Forebyggelse af fald ved hjælp af træning

1. Forebyggelse af fald ved hjælp af træning v. Nina Beyer Idrætsmedicinsk Forskningsenhed Bispebjerg Hospital

2. Proportion of older women who fell during a 12 months period (n=704) Lord 1993 Falls in the elderly Proportion who falls at least once a year (MF)  33% in 65+ yr old people  40% in 70+ yr old people  50% in 80+ yr old people Campbell 198, Tinetti 1988, Lord 1993, Feder 2000 Consequences of falls 20-60% injuries 10-15% serious injuries 2-6% fractures 0.2-1.5% hip fractures

3. Location of falls in home-dwelling women (65+ years old, n= 704) Falls occur during physical activity 3% 56% 6% 3% 6% 26% Lord 1993

4. Falls in elderly citizens of Copenhagenduring a half-year period SIF 2002

5. Primary risk factors for falls ***Strong evidence, ** moderate evidence, * weak evidence, - no evidence. Internal Psycosocial Demographic Environmental Muscle weakness *** Gait + mobility  *** ADL limitation *** Stability  ** Poor reaction time *** Peripheral sensation *** Visual contrast sensitivity *** Impaired cognition *** Depression ** Stroke *** Parkinson’s disease *** Arthritis ** Dizziness * Orthostatic hypotension ……….. Living alone ** History of falls *** Inactivity ** Alcohol consumption - Advanced age *** Female gender ** Psychoactive medication *** More than 4 medications *** Poor footwear * Inappropriate spectacles * Home hazards - External hazards - Fear of falling Lord et al. 2001

6. Cochrane Systematic Review2000 There is inadequate evidence for the effectiveness of single interventions such as exercise alone or health education classes for the prevention of falls Gillespie 2000

7. Exercise to prevent of falls in elderly (RCT)metaanalysis of 4 studies Population 1016 community-dwelling men & women aged 65-96 years from 9 cities and towns in New Zealand hospital Intervention Individually tailored (home) exercise programme of strength and balance (PT and Nurse delivered) At 12 months follow-up Training had resulted in # falls  35% # fall related injuries  35% The programme was most effective in 80+ yr old people Robertson 2002

8. Falls prevention in home-dwelling 70+ year old people Invitation letters (n=11120) Responses (n=1967) Baseline assessments (n=1107) Randomization (n=1107) Did not continue (n=17) Continued (n=1090) Exercise n=135 Vision n=139 Exercise & vision n=136 Home hazard management n=136 Exercise & home hazard management n=135 Vision & home hazard management n=137 All three interventions n=135 No intervention n=137 % estimated reduction in annual fall rate (95% CI) 6.9 (1.1-12.8) 3.1 (-2.0-9.7) 4.4 (-1.5-10.2) 9.9 (2.4-17.9) 11.1 (2.2-18.5) 7.4 (-0.9-15.2) 14.0 (3.7-22.6) No needed to treat to prevent 1 fall 14 32 23 10 9 14 7 Supervised exercise 15 w, 1h/w targeting: Leg strength Balance Flexibility + daily home exercises Day et al. BMJ 2002

9. Prevention and management of falls Components of fitness to include • Strength / Power • Balance / Postural stability • Endurance / Gait • Flexibility • Bone loading (weight resisted) • Training must be • Regular • Individually tailored • Progressive • Based on components of fitness from successful interventions

10. The recommended quantity and quality of exercise in the elderly • Resistance exercise, 10-15 RM x 2 weekly • Endurance training • Balance • Flexibility Resistance exercise should be a high priority because it • is essential for the maintenance of functional capacity • has a beneficial effect on several health variables • does not take a long time • can be accomplished by virtually anyone American College of Sports Medicine position stand, 1998

11. Physical activity reduces the risk of fracture 9704 women 65+ years, follow-up avg. 7.6 years Lowest Highest Gregg 1998

12. Effect of training on risk factors for falls and disability in elderly women Sports Medicine Research Unit, Bispebjerg Hospital Training 2 x1 h/w (n=24) Emergency room Women 70-90 yrs who had suffered a fall Test Control (n=29) mths 0 6 12 Test Test

13. Training components • 5-10 min flexibility • 10-15 min warm up(with dumbbells & elastic bands) • 20-25 min resistance and endurance exercise70-75% of 1RM: leg press (3 x 10 reps), hip extension (3 x 10 reps), ankle plantar flexion (3 x10 reps) • and dorsi-flexion (50 reps), step-ups (20 cm, 30 reps) • 10-15 min balance different activities performed at different speed, individually, in pairs or by the whole group, with or without shoes and on different surfaces. • 2-5 min stretching

14. Effect of training(Training group / Control group %) At 6 months At 12 months Muscle strength Thigh muscle strength 20-41% / ns Trunk strength 38-57% / ns Hand grip 7% / ns Power 35% / ns Function Gait speed 11-14% / ns Stair climbing 27% / ns Chair stand 21% / ns Berg Balance score 9% / ns 6 months after completion of training the improvements were maintained and the level of physical activity was significantly higher than on inclusion ------------------------------------------- 6 months of regular training and increased habitual activity contribute to the maintenance of muscle strength and function in elderly people with co-morbidity

15. Rantanen 2002

16. Mortality Rate after Fracture According to Knee Extension Strength Before the Fracture Number of Deaths / 1000 Person Months Tertiles of Knee Extension Strength Before the Fracture Rantanen 2002

17. Algorithm summarizing the clinical approach to prevention of falls among elderly persons living in the community. The algorithm is based on available evidence (Tinetti NEJM 2003). Recommend participation in an exercise program that includes balance and strength training No falls and no balance or gait difficulties One fall and no balance and gait difficulties Two or more falls or balance and gait difficulties Assessment of predisposing and precipitating factors, followed by intervention suggested by the results of detailed assessment Ask all patients 75 yrs old about falls and balance or gait difficulties. Observe the patient getting into and out of a chair and walking