Professor Keith Hill, School of Physiotherapy and Exercise Science Curtin University

Transcription

1 Professor Keith Hill, School of Physiotherapy and Exercise Science Curtin University Curtin University is a trademark of Curtin University of Technology CRICOS Provider Code 00301J Presentation to SCGH, April 2014

2 Snapshot of some recent research developments in falls prevention research: Tai chi to reduce falls for patients post stroke Adherence factors in multifaceted podiatric intervention Impact of falls on carers

3 There is good research (at least one randomised trial) evidence that a number of single interventions can reduce falls / injuries: exercise (home exercise; tai chi, group exercise) cataract extraction / change multifocal glasses to 2 sets of glasses psychotropic medication withdrawal / medication review home visits by Occupational Therapists improved post hospital discharge follow-up approaches to support client uptake in recommended interventions vitamin D and calcium supplementation (in low vit D cases) cardiac pacemaker for carotid sinus hypersensitivity foot exercise, footwear and orthoses multiple interventions often based on a falls risk assessment have also been shown to be effective (including in high falls risk groups, eg older fallers presenting to ED) COCHRANE REVIEW: Gillespie et al, 2012 (159 trials with 79,193 participants)

4 AIHW: Bradley

5 1. Inadequate funding 2. Limited targeting of falls prevention to key high risk population groups 3. Limited engagement of older people in falls prevention 4. Limited early identification and prevention approach 5. Limited partnerships of key stakeholders 6. Barriers between settings (community hospital residential care) 7. Research issues: Limited representativeness of research samples (eg often no CALD participants, exclude cognitive impairment) Setting of assessment or intervention often not typical of real life setting 8. Others

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7 In hospital First month First year Long term

8 Falls in first 7 months number of falls Another study found 28% fell in first 2 weeks (Batchelor et al, 2012) NOT JUST STROKE PATIENTS 15% of older people fall at least once within 1 month of discharge home from hospital, with 11% experiencing serious injuries (Mahoney et al, 2000) months since discharge from rehabilitation First Falls Subsequent Falls Mackintosh et al, Clinical Rehabilitation, 2005

9 the neurological / chronic condition modifiable / non-modifiable unrecognised falls risk factors inadequate preparation for transition home other

10 Meta-analysis criteria: Randomised or quasi-randomised trial Adult stroke survivors, any chronicity, any setting (>80% participants stroke diagnosis) Any intervention (single or multifactorial) Falls related outcomes 14 papers identified (4 studies used same populations) 1377 participants PEDro scores (quality) range 4-10 All studies were single intervention (no multifactorial interventions) Batchelor et al, Stroke 2010; 41:

11 Forest plot: rate of falls (intervention vs control) Study or Subgroup Barreca 2004 Bernhardt 2008 Mayo 1994 Rossi 1990 Sato 2005 Sato 2005b Von Koch 2000 Von Koch 2001 log[rate Ratio] Intervention Control Rate Ratio Rate Ratio SE Total Total IV, Fixed, 95% CI 1.42 [0.46, 4.42] 1.19 [0.70, 2.01] 1.17 [0.63, 2.20] 1.17 [0.29, 4.72] 0.16 [0.10, 0.25] 0.96 [0.82, 1.12] 1.27 [0.65, 2.48] 0.91 [0.64, 1.30] IV, Fixed, 95% CI Favours intervention Favours control Vitamin D intervention convalescent hospital / residential care Batchelor et al, Stroke 2010; 41:

12 Batchelor 2012 Otago exercises as part of multifactorial intervention (12 months post rehab) Dean et al Chronic stroke Exercise classes & home program Improved mobility Lau et al 2012 Chronic stroke Whole body vibration Verheyden et al, Cochrane review 2013

13 RCT, stroke patients >3 months post stroke (n=145) (mean 37 months post stroke, mean age=70 years) Few exclusion criteria 12 weeks (3x/week) 24 form Yang style Tai Chi vs Strength + ROM program vs usual care Participants were allowed to use walkers / canes / chairs as required in the classes Adherence: Tai Chi 82%, Strength program 81% Tai Chi achieved 66% fewer falls than other groups (only measured during 12 week intervention) Taylor-Piliae et al 2014 in press, Arch Phys Med Rehabil

14 Outcomes Tai Chi achieved 66% fewer falls than other groups (only measured during 12 week intervention) All groups improved significantly on: Short Physical Performance Battery (no significant difference between groups) Physical and mental health composite scores (SF-36) Both Tai Chi and Strength & flexibility program achieved significant improvement in: aerobic endurance Taylor-Piliae et al 2014 in press, Arch Phys Med Rehabil

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16 305 older people with increased falls risk and disabling foot pain Sample Spink M et al, 2011

17 RCT usual care vs (foot and ankle exercise + orthosis+new footwear) Control group received routine podiatry care Spink et al, 2011, BMJ: 342

18 Significant reduction in falls (36%) Associated significant improvements in balance, strength and range of movement First RCT to demonstrate effectiveness of a podiatric intervention on falls Spink M et al, 2011

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20 Varying compliance with 3 intervention components: Exercise 66% of recommended 3 sessions / week were completed 67% of intervention participants were provided with orthoses. 55% of those provided with orthoses wore them most of the time 27% of participants had inappropriate footwear and were provided with $100 footwear voucher and advice. At followup, 37% were wearing their new footwear most of the time Despite several factors designed to improve adherence such as footwear subsidy Spink et al, 2013, J American Podiatric Medicine Association

21 (Nyman and Victor, Age and Ageing, 2012) Reviewed 99 randomised trial in 2009 Cochrane review (falls prevention in the community) Adherence rates (n = 69) were: 80% for vitamin D/calcium supplementation; 70% for walking and class-based exercise; 52% for individually targeted exercise; approximately 60-70% for fluid/nutrition therapy and interventions to increase knowledge; 58-59% for home modifications; Adherence to multifactorial interventions was generally 75% but ranged 28-95% for individual components. Home-exercises on average 11 times per month CONCLUSIONS: Using median rates for recruitment (70%), attrition (10%) and adherence (80%), we estimate that, at 12 months, on average half of community-dwelling older people are likely to be adhering to falls prevention interventions in clinical trials.

22 Anne-Marie Hill et al, 2011, The Gerontologist

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24 Informal caregivers provide up to 80% of support to older people in Australia, enabling them to stay at home rather than enter residential care (Productivity Commission 2011) Often under moderate to high levels of stress / burden Often focus energies on caregiving, rather than own health

25 96 dyads recruited Caregiver Care recipient Age Female n (%) 66 (69%) 36 (38%) Time in caring role (mean) Relationship to care recipient -Spouse -Child -Other Number of health problems mean Falls risk (FROP-Com) -Low risk -Moderate risk -High risk 6.1 years 82 (85%) 11 (12%) 3 (3%) % 31.6% 61.0% Meyer et al, Australasian J Ageing, 2012; Dow et al, Aust Health Rev. 2013

26 12 month prospective follow-up 198 falls by 54/96 care recipients (56%) 33/56 were multiple fallers (59%)

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29 Falls rates remain unacceptably high Need focus on issues likely to improve translation of research evidence Key factors to consider: Specific needs for high falls risk groups (stroke, PD, arthritis, dementia) Strategies to support improved engagement and sustained participation by older people Carer support considerations (including minimising falls risk for care recipients) Other.

30 COLLABORATORS Falls prevention and stroke: Frances Batchelor Cathy Said Shylie Mackintosh Craig Whitehead FUNDING: NHMRC Australian Government Falls prevention and podiatry Martin Spink Hylton Menz Stephen Lord Karl Landorf Elin Wee Mohammad Fotoohabadi Falls prevention and carers Claudia Meyer Briony Dow Kirsten Moore