Fall Prevention For Older People In Care Homes Julie Whitney 20 th June 2017
Falls in care homes
Community Care home Cognitive impairment Fallers 30% 50% 67% Falls rate PPPY 0.65 1.4 2.4 Injury 10-30% 30% 40% Any fracture 5% 10-25% Hip fracture 2% 4%
Adventures developing an intervention
Falls prevention where did we still need evidence? 2004 Good evidence base developing for interventions in community dwellers No clear evidence to support interventions for people living in care homes
Cochrane effective interventions (pooled data) Rate ratio (falls) Risk ratio (fallers) Exercise Medication review Vitamin D Environment Social environment Lavender patch Sunlight exposure Exercise, incontinence management and fluids Sunlight and calcium Multifactorial Multifactorial (high level nursing) Multifactorial (intermediate level care) Multifactorial with cognitive impairment Multifactorial without cognitive impairment or mixed
Falls prevention where did we still need evidence? 2004 Good evidence base developing for interventions in community dwellers No clear evidence to support interventions for people living in care homes Two well conducted multi-factorial studies with no effect on falls (Shaw and Jensen)
Options: To the drawing board.. 1. Try another intervention study 2. Take a step back
MRC guidance for developing interventions
Defining fall risk factors
Defining fall risk factors in older adults with cognitive impairment
Adventures developing an intervention
Feasibility and Efficacy of a Multi-Factorial Intervention to Prevent Falls in Older Adults With Cognitive Impairment Living in Residential Care (ProF-Cog). A Feasibility and Pilot Cluster Randomised Controlled Trial National Institute for Health Research (NIHR) Research for Patient Benefit (RfPB) Programme Reference Number PB-PG-0211-24,140
Previous falls Poor balance Walking frame use Antidepressants Axiolytics / hypnotics Risk factors Impaired cognition MMSE<17 Impaired attention and concentration Impulsivity (trying to get up all the time) Ill-being Anxiety Agitation Comprehensive geriatric assessment Balance training Medication review
Previous falls Poor balance Walking frame use Antidepressants Axiolytics / hypnotics Risk factors Impaired cognition MMSE<17 Impaired attention and concentration Impulsivity (trying to get up all the time) Ill-being Anxiety Agitation Dementia care mapping Person centred care Meaningful activities - PAL Movement sensors Environment
ProF-Cog Pilot and feasibility study Randomised controlled trial (clustered by care home) Primary outcome was standing balance Other outcomes: Walking speed, sit to stand ability, cognition, mood, physical activity, quality of life, fear of falling and falls Adherence and engagement, number of tests completed, recruitment, safety
Could we recruit for this trial?
No. Did it improve balance?
Did it reduce falls? 28% of control group fell 30% of intervention group fell Risk ratio=1.09 (95%CI 0.58-2.03) Rate ratio=1.59 (95%CI 0.67-3.76) Injury rate=1.20 (95%CI 0.66 2.20)
Was it safe? 1 fall during an exercise session No other adverse events
Power Why did it not work? Not enough participants Large differences between homes (clusters) Differences at baseline Measurement Difficulty with primary outcome Intervention Adherence to exercise / recommendations Participants Too large a range of risk factors
Did the randomisation work? Control (N=88) Intervention Significance (N=103) N (%) N (%) Nursing home 63 (72%) 57 (55%) 0.02 Female 60 (68%) 72 (70%) NS Age (years) 83.0 (9.2) 84.1 (8.4) NS Number of medications 8.0 (3.7) 8.0 (4.1) NS Number of medical conditions 1.5 (1.2) 2.0 (1.4) 0.03 Specific medical conditions: Diabetes 13 (15%) 28 (27%) 0.04 Fall in the past year 36 (41%) 56 (54%) 0.06 EQ5D questions: Mobility problems Problems looking after self Problems with usual activities Pain Anxiety 23 (32%) 23 (50%) 15 (37%) 18 (38%) 20 (44%) 34 (37%) 34 (52%) 21 (33%) 35 (52%) 41 (62%) NS NS NS NS 0.05
Did the randomisation work? Control (N=88) Intervention Significance (N=103) Mean (SD) Mean (SD ACE-R (n=171) 27.2 (26.9) 29.1 (25.9) NS Barthel (n=189) 9.4 (5.8) 8.6 (5.9) NS Health today (n=90) 70.2 (30.2) 65.4 (24.1) NS FES-I (n=80) 17.4 (7.2) 18.5 (8.2) NS PAM-RC (n=188) 10.4 (6.4) 9.2 (6.3) NS Cornell resident (n=111) 3.8 (5.0) 4.9 (4.8) NS b Cornell carer (n=188) 3.7 (3.9) 3.4 (3.7) NS b Impulsivity (n=189) 2.2 (3.1) 2.0 (3.1) NS b NPI-NH (n=191) 11.5 (12.4) 10.1 (10.4) NS b NPI disruptiveness (n=191) 2.6 (5.1) 2.1 (3.4) NS b Balance score (n=150) 13.8 (11.9) 13.7 (14.2) NS Near tandem stand (n=132) 1.7 (3.4) 1.5 (3.7) NS b Timed up and go (n=92) 37.6 (29.2) 61.8 (54.6) 0.005 a Sit to stand score (n=167) 2.6 (1.0) 2.4 (1.2) NS
Power Why did it not work? Not enough participants Large differences between homes (clusters) Differences at baseline Measurement Choice of outcome measure Intervention Adherence to exercise / recommendations Participants Too large a range of risk factors
Were the outcome measures the right ones? Test Standing balance Near tandem standing Timed up and go Sit to stand rating Sit to stand x5 EQ5D (quality of life) Cornell (patient version) FES-I (fear of falling) Barthel (function) PAM-RC (physical activity) Cornell (carer version) Impulsivity NPI-NH (behaviours) Rating for completion >80% 40-80% <40% N= 100 (52%) in analysis Rating for time taken and difficulty Speed= <5mins 5-10mins >10mins Ease rating= <3/10 4-5/10 >6/10
Power Why did it not work? Not enough participants Large differences between homes (clusters) Differences at baseline Measurement Choice of outcome measure Intervention Adherence to exercise / recommendations Participants Too large a range of risk factors
Adherence to advice Environment N (%) Followed fully Followed partially Not followed at all 74 (45%) 30 (18%) 61 (37%) Engagement with environment advice Mean (SD) range Engagement 0-10 8.3 (1.6) 3-10 Activity N (%) Followed fully Followed partially Not followed at all Engagement with activity advice 19 (21%) 48 (55%) 21 (24%) Mean (SD) range Engagement 0-10 8.0 (1.8) 5-10 Dementia care mapping N (%) Followed fully Followed partially Not followed at all 2 (7%) 20 (74%) 5 (19%) Engagement with DCM advice Mean (SD) range Engagement 0-10 7.1 (1.6) 5-9
Adherence to exercise Adherence (all) 41% Adherence (those who completed 68% Engagement with exercise 5/10 Reasons for missing sessions Refusal Unable for physical or cognitive Unwell 45% 21% 4%
Why didn t exercise work? Exercise for fall prevention requires: (Community dwellers) Frequency of 3 hours a week Inclusion of highly challenging balance training Minimising base of support Moving centre of gravity Reducing upper limb support Sherrington et al (2016)
Was this dose achieved? Refusals Pain Physical frailty Fluctuating function Mean no of sessions =21 /52 Mean time spent exercising = 23 minutes Mean time spent standing = 11 minutes Mean dose = 8 hours (20 mins a week)!
How does this relate to what we already know? Cameron et al (2012)
How does this relate to what we already know? Sherrington et al (2016)
What next?
What next? Not to give up PUBLISH +++++ Back to the drawing board More understanding about why it didn t work
Questions