Fall prevention research update Professor Stephen Lord Neuroscience Research Australia University of NSW Sydney, Australia
Simple Predictors of Falls in Residential Care Dwellers Whitney J et al, Arch Gerontol and Geriatrics 2012;55:690-5
Methods Prospective observational cohort study 254 residents Measures taken using care/medical records and by talking to care staff Measures taken: Barthel, MMSE, neuro-psychiatric inventory, impulsivity, medical conditions, medication use, sit-to-stand, standing balance ratings
Impulsivity Is resident n impulsive? where impulsivity was defined as rushing to carry out an activity without thinking about it first. Three further questions were asked: How often does the resident do the following? Try to sit down before getting right up to the chair / toilet / bed? Attempt to stand before wheelchair brakes have been applied / footplates moved or walking frame placed in front of them? Try to walk without help when asked not to? The answers to these questions were graded as: never/na (=0), occasionally (=1), often (=2), frequently (=3) or very frequently (=4). The FIBS score was calculated by summing the scores for the four questions. Carers were asked all 4 questions regardless of the answer to question 1.
Standing balance 1=Unable to stand 2=Requires assistance of 2 people 3=Requires assistance of 1 person 4=Requires use of walking aid 5=Stands without aid / assistance but unsteady 6=Stands without aid / assistance and steady
Falls in the six month f/u Of the 240 residents who completed the follow-up, 121 (50.4%) fell one or more times The fallers sustained a total of 281 falls (range 1-16, mean=2.3) Overall, this equated to 2.8 falls per person per year
Multiple Logistic Regression Analysis Seven independent, significant predictors of falls: Variable & cut point OR 95%CI MMSE <17 2.17 1.11-4.24 Impulsivity score 2 2.78 1.45-5.31 Standing balance score <6 2.40 1.17-4.96 Use of a walking frame 2.07 1.06-4.40 Fall in previous year 3.46 1.77-6.81 Hypnotic / anxiolytic medication 3.75 1.25-11.21 Antidepressant medication 2.92 1.51-5.64 Area under ROC curve 0.79 (95% CI 0.73 0.84)
Absolute risk of falling
Step training proactive & reactive stepping are risk factors for falls specific cognitive functions (attention, EF) are risk factors for falls adding cognitive load to step test increases discriminative ability
Exergames = exercise + video games wii, Kinect, DDR
Youtube.com
Pilot RCT randomised controlled trial 8 weeks in-home training recommended dose: DDR 2-3/week, 15-20min; CSRT 1/week 90 minutes individual learning session IG participants contacted by phone in week 1, 2, 3 & 6 to facilitate compliance Schoene DS et al. A randomized controlled pilot study of home-based step training in older people using videogame technology. PLOS ONE. 2013.
In-home system
Intervention adapted open source game stepping as accurately as possible, both in terms of direction and timing additional cognitive load: bombs inhibit response music stepping sequences not synchronized with rhythm of music to enhance movement speed in addition to movement coordination choice stepping reaction time (CSRT) task
Time in ms Time in ms Time in ms Time in ms 800 750 CSRT reaction time 700 650 600 pre post IG CG 100 0-100 diff pre-post -76 * +8 270 250 230 210 190 170 150 pre post CSRT movement time 20 0-20 -40-60 diff pre-post * -41-4
Sway area in mm Sway area in mm Z-score Z-score 2 1.5 PPA 1 diff pre-post 0.5 0.5 0 pre post 0-0.5 -.61.00 450 400 IG CG sway -1 * 350 300 250 200 pre post 0-50 -100-150 diff pre-post *
Reactive stepping balance training Induced perturbation with a forward translating platform On the first perturbation 100% experienced backward loss of balance, 44% experienced a fall 23 additional trials within a single 90-minute training session 0% loss of balance, 0% falls incidence Bhatt et al., 2012
Aim and Methods Aim: To evaluate the effects of a water exercise training program that includes perturbation exercises (WEP) to improve the speed of voluntary stepping reaction in older adults. 36 independent participants(64 88 years old) Single-blinded RCT with a crossover design Group A received WEP for the first 12 weeks, followed by no intervention for the second 12 weeks. Group B did not receive intervention for the first 12 weeks and received WEP for the second 12 weeks. Outcome measures: voluntary stepping and postural sway (eyes open and closed)
Study design
Stepping WEP training resulted in improved step initiation phase and swing phase
Postural sway WEP training resulted in reduced sway in eyes open and closed conditions
Aim and Methods Aim: To investigate the effects of lavender olfactory stimulation intervention on fall incidence in elderly nursing home residents RCT in 3 randomly selected nursing homes in northern Japan 145 nursing home residents aged 65 and older Participants were randomly assigned to the lavender (n = 73) or placebo group (n = 72) for 1 year The lavender group received continuous olfactory stimulation from a lavender patch. The placebo group received an unscented patch
Study design
Main findings There were fewer fallers in the lavender group (n = 26) than in the placebo group (n = 36) (hazard ratio (HR)=0.57, 95% CI=0.34 0.95) The lavender group also had a significant decrease in CMAI score (P =.04) from baseline to follow-up in a per protocol analysis Lavender olfactory stimulation may reduce falls and agitation in elderly nursing home residents; further research is necessary to confirm these findings
Cochrane Review
Gold bar evidence scale One good quality RCT At least two good quality RCTs, - little inconsistency Multiple RCTs and/or systematic reviews - little inconsistency
Fall prevention what works High level balance exercise in group or home settings (functional balance exercises, Otago, Tai Chi) Occupational therapy interventions (home safety modifications in association with transfer training and education) in high risk populations Expedited first eye cataract surgery Restriction of multifocal glasses use in older people who take part in regular outdoor activity Pharmacist-led education and GP medication review Podiatry intervention in people with disabling foot pain
Falls prevention - what works Withdrawal of psychoactive medications Intensive multidisciplinary assessment of high risk populations Intensive interventions in hospitals Comprehensive geriatric assessment in residential aged care Vitamin D supplementation in residential aged care Medication review in residential aged care
What doesn t appear to work Updating glasses (increases fall risk?) Multifocal glasses restriction in inactive older people Brisk walking (increases fall risk?) Otago exercise program in people < 80, with visual impairment or taking psychoactive drugs Tai Chi in frail older people? Gentle and seated exercise Sloppy slippers campaigns Stand alone home modifications Stand alone education programs Low intensity interventions in hospitals and residential aged care Falls prevention in the cognitively impaired Multi-factorial interventions reliant on referrals
Summary There is strong evidence that specific intervention strategies can prevent falls It is not a one size fits all solution - What works in one group may not work in another Research is a work in progress: absence of evidence evidence of absence