Active for Later Life

1. Active for Later Life Physical activity and the prevention of falls among older people Evidence into practice

2. Why are falls important? • How active are older people? • Physical activity in falls prevention. Does it work? Evidence of effectiveness • Putting it into practice: Recommendations and guidelines • Putting it into practice: Education and training

3. Why are falls important?

4. Why are falls important? Why are falls important? • The human costs of falls • Large numbers of older people are falling • Impact on local services • Costs to the health services

5. Why are falls important? The human costs of falls A downward spiral? • Further loss of function • Loss of mobility, independence, dignity and confidence • Fear of another fall and further loss of function • Increased isolation and loneliness • Frequent fallers have poor outcomes

6. Why are falls important? 90-day outcome after hip fracture • 24% return to pre-fracture level of function • 42% of survivors require extra help with half their daily activities • 21% require an increased level of residential or hospital care • 35% receive increased community health and social service care at home (Bandolier, 1998)

7. Why are falls important? Large numbers of older people are falling Each year… • One-third of people aged 65+ and 50% of over-80s living in the community will fall. • Over 60% of those living in nursing homes will fall repeatedly. • 75% of falls-related deaths occur in the home. • 75% of falls are not reported. (Cryer and Patel, 2001)

8. Why are falls important? Are certain groups more at risk? • Men and women fall at the same rate but men are far less likely to injure themselves. • There is no evidence of higher rates of falls among minority ethnic groups. • Older people over 80 • Older people living in nursing homes

9. 120 100 Estimate based on increased rate of hip fracture 80 Estimate based on population growth alone 60 40 20 0 1985 1994 1996 2006 2016 Why are falls important? Estimated incidence of hip fracture in England and Wales People (000) Source: Grimley-Evans et al, 1997

10. Why are falls important? Impact on local services • Over 10% of the London ambulance service workload (Halter et al, 2000) • Contributes to local authority care costs of £3 billion residential and £2 billion non-residential • Long-term nursing care £19,000 per year for older person affected by a fall • Social care costs caused by falls of £2.5 million per year for an urban primary care trust (population 260,000+) (Department of Health, 2001)

11. Why are falls important? Costs to the health servicesThe financial costs of hip fractures £4,808 £7,125 £164 £12,097 • Estimated acute hospital costs for fractured neck of femur • Long stay/social cost • Primary care costs • Total cost The annual cost of treatment of fractures among women is now in excess of £1.8 billion. (Dolan and Torgerson, 2000)

12. Physical activity in falls prevention. Does it work? Evidence of effectiveness

13. Physical activity in falls prevention. Does it work? Modifying risk factors for falls Intrinsic – States or traits of an individual e.g. • Sensory decline • Medical conditions • Strength, balance, gait and physical performance • Four or more medications (More important in over-70s) Extrinsic – Social or physical environment e.g. • Poor housing and lighting • Baths without handles • Ill-fitting shoes • Unsafe walking areas (More important in under-70s)

14. Physical activity in falls prevention. Does it work? Intrinsic vs extrinsic risk factors “We are all trippers.” • Over half of falls experienced in the home are due to environmental hazards – e.g. trips, slips, unsafe or unlit stairs. • A decline in a person’s intrinsic risk factors (declining function and balance) means that the extrinsic risk factors (loose mat, slippery floor) no longer cause a correctable trip; they cause an injurious fall.

15. Physical activity in falls prevention. Does it work? Risk factors for falls that cannot be modified • Age • Gender • Social class • Chronic medical conditions • Irreversible vision problems • Osteoporosis

16. Physical activity in falls prevention. Does it work? Targeting the modifiable risk factors for falling • Foot care • Poor housing • Depression • Previous falls • Fear of falling • Functional capacity • Poor heating • Poor diet • Low strength and power • Medical condition • Medications • Incontinence • Cognitive impairment • Balance/gait • Postural hypotension • Vision/hearing

17. Physical activity in falls prevention. Does it work? Improving risk factors – duration vs outcome • Gait (8 weeks) • Balance (Static 8 weeks + Dynamic 8 weeks) • Muscle strength (8-12 weeks) • Muscle power (12 weeks) • Endurance (26 weeks) • Transfer (6 months) • Postural hypotension (24 weeks) • Bone strength (1 year for femur and lumbar spine) (Skelton and McLaughlin, 1996)

18. Physical activity in falls prevention. Does it work? Reviews of effectiveness in falls prevention • Guidelines for the prevention of falls in older people (Clinical Effectiveness Group, 1998) • Gardner et al (2000) • National Service Framework for Older People – Standard 6: Falls (Department of Health, 2001)

19. Physical activity in falls prevention. Does it work? Effective interventions • Tinetti et al, 1994 • FICSIT Trials: Province et al, 1995 • Wolf et al, 1996 • Campbell et al, 1997 • PROFET: Close et al, 1999 • FaME Project: Skelton, 2001 • Day et al, 2002

20. Physical activity in falls prevention. Does it work? Tinetti et al, 1994 • Community-dwelling older women 70+ • More than one risk factor • Multi-factorial intervention • Included transfer training, gait 30% reduction in falls

21. Physical activity in falls prevention. Does it work? FICSIT Trials (Province et al, 1995) • 7 sites (balance, strength, endurance and other multi-disciplinary interventions)10% lower risk of falling • 4 sites (balance training)25% lower risk of falling • 1 site (Tai Chi only – 10 moves)47% lower risk of falling

22. Physical activity in falls prevention. Does it work? Wolf et al, 1996 • Community-dwelling population (n=200) with no debilitating conditions • Intervention based on Tai Chi • A synthesis of 108 existing forms into 10 exercise moves • 2 sessions a week for 15 weeks Falls rate cut by half

23. Physical activity in falls prevention. Does it work? Campbell et al, 1997 • Women aged 80+, community dwelling • Physical activity prescribed by a physiotherapist • 4 home visits over 2 months • Strength, balance and gait training 20%-30% reduction in falls

24. Physical activity in falls prevention. Does it work? PROFET Trial (Close et al, 1999) • Community-dwelling, aged 65+ • Multi-factorial intervention • Medical assessment • Physiotherapy and occupational therapy 60% reduction of risk

25. Physical activity in falls prevention. Does it work? FaME Project (Falls Management Exercise trial) • Independent, community-dwelling women with history of 3 or more falls in previous year (high risk) • 9-month intervention – exercise only • Weekly exercise class and home exercise with trained seniors exercise instructor • After 3 years, 10% of those in exercise group had died or were in hospital or in a nursing home, compared with 33% of those not exercising 60% reduction in falls and 75% reduction in injuries (Skelton, 2001)

26. Physical activity in falls prevention. Does it work? Day et al, 2002 • 1,000+ aged 70 years +, living at home • Interventions included group-based exercise, home hazard management and vision improvement. • Exercise (including balance training) comprised a weekly supervised group session together with 2 x weekly home exercise sessions. 14% reduction in annual rate of falls. Group-based exercise was the most potent single intervention tested.

27. Physical activity in falls prevention. Does it work? Evidence of effectiveness A critical review of 29 physical activity interventions reported: • Increased activity levels over a longer period of time • Group/class-based and home-based activity were effective • Tailored to individual needs • Cognitive-behavioural strategies and goal-setting • Telephone support and continued contact (King et al, 1998)

28. How active are older people?

29. How active are older people? Overview • Low levels of physical activity among older people • Thresholds for quality of life and functional capacity • Physical activity and frailty • Environmental factors assisting the ‘spiral of decline’

30. 5 kcal/min including brisk/fast walks 2 miles 80% 4 kcal/min including all walks 2 miles 4 kcal/min plus all walks 1 mile 60% 40% 20% 0% 50-54 55-59 60-64 65-69 70-74 75-79 80+ Age How active are older people? Levels of sedentary behaviour among MEN aged 50+, England % participating less than once a week (Skelton, Young et al, 1999)

31. 5 kcal/min including brisk/fast walks 2 miles 80% 4 kcal/min including all walks 2 miles 4 kcal/min plus all walks 1 mile 60% 40% 20% 0% 50-54 55-59 60-64 65-69 70-74 75-79 80+ Age How active are older people? Levels of sedentary behaviour among WOMEN aged 50+, England % participating less than once a week (Skelton, Young et al, 1999)

32. How active are older people? Levels of sedentary behaviour among minority ethnic groups aged 55+, England Those participating less than once a week Men Women African-Caribbean Indian Pakistani Bangladeshi Chinese 57% 67% 73% 85% 68% 59% 78% 85% 92% 64% (Erens et al, 2001)

33. How active are older people? Older people living in care and residential settings • 86% of women and 78% of men in care homes are sedentary. • Sedentary behaviour in care homes is double that in private households (at age 65+). • Half of all men and women in local authority residential homes never or very occasionally take trips outside the home. (Department of Health, 2002)

34. How active are older people? The physical activity paradox • 39% of men and 42% of women aged 50+ are sedentary. • YET over half of sedentary men and women aged 50+ believe they take part in enough activity to keep fit. • 26% of men and 34% of women aged over 70 are unable to walk a quarter of a mile on their own.

35. Physically active Physically inactive How active are older people? Thresholds for quality of life Exercise performance ‘Threshold’ value necessary for performance of an everyday task Age Adapted from Young (1986)

36. 60 Men Women 50 40 30 20 10 VO2 max to walk comfortably at 3mph 0 50-54 55-59 60-64 65-69 70-74 50-54 55-59 60-64 65-69 70-74 Age How active are older people? Aerobic capacity in MEN and WOMEN aged 50-74 (mean ± 2sd) Maximum oxygen uptake (ml/kg/min) (Skelton, Young et al, 1999)

37. 12 Men Women 10 8 6 4 2 Strength to be confident of rising from low chair without using one’s arms 0 50-54 55-59 60-64 65-69 70-74 50-54 55-59 60-64 65-69 70-74 Age How active are older people? Knee extension strength inMEN and WOMEN aged 50-74 (mean ± 2sd) Isometric knee extension strength (N/kg) (Skelton, Young et al, 1999)

38. 200 Men Women 160 120 80 40 Requirement to wash hair without difficulty 0 50-54 55-59 60-64 65-69 70-74 75-79 80+ 50-54 55-59 60-64 65-69 70-74 75-79 80+ Age How active are older people? Shoulder flexibility inMEN and WOMEN aged 50+ (mean ± 2sd) Shoulder abduction (degrees) (Skelton, Young et al, 1999)

39. How active are older people? Functional capacity Even healthy older people lose functional capacity. • Muscle strength ‘lost’ at 1%-2% per year • Muscle power ‘lost’ at 3%-4% per year • Aerobic capacity ‘lost’ at 1% per year • Bone density ‘lost’ at 1% in men and 2%-3% in women after menopause • Flexibility and balance • Proprioception and kinesthetic awareness • Co-ordination and reaction • Thermo-regulation Sedentary behaviour increases loss of performance. (Skelton and Dinan, 1999)

40. Time Human frailty Disease Disuse How active are older people? Functional decline and frailty (Spirduso, 1995)

41. How active are older people? Inactivity-related disease? Disuse rather than disease? • One week’s bed rest reduces:– strength by up to 20%– spine bone mineral content by 1%. • 86% of women and 78% of men in residential homes in England are sedentary. • Nursing home residents spend 80%-90% of their time seated or lying down – leading to inactivity-related disability. • Those who are less active and weaker will enter nursing homes earlier than those who maintain their fitness.

42. How active are older people? Environmental factors assisting the ‘spiral of decline’ Following a fall • Further loss of function • Loss of mobility and independence • Further loss of function • Increased isolation and institutionalisation • Loss of dignity and confidence and fear of a further fall • Fear of using stairs • Concerns for personal safety out of the house • Poorly designed pavements/kerbs • Concerns of family, friends and carers

43. Putting it into practice Recommendations and guidelines

44. Putting it into practice: Recommendations and guidelines What do we mean by physical activity? • Physical activity “Any bodily movement produced by skeletal muscles that results in energy expenditure.” ‘Physical activity’ is a broad term covering all types of movement (including leisure, work, chores and movement). • Exercise“Any leisure time physical activity which is planned and structured, and repetitive bodily movement undertaken to improve or maintain one or more components of physiological fitness.” (Bouchard et al, 1990)

45. Putting it into practice: Recommendations and guidelines Specificity of intervention – older people (Simey et al, 1999) • To improve health and modify certain risk factors for falling (e.g. strength), moderate physical activity is appropriate. • To reduce injurious falls, exercise should include training in balance, strength, co-ordination and reaction times. • To reduce fractures, exercise should include bone- loading in addition to the elements outlined for reducing falls.

46. Putting it into practice: Recommendations and guidelines Recent recommendations and guidelines • American Geriatrics Society, British Geriatrics Society and the American Academy of Orthopaedic Surgeons Panel on Falls Prevention (2001) • Guidelines for the collaborative, rehabilitative management of older people who have fallen (Simpson, 1996) Summarised in Falls, Fragility and Fractures (Cryer and Patel, 2001)

47. Putting it into practice: Recommendations and guidelines Specific recommendations: multi-factorial interventions Community-dwelling older people • Gait training and appropriate use of assistive devices • Review and modification of medication (especially psychotropics) • Exercise programmes, balance training • Treatment of postural hypotension • Modification of environmental hazards • Treatment of cardiovascular disorders (including arrhythmias) (Cryer and Patel, 2001)

48. Putting it into practice: Recommendations and guidelines Specific recommendations: multi-factorial interventions Long-term care and assisted living settings • Staff education • Gait training and appropriate use of assistive devices • Review and modification of medications (especially psychotropics) Acute hospital settings • No recommendations Older people who have recurrent falls • Long-term exercise and balance training (Cryer and Patel, 2001)

49. Putting it into practice: Recommendations and guidelines Recommendations and guidelines for falls prevention for those aged 65+ • Individually tailored exercise programmes administered by a qualified professional reduce the incidence of falls in a selected high-risk group living in the community. • Exercise programmes reduce the risk of falls in a selected group of older people with mild deficits of strength and balance living in the community. • Tai Chi classes with individual tuition can reduce the risk of falls in older adults. • Programmes that combine interventions (multi-faceted – mostly including exercise) reduce falls. (Feder et al, 2000)

50. Putting it into practice Education and training