Understanding Chronic Musculoskeletal Pain in Older Adults and Falls Risk

1. Prof Pat Schofield Positive Ageing Research Institute (PARI)

2. DISCLOSURE I have no relevant commercial relationships to disclose.

3. Pain & Mobility / Falls Background PhD project (Dr Brendon Stubbs) Umbrella reviews Future directions

4. October 2012-September 2015 Leveille 2009 study Chronic Musculoskeletal pain (CMP) 3> months Untangle the relationship between CMP and physical activity, psychological concerns related to falls and falls – starting point

5. 3 main areas of focus – is chronic musculoskeletal pain associated with: • Lower levels of physical activity and higher levels of sedentary behaviour? • Increased psychological concerns related to falls? • Increased risk of actual falls? *What are the experiences of older adults of these factors?

6. Falls are: • Leading cause of accidental death, disability and reason for nursing home admission (Deandrea et al 2010, 2013) • Associated with greatly reduced QOL • Around 30% of community dwelling older adults fall each year • Risk increased with age (Gillespie et al 2012) • Economic cost considerable

7. Importance of identification of key risk factors Integral to inform clinical practice Multifactorial falls interventions disappointing ? Missed some key risk factors? (Leveille et al 2009) Chronic musculoskeletal pain surprising oversight?

8. American and British Geriatrics Society Falls prevention guidelines 2011 • Very comprehensive update for clinicians • Provides info on key risk factors • What to assess, what assessments etc • No mention of pain as a risk factor of even asking the older adult if they are in pain

9. Reasons why this oversight is Surprising 1. Chronic pain is associated with: Mobility deficits Impaired gait Balance deficits (Leveille et al 2002) Recognised internal risk factors for falls! 2. Pain is common in older people: Recent guidelines in Age and Ageing (Abdulla et al 2013)

10. Why might this oversight be? Lack of research? • Arden et al 1999 established older adults with CMP at 50% increased risk of falls • Recent review (Deandrea et al 2010) investigated 31 risk factors, pain hidden in there: • Single falls - 2 studies; OR 1.39 (CI: 1.14 to 1.62) • Multiple falls -6 studies; OR 1.60 (CI: 1.44 to 1.78)

12. Results • 21 studies reported an association between pain and falls • All 21 found a relationship between pain and falls • We calculated the odds ratio (OR) for 14 of 21 studies using the raw data

13. Meta Analysis

14. Does the type of falls ascertainment make a difference?

15. Does the location of pain make a difference?

16. Does the duration of pain make a difference?

17. Summary of results from MA Regardless of location and duration, pain is associated with falls. Older adults with pain are more likely to have fallen in past 12 months and fall again in the future Chronic pain and foot pain particularly strongly associated with falls

18. How much does pain increase falls risk compared to other well established risk factors? Deandrea et al 2010Stubbs et al 2013b: History of falls: 177% Foot pain 138% Walking aid use: 118% Hip pain 36% Cognitive impairment: 36% Chronic pain 81% Depression: 63% Any pain 56% Hx stroke: 61% Dizziness: 80% Urinary incontinence: 80% FOF: 55% PD: 171% Gait problems: 106% Visual impairment: 35%

20. Hierarchy of evidence

21. Umbrella reviews • Increasing recognition that SR & MA can only provide partial insight into an intervention. • Particularly true in complex interventions such falls. • Number of SR & MA on certain topics difficult to navigate and understand. • Rising popularity of umbrella reviews

22. Falls prevention interventions Exercise Vitamin D Medication review Multifactorial interventions Environmental risk factor changes

23. Aim Provide a comprehensive overview and critique of ‘what works to prevent falls’ in community dwelling older adults and long term care facilities (LTCF).

24. Method Prospero registration MA >3 RCTs Eligibility P Older adults (60>) community or LTCF/ hospitals. Free major neurological conditions I Any sought to decrease falls – single or multifactorial C Any non active intervention O rate, odds, incidence of falls

25. Searches Two authors major databases inception to 08/2014 Key words Two authors extracted data. Methodological appraisal AMSTAR – methodological appraisal of SR 11 items – met, unmet, unclear 0-3 low 4-7 medium 8>good

26. Summary included studies • 15 MA’s • Each MA contained between 3 and 22 individual RCTs • 348 (23Education & exercise analysis, N=3) and 27,522 21 unique participants across the pooled analyses. • Only 3 MA defined a fall. • 3 MA reported AE – minor • Quality of MA moderate to high AMSTAR

27. Conclusions of what works for falls prevention so far Consistent and moderate-high quality evidence that exercise and multifactorial interventions reduce the risk, odds and rate of falls. Evidence for falls prevention in LTCF and hospitals is less consistent.

28. Future directions Objective physical testing to identify people at risk before fall Wearable technology. Cost effectiveness studies. LTCF and hospital – gaps in literature.

29. Chat Bot for Pain

30. Possible technological solutions • Flossie Chambers, 89, playing 10-pin bowling at the Sunrise Senior Living Centre, Edgbaston Daily Telegraph, 14 September 2007 • “Digital natives” are growing up!

31. Patricia.Schofield@Anglia.ac.uk • Thanks to Dr Brendon Stubbs

32. THANK YOU!