Evidence-Based Multifactorial Interventions to Prevent Falls

1. “C4A Fall Prevention Conference”, San Jose, CA. April 14, 2008 Evidence-Based MultifactorialInterventions to Prevent Falls Debra J. Rose, Ph.D. Co-Director, Fall Prevention Center of Excellence California State University, Fullerton www.stopfalls.org

2. Components of Multifactorial Fall Prevention Programs • Screening and/or Assessment (with or without medical exam) • Physical Activity (Exercise) • Home Assessment and Modification • Medical Management • Vision Assessment and/or correction; postural hypotension; medication; assistive device, etc • Fall Risk Education/ Behavior Change

3. Evidence-Based Research • Single vs Multiple Intervention Strategies • General vs Tailored Approaches • Different Target Audiences (Or Not) • Different Methods of Delivery • Different Intervention Settings • Different Providers

4. Physical Activity (Exercise) • Effective as a Stand-Alone Strategy • Core component of most successful multifactorial approaches • Exercise strategy differs as function of fall risk

5. Stand-Alone Intervention Strategies • Single modes of exercise include tai chi, strength training, walking. • Multiple modes may include aerobic endurance, strength, flexibility, balance, and mobility. • Fall risk and/or fall incidence rates lowered irrespective of type BUT not to same extent. • Few head-to-head comparisons to date.

6. Home Modifications Successful programs: • Include financial or manual assistance • Hire trained health care professionals (OTs) to perform initial assessments • Target older adults who are ready for change (e.g., Fall history, increased understanding of risk) • Are combined with education and counseling about how to decrease risk

7. Fall Risk Education/ Behavior Change • Insufficient evidence to evaluate as a stand-alone intervention. • Often included as part of a multi-component strategy. • Accurate perception of fall risk not always evident. • Timing of program is important. • Education of consumer and service provider important.

8. Fall Risk Education/ Behavior Change • Can take many forms. • Trained peer volunteers are well received by seniors. • First step in continuum of injury prevention. • Must raise awareness about importance of preventing falls. • Must change notions that falls cannot be prevented and change behavior to increase long-term adherence.

9. Multifactorial Approaches • Require a multidisciplinary team approach • Can be labor and resource intensive depending on complexity • Most effective when targeted to high risk older adults at individual vs community level • Intervention strategies need to specifically target identified risk factors

10. “There is NO One-Size-Fits-All Fall Prevention Program”

11. Low-Risk Fall Prevention Programs • Primary goal is to prevent onset of pathology and/or disability • Many activity choices available (single vs multimodal exercise; less structured lifestyle activity) • Fall risk education component may be helpful addition for purpose of raising awareness. • Self-assessment of home desirable

12. Examples of Programs1,2 • Low- Moderate Risk • Enhance Fitness(Community-based; Group; SS)* • Tai Chi – Moving for Better Balance (Community-based; Group; SS)* • Matter of Balance (Community-based; Group; MF)* • Osteofit (Community-based; Group; MF)*

13. Comprehensive assessment of fall risk factors desirable. Benefit from programs that specifically target identified physical risk factors. Specific balance and gait activities selected on basis of comprehensive evaluation of system impairments Moderate Risk Fall Prevention Programs

14. Examples of Programs • Moderate – High Risk • Fallproof™ (Community-based; Group plus home-based program; MF)* • Stepping On (Community-based; Group; MF – US replication in progress)* • Step-By-Step (Community-based; Group; MF – Pilot phase of development)

15. Carefully tailored and prioritized exercise program, usually as part of an individualized or staged multifactorial intervention strategy. Individually designed program that progresses from low to moderate intensity over longer duration. Couple exercise program with behavior skills training component and monitoring. High Risk Fall Prevention Programs

16. Examples of Programs • High-Risk • FaME (Falls Management Exercise – Group plus home-based program; SS) • Otago Programme (Home-based exercise; SS)* • SAIL (Strategies and Actions for Independent Living – Home-based; MF) • InSTEP (Increasing Stability through Evaluation and Practice – Community-based, Group; MF – Pilot phase of development)

17. Changing Behavior3 • Recommended Strategies: • Secure social support from family and friends • Promote participant’s self-efficacy and perceived competence • Providing older adults with active choices that are tailored to their personal needs and preferences • Negotiate realistic and measurable goals, action plans, and health contracts to promote adherence • Educate participants about actual risks of intervention • Provide regular and accurate performance feedback.

18. Marketing Strategies4 • ProFANE Network recommends the following: • Promote benefits of intervention relative to improving balance and reducing fall risk • Foster self-management skills (active vs passive role) • Match intervention to needs, preferences, and capabilities • Market program in a manner that is highly valued by older adults.

19. Sustainability5 • What is sustainability? • Why is it important? • What is the best pathway to follow to ensure sustainability? • Pathway #1 – Redefine scope of FP activities or program • Pathway #2 – Creative use available resources

20. Selected References • Multifactorial and Physical Activity Programs for Fall Prevention Fact Sheet (2008). Available at: http://www.stopfalls.org/grantees_info/index.shtml • Preventing Falls: What Works (2008). Available at: www.cdc.gov/ncipc/preventingfalls 3. WHO Global Report on Falls Prevention in Older Age (2007). Available at: http://www.who.int/ageing/projects/falls_prevention_older_age/en/index.html • Yardley L et al. (2007). J Active Aging; Sept/Oct: 46-52. • Basner E. et al. (2008). Pathways to sustaining fall prevention activities. Available at: http://www.stopfalls.org/grantees_info/files/SustainabilityTA_Brief.pdf