Fall and fracture prevention - research update Professor Stephen Lord Neuroscience Research Australia University of NSW
Overview Risk factors for indoor and outdoor falls Multiple Profile Assessment for understanding fall risk Cochrane hospital and residential aged care review Vitamin D and falls and fractures Q Fracture score calculator
Indoor fall predictors older age being female poor grip strength impaired balance slower walking speed slow Timed Up and Go times comorbidities obesity fear of falling poor cognition difficulty walking 400 meters
Outdoor fall predictors younger age being male higher educational status more leisure-time physical activity better health better physical functioning less obesity alcohol consumption faster walking speed ability to cope with higher steps visual impairment
References Bergland A, Jarnlo GB, Laake K. Predictors of falls in the elderly by location. Aging Clin Exp Res 2003;15:43-50. Bergland A, Pettersen AM, Laake K. Falls reported among elderly Norwegians living at home. Physiother Res Int 1998;3:164-74. O'Loughlin JL et al. Falls among the elderly: distinguishing indoor and outdoor risk factors in Canada. J Epidemiol Comm Hth 1994;48:488-9. Li W et al. Outdoor falls among middle-aged and older adultsam J Public Health 2006;96:1192-200. Bath PA, Morgan, K. Differential risk factor profiles for indoor and outdoor falls in older people living at home in Nottingham UK. Eur J Epidemiol 1999;15:65-73. Mänty M et al. Outdoor and indoor falls as predictors of mobility limitation in older women. Age Ageing 2009;38:757-61.
A multi-profile approach for understanding fall risk in older people a decision tree model Kim Delbaere, Jacqui Close, Stephen Lord Journal of the American Geriatrics Society. In Press
Decision Tree analyses Splits variables into two or more groups based for optimal discrimination Sequentially identifies variables that aid in the discrimination of fallers and non-fallers Can identify different risk factors for falls in subgroups of older people
Study design 500 independent-living older adults Screening Questionnaires on general health Neuropsychological assessment Physiological assessment 12 months follow-up Monthly questionnaire on falls for one year Three-monthly questionnaire on concern about falls for one year
Physiological Profile Assessment [Lord et al, 2003] Proprioception Vision Quad strength Reaction time Sway
Additional performance test Coordinated stability test: assesses the integration of physiological systems in the maintenance of dynamic balance control [Lord et al, 1996]
Activity and disability Levels of physical activity Incidental and Planned Activity Questionnaire (IPAQ) [Delbaere et al 2009] General disability World Health Organization Disability Assessment Schedule (WHODAS) Quality of life Australian Quality of Life assessment (AQOL)
Disability and QOL A new stringent disability score was computed based on Rasch modelling This score was devised to identify people with very low levels of disability. Five questions were selected from both questionnaires (AQOL items 2 and 15, WHODAS items 3, 6 and 8) assessing disability in five different areas: mobility on three levels (activities at home, activities outside home, walking) emotional status pain
Disability and QOL 1. How much difficulty did you have in taking care of your household responsibilities? 2. How much difficulty did you have to get around by yourself outside your house (e.g. shopping, visiting)? 3. How much difficulty did you have in walking a long distance such as a kilometre? 4. How much have you been emotionally affected by your health problems? 5. How often did you experience serious pain?
Psychological test battery Depressive symptoms Geriatric Depression Scale Fear of falling Falls Efficacy Scale International Attention Trail making test, Part A Executive functioning Trail making test, Part B
Non Fallers (66.8%) Fallers (33.2%) PPA < 0.60 (39.2%) Fallers (25.5%) PPA 0.60 (60.8%) Fallers (38.2%) No disability (11.0%) Some disability (28.6%) Normal Trails (17.0%) Impaired Trails (43.4%) Fallers (10.9%) Fallers (30.8%) Fallers (28.2%) Fallers (42.6%) Moderate exercise (11.2%) Fallers (21.4%) No or excessive exercise (17.4%) Fallers (36.8%) Good costab (14.6%) Fallers (34.2%) Poor costab (28.8%) Fallers (46.5%) Some exercise (17.4%) Fallers (41.4%) No exercise (11.4%) Fallers (54.4%)
Fallers (%) 60 50 Non Fallers (66.8%) Fallers (33.2%) 40 PPA < 0.60 (39.2%) Non Fallers (74.5%) Fallers (25.5%) PPA 0.60 (60.8%) Non Fallers (61.8%) Fallers (38.2%) No disability 30 (11.0%) Non Fallers (89.1%) Fallers (10.9%) Some disability (28.6%) Non Fallers (69.2%) Fallers (30.8%) Normal Trails (17.0%) Non Fallers (71.8%) Fallers (28.2%) Impaired Trails (43.4%) Non Fallers (57.6%) Fallers (42.6%) 20 10 Moderate exercise (11.2%) Non Fallers (78.6%) Fallers (21.4%) No or excessive exercise (17.4%) Non Fallers (63.2%) Fallers (36.8%) Good costab (14.6%) Non Fallers (65.8%) Fallers (34.2%) Poor costab (28.8%) Non Fallers (53.5%) Fallers (46.5%) 0 Elite Active Aware Less aware Some exercise (17.4%) Under or overactive Frail active Non Fallers (58.6%) Fallers (41.4%) No exercise (11.4%) Frail inactive Non Fallers (45.6%) Fallers (54.4%)
Conclusions A decision tree approach can elucidate interrelationships and discriminatory value of important explanatory fall risk factors Sensorimotor, balance, executive functioning, activity (exposure),disability This approach provides a model for implementing individualised interventions for preventing falls in community living older people
Cochrane Review www.cochranejournalclub.com/preventing-falls-innursing-care-facilities-and-hospitals/
Main results Of 7 trials targeting multiple risk factors, one significantly reduced falls and number of fallers, one reduced falls and one reduced the number of fallers Pooled results for all 7 studies showed a rate ratio (falls) of 0.78 (95% CI 0.57 to 1.07), and a risk ratio (fallers) of 0.90 (95% CI 0.82 to 0.98) Two trials studied vitamin D and calcium supplementation compared with calcium alone in residents with relatively low serum vitamin D. The rate ratio (falls) of 0.71 (95% CI 0.56 to 0.90) and the risk ratio (fallers) of 0.85 (95% CI 0.69 to 1.05) Pooled results of 2 trials that studied vitamin D supplementation without calcium were not significant
Single exercise modalities
Medication Review
Vitamin D supplements
Multifactorial interventions
Multifactorial with geriatric assessment and w.r.t. cognitive impairment
Reviewers conclusions Interventions in nursing care facilities and hospitals targeting multiple risk factors can be effective In nursing care facilities, vitamin D plus calcium supplementation can be effective
BMJ 2009;339:b3692 doi:10.1136/bmj.b3692
JAMA 2010:303:1815-1822
Main findings
BMJ 2009;339:b4229 doi:10.1136/bmj.b4229
Objective and methods
Q Fracture calculator http://www.clinrisk.co.u k/qfracture/
Results
Conclusions