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

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1 Professor Keith Hill, Head, School of Physiotherapy and Exercise Science Curtin University Dr Frances Batchelor, Research Fellow, National Ageing Research Institute Curtin University is a trademark of Curtin University of Technology CRICOS Provider Code 00301J NARI Annual Seminar, Oct 2014

2 Transportation related hospitalisations 55,457 Falls related hospitalisations 153,170 Australian Institute of Health and Welfare, 2012 Hospital separations due to injury and poisoning, Australia

3 Australian Institute of Health and Welfare, 2012 Hospital separations due to injury and poisoning, Australia

4 Community Hospital Residential Care Number of RCTs # Number of subjects # Single interventions shown to be effective Multifactorial interventions 79,193 29,972 30,373 Multiple single Exercise Pt education Vitamin D Possible effect Staff with key role # Community-Gillespie et al 2012; Hospital and Residential care Cameron et al 2012 (Cochrane reviews)

5 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 Common withdrawal / medication review home visits by Occupational exclusion Therapists improved post hospital discharge criteria: follow-up cognitive approaches to support client uptake in recommended interventions impairment 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)

6 AIHW: Bradley

7 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

8 A neglected area of research and practice: Fear of falling Dr Frances Batchelor Research Fellow/Physiotherapist National Ageing Research Institute

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16 Fear of falling Psychological trauma associated with falling Realistic or unrealistic Adaptive or maladaptive? a lasting concern about falling that leads to an individual avoiding activities that he/she remains capable of performing (Tinetti et al, 1990 Tinetti & Powell, 1993)

17 Fear of falling: common In older people 20-85% prevalence People who have fallen People who haven t fallen Women Increases with age Murphy 2002, Friedman 2002, Scheffer 2008

18 A vicious cycle? Fall Increased risk of falling Fear of falling Functional impairment Activity restriction

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20 Inconsistent findings? Fear of falling Falls efficacy Balance efficacy Balance confidence Perceived control over falling Concern about falling

21 Fear of falling: measurement Are you afraid of falling? How afraid are you of falling? (Reinsch et al, 1992) Falls efficacy: FES (Tinetti et al 1990) MFES (Hill et al) FES-I (Yardley et al 2005) Short FES-I (Yardley et al 2005) Stroke: FES-S (Hellström & Lindmark, 1999) Balance confidence ABC

22 FES-I: long and short

23 Icon FES page-downloads/iconfes.pdf

24 FOF is associated with. Falls Balance Gait Functional ability Activity restriction Personality Psychological state e.g. anxiety/depression Female gender Increasing age Tinetti 1994, Arfken 1994, Franzoni 1994, Kloseck Zijlstra 2007

25 Fear of falling and falls Clear associations in the literature between BUT Fear of falling/ falls efficacy and previous falls Fear of falling/efficacy and future falls What is the causality??? Very few longitudinal studies (Arfken et al 1994, Lachmann 1998)

26 Is there a pattern? Spaghetti plot: FES vs time

27 Individual trajectories Variable impact of fall No impact of fall

28 Individual trajectories Improvement, no fall Fluctuation, no fall

29 Fear of falling & gait/balance Reduced gait speed Reduced step length Increased step width Increased double support phase Postural stiffening strategy? Age, disease dependent Adjustments normal, but FOF alters adjustment Donoghue et al 2013; Shaw et al 2012; Delbaere et al 2009

30 Fear of falling highly prevalent There are tools we can use to assess fear of falling/confidence and efficacy What interventions work????

31 The challenge of management Limited research targeting FOF directly FOF usually a secondary outcome in falls prevention/exercise trials What should be targeted? Psychological factors Physical factors Falls risk factors All factors

32 Study Participants Intervention FOF measure Results Tennstedt , self reported activity restriction due to FOF Group therapy Cognitive behavioural Exercise 4 weeks, 2hrsx2/week Adapted FES Significant difference in compliant group, small effect size; not intention to treat Clemson , fallen or concerned about falling Group Exercise, medication management Home and community safety, action planning 7 weeks, 2hrs/week + HV MFES No significant difference between groups Zhang , decreased balance Group intervention Tai Chi 8 weeks, 1 hr daily FES Significant difference between groups Huang groups: CBT 8 weeks, hr CBT + Taichi 8 weeks + 3x/week taichi Control FES GFFM Significantly improved efficacy in CBT + Taichi at 2 and 5 months Zijlstra , self reported fear of falling/activity restriction Group therapy Multicomponent 8 weekly sessions, exercise FOF PCOF Activity restriction Significant and durable differences

33 Does the cycle exist? Fall Efficacy expectation Increased risk of falling Fear of falling Outcome expectancy Functional impairment Activity restriction (Lach 2006, Bandura 1997)

34 Risk factors for falls: Vision problems Sensory problems Demographics FALLS Deconditioning Appraisal of one s abilities: realistic unrealistic Balance performance Falls efficacy Activity avoidance or restriction Fear of falling Anxiety Adapted from Hadjistavropoulos et al 2011 Other contributors to fear/avoidance: Previous falls Beliefs Personality/perception/cognition Social supports

35 The message Assess both fear of falling AND efficacy in research & practice Context is important Identify individuals at risk of activity restriction Intervention based on accurate appraisal TRANSLATION/UPTAKE.

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37 Falls in hospital result in increased length of stay and healthcare costs 26 patient deaths, 530 hip fractures and about 1000 other fractures occurred in UK hospitals in 12 months Adelaide acute hospital data reports 68% of falls occurred in those aged >75 years and almost half had cognitive impairment Falls in hospital commonly occur at night when nurse staffing levels are lowest and patient confusion is common Many falls in hospital are not witnessed Pilot data: Ranasinghe et al, Gait and Posture 39(1):118-23

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39 Collaboration engineering, geriatric medicine, falls prevention Development and refinement of the sensor technology Pilot testing in hospital room environment of Young volunteers undertaking typical transitions Healthy older people undertaking typical transitions Comparison of different sensor position On older person Configuration of sensor detection devices within a room NHMRC Project Grant application under review (Stepped wedge RCT)

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41 305 older people with increased falls risk and disabling foot pain Sample Spink M et al, 2011

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

43 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

44 (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.

45 I don t think I need it My doctor said I should go to an exercise program to reduce my risk of falling Low uptake and participation Part of NHMRC Partnership grant CIA Lesley Day (Monash) Protocol paper for full project: Day et al, Injury Prevention, 2011, Apr;17(2):e3.

46 Percentage % strongly agree or agree Group exercise Home exercise Home asessment & modification Multifactorial (falls clinic) assessment Good for other people my age Good for me Haines T et al, 2014, Arch Clin Gerontol and Geriatr

47 Think will fall in next year (undecided, agree or strongly agree) 29 (48%) 31 (51%) 1 (1%) One or more falls in past year - n= (34%) 29 (58%) 4 (8%) 0% 20% 40% 60% 80% 100% Hill et al, In Press, Clinical Interventions in Ageing Undecided if falls clinic would be of benefit Disagree that falls clinic would be of benefit Strongly disagree that falls clinic would be of benefit Note: percentages reported are for the proportion of participants at increased risk of falls due to: (1) reporting that they thought they would fall in the next 12 months; and (2) had one or more falls in the past 12 months (n=132). The Figure does not include the (1) participants who didn t think they would fall in the next 12 months; and (2) the participants who did not fall in the past 12 months.

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49 20% reduced balance performance compared to age matched controls 1 Accelerated decline in balance performance over 12 months relative to age matched controls 2 Pilot RCT physiotherapy prescribed home-based exercise program (with carer involvement) achieved significant balance improvement 3 Dr Plaiwan Suttanon, Thammasat University, Thailand NARI) 1. Suttanon P et al, 2012, Am J Phys Med Rehabil; 2. Suttanon P et al, 2013, Am J Phys Med Rehabil; 3. Suttanon P et al, 2013, Clinical Rehabil.

50 Identification of a need Department of Health Gippsland Regional Office Aged Care Team following the development of the Gippsland Dementia Plan Fragmentation of services for people with dementia Lack of linking of falls prevention with early stages of dementia Proposal for Dept of Health funding approx 18 months ago Assessment and care pathway Focus on emerging research demonstrating effect of balance exercise to reduce falls risk in people with dementia (NARI, Dr Plaiwan Suttanon)

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52 Project funded by Department of Human Services, through the Central West Gippsland PCP Project Steering Committee including: Richard Adams (Dept. of Health, Active Service Model Industry Consultant -HACC & Aged Care) Colleen Oakley-Browne (project officer, Central West Gippsland PCP) Petra Bovery-Spencer (Latrobe Community Health Service, Manager Primary Interventions) Kate Palmer (West Gippsland Healthcare Group, Community Allied Health Manager) Bruce Campbell (SACS Coordinator, LaTrobe Regional Hospital) Karen Price (Alzheimer's Australia Victoria, Dementia Consultant) Kay Jellis (Latrobe City Council, HACC Coordinator) Annette Wheatland (Gippsland Regional Manager, Southern Cross Care) Keith Hill (researcher / project advisor, Curtin University) Selena Northover (Manager Health Independence Programs, LaTrobe Regional Hospital)

53 Regular project steering committee meetings Literature review exercise to reduce risk of falls for people living with dementia (community focus) Development and refinement of Assessment Service Pathway for Gippsland Launch of Pathway, and series of forums, workshops and videoconferences, targeting: Referrers Health professionals who may be involved in exercise prescription General Practitioners and Practice Nurses Home Care Workers HACC Assessment staff and District Nursing staff >200 people attended, including 60 GPs and practice nurses! Ongoing support and evaluation of uptake

54 An important focus of the project is introducing exercise to improve balance and reduce falls risk for people with mild to moderate severity dementia Limited research, only several small studies Review led by Dr Elissa Burton (Curtin University) Involvement and feedback by members of the project Steering Committee Has been accepted for publication: Clinical interventions in Ageing journal

55 Burton E et al, e-pub ahead of publication, Clinical Interventions in Aging

56 Limited fall prevention focus for people with dementia Major negative impact of falls for people with dementia (increased carer burden, trigger for residential care admission) Engage broad range of stakeholders Multiple points of entry Change falls prevention focus to mild to moderate severity dementia

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59 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

60 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

61 12 month prospective follow-up 198 falls by 54/96 care recipients (56%) 33/56 were multiple fallers (59%)

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64 Falls hospitalisation rates remain unacceptably high and are not reducing 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) Recognition of silent consequences of falls such as fear of falling and low falls efficacy Other.

65 COLLABORATORS AMBIGEM sensor technology Renuka Visvanathan (Uni Adelaide) Damith Ranasinghe (Uni Adelaide) Falls prevention and podiatry Martin Spink (LaTrobe) Hylton Menz (LaTrobe) Stephen Lord (NeuRA) Karl Landorf (LaTrobe) Elin Wee (LaTrobe) Mohammad Fotoohabadi (LaTrobe) Good for others, not for me Terry Haines (Monash) Lesley Day (Monash) Lindy Clemson (Uni Sydney) Caroline Finch (Uni Ballarat) Falls prevention and dementia translation Richard Adams ( Department of Health) Colleen Oakley-Browne (West Gippsland PCP) Elissa Burton (Curtin Uni) Steering Committee FUNDING: NHMRC Project Partnership Queen Elizabeth Hospital (Adelaide) Australian Government Gippsland Dept of Health Falls prevention and carers Claudia Meyer (NARI) Briony Dow (NARI) Kirsten Moore (NARI)