Recent developments in falls prevention research

1. Recent developments in falls prevention research Falls Clinic Coalition March 2006 Associate Professor Keith Hill, Physiotherapist & Researcher, National Ageing Research Institute k.hill@nari.unimelb.edu.au

2. Research review: what works? • Funded by Commonwealth Dept Health & Aged Care • Randomised controlled trials • Community, residential aged care, and hospital settings • Published in 2000, updated by NARI and re-published in 2004

3. Cochrane Systematic reviews 2000 2004 Falls Falls Hip protectors Hip protectors Vitamin D Environmental mods

4. Evidence of intervention effectiveness: Community (2000) Exercise-bal Environment Exercise-gen Multiple strat Medical screen Medication Exercise-str Injury min Sensory Education Risk factor Chronic medical conditions Environmental hazards Reduced activity Reduced balance Reduced strength Poor vision Cognitive impairment Polypharmacy Osteoporosis Low body mass index Depression Other Level II

5. Evidence of intervention effectiveness: Community (2004) Exercise-bal Environment Multiple strat Medical screen Exercise-gen Exercise-str Injury min Post-hosp Medication Education Sensory Risk factor Chronic medical conditions Environmental hazards Reduced activity Reduced balance Reduced strength Poor vision Cognitive impairment Polypharmacy Osteoporosis Low body mass index Depression Other Level II (2000) Level II (2004)

6. Randomised controlled trials with significant outcomes

7. Environmental safety: Home falls risk assessment & modification • commonly used • One RCT identifying significant reduction in falls rates for an OT home visit / environmental assessment / behaviour risk modification IN AT RISK GROUP ONLY (Cumming et al, 1999) • NB: equally as effective at home and away from home : issues of compliance

8. Post hospitalisation • 15% of older people fall at least once within 1 month of discharge home from hospital, with 11% experiencing serious injuries (Mahoney et al, 2000) • Nikolaus and Bach 2003 • older people admitted to hospital with functional decline • post discharge, usual care vs additional home intervention including follow-up visits, instructions on use of aids and home modifications, support for compliance • significant reduction in falls at 12 months • differential outcome based on compliance

9. Exercise strong evidence of effectiveness of training in older people to improve specific risk factor • various forms of exercise • balance • strength • cardiovascular fitness • flexibility • specificity of training • other health benefits of exercise programs

10. Exercise • tai chi (Wolf et al, 1996; Li et al, 2005) • physiotherapy prescribed home program (Campbell et al, 1997; Robertson et al, 2001) • group exercise program (Day et al, 2002, Barnett et al, 2003; Lord et al, 2003)

11. Clinical screen: Medical (including medication) • no published RCT’s evaluating medical screen with falls rate as an outcome • Campbell et al (1999) - RCT - psychotropic medication withdrawal • 66% reduction in falls rates in intervention group • 47% had resumed psychotropics after one month

12. Vision correction • Critical role of vision in balance and obstacle avoidance • Melbourne study identified identified that a third of people over 65 have inadequate visual correction • Cataract surgery has been shown to reduce falls (RCT – Harwood et al, 2004) • ?? Effectiveness of visual assessment and correction • ?? Effectiveness of changing bifocals to separate distance and reading glasses (current Sydney study)

13. Clinical screen: Multiple strategy (restricted) • Tinetti et al (1994) - RCT - subjects with one or more falls risk factors, all provided with 3 interventions (home mods, home exercise, medication review) • sig difference in time to first fall, number of falls and fear of falling • Rizzo et al (1996) - cost benefit analysis of Tinetti’s program

14. Clinical screen: Multiple strategy (unrestricted) • incorporates assessment and tailored management • Close et al (1999) - RCT - assessment by medical and occupational therapy staff • significant reduction in falls rates • Cochrane meta-analysis (Gillespie et al, 2004) • Current NARI study nearing completion (700 older fallers presenting to Emergency Departments after a fall)

15. Injury minimisation • Alternative strategies may be indicated if: • falls risk is high • intervention has not been successful • other factors limit likelihood of successful intervention (eg poor cognition) • Osteoporotic / high fracture risk

16. Hip protectors Limited studies in community setting • shown to be effective in residential care settings (though less so with recent studies) • issues of limited compliance

17. Injury minimisation • Vitamin D & calcium supplementation • RCT of older people in community / residential aged care settings identified significant reduction in falls fracture rates (Chapuy et al, 1992) • Mechanism of slowing normal bone loss • Recent evidence of effect on reducing falls

18. Research gaps: Community setting • Some risk factors poorly understood and managed • dizziness • Some interventions have good clinical basis, but limited research evidence • use of walking aids • footwear • Effect of early identification of falls risk • All interventions are only as good as the adherence to the intervention regime - issues to improve uptake and compliance need further exploration • Almost all interventions that have been shown to be effective have not included subjects with an important falls risk factor - cognitive impairment (NB- Shaw et al 2003)

19. Current and new NARI projects

20. Falls prevention for people presenting to Emergency Departments after a fall • Large study, in its 4th year • Recruited 700 participants • Evaluating effectiveness of a comprehensive assessment (using a NARI developed tool-the FROP-Com) in reducing falls and falls injuries • Also evaluating cost effectiveness • Will be one of the few studies to evaluate outcomes on injuries and costs Dr Irene Blackberry Melissa Russell undertaking her PhD

21. Early balance screening & exercise Keith Hill, Kirsten Black, Xiao Jing Yang, Sarah Tarquinio • Using Neurocom force platform to detect mild levels of balance dysfunction • Participants with mild balance dysfunction will be randomised to receive Otago home exercise program or info booklet • 12 month followup, to determine effectiveness in improving balance and mobility • 2.5 year project Funded by the Dept Veterans’ Affairs; Xaio Jing Yang undertaking her PhD

22. Falls prevention for stroke patients after in-patient discharge Keith Hill, Cathy Said, Shylie Mackintosh, Craig Whitehead, Sarah Tarquinio, Frances Batchelor • High falls risk stroke patients recruited at discharge • Randomised to information booklet, or risk assessment and targeted management program • 12 month follow-up (falls, balance, QoL, etc) • Sub-studies: • Temporal changes in fear of falling after a fall • Obstacle negotiation skills at 12 months, and association with falls Funded by NHMRC; Frances Batchelor commencing her PhD

23. Balance problems and exercise response in clinical populations Keith Hill, Sue Williams, Sue Hunt, Caroline Brand Keith Hill, Marcia Fearn • Neurocom and clinical measures of balance in OA and RA patients • Identify any differences in balance abilities • Determine responsiveness to Otago home exercise program • Neurocom and clinical measures of balance in patients with haemophilia • Identify falls history, level of balance dysfunction (relative to joint pathology) • Determine responsiveness to Otago home exercise program Funded by Haemophilia Foundation (Aust) Funded by JO & JR Wicking Trust

24. Resources • VQC Guidelines:http://www.health.vic.gov.au/qualitycouncil/plans/falls_5d.htm • National Falls Prevention Guidelines for Hospital and Residential Care settings: http://www.health.qld.gov.au/fallsprevention/project/default.asp