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  1. 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. 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

  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) Todd et al 2008 report to DH Increasing rates over 10 year period

  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) Rubenstein 1993 from WHO 2008.

  9. Medications and falls JAGS 200149,  664-672. Medication review within multifactorial (RR 0.75 [0.65, 0.86]) WHO 2008 Cochrane review 2009

  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 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

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

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

  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 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

  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. 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

  22. Gates S et al . BMJ 2008

  23. 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.”

  24. Falls and the environment

  25. Environment modification • Slippery walking surfaces • Lack of handrails • Hazards • Visual pattern

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

  27. 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

  28. 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]

  29. 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)

  30. 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

  31. 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

  32. 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

  33. Algorithm for exercise prescription Sherrington, Whitney, Close, Herbert, Cumming, Lord . Exercise for preventing falls: meta-analysis ProFaNE WP2 Australia Falls Conference Brisbane 2006

  34. Training needs to be challenging, progressive, regular and aimed at strength and balance. www.laterlifetraining.co.uk Otago exercises

  35. WP4: Psychological aspects of falling • Motivation for prevention • Consequences • fear of falling (efficacy) • FES-I • fear of falling interventions

  36. 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

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

  38. 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

  39. 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

  40. 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)

  41. 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.

  42. 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)

  43. 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)

  44. 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

  45. 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

  46. 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

  47. 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)

  48. 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