Exercise for Falls Prevention in Older People: Evidence & Questions Professor Pam Dawson Associate Pro Vice Chancellor Strategic Workforce Planning and Development Northumbria University 13 March 2017
A fall is defined as an unintentional or unexpected loss of balance resulting in coming to rest on the floor, the ground, or an object below knee level (NICE). What is a fall?
Falls: the scale of the problem 30% people >65yrs 50% people >80yrs fall at least once per year 5% of community dwelling fallers will experience a fracture Falls are the most commonly reported patient safety incident in NHS Trusts in England Falls affect the faller, family and carers: Injury, pain, distress, fear, loss of confidence and independence, reduced quality of life, mortality Falls cost the NHS > 2.3b per year
Evidence for falls prevention: the problem of the scale Huge number of individual trials and studies globally over more than 2 decades Individual trials inform systematic reviews, Cochrane reviews, position statements, NICE guidelines, pt pathways Outcome measures Fall rates (falls per person year) or Fall risk (number of fallers in each group of a trial) Evidence doesn t speak for itself it has to be interpreted for the individual and their context Primary versus secondary prevention Community versus care settings
Most recent NICE (2017 update) guideline messages re exercise in falls prevention
Exercise (strength and balance training) offered as a single intervention Older people living in the community with a history of recurrent falls and/or an identified gait and balance deficit should be offered multiple component exercise (strength and balance training) in an individual or group programme (following a multifactorial falls risk assessment) as a single falls prevention intervention individually prescribed and monitored by an appropriately trained professional Untargeted group based exercise has not been shown to be effective in these conditions NICE 2017
Exercise (strength and balance training) offered as a component of multidisciplinary falls prevention Older people living in extended care settings (e.g. nursing homes) who are at risk of falling and Older people > 65yrs (or 50-64 yrs judged to be at higher risk of falls) admitted to hospital where any identified muscle weakness or gait/balance problem can be treated, improved or managed with individualised intervention during the patient's expected stay should be offered individually prescribed exercise as a component of multidisciplinary falls prevention intervention NICE 2017
Considerations when designing and delivering evidence based exercise for falls prevention Target group Type and setting of exercise Previous falls (secondary prevention) versus identified fall risk (primary prevention) Consider cognitive function Consider motivation and likely adherence Gender? Strength/resistance exercises Balance/gait training Individual or group based Trained professional Social aspect? Frequency and duration How many times per week Over how many weeks Intensity The right degree of challenge for the individual Supervision/progression over time
How evidence-based are our exercise programmes? Survey of 1768 patients* referred to falls prevention services in England, Wales and NI wide shows two thirds were participating in group based exercise but wide variation in models of delivery of exercise interventions Recommended exercise programmes should be individually tailored, progressive and delivered over long periods (Otago 1 year; FaME 35 wks) Most patients attended group-based classes of short duration (<12 weeks) and only once/week Only 50% patients said their programme was progressed as they improved High levels of patient satisfaction with programme But lack of follow up afterwards *Buttery et al 2014
Where the evidence doesn t help Dementia Evidence inconclusive that exercise prevents falls in dementia/ cognitive impairment* Poor adherence and loss to follow up* Cognitive impairment frequently cited as a reason not to refer or not to offer exercise** Recent small trial - 6 month tailored programme can improve balance, concern about falls, and planned physical activity in community-dwelling older people with dementia*** Fear of falls Exercise alone may possibly reduce fear of falls but only in the short term**** Not all trials have fear of falling as an outcome**** *Winter et al 2013 **Buttery et al 2014 ***Taylor et al 2017 ****Kendrick et al 2014
Adherence and compliance Trials report uptake of exercise interventions can drop from as high as 80% in the first 10 weeks to 50% at one year* In practice adherence can be much lower than 50% Patient level barriers include transport, cost, motivation and fear of injury 50-82% community dwelling older people did not consider that participation in exercise programs would be worthwhile, even if it reduced risk of falling to 0%.** Programme level barriers Group Decreased adherence with duration of 20 weeks or more, two or fewer sessions per week, or a flexibility component*** Home - Increased adherence with balance component, home visit support and physiotherapy led**** Decreased adherence with flexibility component**** * Nyman and Victor 2011 ** Franco et al 2016 ***McPhate et al 2013 ****Simek et al 2012
How can we promote and improve adherence? Older people participate in exercise to remain independent and they value approaches that promote autonomy and self management Physiotherapists are fatalistic with a take it or leave it attitude to the exercise they prescribe and instruct Robinson et al 2013
Barriers and facilitators in exercise for falls prevention Barriers Practical issues - transport Concerns adverse effects, too difficult Unawareness denial of fall risk Reduced health status unwell, fatigue Lack of support poor instructor, no support at home Lack of interest low motivation Facilitators Support professional and family Social interaction relationships, social time Perceived benefit staying independent Supportive exercise context trust, individual adaptation Feelings of commitment structured programme Having fun - enjoyment Sandlund et al 2017 systematic review
Population-based interventions for prevention of fall related injuries in older people Systematic review to assess the effectiveness of population-based interventions, defined as coordinated, community-wide, multi-strategy initiatives, for reducing fall-related injuries among older people. Preliminary claim that the population-based approach to the prevention of fall-related injury is effective and can form the basis of public health practice. Randomised, multiple community trials of population-based interventions are indicated to increase the level of evidence in support of the population-based approach. McClure et al 2008
Exercise and falls prevention: from evidence to implementation Multiple agency commitment and older people involvement Population based and whole system approach involving all sectors Evidence based intervention applied consistently and with training Joined up approach with other pathways/ services, e.g. dementia Leadership and continuous innovation and quality improvement Joint commissioning
References Buttery AK et al (2014) Older people s experiences of therapeutic exercise as part of a falls prevention service: survey findings from England, Wales and Northern Ireland. Age and Ageing, 43: 369 374 Franco MR et al (2016) Smallest worthwhile effect of exercise programs to prevent falls among older people: estimates from benefit harm trade-off and discrete choice methods. Age and Ageing, 45: 806-12 Kendrick D et al (2014) Exercise for reducing fear of falling in older people living in the community (Review), Cochrane Library, Issue 11 McClure RJ (2005) Population-based interventions for the prevention of fall related injuries in older people (Review), Cochrane Library, Issue 1 McPhate L et al (2013) Program-related factors are associated with adherence to group exercise interventions for the prevention of falls: a systematic review. Journal of Physiotherapy, Australian Physiotherapy Association Vol. 59 NICE (2017 update) Falls: assessment and prevention of falls in older people, NICE clinical guideline 161.
References Nyman S and Victor CR (2012) Older people s participation in and engagement with falls prevention interventions in community settings: an augment to the Cochrane systematic review. Age and Ageing, 41: 16 23 Robinson L et al (2014) Self-management and adherence with exercise-based falls prevention programmes: a qualitative study to explore the views and experiences of older people and physiotherapists. Disability and Rehabilitation, 36(5): 379 386 Sandlund et al (2017) Gender perspectives on views and preferences of older people on exercise to prevent falls: a systematic mixed studies review. BMC Geriatrics (2017) 17:58 Simek EM et al (2012) Adherence to and efficacy of home exercise programs to prevent falls: A systematic review and meta-analysis of the impact of exercise program characteristics. Preventive Medicine, 55: 262-75 Taylor et al (2017) A home-based, carer-enhanced exercise program improves balance and falls efficacy in community-dwelling older people with dementia. International Psychogeriatrics, 29:1, 81 91. Winter H et al (2013) Falls prevention interventions for community dwelling older persons with cognitive impairment: A systematic review. International Psychogeriatrics, 25(2):215 227