r educing falls for older people
DESCRIPTION
R educing Falls for Older People. Ngaire Kerse, FRNZCGP, PhD Department of General Practice and Primary Health Care University of Auckland Presentation 2 to National Falls Programme Expert Advisory Group meeting 13 July 2012, HQSC. Definitions. - PowerPoint PPT PresentationTRANSCRIPT
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
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
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
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
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
The mechanism
The person
risk factors
The place – environment
Other people, context
The exposure
Risky activity
Community
30% in 1 year Injury common Hip fracture tip of
the iceburg Risk factors
– Poor mobility– Lower limb, balance– Vision – Medication
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!
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
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!
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!
Med review
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
Single interventions
Multifactorial interventions
Conclusions: falls and injury
common problem disastrous consequences identified risks Interventions may maintain
independence, stop hip fracture
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
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
Hazards
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
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
Nursing care homes - Vitamin D
Exercises – overall
Exercises – combination exercise modalities
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
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)
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
Results
Nursing care homes Effect of exercise
inconsistent Multifactorial
interventions– Team based > nurse
led Vitamin D effective Knowledge alone
ineffective
Hospitals
Overall success– Exercise – Orthogeriatrics– AT&R
Less success – Acute
Exercise - hospitals
Multifactorial – hospitals
Stenvall – ortho and geriatric ward Sweden
Stenvall
Healey elderly care wards UK
Cummings – acute & subacute Sydney
Hospitals
Multifactorial – Success related to resources
Exercises promising