Preventing and managing falls. Emma Spellman Msc, BAOT Falls Lead, Salford

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1 Preventing and managing falls Emma Spellman Msc, BAOT Falls Lead, Salford

2 Falls in the UK 11 million people aged over 65 28,000 women aged over people admitted to hospital every day (33 never go home) Fractures cost 1.8 billion per year Annual European Home and Leisure Accident Surveillance Survey (EHLASS) Report UK, 2000

3 When do we become fallers instead of trippers? When intrinsic abilities to remain upright cannot cope with extrinsic risk factors. Nervous system, reaction time and gait speed slows down Balance and strength deteriorates Fracture site changes with age wrist fractures more common in younger people, hip fractures more common in older people

4 CMO Guidelines for older adults Older adults: should aim to be active daily. Over a week, activity should add up to at least 150 minutes of moderate intensity activity in bouts of 10 minutes or more. should also undertake physical activity to improve muscle strength on at least two days a week. at risk of falls should incorporate physical activity to improve balance and co-ordination on at least two days a week. All other adults should minimise the amount of time spent being sedentary (sitting) for long periods of time.

5 Sedentary behaviour = active bone and strength loss No standing activity leads to active loss of bone and muscle o o 1 week bed rest decreases leg strength by 20% 1 week bed rest decreases spine BMD by 1% Sedentary behaviour = worse balance Nursing home residents spend 80-90% of their time seated or lying down Krolner 1983, Tinetti 1988, Skelton 2001

6 Sedentary UK 40% of people aged 50 or over in the UK are sedentary 60-85% are sedentary in ethnic minority groups Half of the sedentary over 50 s and 2/3 of over 70 s believe they take part in enough physical activity to keep fit. Those who break up long periods of sitting are less likely to develop obesity or diabetes than those who sit for long periods, even if they meet physical activity guidelines.

7 Making better choices More than 3 hours per week targeted exercise o Osteoporosis 2 times less likely o Hip fracture 2 times less likely o Also reduces risk of high blood pressure, obesity, stroke and diabetes and improves quality of life with medical conditions More than 3 hours per week on your feet o Reduced risk of falls and fractures Active people are more likely to have better mood, be less anxious, have better memory, sleep better and have more social contacts ACSM 2007, CDC 1996, 2002, Sesso 2000, Nicholl 1994, WHO 1997, NIA 1998, BHF 2010

8 Major risk factors All fallers (odds ratio) History of falls Gait problems Walking aids Vertigo Parkinson's Anti-epileptic drugs Physical disability Fear of falling All fallers = fell at least once during follow up Recurrent fallers = fell at least twice during follow up Recurrent fallers (odds ratio) Deandrea S et al. Epidemiology. 2010;21:

9 Other risk factors Strength and balance Prescribed medications/multiple drug regimes (Analgesics, Antidepressants, Sedatives, Antipsychotics, Diuretics) - Any 4 or more medications Alcohol (more than 7 units per week) Poor foot health and foot pain Poor vision (acuity, contrast, depth perception) Multiple conditions and co-morbidities (esp. Stroke, PD, dementias) Continence (urge, frequency, overactive bladder, nocturia) Environment

10 Fear of falling Fear and lack of confidence in balance predict: Deterioration in physical functioning (Arfken 1994, Vellas 1997) Decreases in physical activity, indoor and outdoor (Arfken 1994, Finch 1997) Increase in fractures (Arfken 1994) Admission to Institutional Care (Cumming 2000, Vellas 1997)

11 Cochrane evidence 159 trials with 79,193 participants Group and home-based exercise programmes,. Multi-factorial assessment and intervention programmes reduce rate of falls but not risk of falling; Tai Chi reduces risk of falling. Insufficient evidence that interventions designed to prevent falls will also prevent hip or other fallassociated fractures Home safety assessed by OTs Gillespie et al. Interventions for preventing falls in older people living in the community. Cochrane Library 2012

12 Cochrane evidence continued Insertion of pacemakers Vitamin D First eye cataract surgery Prescribing modification An anti-slip shoe device reduced rate of falls in icy conditions (RaR 0.42; 1 trial).

13 Falls prevention education Trials testing interventions to increase knowledge/educate about fall prevention alone did not significantly reduce the rate of falls or risk of falling (RaR 0.33; 1 trial) (RR 0.88; 4 trials). Gillespie et al. Interventions for preventing falls in older people living in the community. Cochrane Library 2012

14 Exercise Exercise must provide a moderate/high challenge to balance Sufficient exercise dose (20 mins per day On-going exercise Target general community as well as those at high risk Brisk walking should not be prescribed to high risk individuals Strength training may be included in addition to balance

15 Conclusions Falls are preventable Strength and balance exercise targets bone health and falls prevention Exercise and physical activity improvements will do more than influence falls and fractures Our challenge now is to encourage frailer older people to uptake and adhere to interventions and all older adults to be as active as possible

16 Government stipulation Multifactorial interventions offer individualised multifactorial intervention to older people at risk, Including: strength and balance training home hazard assessment and intervention vision assessment and referral medication review/withdrawal After medical treatment for an injurious fall, patients should be offered multidisciplinary assessment and intervention.

17 Summary - Falls provision in Salford Clinical Home visits Home rehab programme Full falls assessments and intervention on each rehab unit Teaching Variety of falls teaching packages

18 Clinical Provision Assessment Home environment Strength and movement Various balance tests Screen tests for vision, hearing, feet and bone health Memory/thinking Functional tasks Intervention Falls prevention information Referrals 6/52 home rehab programme. Provision of any aids, adaptations or equipment and practice with these. 12/52 community balance group 3/52 rolling falls prevention programme in all ICS rehab units

19 Teaching and collaborative work Teaching Who: Health, social, voluntary and private sector staff Salford city wide What: Variety of teaching packages to suit audience When: Follow falls training calendar focussing on one group each month Why: Promotion of high standards across Salford Where: Salford Royal, Gateways and other settings Current projects Fire Service - inter-referrals NWAS - same Care on call top to toe training Learning disabilities teaching to service users Public health falls prevention to public Mental health fear of falls study Care homes policy, protocols and prevention work Quality Improvement see next slide

20 Test of change across Salford Area Community rehab Swinton Hall The Limes Heartly Green Rapid response Test of change update Crib sheet for CR staff providing service to care home residents. Balance assessments Falls Pathway re-vamp Education of care staff re falls management and documentation Trial of standardised assessments Trail of standardised assessments as above Medication review protocol Education of care staff re falls management and documentation. Postural BPs 3 rd Telecare trial Trail of standardised assessments as above MDT roles with falls management Postural BPs Medication review protocol Trail of standardised assessments as above