john phd nzrp

Senior Lecturer  and Director  of Post‐graduate Research

Applied Ageing Research  Group

School of NursingThe University of Auckland

Academic Lead, RehabilitationThe Institute of Healthy 

AgeingWaikato District Health Boardj.parsons@auckland.ac.nz

John Parsons PhD NZRP

WHY?

Objectives

To gain an understanding of the different strategies to 

limit falls risk in older people

To provide evidence based interventions that can be 

applied in clinical settings

Goals

Review physical changes that occur that increase falls 

risk among older people

Examine interventions that can be put in place to 

reduce falls risk

What is the evidence for falls in older people?

Falls third commonest cause of injury related death. 

1/3 falls need medical care

5% of falls – serious injury

Hip fracture 

5% residential care

1% in community dwelling older people

QOL, functional status, care needs, disability 

Injury is the tip of the iceberg of morbidity from falls

Costs – 106‐400m/year

1 Death

1 Death39 Hospitalisations

1 Death39 Hospitalisations

1,316 Medical treatments

1 Death39 Hospitalisations

1,316 Medical treatments

4,200 fallsof 12,600 people over age 

65 years

Physical changes with age

Reaction time 

Coordination of balance

Coordination of supportive muscle function

Dependence on visual acuity and peripheral sensing

Dual task performance

General wellbeing (physical, psychological...) 

Impact on functioning

Slowed reaction time

Greater difference in choice reaction time

Loss of muscle strength

Decreased by 1/3 from a  peak at 25 years to age 65

Small decrease in gait comfort speed

Greater difficulty rising from a chair / bed

Altered postural control 

Intervening

Intervening

The Person

Intervening

The Person The Environment

Intervening

The Person The Environment

The Exposure

Intervening

The Person The Environment

The Exposure

The person Hot and cold falls

–

pragmatic clinical advice

Hot falls: acute  medical problem

Infection

Cardiovascular event

Cold falls: less‐acute

multifactorial

Post hot fall: health professional a detective

Is it new or old

Are they acutely unwell

Intrinsic causes of falls, Stroke, MI, other CV, infection, 

constipation, dehydration

Are they poisoned

Assume medication as a cause until proven otherwise, 

new mediation, interaction, adverse reaction

Is there an injury

Cold fall ‐ assessment

Opportunistic or after a fall

Consider risk factors in hx, fear of falling

Parkinsons, stroke, mobility, functional status, medications

Psychotropics esp hypnotics, cardiovascular

Physical exam, esp cardiovasc, neurological, gait and balance

Feasible intervention based on risk factors

Gillespie, Cochrane review 2004

Prevention –

the person community setting

Medication adjustment, behavioural instructions, 

and individualised exercise programmes 0.69 (0.52 ‐ 0.90)

(Tinetti, NEJM 1994)

Exercise programs 

Individualised, Otago Exercise Programme falls reduced  30% (Campbell, BMJ 1998)

Group based LLimb strengthening, balance and reaction  time, falls reduced 40%

(Lord JAGS 2003)

Tai Chi, 15 wks, fear & mult falls reduced 47% (Wolf, JAGS 1996)

Reduction of sedatives 

0.34 (0.16 ‐

0.74)

(Campbell 1999, JAGS)

Success in Residential care (Jensen, Ann  Int Med 2002, Norway)

Multifaceted strategy

Staff education, Modify the environment, Targetted 

strength and balance

programmes, Supply and repair  aids, Review drug regimens, Provide free hip protectors, 

Post‐fall problem solving conferences (Becker 2003)

Vitamin D – 3 trials

Hip protectors

Personal risk  age, living alone, residential carePsychotropicsDepression DementiaMultiple co‐

morbidity

Age & previous falls &Wandering & gait 

6xWandrng & environmt 

5xEnvironmt & depressn

3x

Frailty

Lower leg weakness

Balance problems

Visual problems

Personal riskPersonal riskResidential care Community

Prev falls 50% 30%

Gait & balance deficitUse of assistive devises

80% 25%

Visual impairment ArthritisImpaired ADL 100% 20-30%

Cognitive impairment

50-75% 10-25%

Age >80 years 40-50% 6%

The health system‐

care pathways

Pacemaker insertion for carotid hypersensitivity,  SAFE PACE 0.48 (0.32 ‐

0.73)

(Kenny, Am J Cardiol, 2001)

Screened 24,251 people for 257 potential participants 

A&E fallers ‐

Clinical assessment & referral

&  home safety assessment & modification

0.39 (0.25‐

0.48) (Close, Lancet, 1999)

Rehabilitation ward – targeted multiple 

intervention, 3 hosp wards

Fall alert card, info brochure

Exercise programme

Education programme

Hip protectors (57% wore them >12 hrs/day)

Falls reduced by 30%, evident after 45 days

The environmentHome hazard assessment; greater effect 

with high risk 0.85 (0.74 to 0.96) (4 trials)Paths and stairs and rails in public 

buildings, road crossings, pedestrian  protection

Safer communities

Multiple strategies

Exposures – risky behaviour

Tie them down? Give them aids?

Wrap them up? Education?

Targeted strategies

Assessment

Falls prevention strategies

Injury prevention strategies

Patient education

Staff education

Falls prevention strategies

Medication review

Footwear

Exercise

Continence management

Restraints

Environmental adaptation

Falls prevention strategies

Medication review

Footwear

Exercise

Continence management

Restraints

Environmental adaptation

Strong evidence for physical Strong evidence for physical performance changes post performance changes post training training

Gait speed

Stair climbing

Sit to stand

Transfers in/out of car

Lifting loads

Overall daily activity level

Treatment.

Improve strength, motor control.

Sensory retraining.

Improve fitness, functional ability.

To attempt to prevent further falls.

Muscle strengthening

Transfer practice on/off floor, sit to stand, lying to 

sitting.

Balance retraining

Exercise

Individually tailored strength and balance 

programmes

Otago falls prevention programme

Functional rehabilitation

Sit to stand exercises

Group based programmes

Tai Chi

Adjusted Effects of Exercise on  Falls (Sherington et al, 2008)

High BalanceChallenge

Mod‐Low BalanceChallenge

Programme Adjusted Pooled Rate Ratios(95% Confidence Interval)

High dose and walking  0.76 (0.66–0.88)  0.96 (0.80–1.16)

High dose, no walking  0.58 (0.48–0.69)  0.73 (0.60–0.88)

Low dose and walking  0.95 (0.78–1.16)  1.20 (1.00–1.44 )

Low dose, no walking 0.72 (0.60–0.87)  0.91 (0.79–1.05)

Potential for Harm 

PRT in frail 

hospitalised decr  function & incr pain 

(Latham 2003)

Lo intensity intv in  res care ‐

incr falls 

(Kerse 2004)

Walking after arm  fracture increased  falls (Ebrahim 1996)

Fall rates

00.5

11.5

22.5

33.5

44.5

5

Jan/F

ebMch

/AprMay

/Jun

Jul/A

ugSep

t/Oct

Nov/D

ecJa

n/Feb

Mch/Apr

falls

/resi

dent

yea

r

interventioncontrol

Wolf et al (2003)

Exposures – risky behaviour

Tie them down? Give them aids?

Wrap them up? Education?

Residential Aged Care

Other factors increasing falls risk and influencing 

functional changes and decreased physical activity in  residents include:

underlying physical and cognitive function

health status

motivation

cultural expectations

environmental factors

coexisting disease states

fear of falling 

( Cameron, Kurle, Cumming, & Quine, 2000 ; Crews, 2005 )

Who should encourage physical  activity and so reduce falls risk in  RAC?

Applying the evidence – stamp out the epidemic

Sustainable strategies, resources 

Within existing health structures 

Where to find high risk elders

At 

home, 

at 

the 

shops, 

primary 

health 

care, 

A&E, hospital wards

Where to intervene

At 

home, 

in 

the 

community, 

at 

the 

GPs, 

at 

a 

clinic or referral place, in the hospital, 

What to do

Proven 

strategies, 

acceptable, 

sustainable, 

resourced

Care with monitoring