Falls: what

1
Falls whats the big deal??

• Transferring research into function forum
• Port Fairy October 2005
• Associate Professor Keith Hill,
• Physiotherapist Researcher,
• National Ageing Research Institute
• k.hill_at_nari.unimelb.edu.au

2
Overview

• How big is the problem of falls among older
  people?
• What are the key falls risk factors?
• What is the research evidence?
• How can the research evidence be practically
  applied?
• Gaps in the research evidence
• Other settings

3
Falls as a National Issue
Australian Institute of Health and Welfare, 2002
Hospital separations due to injury and
poisoning, Australia 199900
Research Centre for Injury Studies, AIHW
4
Falls related mortality in Australia
Data from NISU, AIHW, 2000
5
Falls related hospitalisations in Austalia
Data from NISU, AIHW, 2000
6
Falls rates increase with increasing age...
Campbell et al, 1981
7
Frequency of falls in older people (Australia)

• community based surveys using
• proportional sampling
• retrospective falls recall

• approximately 30 of community dwelling people
  aged 65
• experience one or more falls in a 12 month period
• approximately 10 seek medical assistance or
  curtail activity
• as a result of their fall

Dolinis et al, 1997 Kendig et al, 1996
8
Systems involved in balance
Central integration
SENSORY
MOTOR
vision
coordination
strength
vestibular
range of motion
somato-sensory
reaction time
9
The balance system
Central integration
AGE
PATHOLOGY / DISEASE

• Neuro-musculo-skeletal (efferent) components
  (balance response)
• muscle strength
• motor reaction time
• joint integrity..etc

• Sensory (afferent) components
• visual
• somatosensory
• vestibular

10
Falls at a Victorian level
MUARC Hazard No 54, 2003
11
Falls at a Victorian level
MUARC Hazard No 54, 2003
12
Falls at a regional level hospital admissions
VAED data July 2001-Jun 2004
13
Age of fallers (2002-3 data)
14
Injuries for hospitalised fallers

• SGG PCP
  SW PCP
• Fractures ( adm) 52 56
• Lower limb injury 39 33
• Injury to the head 13 18

2002/3 data
15
Fall circumstances
Large number unclassified circumstances of fall
2002/3 data
16
Separation
2002/3 data
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Fear of falling (falls efficacy)

• fear of falling is the greatest fear for older
  people (25) (Walker Howland, 1991)
• Australian data (Kendig et al, 1996)
• one in three community dwelling people aged 65
  have some self-reported fear of falling
• approximately 7 report severe fear of falling

18
Fear of falling

• need not be proportional to severity of
• physical deficits
• perceptual deficits
• needs to be identified as a problem, and
  incorporated into management
• use of additional physical / psychological /
  other supports

19
Other factors

• implicated in up to 40 of admissions to
  residential care
• quality of life issues
• independence
• community living
• active life-style
• other

20

• health care costs for falls related injuries
  among those aged gt55 years are estimated at 489
  million annually (Australia) (Moller 2003)
• estimated to triple by 2051 if rates remain
  unchanged (Moller 2003)

21
Key points

• although falls rates increase with age, they are
  NOT due to age alone
• many people in their 70s, 80s and 90s lead
  active and busy lifestyles
• many falls can be prevented
• even falls which do not cause serious injury can
  reduce confidence and activity level, which over
  time increases falls risk

22
Falls are multi factorial
Intrinsic factors
Health problems
Ageing
Medications
Environment
eg. psychoactive meds
Activity related risks
Extrinsic factors
23
Identifying who is at risk of falls

• factors commonly associated with fallers
• previous falls
• lower extremity weakness
• arthritis (hips / knees)
• gait / balance disorders
• cognitive disorders (depression / dementia / poor
  judgement...)
• visual disorders
• postural hypotension
• bladder dysfunction (frequency / urgency /
  nocturia / incontinence...)
• medications (psychotropics/ sedatives / hypnotics
  / antihypertensives...)

Tideiksaar, 1995
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Falls risk index Rubenstein et al, 1994 (review)
RISK FACTOR
Odds Ratio Range Physical
examination weakness
6.2
4.9 - 8.4 balance deficit
4.6 3.9 -
5.4 gait deficit
3.6 2.4 -
4.8 impaired mobility / use of gait aid
3.3 2.0 - 4.6
functional impairment
3.1 ? visual
deficit
2.7 1.1 - 4.5 postural
hypotension
2.1 1.0 - 3.4 cognitive
impairment
1.5 1.0 - 2.0 Drugs
antidepressants
2.4 1.0 - 5.7
sedative / hypnotic agents
2.0 1.0 - 3.2 Diagnoses
arthritis
1.6 0.9 - 2.4
depression
1.6 1.0 - 2.5
25
Number of risk factors
Tinetti et al, 1988
26
Early identification of risk
Samples often used to evaluate prediction accuracy
Ideal range for studies aiming for prediction
accuracy
Very frail/ High falls risk
Healthy older people
CONTINUUM OF FRAILTY
27
Periodic case finding in primary care ask all
patients about falls in past year
JAGS, 2001
No intervention
Patient presents to medical facility after a fall
Check for balance and gait problem
Fall evaluation
Assessment history medications vision gait and
balance lower limb joints neurological cardiovascu
lar
Multifactorial intervention (as
appropriate) gait, balance and exercise
programs medication modification postural
hypotension treatment environmental hazard
modification cardiovascular disorder treatment
28
Falls risk screening self screen
29
Elderly Falls Screening Test (EFST) Cwikel et
al, 1998 community dwelling older people
1. Self reported falls history 0-1 0
2 1 2. Did you injure yourself
no injury 0
any injury 1 3. Frequency of
near falls never or rarely 0

occasionally or frequently 1 4. Gait speed
gt/ 30 m/min 0

lt30 m/min 1 5. Gait style
even, straight and feet clear each step 0
uneven, shuffling, wide base, or
unsteady 1
High falls risk 2 or more points
30
Elderly Falls Screening Test (EFST) Cwikel et
al, 1998 community dwelling older people

• EFST conducted on 361 subjects
• significant (though low) correlations between
• components
• small subgroup also assessed by blinded
  physicians to
• identify falls risk (n28)
• sensitivity 0.83
• specificity 0.69

31
Comprehensive falls risk assessment tool
32
Research review what works?

• Funded by Commonwealth Dept Health Aged Care
• Randomised controlled trials
• Community, residential aged care, and hospital
  settings
• Published in 2000, updated by NARI and
  re-published in 2004

33
Cochrane Systematic reviews

• 2000 2004
• Falls Falls
• Hip protectors Hip protectors
• Vitamin D
• Environmental mods

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Evidence of intervention effectiveness
Community (2000)
Exercise-bal
Environment
Exercise-gen
Multiple strat
Medical screen
Medication
Exercise-str
Injury min
Sensory
Education
Risk factor Chronic medical conditions Environment
al hazards Reduced activity Reduced
balance Reduced strength Poor vision Cognitive
impairment Polypharmacy Osteoporosis Low body
mass index Depression Other
Level II
35
Evidence of intervention effectiveness
Community (2004)
Exercise-bal
Environment
Multiple strat
Medical screen
Exercise-gen
Exercise-str
Injury min
Medication
Post-hosp
Education
Sensory
Risk factor Chronic medical conditions Environment
al hazards Reduced activity Reduced
balance Reduced strength Poor vision Cognitive
impairment Polypharmacy Osteoporosis Low body
mass index Depression Other
Level II (2000)
Level II (2004)
36
Randomised controlled trials with significant
outcomes
37
Home assessment and modification whose role?

• Environmental hazards are common in the homes of
  older people
• In many cases, there has been no previous
  assessment of the home for falls hazards
• The majority of environmental hazards within the
  home are easily remedied

Any health professional with a role within the
home of older people should consider providing
advice regarding falls hazards
38
Environmental safety Home falls risk assessment
modification

• commonly used
• One RCT identifying significant reduction in
  falls rates for an OT home visit / environmental
  assessment / behaviour risk modification IN AT
  RISK GROUP ONLY (Cumming et al, 1999)
• NB equally as effective at home and away
  from home
• issues of compliance

39
Behavior modification

• Observe activities and behaviors which increase
  an individuals risk of falling
• discuss alternative strategies with
• the patient
• the carer / family
• Assess environment in the context of the
  individual
• Home FAST tool (MacKenzie et al, 2000 2001)

40
Post hospitalisation

• 15 of older people fall at least once within 1
  month of discharge home from hospital, with 11
  experiencing serious injuries (Mahoney et al,
  2000)
• Nikolaus and Bach 2003
• older people admitted to hospital with functional
  decline
• post discharge, usual care vs additional home
  intervention including follow-up visits,
  instructions on use of aids and home
  modifications, support for compliance
• significant reduction in falls at 12 months
• differential outcome based on compliance

41
Exercise
strong evidence of effectiveness of training in
older people to improve specific risk factor

• various forms of exercise
• balance
• strength
• cardiovascular fitness
• flexibility
• specificity of training
• other health benefits of exercise programs

42
Exercise

• tai chi (Wolf et al, 1996)
• physiotherapy prescribed home program (Campbell
  et al, 1997)
• group exercise program (Day et al, 2002, Barnett
  et al, 2003 Lord et al, 2003)

43
Clinical screen Medical (including medication)

• no published RCTs evaluating medical screen with
  falls rate as an outcome
• Campbell et al (1999) - RCT - psychotropic
  medication withdrawal
• 66 reduction in falls rates in intervention
  group
• 47 had resumed psychotropics after one month

44
Vision correction

• Critical role of vision in balance and obstacle
  avoidance
• Melbourne study identified identified that a
  third of people over 65 have inadequate visual
  correction
• Cataract surgery has been shown to reduce falls
  (RCT Harwood et al, 2004)
• ?? Effectiveness of visual assessment and
  correction
• ?? Effectiveness of changing bifocals to separate
  distance and reading glasses (current Sydney
  study)

45
Clinical screen Multiple strategy (restricted)

• Tinetti et al (1994) - RCT - subjects with one or
  more falls risk factors, all provided with 3
  interventions (home mods, home exercise,
  medication review)
• sig difference in time to first fall, number of
  falls and fear of falling
• Rizzo et al (1996) - cost benefit analysis of
  Tinettis program

46
Clinical screen Multiple strategy (unrestricted)

• incorporates assessment and tailored management
• Close et al (1999) - RCT - assessment by medical
  and occupational therapy staff
• significant reduction in falls rates
• Cochrane meta-analysis (Gillespie et al, 2004)
• Current NARI study nearing completion (700 older
  fallers presenting to Emergency Departments after
  a fall)

47
Walking aids - issues to consider

• who prescribed the aid?
• is it the correct height?
• is it being used correctly?
• is the aid providing the appropriate amount of
  support?
• does the aid interfere with daily activities?
• is the aid in good condition (eg stoppers)?

IS THERE A NEED FOR OTHER INTERVENTIONS WHICH MAY
MINIMISE LONG TERM NEED FOR THE GAIT AID?
48
Common problems with walking aids

• forgetting to use it
• not using it when it has been recommended
• not maintaining in good condition
• Observe negotiation of tight spaces
• eg using a frame in a toilet
• Observe need for dual tasks
• eg carrying a plate to the table if needing to
  use a frame (alternatives include a trolley or a
  frame with a tray)
• Observe stepping backwards
• eg opening a door

Consider the functional requirements of the
individual
49
Feet

• provide the base of support (wider apart results
  in greater stability)
• base of support includes other ground contacts
  such as walking aid
• stability can be compromised by pain / deformity
• consider referral to a podiatrist if problems
  persist

50
Footwear

• important interface between the person and the
  support surface
• base of support is determined by the amount of
  shoe in contact with the ground
• high, narrow heels have small base of support and
  high falls risk
• stability is increased with
• low broad heels
• good fit shoe
• textured sole
• lace up

51
Common problems with footwear

• conflict between fashion and common sense /
  safety
• poor footwear often worn at home (eg poor fitting
  moccasins / slippers)
• scuffs
• poor condition (eg front of sole of shoe becoming
  loose)

52
Injury minimisation

• Alternative strategies may be indicated if
• falls risk is high
• intervention has not been successful
• other factors limit likelihood of successful
  intervention (eg poor cognition)

53

• Hip protectors
• Limited studies in community setting
• shown to be effective in residential care
  settings
• issues of limited compliance

54
Injury minimisation

• Vitamin D calcium supplementation
• RCT of older people in community / residential
  aged care settings identified significant
  reduction in falls fracture rates (Chapuy et al,
  1992)
• Mechanism of slowing normal bone loss
• Recent evidence of effect on reducing falls

55
Getting up after a fall

• important for older people at risk of falling
• consequences of long lies
• increased death rates
• reduced functional outcomes
• practice can be beneficial in improving abilities
  at getting up from the floor

Potential need for personal alarm
56
Achieving and sustaining change

• Key issue across all aspects of falls
  prevention
• Exercise / activity - up to 50 dropout over 6-12
  months
• Psychotropic reduction - half resumed medication
  within 1 month of end of study
• Hip protectors poor compliance, despite
  considerable enhancements
• Home modifications - variable compliance
• Comprehensive assessment and targeted management

57
Potential factors influencing limited outcomes in
implementing research evidence
Service system
Optimal outcomes
Practitioners
Client / family
58
Knowledge and perception of falls related risk
factors and falls reduction techniques

• 86 of sample considered falls were preventable
• Most considered falls to be a moderately
  important concern relative to other health
  concerns
• Environmental factors perceived as most common
  causes of falls

(Braun, 1998)
59
Knowledge and perception of falls related risk
factors and falls reduction techniques

• Risk factor
  Importance
• General Personal
• Interior environment (eg rugs)
  7.5 3.8
• Exterior environment (eg uneven paths)
  9.0 7.4
• Physical factors (eg coordination/ balance)
  8.2 2.7
• Physical factors (eg muscle weakness)
  8.0 2.5
• Psychological factors (eg doing risky things)
  8.0 1.9
• Psychological factors (eg not paying attentn)
  7.7 2.2

Range 0-10, 10 being most likely to increase
falls risk
(Braun, 1998)
60
Stepping on program
(Clemson et al, 2004)

• RCT, sample 70 years, recent fall or loss of
  confidence
• Intervention aims to support
• Self efficacy
• Facilitate / support behavioural change
• Exercise (balance and strength)
• Improving home and community environment
  behavioural safety
• Encourage regular vision screening vision
  adaptations
• Encourage medication review
• 2hrs weekly x 7 weeks sessions followup OT home
  visit
• 31 reduction in falls (RR 0.69, 95CI
  0.50-0.96)

61
Becoming salespersons

• Number of recommendations
• Mode of making recommendations
• Verbal
• Written
• Consistency of message
• Family
• Home care workers / other support staff
• Other health practitioners
• Client empowerment

62
Research gaps Community setting

• Some risk factors poorly understood and managed
• dizziness
• Some interventions have good clinical basis, but
  limited research evidence
• use of walking aids
• footwear
• Effect of early identification of falls risk
• All interventions are only as good as the
  adherence to the intervention regime - issues to
  improve uptake and compliance need further
  exploration
• Almost all interventions that have been shown to
  be effective have not included subjects with an
  important falls risk factor - cognitive
  impairment (NB- Shaw et al 2003)

63
Where to from here

• Address remaining research gaps
• Develop innovative strategies to improve
• service system response
• health practitioners knowledge, skills, and
  capacity to deliver strategic interventions
• older peoples engagement in recommended falls
  prevention activities

across the continuum of risk
64
Other settings

• falls rates even higher in hospital and
  residential care settings
• limited research evidence of effective
  interventions in these settings
• ?? greater importance / control over key factors
  of environment and staffing
• evidence of multifactorial interventions reducing
  falls rates

65
In summary

• many falls and falls injuries among older people
  are preventable
• early identification of specific risk factors is
  likely to improve outcomes
• client compliance is critical to optimise
  successful falls prevention activities
• practitioners have a key role in maximising
  uptake of recommended intervention
• most research evidence in community setting, need
  for further research in residential and hospital
  settings, where falls rates are even higher

Rapidly expanding evidence base