Community Falls Prevention Guidelines - Preventing Falls ...
Preventing falls: Evidence from ProFaNE
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Transcript of Preventing falls: Evidence from ProFaNE
School of Nursing, Midwifery and Social Work
Preventing falls: Evidence from ProFaNE
Chris ToddProfessor of Primary Care & Community Health
Director of Research
Director, ProFaNE
Plan• Epidemiology of falls and fractures• What is ProFaNE?• What works to reduce falls
– A review of reviews
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EVOS/EPOS Group
Falls explain between-center differences in the incidence of limb fracture across Europe. JBMR 2002
Low BMD is less predictive than risk of falling for future limb fractures in women across Europe. Bone 2005
Osteoporosis, falls and fractures
• 30-40% community dwelling 65+ fall in a year– 40-60% no injury– 30-50% minor injury– 5-6% major injury (excluding fracture)– 5% fractures– 1% hip fractures
• Falls most serious frequent home accident• 50% hospital admissions for accidental injury
due to fall• History of falls a major predictor future fall
Masud, Morris Age & Ageing 2001; 30-S4 3-7Rubenstein. Age & Ageing; 2006; 35-S2; ii37-41
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50-59 60-69 70-79 80-89 90+Agegroup (10 yrs)
male female
person years based on 2001 Census data
by age and sexCrude Rate of Falls
Risk of fall admission by age and sex (1.5 million cases 1991-2002)
Increasing rates over 10 year periodTodd et al 2008 report to DH
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rude
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50-59 60-69 70-79 80-89 90+Agegroup (10 yrs)
male female
person years based on 2001 Census data
by age and sexCrude Rate of Death within 90 days of Falling
Mortality rates after fall admission by sex
Todd et al 2008 report to DH
• Consequences– Injury
• 4 million NHS England bed days/annum– £2 billion/annum cost of fragility fractures
– Peripheral fractures– Hip fractures
• 70,000/annum• Expensive to treat
– Expensive for patients and families » Money, morbidity, mortality and suffering » 20% die within 90 days» 50% survivors do not regain mobility
– Psychological and social consequences• Disability
– Admission to long term care– Loss of independence
• Falling most common fear of older people– More common than fear of crime or financial fear– Leads to activity restriction, medication use
Risk factors for falls (17 studies)
Risk factor RR or OR RangeMuscle weakness 4.9 1.9-10.3
Impaired balance 3.2 1.6-5.4Gait deficit 3.0 1.7-4.8
Visual deficit 2.8 1.1-7.4Limited mobility 2.5 1.0-5.3
Cognitive impairment 2.4 2.0-4.7Impaired ADL 2.0 1.0-3.1
Postural hypotension 1.9 1.0-3.4
Rubenstein 1993 from WHO 2008.
Medications and fallsCNS benzodiazepines, antidepressants,
antipsychotics (RR 0.34 [0.16, 0.73])
Antihypertensives centrally acting, beta blockers, ACE inhibitors, diuretics
Cardiac medications
cardiac glycosides, anti-arrhythmics, calcium channel blockers
Analgesics NSAIDs, opioids, anticonvulsants, antihistamines gastro-intestinal histamine antagonists
Polypharmacy 4 or more medications 9 fold risk (GP education RR 0.61 [0.41, 0.91])
WHO 2008Cochrane review 2009
Medication review within multifactorial (RR 0.75 [0.65, 0.86])
JAGS 2001 49, 664-672.
Plan• Epidemiology of falls and fractures• What is ProFaNE?• What works to reduce falls
– A review of reviews• The work of ProFaNE
ProFaNEUK Manchester
Warwick Southampton
London Newcastle
D Ulm/Stuttgart Heidelberg
NL Groningen Maastricht
FIN Kuopio Tampere
Turku Jyväskylä
S Lund UmeåF LyonI FlorenceE BarcelonaEL AthensDK CopenhagenNO Bergen
TrondheimCH Lausanne
Lausanne PL Cracow
WP1 Taxonomy and classification
WP 2 Clinical assessment and management
WP 3 Assessment of balance function
WP4 Psychological aspects of falling
www.profane.eu.org
4,500+ members
http://profane.co
Plan• Epidemiology of falls and fractures• What is ProFaNE?• What works to reduce falls
– A review of reviews• The work of ProFaNE
2010
Barreca 2004: sit to stand exercises in groups (stroke patients)Donald 2000: strength training 2X daily with physiotherapist in rehabJarvis 2007: extra physiotherapy strength and balance in rehab (stroke excluded)
Haines 2004 & Cumming 2008: multifactorial interventions Healey 2004: fall risk assessment in fallers Stenvall 2007: comprehensive geriatric assessment , calcium & Vit D post #NoF
Haines 2004 & Cumming 2008: multifactorial interventions Healey 2004: fall risk assessment in fallers Stenvall 2007: comprehensive geriatric assessment , calcium & Vit D post #NoF
Oliver et al BMJ 2006
Included “poor quality” studies
Falls: 0.82 (0.68 to 0.997)Fractures :0.59 (0.22 to 1.58) Relative risk for fallers: 0.95 (0.71 to 1.27)
Conclusions for hospitals• Multi-factorial fall prevention appear
effective for patients >3 weeks LoS• No recommendation re: specific
components of interventions • Exercise in subacute appears
effective
Gates S, et al. Multifactorial assessment and targeted intervention for preventing falls and injuries among older
people in community and emergency care settings: systematic review and meta-analysis BMJ 2008
Gates S et al . BMJ 2008
Gates S, Lamb S, Fisher J, Cooke M, Carter Y. Multifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency
care settings: systematic review and meta-analysis BMJ 2008
• “Evidence of benefit from multifactorial risk assessment and targeted interventions … was limited and reductions in the number of fallers may be smaller than thought.”
Falls and the environment
Slippery walking surfaces Lack of handrails Hazards Visual pattern
Environment modification
Randomised controlled trials of environmental assessment and modification on falls in community samples. (Ballinger, Todd, Whitehead, 2007)
AUTHORS PARTICIPANTS INTERVENTION FINDINGS COMMENTS
Cumming et al (1999)
530 people aged 65+ Home assessment and supervisionOccupational therapist
Not effective for participants who hadn’t experienced a previous fallReduced falls in people who had fallen previously
Reduction in falls outside the home
Day et al (2002) 1090 people, mean age 76.1 (SD 5.5)
Home assessment, advice and provision of materials and labourTrained assessor
Not effective in reducing falls Significant reduction in home hazards
Nikolaus and Bach (2003)
360 people, mean age 81.5 (SD 6.4)
Home assessment, advice and training in use of devicesOccupational therapists and physiotherapists
Effective in reducing falls Particularly effective in those with a history of multiple falls
Pardessus et al (2002)
60 people aged 65+ Home assessment, advice, information about living safely with hazardsOccupational therapist
Not effective in reducing falls Underpowered for falls as outcome measure
Stevens et al (2001)
1737 people aged 70+
Home assessment, education, free installation of safety devicesTrained nurse assessor
Not effective in reducing falls Significant reduction in home hazards
Interventions for preventing falls in older people living in the community (Review)
Gillespie LD, Robertson MC, Gillespie WJ, Lamb SE, Gates S, Cumming RG, Rowe BH
2009
Interventions: Cochrane review 2009 • Exercise targets strength, balance, flexibility, endurance
– programmes with 2 or more components reduce falls & fallers• Supervised group exercise, Tai Chi, & individual prescribed at
home can be effective• Multifactorial assessment and referral works under certain
circumstances – complex interventions causal mechanisms need clarification
• Appropriate medication review and withdrawal can reduce falls• Environment
– Home safety only effective for high risk- professionally administered • VIP
• Surgery in appropriate clinical populations can reduce falls – Cataract surgery, pacemakers (carotid sinus hypersensitivity)– Vitamin D does not reduce falls (except in low baseline) (?)
Rate of falls (Rate Ratios)Group exercise: 0.78 [0.71, 0.86]Individual exercise 0.66 [0.53, 0.82]Group exercise: tai chi 0.63 [0.52, 0.78]Group exercise: gait, balance or functional training 0.73 [0.54, 0.98]Group exercise: strength/ resistance training 0.56 [0.19, 1.65]
Vitamin D meta-analysis Bischoff-Ferrari et al BMJ 2009
High dose – >700IU/day 19% reduction
• (RR 0.81 95% CIs 0.71-0.92)– Serum 25 (OH)D >60nmol/l 23% reduction
• (RR 0.77 95% CIs 0.65-0.90)
Low dose no effectActive vitamin D
reduced risk by 22% • (RR 0.78 95% CIs 0.64-0.94)
ResultsStudy name Rate ratio and 95% CI
BarnettBunoutBuchnerCampbell, 1997Campbell, 1999Campbell, 2005CarterCernyDayEbrahimGreenHauerKorpelainenLathamLiLord, 1995Lord, 2003Liu-Ambrose, ResistanceLiu-Ambrose, AgilityMcMurdoMeansMorganMulrowNowalk, Resist./EnduranceNowalk, Tai ChiProtasReinschResnickRobertsonRubensteinSchoenfelderSchnelleSihvonenSkeltonSteinbergSuzukiToulotteWolf, Tai ChiWolf, BalanceWolf
0.01 0.1 1 10 100
Favours Exercise Favours Control
Exercise and falls
Meta Analysis
Exercise effect RR=0.83, 95% CI=0.75-0.93, 17% reduction
Study name Rate ratio and 95% CI
0.01 0.1 10 1001
Sherrington et al 2006
37 studies 40 comparisons 7111 subjects
Group byHighbal
Study name Rate ratio and 95% CI
0.00 Bunout0.00 Buchner0.00 Carter0.00 Cerny0.00 Day0.00 Ebrahim0.00 Green0.00 Latham0.00 Liu-Ambrose, Resistance0.00 McMurdo0.00 Means0.00 Mulrow0.00 Nowalk, Resist./Endurance0.00 Nowalk, Tai Chi0.00 Reinsch0.00 Resnick0.00 Rubenstein0.00 Schoenfelder0.00 Schnelle0.00 Steinberg0.00 Wolf, Balance0.001.00 Barnett1.00 Campbell, 19971.00 Campbell, 19991.00 Campbell, 20051.00 Hauer1.00 Korpelainen1.00 Li1.00 Lord, 19951.00 Lord, 20031.00 Liu-Ambrose, Agility1.00 Morgan1.00 Protas1.00 Robertson1.00 Sihvonen1.00 Skelton1.00 Suzuki1.00 Toulotte1.00 Wolf, Tai Chi1.00 Wolf1.00
0.01 0.1 1 10 100
Favours A Favours B
Balance exercise and falls
Meta Analysis
Study name Rate ratio and 95% CI
0.01 0.1 10 1001
Low intensity
High intensit
y
Group byHighbal
Study name Rate ratio and 95% CI
0.00 Bunout0.00 Buchner0.00 Carter0.00 Cerny0.00 Day0.00 Ebrahim0.00 Green0.00 Latham0.00 Liu-Ambrose, Resis tance0.00 McMurdo0.00 Means0.00 Mulrow0.00 Nowalk, Resist./Endurance0.00 Nowalk, Tai Chi0.00 Reinsch0.00 Resnick0.00 Rubenstein0.00 Schoenfelder0.00 Schnelle0.00 Steinberg0.00 Wolf, Balance0.001.00 Barnett1.00 Campbell, 19971.00 Campbell, 19991.00 Campbell, 20051.00 Hauer1.00 Korpelainen1.00 Li1.00 Lord, 19951.00 Lord, 20031.00 Liu-Ambrose, Agility1.00 Morgan1.00 Protas1.00 Robertson1.00 Sihvonen1.00 Skelton1.00 Suzuki1.00 Toulotte1.00 Wolf, Tai Chi1.00 Wolf1.00
0.01 0.1 1 10 100
Favours A Favours B
Balance exercise and falls
Meta Analysis
High intensity
Balance training intensity
0.01 0.1 10 1001Sherrington et al 2006
RR= 0.98 [0.84-1.14]RR= 0.71 [0.63-0.80]
Group byHigh_risk
Study name Rate ratio and 95% CI
0.00 Bunout0.00 Carter0.00 Cerny0.00 Day0.00 Korpelainen0.00 Li0.00 Lord, 19950.00 Liu-Ambrose, Resistance0.00 Liu-Ambrose, Agility0.00 McMurdo0.00 Means0.00 Reinsch0.00 Steinberg0.00 Suzuki0.00 Wolf, Tai Chi0.00 Wolf, Balance0.001.00 Barnett1.00 Buchner1.00 Campbell, 19971.00 Campbell, 19991.00 Campbell, 20051.00 Ebrahim1.00 Green1.00 Hauer1.00 Latham1.00 Lord, 20031.00 Morgan1.00 Nowalk, Resist./Endurance1.00 Nowalk, Tai Chi1.00 Protas1.00 Resnick1.00 Robertson1.00 Rubenstein1.00 Skelton1.00 Wolf1.00
0.01 0.1 1 10 100
Favours exercise Favours control
Risk status, exercise and falls
Meta Analysis
Group byHigh_risk
Study name Rate ratio and 95% CI
0.00 Bunout0.00 Carter0.00 Cerny0.00 Day0.00 Korpelainen0.00 Li0.00 Lord, 19950.00 Liu-Ambrose, Resistance0.00 Liu-Ambrose, Agility0.00 McMurdo0.00 Means0.00 Reinsch0.00 Steinberg0.00 Suzuki0.00 Wolf, Tai Chi0.00 Wolf, Balance0.001.00 Barnett1.00 Buchner1.00 Campbell, 19971.00 Campbell, 19991.00 Campbell, 20051.00 Ebrahim1.00 Green1.00 Hauer1.00 Latham1.00 Lord, 20031.00 Morgan1.00 Nowalk, Resist./Endurance1.00 Nowalk, Tai Chi1.00 Protas1.00 Resnick1.00 Robertson1.00 Rubenstein1.00 Skelton1.00 Wolf1.00
0.01 0.1 1 10 100
Favours exercise Favours control
Risk status, exercise and falls
Meta Analysis
Low risk
High risk
Risk statusRate ratio and 95% CIStudy name
0.01 0.1 10 1001
Sherrington et al 2006
RR= 0.78 [0.66-0.92]RR= 0.84 [0.74-0.95]
Algorithm for exercise prescription
POPULATION PROGRAM
Population Low Risk 60-80 Years
Tai Chi type exercises in groups
Population at Increased Risk 70-80 Years
Group balance and strength training
Population at Increased Risk 80 + Years
Otago exercise program
Sherrington, Whitney, Close, Herbert, Cumming, Lord . Exercise for preventing falls: meta-analysis ProFaNE WP2 Australia Falls Conference Brisbane 2006
Training needs to be challenging, progressive, regular and aimed at
strength and balance.
www.laterlifetraining.co.uk Otago exercises
WP4: Psychological aspects of falling• Motivation for prevention• Consequences
– fear of falling (efficacy)• FES-I
– fear of falling interventions
The Problem of Interest: Refusal, drop out & adherence
• High refusal– 50% common
• Low adherence• 18% dropout
average (15 weeks)
• 44% dropout• Long term adherence
poor• Refusal and non-
adherence 50% - 90% thus prevention may not be effective
• Prevention programmes are efficacious
• Refusal/non-adherence 50% - 90% thus prevention may not be effective
• Training needs to be challenging, progressive and done regularly.
Study name Rate ratio and 95% CI
BarnettBunoutBuchnerCampbell, 1997Campbell, 1999Campbell, 2005CarterCernyDayEbrahimGreenHauerKorpelainenLathamLiLord, 1995Lord, 2003Liu-Ambrose, Resis tanceLiu-Ambrose, AgilityMcMurdoMeansMorganMulrowNowalk , Res is t./EnduranceNowalk , Tai ChiProtasReinschResnickRobertsonRubensteinSchoenfelderSchnelleSihvonenSkeltonSteinbergSuzukiToulotteWolf, Tai ChiWolf, BalanceWolf
0.01 0.1 1 10 100
Favours Exercise Favour s Control
Exercise and falls
Meta Analysis
The studies1. UK Qualitative interviews and focus groups2. UK Quantitative surveys3. EU Qualitative interviews and focus groups
Yardley L, Todd C et al
Older people’s views of advice about falls prevention: A qualitative study. Health Education Research. 2006. 21(4); 508-517.
Attitudes and beliefs that predict older people’s intention to undertake strength and balance training. Journals of Gerontology Series B-Psychological Sciences & Social Sciences. 2007; 62(2): 119-25,
Encouraging positive attitudes to falls prevention in later life. London: Help the Aged 2005
Older people’s views of falls prevention interventions in Six European countries. The Gerontologist. 2006. 46(5) 650-660.
Recommendations for promoting the engagement of older people in activities to prevent falls. Quality and Safety in Health Care. 2007 16 230-234.
How likely are older people to take up different falls prevention activities? Preventive Medicine 2008 47 554–558
Socio-demographic factors predict the likelihood of not returning home after hospital admission following a fall Journal of Public Health 2010
FindingsPerceptions of available falls
prevention advice• Reported none received!
– though actually mention of receiving information)
• Perceived falls prevention in terms of hazard reduction – rather than balance improvement– often through restriction of activity
Perceptions of falls prevention messages presented
Discussion of falling prevention is beneficial
I think it would be helpful if someone knows what you should do and what you shouldn’t do..
I think it would give me more confidence of building up your balance if I read this [leaflet about improving balance] now. I think it would give me more confidence when I’m out..
(members of focus group of women aged 78 to 95 living in sheltered accommodation)
Perceptions of falls prevention messages presented cont.
It’s good advice BUT- they wouldn’t necessarily act on (all of)
itIt’s all good. I mean its good advice, yes, excellent, I
agree. I doesn’t mean to say I do it all but I agree.
- it may not fit with their circumstances, lifestyle, prioritised goals
No, no, no, no, no, no ... Nobody would go around with padding.
Perceptions of falls prevention messages presented cont.
It’s good advice - for ‘them’- only seen as relevant to ‘elderly’Because we’re that much fitter -- we don’t really take too
much notice of it, only for other people, for other disabled or elderly people that we have to watch when we’re – we always watch older people anyway.
(man aged 79 in sheltered accommodation)- rejected by fit, younger people, seen as humiliatingI wouldn’t go for that [advice] because it didn’t apply to me in
any shape or form. Is there a bit of pride, is there a bit of “Well, you know, I’m not there yet”
(fit woman in 60s)
Perceptions of falls prevention messages presented cont.
Falls prevention advice unnecessary, upsettingIt can make you feel – somebody producing the leaflets
here – that these people here are senile and they just don’t have any common sense and they need to be told everything.
The last thing you want as you get older is to be told that you’ve got to be conscious every time you go out and might fall, you don’t want that, otherwise your life’s gone.
(woman 78, who had recently fallen)
Suggestions for future advice
• Incorporate falls prevention into lifestyle and general exercise programmes,
• Promote activities as – enjoyable – interesting,– sociable
• Give suggestions in constructive manner • Give explanations • Recognise
– individual’s knowledge – choice of own lifestyle
Quantitative test of conclusions from qualitative studies
558 people aged 60-95 71% women, mean 74.4 yrs53% fell in past year 23% repeat fallers
1918 people aged 54+ (subgroup of 5396 surveyed)57% womenMean 69.747% fell in past year22% repeat fallers
Expected benefits of SBT
Expected attitudes of others
Expected ability to carry out SBT
Identity right to do SBT
Fear of falling (FES-I)
Perceived vulnerability- risk of falling
Perceived severity -consequences of falling
Perceived causes of falling
Threat appraisal Coping appraisal
Intention to carry out Strength &
Balance Training.09 .87
Conclusions• Abandon efforts at ‘falls prevention’ -
emphasise positive benefits of exercise• Emphasise positive benefits of
measures, phrase advice to allow recipients to select/modify to suit goals and lifestyle
• Target advice to different groups of older people (e.g. high/low perceived/actual risk)
Implications for practiceDo not present initially to older people in terms of falling
prevention (since falling risk denied anyway)Talk in terms of Activity Emphasise/maximise immediate wider Benefits: looking
and feeling good; remaining active and independent; taking part in an enjoyable and interesting Communal/social activity
Most effective approach is personal invitation from health professional explaining exactly what is involved, benefits.
Illness, evidence of increasing Disability provides good opportunity to suggest taking this up.
Exercise in terms of everyday activities“F” word Groups only for some Home based exercise preferred
Implications for practiceDo not present initially to older people in terms of falling
prevention (since falling risk denied anyway)Talk in terms of Activity Emphasise/maximise immediate wider Benefits: looking
and feeling good; remaining active and independent; taking part in an enjoyable and interesting Communal/social activity
Most effective approach is personal invitation from health professional explaining exactly what is involved, benefits.
Illness, evidence of increasing Disability provides good opportunity to suggest taking this up.
Exercise in terms of everyday activities“F” word Groups only for some Home based exercise preferred
• Prevention programmes are efficacious
• We have the technology to make them effective
Study name Rate ratio and 95% CI
BarnettBunoutBuchnerCampbell, 1997Campbell, 1999Campbell, 2005CarterCernyDayEbrahimGreenHauerKorpelainenLathamLiLord, 1995Lord, 2003Liu-Ambrose, Resis tanceLiu-Ambrose, AgilityMcMurdoMeansMorganMulrowNowalk , Res is t./EnduranceNowalk , Tai ChiProtasReinschResnickRobertsonRubensteinSchoenfelderSchnelleSihvonenSkeltonSteinbergSuzukiToulotteWolf, Tai ChiWolf, BalanceWolf
0.01 0.1 1 10 100
Favours Exercise Favour s Control
Exercise and falls
Meta Analysis
www.profane.eu.orgFunders WP4European CommissionUnited Kingdom Department of HealthDanish Ministry of Social AffairsHelp the AgedSwiss Federal Office for Education and Science Maastricht University University of Manchester Robert-Bosch-Foundation
Lucy Yardley University of Southampton
Nina Beyer Copenhagen University Hospital
Klaus HauerUniversity of Heidelberg
Ruud KempenUniversity of Maastricht
Chantal Piot-ZieglerUniversity of Lausanne
www.profane.eu.org