Preventing falls for older people presenting to ED - RESPOND program

Keith Hill, Anna Barker, Peter Cameron, Leon Flicker, Glenn Arendts, Caroline Brand, Chris Etherton-Beer, Andrew

Forbes, Terry Haines, Anne-Marie Hill, Peter Hunter, Judith Lowthian, Samuel Nyman, Judith Redfern, de Villiers Smit, Nicholas Waldron, Eileen Boyle, Ellen McDonald, Darshini

Ayton, Renata Morello

MONASHMEDICINE,NURSING ANDHEALTH SCIENCES

GrassRoots Falls Festival – Perth, Sept 2019

Keith.Hill@Monash.edu

PRIMARY FUNDING: NHMRC Partnership grant

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Falls prevention for older people presenting to Emergency Departments – what do we know

Morello R et al, IN PRESS (systematic review and meta-analysis, Injury Prevention, doi: 10.1136/injuryprev-2019-043214

High risk

High risk

High risk

High falls risk group

Low uptake of guide- line level care

Limited effect of interventions to reduce falls

Low level adherence

Reduced effect for referral type interventions

Guideline level practice in falls prevention: Canada

• 54 older adults after an emergency department (ED) fall presentation

• 2 of 54 (3.7%) of the fallers received care consistent with AGS Guidelines

• NB – More recent International fall prevention Guidelines (JAGS 2011)

Salter et al, Osteoporosis Int, 2006

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RESPOND – a new RCT building on previous findings

The gap being addressed:RESPOND was specifically designed to provide personalised and timely education and support to improve knowledge, self-efficacy, and participation in evidence based falls prevention activities

Aim:to investigate the effectiveness of RESPOND for reducing falls and fall injuries in older people after presenting to the ED with a fall.

The name RESPOND was coined based on an underlyingphilosophy of, ‘respond to the first fall to prevent the second’

Barker et al, (Protocol) Injury Prevention, 2019, 10.1136/injuryprev-2014-041271

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Method Recruitment through Alfred Hospital (Melbourne) and Royal

Perth Hospital (Perth) Inclusion criteria:

– Present to ED from community setting with a fall*, and discharged home within 72 hours

– Age 60-90 years Exclusion criteria

– Planned discharge to residential care– receiving palliative care or presence of a terminal illness– Requiring hands-on assistance to walk from another individual– Unable to use a telephone– Non-English speaking– Cognitive impairment (Mini Mental State Examination [MMSE] score

<23) [24], social aggression, or a history of psychosis– Living >50 km from trial sites

* Fall defined as “an event resulting in a person coming to rest inadvertently on the ground, floor, or other lower level” (WHO, 2007)

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Method: Assessment

Home visit within 2 weeks of ED discharge

Assessors blind to group allocation– Falls risk assessment (FROP-Com)– Health literacy (Health Literacy

Questionnaire)– Health related quality of life (EQ-5D-5L)– Falls efficacy (Falls Efficacy Scale

International-short form)

Reassessment 12 months

Primary outcomes:- falls (falls diary)- falls injuries (any

physical harm resulting from a fall (including fractures, dislocations, sprain, skin tears, and bruising)

Secondary outcomes:- ED re-presentations,

hospitalisations, fractures, falls risk, falls efficacy, quality of life, and deaths/person-year over the 12-month study period.

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Method: Intervention and control Randomisation: permuted block randomization

stratified by recruitment site Concealed allocation

Intervention (6 months)– Standard care as initiated by ED staff and their healthcare providers– Discussion of falls risk findings, and four modules of intervention,

and shared prioritisation of initial intervention– Phone followup and support for participation by clinicians (registered

health professional - PT, OT, Ns, Dietitian) with motivational interviewing training Initial phone call within 2 weeks of assessment, then as mutually agreed

for 6 months

Control– Standard care as initiated by ED staff and their healthcare providers

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Key elements of RESPOND: learnings from previous trials• Limited suite of evidence based interventions (4)

• Positive health messages in all program materials

• Clinicians trained in motivational interviewing to support sustained participation

• After initial visit: Phone based intervention x 6 months

Barker et al, (Protocol) Injury Prevention, 10.1136/injuryprev-2014-041271Barker et al, outcome paper – 2019– PloS Medicine

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Statistical analysis

Statistician blind to group allocation

Intention to treat analysis

For primary outcomes, rates were calculated per person-year of exposure time and compared between groups using negative binomial regression models (including adjustment by site and an offset for exposure time)

T-tests used to evaluate change in falls risk, falls efficacy, quality of life measures over time.

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Study flow chart

20% loss to follow-up

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Results: Participant characteristics

Intervention (n=263) Control (n=260)

Age (years) – Mean (SD) 73 (8.4) 73 (8.6)

Female (%) 132 (50.2%) 156 (60.0%)

Lives alone (%) 93 (41.5%) 94 (43.3%)

Three or more comorbidities (%) 63 (28.1%) 64 (29.5%)

FROP-Com total score – Mean (SD) 16.4 (6.1) 16.6 (5.6)

FROP-Com - % high risk (>19) 80 (35.7%) 69 (31.8%)

Falls Efficacy Scale International

(short form) – Mean (SD) (0-28)

11.6 (4.8) 11.6 (5.1)

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Results: Participant outcomes (outcome events over 12 months)

Intervention (n=217)

Control (n=213)

Rate ratio p

Observed days 69803 70993

Number of falls 220 255 0.65 (0.43-0.99) 0.042

Number of fallers 100 (46.1%) 106 (49.8%)

Number of injurious falls

112 (50.9%) 172 (48.5%)

Number of fall injuries

206 269 0.81 (0.51-1.29) 0.374

- Fractures 10 (4.9%) 23 (8.6%) 0.37 (0.15-0.91) 0.030

ED presentations (all cause)

141 154 0.92 (0.64-1.32) 0.653

Hospitalisations (all cause)

173 226 0.78 (0.55-1.10) 0.152

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Results: Secondary outcomes

No significant difference between intervention and control groups in change from baseline to 12 months for:– Falls risk– Falls efficacy– Quality of life

No adverse events or unintended harm were reported to the research team for any participant during the study period

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Results

Barker et al, (Protocol) Injury Prevention, 10.1136/injuryprev-2014-041271Barker et al, outcome paper – 2019– PloS Medicine

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Significant reduction in falls and fractures

No significant change in fall-related injuries, ED representations, other secondary outcomes

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Further results to be published ….

Morris et al, Inj Prev. 2017 Apr;23(2):124-130. doi: 10.1136/injuryprev-2016-042169. Morello et al, Inj Prev. 2017 Apr;23(2):124-130. doi: 10.1136/injuryprev-2016-042169.

Will include: Detailed program

evaluation (BeccyMorris PhD)

Economic evaluation

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Falls prevention for older people presenting to Emergency Departments – systematic review

Morello R et al, IN PRESS (systematic review and meta-analysis, Injury Prevention, doi: 10.1136/injuryprev-2019-043214

A=falls; B=fallers; C=neck of femur fractures

RCTs of multifactorial falls prevention, targeting community-dwelling adults >60 years presenting to the ED with a fall

12 studies, 3986 participants, from 6 countries

Several successful RCTs, a number non-successful

No significant effects in any meta-analyses

Summary and clinical implications

• Relatively low resource intervention successful in high falls risk population (await economic and program evaluation)

• ??model able to be integrated with existing ED services (eg allied health care coordination teams) or in community services

• Key messages for falls prevention generally:– Limited suite of intervention options– Shared prioritisation of interventions– Positive messages to maximise engagement– Motivational interviewing to support participation

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Funding (additional to NHMRC partnership grant):Financial and in-kind contributions from the following partner organisations: Health Strategy and Networks Branch, Strategic System Policy and Planning, Department

of Health, WA Aged and Continuing Care Directorate, Department of Health, WA Royal Perth Hospital Curtin University The University of Western Australia The Royal Perth Hospital Medical Research Foundation Sir Charles Gairdner Hospital (SCGH) Area Rehabilitation and Aged

Care Falls Specialist Program Injury Control Council of Western Australia (ICCWA) The George Institute for Global Health The Alfred Hospital Monash University Integrated Care, Victorian Department of Health