Maintaining Mobility into Old Age and Preventing Falls · President, British Geriatrics Society...
Transcript of Maintaining Mobility into Old Age and Preventing Falls · President, British Geriatrics Society...
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Professor T.Masud
President, British Geriatrics Society
Nottingham University Hospitals NHS Trust University of Nottingham
University of Southern Denmark
Maintaining Mobility into Old Age and Preventing Falls
Twitter:@TashMasud
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Disclosures
I have no conflict of interest or disclosure in relation to this
presentation
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Statistical summaries of risk factors for fallsFrom cohort studies- Perell 2001
n Muscle weakness 4.4 (1.5-10.3)
n Falls history 3.0 (1.7-7.0)
n Gait deficit 2.9 (1.3-5.6)
n Balance deficit 2.9 (1.6-5.4)
n Use of assistive devices 2.6 (1.2-4.6)
n Visual deficit 2.5 (1.6-3.5)
n Arthritis 2.4 (1.9-2.7)
n Impaired ADLs 2.3 (1.5-3.1)
n Depression 2.2 (1.7-2.5)
n Cognitive impairment 1.8 (1.0-2.3)
n Age > 80 1.7 (1.1-2.5)
RISK FACTOR Mean RR/OR Range
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Simple Model for Balance
CNS
Vision
Vestibular
Proprioception
Tactile sensation
Musculo-skeletal
Balance
Activity & environmental hazards
FALLS
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INTRINSIC FACTORS EXTRINSIC FACTORSFALLS
Falls are Often Multifactorial
Co-morbidity & Frailty increase the risk of falls
CAUSES OF FALLS
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Intrinsic (personal) Factors Causing Falls
& Delirium
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Extrinsic (Environmental) Factors
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Fall Prevention : Intervention Strategies
Population Community
Institutional
InterventionsMultiple
Single (unifactorial)
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n Occupational Therapyü Functionü Physical handicap
n Medical assessmentü General medicalü Postural hypotensionü Visual acuityü Balanceü Cognition and affectü Corotid sinus synd.ü Psychological handicapü Environmental hazards
n Referral / intervention– Day hospital– GP– O/P– Optician– Social services– Supply minor equipment
Multidisciplinary assessment of fallers attending A/E (n=397): - 65+ years, medical assessment at day hospital + OT at home
PROFET – Lancet 1999- Close et al
1 year, falls â 61%, recurrent falls â 67%Failed in Holland-Hendricks 2008
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• 70+ High Risk Community Dwellers, n= 1314
• Rate of Falls IRR 0.72 (95%CI 0.61-0.86) NNT= 3
• Fall related Injuries IRR 0.74 (95%CI 0.61-0.89) NNT= 5
Injury 2014
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Unifactorial Interventions
n Medication Review
n Environmental Modification
n Improving Vision
n Vitamin D
n Exercise
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21 3 4 5 6 7 8 92 100
Fallers OR (95%CI)
●
●
Antidepressants Overall
Tricyclics
SSRIS
Antidepresssants and Falls- the SOMA study
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Masud T, Frost M, Ryg J, Matzen L, Ibsen M, Abrahamsen B, Brixen K. Central nervous system medications and falls risk in men aged 60-75 years: the Study on Male Osteoporosis and Aging (SOMA).Age Ageing 2013; 42: 121-4.
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21 3 4 5 6 7 8 92 100
Fallers OR (95%CI)
●
●
●
Opiates Overall
Opiates ≥ 67 yrs
Opiates < 67 yrs
Opiates and Falls - The SOMA study
Masud et al 2013
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Initiation of Hypertensives
Current prescribing of thiazides is associated with an increased risk of falling and that this is strongest in the 3 weeks following the first prescription(Gribbin 2010, UK, case controlled, GPRD, n= 9682)
The risk of falls on initiation of antihypertensivedrugs in the elderly
First 14 Days
(Butt 2012, population based Canadian case controlled)
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EUGMS Task & Finish Group on Fall-risk increasing drugs
Seppala L, van der Velde N, Masud T et al
Drugs Aging 2019 36: 299-307
Contact [email protected]
Deprescribing Guidelines
Educational Materials
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Unifactorial Interventions -RCTs
n Medication Review
n Environmental Modification
n Improving Vision
n Vitamin D
n Exercise
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Environmental Modification
n Cochrane Review* 2012 (6 studies) -Home safety intervention reduced falls rate by 19%-Subgroup analysis on those at high risk showed fall rate reduction by 44%
n In the visually impairedHome safety programme reduced fall rates by 41%(Campbell 2005)
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Unifactorial Interventions -RCTs
n Medication Review
n Environmental Modification
n Improving Vision
n Vitamin D
n Exercise
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Vision and falls
Visual acuity Contrast sensitivity Depth perception
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Nottingham expedited cataract study
days in study
390360
330300
270240
210180
150120
9060
300
Cum
ulat
ive
risk
of s
econ
d fa
ll.5
.4
.3
.2
.1
0.0
GROUP
routine
expedited
Hazard ratio = 0.60 (95% CI 0.36-0.98)
Harwood, RH, Foss AJ, Osborn F, Gregson RM, Zaman A, Masud T. BJ Opthalmol 2005
Fall rates ↓ 34% (IRR 0.66; CI 0.45-0.96)
Fractures ↓ 77% (IRR 0.33; CI 0.1-1.0, p 0.04)
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Unifactorial Interventions -RCTs
n Medication Review
n Environmental Modification
n Improving Vision
n Vitamin D
n Exercise
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Forest Plot Meta-analysis: Effect of vitamin D on fallsBischoff-Ferrari HA et al.; JAMA 2004
pooled corrected OR = 0.78; 95% CI [0.64, 0.92]
800 IU
800 IU
400 IU
Cochrane review on falls 2009 (13 studies)
• No significant reduction in fall rates or risk
• Subgroup analysis showed significant reduction in fall rate of 43% if
participants had low Vitamin D levels at recruitment
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Recent Vitamin D Data
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Unifactorial Interventions -RCTs
n Medication Review
n Environmental Modification
n Improving Vision
n Vitamin D
n ExerciseBest Evidence
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Campbell et al, BMJ, 1997
Robertson et al, BMJ, 2001, 2005
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17 trials, n = 4305
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Falls in Dementia
• 60-80% if people with dementia fall each year
• Mean 3 falls/year
• Two-fold increased risk in Mild Cognitive Impairment
• 60% of hospital admissions for people with dementia due to falls
• 40% of hip fractures in someone with dementia
• People with dementia who fall 5 x more likely to enter care home
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• Executive dysfunction associated with increased falls risk and reduced gait speed
• Future research should focus on executive dysfunction as a training target for falls prevention
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• Initiation (reasoning, planning, judgement)
• Maintenance (attention)
• Set shifting (vigilance, change in light of new information)Suchy 2009; Lezak 2004; Montero Odasso 2012
Executive function and dual-task deficit
”Stops Walking and Talking” predicts falls
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Effect of music-based multitask training on gait, balance, and fall risk in elderly people: a randomized controlled trial.Trombetti A1, Hars M, Herrmann FR, Kressig RW, Ferrari S, Rizzoli R.Arch Intern Med 2011
Jaques-Dalcroze eurhythmics
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Dual-task cost (DTC): mean change for A) counting, B) serial 7s , C) naming animals conditions
Can Cognitive Enhancers improve Gait and Reduce Falls? Montero-Odasso et al. Eur J Neurol. 2019 (n= 60)
MCI, n= 60
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Prevention of Delirium Trial
The mean fall rate before the intervention was 4.9/month (95%CI=4.5–5.7) which fell to 2.5/month (95%CI=1.5-3.4),
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Component of the NHS 10 year long term plan (UK Gov 2019)
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Sarcopenia (ICD 10)
• Loss of muscle mass and function (strength or performace)
• Prevalence increases with age
• Associated with disability, morbidity, frailty and mortality
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Age Ageing 2019Cruz-Jentoft et al
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Once Sarcopenia Identified
Resistance Exercise
Nutrition?
Therapeutic Advances ?
Protein
Vit D
Myostatin inhibitors
ACEIsSARMS
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Exercises Recommended for Older Adults
Montero-Fernandez & Serra-Rexach 2013- Eur J Phys Rehabil Med
EXERCISE
Aerobic-brisk walk, -jog,-swim-cycle-dance
Progressive Resistance-weights -resistance bands-stairs-pull-ups-push-ups-heavy loads, -heavy gardening
Flexibility-yoga,-Tai Chi-pilates
Balance TrainingStatic- stand on one leg
Dynamic- (semi-) tandem- walk backwards- Tai Chi
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41Image © Public Health England, Department of Health UK
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42
Image (c) Public Health England, Department of Health, UK
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Nutrition & Optimal Protein Intakes
(Franzke et al, Nutrients 2018)
• Old age + Inactivity → Anabolic Resistance (Impaired MPS )
• MPS rates higher after exercise (↑ Anabolic Sensitivity, timing may be important)
• WHO recommendations 2007 for all age groups: 0.8 g/kg/day
• ESPEN : Healthy adults ≥65 yrs: 1.0-1.2 g/kg/dayChronically ill or malnourished: 1.2- 1.5 g/kg/day
• 25-30 g per each meal
• Role of Essential Amino Acids + related compounds eg leucine, HMB
Protein / AA intake
Muscle contraction(Exercise – Resistance + Endurance)
Muscle Protein synthesis (MPS)
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Sarcopenia Frailty
Disability
Reduced Physical Function
Reduced quality of Life
DeathProtein/Amino Acids Exercise
? treatsprevents
Systematic Review: Delaying and Reversing Frailty in Primary care(Travers et al, B J Gen Pract 2019; 46 studies)
”A combination of muscle strength training and protein supplementation was the most effective intervention to delay or reverse frailty and the easiest to implement in primary care”
Falls
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“The conservation of health by exercise and various diets”Averroes (Ibn Rushd) 1126-1198 AD (Cordoba) دشر نبا