What s the Use? And in the end, it s not the years in your life that count. It s the life in your years...abraham Lincoln

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1 What s the Use? ISSUE #6 SPRING 2008 The System-Linked Research Unit on Health and Social Service Utilization PREVENTING FALLS IN OLDER PEOPLE inside The Effects and Costs of a Multifactorial and Interdisciplinary Team Approach to Falls Prevention for Older Home Care Clients At-Risk of Falling Risk Factor Model for Falls in Older Age Assessment and Management of Falls Key Findings and Implications: A Multifactorial and Interdisciplinary Team Approach to Falls Prevention for Older Home Care Clients At-Risk of Falling YOU Can Prevent Falls By Following These Tips FALLS ARE ESTIMATED TO COST CANADIANS $2.8 BILLION ANNUALLY 1. ONE IN THREE CANADIANS OVER THE AGE OF 65 WILL FALL IN THE NEXT 12 MONTHS. OF THOSE PEOPLE, 15% WILL REQUIRE MEDICAL ATTENTION 2. IN CANADA, FALLS ARE THE SECOND LEADING CAUSE, AFTER MOTOR VEHICLE COLLISIONS, OF INJURY- RELATED HOSPITALIZATIONS FOR ALL AGES, ACCOUNTING FOR 29% OF INJURY ADMISSIONS 3. TWENTY-FIVE PERCENT OF PEOPLE 75 OR OVER WHO LIVE INDEPENDENTLY, UNNECESSARILY RESTRICT THEIR ACTIVITIES BECAUSE OF FEAR OF FALLING 2. DID YOU KNOW? HALF OF THE PEOPLE WHO FRACTURE A HIP AFTER A FALL WILL NOT RETURN TO THEIR PREVIOUS LEVEL OF FUNCTION 2. ALMOST 62% OF INJURY RELATED HOSPITALIZATIONS FOR SENIORS ARE THE RESULT OF FALLS 3. FALLS ACCOUNT FOR TWO-THIRDS OF INJURIES WHICH LIMIT MOBILITY AND ACTIVITIES FOR CANADIANS. NEARLY 14,000 CANADIANS DIE AS THE RESULT OF FALLS EVERY YEAR 4. FALLS ARE BOTH PREDICTABLE AND PREVENTABLE. FALL PREVENTION STRATEGIES COULD RESULT IN 7,500 FEWER HOSPITALIZATIONS PER YEAR AMONG CANADIAN SENIORS 5. Contact Us 6 Funded by Ontario Ministry of Health and Long-Term Care And in the end, it s not the years in your life that count. It s the life in your years....abraham Lincoln

2 ISSUE #6 PAGE 2 The Effects and Costs of a Multifactorial and Interdisciplinary Team Approach to Falls Prevention for Older Home Care Clients At-Risk of Falling Maureen Markle-Reid, RN, MScN, PhD, Melody Miles, BScN, BComm, MBA, Vida Vaitonis BScN, MA, Gina Browne, RN, PhD, Robin Weir, RN, PhD, Amiram Gafni, PhD, Jacqueline Roberts, RN, MSc, Pamela Baxter, RN, PhD, Catherine Hecimovich, PT, BHSc, MEd, Lehana Thabane, PhD, Sandra Henderson, RN, MSc, CHE FUNDED BY CANADIAN PATIENT SAFETY INSTITUTE; COMMUNITY CARE ACCESS CENTRE OF HALTON; AND THE ONTARIO MINISTRY OF HEALTH AND LONG-TERM CARE Background: Falls are the leading cause of injury deaths and serious injuries among older adults. They are also associated with significant morbidity, reduced mobility, decreased functioning, and loss of independence. Objective: The purposes of this study were to: (1) examine the prevalence, correlates and costs of falls; and, (2) evaluate the effects and costs of a multifactorial and interdisciplinary team approach to falls prevention compared to usual home care services. Methods: Randomized controlled trial with a six month follow-up of 109 older adults (> 75 years) atrisk for falling, and eligible for home support services through a home care program in Ontario. Subjects were randomized to intervention (n=54) or control (n=55) groups. A total of 92 subjects completed the six month follow-up. The intervention was a six-month multifactorial and evidence-based prevention strategy involving an interdisciplinary team. Prevalence, Correlates and Costs of Falls - Key Findings: Over two in three (71%) of older home care clients over 75 years of age reported a fall over the last six months (three times the risk of healthy seniors). More than one in two of those who fell did so repeatedly. Over two in three (67%) had two or more of the leading risk factors for falls: fall in the last six months, fear of falling, or unsteadiness on their feet. People who fell had lower levels of physical, social and psychological functioning compared to non-fallers. Forty percent of those who fell developed serious injuries, such as a hip or other type of fracture. One in two of those who fell required hospitalization (20% more than healthy seniors). The average hospital costs for a fall was $18,550 per person (two times more than healthy seniors). Seventy-six percent of falls happened at home, during the day (63%), and while walking (58%). Dementia, Parkinson s disease, 85 years or older, environmental hazards, slip or trip in the last six months, and visual impairment, explained 22% of the variation in the number of falls. S Y S T E M L I N K E D

3 ISSUE #6 PAGE 3 Risk Factor Model for Falls in Older Age 6 Behavioural Risk Factors Multiple medication use Excess alcohol intake Lack of exercise Inappropriate footwear Environmental Risk Factors Poor building design Slippery floors and stairs Looser rugs Insufficient lighting Cracked or uneven sidewalks Falls and Fall-related Injuries Biological Risk Factors Age, gender and race Chronic illnesses (e.g., Parkinson, Arthritis, Osteoporosis) Physical, cognitive and affective capacities decline Socioeconomic Risk Factors Low income and education levels Inadequate housing Lack of social interactions Limited access to health and social services Lack of community resources IT IS IMPORTANT TO INFORM YOUR DOCTOR AND FAMILY IF YOU HAVE FALLEN. YOUR DOCTOR, NURSE OR THERAPIST CAN HELP YOU PREVENT FURTHER FALLS 1. Economic determinants Older people with lower economic status, especially those who are female, live alone or in rural areas face an increased risk of falls. Costs of falls The economic impact of falls is critical to family, community, and society. Health care impacts and costs of falls in older age are significantly increasing all over the world. Protective factors for falls in older age are related to behavioural change and environmental modification. Behavioural change to healthy lifestyle is a key ingredient to encourage healthy aging and avoid falls. Determinants related to the social environment Social connection and inclusion are vital to health in older age. Social interaction is inversely related to the risk of falls. Those who love deeply never grow old; they may die of old age, but they die young....benjamin Franklin S Y S T E M - L I N K E D R E S E A R C H U N I T

4 ISSUE #6 PAGE 4 Assessment and Management of Falls 7,8 PRIMARY PREVENTION SUCCESSFUL AGING 1 SECONDARY PREVENTION SUCCESSFUL AND USUAL AGING 2 TERTIARY PREVENTION ACCELERATED AGING 3 Case Finding: Ask all patients about falls in past year No Falls Single Fall Recurrent Falls No problems Check for balance and gait problems or fear of falling Gait and balance problems or fear of falling Fall evaluation Interventions Educational materials. Fall Risk Screening and Assessment: history medications vision gait and balance lower limb strength environmental neurological cardiovascular Multifactorial Interventions: (as appropriate) gait, balance and exercise program medication modification postural hypotension treatment environmental hazard modification cardiovascular disorder treatment Brief screen for fall risk factors 1 In the context of health, those who are aging successfully are those who continue to experience good health for an extended period of time. Those who are successfully aging come into contact relatively rarely with the primary health care and acute care systems. 2 Those who age at a usual rate are older adults who enter their retirement years with some chronic disease symptoms, such as high cholesterol, high blood pressure, or diabetes. Those who are aging at a usual rate manage their health conditions relatively well and stave off functional impairment for some time, but see their primary care provider on a frequent basis for maintenance of their condition and prevention of further effects. 3 The older adult experiencing accelerated aging appears more frail and more functionally dependent for their age. They experience the functional effects of long-standing chronic disease or rapid progression of disease. These individuals are frequently in contact with the health system, including acute care hospitalization and home care services. S Y S T E M - L I N K E D R E S E A R C H U N I T

5 ISSUE #6 PAGE 5 The Effects and Costs of a Multifactorial and Interdisciplinary Team Approach to Falls Prevention for Older Home Care Clients At-Risk of Falling Preventing 100 falls among seniors receiving home care services could lead to a cost savings of $1,150,000 KEY FINDINGS: A multifactorial and interdisciplinary team approach to falls prevention is more effective and no more expensive in enhancing quality of life, decreasing the incidence of slips and trips, and reducing the number of falls in select subgroups of frail older home care clients. The intervention was particularly effective in reducing falls in men, years of age, who had a fear of falling, or did not report a fall in the last six months. IMPLICATIONS: Falls prevention for older home care clients at-risk of falling needs to be a priority given the high prevalence of falls and associated morbidity and costs in this population. Falls are both predictable and preventable. Home care providers are well positioned to prevent falls by proactively screening older adults for falls risk to identify needs and target resources to those most in need. A key strategy for preventing multifactorial adverse events (such as falls) is the development of partnerships among individuals, service providers, and organizations, because no single discipline alone can identify and address all risk factors. Team Approach Screening Predictable & Preventable Home care providers, funding agencies, and policy makers should work together to ensure that a multifactorial and interdisciplinary team approach to falls prevention is available to people who could benefit from it most, to reduce falls, enhance quality of life and independence, and reduce on-demand use of expensive healthcare resources. The reorientation of home care services to focus on prevention, health promotion and community support for seniors with chronic needs should start with falls. This research was possible through the ongoing support of the Community Care Access Centre of Halton, Hamilton Niagara Haldimand Brant Community Care Access Centre, Mississauga Halton Community Care Access Centre, Halton Region Health Department, Community Rehab, Ellen Williams, Brant Arts Dispensary, and Dr. Heather H. Keller, Department of Family Relations and Applied Human Nutrition, University of Guelph. A FINAL REPORT ON THIS STUDY WILL SOON BE POSTED ON THE CANADIAN PATIENT SAFETY INSTITUTE WEBSITE AT R E S E A R C H U N I T

6 ISSUE #6 PAGE 6 YOU Can Prevent Falls By Following These Tips (Health Canada Fact Sheet No. 5) 9 Maureen Markle-Reid, RN, MScN, PhD Career Scientist, Ontario Ministry of Health and Long-Term Care; Associate Professor, School of Nursing; Director, SLRU Research on Aging at Home McMaster University Telephone: , ext mreid@mcmaster.ca Be physically active every day exercise for strength and balance. Eat regular, well-balanced meals. Keep your home and garden free of hazards. Install aids around your home such as grab bars, railings and non-slip surfaces. Keep your pathways and steps free of ice, snow, newspapers and leaves. Plan your outings to allow plenty of time never rush. Use walking/balancing/hearing/seeing aids. Always remove your reading glasses when you re walking. Ask for assistance with heavy work. Keep an eye out for dangers and hazards; inform the proper officials of any unsafe condition. Manage and monitor your medications properly (check with your doctor or pharmacist). References 1 SCO Health Service Foundation (2008). Mild winter increases risk of falls for the elderly. Retrieved May 30, 2008 from bins/news_display_page.asp?cid= SCO Health Service Foundation (2008). Only Canadian falls clinic of its kind raises alarm. Retrieved June 2, 2008 from bins/news_display_page.asp?cid= &lang=1. 3 Saskatoon Health Region (2008). Preventing falls in seniors. Retrieved June 2, 2008 from ps_ip_falls_about.htm. 4 Ontario Long-Term Care Association (2008). Falls prevention reduces injuries, improves quality of life. Retrieved May 28, 2008 from SmartRisk (1998). The economic burden of unintentional injury in Canada. Retrieved May 10, 2008 from cf pdf. 6 WHO Global Report on Falls Prevention in Older Age, Risk factor model for falls in older age. Retrieved June 2, 2008 from Keller, H.H. (2007). Promoting food intake in older adults living in the community: A review. Applied Physiology, Nutrition and Metabolism, 32, Kenny, R.A., Rubenstein, L.Z., Martin, F.C., & Tinetti, M.E. (2001). Guideline for the prevention of falls in older persons. Journal of the American Geriatrics Society, 49(5), Veterans Affairs Canada Falls Prevention Initiative. You can prevent falls: By following these tips! Retrieved June 3, 2008 from NEXT ISSUE - SLRU Success story: integration WE HOPE YOU HAVE ENJOYED THIS ISSUE OF OUR SYSTEM-LINKED RESEARCH UNIT NEWSLETTER. Questions? Please contact us: McMaster University Faculty of Health Sciences System-Linked Research Unit 75 Frid Street, Hamilton, ON L8P 4M3 Telephone: , ext Gina.Browne@mcmaster.ca We cannot solve the problems we face with the same kind of thinking that created them. Einstein S Y S T E M - L I N K E D R E S E A R C H U N I T