Professor Keith Hill, Head, School of Physiotherapy and Exercise Science,

1. Falls prevention for people living with dementia:Education session for HACC Assessment Officers and District Nurses Professor Keith Hill, Head, School of Physiotherapy and Exercise Science, Curtin University– Keith.Hill@urtin.edu.au Gippsland (Victoria): September 2014

2. Overview • How common are falls among older people • What are the effects of falls on an older person • Why do older people fall • What effect does dementia have on falls • What should an older person do if they have a fall • Case study • How can HACC Assessment Officers and District Nurses help clients (with and without dementia) to avoid falls • Introduction to the Gippsland Falls Prevention Pathway for People Living With Dementia • Resources to help older people who fall

3. Falls as a National Issue Transportation related hospitalisations – 55,457 Falls related hospitalisations – 153,170 Australian Institute of Health and Welfare, 2012 Hospital separations due to injury and poisoning, Australia 2008-9

4. Falls as a National Issue Australian Institute of Health and Welfare, 2007 Hospital separations due to injury and poisoning, Australia 2003-4

5. Other factors • implicated in up to 40% of admissions to residential care • quality of life issues • independence • community living • active life-style • other

6. Falls are multi factorial Health problems Intrinsic factors Ageing Medications eg. psychoactive meds Environment Activity related risks Extrinsic factors

7. Identifying who is at risk of falls… • Factors commonly associated with fallers: • previous falls • lower extremity weakness • arthritis (hips / knees) • gait / balance disorders • cognitive disorders (depression / dementia / poor judgement...) • visual disorders • postural hypotension • bladder dysfunction (frequency / urgency / nocturia / incontinence...) • medications (psychotropics/ sedatives / hypnotics / antihypertensives...) Tideiksaar, 1995

8. Number of risk factors Modifiable and non-modifiable risk factors Tinetti et al, 1988

9. Falls risk assessment Falls risk screening Systematic process of identifying an individual’s intrinsic falls risk factors (...to tailor an intervention) Systematic process of identifying an individual’s level of falls risk (eg low, medium, high)

10. The falls prevention pathway for people living with dementia in Gippsland • Tools: • Falls risk screening tool (FROP-Com* screen) FROP-Com = Falls Risk for Older People: Community version: Screen available from-http://www.mednwh.unimelb.edu.au/nari_tools/nari_tools_falls.html

11. The falls prevention pathway for people living with dementia in Gippsland • Tools: • Eg Falls risk assessment tool (FROP-Com*) FROP-Com = Falls Risk for Older People: Community version: Assessment tool available from-http://www.mednwh.unimelb.edu.au/nari_tools/nari_tools_falls.html

12. Environmental problems contributing to risk of falling Poor lighting Poor footwear Loose mat or slippery / uneven surface

13. The biggest risk for having a future fall is ……. ….. having had a recent fall

14. However many older people who fall do not tell a Doctor or other health professional • Why is this important? • The Doctor can • assess the cause of the falls • provide treatment to reduce risk of a further fall • But if the Doctor is not aware of the fall • there will be no actions put in place to reduce ongoing risk of falls • another fall is likely to occur

15. American Geriatrics Society / British Geriatrics Society guidelines: JAGS 2011, 59: 148-157

16. Case: Mary • 85 yo lady • Lives at home alone, has a home care worker visit twice weekly • Has a personal alarm • Has been falling for more than 10 years • Multiple fractures from falls • Medical past history includes osteoporosis, diabetes, depression, osteoarthritis, cataracts • Medications include sleeping tablets, antidepressants, and several others • Increasing unsteadiness in past few months • Had a recent fall, has not seen Doctor about falls • Environmental hazards

17. Early identification of risk: Mary                

18. What effect does dementia have on a person’s risk of falling? • Reduced awareness of environment and safety • Agitation • Wandering • Increased unsteadiness Even greater risk of falling

19. But the person with dementia may also have other falls risk factors… Poor eyesight Dizziness Incontinence Arthritis in the legs • OFTEN THESE CAN BE TREATED • Poor eyesight • Dizziness • Incontinence • Arthritis • etc • Poor eyesight • Dizziness • Incontinence • Arthritis • etc

20. Can the risk of falls among older people be reduced? YES!

21. What can help to reduce an older person’s risk of falls: 1. See the doctor or other health professional • If a person has a fall - even if they think it was just an accident • If a person is feeling more unsteady when walking / turning • Commences using a different walking aid • If a person is reducing their activities

22. What can help an older person to reduce their risk of falls: 2. Exercise

23. What can an older person do to reduce their risk of falls: 2. Exercise COCHRANE REVIEW: “Multiple-component group exercise significantly reduced rate of falls …….. and risk of falling ….., as did multiple-component home-based exercise …... For Tai Chi, the reduction in rate of falls bordered on statistical significance …… but Tai Chi did significantly reduce risk of falling ……. Overall, exercise interventions significantly reduced the risk of sustaining a fall-related fracture …….”. Cochrane review: Gillespie et al, 2012

24. Exercise / physical activity • Most researched single intervention in falls prevention • Majority of research in the community setting • Meta-analysis of >50 RCTs identified key elements for success in reducing falls (Sherrington et al, (JAGS, 2011): • Balance component • Moderate intensity NOTE: Exercise programs usually have a range of other benefits as well as falls prevention

25. Many older people have an exercise program to do at home • Usually under intermittent supervision of physiotherapist or accredited exercise physiologist • Often need for encouragement to maintain participation

27. What can an older person do to reduce their risk of falls: 3. Medication review • Keep medications to the minimum needed • Take medications as prescribed • Have medications reviewed by the doctor regularly • Try to avoid / minimise use of sleeping tablets, anti anxiety tablets etc Largest effect of any falls prevention study involved weaning people off sleeping / anxiety medications

28. What can an older person do to reduce their risk of falls: 4. Vision check • Regular vision review • Cataract surgery • First eye effective • Bifocals and multi-focal glasses– can be a problem

29. What can an older person do to reduce their risk of falls: 5. Home safety • Removing environmental hazards will reduce risk of falls • If having falls should have an occupational therapy home assessment • Outcomes associated with level of adherence with recommendations

30. What can an older person do to reduce their risk of falls and fall injuries: Vitamin D and calcium • Many older people have low levels of vitamin D • Main sources of vitamin D are: • Sunlight (approx 20 min/day) • Some foods (eg sardines) • Supplements • Vitamin D and calcium together have been shown to reduce fractures and falls (in high risk samples)

31. Effect of vitamin D on falls COCHRANE REVIEW: “Overall, vitamin D did not reduce rate of falls ……. or risk of falling ……, but may do so in people with lower vitamin D levels before treatment..” • Complex series of studies to interpret because of: • different types of vitamin D (D2 and D3) • different dosages • different samples in terms of vit D deficiency • supplementation of vitamin D with calcium • outcomes of fractures as well as falls Cochrane review: Gillespie et al, 2012

32. What can an older person do to reduce their risk of falls injuries: Hip protectors • Useful if falling frequently, and / or if bones are weak • Will reduce risk of hip fracture substantially, if worn... • Several different types • Hard shields • Foam

33. Factors influencing low adherence with hip protectors • Design and style • Fashion / concern about “extra width on hips” • Cost • Impact of: • Reduced dexterity • Incontinence (some come with continence pads) • Staff / family not reinforcing value of hip protectors

34. Other interventions from best practice guidelines Safe footwear Education Change walking aid Treat postural hypotension Treat incontinence

35. Case: Mary – how can her falls risk be reduced? • Use her personal alarm if a fall occurs and cannot get up • Discuss hip protectors / vitamin D / possibly antiresorptive medications • Review re cataracts-?surgery • Review medications, in particular sleeping tablets • Physiotherapy assessment of balance and mobility - ?exercise program • Have a medical review AND report the fall • Home safety assessment by occupational therapist • 85 yo lady • Lives at home alone, has a home care worker visit twice weekly • Has a personal alarm • Has been falling for more than 10 years • Multiple fractures from falls • Medical past history includes osteoporosis, diabetes, depression, osteoarthritis, cataracts • Medications include sleeping tablets, antidepressants, and several others • Increasing unsteadiness in past few months • Had a recent fall, has not seen Doctor about falls • Environmental hazards

36. Case: if Mary also had dementia… • POSSIBLE OPTIONS TO REDUCE RISK OF FALLS • Use her personal alarm if a fall occurs and cannot get up • Discuss hip protectors / vitamin D / possibly antiresorptive medications • Review re cataracts-?surgery • Review medications, in particular sleeping tablets • Physiotherapy assessment of balance and mobility - ?exercise program • Have a medical review AND report the fall • Home safety assessment by occupational therapist • 85 yo lady • Lives at home alone, has a home care worker visit twice weekly • Has a personal alarm • Has been falling for more than 10 years • Multiple fractures from falls • Medical past history includes osteoporosis, diabetes, depression, osteoarthritis, cataracts • Medications include sleeping tablets, antidepressants, and several others • Increasing unsteadiness in past few months • Had a recent fall, has not seen Doctor about falls • Environmental hazards • Dementia friendly environment • Consider any additional carer burden in interventions • Ensure consideration of causes and management of agitation • Other …..

37. Additional considerations • Falls risk can change quickly • Acute health problems such as urinary tract / chest infections • Transitions between settings appear to increase risk of falls (eg home to hospital, home to respite) Greater level of care / falls risk management at these times

38. Summary of what works: falls prevention interventions in the community setting for people with dementia (randomised controlled trials)

39. Reasons for lack of research evidence … • Exclusion criteria for most community falls prevention randomised trials • Difficult area of research • Limitations in few randomised trials to date (mainly replicating approaches found successful for people who don’t have dementia)

40. An area with recent promising results • Home based exercise for people with mild to moderate dementia • Prescribed by a physiotherapist • Individualised exercise program, based on balance and mobility assessment findings • Key role of carer in supporting / encouraging exercise participation by the person with dementia (sometimes doing the exercises together) • Regular review and update by physiotherapist (6 times in 6 months) Improved balance, mobility and falls risk after 6 months Suttanon et al, Clinical Rehabilitation, 2013

41. The falls prevention pathway for people living with dementia in Gippsland

42. The falls prevention pathway for people living with dementia in Gippsland Identification of falls risk and referral / screen • Many people accept falls as an inevitable part of ageing (irrespective of cognitive impairment) • Only a quarter of older people who fall report the fall to a Dr or health professional • Many falls risk factors are not identified or managed optimally (eg guideline care in Emergency Departments) • Need for multiple access / referring points Timing • Consider falls risk screening • in early stages of dementia, and • intermittent review, especially if increased unsteadiness, falls or near falls

43. Ways nursing or assessment staff can assist in reducing risk of falling for a client with dementia • Observe for signs of increased falls risk • Ask the client to complete a falls risk self assessment (eg: http://www.health.wa.gov.au/stayonyourfeet/docs/2857_SOYF.pdf) • Encourage: • Medical review if falls, near falls, unsteadiness, change in mobility • Participation in recommended interventions (exercise, use of gait aid, home modifications, etc) • Home care workers to report changes in potential level of risk • If provided with training, encourage home care workers to observe and encourage participation in home exercise programs

44. Summary • Falls are common among older people and can cause serious injuries and loss of confidence • All falls should be reported to a doctor • There are a number of ways that falls risk can be reduced • Home care assessment staff, home nursing staff and other health professionals can play an important role in identifying potential risks for falling among their clients • Consider the Gippsland falls prevention pathway for people with dementia in assessment and management of clients with dementia

45. Falls prevention resources

46. National Falls Prevention Guidelines for Community setting (UPDATED – Nov 2009): http://www.safetyandquality.gov.au/our-work/falls-prevention/falls-prevention-community/

47. Victorian Government Dept of Health– website of falls prevention resources for community and residential aged care settings (UPDATED 2009) http://health.vic.gov.au/agedcare/maintaining/falls_dev/index.htm