exercise for falls prevention in older people: evidence...
TRANSCRIPT
Exercise for Falls Prevention in Older People:
Evidence & Questions
Professor Pam Dawson
Associate Pro Vice Chancellor
Strategic Workforce Planning and Development
Northumbria University
13 March 2017
#fallsnenc
What is a fall?
A fall is defined as an unintentional or unexpected loss of balance resulting in coming to rest on the floor, the ground, or an object below knee level (NICE).
#fallsnenc
Falls: the scale of the problem
30% people >65yrs
50% people >80yrs
fall at least once per year
5% of community
dwelling fallers will experience a
fracture
Falls are the most commonly reported patient safety incident in NHS Trusts in
England
Falls affect the faller, family and carers:
Injury, pain, distress, fear, loss of
confidence and independence,
reduced quality of life, mortality
Falls cost the NHS >£2.3b per
year
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Evidence for falls prevention: the problem of the scale
Huge number of individual trials
and studies globally over more than 2
decades
Individual trials inform systematic reviews, Cochrane reviews, position statements, NICE
guidelines, ptpathways …
Evidence doesn’t speak
for itself – it has to be
interpreted for the individual
and their context
Outcome measures –
Fall rates (falls per person year) or
Fall risk (number of fallers in each group of a trial)
Primary versus secondary prevention
Community versus care
settings
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Most recent NICE (2017 update) guideline messages re exercise in falls
prevention
Exercise (strength and balance training) offered as a single intervention
by an appropriately trained professional
Untargeted group based exercise has not been shown to be effective in these conditions
should be offered multiple component exercise (strength and balance training) in an individual or group programme
(following a multifactorial falls risk assessment)
as a single falls prevention intervention individually prescribed and monitored
Older people living in the community
with a history of recurrent falls and/or an identified gait and balance deficit
NICE 2017
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Exercise (strength and balance training) offered asa component of multidisciplinary falls prevention
should be offered individually prescribed exercise as a component of multidisciplinary falls prevention intervention
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
Older people living in extended care settings (e.g. nursing homes)
who are at risk of falling
NICE 2017
and
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Considerations when designing and delivering evidence based exercise for falls prevention
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• Previous falls (secondary prevention) versus identified fall risk (primary prevention)
• Consider cognitive function
• Consider motivation and likely adherence
• Gender?
Target group
• Strength/resistance exercises
• Balance/gait training
• Individual or group based
• Trained professional
• Social aspect?
Type and setting
of exercise
• How many times per week
• Over how many weeks
Frequency and duration
• The right degree of challenge for the individual
• Supervision/progression over timeIntensity
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
• Most patients attended group-based classes of short duration (<12 weeks) and only once/week
Only 50% patients said their programme was progressed as they improved
Recommended exercise programmes should be
individually tailored, progressive and delivered over long periods
(Otago 1 year; FaME 35 wks)
• But lack of follow up afterwards High levels of patient
satisfaction with programme
*Buttery et al 2014
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Where the evidence doesn’t help …
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•Evidence inconclusive that exercise prevents falls in dementia/ cognitive impairment*•Poor adherence and loss to follow up*•Cognitive impairment frequently cited as a reason not to refer or not to offer exercise**•Recent small trial - 6 month tailored programme can improve balance, concern about falls, and planned physical activity in community-dwelling older people with dementia***
Dementia
• Exercise alone may possibly reduce fear of falls but only in the short term****
• Not all trials have fear of falling as an outcome****
Fear of falls
*Winter et al 2013 **Buttery et al 2014 ***Taylor et al 2017 ****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 than 50%
Patient level barriers include transport, cost, motivation and fear of injury
50-82% community dwelling older people did not consider that participation in exercise programs would be worthwhile, even if it reduced risk of falling to 0%.**
Programme level barriersGroup – 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 ** Franco et al 2016 ***McPhate et al 2013 ****Simek et al 2012
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How can we promote and improve adherence?
Older people participate in exercise to remain
independent and they value approaches that promote
autonomy and self management
Physiotherapists are fatalistic with a ‘take it or leave it’
attitude to the exercise they prescribe and instruct
Robinson et al 2013
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Barriers and facilitators in exercise for falls prevention
Barriers
Practical issues - transport
Concerns – adverse effects, too difficult
Unawareness – denial of fall risk
Reduced health status –unwell, fatigue
Lack of support – poor instructor, no support at home
Lack of interest – low motivation
Facilitators
Support – professional and family
Social interaction –relationships, social time
Perceived benefit – staying independent
Supportive exercise context –trust, individual adaptation
Feelings of commitment –structured programme
Having fun - enjoyment
Sandlund et al 2017 systematic review
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Population-based interventions forprevention 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.
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McClure et al 2008
Exercise and falls prevention:from evidence to implementation
Multiple agency
commitment and older
people involvement
Population based and
whole system
approach involving all
sectors
Evidence based
intervention applied
consistently and with training
Joined up approach with
other pathways/
services, e.g. dementia
Leadership and
continuous innovation and quality
improvement
Joint commissioning
#fallsnenc
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
Franco MR et al (2016) Smallest worthwhile effect of exercise programs to prevent falls among older people: estimates from benefit–harm trade-off and discrete choice methods. Age and Ageing, 45: 806-12
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 (2017 update) Falls: assessment and prevention of falls in older people, NICE clinical guideline 161.
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References
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
Sandlund et al (2017) Gender perspectives on views and preferences of older people on exercise to prevent falls: a systematic mixed studies review. BMC Geriatrics (2017) 17:58
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
Taylor et al (2017) A home-based, carer-enhanced exercise program improves balance and falls efficacy in community-dwelling older people with dementia. International Psychogeriatrics, 29:1, 81–91.
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
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