john phd nzrp
TRANSCRIPT
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Senior Lecturer and Director of Post‐graduate Research
Applied Ageing Research Group
School of NursingThe University of Auckland
Academic Lead, RehabilitationThe Institute of Healthy
AgeingWaikato District Health [email protected]
John Parsons PhD NZRP
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WHY?
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Objectives
To gain an understanding of the different strategies to
limit falls risk in older people
To provide evidence based interventions that can be
applied in clinical settings
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Goals
Review physical changes that occur that increase falls
risk among older people
Examine interventions that can be put in place to
reduce falls risk
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What is the evidence for falls in older people?
Falls third commonest cause of injury related death.
1/3 falls need medical care
5% of falls – serious injury
Hip fracture
5% residential care
1% in community dwelling older people
QOL, functional status, care needs, disability
Injury is the tip of the iceberg of morbidity from falls
Costs – 106‐400m/year
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1 Death
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1 Death39 Hospitalisations
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1 Death39 Hospitalisations
1,316 Medical treatments
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1 Death39 Hospitalisations
1,316 Medical treatments
4,200 fallsof 12,600 people over age
65 years
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Physical changes with age
Reaction time
Coordination of balance
Coordination of supportive muscle function
Dependence on visual acuity and peripheral sensing
Dual task performance
General wellbeing (physical, psychological...)
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Impact on functioning
Slowed reaction time
Greater difference in choice reaction time
Loss of muscle strength
Decreased by 1/3 from a peak at 25 years to age 65
Small decrease in gait comfort speed
Greater difficulty rising from a chair / bed
Altered postural control
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Intervening
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Intervening
The Person
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Intervening
The Person The Environment
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Intervening
The Person The Environment
The Exposure
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Intervening
The Person The Environment
The Exposure
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The person Hot and cold falls
–
pragmatic clinical advice
Hot falls: acute medical problem
Infection
Cardiovascular event
Cold falls: less‐acute
multifactorial
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Post hot fall: health professional a detective
Is it new or old
Are they acutely unwell
Intrinsic causes of falls, Stroke, MI, other CV, infection,
constipation, dehydration
Are they poisoned
Assume medication as a cause until proven otherwise,
new mediation, interaction, adverse reaction
Is there an injury
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Cold fall ‐ assessment
Opportunistic or after a fall
Consider risk factors in hx, fear of falling
Parkinsons, stroke, mobility, functional status, medications
Psychotropics esp hypnotics, cardiovascular
Physical exam, esp cardiovasc, neurological, gait and balance
Feasible intervention based on risk factors
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Gillespie, Cochrane review 2004
Prevention –
the person community setting
Medication adjustment, behavioural instructions,
and individualised exercise programmes 0.69 (0.52 ‐ 0.90)
(Tinetti, NEJM 1994)
Exercise programs
Individualised, Otago Exercise Programme falls reduced 30% (Campbell, BMJ 1998)
Group based LLimb strengthening, balance and reaction time, falls reduced 40%
(Lord JAGS 2003)
Tai Chi, 15 wks, fear & mult falls reduced 47% (Wolf, JAGS 1996)
Reduction of sedatives
0.34 (0.16 ‐
0.74)
(Campbell 1999, JAGS)
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Success in Residential care (Jensen, Ann Int Med 2002, Norway)
Multifaceted strategy
Staff education, Modify the environment, Targetted
strength and balance
programmes, Supply and repair aids, Review drug regimens, Provide free hip protectors,
Post‐fall problem solving conferences (Becker 2003)
Vitamin D – 3 trials
Hip protectors
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Personal risk age, living alone, residential carePsychotropicsDepression DementiaMultiple co‐
morbidity
Age & previous falls &Wandering & gait
6xWandrng & environmt
5xEnvironmt & depressn
3x
Frailty
Lower leg weakness
Balance problems
Visual problems
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Personal riskPersonal riskResidential care Community
Prev falls 50% 30%
Gait & balance deficitUse of assistive devises
80% 25%
Visual impairment ArthritisImpaired ADL 100% 20-30%
Cognitive impairment
50-75% 10-25%
Age >80 years 40-50% 6%
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The health system‐
care pathways
Pacemaker insertion for carotid hypersensitivity, SAFE PACE 0.48 (0.32 ‐
0.73)
(Kenny, Am J Cardiol, 2001)
Screened 24,251 people for 257 potential participants
A&E fallers ‐
Clinical assessment & referral
& home safety assessment & modification
0.39 (0.25‐
0.48) (Close, Lancet, 1999)
Rehabilitation ward – targeted multiple
intervention, 3 hosp wards
Fall alert card, info brochure
Exercise programme
Education programme
Hip protectors (57% wore them >12 hrs/day)
Falls reduced by 30%, evident after 45 days
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The environmentHome hazard assessment; greater effect
with high risk 0.85 (0.74 to 0.96) (4 trials)Paths and stairs and rails in public
buildings, road crossings, pedestrian protection
Safer communities
Multiple strategies
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Exposures – risky behaviour
Tie them down? Give them aids?
Wrap them up? Education?
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Targeted strategies
Assessment
Falls prevention strategies
Injury prevention strategies
Patient education
Staff education
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Falls prevention strategies
Medication review
Footwear
Exercise
Continence management
Restraints
Environmental adaptation
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Falls prevention strategies
Medication review
Footwear
Exercise
Continence management
Restraints
Environmental adaptation
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Strong evidence for physical Strong evidence for physical performance changes post performance changes post training training
Gait speed
Stair climbing
Sit to stand
Transfers in/out of car
Lifting loads
Overall daily activity level
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Treatment.
Improve strength, motor control.
Sensory retraining.
Improve fitness, functional ability.
To attempt to prevent further falls.
Muscle strengthening
Transfer practice on/off floor, sit to stand, lying to
sitting.
Balance retraining
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Exercise
Individually tailored strength and balance
programmes
Otago falls prevention programme
Functional rehabilitation
Sit to stand exercises
Group based programmes
Tai Chi
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Adjusted Effects of Exercise on Falls (Sherington et al, 2008)
High BalanceChallenge
Mod‐Low BalanceChallenge
Programme Adjusted Pooled Rate Ratios(95% Confidence Interval)
High dose and walking 0.76 (0.66–0.88) 0.96 (0.80–1.16)
High dose, no walking 0.58 (0.48–0.69) 0.73 (0.60–0.88)
Low dose and walking 0.95 (0.78–1.16) 1.20 (1.00–1.44 )
Low dose, no walking 0.72 (0.60–0.87) 0.91 (0.79–1.05)
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Potential for Harm
PRT in frail
hospitalised decr function & incr pain
(Latham 2003)
Lo intensity intv in res care ‐
incr falls
(Kerse 2004)
Walking after arm fracture increased falls (Ebrahim 1996)
Fall rates
00.5
11.5
22.5
33.5
44.5
5
Jan/F
ebMch
/AprMay
/Jun
Jul/A
ugSep
t/Oct
Nov/D
ecJa
n/Feb
Mch/Apr
falls
/resi
dent
yea
r
interventioncontrol
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Wolf et al (2003)
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Exposures – risky behaviour
Tie them down? Give them aids?
Wrap them up? Education?
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Residential Aged Care
Other factors increasing falls risk and influencing
functional changes and decreased physical activity in residents include:
underlying physical and cognitive function
health status
motivation
cultural expectations
environmental factors
coexisting disease states
fear of falling
( Cameron, Kurle, Cumming, & Quine, 2000 ; Crews, 2005 )
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Who should encourage physical activity and so reduce falls risk in RAC?
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Applying the evidence – stamp out the epidemic
Sustainable strategies, resources
Within existing health structures
Where to find high risk elders
At
home,
at
the
shops,
primary
health
care,
A&E, hospital wards
Where to intervene
At
home,
in
the
community,
at
the
GPs,
at
a
clinic or referral place, in the hospital,
What to do
Proven
strategies,
acceptable,
sustainable,
resourced
Care with monitoring