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