Download - R educing Falls for Older People
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Reducing Falls for Older People
Ngaire Kerse, FRNZCGP, PhDDepartment of General Practice and Primary Health Care
University of Auckland
Presentation 2 to National Falls Programme Expert Advisory Group meeting 13 July 2012, HQSC
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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
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Hospitalisation
Unintentional injury hospitalisation rates, Victoria, 1990
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
<5 5-14 15-24 25-34 35-44 45-49 55-64 65-74 75-84 85+
age group
rate
pe
r 10
0,00
0 p
op
ula
tio
n
male
female
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Mortality
Age specific mortality
0.00
500.00
1,000.00
1,500.00
65-74 75-84 85+
age group
rate
pe
r m
illio
n
po
pu
lati
on
male
female
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Personal risk age, living alone, residential care
Psychotropics
Depression
Dementia
Multiple co-morbidity
Age & previous falls &
Wandering & gait 6x
Wandrng & environmt 5x
Environmt & depressn 3x
Frailty
Lower leg weakness
Balance problems
Visual problems
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The mechanism
The person
risk factors
The place – environment
Other people, context
The exposure
Risky activity
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Community
30% in 1 year Injury common Hip fracture tip of
the iceburg Risk factors
– Poor mobility– Lower limb, balance– Vision – Medication
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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 safetyGillespie LD et al. Cochrane Database Syst Rev 2009(2) Art. No.:
CD007146!
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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
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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!
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Effective single strategies
Home safety assessment and modification for those at high risk only (6 trials)– Risk of falling 21%
Vitamin D (only if lower levels, 2 trials), no reduction overall
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;20:9541Gillespie LD et al. Cochrane Database Syst Rev 2009(2) Art. No.:
CD007146!
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Med review
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Multifactorial intervention
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
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Single interventions
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Multifactorial interventions
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Conclusions: falls and injury
common problem disastrous consequences identified risks Interventions may maintain
independence, stop hip fracture
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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
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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
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Hazards
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Unsuccessful trial – Auckland 2004
Increased falls– 1.34 (1.06-1.72)– ?mobility– ?staffing– ?measurement
Fall rates
00.5
11.5
22.5
33.5
44.5
5
falls
/res
iden
t ye
arintervention
control
Kerse JAGS 2004
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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, 10 rest home 1 acute hosptial 6 subacute
ProFaNE (Prevention of Falls Network Europe)http://www.profane.eu.org
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Nursing care homes - Vitamin D
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Exercises – overall
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Exercises – combination exercise modalities
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Exercises – by typeReview: Interventions for preventing falls in older people in nursing care facilities and hospitalsComparison: 02 Single exercise modalities vs usual care (nursing care facilities) Outcome: 01 Rate ratio (falls)
Study Intervention Usual care Rate ratio (fixed) Weight Rate ratio (fixed)or sub-category N N log[Rate ratio] (SE) 95% CI % 95% CI
01 3D exercisesFaber 2006 78 90 -0.0400 (0.1100) 89.27 0.96 [0.77, 1.19]
Subtotal (95% CI) 78 90 89.27 0.96 [0.77, 1.19]Test for heterogeneity: not applicableTest for overall effect: Z = 0.36 (P = 0.72)
02 Gait, balance and coordination exercises vs usual care (nursing care facilities)Shimada 2004 15 11 -0.6300 (0.4700) 4.89 0.53 [0.21, 1.34] Sihvonen 2004 20 7 -0.9200 (0.4300) 5.84 0.40 [0.17, 0.93]
Subtotal (95% CI) 35 18 10.73 0.45 [0.24, 0.85]Test for heterogeneity: Chi² = 0.21, df = 1 (P = 0.65), I² = 0%Test for overall effect: Z = 2.48 (P = 0.01)
Total (95% CI) 113 108 100.00 0.89 [0.72, 1.09]Test for heterogeneity: Chi² = 5.17, df = 2 (P = 0.08), I² = 61.3%Test for overall effect: Z = 1.16 (P = 0.25)
0.1 0.2 0.5 1 2 5 10
Favours intervention Favours usual care
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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)
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Becker; by cognition a)
Time (days)
Impaired cognition
Time (days)
Intact cognition
Pro
babi
lity
of s
urvi
val w
ithou
t fal
l
Pro
babi
lity
of s
urvi
val w
ithou
t fal
l
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Results
Nursing care homes Effect of exercise
inconsistent Multifactorial
interventions– Team based > nurse
led Vitamin D effective Knowledge alone
ineffective
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Hospitals
Overall success– Exercise – Orthogeriatrics– AT&R
Less success – Acute
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Exercise - hospitals
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Multifactorial – hospitals
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Stenvall – ortho and geriatric ward Sweden
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Stenvall
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Healey elderly care wards UK
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Cummings – acute & subacute Sydney
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Hospitals
Multifactorial – Success related to resources
Exercises promising