Falls Prevention for Older Adults Living in the Community: Evidence Update for Private Practitioners. 5th April 2014 The Niche, Nedlands

Transcription

1 Falls Prevention for Older Adults Living in the Community: Evidence Update for Private Practitioners 5th April 2014 The Niche, Nedlands

2 Welcome Vanessa Jessup Co-chair of Gerontological Physiotherapy Association WA Branch

3 Associate Professor Anne-Marie Hill Australian Physiotherapy Association Gerontological Physiotherapist

4 Older People Maintaining Independence with Falls Prevention Associate Professor Anne-Marie Hill RESEARCH FELLOW NHMRC Early Career Fellowship

5 Overview Why Focus on Falls Prevention? What is the Latest? Highlight Key Relevant research for first point of contact Practitioners Ongoing Resources 3 part Presentation Questions, Feedback, Panel discussion 5

6 Community Evidence Evidence focuses on key areas Community, RACFs, Hospitals Special populations Dementia, Stroke, Post Discharge Younger old vs Older old May not be chronological Important to start Early Decline in balance 6

7 Do we have a problem? Falls - leading cause of injury-related hospital admissions among older people in Australia 1.4 million patient bed days Estimated direct hospital costs alone > $645 million Total cost of health care associated with fall injuries NSW 2006/07 alone - estimated at $558.5M Age-standardised rates of fall injury cases increased by 2% per year ( 25,000 extra falls injuries) 7 Harrison AIHW, 2010; Watson, 2010

8 Background Studies consistently show that 30-40% of people 65 years and older fall each year About 50% within home or immediate vicinity Recent survey NSW 66% injured (3.3% HI,1.9% #NoF) 20% visited a hospital 8 Harrison AIHW 2012; Milat 2011

9 Traumatic Brain Injury Falls resulting in TBI increased by 7% each year 25,000 ( Principal diagnosis only) Causes of Traumatic Brain Injury 42.2% 57.8% Other Cause Falls as cause 9 Helps et al, 2008; Harrison AIHW, 2012

10 Causes and Costs of Hospitalisation due to Community Injuries Cost for Falls $618M Transport $310M Falls 25-64yrs 21% 65+yrs 69.5% Transport 25-64yrs 13.9% 65+yrs 6.1% 10 Ballestas et al, 2011

11 What is a fall? Health Professional A fall is an event which results in a person coming to rest inadvertently on the ground or floor or other lower level Patient Trip, slip, stumble Fell over hose not a real fall Fell over dog.. Does not classify themself as an older person! 11 WHO 2010

12 Risk factors for falls Differentiate between Risk, Screening and Management. Being Older and having a previous Fall is consistently shown to predict Falls Screening for RFs allows you to Manage Identified Problems However don t screen out EVERYONE needs to do exercise 12

13 National falls prevention guidelines Increased age / female History of falls Chronic medical conditions / Medications ( type, amount) such as Stroke, Parkinson s disease, Arthritis, Depression Impaired balance and mobility Reduced muscle strength Sensory problems (eg impaired vision, peripheral neuropathy) Dizziness Incontinence Low levels of physical activity Fear of falling Footwear, Glasses, Hazards 13

14 Evidence - Summary Multiple-component exercise home, group, Tai Chi Home safety assessment and modifications for high risk groups Vitamin D for people with inadequate levels Pacemakers and first Cataract surgery Withdrawal of psychotropic medication Multifaceted podiatry including foot and ankle exercises Gillespie et al, 2012 Cochrane Review 14

15 Exercise - The Evidence Levels of evidence - Cochrane review cites 159 trials (79,193 participants) Effect of exercise programmes in reducing the rate of falls and risk of falling should now be regarded as established Effective for high/ low risk groups Group exercise, multiple components Rate ratio 0.78, (95%CI ) Individual exercise at home Rate ratio 0.66, (95%CI ) Tai chi Rate ratio 0.63, 95%CI Gillespie et al, 2012 Cochrane review

16 Balance Training Essential High Balance Challenge Mod-Low Balance Challenge High dose*/ walking 0.76 ( ) 0.96 ( ) High dose/ no walking 0.58 ( ) 0.73 ( ) Low dose/ walking 0.95 ( ) 1.20 ( ) Low dose/ no walking 0.72 ( ) 0.91 ( ) 16 Sherrington et al, 2008

17 Recommendations 2w for 25 weeks, >50 hours over trial period Tai Chi and Otago program successful examples Strength training alone not associated with reducing Falls ( improves TUG, gait speed) Summary challenge Balance, include high total dose, don t include walking ( add on afterwards ) Note walking and strength part of overall program but not instead of. 3D programs improve balance ( not others) 17 Howe et al, 2011 Cochrane review; Sherrington et al, 2008

18 Home Assessment +Modifications Effective in reducing rate of falls and risk of falling More effective in people at higher risk of falling eg: discharge, previous falls, severe visual impairment when delivered by OT Reduction of risk can be provided by just one or two home visits - potentially cost-effective and desirable 18

19 Home Safety Comprehensive evaluation process of hazard identification and priority setting - personal and environmental audit Use of an assessment tool validated for broad range of potential fall hazards Formal or observational evaluation - functional capacity of the person within their environment Provision of adequate follow-up by health professional, support for adaptations / modifications 19 Clemson et al, 2008

20 High Risk group Visual Impairment visual field loss in Glaucoma directly correlates with rates of falls Age related Macular Degeneration increased visual impairment associated with increased rates of falls Complexity of research home modifications alone more effective than combined with exercise, earlier trial of visual assessment increased falls 20 Black et al, 2010, Wood et al, 2010, Cumming et al, 2007; Campbell et al, 2005

21 Vision For each 10% loss in visual field - 8% higher odds of falling after adjustment for other factors Person with bilateral glaucoma, who on average would miss 48 points in the total visual field = 46%higher odds of falling RCT showed increased falls when prescription changed Multifocal lens increase the risk of falling Patients not attune to visual loss Campbell, 2010, Cumming et al 2007, Freeman

22 Multi- focal Lens wearers RCT single vision glasses provided to multifocal glass wearers Included >80y OR 65y and fall in previous year OR TUG >15s, used MFL at least 3x week outside Results - Single lens glasses reduced falls (and injuries) by 40% in those who went outside regularly, but increased in those who did little outside activity 22 Haran et al BMJ, 2010;

23 Recommendations Counselling to educate older people on the benefits of Eye checks, SVLs and changes in prescriptions Reading glasses and SVLs for people doing outdoor activities Home advice and assessment ( personalised) Individual advice on safe activity by a trained occupational therapist - for people with severe vision loss Reminders to wear glasses. Cataract surgery - 34% reduction in falls ( also improves mood and activity) 23

24 Older people Health Professionals Inevitable Falls an accident to be avoided, consequential to activity Address risk factors to reduce falls risk Preventable 24

25 Knowledge about Falls Prevention 3% Participants Suggesting Exercise 1% Suggesting Monitor Medication or Avoid dizziness Single behavioural strategies a constant theme e.g. walk slowly, be careful. 22% Suggesting three or more Strategies 4% Strategies that were supported by Evidence 25 Hill et al, The Gerontologist 2011

26 Adherence levels Low Levels of Engagement - Need to Engage the Older Person themself Low self perceived risk, Levels of Knowledge No one wants to be identified as old! Positive messages required Strength and Balance helps you with Independence Fit and Active. 26 Nyman, 2011 Yardley et al, 2006; Hill et al 2013; Haines et al 2012

27 Screening and Management Balance Gait Exercise Mobility Advice Referral Vision Home Ax Advice Referral Environment NOTE: Medication, Vitamin D, Calcium - Advice and Information 27

28 Everyone over 65 Information Exercise program Fall or RF (s) Specific Screen Exercise program Advice regarding RFs Refer for Relevant follow-up Specific Screen Exercise Program Home Modifications, Vitamin D Refer for Relevant Follow-up Over 80 / Medical condition 28

29 Summary Waiting room resources History Physical Exam Exercise + Ongoing Referral Database 29