falls prevention in community setting
TRANSCRIPT
Preventing falls in older persons in the community setting
Geriatric Medicine Grand Rounds
15 Jun 2015
Falls are common among community dwelling older persons
• One-third of community-dwelling older people experience at least one fall in a year
• In NSW:– Majority of falls happen in and around their homes
– 66% were injured as a result and 20% had to visit a hospital
– Falls related-hospitalisations increased from 1990-91 to 2009-10 (approx. 32,000)
• >90% hip fractures are associated with falls, and most occur in >70 year olds3
NSW Health 2010, Gill et al SA Health 2009Grisso et al Engl J Med. 1991;324: 1326-31
What predicts the future risk of falls in the community setting?
Risk Factor Likelihood Ratio
History of falls in the past 1 year 2.3-2.8
Clinically detected abnormalities of gait or balance
1.7-2.4
visual impairment OR 1.6-2.0
impaired cognition 5 errors on SPMSQ21 1.9-9.6Dementia 1.9-149
medication use Psychotrophic 1.3-2.2≥4 medications 1.4-2.5
ADL Impairments 1.4-2.6
Note: Orthostatic hypotension did not predict falls after controlling for other factors
Ganz et al JAMA. 2007;297:77-86
Indoor and Outdoor Falls in Older Adults are Different
• Outdoor fallers - younger, male, healthy and physically active
• Indoor fallers – older, female, more comorbidities, slower gait speed, ADL impairments
• 50% of falls in community-dwelling older people occur outdoors
MOBILIZE Boston Study JAGS 2010; 58:2135–2141
Which screening/ assessment tools are most useful?
• Only some tools have been evaluated in prospective studies
• In general, tests have high specificity and lack adequate sensitivity
• In one systematic review, three tools—the 5 min walk, the five-step test and the Functional Reach were found to have strong predictive validity (On the basis of predictive values of 70% or higher for both sensitivity and specificity)
Gates et al J Rehabil Res Dev. 2008;45(8):1105-16Scott et al Age & Ageing (2007) 36 (2): 130-139
Gates et al J Rehabil Res Dev. 2008;45(8):1105-16
Falls prevention programs
1. Single programs – single intervention directed at all residents
2. Multiple programs – more than one intervention provided to all residents
3. Multifactorial – more than one intervention targeted to individual risk profile
Prevention of Falls Network Europe (ProFaNE)
Outcome measures: falls and fallers
• Rate of falls = number of falls per unit of person time Rate Ratio=
number of falls per person year in the intervention group
number of falls per person year in the control group
• Risk of falls= number of fallersRelative Risk (risk ratio) =
proportion of fallers in intervention group
proportion of fallers in control group
Total of 159 trials with 79,193 participants in 21 countries; 70% female
Intervention Number of trials included
Exercise 59 trials (n= 13,264)
Vitamin D 16 trials (n=29,002)
Medication withdrawal 5 trials
Cataract surgery 2 trials - expedited cataract surgery for the first eye (Harwood 2005) and second affected eye (Foss 2006)
Environment/assistive technology 13 single intervention: home safety, eye glasses, foot wear
Education interventions 5 trials
cardiac pacing in carotid sinus hypersensitivity
3 trials
Psychological intervention e.g. CBT 2 trials
Multifactorial 40 trials
Gillespie et al 2012
Gillespie et al Cochrane Database Syst Rev. 2012 ;9:CD007146
Exercise interventionType Intervention Pooled analysis
Group exercise Multiple categories of exercise
rate of falls: pooled RaR 0.71 (0.63 -0.82), n= 3622, 16 trials
risk of falling: pooled RR 0.85 (0.76-0.96), n= 5333, 22 trials
Thai Chi rate of falls: RaR 0.72 (0.52- 1.00), n=1563, 5 trialsrisk of falling: RR 0.71, (0.57- 0.87); n= 1625, 6 trials
Individual Exercise
Multiple categories of exercise at home
rate of falls: RaR 0.68 (0.58 - 0.80), n= 951, 7 trialsrisk of falling: RR 0.78 (0.64 - 0.94), n= 714, 6 trials
Walking No reduction in risk of falling or number of falls
Gillespie et al Cochrane Database Syst Rev. 2012 ;9:CD007146
Exercise interventionType Intervention Pooled analysis
Group and individual exercise
Balance Training rate of falls: pooled RaR 0.72 (0.55-0.94), n= 519, 4 trialsNo reduction in risk of falling: Pooled RR 0.81 (0.62- 1.07), n= 453, 3 trials
Strength/resistance training
No reduction in rate of falls or risk of falls; 2 trials reported risk of adverse events – MSK injuries/ complaints
High intensity vs. low intensity/frequency exercise
1/7 studies showed significant reduction in rate and risk of falls
Gillespie et al Cochrane Database Syst Rev. 2012 ;9:CD007146
Fracture risk: Exercise interventions did not result in a statistically significantreduction in risk of fracture (RR 0.72, 0.47-1.11; 570 participants, 5 trials).
• Exercise as a single intervention can prevent falls (pooled rate ratio 0.84, 95% CI 0.77–0.91)
• 64% variance in rate reduction was explained by balance training, a dose of >50 hours and no walking programme
Sherrington et al NSW Public Health Bull 2011, 22:78-83
Vitamin D supplementation
• 14 trials, n=28,135
• rate of falls: RaR 1.00 (0.90-1.11), n=9324, 7 trials
• risk of falling: RR 0.96 (0.89-1.03), n=26,747, 13 trials
• risk of fracture: RR 0.94 (0.82-1.09), n=27,070, 10 trials
Gillespie et al Cochrane Database Syst Rev. 2012 ;9:CD007146
Supplementation in Vitamin D deficient subjects
• Trials only recruiting participants with lower vitamin D levels at enrolment:
–RaR 0.57 (0.37- 0.89), n=260, 2 trials
–RR 0.70 (CI 0.56- 0.87), n=804, 4 trials
• Trials not selecting participants on the basis of vitamin D levels
–RaR 1.02 (0.93-1.13), n=9064, 5 trials
–RR 1.00 (0.93- 1.07), n=25,943, 9 trials
Gillespie et al Cochrane Database Syst Rev. 2012 ;9:CD007146
Medication withdrawal
Gillespie et al Cochrane Database Syst Rev. 2012 ;9:CD007146
Home safety assessment and modification by Occupational Therapist
Gillespie et al Cochrane Database Syst Rev. 2012 ;9:CD007146
Vision improvementStudy Intervention n Result
Cumming 2007 vision assessment and eye examination and intervention
616 Significant increase in both rate of falls (RaR 1.57, 1.19-2.06) and risk of falling (RR 1.54, 1.24 -1.91).
Day 2002 Visual acuity assessment and referral
1090 No significant reduction in rate of falls (RaR 0.91, 0.77-1.09) or risk of falling (RR 0.89, 0.76 -1.04).
Haran 2010 Switch multifocal to single lens glasses for most walking and standing activities(indoors and outdoors)
597 No significant reduction in rate of falls (RaR 0.92, 0.73-1.17) or risk of falling (RR 0.97, 0.85-1.11). Significant reduction in indoor+outdoor falls in subgroup who took part in outdoor activities.
Gillespie et al Cochrane Database Syst Rev. 2012 ;9:CD007146
Footwear modificationStudy Intervention n Result
McKiernan 2005
non-slip device (Yaktrax® walker) on outdoor shoes in winter
109 Significant reductionin rate of outdoor falls (RaR0.42, 0.22-0.78)
Perry 2008 balance-enhancinginsoles
1090 No significant reduction in risk of falling (RR 0.56, 0.23 -1.38)
Gillespie et al Cochrane Database Syst Rev. 2012 ;9:CD007146
Surgical Interventions
Gillespie et al Cochrane Database Syst Rev. 2012 ;9:CD007146
Multifaceted podiatry
• In one study rate of falls was reduced in people with disabling foot pain receiving “multifaceted podiatry”(customised orthoses, footwear review, foot and ankle exercises, fall prevention education in addition to “usual podiatry care”).
Gillespie et al Cochrane Database Syst Rev. 2012 ;9:CD007146
Education interventions
• No evidence that Education, as a single intervention, reduces either rate of falls or risk of falls
Gillespie et al Cochrane Database Syst Rev. 2012 ;9:CD007146
Multifactorial interventions
• Significantly reduced the rate of falls (RaR 0.76, 0.67-0.86, n= 9503, 19 trials, but substantial heterogeneity between individual studies (I2 = 85%, P < 0.00001).
• No significant reduction in risk of falling (RR 0.93, 0.86-1.02, n=13,617, 34 trials, also substantial heterogeneity (I2 = 69%, P < 0.00001)
• No significant reduction in risk of fracture (RR 0.84, 0.67-1.05, n=3808, 11 trials)
Gillespie et al Cochrane Database Syst Rev. 2012 ;9:CD007146
Gates et al BMJ. 2008; 336: 130–133
Gates et al BMJ. 2008; 336: 130–133
Campbell et al Age and Ageing2007;36: 656-662
Multiple interventions
• Various combinations of multiple interventions
• 18/19 combinations from 14 trials and 15/18 combinations from 13 trials looking at rate of falls and risk of falls included an exercise component
• Few multiple component interventions were effective
• Studies were not pooled due to clinical heterogeneity of the interventions
Gillespie et al Cochrane Database Syst Rev. 2012 ;9:CD007146
Forest plot from the meta-analysis of multiple component interventions on number of fallers showing estimates of risk ratio, 95% confidence intervals and relative weight of each study.Goodwin et al. BMC Geriatrics 2014 14:15
Forest plot from meta-analysis of multiple component interventions on fall rates showing estimates of rate ratio, 95% confidence intervals and relative weight of each study.Goodwin et al. BMC Geriatrics 2014 14:15
Gillespie et al Cochrane Database Syst Rev. 2012 ;9:CD007146
Key Points
• Exercise must be of a sufficient dose to have an effect
• Falls prevention exercise should be targeted at the general community as well as those at high risk for falls
• More interventions are not necessarily better
• Multiple interventions that are not tailored to the individual can be effective
RaR = Rate ratio (falls per person-year); RR= relative risk (no of fallers)
RaR 0.78 RR 0.89
RaR 1.03 RR 1.07
but not risk of falling