Presentation is loading. Please wait.

Presentation is loading. Please wait.

School of Nursing, Midwifery and Social Work Preventing falls: Evidence from ProFaNE Chris Todd Professor of Primary Care & Community Health Director of.

Similar presentations


Presentation on theme: "School of Nursing, Midwifery and Social Work Preventing falls: Evidence from ProFaNE Chris Todd Professor of Primary Care & Community Health Director of."— Presentation transcript:

1 School of Nursing, Midwifery and Social Work Preventing falls: Evidence from ProFaNE Chris Todd Professor of Primary Care & Community Health Director of Research Director, ProFaNE

2 Plan Epidemiology of falls and fractures What is ProFaNE? What works to reduce falls –A review of reviews

3 www.iofbonehealth.org 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

4 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 3-7 Rubenstein. Age & Ageing; 2006; 35-S2; ii37-41

5 Risk of fall admission by age and sex (1.5 million cases 1991-2002) Increasing rates over 10 year period Todd et al 2008 report to DH

6 Mortality rates after fall admission by sex Todd et al 2008 report to DH

7 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

8 Risk factors for falls (17 studies) Risk factorRR or ORRange Muscle weakness4.9 1.9-10.3 Impaired balance3.21.6-5.4 Gait deficit3.01.7-4.8 Visual deficit2.81.1-7.4 Limited mobility2.51.0-5.3 Cognitive impairment2.42.0-4.7 Impaired ADL2.01.0-3.1 Postural hypotension1.91.0-3.4 Rubenstein 1993 from WHO 2008.

9 Medications and falls CNS 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 2008 Cochrane review 2009 Medication review within multifactorial (RR 0.75 [0.65, 0.86]) JAGS 2001 49, 664-672.

10 Plan Epidemiology of falls and fractures What is ProFaNE? What works to reduce falls –A review of reviews The work of ProFaNE

11 ProFaNE UK Manchester Warwick Southampton London Newcastle D Ulm/Stuttgart Heidelberg NL Groningen Maastricht FIN Kuopio Tampere Turku Jyväskylä S Lund Umeå F Lyon I Florence E Barcelona EL Athens DK Copenhagen NO Bergen Trondheim CH Lausanne Lausanne PL Cracow

12 WP1 Taxonomy and classification WP 2 Clinical assessment and management WP 3 Assessment of balance function WP4 Psychological aspects of falling

13 www.profane.eu.org 4,500+ members http://profane.co

14 Plan Epidemiology of falls and fractures What is ProFaNE? What works to reduce falls –A review of reviews The work of ProFaNE

15 2010

16 Barreca 2004: sit to stand exercises in groups (stroke patients) Donald 2000: strength training 2X daily with physiotherapist in rehab Jarvis 2007: extra physiotherapy strength and balance in rehab (stroke excluded)

17 Haines 2004 & Cumming 2008: multifactorial interventions Healey 2004: fall risk assessment in fallers Stenvall 2007: comprehensive geriatric assessment, calcium & Vit D post #NoF

18 Haines 2004 & Cumming 2008: multifactorial interventions Healey 2004: fall risk assessment in fallers Stenvall 2007: comprehensive geriatric assessment, calcium & Vit D post #NoF

19 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)

20 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

21

22 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

23 Gates S et al. BMJ 2008

24 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.”

25 Falls and the environment

26 Slippery walking surfaces Lack of handrails Hazards Visual pattern Environment modification

27 Randomised controlled trials of environmental assessment and modification on falls in community samples. (Ballinger, Todd, Whitehead, 2007) AUTHORSPARTICIPANTSINTERVENTIONFINDINGSCOMMENTS Cumming et al (1999) 530 people aged 65+Home assessment and supervision Occupational therapist Not effective for participants who hadn’t experienced a previous fall Reduced 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 labour Trained assessor Not effective in reducing fallsSignificant 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 devices Occupational therapists and physiotherapists Effective in reducing fallsParticularly 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 hazards Occupational therapist Not effective in reducing fallsUnderpowered for falls as outcome measure Stevens et al (2001) 1737 people aged 70+ Home assessment, education, free installation of safety devices Trained nurse assessor Not effective in reducing fallsSignificant reduction in home hazards

28 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

29 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]

30 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 effect Active vitamin D reduced risk by 22% (RR 0.78 95% CIs 0.64-0.94)

31 Results Exercise effect RR=0.83, 95% CI=0.75-0.93, 17% reduction Study nameRate ratio and 95% CI 0.010.1101001 Sherrington et al 2006 37 studies 40 comparisons 7111 subjects

32 Study nameRate ratio and 95% CI 0.010.1101001 Low intensity High intensit y Balance training intensity 0.010.1101001 Sherrington et al 2006 RR= 0.98 [0.84-1.14] RR= 0.71 [0.63-0.80]

33 Low risk High risk Risk status Rate ratio and 95% CI Study name 0.010.1101001 Sherrington et al 2006 RR= 0.78 [0.66-0.92] RR= 0.84 [0.74-0.95]

34 Algorithm for exercise prescription POPULATIONPROGRAM 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

35 Training needs to be challenging, progressive, regular and aimed at strength and balance. www.laterlifetraining.co.ukOtago exercises

36 WP4: Psychological aspects of falling Motivation for prevention Consequences –fear of falling (efficacy) FES-I –fear of falling interventions

37 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

38 Prevention programmes are efficacious Refusal/non-adherence 50% - 90% thus prevention may not be effective Training needs to be challenging, progressive and done regularly.

39 The studies 1.UK Qualitative interviews and focus groups 2.UK Quantitative surveys 3.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

40 Findings Perceptions 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

41 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)

42 Perceptions of falls prevention messages presented cont. It’s good advice BUT - they wouldn’t necessarily act on (all of) it It’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.

43 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 humiliating I 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)

44 Perceptions of falls prevention messages presented cont. Falls prevention advice unnecessary, upsetting It 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)

45 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

46

47 Quantitative test of conclusions from qualitative studies 558 people aged 60-95 71% women, mean 74.4 yrs 53% fell in past year 23% repeat fallers 1918 people aged 54+ (subgroup of 5396 surveyed) 57% women Mean 69.7 47% fell in past year 22% repeat fallers

48 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 appraisalCoping appraisal Intention to carry out Strength & Balance Training.09.87

49 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)

50 Implications for practice Do not present initially to older people in terms of falling prevention (since falling risk denied anyway) Talk in terms of A ctivity Emphasise/maximise immediate wider B enefits: looking and feeling good; remaining active and independent; taking part in an enjoyable and interesting C ommunal / social activity Most effective approach is personal invitation from health professional explaining exactly what is involved, benefits. Illness, evidence of increasing D isability provides good opportunity to suggest taking this up. E xercise in terms of everyday activities “F” word G roups only for some H ome based exercise preferred

51 Implications for practice Do not present initially to older people in terms of falling prevention (since falling risk denied anyway) Talk in terms of A ctivity Emphasise/maximise immediate wider B enefits: looking and feeling good; remaining active and independent; taking part in an enjoyable and interesting C ommunal / social activity Most effective approach is personal invitation from health professional explaining exactly what is involved, benefits. Illness, evidence of increasing D isability provides good opportunity to suggest taking this up. E xercise in terms of everyday activities “F” word G roups only for some H ome based exercise preferred

52 Prevention programmes are efficacious We have the technology to make them effective

53 www.profane.eu.org Funders WP4 European Commission United Kingdom Department of Health Danish Ministry of Social Affairs Help the Aged Swiss 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 Hauer University of Heidelberg Ruud Kempen University of Maastricht Chantal Piot-Ziegler University of Lausanne

54 www.profane.eu.org


Download ppt "School of Nursing, Midwifery and Social Work Preventing falls: Evidence from ProFaNE Chris Todd Professor of Primary Care & Community Health Director of."

Similar presentations


Ads by Google