falls should be recorded using prospective daily recording and a notification system with a minimum of monthly reporting. Telephone or face-to-face interview should be used to rectify missing data and to ascertain further details of falls and injuries.
• 4. Fall data should be summarized as number of falls, number of fallers/ non fallers/frequent fallers, fall rate per person year, and time to first fall (as a safety measure).
• 5. Primary analysis of fall data should not be adjusted for physical activity, and reporting should include the absolute risk difference between groups.
Recommendation 4: Psychological Consequences of Falling
1.Psychological consequences of falls should be conceptualized in terms of fall-related self-efficacy, defined as ‘‘the degree of confidence a person has in performing common activities of daily living without falling’’ and measured using the modified Falls Efficacy Scale (mFES).18
2. The measure should be scored per published guidance.18
Recommendation 5: Measure Health Related Quality of Life
1. The recommended measures of quality of life are the Short Form 12 (SF12) version 2 and European Quality of Life Instrument (EuroQoL EQ-5D).
__________________________Reference: EuroQol Group. EuroQolFa new facility for the
measurement of health related quality of life. Health Policy 1990;16:199–208.
• http://video.google.com/videoplay?docid=4776181634656145640
Bibliography• Tinetti, M (2003). Preventing falls in elderly persons. New England Journal of Medicine, 348 (1 ), 42-49.
• Carter, N D; Kannus, P & Khan, K M. (2001). Exercise in the Prevention of Falls in Older People: A Systematic Literature Review Examining the Rationale and the Evidence. Sports Med 31 (6), 427-438.
• Lehtola, S; Hanninen L & Paatalo, M. (2000). The incidence of falls during a six-month exercise trial and four-month followup among home dwelling persons aged 70-75 years [Finnish]. Liikunta Tiede 6: 41-7.
• Campbell AJ, Roberton MC, Gardner MM, et al. (1997). Randomized controlled trial of a general practice programme of home based exercise to prevent falls in elderly women. British Medical Journal, 315, 1065-9.
• Campbell AJ, Roberton MC, Gardner MM, et al. (1999). Psychotropic medicine withdrawal and a home-based exercise program to prevent falls: a randomized controlled trial. Journal of the American Geriatric Society, 47, 850-3.
• Buchner DM, Cress ME, de Lauteur BJ, et al. (1997). The effect of strength and endurance training on gait, balance, fall risk and health services use in community-living older adults. J Gerontol A Biol Sci Med Sci 1997; 52 (4), M218-M24.
• Wolf SL, Barnhart MX, Kutner NG, et al. (1996). Reducing frailty and falls in older persons: an investigation of Tai-Chi and computerized training. J Am Geriatr Soc, 44:,489-97.
• Development of a common outcome data set for fall injury prevention trials: the prevention of Falls Network Europe consensus. (includes abstract) Lamb SE; Journal of the American Geriatrics Society, 2005 Sep; 53 (9): 1618-22. (journal article - tables/charts) PMID: 16137297 CINAHL AN: 2009084166
• Fall-prevention programs for the elderly: a Bayesian secondary meta-analysis. (includes abstract) Lucke JF; Canadian Journal of Nursing Research, 2004 Sep; 36 (3): 49-64. (journal article - equations & formulas, tables/charts) PMID: 15551662 CINAHL AN: 2005015262
Bibliography• Trauma library in review. [Commentary on] A meta-analysis of fall prevention programs for the
elderly. Strever T; Whalen E; Journal of Trauma Nursing, 2002 Jul-Sep; 9 (3): 84. (journal article - abstract, commentary) CINAHL AN: 2003064892
• A meta-analysis of fall prevention programs for the elderly: how effective are they? (includes abstract) Hill-Westmoreland EE; Nursing Research, 2002 Jan-Feb; 51 (1): 1-8. (journal article - research, tables/charts) PMID: 11822564 CINAHL AN: 2002038264
• Exercise in the prevention of falls in older people: a systematic literature review examining the rationale and the evidence. (includes abstract) Carter ND; Sports Medicine, 2001; 31 (6): 427-38. (journal article - research, systematic review, tables/charts) PMID: 11394562 CINAHL AN: 2002022846
• Do hospital fall prevention programs work? A systematic review. (includes abstract) Oliver D; Journal of the American Geriatrics Society, 2000 Dec; 48 (12): 1679-89. (journal article - research, systematic review, tables/charts) PMID: 11129762 CINAHL AN: 2001029614
• Gillespie LD, Gillespie WJ, Robertson MC, Lamb SE, Cumming RG, Rowe BH. (2003). Interventions for preventing falls in the elderly. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD000340. DOI: 10.1002/14651858.CD000340.
• Chang, J. T., Morton, S. C., Rubenstein, L. Z., Mojica, W. A., Maglione, M., Suttorp, M. J., Roth, E. A., Shekelle, P. G. (2004). Interventions for the prevention of falls in older adults: Systematic review and meta-analysis of randomised clinical trials. British Medical Journal, 328, 680.
• Clemson, L.,Cumming, R. G., Kendig, H., Swann, M., Heard, R., & Taylor, K. (2004). The effectiveness of a community-based program for reducing the incidence of falls in the elderly: A randomized trial. Journal of the American Gerontological Society, 52: 1487-1494, 2004
• Diener D D, & Mitchell J M. (2005). Impact of a multifactorial fall prevention program upon falls of older frail adults attending an adult health day care center. Topics in Geriatric Rehab, 21 (3), 247-252.
• Stevens, M., Holman, C. D., Benet, N., de Klerk, N. (2001). Preventing falls in older people: Outcome evaluation of a randomized controlled trial. Journal of the American Gerontological Society, 49: 1448-1455.
Bibliography• Lord, S. R., Tiedemann, A., Chapman, K., Munro, B., Murray, S. M., Remed, D., & Sherington. C.
(2005). The effect of an individualized fall prevention program for fall risk and falls in older people: A randomized controlled trial. Journal of the American Gerontological Society, 53: 1296-1304.
• Dyer, C. A. E., Taylor, G. J., Reed, M., Dyer, C. A., Robertson, D. R., & Harrington, R. (2004). Falls prevention in residential care homes: a ransomised controlled trial. Age and Aging, 33 (6): 596-602.
• Kerse, N., Butler, M., Robinson, E., & Todd, M. (2004). Fall prevention in residential care: A cluster, randomized, controlled trial. Journal of the American Gerontological Society, 52: 524-531.
• Eakman A M et al. (2002). Fall prevention in long-term care: An in-house interdisciplinary team approach. Topics in Geriatric Rehabilitation, 17 (3): 29-39.
