Exercise (strength and balance training) offered as a component of multidisciplinary falls prevention Older people living in extended care settings (e.g. nursing homes) who are at risk of falling and Older people > 65yrs (or 50-64 yrs judged to be at higher risk of falls) admitted to hospital where any identified muscle weakness or gait/balance problem can be treated, improved or managed with individualised intervention during the patient's expected stay should be offered individually prescribed exercise as a component of multidisciplinary falls prevention intervention NICE 2013
Considerations when designing and delivering evidence based exercise for falls prevention • Previous falls (secondary prevention) • Identified fall risk (primary prevention) Target group • Consider cognitive function • Consider motivation and likely adherence Type and setting • Strength/resistance exercises • Balance/gait training • Individual or group based of exercise • Trained professional Frequency and • How many times per week duration • Over how many weeks • The right degree of challenge for the individual Intensity • Supervision/progression over time
How evidence-based are our exercise programmes? Survey of 1768 patients* referred to falls prevention services in England, Wales and NI wide shows two thirds were participating in group based exercise but wide variation in models of delivery of exercise interventions Recommended exercise • Most patients attended group-based classes of programmes should be short duration (<12 weeks) and only once/week individually tailored, progressive Only 50% patients said their programme was and delivered over long periods progressed as they improved (Otago 1 year; FaME 35 wks) High levels of patient • But lack of follow up afterwards satisfaction with programme *Buttery et al 2014 #t1noefs
Where the evidence doesn’t help … • Evidence is inconclusive that exercise prevents falls in dementia/cognitive impairment* Dementia • Poor adherence and loss to follow up* • Cognitive impairment is frequently cited as a reason not to refer or not to offer exercise** Fear of • Exercise alone may possibly reduce fear of falls but only in the short term*** falls • Not all trials have fear of falling as an outcome*** *Winter et al 2013 **Buttery et al 2014 ***Kendrick et al 2014
Adherence and compliance Trials report uptake of exercise interventions can drop from as high as 80% in the first 10 weeks to 50% at one year* In practice adherence can be much lower Patient level barriers include transport, cost, motivation and injury Programme level barriers Group – Decreased adherence with duration of 20 weeks or more, two or fewer sessions per week, or a flexibility component** Home - Increased adherence with balance component, home visit support and physiotherapy led*** Decreased adherence with flexibility component*** * Nyman and Victor 2011 **McPhate et al 2013 ***Simek et al 2012
How can we promote and improve adherence? Older people participate in exercise to remain Physiotherapists are fatalistic independent and they value with a ‘take it or leave it’ approaches that promote attitude to the exercise they autonomy and self prescribe and instruct management Robinson et al 2013
Population-based interventions for prevention of fall related injuries in older people Systematic review to assess the effectiveness of population-based interventions, defined as coordinated, community-wide, multi-strategy initiatives, for reducing fall-related injuries among older people. Preliminary claim that the population-based approach to the prevention of fall-related injury is effective and can form the basis of public health practice. Randomised, multiple community trials of population-based interventions are indicated to increase the level of evidence in support of the population-based approach. McClure et al 2008
Exercise and falls prevention: from evidence to implementation Evidence Joined up Multiple Leadership based approach agency Population and intervention with other commitment based and continuous Joint applied pathways/ and older whole system innovation and commissioning consistently services, people approach quality and with e.g. involvement improvement training dementia
References Buttery AK et al (2014) Older people’s experiences of therapeutic exercise as part of a falls prevention service: survey findings from England, Wales and Northern Ireland. Age and Ageing , 43: 369 – 374 Kendrick D et al (2014) Exercise for reducing fear of falling in older people living in the community (Review), Cochrane Library, Issue 11 McClure RJ (2005) Population-based interventions for the prevention of fall related injuries in older people (Review), Cochrane Library, Issue 1 McPhate L et al (2013)Program-related factors are associated with adherence to group exercise interventions for the prevention of falls: a systematic review. Journal of Physiotherapy , Australian Physiotherapy Association Vol. 59 NICE (2013) Falls: assessment and prevention of falls in older people, NICE clinical guideline 161. Nyman S and Victor CR (2012) Older people’s participation in and engagement with falls prevention interventions in community settings: an augment to the Cochrane systematic review, Age and Ageing , 41: 16 – 23 Robinson L et al (2014) Self-management and adherence with exercise-based falls prevention programmes: a qualitative study to explore the views and experiences of older people and physiotherapists. Disability and Rehabilitation , 36(5): 379 – 386 Simek EM et al (2012) Adherence to and efficacy of home exercise programs to prevent falls: A systematic review and meta-analysis of the impact of exercise program characteristics. Preventive Medicine , 55: 262-75 Winter H et al (2013) Falls prevention interventions for community dwelling older persons with cognitive impairment: A systematic review. International Psychogeriatrics , 25(2):215 – 227
A Hybrid Approach to Falls Rehab Dean W Metz, BSc MPH Falls Specialist Physiotherapist South Tyneside Foundation Trust 1 st North of England Falls Summit 16 March 2015 #t1noefs
A Unique Approach 1. A multifactorial Assessment done jointly by a nurse and a physiotherapist 2. A home programme to address specific identified weaknesses 3. A six stage progressive exercise programme administered by HCA and rehab nurses 4. Physio interventions not already included in the six stage programme #t1noefs
The Six Stage Programme 1. Supine 2. Seated in armchair 3. Seated on edge of mat table 4. Standing using rail for support 5. Standing using no upper extremity support 6. Dynamic standing on challenging surfaces BP and medications are monitored throughout
People need to function in challenging environments
People don’t walk solely on linoleum.
People need to reach and balance to perform everyday tasks
Our Programme • Builds on static strength training and incorporates trunk (core) exercises on gym balls and standing on alternative surfaces • Emphasizes quick reactions to stimuli • Is transferable to day to day functional activities
Tossing a ball whilst on pliable surface
Reaching and placing whilst on unstable surface
Kicking a ball or Playing football
Our Audit Results • Reduced Risk of Falling Timed up and go: Mean decreased by 8.2 seconds Tinetti: Mean score increased by 5.8 points FES-I: Mean score decreased by 5.9 points • Reduced Rate of Falling Self reported falls decreased by 81% 6 months after discharge
Refreshments and Networking #t1noefs
F A S S Multifactorial Falls Prevention Dr John Davison FRCPE PhD Falls & Syncope Service Newcastle-upon-Tyne Hospitals NHS Trust
A fall is not a diagnosis “ A fall may occur as a consequence of summative interaction of pathologies with reduced adaptive reserve ” Swift C 2006 Falls may signal unidentified medical problems unresolved underlying medical conditions Resultant of ≥1 intrinsic and / or extrinsic factors A cumulative risk Risk factors predispose events
Steinweg KK. Am Fam Physician 1997;56:1815-22
Epidemiology of falls the most common cause of accidents and associated morbidity in older people 35% aged >65 years will fall in any given year Campbell 1981, Blake 1988, Prudham 1981 Up to 75% in those > 85 years Lehtola 2006 Up to 45% of Emergency attendances in those Subjects > 50 Years attending >65 years are associated with a fall A&E (n = 71,279) Non-Fallers 59% 20 % of these are admitted Richardson 1997 25 -60% result in injury Cummings 1988, Tinetti 1988, Nevitt 1991 2 - 5% lead to a fracture No Data 7% Tinetti 1988, Luukinen 1995 Fallers 34% (n = 24,251) Richardson 1997
Sequelae of a fall Loss of confidence to perform ADLs Tinetti M et al 1994, Vellas B et al 1997 Changes in health status Cwikel J et al 1992 Social isolation Increased hospitalisation Mortality at 1 year increased - recurrent fallers (OR 2.6, CI 1.4-4.7) Increased Risk of admission to long-tem care single fallers (OR 3.8, CI 1.8-8.3) recurrent fallers (OR 4.5, CI 1.7-12) Donald, Bulpitt 1999
Fall Risk Factors Perell 2001, Leipzig 1999, Intrinsic Cesari 2002, Tinetti 1993 Extrinsic Lower limb muscle weakness Walking aids (OR 2.6) (OR 4.4) Polypharmacy (OR 1.6 – 3.0) Gait abnormalities (OR 2.9) Culprit medication (OR 1.5 – 2.0) Balance abnormalities (OR 2.9) Environmental hazards (OR 1.5) Visual impairment (OR 2.5) Balance 100 Arthritis (OR 2.4) Median 5 fall Risk Factors 90 Gait identified (Range 1-10) ( n=146) Cognitive impairment (OR 1.8) 80 70 Neurocardiovascular Medication % Home Hazards with 60 abnormalities Carotid Sinus Hypersensitivity risk 50 factor Orthostatic Hypotension 40 Vision Synergism 30 Neurological 20 Depression of risk Vasovagal 10 0 Davison J, Age Ageing 2005;34:162-8
Fall risk No risk factors 3 or more risk factors Nevitt, 1989; Robbins, 1989; Tinetti, 1988
Overlap Between Syncope and Falls Unreliability of history 32% of elderly with documented falls were unable to recall the event 3 months later (Cummings 1988) Lack of witness account Only 40-60% of syncopal events are witnessed (McIntosh 1993) Amnesia for loss of consciousness (Kenny 1991)
Which population? Older community dwelling adults +/- fall risk factors Recruitment population for majority of exercise only interventions 7 RCT (n = 2361) RR 0.72 (0.58 – 0.90) Older adults who have sustained a fall Multifactorial intervention studies indicate benefit 17 RCT – pts selected for higher risk of falling (n = 5954) RR 0.77 (0.66 – 0.90) Benefit not seen in multifactorial Rx when patients not selected for high falls risk Group exercise in higher risk group (n = 1261, 9 studies) RR 0.70 (0.58 – 0.85)
Key Intervention Studies - Community Tinetti NEJM 1994 Age 70+ with at least 1 fall risk factor (30% prev fallers) Multifactorial intervention 31% reduction in percentage falling (35% v 47%) Campbell BMJ 1997 Women age 80+ (40% prev fallers) Individually tailored strength & balance training programme 152 falls in control gp (n=117) v 88 in exercise gp (n=116) Robertson BMJ 2001 Age 75+ (36% prev fallers) nurse delivered strength & balance training programme 109 falls in control gp (n=119) v 80 in exercise gp (n=121)
Community dwelling – present with a fall • PROFET study • Age 65+ • Attending A&E with fall (72% single fallers) • Medical and OT intervention • Day hospital referral for identified risk factors • Falls • 510 falls in control gp (n=163) vs. 183 (n=141) • RR 0.39 (95% CI 0.23 - 0.66) • Fallers Close et al, Lancet 1999;353:93-7
Recurrent Fallers – Emergency Dept Davison et al, Age Ageing 2005;34:162-8
Recurrent Fallers – Emergency Dept • Recurrent fallers (median 3 falls) • Medical, PT and OT intervention • Neurocardiovascular risk factor assessment & intervention • 387 falls intervention gp (n=144) vs. 617 (n=149) • Mean rate of falls 3.3 (SD 5.0) vs. 5.1 (SD 7.9) • RR 0.64 (95% CI 0.46 - 0.90) = 36% reduction • No effect on fallers (68% control vs 65% intervention)
Community dwelling fallers – ambulance response 204 adults > 60 years ambulance called - subject not conveyed Randomised to community falls prevention (PT, OT, Nurses, medical review) or standard care Incidence rate of falls per year 3.46 vs 7.68 IRR 0.45 (95% C.I. 0.35 – 0.58) – negative binomial regression Number of further ambulance calls reduced – IRR 0.60 (95% C.I. 0.40 – 0.92) Logan PA et al, BMJ 2010;340:2102
Exercise (Tai Chi, multiple component group, individually prescribed home) is effective as a single intervention Pooled RR = 0.71 (95%CI 0.62-0.80) A J Campbell, Age & Ageing 2007:36:656-62
Multifactorial interventions reduce rate of falls Pooled RR = 0.76 (95%CI 0.67-0.86) Gillespie LD et al: Cochrane Systematic Review 2012
Hospital Inpatients Assess for Risk of Falls cognitive impairment continence problems falls history, including causes and consequences (such as injury and fear of falling) footwear that is unsuitable or missing health problems that may increase risk of falling medication postural instability, mobility problems and/or balance problems syncope syndrome visual impairment
Hospital Inpatients Act on risks identified Multifactorial intervention – Fall rate reduction 20 – 30% significant reductions in falls no significant reductions in falls 100 perecentage of trials 90 80 70 60 50 40 30 20 10 0 multi-professional > five components post-fall review numerical risk score patient information toileting plans medication review staff education urine screening environment footwear hip protectors wristband exercise alarms beside sign Fall rate ratio 0.75 (0.68-0.84) Oliver D, Healey F, Haines T (2010) Clinics in Geriatric Medicine 26 (4) 645-92
Contributing Interventions that work • Vitamin D – in those with low Vit D levels – > 800 units / day • Home safety interventions – only effective in visual impairment and if at ‘ high risk ’ of falling • First eye cataract surgery Harwood BJO 2005 • Pacemakers for carotid sinus hypersensitivity? Kenny JACC 2001, Parry 2009, Ryan 2010 3 studies, n=349, RR 0.73 (0.57 – 0.93) • Podiatry for those with foot problems Spinks BMJ 2011 • Integration of balance & strength training into daily life activity Clemson BMJ 2012
When is multifactorial intervention less effective? • Patients with dementia • ‘ Treat the reversible ’ – look at medication change, BP control, behaviour management, # risk Shaw BMJ 2003;326:73 • Single assessor intervention Kingston 2001, Lightbody 2002, Hendricks 2008 • Generalist multifactorial intervention? Spice, Age Ageing 2009
Single assessor intervention Nurse-led multifactorial intervention medication ECG F/U after ED attendance with fall blood pressure 348 patients > 65 years cognition multifaceted assessment visual acuity trend towards reduction in falls - hearing vestibular dysfunction 89 in 36 intervention vs. 145 in 39 controls (ns) Balance Feet and footwear Mobility Lightbody et al Age Ageing 2002;31:203-10 Medication review education Single assessor assessment & intervention after ED attendance with fall – modelled on PROFET environmental risk ax exercise advice N=333 fallers age > 65 years referrals individualised intervention OR of further falls = 0.86 (0.50-1.49) Hendricks MR et al, JAGS 2008; 56(8):1390-7
Cluster randomised controlled trial Community dwelling recurrent fallers age >65 yrs not presenting to ED Intervention: 18 general practices randomly allocated Primary care group – nurse assessment in the community, using risk factor review and targeted 1. referral Secondary care group – day hospital multi-disciplinary assessment and intervention 2. Controls – usual care 3. Results: 505 recruited (complete FU in 83%) Fewer fallers in secondary care group - 75%, (158/210) vs. 84%, (133/159) adjusted OR = 0.52 (95% CI 0.35 – 0.79) P = 0.002 Primary care group similar to controls - 87%, 118/136, OR 1.17 (95% CI 0.57 – 2.37)
What to do in practice? Case find for falls 1. Assessment Get up and go test History Previous falls Examination Arthritis Cardiovascular Muscle weakness Orthostatic hypotension Gait / balance problems murmurs Stroke / PD Neurological Medication Muscle strength Cognition Sensation Sensation Locomotor Vision Gait inc feet / footwear Vestibular Dix-Hallpike
Is there a medical cause ? Is the fall unexplained? Does the patient recall the fall? Are the injuries proportionate? Are there other clinical pointers from the history? Lightheadedness Think…white coat hypertension – beware single BP symptoms with posture change Think….OH, culprit meds Symptoms when lying back / turning in bed Think….BPPV
What to do in practice? Investigations Visual acuity / Treatment Contrast Medication modification Active Stand Treat Orthostatic ECG Hypotension Haematology / Targeted muscle biochemistry strengthening exercise CSM if syncope Duration > 12 weeks Dix-Hallpike Balance exercise DEXA Environment modification Vitamin D if deficient Treatments for specific conditions Epley PPM
Visual assessment Verbaken A, Johnston A.W. Am J Optom 63: 724-732, 1986 .
Investigations Spacelabs 90207
Medication review Any new medications? Timing of tablets? Culprit medications - FRID? antidepressants (esp SSRI on initiation) benzodiazepines neuroleptics /antipsychotics sedatives / hypnotics antihypertensives diuretics Ziere Br J Clin Pharm 2006, Leipzig JAGS 1999, Ensrud JAGS 2002, Woolcott Arch Int Med 2009, Sterke Br J Clin Pharm 2012
Medication Change • Gradual withdrawal of psychotropic meds Campbell JAGS 1999 Community group with fall risk factors n = 93 Relative Risk of falling at end of intervention 0.34 [0.16, 0.73] Not sustained • Withdrawal of Fall Risk Increasing Drug n = 139 with one or more falls in previous year FRID stopped in 67, reduced in 8 All FRID (n = 75) 0.48 (95% CI 0.23, 0.99) Cardiovascular Drugs 0.35 (95% CI 0.15, 0.82) Psychotropics (n = 29) 0.56 (95% CI 0.23 – 1.38) Van der Velde, Br J Clin Pharm 2007; 63(2): 232-7)
Don ’ t forget about bone health ! www.shef.ac.uk/FRAX
Take Home Messages Both single and multifactorial interventions reduce fall rates by about 30% Single interventions esp exercise work in community settings – early targeting of those with risk factors Multifactorial intervention is effective for specific patient groups - when delivered by specialist teams Multifactorial intervention essential for hospital inpatients Heterogeneity of interventions remains large Consider specific interventions for sub-groups Look out for ‘ easy wins ’
Posture induced symptoms • Lightheaded on standing? • Unsteady on standing? • Symptoms on lying flat or turning? Facial or head injury • Disproportionate injury Fall with no apparent hazard Loss of consciousness
East Riding Falls Service Jon Duckles – Service Manager Claire Sellers – Clinical Therapy Lead Humber NHS Foundation Trust 1 st North of England Falls Summit 16 March 2015 #t1noefs
Local Drivers Why change? - Circa 20,000 people in the East Riding fall each year (POPPI data) - 30% of admissions to A&E are as a result of a fall - Limited falls service The new model: - Evidence based - Community focused, patient centred - Multi disciplinary, multi agency approach Investment: - £340k investment - Risk share agreement Benefits: - Improved patient care - 12% reduction in unplanned admissions = £400k savings
Risk Share 1130 Acute Admissions due to Falls relative to 1130 Admissions Risk £’s
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