Falls and Examples of Evidence-Based Programs for Falls

1. Falls and Examples of Evidence-Based Programs for Falls Angela Deokar, MPH, CHES Kentucky Department for Public Health Osteoporosis Prevention and Education Program

3. Definition of a Fall An accidental fall is defined as �an event which results in a person coming to rest inadvertently on the ground or other lower levels, and other than as a consequence of the following: sustaining a violent blow; loss of consciousness; sudden onset of paralysis, as in a stroke; an epileptic seizure.� (Kellogg 1987)

4. Falls Leading cause of injury and death for older adults Up to 30% of community dwelling adults fall each year Of those who fall, as many as half may suffer moderate to severe injuries that reduce mobility and independence About 50 percent of older adults hospitalized for hip fracture never regain their previous level of function Falls or fear of falling may contribute other complications and perpetuates a vicious cycle Community dwelling = people who live independently in the communityCommunity dwelling = people who live independently in the community

6. Falls are not an inevitable consequence of aging, but falls do occur more often among older adults because fall risk factors increase with age and are usually associated with health and aging conditions. Falls are not an inevitable consequence of aging, but falls do occur more often among older adults because fall risk factors increase with age and are usually associated with health and aging conditions.

7. Falls 1/2 to 2/3 of falls occur around the home A majority of falls occur during routine activities Falls usually are not caused by just one issue. It�s a combination of things coming together - multifactorial A large portion of falls are preventable! However, older adults and their caregivers are often not aware of their risk factors for falls and what they can do to prevent them. Fall risk factor assessment is not a routine part of their health care� even if they have fallen or are at risk of falling.However, older adults and their caregivers are often not aware of their risk factors for falls and what they can do to prevent them. Fall risk factor assessment is not a routine part of their health care� even if they have fallen or are at risk of falling.

9. Biological risk factors Mobility problems due to muscle weakness or balance problems Chronic health conditions such as alzheimers disease, arthritis and stroke Vision changes and vision loss Loss of sensation in feet Behavioral risk factors Inactivity Medication side effects and/or interactions Alcohol use Environmental risk factors Home and environmental hazards (clutter, poor lighting, etc.)Incorrect size, type, or use of assistive devices (walkers, canes, crutches, etc.) Poorly designed public spaces or hazardous shoesBiological risk factors Mobility problems due to muscle weakness or balance problems Chronic health conditions such as alzheimers disease, arthritis and stroke Vision changes and vision loss Loss of sensation in feet Behavioral risk factors Inactivity Medication side effects and/or interactions Alcohol use Environmental risk factors Home and environmental hazards (clutter, poor lighting, etc.)Incorrect size, type, or use of assistive devices (walkers, canes, crutches, etc.) Poorly designed public spaces or hazardous shoes

10. CDC�s Building Blocks for Falls Prevention Programs Education about falls and risk factors Exercises that improve balance, strength and mobility Medication review and management Vision exam Home safety assessment and modifications All delivered or performed by certified professionalsAll delivered or performed by certified professionals

12. Protect Your Bones Ways to Make Your Home Safer

15. Matter of Balance Designed to reduce the fear of falling and increase the activity levels of older adults who have concerns about falls. Research by the Roybal Center for Enhancement of Late-Life Function at Boston University.* Studied effect of program on fear of falling and associated activity restriction in older adults Based on Cognitive Restructuring (Bandura and Lachman, 1997) *Tennsdedt, S., Howland, J., Lachman, M., Peterson, E., Kasten, L. & Jette, A. (1998). A randomized, controlled trail of a group intervention to reduce fear of falling and associated activity restriction in older adults. Journal of Gerontology, Psychological Sciences, 54B (6), P384-P392.

16. Cognitive Restructuring Method of turning negative thoughts into positive thoughts Define barriers, obstacles when engaging in a new behavior Identify strategies for overcoming the barriers Plan realistic/feasible experiences so one can experience success

17. Who can benefit from A Matter of Balance? Designed to benefit community-dwelling older adults who: Are concerned about falls Have sustained a fall in the past Restrict activities because of concerns about falling Are interested in improving flexibility, balance and strength Are age 60 or older, ambulatory and able to problem-solve

18. A Matter of Balance Class During 8 two-hour sessions, participants learn: To view falls and fear of falling as controllable To set realistic goals for increasing activity To change their environment to reduce fall risk factors To promote exercise to increase strength and balance

19. A Matter of Balance What Happens During Sessions? Facilitated by two leaders Group discussion Problem-solving Skill building Assertiveness training Sharing practical solutions Videotapes with peers who model behaviors Exercise training

20. Maine Partnership for Healthy Aging Project: Lay Leader Model Model Program Adaptations: Classes taught by volunteer lay leaders, called coaches, instead of healthcare professionals Healthcare connection via guest therapist Participant workbook developed and coach manual modified Exercises modified Maintaining Fidelity: Two day coach training based on original MOB leader manual Master Trainer observes coaches during training and while leading a MOB/VLL class Use of a mentor model - new volunteer is paired with an experienced coach Communication, support and sharing outcomes

23. Participants Report: Increased confidence in taking a walk, climbing stairs, carrying bundles without falling More confidence that they can increase their strength, find ways to reduce falls, and protect themselves if they do fall An increase in the amount they exercise on a regular basis Fewer falls after taking MOB

25. Training will be paid for by DPH, selecting partners who are able to implement the program and have capacity to sustain. Open to community partners and emphasizing community partnerships. Training will be paid for by DPH, selecting partners who are able to implement the program and have capacity to sustain. Open to community partners and emphasizing community partnerships.

26. Video A Matter of Balance: Fear of Falling

27. Reducing Falls & Building Confidence An Effective Program for Older People.

28. Stepping On Identified as a multi-factorial program in CDC Compendium Based on research by Clemson* conducted in Australia

29. Outcomes Randomized trial in Australia Intervention group experienced a 31% reduction in falls Maintained confidence to avoid a fall Used more protective behavioral practices

30. Stepping On: Underlying Concepts Decision-making is a process (5 stages) Story telling to facilitate learning & confidence Self-efficacy (Bandura 1997,1986,1997) Learning and older adults as learners Sustaining and follow-through with safety behaviors

31. Decision-Making as a Process* Appraising the challenge Surveying the alternatives Weighing the alternatives Deliberating about commitment Adhering despite negative feedback

32. Story Telling* Facilitate confidence and learning Participants Explore negative events Describe and question the struggle to make a change Reaffirm the positive and what they could do in the future Re-tell and recreate their stories with a sense of personal control Cause and consequences of falls in the story? Ways in which you could prevent falls in the future? How can you make this happen? Barriers? How can you keep this happening?Cause and consequences of falls in the story? Ways in which you could prevent falls in the future? How can you make this happen? Barriers? How can you keep this happening?

33. Learning and Older Adults as Learners Think creatively about opportunities Learning for an older adult is best when: It is self-paced- benefit from breaks Optimistic and positive feedback Visual aids and practical examples Learning builds on previous experience and knowledge Learning must go both ways and leaders must recognize that participants bring their own unique perspective, life stage and knowledge Review principles of adult education A lot of the same things go for younger people, too!A lot of the same things go for younger people, too!

34. Follow-Through with Safety Behaviors* Sustaining prevention strategies depends on: 1. Level of support: social, peer and organizational 2. Ease of complying: cost, effort, complexity, intrusiveness. Older adults will spend if they view it on a path that has a link with a goal. 3. Technical competence and interpersonal skills of professional 4. Opportunity and willingness for personal goal setting: Having an overarching goal and breaking it into smaller steps 5. Feedback about success: reporting back on exercise or home safety check or how they used different cues to prompt exercise like the start of a TV show or by leaving their exercise manual and or weights out on the table

35. Bringing Stepping On to the U.S. Aging and Disability Resource Center of Kenosha County, WI Several projects, including funding from CDC in 2007 to : Translate the �Stepping-On� fall prevention intervention for older adults into a program package that can be delivered to community-based organizations for implementation with older adults Prepare a final program package that can be broadly disseminated

36. Original Australian Study vs. Implementation in Wisconsin Original study Led by OT No lay leader Home visit by OT Booster session 3 months after completion WI implementation Led by health professional (OT, RN, dietician, educator) Lay co-leader No home visit Booster classes 2, 4 and 6 months after completion

37. WI: Train-the-Trainer Lead Trainer Licensed health professional, trains Master Trainers Master Trainers Licensed health professional, trains Leaders and Peer Leaders Leader (delivers program) Licensed health professional or health educator with knowledge of fall prevention Peer Leader (delivers program) Older adult who can effectively deliver the program with another trained Leader

38. Bringing Stepping On to the U.S. May be ready to disseminate beyond Wisconsin by end of 2008

39. The Safety of Seniors Act �The Safety of Seniors Act� Now titled Public Law 110-202, the act will develop education strategies to raise awareness about elder falls, encourage research to identify at-risk populations and evaluate falls interventions, and support demonstration projects. Thirty national policy organizations are now calling on Congress to provide $20.7 million in FY 2009 for the Centers for Disease Control to fund these initiatives.

40. Challenge and Opportunity for Kentucky ��evidence-based interventions are particularly strong when the fall prevention intervention includes both health care and community programming components working collaboratively�What we don�t know is how to effectively integrate community interventions that link the unique fall prevention contributions of health care and aging (services)� Testimony Lynn Beattie at the �Falls Prevention Briefing to Congress� on May 7, 2008

41. Collaboration �When spider webs unite they can tie up a lion� Ethiopian Proverb

42. Manuals Matter of Balance = coach manual Matter of Balance = exercises Stepping On = leader manual

43. Thank you to� Patti League, Partnership for Healthy Aging (Maine) Sandy Cech, Kenosha County Aging and Disability Resource Center (Wisconsin) for resources used in this presentation