Strengths and Weaknesses of Strengths and Weaknesses of

Falls Prevention Strategies Falls Prevention Strategies

Dr Dawn Skelton,

Reader in Ageing & Health, Glasgow Caledonian University

My presentation will….My presentation will….

�� Very briefly explore the prevalence and Very briefly explore the prevalence and consequences of fallsconsequences of falls

�� Discuss the evidence base in relation to Discuss the evidence base in relation to single interventions and populationsingle interventions and population--based based interventionsinterventions–– Strengths and WeaknessesStrengths and Weaknesses

�� Very briefly explore the gaps in the evidence Very briefly explore the gaps in the evidence base base

�� Be available to downloadBe available to download

Prevention of Falls Network Prevention of Falls Network

Europe (ProFaNE)Europe (ProFaNE)

www.profane.eu.orgwww.profane.eu.org

Discussion BoardDiscussion Board

ResourcesResources

InformationInformation

22--Monthly eMonthly e--newsletternewsletter

Figure 9. Mortality rate (age standardised - per 100,000) due to

falls in the elderly (65+) in the EU25 and EEA, in countries having

less than 10% "Other and unspecified" (Table 1)

164.5

112.2

94.9

89.1

73

66.4

65.3

61.7

57.8

50.3

38.9

35.1

33.1

24.8

14.4

0 20 40 60 80 100 120 140 160 180

Hungary

Czech Republic

Finland

Slovenia

Italy

Poland

Latvia

Ireland

Belgium

Austria

Iceland

Lithuania

Slovakia

Estonia

Greece

European Network

on Safety among Elderly (EUNESE)

Priorities for Elderly Safety in Europe

2006

10 fold difference in mortality from falls in different EU countries

Falls in the UKFalls in the UK

�� 11 million people aged > 65 yrs11 million people aged > 65 yrs

�� 28,000 women aged > 90 yrs28,000 women aged > 90 yrs

�� Fractures costs Fractures costs ££1.81.8 billion pabillion pa

�� 1 Hip Fracture every 10 1 Hip Fracture every 10 minsmins

�� 1 Wrist Fracture every 9 1 Wrist Fracture every 9 minsmins

�� 1 Spine Fracture every 3 1 Spine Fracture every 3 minsmins

�� 500 admitted to Hospital every day500 admitted to Hospital every day

�� 3333 never go homenever go homeAnnual European Home and Leisure Accident Surveillance Survey (EHLASS) Report UK 2000

DoH Prevention Package 2009

How common are falls?How common are falls?

�� In In > 75s> 75s, falls are the leading cause , falls are the leading cause of of deathdeath resulting from injuryresulting from injury

�� 7575--80%80% of falls are not reportedof falls are not reported

�� 1 in 3 >65’s1 in 3 >65’s and 1 in 2 >80’s fall p.a.and 1 in 2 >80’s fall p.a.

�� 10%10% of all callof all call--outs for outs for UK UK Ambulance ServiceAmbulance Service are for people are for people aged 65+ who have ‘fallen’ but aged 65+ who have ‘fallen’ but nearly nearly half half are not taken to Hospital.are not taken to Hospital.

Skelton & Todd, WHO 2004,

Gillespie 2005, Close 2008

EPIDEMIOLOGY OF FALLING EPIDEMIOLOGY OF FALLING

cont.cont.

�� Falls more common in people with Falls more common in people with multiple medical multiple medical conditionsconditions and with and with poor function and mobilitypoor function and mobility

�� There are There are global variationsglobal variations in fall rates (in fall rates (egeg China 6China 6--20%, 20%, Japan 20%), and few figures are available for developing Japan 20%), and few figures are available for developing worldworld

�� Appear to be Appear to be racial differencesracial differences in likelihood of a fall (white in likelihood of a fall (white Caucasians particularly at risk)Caucasians particularly at risk)

�� WomenWomen are more likely to fall than men, and to suffer are more likely to fall than men, and to suffer nonnon--fatal injuries (higher risk of osteoporosis)fatal injuries (higher risk of osteoporosis)

�� Social deprivationSocial deprivation linked to linked to nocturia nocturia and falls at nightand falls at night(WHO 2007, Booth 2009)(WHO 2007, Booth 2009)

With thanks to Dr David Reid, University of Aberdeen & NOS

Consequences of Hip FractureConsequences of Hip Fracture

�� By Year 2030 expected 100,000 By Year 2030 expected 100,000

hip fractures a year.hip fractures a year.

�� RiskRisk of a hip # of a hip # 10x10x

higher for those in higher for those in residential residential

settingssettings than in than in own homeown home

�� 50%50% of individuals will die, of individuals will die,

move into a nursing home or move into a nursing home or

be in hospital within be in hospital within sixsix months of Hip #months of Hip #

�� 80%80% do not regain predo not regain pre-- fracture mobilityfracture mobilityDoH Prevention Package 2009

Cost to the IndividualCost to the Individual

�� InjuriesInjuries include: include:

–– Cuts and lacerations, Cuts and lacerations,

–– Deep bruises, Soft Tissue Injuries,Deep bruises, Soft Tissue Injuries,

–– Dislocations, SprainsDislocations, Sprains

–– Increase in joint painIncrease in joint pain

�� Less than Less than 5%5% of all falls result in a of all falls result in a

fracturefracture

�� Long lie’s (floor) & complications Long lie’s (floor) & complications

�� Depression, fear of fallingDepression, fear of falling

�� Avoidance of activitiesAvoidance of activities and social and social

isolationisolation

Skelton & Todd, WHO, 2004

For a typical PCT: 300k For a typical PCT: 300k

populationpopulation

�� ~ 300 ~ 300 -- 350 hip fractures pa350 hip fractures pa

�� > 1000 other fragility fractures> 1000 other fragility fractures

�� > 15,000 fall each year, 6000 twice > 15,000 fall each year, 6000 twice

or moreor more

�� > 70 per week will attend A&E > 70 per week will attend A&E

�� This costs PCT & council £50m per This costs PCT & council £50m per

annumannum

�� This will increase 50% by 2020This will increase 50% by 2020

DoH Prevention Package 2009

Objective 1: Improve outcomes and improve efficiency of care after hip

fractures – by following the 6 “Blue Book” standards

Hip fracture

patients

Objective 2: Respond to the first

fracture, prevent the second – through Fracture Liaison Services in

acute and primary care

Non-hip fragility fracture patients

Objective 3: Early intervention to restore

independence – through falls care

pathway linking acute and urgent care services to

secondary falls prevention

Individuals at high risk of 1st fragility fracture

or other injurious falls

Objective 4: Prevent frailty, preserve bone health, reduce accidents –

through preserving physical activity, healthy lifestyles and

reducing environmental hazards

Older people

DH 2009: falls & fracture care & DH 2009: falls & fracture care &

prevention: four key objectivesprevention: four key objectives

Bone health opportunities Bone health opportunities

missedmissed

�� Royal College of Physicians (RCP) 2009 audit of falls and Royal College of Physicians (RCP) 2009 audit of falls and

bone health servicesbone health services

–– “systems to ensure initiation of secondary prevention “systems to ensure initiation of secondary prevention

medical treatments for osteoporotic fragility fractures are medical treatments for osteoporotic fragility fractures are

not in place”.not in place”.

�� In the RCP national clinical audit of 2007, only 19% of over In the RCP national clinical audit of 2007, only 19% of over

5,000 patients presenting to hospital with a non5,000 patients presenting to hospital with a non--hip fragility hip fragility

fracture were on the appropriate bone medication three fracture were on the appropriate bone medication three

months later. months later.

–– Yet over 40% of people who sustain a hip fracture have Yet over 40% of people who sustain a hip fracture have

had a previous nonhad a previous non--hip fragility fracture.hip fragility fracture.

Exercise opportunities Exercise opportunities

missedmissed

0

10

20

30

40

50

60

70

80

90

100

Bone Health Vision Gait & Balance

NICE

Assessment

Intervention

Direct

81% run strength and balance training

classes BUTAverage duration 8 weeks and

frequency once per week!

Lamb et al, SDO report, 2008

Falls Prevention ApproachesFalls Prevention Approaches

�� Individual Approach (high risk patients) Individual Approach (high risk patients)

–– MultiMulti--factorial (factorial (egeg. PROFET . PROFET -- Close et al, 1999Close et al, 1999))

�� 2004 Review 2004 Review -- MultifactorialMultifactorial trials reduce risk (RR 0.82) Chang 2004trials reduce risk (RR 0.82) Chang 2004

�� 2008 Review 2008 Review -- MultifactorialMultifactorial trials ineffective trials ineffective -- Gates 2008Gates 2008

–– UniUni--factorial (factorial (egeg. . FaMEFaME -- Skelton et al, 2005Skelton et al, 2005))

�� Exercise only trials reduce risk (RR 0.86) Chang 2004Exercise only trials reduce risk (RR 0.86) Chang 2004

�� Pacemakers, Cataract Removal, Medication Withdrawal Pacemakers, Cataract Removal, Medication Withdrawal

�� Population based approach (targeting communities)Population based approach (targeting communities)

–– Emerging evidence (Emerging evidence (McClure, 2005McClure, 2005))

–– Most include increasing awareness and Most include increasing awareness and physical activityphysical activity, ,

medication and home hazard reviewsmedication and home hazard reviews

�� Reductions in injuries 6Reductions in injuries 6--33% but no 33% but no RCTsRCTs

Different costs to interventionsDavis 2010

PROFET: targeting risk factors PROFET: targeting risk factors (Close et al. Lancet 1999)(Close et al. Lancet 1999)

�� Medical assessmentMedical assessment�� General medicalGeneral medical

�� Postural hypotensionPostural hypotension

�� Visual acuityVisual acuity

�� BalanceBalance

�� Cognition and affectCognition and affect

�� CorotidCorotid sinus syndromesinus syndrome

�� Occupational TherapyOccupational Therapy�� FunctionFunction

�� Physical handicapPhysical handicap

�� Psychological handicapPsychological handicap

�� Environmental hazardsEnvironmental hazards

�� Referral / Referral / interventionintervention–– Day hospitalDay hospital

–– GPGP

–– O/PO/P

–– OpticianOptician

–– Social servicesSocial services

–– Supply minor equipmentSupply minor equipment

The rate of falls was reduced by 60%

Falls ClinicsFalls Clinics

�� Geriatrician, Geriatrician, PhysioPhysio, OT, nurse, OT, nurse

�� StrengthsStrengths: Intensive CGA assessment and onward : Intensive CGA assessment and onward referralreferral–– Intended interventions not always undertakenIntended interventions not always undertaken

–– Not always evidence based interventions Not always evidence based interventions

� Weaknesses: different messages from different professionals, lots of double handling and assessment but little ‘action’, lots of waiting around, concern about institutionalisation….lots of DNAs…

� Reports of attendance suggest that the population reach of fall clinics is low (<3% of the population at risk)

Lamb 2008, Gates 2008

Behavioural ModificationsBehavioural Modifications

�� Stepping On (Clemson, 2004)Stepping On (Clemson, 2004)

�� Small Group Learning EnvironmentSmall Group Learning Environment

�� N= 310 >70s with history or concern about fallsN= 310 >70s with history or concern about falls

�� Aimed to improve Aimed to improve self efficacyself efficacy and encourage and encourage

behaviourbehaviour changechange (exercise, medication, home and (exercise, medication, home and

outdoor safety, vision)outdoor safety, vision)

�� 31% reduction in falls31% reduction in falls

OT InterventionOT Intervention

Cumming et al, JAGS 1999 - 65+ years, 1 year, n= 530, RCT- OT home visit < 3 wks hospital discharge- list of recommendations and telephone call 2 wks later - Subjects with fall(s): 36% vs 45% [p=0.05]

Interactive interventions delivered by professionals involving older people in discussion around falls, behaviour and lifestyle are more

successful with high risk groups(WHO 2007)

–– Consider major modifiable Consider major modifiable risk factorsrisk factors

–– Consider bone health / Consider bone health / risk of fracturerisk of fracture

–– Consider if onward Consider if onward referral necessaryreferral necessary

–– Not be repeated by Not be repeated by everyone that comes into everyone that comes into contact with an older contact with an older person!person!

–– Lead to effective Lead to effective interventionsinterventions

–– Be predictive??Be predictive??

Oliver 2009Oliver 2009

Systematic reviews of tools Systematic reviews of tools

that predict risk of a future fallthat predict risk of a future fall

�� Myers H 2003Myers H 2003

�� Oliver D et al 2004Oliver D et al 2004

�� Scott V et al 2007Scott V et al 2007

�� Hill K and Haines T 2008Hill K and Haines T 2008

�� All cast doubt on predictive validity of falls toolsAll cast doubt on predictive validity of falls tools

�� And show up the almost total lack of validated tools And show up the almost total lack of validated tools

in community or nursing home or mental health in community or nursing home or mental health

settingsetting

So what about case So what about case

finding for bone fragility?finding for bone fragility?

Used to determine 10 year fracture risk in community dwelling adults –then NOGG suggests guidance on treatment

FRAX in a falls clinic FRAX in a falls clinic

population?population?

�� NOGG advice (DEXA or treat) followed:NOGG advice (DEXA or treat) followed:

–– 46% (n=6) of those with OP at either spine and/or 46% (n=6) of those with OP at either spine and/or hip would hip would not be treated or advised a DEXAnot be treated or advised a DEXA

–– Of those where DEXA was advised, 72% did not have Of those where DEXA was advised, 72% did not have osteoporosis (n=13)osteoporosis (n=13)

–– Treatment advised in 2 patients both of whom had Treatment advised in 2 patients both of whom had osteoporosis on subsequent DEXAosteoporosis on subsequent DEXA

McCarthy C, Skelton DA,McCarthy C, Skelton DA, GallacherGallacher S, Mitchell LE S, Mitchell LE Abstract presented at Abstract presented at 1010thth National Conference on Postural Stability and Falls, Blackpool,National Conference on Postural Stability and Falls, Blackpool, 07/09/0907/09/09

Tools to target your Tools to target your

intervention intervention egeg. .

Balance and Strength Exercise (group or home) /

Walking aids

Lower Urinary Tract Symptoms Continence training /

Surgical / Medical

Fear of Falling CBT / Counselling /

Exercise / Hip Protectors

Vestibular Function Vestibular Rehabilitation Exercise

Surgery

Postural Hypotension Pre-transfer exercise / Behavioural

Surgical stockings / Medical

Vision Surgery / Glasses / OT

Foot health Chiropody / Insoles / Surgery

……

Weaknesses in EvidenceWeaknesses in Evidence

�� Falls definitionFalls definition

�� Consensus on outcome measuresConsensus on outcome measures

�� Consensus on reporting intervention detailConsensus on reporting intervention detail

�� ? Fall per unit of activity ? Fall per unit of activity –– exposure to riskexposure to risk

�� Different models of delivery?Different models of delivery?

�� Cost effectiveness and utility reporting rareCost effectiveness and utility reporting rare

�� Poor fidelity at implementation (Poor fidelity at implementation (egeg. 12 week exercise . 12 week exercise

programme programme ��))Lamb 2005, 2008,

Skelton & Todd 2004

When do we become “fallers” When do we become “fallers”

instead of “trippers”?instead of “trippers”?

Fracture site changes

with age, wrist

fractures more common

in younger people, hip

fractures more common

in older people

Reaction times and gait

speed slows, balance

deteriorates, strength

reduces…..

Functional Ability in older ageFunctional Ability in older age

�� Strength (1 % to 2% p.a.)Strength (1 % to 2% p.a.)

�� Power (3% to 4% p.a.)Power (3% to 4% p.a.)

�� Bone density (Women:1% to 3%, Bone density (Women:1% to 3%,

Men:0.4% p.a.)Men:0.4% p.a.)

�� Balance, Coordination and Balance, Coordination and

reactionreaction

�� Transfer skillsTransfer skills

�� Maintenance of temperature Maintenance of temperature

controlcontrol

�� Vision, hearing and other balance Vision, hearing and other balance

sensory inputssensory inputs

EVEN HEALTHY OLDER PEOPLE LOSE...EVEN HEALTHY OLDER PEOPLE LOSE...

Sedentary Sedentary behaviourbehaviour increases the loss of performance...increases the loss of performance...

Exercise to Prevent FallsExercise to Prevent Falls

Exercise Exercise couldcould help fallers in a number of ways:help fallers in a number of ways:

�� Reducing Falls (or injurious falls) Reducing Falls (or injurious falls)

�� Reducing known Risk Factors for Reducing known Risk Factors for

Falls Falls

�� Reducing Fractures ? (or changing Reducing Fractures ? (or changing

the site of fracture)the site of fracture)

�� Increasing Quality of Life & Social Increasing Quality of Life & Social

ActivitiesActivities

�� Improving bone densityImproving bone density

�� Reducing FearReducing Fear

�� Reducing Long LiesReducing Long Lies

�� Reducing InstitutionalisationReducing Institutionalisation

Sherrington 2008; Skelton & Dinan 1999; NICE 2004

Wide range of abilities and Wide range of abilities and

needsneeds

Not all physical activity is Not all physical activity is

safe for fallers!safe for fallers!

�� RCT Increasing physical activity in RCT Increasing physical activity in

people with previous upper arm people with previous upper arm

fracturefracture

�� Intervention: Brisk walkingIntervention: Brisk walking

�� Control: exercise of upper armControl: exercise of upper arm

�� Falls risk Falls risk ↑↑ (Brisk walking > control)(Brisk walking > control)

�� Fracture risk Fracture risk ↑↑ (Brisk walking > (Brisk walking >

control)control)

�� Beware unsafe pavements!Beware unsafe pavements!

Ebrahim et al. (1997)

NICE 2004 do not recommend brisk walking!

Overall (I-squared = 61.5%, p = 0.000)

Ebrahim, 1997

Barnett, 2003

Woo, Tai Chi, 2007

Luukinen, 2007

Campbell, 2005

Schoenfelder, 2000

Sihvonen, 2004

Lord, 2003

Buchner, 1997

Author,

Nowalk, Tai Chi, 2001

Mulrow, 1994

Day, 2002

Reinsch, 1992

Skelton, 2005

Wolf, Balance, 1996

Woo, Resistance, 2007

Wolf, Tai Chi, 1996

year

McMurdo, 1997

Korpelainen, 2006

Morgan, 2004

Campbell, 1999

Hauer, 2001

Voukelatos, 2007

Faber, Functional walking, 2006

Li, 2005

Lord, 1995

Schnelle, 2003

Steinberg, 2000

Faber, Tai Chi, 2006

Liu-Ambrose, Resistance, 2004

Lin, 2007

Bunout, 2005

Liu-Ambrose, Agility, 2004

Resnick, 2002

Latham, 2003

Madureira, 2007

Carter, 2002

Green, 2002

Toulotte, 2003

Wolf, 2003

Cerny, 1998

Sakamoto, 2006Rubenstein, 2000

Means, 2005

Protas, 2006

Suzuki, 2004

Campbell, 1997

Nowalk, Resist./Endurance, 2001

Robertson, 2001

0.83 (0.75, 0.91)

1.29 (0.90, 1.83)

0.60 (0.36, 0.99)

0.49 (0.24, 0.99)

0.93 (0.80, 1.09)

1.15 (0.82, 1.61)

3.06 (1.61, 5.82)

0.38 (0.17, 0.87)

0.78 (0.62, 0.99)

0.61 (0.40, 0.94)

Effect

0.77 (0.46, 1.28)

1.26 (0.90, 1.76)

0.82 (0.70, 0.97)

1.24 (0.77, 1.98)

0.69 (0.50, 0.96)

0.98 (0.71, 1.34)

0.78 (0.41, 1.48)

0.51 (0.36, 0.72)

size (95% CI)

0.53 (0.28, 0.98)

0.79 (0.59, 1.05)

1.05 (0.66, 1.68)

0.87 (0.36, 2.10)

0.75 (0.46, 1.25)

0.67 (0.46, 0.97)

1.32 (1.03, 1.69)

0.45 (0.33, 0.62)

0.85 (0.57, 1.27)

0.62 (0.38, 1.00)

0.90 (0.79, 1.03)

0.96 (0.76, 1.22)

1.80 (0.67, 4.85)

0.67 (0.32, 1.41)

1.22 (0.70, 2.14)

1.03 (0.36, 2.98)

0.71 (0.04, 11.58)

1.08 (0.87, 1.35)

0.48 (0.25, 0.93)

0.88 (0.32, 2.41)

1.34 (0.87, 2.07)

0.08 (0.00, 1.37)

0.75 (0.52, 1.08)

0.87 (0.17, 4.29)

0.82 (0.64, 1.04)0.90 (0.42, 1.91)

0.41 (0.21, 0.77)

0.62 (0.26, 1.48)

0.35 (0.14, 0.90)

0.68 (0.52, 0.89)

0.96 (0.63, 1.46)

0.54 (0.32, 0.91)

100.00

2.64

1.88

1.22

3.85

2.74

1.40

0.98

3.38

2.21

%

1.88

2.75

3.80

2.04

2.81

2.86

1.41

2.67

Weight

1.48

3.05

2.04

0.88

1.89

2.56

3.31

2.87

2.38

1.98

3.97

3.34

0.72

1.13

1.67

0.65

0.11

3.46

1.34

0.70

2.21

0.10

2.58

0.31

3.341.11

1.40

0.88

0.80

3.13

2.27

1.84

0.83 (0.75, 0.91)

1.29 (0.90, 1.83)

0.60 (0.36, 0.99)

0.49 (0.24, 0.99)

0.93 (0.80, 1.09)

1.15 (0.82, 1.61)

3.06 (1.61, 5.82)

0.38 (0.17, 0.87)

0.78 (0.62, 0.99)

0.61 (0.40, 0.94)

Effect

0.77 (0.46, 1.28)

1.26 (0.90, 1.76)

0.82 (0.70, 0.97)

1.24 (0.77, 1.98)

0.69 (0.50, 0.96)

0.98 (0.71, 1.34)

0.78 (0.41, 1.48)

0.51 (0.36, 0.72)

size (95% CI)

0.53 (0.28, 0.98)

0.79 (0.59, 1.05)

1.05 (0.66, 1.68)

0.87 (0.36, 2.10)

0.75 (0.46, 1.25)

0.67 (0.46, 0.97)

1.32 (1.03, 1.69)

0.45 (0.33, 0.62)

0.85 (0.57, 1.27)

0.62 (0.38, 1.00)

0.90 (0.79, 1.03)

0.96 (0.76, 1.22)

1.80 (0.67, 4.85)

0.67 (0.32, 1.41)

1.22 (0.70, 2.14)

1.03 (0.36, 2.98)

0.71 (0.04, 11.58)

1.08 (0.87, 1.35)

0.48 (0.25, 0.93)

0.88 (0.32, 2.41)

1.34 (0.87, 2.07)

0.08 (0.00, 1.37)

0.75 (0.52, 1.08)

0.87 (0.17, 4.29)

0.82 (0.64, 1.04)0.90 (0.42, 1.91)

0.41 (0.21, 0.77)

0.62 (0.26, 1.48)

0.35 (0.14, 0.90)

0.68 (0.52, 0.89)

0.96 (0.63, 1.46)

0.54 (0.32, 0.91)

100.00

2.64

1.88

1.22

3.85

2.74

1.40

0.98

3.38

2.21

%

1.88

2.75

3.80

2.04

2.81

2.86

1.41

2.67

Weight

1.48

3.05

2.04

0.88

1.89

2.56

3.31

2.87

2.38

1.98

3.97

3.34

0.72

1.13

1.67

0.65

0.11

3.46

1.34

0.70

2.21

0.10

2.58

0.31

3.341.11

1.40

0.88

0.80

3.13

2.27

1.84

Favours exercise Favours control

1.25 .5 1 2 4

RR = 0.8395%CI 0.75-0.91

P<0.001

17% reduction in falls

ResultsResults

I² = 62% moderate heterogeneity

Sherrington et al.,

JAGS 2008

Highly challenging Balance TrainingHighly challenging Balance Training

�� Exercise in standing involving:Exercise in standing involving:

–– movement of the centre of massmovement of the centre of mass

–– narrowing of the base of supportnarrowing of the base of support

–– minimisingminimising upper limb supportupper limb support

24%

RR 0.76(95%CI =0.62 to 0.93)

Sherrington et al., JAGS 2008

New Zealand New Zealand RCTsRCTs -- OTAGOOTAGO

Individually tailored programme: Campbell, BMJ 1997

-80+ years, n=233, home-based, physiotherapist -1 year, falls � 32%, injuries � 39%

Nurse delivered programme at home: Robertson, BMJ 2001

-75+ years, n= 240, home-based, district nurse

-1 year, falls � 46%, � serious injuries and hospital costs

Nurse programme at GP centres: Robertson, BMJ 2001

-80+ years, n=450, home-based, general practice nurse

-1 year, falls � 30%, injuries � 28%

Visually Impaired Older People: Campbell, BMJ 2005

-1 year, home-based. Only effective with full compliance, falls� 28%

6 month programme: Liu-Ambrose, JAGS 2008

-70+ years, home-based, cognitive function improvements after 6 months

and after 1 year falls� 47%

FaME Group ExerciseFaME Group Exercise

Managing frequent fallersManaging frequent fallers

� Women aged 65+ with a history of 3 or more falls in previous

year

� 9 months community based intervention

� Group exercise – individually tailored, trained exercise instructors

(PSIs)

� Falls risk decreased by half – RR 0.46

� Significantly less people in exercise group had died, entered a

nursing home or were in hospital after 3 years

Skelton et al. J.Aging Phys Act 2004; 12 (3); 457-458 & Age and Ageing, 2005: 34: 636-639

FaME

FUNCTIONAL ABILITY & BONE

�� Fun and social activityFun and social activity

�� Confidence in balance Confidence in balance

�� Reduced anxiety and fearReduced anxiety and fear

�� ‘tripping’ not ‘falling’‘tripping’ not ‘falling’

�� Playing with grandchildrenPlaying with grandchildren

�� ‘Caring’ skills‘Caring’ skills

Functional Reach 20%

Up and go 20%

Floor rise 50%

Balance 60%

Avoiding long lies?Avoiding long lies?

Long lies with or without Long lies with or without

injuryinjury

�� Long lies (> 1Long lies (> 1--2 2 hours) lead to an hours) lead to an increased risk of:increased risk of:

–– dehydrationdehydration

–– hypothermiahypothermia

–– pneumoniapneumonia

–– pressure sorespressure sores

–– kidney failurekidney failure

–– depressiondepression

–– post fall post fall syndromesyndrome

–– deathdeath((TinettiTinetti 1993, 1994)1993, 1994)

High DoseHigh Dose

�� 50+ hours 50+ hours

–– At least 2 hours a week of exercise At least 2 hours a week of exercise

for at least 6 monthsfor at least 6 months

–– Home or groupHome or group--based or a based or a

combination of bothcombination of both

20%

RR 0.80(95%CI =0.65 to 0.99)

Sherrington et al., JAGS 2008

No reduction:

RR 0.95 (0.78 to 1.16)

No reduction:

RR 0.96 (0.80 to 1.16)

No reduction:

RR 0.91 (0.79 to 1.05)

Increased risk: RR 1.20 (1.00 to 1.44)

High balanceLow doseWalking

Low balance

Low doseWalking

Low balanceLow dose

No walking

Low balanceHigh doseWalking

Reducing barriersReducing barriers

��Walk from Home Walk from Home

��Keighley Peer MentorsKeighley Peer Mentors

Mary Moffat Mary Moffat -- 9393

–– Referred by physio after a fallReferred by physio after a fall

–– Loss of confidence and fear of Loss of confidence and fear of

fallingfalling

–– Isolated and lonely and Isolated and lonely and

dependent upon others to get dependent upon others to get

outout

Tai Chi Tai Chi –– secondary secondary prevention in younger years ?prevention in younger years ?

-- Community Dwelling older people Community Dwelling older people -- mild deficits of strength/balancemild deficits of strength/balance-- 2x/week for 15 weeks2x/week for 15 weeks–– Cut trip and fall rate byCut trip and fall rate by halfhalf

- Frail older adults aged 70-97- 2 x/week for 48 weeks- no significant reduction in risk of falls

Wolf et al. J Am Wolf et al. J Am Wolf et al. J Am Wolf et al. J Am GeriatGeriatGeriatGeriat Soc 2003; 55: 1693Soc 2003; 55: 1693Soc 2003; 55: 1693Soc 2003; 55: 1693----1701170117011701

Wolf et al. Wolf et al. Wolf et al. Wolf et al. Wolf et al. Wolf et al. Wolf et al. Wolf et al. (1996)(1996)(1996)(1996)(1996)(1996)(1996)(1996)

- Community Dwelling older people aged 70+ Community Dwelling older people aged 70+ Community Dwelling older people aged 70+ Community Dwelling older people aged 70+ - 3 x/week for 24 weeks3 x/week for 24 weeks3 x/week for 24 weeks3 x/week for 24 weeks- IncreasedIncreasedIncreasedIncreased Falls SelfFalls SelfFalls SelfFalls Self----EfficacyEfficacyEfficacyEfficacy (ABC) and (ABC) and (ABC) and (ABC) and DecreasedDecreasedDecreasedDecreased Fear of FallingFear of FallingFear of FallingFear of Falling (SAFFE) (SAFFE) (SAFFE) (SAFFE)

Li et al. J Li et al. J Li et al. J Li et al. J Li et al. J Li et al. J Li et al. J Li et al. J GerontolGerontolGerontolGerontolGerontolGerontolGerontolGerontol B B B B B B B B PsycholPsycholPsycholPsycholPsycholPsycholPsycholPsychol SciSciSciSciSciSciSciSci Soc Soc Soc Soc Soc Soc Soc Soc SciSciSciSciSciSciSciSci 2005; 60:P342005; 60:P342005; 60:P342005; 60:P342005; 60:P342005; 60:P342005; 60:P342005; 60:P34--------4040404040404040

Wider Benefits of ExerciseWider Benefits of Exercise

�� PsychologicalPsychological

–– Anxiety, depression, sleep, fear of fallingAnxiety, depression, sleep, fear of falling

�� PhysiologicalPhysiological

–– Maintain bone density, ability to perform everyday Maintain bone density, ability to perform everyday

activities, reduce breathlessness, reduce stiffness and activities, reduce breathlessness, reduce stiffness and

chance of injurychance of injury

�� PsychosocialPsychosocial

–– Isolation, social contacts, peer support, playing with Isolation, social contacts, peer support, playing with

grandchildren, using the bathgrandchildren, using the bath

�� Even the very frailEven the very frail

–– DVT, constipation, transfer skills DVT, constipation, transfer skills

Too frail to benefit? Too frail to benefit?

Dose response curveDose response curve

�� The lower the baseline level The lower the baseline level

of physical activity, the of physical activity, the

greater the health benefit greater the health benefit

associated with an increase associated with an increase

in physical activity. Exercise in physical activity. Exercise

can be adapted for any can be adapted for any

medical conditionmedical condition

(Haskell 1994)(Haskell 1994)

Patients in HospitalPatients in Hospital

�� 3 rehabilitation and care of the elderly wards, 3 rehabilitation and care of the elderly wards,

626 patients, 80 yrs626 patients, 80 yrs

�� Falls risk card, Falls risk card, exercise programmeexercise programme, education and hip , education and hip

protectorsprotectors

�� Intervention group had less falls, most significant >45 daysIntervention group had less falls, most significant >45 days

Haines et al. Brit Med J 2004; 328:676Haines et al. Brit Med J 2004; 328:676--680680

�� Tai Chi + reaching + stepping + transferring chair to chairTai Chi + reaching + stepping + transferring chair to chair

�� 1 physiotherapist to max 4 patients, 3 x p/w, 45 1 physiotherapist to max 4 patients, 3 x p/w, 45 minsmins. .

�� 173 patients, 82 yrs, sub173 patients, 82 yrs, sub--acute wardacute ward

�� Halved the number of falls (participant days in hospital)Halved the number of falls (participant days in hospital)

Haines et al. Haines et al. ClinClin Rehab 2007; 21:742Rehab 2007; 21:742--753753

Nursing Home ResidentsNursing Home Residents

Individually tailored GROUP exercise as part of a multifactorialintervention (staff training, environment modification, drug review etc)

Reduces falls - Becker et al. J Am Becker et al. J Am GeriatGeriat Soc 2003; 51:306Soc 2003; 51:306--313313Improves mobility - Jensen et al. Aging Jensen et al. Aging ClinClin Exp Res 2004; 16: 283Exp Res 2004; 16: 283--292292Reduces falls risk factors Reduces falls risk factors -- Dyer et al. Age Ageing 2004; 33:596Dyer et al. Age Ageing 2004; 33:596--602602

Components of multifaceted Components of multifaceted

interventions interventions in Hospitals and in Care Homesin Hospitals and in Care Homes

�� Risk stratification or labellingRisk stratification or labelling

�� Risk factor assessment (and tailored intervention)Risk factor assessment (and tailored intervention)

�� Medical review (inc. cardiovascular risk)Medical review (inc. cardiovascular risk)

�� Nursing review/care planNursing review/care plan

�� Education (staff/patients/carers)Education (staff/patients/carers)

�� Exercise/Additional PhysiotherapyExercise/Additional Physiotherapy

�� Equipment/environmental change/A.T.Equipment/environmental change/A.T.

�� Medication review/adjustmentMedication review/adjustment

�� Restraint reduction/removalRestraint reduction/removal

�� Hip protectorsHip protectors

D Oliver, et al. Systematic Review, 2007D Oliver, et al. Systematic Review, 2007

Addressing balance in all Addressing balance in all

settingssettings

4 weeks 3 x p/w (5-20mins)

Improvements in

• Ankle Strength

• Lower limb Power

• Balance (TUSS and sway)

• Balance confidence

• Functional Reach

• Timed Up & Go

Skelton, Simey and Dinan (2001) - Data presented at the 2nd National Conference on Falls and Postural Stability, Royal College Physicians, London

Gaps in evidence….Gaps in evidence….

� Patient concordance and presentation of information

� Fear of falling and activity avoidance

� Ethnicity and Socioeconomic deprivation

� Reducing falls and injury in stroke, parkinson’s, dementia….

� Different professionals or models of delivery

� Different models of exercise (home vs group, games for health) and

necessary duration / intensity / frequency and type

� Different exercise in different population groups?

� Value of falls prevention on other outcomes (quality of life, depression,

other syndromes of ageing)

� Getting people to USE fall alarms

� Tele-health and technology opportunities

Perceptions of falls Perceptions of falls

prevention messagesprevention messages

It’s good advice It’s good advice -- for ‘them’ for ‘them’ -- only seen as relevant to only seen as relevant to ‘elderly’‘elderly’

Because we’re that much fitter Because we’re that much fitter ---- we don’t really take too much we don’t really take too much notice of it, only for other people, for other disabled or eldernotice of it, only for other people, for other disabled or elderly ly people that we have to watch when we’re people that we have to watch when we’re –– we always watch we always watch older people anyway. older people anyway.

(man aged 79 in sheltered accommodation)(man aged 79 in sheltered accommodation)

Rejected by fit, younger people, seen as humiliatingRejected by fit, younger people, seen as humiliating

I wouldn’t go for that [advice] because it didn’t apply to me inI wouldn’t go for that [advice] because it didn’t apply to me in any any shape or form. Is there a bit of pride, is there a bit of “Wellshape or form. Is there a bit of pride, is there a bit of “Well, , you know, I’m not there yet”you know, I’m not there yet”

(fit woman in 60s)(fit woman in 60s)

Yardley L, Beyer N, Hauer K, McKee K, Ballinger C, Todd C. Qual. Saf.

Health Care. 2007

Ballinger C, Clemson L. B J Occ Ther 2006

Recommendations for Promoting the Recommendations for Promoting the

Engagement of Older People in Falls Engagement of Older People in Falls

Prevention ExercisePrevention Exercise Yardley L, 2007Yardley L, 2007

1.1. Raise awarenessRaise awareness in the general population that undertaking specific in the general population that undertaking specific physical activities has the potential to improve balance and prephysical activities has the potential to improve balance and prevent vent fallsfalls

2.2. When offering or publicising interventions, When offering or publicising interventions, promote benefits which fit promote benefits which fit with a positive selfwith a positive self--identityidentity

3.3. Utilise a variety of forms of Utilise a variety of forms of social encouragementsocial encouragement to engage older to engage older people in interventionspeople in interventions

4.4. Ensure the intervention is Ensure the intervention is designed to meet the needs, preferences designed to meet the needs, preferences and capabilitiesand capabilities of the individual of the individual

5.5. Encourage selfEncourage self--managementmanagement rather than dependence on rather than dependence on professionals by giving older people an active role professionals by giving older people an active role

6.6. Draw on Draw on validated methodsvalidated methods for promoting and assessing the for promoting and assessing the processes that maintain adherence, especially in the longerprocesses that maintain adherence, especially in the longer--termterm

Concordance with interventions ?

•• Whole Body Vibration Whole Body Vibration

•• 66 mthsmths, 3 x p/w, 3 x p/w

•• postpost--menopausal women menopausal women •• Strength 15%, Balance 20%,Strength 15%, Balance 20%,•• Hip BMD 1%Hip BMD 1%

VerschuerenVerschueren SM et al. 2004SM et al. 2004

Wii-fit (Nintendo) ?

Practical ExamplesPractical Examples

�� Review the local falls pathwayReview the local falls pathway

–– community acute providerscommunity acute providers

�� Agree who does what? Who attends Agree who does what? Who attends

specialist clinics?specialist clinics?

�� Build falls prevention into Build falls prevention into

mainstream services and mainstream services and

intermediate careintermediate care

�� Commission effective exercise Commission effective exercise

programmesprogrammes

�� Consider working with leisure Consider working with leisure

services / voluntary sectorservices / voluntary sector

GGC Community Falls GGC Community Falls

Prevention ProgrammePrevention Programme

�� Specialist falls service which aims to prevent further falls by Specialist falls service which aims to prevent further falls by

providing a comprehensive falls screening, health education, providing a comprehensive falls screening, health education,

exercise, rehabilitation and onward referralexercise, rehabilitation and onward referral

�� The service is available to individuals who are over 65, live atThe service is available to individuals who are over 65, live at

home and have had a fall in the last yearhome and have had a fall in the last year

�� 177 referrals a month Jan177 referrals a month Jan--Jun 2008, up to 221 referrals a Jun 2008, up to 221 referrals a

month Junmonth Jun--Dec 2008, 250 a month nowDec 2008, 250 a month now

�� Telephone triage completed within 24 hours of receiving Telephone triage completed within 24 hours of receiving

referralreferral

�� Home screening completed within 5 working days of triageHome screening completed within 5 working days of triage

Falls and Bone Health in Falls and Bone Health in

GGCGGC

�� In 2006 the GG&C falls and bone health strategy was launched In 2006 the GG&C falls and bone health strategy was launched

although work towards aspects of this strategy has been ongoing although work towards aspects of this strategy has been ongoing

since 1998. since 1998.

�� Over a 10 yr period in GGC, there has been a Over a 10 yr period in GGC, there has been a 32% reduction32% reduction in in

admissions due to admissions due to falls at homefalls at home and a and a 3.2% reduction 3.2% reduction in admissions in admissions

due to due to hip fractureship fractures. .

Number of admissions - following a fall at home

0

500

1000

1500

2000

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Year

Nu

mb

er

of

ad

mis

sio

ns

du

e

to f

all

s a

t h

om

e

The role of the OTSW includes:

�Completion of a Falls Risk Screening and Data

Collection Tool.

�Raising awareness of falls, consequences and

prevention.

�Promotion of functional independence and safety.

�Provision of advice and support to both patients and

carers.

�Guided by the Screening Tool, formulates a person

centred Action Plan and seeks patient consent.

�Action Plan makes recommendation for referrals on to

specialist services and also advice for the patient/carer.

The CFPP patient pathway sees an average of 250 clients/month

20%

20%

17%

18%

9%

4%

4%

3%2%1%1%1%0%

Physiotherapy including exercise

sessions

Falls Clinic

Occupational Therapy

Pharmacy

Pendant Alarm

Podiatry

COPT

Audiology

Continence

Dietician

SWOT

Sensory Impairment

DADS

Glasgow exampleGlasgow example

Active Ageing Weeks…Active Ageing Weeks…

- To provide a national and local profile to celebrate and promote

the concept of Active Ageing.

- To provide support for local Active Ageing programmes.

- To stimulate debate and policy on Active Ageing.

- To provide a national and local programme of Active Ageing

events and promotions.

- To ensure that older people are included in activities designed to

leave a health and physical activity legacy.

WANT TO GET INVOLVED: email bob.laventure@ntlworld.com

OlympageOlympage Games Games –– Sheffield Sheffield

20092009

�� 20 Teams competing20 Teams competing

�� 6 events6 events

�� Teams of 6 Teams of 6 –– 8 8

(participants + carers)(participants + carers)

�� Unruly supporters in team Unruly supporters in team

kit !kit !

�� Medals, certificates and Medals, certificates and

prizesprizes

�� Lots of cheating as well !Lots of cheating as well !

Other ideas for AA WeeksOther ideas for AA Weeks

�� Walking your local area, be Walking your local area, be

a guide or share your a guide or share your

knowledgeknowledge

�� Open days to gyms, Open days to gyms,

community centres with community centres with

sessions etc…..sessions etc…..

�� Activity breaks in LibrariesActivity breaks in Libraries

Glasgow SECC Aug 13Glasgow SECC Aug 13--1717thth 20122012

www.wcaa2012.comwww.wcaa2012.com

dawn.dawn.skeltonskelton@@gcalgcal.ac..ac.ukuk