Reducing 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

2. Aged 80 Hypertension Arthritis Widow (4 years) Lives with her son Medications Temazepam 10mg nocte Inhibase plus April JonesSore knee after a fall – for repeats

3. 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

4. Hospitalisation

5. Mortality

6. 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

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

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

9. 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!

10. 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

11. 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!

12. Effective single strategies • Home safety assessment and modification (6 trials) • Risk of falling 21% • Vitamin D (if lower levels, 2 trials) • Rate of falls 43% • 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!

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 Multifactorial interventions

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

16. 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

17. 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

18. Risk Factors – prospective studies Muscle weakness (4.4) Hx Falls (3.0) Gait & balance deficit (2.9) Use of assistive devises (2.6) Visual impairment (2.5) Arthritis (2.4) Impaired ADL* (2.3) Cognitive impairment (1.8) Age >80 years (1.7) Psychotropics (1.5) Mobility, being able to ambulate* OR/RR 16 studies, residential care

19. Hazards

22. A Cochrane systematic review and meta analysis - methods Hypothesis – Interventions are effective Population – residential care (nursing care facilities) and hospitals Type - Randomised controlled trials, quasi-rand Interventions to reduce falls in older people in nursing care facilities or hospitals Majority >65 years. Outcomes –raw data - falls, fallers Definition of fall essential Search Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (January 2009); the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue MEDLINE, EMBASE, and CINAHL (all to November 2008); trial registers and reference lists of articles

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 Single 1 multiple 9 multifactorial

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 study • 6 LTC homes, 509 Int, 472 control • Data feedback, staff training, champion, resident info and education, exercise, hip protectors, environmental assessment • Exercise: balance, PRT, ankle wts, dumbbells, (stand while holding chair and lift leg), 6-8/grp, 2xweekly x 12m • Improved chair rise, 6 min walk

31. Becker; by cognition

32. Becker: by prior fall

33. Will it work in New Zealand setting? Germany Staffing – 50% RN special training for long term care RN Support for innovation Falls monitoring state wide Case mix New Zealand 30% RN Change in the sector Variability in staffing and processes Buy in for innovation

34. Results Nursing care homes Effect of exercise inconsistent Multifactorial interventions Team based > nurse led Vitamin D effective

35. An exercise programme Staying upright Adapted from German program, Denise Taylor, Liz Binns, John Parsons, Madeline Calder Group based Designed for those with dementia Physio or physio aid Coming soon to you See Andrew Jull (next presenter)

36. Hospitals - exercise

37. Hospitals - multifactorial

38. Acute management Change medications Visual impairment Foot problem Residential setting ?appropriate Behavioural issues Environment Vit D Exercise Home safety Medication review Review Feasible interventions