R educing Falls for Older People

1. Reducing Falls for Older People Ngaire Kerse, FRNZCGP, PhD Department of General Practice and Primary Health Care University of Auckland Presentation 2 to National Falls Programme Expert Advisory Group meeting 13 July 2012, HQSC

2. 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

3. Hospitalisation

4. Mortality

5. Psychotropics Depression Dementia Multiple co-morbidity Age & previous falls & Wandering & gait 6x Wandrng & environmt 5x Environmt & depressn 3x Personal risk age, living alone, residential care Frailty Lower leg weakness Balance problems Visual problems

6. The mechanism The place – environment Other people, context The person risk factors The exposure Risky activity

7. Community • 30% in 1 year • Injury common • Hip fracture tip of the iceburg • Risk factors • Poor mobility • Lower limb, balance • Vision • Medication

8. 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 safety Gillespie LD et al. Cochrane Database Syst Rev 2009(2) Art. No.: CD007146!

9. 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

10. 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!

11. 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;20:9541 Gillespie LD et al. Cochrane Database Syst Rev 2009(2) Art. No.: CD007146!

12. Med review

13. 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 Multifactorial intervention

14. Single interventions

15. Multifactorial interventions

16. Conclusions: falls and injury • common problem • disastrous consequences • identified risks • Interventions may maintain independence, stop hip fracture

17. 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

18. 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

19. Hazards

22. Unsuccessful trial – Auckland 2004 Increased falls 1.34 (1.06-1.72) ?mobility ?staffing ?measurement Kerse JAGS 2004

23. 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

24. Nursing care homes - Vitamin D

25. Exercises – overall

26. Exercises – combination exercise modalities

27. Exercises – by type

29. 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)

30. Becker; by cognition

31. Results Nursing care homes Effect of exercise inconsistent Multifactorial interventions Team based > nurse led Vitamin D effective Knowledge alone ineffective

32. Overall success Exercise Orthogeriatrics AT&R Less success Acute Hospitals

33. Exercise - hospitals

34. Multifactorial – hospitals

35. Stenvall – ortho and geriatric ward Sweden

36. Stenvall

37. Healey elderly care wards UK

38. Cummings – acute & subacute Sydney

39. Hospitals • Multifactorial • Success related to resources • Exercises promising