preventing falls evidence from profane n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Preventing falls: Evidence from ProFaNE PowerPoint Presentation
Download Presentation
Preventing falls: Evidence from ProFaNE

Loading in 2 Seconds...

play fullscreen
1 / 54

Preventing falls: Evidence from ProFaNE - PowerPoint PPT Presentation


  • 187 Views
  • Uploaded on

Preventing falls: Evidence from ProFaNE. Chris Todd Professor 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. Osteoporosis, falls and fractures.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Preventing falls: Evidence from ProFaNE' - bertha


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
preventing falls evidence from profane

Preventing falls: Evidence from ProFaNE

Chris Todd

Professor of Primary Care & Community Health

Director of Research

Director, ProFaNE

slide2
Plan
  • Epidemiology of falls and fractures
  • What is ProFaNE?
  • What works to reduce falls
    • A review of reviews
osteoporosis falls and fractures
Osteoporosis, falls and fractures

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

www.iofbonehealth.org

slide4
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

slide5

Risk of fall admission by age and sex (1.5 million cases 1991-2002)

Todd et al 2008 report to DH

Increasing rates over 10 year period

slide7
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 factors for falls (17 studies)

Rubenstein 1993 from WHO 2008.

medications and falls
Medications and falls

JAGS 200149,  664-672.

Medication review within multifactorial (RR 0.75 [0.65, 0.86])

WHO 2008

Cochrane review 2009

slide10
Plan
  • Epidemiology of falls and fractures
  • What is ProFaNE?
  • What works to reduce falls
    • A review of reviews
  • The work of ProFaNE
profane
ProFaNE

UKManchester 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

slide12

WP1 Taxonomy and classification

WP 3 Assessment of balance function

WP 2 Clinical assessment and management

WP4 Psychological aspects of falling

slide13

www.profane.eu.org

http://profane.co

4,500+ members

slide14
Plan
  • Epidemiology of falls and fractures
  • What is ProFaNE?
  • What works to reduce falls
    • A review of reviews
  • The work of ProFaNE
slide16

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)

slide17

Haines 2004 & Cumming 2008: multifactorial interventions

Healey 2004: fall risk assessment in fallers

Stenvall 2007: comprehensive geriatric assessment , calcium & Vit D post #NoF

slide18

Haines 2004 & Cumming 2008: multifactorial interventions

Healey 2004: fall risk assessment in fallers

Stenvall 2007: comprehensive geriatric assessment , calcium & Vit D post #NoF

slide19

Oliver et al BMJ 2006

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)

Included “poor quality” studies

conclusions for hospitals
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
slide22

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

slide24

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.”
slide26

Environment modification

  • Slippery walking surfaces
  • Lack of handrails
  • Hazards
  • Visual pattern
slide27

Randomised controlled trials of environmental assessment and modification on falls in community samples. (Ballinger, Todd, Whitehead, 2007)

slide28

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
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
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)
results

Exercise effect RR=0.83, 95% CI=0.75-0.93, 17% reduction

Results

Study name

Rate ratio and 95% CI

37 studies 40 comparisons 7111 subjects

0.01

0.1

1

10

100

Sherrington et al 2006

slide32

Balance training intensity

RR= 0.98 [0.84-1.14]

RR= 0.71 [0.63-0.80]

Study name

Rate ratio and 95% CI

Low intensity

High intensity

High intensity

0.01

0.1

1

10

100

0.01

0.1

1

10

100

Sherrington et al 2006

slide33

Risk status

RR= 0.78 [0.66-0.92]

RR= 0.84 [0.74-0.95]

Study name

Rate ratio and 95% CI

Low risk

High risk

0.01

0.1

1

10

100

Sherrington et al 2006

algorithm for exercise prescription
Algorithm for exercise prescription

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
Training needs to be challenging, progressive, regular and aimed at strength and balance.

www.laterlifetraining.co.uk

Otago exercises

wp4 psychological aspects of falling
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

The Problem of Interest: Refusal, drop out & adherence
slide38
Prevention programmes are efficacious
  • Refusal/non-adherence 50% - 90% thus prevention may not be effective
  • Training needs to be challenging, progressive and done regularly.
the studies
The studies
  • UK Qualitative interviews and focus groups
  • UK Quantitative surveys
  • 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 Aged2005

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

findings
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
perceptions of falls prevention messages presented
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 focusgroup of women aged 78 to 95 living in sheltered accommodation)

perceptions of falls prevention messages presented cont
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.

perceptions of falls prevention messages presented cont1
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)

perceptions of falls prevention messages presented cont2
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)

suggestions for future advice
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
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

slide48

Intention to carry out Strength & Balance Training

.87

.09

Threat appraisal

Coping appraisal

Fear of falling (FES-I)

Expected benefits of SBT

Perceived vulnerability

- risk of falling

Expected attitudes of others

Perceived severity -consequences of falling

Expected ability to carry out SBT

Perceived causes of falling

Identity right to do SBT

conclusions
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 practice
Implications for practice

Do 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 practice1
Implications for practice

Do 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

slide52
Prevention programmes are efficacious
  • We have the technology to make them effective
www profane eu org
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