The Bavarian Fall and Fracture Prevention Project in Long-term Care
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1 The Bavarian Fall and Fracture Prevention Project in Long-term Care Introduction and background Clemens Becker, MD Robert-Bosch-Krankenhaus Stuttgart
2 Fall and fracture prevention in LTC - why nursing homes and assisted living - which components - what strategies - (some future perspectives)
3 Hip fractures and ADL dependence Rate per 100 person years 7/2003-6/ ,1 with care 4 3,9 w ithout care 3 2 2,2 2,1 all AOK Berlin ,3 1,0 0,7 0,3 0,02 0,1 0,1 0,3 age Approximately 50% of all hip fracture patients in Bavaria are B-ADL dependent (Pflegestufe / Level of Care 1+)
4 Hip fracture and residence rate per 100 persons - 7/2003 until 6/ ,5 4,9 Residents of LTC 4 3,4 community dw ellers 3 2,6 2 1,8 1,5 Source AOK Berlin., ,4 0,5 0,5 0,1 0,2 0,02 age Approximately % of all hip fracture patients in Bavaria are residents in nursing homes
5 Epidemiology Summary Falls and Fractures in Nursing Homes falls per resident p.a. > 50 % of residents falling app. 10 % lead to medical treatment > 3-8 % annual risk for hip fractures Few data on non-hip fractures
6 Screening and assessing residents Risk factors for falls in LTC Unstable stance x 1.7 Gait disorder x 2.3 Transfer difficulties x 2.2 Cognitive deficit (executive function) x 1.9 Inappropriate medication x 1.9 Incontinence (urge) x 2.3 Vision impairment x 1.6 Fall history (best time period?) x 4 Intermittent restraint use x 2 Rubenstein L 2001; Lord S 2004, Kron M & Becker C 2003; Lundin-Ollson L 2003, 2004; Brown 2004, Hartikainen S 2007, Bentzen 2010
7 Ecology and Falls (2007) 9,413 falls (January - March 2007) Time: 2,683 of falls from 8 p.m. to 6 a.m. Location: 1,203 of falls are located within bathroom area Activity: 3,816 associated with sit-to-stand transfers
8 Physical Activity Levels of Older Persons Cumulated walking time Nursing home: < 20 minutes per day Community dwellers: 80 minutes (Nicolai 2010)
9
10 Which interventions Levels of evidence () Incident reporting (C) Staff knowledge and attitude (C) Fall conferences (C) Balance and strength exercise (A) Environmental modifications (A) Medication review (A) Hip protectors (A) Vitamin D (A) Orthostatic hypotension (B)
11 Efficacy trial LTC Ulm study Study participants: 981 residents of 6 LTC facilities Intervention: Multifactorial fall prevention program Exercise, hip protectors, staff empowerment, environment Combination and timing chosen by residents Outcome measure: Fall rates and fallers in intervention and control group Becker et al. JAGS 51:306-13, 2003
12 Risk Reduction for Falls and Fallers n (%) - C n (%) - I Risk Reduction Falls Fallers Multiple fallers 980 (2.09) 546 (1.08) 44 % 247 (52,8) 185 (36,5) 30 % 115 (24,6) 63 (12,4) 45% n = 975, C = Controls, I = Intervention Becker C, JAGS 2003,
13 Fall preveniton and cognitive impairment Intact short-term memory Impaired short-term memory st _surv STRATA: Kont Censored Kont =0 Kont =1 Censored I nt =0 I nt I nt I nt Kont = st _surv STRATA: Kont Censored Kont =0 Kont =1 Censored I nt =0 I nt I nt I nt Kont =1 Rapp & Becker, JAGS 2008
14 Fall prevention and depressive symptoms No symptoms Depressive symptoms st _surv STRATA: I nt Kont =0 Censored I nt Kont =0 I nt Kont =1 Censored I nt Kont = st _surv STRATA: I nt Kont =0 Censored I nt Kont =0 I nt Kont =1 Censored I nt Kont =1 Rapp & Becker, JAGS 2008
15 Translation 1 Baden-Württemberg Effect on falls (Pre-Post comparison) Fall reduction: 10 % - 25 % Reduction of hospital admissions: 8 % - 22 % Effect on hip fractures Year of the intervention Year after the intervention Fall prevention program Hazard rate ratio* (95% CI) Hazard rate ratio* (95% CI) No (control homes from Baden-Württemberg) Yes (intervention homes from Baden-Württemberg) ( ) Analysis A ( ) No (control homes from Bavaria) Yes (intervention homes from Baden-Württemberg) ( ) * adjusted for age, gender, size of the nursing home, and year of intervention Analysis B ( ) Rapp et al., JAGS 2010
16 Cochrane Review trials. 26 in nursing care facilities. 17,866 participants. Mean age 83 years. 71% female. presentation N.Kerse
17 Components - Standardised incident reporting (benchmark, feedback) - Screening as part of the care empowerment process - Multimodal interventions - Sustainability (3 years contract) - Acceptance and motivation by GPs (medication review) - Fall prevention, PA, and bone health (vitamin D) - Manualized intervention
18 Twice weekly, progressive balance and strength training
19 Hip protectors in LTC Teaching material Testkit for each facility ( 500) Emphasis on new admissions
20 Environmental modifications: proactivity model Lighting Footwear and socks Grab bars Ergonomics: bed height Staff calls Use of assistive device
21 Review medications, e.g. benzodiazepines Hartikainen S, 2007
22 Translational process - Start Facilities per year - 7 training sites - > 1,000 Mentors (nursing staff) - > 1,000 excerise instructors (physiotherapy, OT, )
23 Acknowledgements Ulrich Lindemann: exercise programs Ulrich Rißmann: training of nursing staff Hans-Helmut König: health economics Simone Nicoli, Elisabeth Kapfer, Barbara Walter-Jung, Barbara Eichner, Martina Kron, Thorsten Nikolaus, Sallie Lamb Weblink:
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