School of Nursing, Midwifery and Social Work

Preventing falls: Evidence from ProFaNE

Chris ToddProfessor of Primary Care & Community Health

Director of Research

Director, ProFaNE

Plan• Epidemiology of falls and fractures• What is ProFaNE?• What works to reduce falls

– A review of reviews

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EVOS/EPOS Group

Falls explain between-center differences in the incidence of limb fracture across Europe. JBMR 2002

Low BMD is less predictive than risk of falling for future limb fractures in women across Europe. Bone 2005

Osteoporosis, falls and fractures

• 30-40% community dwelling 65+ fall in a year– 40-60% no injury– 30-50% minor injury– 5-6% major injury (excluding fracture)– 5% fractures– 1% hip fractures

• Falls most serious frequent home accident• 50% hospital admissions for accidental injury

due to fall• History of falls a major predictor future fall

Masud, Morris Age & Ageing 2001; 30-S4 3-7Rubenstein. Age & Ageing; 2006; 35-S2; ii37-41

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50-59 60-69 70-79 80-89 90+Agegroup (10 yrs)

male female

person years based on 2001 Census data

by age and sexCrude Rate of Falls

Risk of fall admission by age and sex (1.5 million cases 1991-2002)

Increasing rates over 10 year periodTodd et al 2008 report to DH

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50-59 60-69 70-79 80-89 90+Agegroup (10 yrs)

male female

person years based on 2001 Census data

by age and sexCrude Rate of Death within 90 days of Falling

Mortality rates after fall admission by sex

Todd et al 2008 report to DH

• Consequences– Injury

• 4 million NHS England bed days/annum– £2 billion/annum cost of fragility fractures

– Peripheral fractures– Hip fractures

• 70,000/annum• Expensive to treat

– Expensive for patients and families » Money, morbidity, mortality and suffering » 20% die within 90 days» 50% survivors do not regain mobility

– Psychological and social consequences• Disability

– Admission to long term care– Loss of independence

• Falling most common fear of older people– More common than fear of crime or financial fear– Leads to activity restriction, medication use

Risk factors for falls (17 studies)

Risk factor RR or OR RangeMuscle weakness 4.9 1.9-10.3

Impaired balance 3.2 1.6-5.4Gait deficit 3.0 1.7-4.8

Visual deficit 2.8 1.1-7.4Limited mobility 2.5 1.0-5.3

Cognitive impairment 2.4 2.0-4.7Impaired ADL 2.0 1.0-3.1

Postural hypotension 1.9 1.0-3.4

Rubenstein 1993 from WHO 2008.

Medications and fallsCNS benzodiazepines, antidepressants,

antipsychotics (RR 0.34 [0.16, 0.73])

Antihypertensives centrally acting, beta blockers, ACE inhibitors, diuretics

Cardiac medications

cardiac glycosides, anti-arrhythmics, calcium channel blockers

Analgesics NSAIDs, opioids, anticonvulsants, antihistamines gastro-intestinal histamine antagonists

Polypharmacy 4 or more medications 9 fold risk (GP education RR 0.61 [0.41, 0.91])

WHO 2008Cochrane review 2009

Medication review within multifactorial (RR 0.75 [0.65, 0.86])

JAGS 2001 49,  664-672.

Plan• Epidemiology of falls and fractures• What is ProFaNE?• What works to reduce falls

– A review of reviews• The work of ProFaNE

ProFaNEUK Manchester

Warwick Southampton

London Newcastle

D Ulm/Stuttgart Heidelberg

NL Groningen Maastricht

FIN Kuopio Tampere

Turku Jyväskylä

S Lund UmeåF LyonI FlorenceE BarcelonaEL AthensDK CopenhagenNO Bergen

TrondheimCH Lausanne

Lausanne PL Cracow

WP1 Taxonomy and classification

WP 2 Clinical assessment and management

WP 3 Assessment of balance function

WP4 Psychological aspects of falling

www.profane.eu.org

4,500+ members

http://profane.co

Plan• Epidemiology of falls and fractures• What is ProFaNE?• What works to reduce falls

– A review of reviews• The work of ProFaNE

2010

Barreca 2004: sit to stand exercises in groups (stroke patients)Donald 2000: strength training 2X daily with physiotherapist in rehabJarvis 2007: extra physiotherapy strength and balance in rehab (stroke excluded)

Haines 2004 & Cumming 2008: multifactorial interventions Healey 2004: fall risk assessment in fallers Stenvall 2007: comprehensive geriatric assessment , calcium & Vit D post #NoF

Haines 2004 & Cumming 2008: multifactorial interventions Healey 2004: fall risk assessment in fallers Stenvall 2007: comprehensive geriatric assessment , calcium & Vit D post #NoF

Oliver et al BMJ 2006

Included “poor quality” studies

Falls: 0.82 (0.68 to 0.997)Fractures :0.59 (0.22 to 1.58) Relative risk for fallers: 0.95 (0.71 to 1.27)

Conclusions for hospitals• Multi-factorial fall prevention appear

effective for patients >3 weeks LoS• No recommendation re: specific

components of interventions • Exercise in subacute appears

effective

Gates S, et al. Multifactorial assessment and targeted intervention for preventing falls and injuries among older

people in community and emergency care settings: systematic review and meta-analysis BMJ 2008

Gates S et al . BMJ 2008

Gates S, Lamb S, Fisher J, Cooke M, Carter Y. Multifactorial assessment and targeted intervention for preventing falls and injuries among older people in community and emergency

care settings: systematic review and meta-analysis BMJ 2008

• “Evidence of benefit from multifactorial risk assessment and targeted interventions … was limited and reductions in the number of fallers may be smaller than thought.”

Falls and the environment

Slippery walking surfaces Lack of handrails Hazards Visual pattern

Environment modification

Randomised controlled trials of environmental assessment and modification on falls in community samples. (Ballinger, Todd, Whitehead, 2007)

AUTHORS PARTICIPANTS INTERVENTION FINDINGS COMMENTS

Cumming et al (1999)

530 people aged 65+ Home assessment and supervisionOccupational therapist

Not effective for participants who hadn’t experienced a previous fallReduced falls in people who had fallen previously

Reduction in falls outside the home

Day et al (2002) 1090 people, mean age 76.1 (SD 5.5)

Home assessment, advice and provision of materials and labourTrained assessor

Not effective in reducing falls Significant reduction in home hazards

Nikolaus and Bach (2003)

360 people, mean age 81.5 (SD 6.4)

Home assessment, advice and training in use of devicesOccupational therapists and physiotherapists

Effective in reducing falls Particularly effective in those with a history of multiple falls

Pardessus et al (2002)

60 people aged 65+ Home assessment, advice, information about living safely with hazardsOccupational therapist

Not effective in reducing falls Underpowered for falls as outcome measure

Stevens et al (2001)

1737 people aged 70+

Home assessment, education, free installation of safety devicesTrained nurse assessor

Not effective in reducing falls Significant reduction in home hazards

Interventions for preventing falls in older people living in the community (Review)

Gillespie LD, Robertson MC, Gillespie WJ, Lamb SE, Gates S, Cumming RG, Rowe BH

2009

Interventions: Cochrane review 2009 • Exercise targets strength, balance, flexibility, endurance

– programmes with 2 or more components reduce falls & fallers• Supervised group exercise, Tai Chi, & individual prescribed at

home can be effective• Multifactorial assessment and referral works under certain

circumstances – complex interventions causal mechanisms need clarification

• Appropriate medication review and withdrawal can reduce falls• Environment

– Home safety only effective for high risk- professionally administered • VIP

• Surgery in appropriate clinical populations can reduce falls – Cataract surgery, pacemakers (carotid sinus hypersensitivity)– Vitamin D does not reduce falls (except in low baseline) (?)

Rate of falls (Rate Ratios)Group exercise: 0.78 [0.71, 0.86]Individual exercise 0.66 [0.53, 0.82]Group exercise: tai chi 0.63 [0.52, 0.78]Group exercise: gait, balance or functional training 0.73 [0.54, 0.98]Group exercise: strength/ resistance training 0.56 [0.19, 1.65]

Vitamin D meta-analysis Bischoff-Ferrari et al BMJ 2009

High dose – >700IU/day 19% reduction

• (RR 0.81 95% CIs 0.71-0.92)– Serum 25 (OH)D >60nmol/l 23% reduction

• (RR 0.77 95% CIs 0.65-0.90)

Low dose no effectActive vitamin D

reduced risk by 22% • (RR 0.78 95% CIs 0.64-0.94)

ResultsStudy name Rate ratio and 95% CI

BarnettBunoutBuchnerCampbell, 1997Campbell, 1999Campbell, 2005CarterCernyDayEbrahimGreenHauerKorpelainenLathamLiLord, 1995Lord, 2003Liu-Ambrose, ResistanceLiu-Ambrose, AgilityMcMurdoMeansMorganMulrowNowalk, Resist./EnduranceNowalk, Tai ChiProtasReinschResnickRobertsonRubensteinSchoenfelderSchnelleSihvonenSkeltonSteinbergSuzukiToulotteWolf, Tai ChiWolf, BalanceWolf

0.01 0.1 1 10 100

Favours Exercise Favours Control

Exercise and falls

Meta Analysis

Exercise effect RR=0.83, 95% CI=0.75-0.93, 17% reduction

Study name Rate ratio and 95% CI

0.01 0.1 10 1001

Sherrington et al 2006

37 studies 40 comparisons 7111 subjects

Group byHighbal

Study name Rate ratio and 95% CI

0.00 Bunout0.00 Buchner0.00 Carter0.00 Cerny0.00 Day0.00 Ebrahim0.00 Green0.00 Latham0.00 Liu-Ambrose, Resistance0.00 McMurdo0.00 Means0.00 Mulrow0.00 Nowalk, Resist./Endurance0.00 Nowalk, Tai Chi0.00 Reinsch0.00 Resnick0.00 Rubenstein0.00 Schoenfelder0.00 Schnelle0.00 Steinberg0.00 Wolf, Balance0.001.00 Barnett1.00 Campbell, 19971.00 Campbell, 19991.00 Campbell, 20051.00 Hauer1.00 Korpelainen1.00 Li1.00 Lord, 19951.00 Lord, 20031.00 Liu-Ambrose, Agility1.00 Morgan1.00 Protas1.00 Robertson1.00 Sihvonen1.00 Skelton1.00 Suzuki1.00 Toulotte1.00 Wolf, Tai Chi1.00 Wolf1.00

0.01 0.1 1 10 100

Favours A Favours B

Balance exercise and falls

Meta Analysis

Study name Rate ratio and 95% CI

0.01 0.1 10 1001

Low intensity

High intensit

y

Group byHighbal

Study name Rate ratio and 95% CI

0.00 Bunout0.00 Buchner0.00 Carter0.00 Cerny0.00 Day0.00 Ebrahim0.00 Green0.00 Latham0.00 Liu-Ambrose, Resis tance0.00 McMurdo0.00 Means0.00 Mulrow0.00 Nowalk, Resist./Endurance0.00 Nowalk, Tai Chi0.00 Reinsch0.00 Resnick0.00 Rubenstein0.00 Schoenfelder0.00 Schnelle0.00 Steinberg0.00 Wolf, Balance0.001.00 Barnett1.00 Campbell, 19971.00 Campbell, 19991.00 Campbell, 20051.00 Hauer1.00 Korpelainen1.00 Li1.00 Lord, 19951.00 Lord, 20031.00 Liu-Ambrose, Agility1.00 Morgan1.00 Protas1.00 Robertson1.00 Sihvonen1.00 Skelton1.00 Suzuki1.00 Toulotte1.00 Wolf, Tai Chi1.00 Wolf1.00

0.01 0.1 1 10 100

Favours A Favours B

Balance exercise and falls

Meta Analysis

High intensity

Balance training intensity

0.01 0.1 10 1001Sherrington et al 2006

RR= 0.98 [0.84-1.14]RR= 0.71 [0.63-0.80]

Group byHigh_risk

Study name Rate ratio and 95% CI

0.00 Bunout0.00 Carter0.00 Cerny0.00 Day0.00 Korpelainen0.00 Li0.00 Lord, 19950.00 Liu-Ambrose, Resistance0.00 Liu-Ambrose, Agility0.00 McMurdo0.00 Means0.00 Reinsch0.00 Steinberg0.00 Suzuki0.00 Wolf, Tai Chi0.00 Wolf, Balance0.001.00 Barnett1.00 Buchner1.00 Campbell, 19971.00 Campbell, 19991.00 Campbell, 20051.00 Ebrahim1.00 Green1.00 Hauer1.00 Latham1.00 Lord, 20031.00 Morgan1.00 Nowalk, Resist./Endurance1.00 Nowalk, Tai Chi1.00 Protas1.00 Resnick1.00 Robertson1.00 Rubenstein1.00 Skelton1.00 Wolf1.00

0.01 0.1 1 10 100

Favours exercise Favours control

Risk status, exercise and falls

Meta Analysis

Group byHigh_risk

Study name Rate ratio and 95% CI

0.00 Bunout0.00 Carter0.00 Cerny0.00 Day0.00 Korpelainen0.00 Li0.00 Lord, 19950.00 Liu-Ambrose, Resistance0.00 Liu-Ambrose, Agility0.00 McMurdo0.00 Means0.00 Reinsch0.00 Steinberg0.00 Suzuki0.00 Wolf, Tai Chi0.00 Wolf, Balance0.001.00 Barnett1.00 Buchner1.00 Campbell, 19971.00 Campbell, 19991.00 Campbell, 20051.00 Ebrahim1.00 Green1.00 Hauer1.00 Latham1.00 Lord, 20031.00 Morgan1.00 Nowalk, Resist./Endurance1.00 Nowalk, Tai Chi1.00 Protas1.00 Resnick1.00 Robertson1.00 Rubenstein1.00 Skelton1.00 Wolf1.00

0.01 0.1 1 10 100

Favours exercise Favours control

Risk status, exercise and falls

Meta Analysis

Low risk

High risk

Risk statusRate ratio and 95% CIStudy name

0.01 0.1 10 1001

Sherrington et al 2006

RR= 0.78 [0.66-0.92]RR= 0.84 [0.74-0.95]

Algorithm for exercise prescription

POPULATION PROGRAM

Population Low Risk 60-80 Years

Tai Chi type exercises in groups

Population at Increased Risk 70-80 Years

Group balance and strength training

Population at Increased Risk 80 + Years

Otago exercise program

Sherrington, Whitney, Close, Herbert, Cumming, Lord . Exercise for preventing falls: meta-analysis ProFaNE WP2 Australia Falls Conference Brisbane 2006

Training needs to be challenging, progressive, regular and aimed at

strength and balance.

www.laterlifetraining.co.uk Otago exercises

WP4: Psychological aspects of falling• Motivation for prevention• Consequences

– fear of falling (efficacy)• FES-I

– fear of falling interventions

The Problem of Interest: Refusal, drop out & adherence

• High refusal– 50% common

• Low adherence• 18% dropout

average (15 weeks)

• 44% dropout• Long term adherence

poor• Refusal and non-

adherence 50% - 90% thus prevention may not be effective

• Prevention programmes are efficacious

• Refusal/non-adherence 50% - 90% thus prevention may not be effective

• Training needs to be challenging, progressive and done regularly.

Study name Rate ratio and 95% CI

BarnettBunoutBuchnerCampbell, 1997Campbell, 1999Campbell, 2005CarterCernyDayEbrahimGreenHauerKorpelainenLathamLiLord, 1995Lord, 2003Liu-Ambrose, Resis tanceLiu-Ambrose, AgilityMcMurdoMeansMorganMulrowNowalk , Res is t./EnduranceNowalk , Tai ChiProtasReinschResnickRobertsonRubensteinSchoenfelderSchnelleSihvonenSkeltonSteinbergSuzukiToulotteWolf, Tai ChiWolf, BalanceWolf

0.01 0.1 1 10 100

Favours Exercise Favour s Control

Exercise and falls

Meta Analysis

The studies1. UK Qualitative interviews and focus groups2. UK Quantitative surveys3. EU Qualitative interviews and focus groups

Yardley L, Todd C et al

Older people’s views of advice about falls prevention: A qualitative study. Health Education Research. 2006. 21(4); 508-517.

Attitudes and beliefs that predict older people’s intention to undertake strength and balance training. Journals of Gerontology Series B-Psychological Sciences & Social Sciences. 2007; 62(2): 119-25,

Encouraging positive attitudes to falls prevention in later life. London: Help the Aged 2005

Older people’s views of falls prevention interventions in Six European countries. The Gerontologist. 2006. 46(5) 650-660.

Recommendations for promoting the engagement of older people in activities to prevent falls. Quality and Safety in Health Care. 2007 16 230-234.

How likely are older people to take up different falls prevention activities? Preventive Medicine 2008 47 554–558

Socio-demographic factors predict the likelihood of not returning home after hospital admission following a fall Journal of Public Health 2010

FindingsPerceptions of available falls

prevention advice• Reported none received!

– though actually mention of receiving information)

• Perceived falls prevention in terms of hazard reduction – rather than balance improvement– often through restriction of activity

Perceptions of falls prevention messages presented

Discussion of falling prevention is beneficial

I think it would be helpful if someone knows what you should do and what you shouldn’t do..

I think it would give me more confidence of building up your balance if I read this [leaflet about improving balance] now. I think it would give me more confidence when I’m out..

(members of focus group of women aged 78 to 95 living in sheltered accommodation)

Perceptions of falls prevention messages presented cont.

It’s good advice BUT- they wouldn’t necessarily act on (all of)

itIt’s all good. I mean its good advice, yes, excellent, I

agree. I doesn’t mean to say I do it all but I agree.

- it may not fit with their circumstances, lifestyle, prioritised goals

No, no, no, no, no, no ... Nobody would go around with padding.

Perceptions of falls prevention messages presented cont.

It’s good advice - for ‘them’- only seen as relevant to ‘elderly’Because we’re that much fitter -- we don’t really take too

much notice of it, only for other people, for other disabled or elderly people that we have to watch when we’re – we always watch older people anyway.

(man aged 79 in sheltered accommodation)- rejected by fit, younger people, seen as humiliatingI wouldn’t go for that [advice] because it didn’t apply to me in

any shape or form. Is there a bit of pride, is there a bit of “Well, you know, I’m not there yet”

(fit woman in 60s)

Perceptions of falls prevention messages presented cont.

Falls prevention advice unnecessary, upsettingIt can make you feel – somebody producing the leaflets

here – that these people here are senile and they just don’t have any common sense and they need to be told everything.

The last thing you want as you get older is to be told that you’ve got to be conscious every time you go out and might fall, you don’t want that, otherwise your life’s gone.

(woman 78, who had recently fallen)

Suggestions for future advice

• Incorporate falls prevention into lifestyle and general exercise programmes,

• Promote activities as – enjoyable – interesting,– sociable

• Give suggestions in constructive manner • Give explanations • Recognise

– individual’s knowledge – choice of own lifestyle

Quantitative test of conclusions from qualitative studies

558 people aged 60-95 71% women, mean 74.4 yrs53% fell in past year 23% repeat fallers

1918 people aged 54+ (subgroup of 5396 surveyed)57% womenMean 69.747% fell in past year22% repeat fallers

Expected benefits of SBT

Expected attitudes of others

Expected ability to carry out SBT

Identity right to do SBT

Fear of falling (FES-I)

Perceived vulnerability- risk of falling

Perceived severity -consequences of falling

Perceived causes of falling

Threat appraisal Coping appraisal

Intention to carry out Strength &

Balance Training.09 .87

Conclusions• Abandon efforts at ‘falls prevention’ -

emphasise positive benefits of exercise• Emphasise positive benefits of

measures, phrase advice to allow recipients to select/modify to suit goals and lifestyle

• Target advice to different groups of older people (e.g. high/low perceived/actual risk)

Implications for practiceDo not present initially to older people in terms of falling

prevention (since falling risk denied anyway)Talk in terms of Activity Emphasise/maximise immediate wider Benefits: looking

and feeling good; remaining active and independent; taking part in an enjoyable and interesting Communal/social activity

Most effective approach is personal invitation from health professional explaining exactly what is involved, benefits.

Illness, evidence of increasing Disability provides good opportunity to suggest taking this up.

Exercise in terms of everyday activities“F” word Groups only for some Home based exercise preferred

Implications for practiceDo not present initially to older people in terms of falling

prevention (since falling risk denied anyway)Talk in terms of Activity Emphasise/maximise immediate wider Benefits: looking

and feeling good; remaining active and independent; taking part in an enjoyable and interesting Communal/social activity

Most effective approach is personal invitation from health professional explaining exactly what is involved, benefits.

Illness, evidence of increasing Disability provides good opportunity to suggest taking this up.

Exercise in terms of everyday activities“F” word Groups only for some Home based exercise preferred

• Prevention programmes are efficacious

• We have the technology to make them effective

Study name Rate ratio and 95% CI

BarnettBunoutBuchnerCampbell, 1997Campbell, 1999Campbell, 2005CarterCernyDayEbrahimGreenHauerKorpelainenLathamLiLord, 1995Lord, 2003Liu-Ambrose, Resis tanceLiu-Ambrose, AgilityMcMurdoMeansMorganMulrowNowalk , Res is t./EnduranceNowalk , Tai ChiProtasReinschResnickRobertsonRubensteinSchoenfelderSchnelleSihvonenSkeltonSteinbergSuzukiToulotteWolf, Tai ChiWolf, BalanceWolf

0.01 0.1 1 10 100

Favours Exercise Favour s Control

Exercise and falls

Meta Analysis

www.profane.eu.orgFunders WP4European CommissionUnited Kingdom Department of HealthDanish Ministry of Social AffairsHelp the AgedSwiss Federal Office for Education and Science Maastricht University University of Manchester Robert-Bosch-Foundation

Lucy Yardley University of Southampton

Nina Beyer Copenhagen University Hospital

Klaus HauerUniversity of Heidelberg

Ruud KempenUniversity of Maastricht

Chantal Piot-ZieglerUniversity of Lausanne

www.profane.eu.org