Evidence for Effective Fall Prevention Strategies Best Bets

Evidence for Effective Fall Prevention Strategies: Best Bets! www. mycahs. colostate. edu/david. greene

Evidence for Effective Fall Prevention Strategies. . . Yes, the evidence is hard to find/understand – it’s a jungle out there!

The information is behind the lion

What I planned to end with but didn’t get to and should have begun with! – the main message follows:

Best bet. . . 1. Search lit, look in meta analyses/systematic reviews/OTCATs, scan favorite journals.

2. Locate a few good articles you can implement – keeping in mind your population; Stay away from (don’t do!) what was done in studies that didn’t decrease falls!

3. Study the articles that report success and recreate the program.

What works? What doesn’t?

Making a list: Interventions NOT! Supported by Evidence • Strengthening program • increase in safety devices and reduction in hazards (installed hand-rails, removed rugs, increased lighting, repaired floors) in a “one-time intervention • decrease in internal risk factors including improved visual acuity, improved sit-to-stand time and improved knee flexion strength • reducing risk factors: gait/balance training, medicine review, optometry and podiatry visits • “low impact” individually prescribed fall risk management (individually prescribed: strength/balance training, ADL devices, caregiver instructions for supervision, medication review, accompany resident to toilet, ID as fall risk, vision/hearing eval & tx)

FINAL: Interventions Supported by Evidence Search with • OTCATS, OTDBASE, AOTA Evidence-Based Practice Abstracts (for other than falls); Ageline, CINAHL & Psych. INFO for full text The “Stepping on” program to improve Intervene with • Some programs using multifactorial and interdisciplinary risk mobility efficacy and protective assessment with reduction in home hazards and behavioral hazards (maybe most effective with a history of falling) behaviors (Clemson & friends) • • • Some programs for balance or strength exercise Tai Chi (certain programs) Individually tailored program of exercise (consult PT) Specific strength training WITH flexibility WITH endurance training The “Stepping on” program to improve mobility efficacy and protective behaviors • Individually prescribed multidisciplinary evaluation and recommendations in residential settings (Eakman & friends)

Interventions Supported by Evidence • Improve mobility efficacy and protective behaviors as in the “Stepping on” program – 7 -sewssion course in hazard identification, adopting safety strategies, etc. (described in Appendix of Clemson, Cumming, Kendig, Swann, Heard, & Taylor. Journal of the American Gerontological Society, 52: 1487 -1494, 2004) • Reduce environmental hazards and behavioral hazards. There was no difference in strength in fall vs no-fall group; but no-fall group benefitted from hazard reduction, so hazard reduction seems more important than strengthening. (Diener & Mitchell, Topics in Geriatric Rehab, 21 (3): 247 -252, 2005)

Interventions Supported by Evidence • Individually prescribed multidisciplinary recommendations ( as per OT / Speech / PT / Nursing / Pharmacy / Social Services evals): scheduled toileting program, ambulate with CNA when restless, clear pathways/clutter, wc modifications and minimal unsupervised use of adaptive mobility aids, restraint-free alarms, role-relevant activities to visit/engage. (Eakman et al. Topics in Geriatric Rehabilitation, 17 (3): 2939, 2002)

. . . Back to the beginning – slowly building lists of what works and what doesn’t. . .

Evidence: The Many Ways of Knowing! Individual articles – AJOT and Physical Therapy (official journal o APTA) subscriptions and journal club discuss – Various journal articles found through databa searches Systematic reviews Meta analyses Critically Appraised Topics (www. otcats. com) AOTA Evidence-Based Practice Briefs & Abstra (www. aota. org)

The M a Know ny Way s of ing! nce: rn ssi u o scu se j l a di i a c b i f b a f t u o l a ( c y nal gh d p ra our u e o r h j h T t s d l a an und le c c i i t s ns r o y f a h o l i s a P ript icle ) d m a n sc t o r a c r a. t b T l s s u t a b O ) s a n A r c t A jou o &. T s P w f s e w u s i r o w w i s ( B r s e c Va arche revie i ic t p c o c a ti T r se s a P d e m e s d s e y se st al prai y a n S B a Ap a e t c Me ically iden ) t v. org i r E • C OTA. aota w w • EAv(w ide

Evidenc e: The M any Wa ys of Knowin g! Individual articles – AJOT and Physical Therapy (official journal of APTA) subscriptions and journal club discussions – Various journal articles found through database searches Systematic reviews Meta analyses Critically Appraised Topics (www. otcats. com) AOTA Evidence-Based Practice Briefs & Abstracts (www. aota. org)

Evidence: The Many Ways of Knowing! • Individual articles – AJOT and Physical Therapy (official journal of APTA) subscriptions and journal club discussions – Various journal articles found through database searches • Systematic reviews • Meta analyses • Critically Appraised Topics (www. otcats. com) • AOTA Evidence-Based Practice Briefs & Abstracts (www. aota. org)

Practitioner-Friendly Sites Introduction of practitioner-focused sites • www. aota. org Evidence-Based Practice Resources • www. otseeker. com Set up like traditional database • www. OTCATS. com Critically Appraised Topics

FREE Sites for Searching: • OT CATS - Critically Appraised Topics in OT: http: //www. otcats. com • Physiotherapy Evidence Database (PEDro): http: //www. pedro. fhs. usyd. edu. au/index. ht ml • OTSeeker: http: //www. otseeker. com/ • Pub Med: http: //www. ncbi. nlm. nih. gov/entrez/query. f cgi? db=Pub. Med

FREE Sites for Searching: • Ageline through AARP: http: //www. aarp. org/research/ageline/ • Psychbite - a free evidence database for cognitive and behavioral interventions in cases of acquired brain injury: http: //www. psycbite. com/ • New England Journal of Medicine: http: //content. nejm. org/search. dtl • Google Scholar: http: //scholar. google. com/

Characteristics of Search Engines/Databases

Search Engines: Yield in Full-Text Articles Courtesy CSU Spring 2007 Research Group

Variation of Experience Courtesy CSU Spring 2007 Research Group

Yield in Citations with Abstracts Courtesy CSU Spring 2007 Research Group

Variation of Experience

Making a list: Where to Search? ? • Citations: OT Seeker (low in variability -of experience – same yield regardless of who’s doing the search) • Abstracts: Ageline, OTCATS, OTDBASE (all low variability); OT Search (high variability though & subscription separate from AOTA membership!) • Abstracts & full-text articles: Ageline, CINAHL & Psych. INFO (all three very low in variability)

Gathering Evidence from Meta Analyses/Systematic Reviews and the Articles Cited Within

Strategies Shown in Randomized Clinical Trials to Be Effective in Reducing the Occurrence of Falls among Elderly Persons Living in the Community. Strategy No. of Trials with + Results Balance and gait training and 2 of 3 strengthening exercise Reduction in home hazards after 1 of 1 hospitalization Discontinuation of psychotropic medication 1 of 1 Multifactorial risk assessment with targeted 3 of 3 management Specific balance or strength exercise 2 of 2 programs Tinetti. n engl j med 348; 1 www. nejm. org january 2, 2003

Impairments and disabilities as risks for falls Risk factor falling Lower limb strength Upper limb strength Lower limb range of motion Sensation Vestibular function Vision Cognition Static Balance Dynamic Balance/Gait Relative Risk for Falls (range between studies). 5 - 10. 3 1. 5 – 4. 3 1. 9 0. 6 – 5. 0 4. 0 1. 3 – 1. 6 1. 2 – 5. 0 1. 5 – 4. 1 1. 6 – 3. 3 Carter, Kannus, Khan. Sports Med 2001; 31 (6): 427 -438

Intervention studies which have used exercise to modify intrinsic risk factors for falls Risk factor falling Average improvement (%) [range between studies] Muscle strength Range of motion Balance Gait Reaction time 6 -174 0. 5 -18 – 7 -53 12 -48 0 -4 Sports Med 2001; 31 (6): 427 -438

Type of Exercise Activity: Number of Effective and Ineffective Studies

Duration of Exercise found Effective and Ineffective

Frequency (times/week) of Exercise found Effective and Ineffective

Out of 13 intervention studies, four reported success in preventing falls; for example: Lehtola et al. , 2000 (n = 92) • N = 131; Intervention of exercise class including Tai Chi once weekly plus walking with sticks, and home exercises each at least 3× weekly for 6 months; Control (n = 39) usual activities • Relative hazard for falls for the exercise group in 10 mo = 0. 60 [95% CI for (Intervention) compared with (Control) 0. 43, 0. 84] Sports Med 2001; 31 (6): 427 -438

Lehtola et al. , 2000 N= 131; Intervention (n=92) an exercise class including Tai Chi once weekly plus walking with sticks, and home exercises each at least 3× weekly for 6 months; Control (n=39) usual activities Sports Med 2001; 31 (6): 427 -438

Lehtola et al. , 2000 An exercise class including Tai Chi once weekly plus walking with sticks, and home exercises each at least 3× weekly for 6 months Sports Med 2001; 31 (6): 427 -438

“. . . a programme of Tai Chi resulted in a 48% reduction of falls in participants (mean age 76 years) compared with controls. Such a reduction was not seen in the individuals who followed a computerised balancetraining programme. It is of interest that whilst the computerised balance-training group developed greater stability on balance platform measures there was little change in this parameter in the Tai Chi group. ” Wolf et al. , 1996

Some meta analyses are difficult to understand. . .

Meta Analysis: Fall-prevention programs for the elderly: a Bayesian secondary metaanalysis. (includes abstract) Lucke JF; Canadian Journal of Nursing Research, 2004 Sep; 36 (3): 49 -64. (journal article - equations & formulas, tables/charts) PMID: 15551662 CINAHL AN: 2005015262

• • Fall-prevention programs for the elderly: a Bayesian secondary metaanalysis. 2004 A secondary meta-analysis of programs to reduce falls in the elderly is undertaken to demonstrate a Bayesian analysis. The Bayesian statistical tradition is carefully distinguished from the standard Neyman-Pearson-Wald (NPW) statistical tradition. In the 12 studies, the logit effect size is used to compare treatment groups using a prevention program to control groups without a program. To contrast the Bayesian analysis, independent-effects and fixed-effect meta-analyses are first conducted in the NPW tradition. This is followed by Bayesian independent-effects and fixed-effect metaanalyses that numerically replicate the NPW results but have conceptually different interpretations. The final analyses comprise Bayesian randomeffects and predictive meta-analyses. These results differ numerically from all the previous meta-analyses and conceptually from the NPW metaanalyses. The random-effects analysis allows for heterogeneity in the effect sizes. The predictive analysis yields the distribution of 5 a ne%^$w, out%^^^%^^-of-sample effect size, which accommodates &*%$(*%^$#not only the heterogeneity of the effects $*(%^)%(*$%*($#$ but also the imprecision in the %^&*%($(*&%parameter estimates. This last analysis shows that the effectiveness of new fall-prevention programs is less definitive than that found in the sample. Bayesian statistical methods are particularly well-suited for #@!&%$^%&$#&$&^%%%*&$*&$ %*&%*&$$&$&$()(*&%% %)(^___%)(%)%($$&*%#$&*#($ 467437376449 $(*$(*##)$$(* $(*$ (* $$(*$$* !@#$%&^*%($%)$(%*$&^#$&#&^@#*#$$(*#$(*$$of nursing science studies. !@#$#$&*%$(*&%%

Bayesian statistical methods are particularly well-suited for #@!&%$^%&$#&$&^%%%*&$*&$ %*&%*&$$&$&$()(*&%% %)(^___%)(%)%($$&*%#$&* #($ 467437376449 $(*$(*##)$$(* $(*$ (* $$(*$$* !@#$%&^*%($%)$(%*$&^#$&#&^ @#*#$$(*#$(*$$of nursing science studies. !@#$#$&*%$(*&%%

. . . Or difficult to read and interpret based on the audience they are written for and the terms used. . .

A meta-analysis of fall prevention programs for the elderly: how effective are they? • RESULTS: The overall mean weighted effect size for the 12 studies included in the meta-analysis was. 0779 (Z = 5. 03, p <. 001). • Exercise alone had a mean weighted effect size of . 0220 (Z =. 5303, p >. 5) • Exercise and risk modification had a mean weighted effect size of. 0687 (Z = 3. 41, p <. 001) • Comprehensive risk assessment intervention studies had an effect size of. 1231 (Z = 3. 97, p <. 001) • Mean weighted effect size for community-based studies was. 0972 (Z = 5. 37, p <. 001) and for institution-based studies was. 0237 (Z =. 7822, p =. 22). • CONCLUSIONS: There was a 4% decrease in the rate of falls for individuals who were in the treatment groups receiving various fall prevention interventions. Hill-Westmoreland EE; Nursing Research, 2002 Jan-Feb; 51 (1): 1 -8.

Effect Size (ES) – What is it? • In a way – a “magic number”: it is an index of what can be seen/observed clinically as an improvement – removed from numbers or “statistical findings” • There are many effect size measures; the most common are r and Cohen’s d effect sizes • Cohen compared various statistical findings to clinical observations in the behavioral sciences and came up with a chart of equivalences

Effect Size (ES) – What is it? • In general, a positive ES indicates the intervention group improved visibly/functionally; ES = 0 indicates no effect of therapy or “the intervention”; a negative ES indicates the intervention was harmful or had a negative effect on the group (and should not be repeated!) • A Cohen’s d of. 5 and an r of. 3 is considered a “medium effect”; d =. 8 or r = . 5 considered “large or larger than typical effect”

One more look at meta analysis results: A meta-analysis of fall prevention programs for the elderly: how effective are they? • RESULTS: The overall mean weighted effect size for the 12 studies included in the meta-analysis was. 0779 (Z = 5. 03, p <. 001). • Exercise alone had a mean weighted effect size of. 0220 (Z = . 5303, p >. 5) • Exercise and risk modification had a mean weighted effect size of. 0687 (Z = 3. 41, p <. 001) • Comprehensive risk assessment intervention studies had an effect size of. 1231 (Z = 3. 97, p <. 001) • Mean weighted effect size for community-based studies was . 0972 (Z = 5. 37, p <. 001) and for institution-based studies was. 0237 (Z =. 7822, p =. 22). • CONCLUSIONS: There was a 4% decrease in the rate of falls for individuals who were in the treatment groups receiving various fall prevention interventions. Hill-Westmoreland EE; Nursing Research, 2002 Jan-Feb; 51 (1): 1 -8.

Exercise in the prevention of falls in older people: a systematic literature review examining the rationale and the evidence. • RESULTS: On the basis of 9 randomized controlled studies conducted since 1996, exercise appears to be a useful tool in fall prevention in older adults, significantly reducing the incidence of falls compared with control groups. However, current limitations such as inconsistencies in the measurement of key dependent and independent variables do not, at present, permit a meta-analysis of intervention trials. Carter ND; Sports Medicine, 2001; 31 (6): 427 -38.

Do hospital fall prevention programs work? A systematic review. • RESULTS: Individual components of interventions showed no significant benefit. The pooled effect of about 25% reduction in the fall rate may be a result of intervention but may also be biased. Studies did not analyze compliance with the intervention or opportunity costs resulting from the intervention. Research and clinical programs in hospital fall prevention should pay more attention to study design and the nature of interventions. Oliver D; Journal of the American Geriatrics Society, 2000 Dec; 48 (12): 1679 -89.

Interventions Supported by Evidence • Reduction in home hazards after hospitalization • Multifactorial risk assessment with targeted management • Discontinuation of psychotropic medication • Specific balance or strength exercise programs (But not computerized balance in Wolf, et al. 1996 study!) • Exercise class including Tai Chi once weekly plus walking with sticks, and home exercises each at least 3× weekly for 6 months

Interventions Supported by Evidence • Tai Chi 15 min twice daily at home for 4 mo • Individually tailored program of exercise. Physiotherapist visited 4× in first 2 mo. Exercises 3× per wk, 30 min each, lower limb strength and balance plus encouraged walking outside 3×/wk • For individuals with at least mild deficits in strength or balance: Strength training: upper and lower limb; 3 sessions per wk for 60 min. PLUS flexibility PLUS endurance training: stationary cycle 75% max. heart rate

Interventions NOT! Supported by Evidence • Strengthening exercise/balance found to “work” but not always: – NOT computerized balance (as described in Wolf, et al. 1996 study)! – NOT Exercise: 60 min, 3× per wk, 12 mo. Standup, step-up, stretching and movement to music – NOT Cognition/behavioral: health and safety curriculum to prevent falls, relaxation, video games. – NOT Exercise/cognition: 2× per wk exercise, once per wk cognition – NOT stand-up/step-up routine progressing to 4 sets of 10 repetitions. 60 min 3× per wk

Interventions NOT! Supported by Evidence – NOT individually tailored one-one physiotherapy sessions 3× per wk for 4 mo, including range of motion, strength, balance, transfer and mobility. Each session 30 -40 min – NOT 60 -min exercise sessions, twice weekly in 4 terms of 10 -12 wk. 4 sections per session: warm-up, conditioning (aerobic, strength, balance and flexibility), stretching and relaxation – NOT 45 min weight-bearing exercise to music, 3× per wk for 3× 10 wk terms for 2 y (although worked for 18 months) – NOT strength, endurance, mobility and balance training for 90 min, 3× per wk for 12 wk

Some hazards are pretty obvious. . .

Some happen involving objects you cannot get rid of. . .

www. vch. ca/abi/img/braincompanypicture. JPG © 2002 -2007 Vancouver Coastal Health

BALANCE STRENGTH

Would you use exercises to teach a chicken to fly? Which exercises? Consider the barnyard exercise class in Chicken Run©

Gathering Evidence from Cochrane Collaboration Systematic Reviews and the Articles Cited Within

Go to: http: //www. cochr ane. org/reviews/ And search “Falls in the elderly” Interventions in Preventing Falls in the Elderly (Cochrane Review) Gillespie, Robertson, Lamb, Cumming & Rowe

The Cochrane Database of Systematic Reviews 2007 Issue 1 Copyright © 2007 The Cochrane Collaboration. Published by John Wiley and Sons, Ltd. Background: Approximately 30 per cent of people over 65 years of age and living in the community fall each year; the number is higher in institutions. Although less than one fall in 10 results in a fracture, a fifth of fall incidents require medical attention. Objectives: To assess the effects of interventions designed to reduce the incidence of falls in elderly people (living in the community, or in institutional or hospital care).

Main results: Sixty two trials involving 21, 668 people were included. Interventions likely to be beneficial: Multidisciplinary, multifactorial, health/environmental risk factor screening/ intervention programmes in the community both for an unselected population of older people (4 trials, 1651 participants, pooled RR 0. 73, 95%CI 0. 63 to 0. 85), and for older people with a history of falling or selected because of known risk factors (5 trials, 1176 participants, pooled RR 0. 86, 95%CI 0. 76 to 0. 98),

Cochrane Review Summary • 62 trials 21, 668 people included in the review • Studies judged according to whether they were “likely to be beneficial” or “of unknown effectiveness” or “unlikely to be effective”

Risk Ratios (RR) of “Beneficial Interventions” * *Incidence Rate

Interventions Supported by Evidence (Cochrane Collaboration reviews) • Exercise may prevent falls? ? ? (Carter – problem with measurement of dependent variables) • Hospital-based fall prevention? ? ? (Oliver – Compliance, costs, inconsistent study designs all a problem; no significant findings per study, but a possible pooled effect across studies) • Multi disciplinary/factorial risk screening

Interventions Supported by Evidence (meta analyses/systematic reviews) • Risk screening (for individuals with a history of falls) • Programs in nursing home settings • Strength and balance programs? • Home hazard evaluation and modification (for individuals with a history of falls) • Tai Chi group

BALANCE STRENGTH

Interventions NOT! Supported • Group-Delivered Exercise • Individual LE Strengthening • Home Hazard Mod. w/ Medication Suggestions • Home Hazard Mod. w/ education packet on exercise and reducing falls • Cognitive/Behavioral Approach Alone • Hm. Haz. Mod. when no Hx of falling • Brisk walking in older women with UE fracture

STRENGTHENING

ion ome pa Haz cke ard red uci t on e Mod ng xer. w/ fall cis NO s e a T H nd om e H aza no his rd mo tor y o difica f fa tion llin wh g en cat NO T H Me om dic e H atio aza n S rd ugg Mod est. w NO ion / edu T H s

Gathering Evidence from Critically Analyzed Topics (CATs) http: //www. otcats. com

Another CAT. . .

• Interdisciplinary/multifactorial assessment and intervention (including OT) for cognitively intact in-patients, ≥ 65 years, whose primary diagnosis in A and E was a fall, reduced the falls rate in the year following their fall. This was also true for those with a history of falls who present as above. Number and length of subsequent hospital admissions may also be reduced and independence in ADL may be improved. • Multifactorial intervention (including OT) had no effect on falls reduction within the following year for people ≥ 65 years, with cognitive impairment and dementia whose primary diagnosis in A and E was a fall. Prepared by S. Patterson and M. Williams 2005. Available at www. otcats. com

One more CAT – look at the entire review

BEST EVIDENCE • The review by Chang and colleagues (2004) was identified as the ‘best’ evidence and selected for critical appraisal. Reasons for selecting this article were: Most current available evidence; highest level of evidence; addressed both multifactorial falls assessment and management plans as an intervention, and compared this intervention to other commonly used falls prevention interventions

• Data from 26 intervention groups in 22 studies was used for the meta-analysis of participants who fell at least once. The combined data from these intervention groups showed a significant reduction in the risk of falling • A multifactorial falls risk assessment and management programme had a statistically significant beneficial effect on both risk of falling and monthly rate of falling • Relative effectiveness of major components of a multifactorial falls risk assessment and management programme not identified

• Exercise. . . also had a statistically significant beneficial effect on the risk of falls. . . [but] not able to detect statistically significant differences or consistent trends in the efficacy of different types of exercises • Environmental modification and education were primary components of some studies. . . did not show statistically significant effects on the reduction of monthly fall rates or reduction in falls risk

Evidence Brief Structured Abstract

Interventions Supported by Evidence (from CATs) • Home hazard assessment and modification/Risk awareness or advice – But which one is more effective? ? • Interdisciplinary/multifactorial assessment and intervention for those with a history of falls – NOT if cognitive impairment/dementia was present!! • multifactorial falls risk assessment and management program – But which components? : Exercise effective – but which type of exercise? – !!Environmental modification and education not necessarily effective!!

Gathering Evidence from Individual Articles You found in a Database Search

Effectiveness of a Community-Based Program for Reducing the Incidence of Falls in the Elderly: A Randomized Trial • Intervention group showed 31% reduction in falls; this was a significant difference compared to control group, p =. 025. • Intervention gp sig. > in mobility efficacy and number of protective behaviors adopted • 70% participants followed 50% of recommendations • “Stepping on” program in Appendix and a reference to its full description Clemson, Cumming, Kendig, Swann, Heard, & Taylor. Journal of the American Gerontological Society, 52: 1487 -1494, 2004

What is “significantly different”? ? • We are all different on just about anything you measure about us – height, weight, how far we throw a ball, etc. • Randomly select 2 groups from this room and get average weight of each group. The two averages will be slightly different – based on CHANCE of a few more people with more weight being in one group compared to the other. • Now I want to try an intervention – a diet for one gp, and the other is the control – “ eat as usual” gp. - and we do this experiment for 2 months.

“significantly different”? ? cont. . . • How much different do the average weights of the two gps need to be to feel confident the diet worked? – as they were different to begin with! • Statistical tests give us an answer – the averages must be different enough that the chances of finding a difference that great would be rare (a low probability) in any two groups selected and weighed WITHOUT either getting the diet.

What is “p”? ? • p tells us how low the probability is • Magic value for p (which stands for “probability of finding a difference this large between groups”) is. 05 • Example: An intervention to prevent falls showed a significant difference between fall-prevention gp. and usual treatment gp, p =. 05

What is “p”? ? cont. . . • p =. 05 means the chances of having a difference in number of falls this great WITHOUT the fall-prevention intervention is only 5 times in 100. • So, a p of <. 001 means the amount of difference was so great, it would happen only 1 time in 1000 of making two gps, having no intervention, and counting the number of falls in each group

Impact of a Multifactorial Fall Prevention Program Upon Falls of Frail Adults Attending an Adult Health Day Care Center • Significantly greater % fallers in control gp compared to fall prevention gp, p<. 001 • Significantly fewer environmental hazards and behavioral hazards in fall prevention gp, p<. 001 • Strength NOT significantly different, p>. 05, between two groups @ 6 months Diener & Mitchell, Topics in Geriatric Rehab, 21 (3): 247 -252, 2005

Preventing Falls in Older People: Outcome Evaluation of a Randomized Controlled Trial • No significant difference between fallprevention gp and control gp even though fall-prevention group showed significant increase in safety devices and significant reduction in hazards: installed hand-rails, removed rugs, increased lighting, repaired floors • Concluded a “one-time intervention not enough” to impact falling in this population Stevens, Holman, Benet, Klerk. Journal of the American Gerontological Society, 49: 1448 -1455, 2001

The Effect of an Individualized Fall Prevention Program on Fall Risks and Falls in Older People: A Randomized, Controlled Trial • No significant difference in the number of falls comparing the fall-prevention group to the usual-care group • No difference in falls – even though there was a significant decrease in internal risk factors resulting from the program including improved visual acuity, improved sit-to-stand time and improved knee flexion strength Lord, Tiedemann, Chapman, Munro, Murray, Remed, & Sherington. Journal of the American Gerontological Society, 53: 1296 -1304, 2005

Fall Prevention in Residential Care Homes: A Randomized Controlled Trial • No significant difference in the number of falls comparing the fall-prevention group (2. 2 falls/resident/year) versus the usual-care group (4 falls/resident/year) • No difference in falls – even though gait/balance training, medicine review, optometry and podiatry visits resulted in reduced risk factors in the fall-prevention group Dyer, Taylor, Reed, Dyer, Robertson, & Harrington. Age and Aging, 33 (6): 596 -602, 2004

Fall Prevention in Residential Care Homes: A Cluster Randomized Controlled Trial • No significant difference in the number of falls comparing the fall-prevention group (2. 2 falls/resident/year) versus the usual-care group (4 falls/resident/year) • This “low impact” individually prescribed fall risk management resulted in 56% of the fall prevention participants falling compared to only 43% of the usual care group – this is a negative effect size = the intervention actually resulted in significantly more falls, p=. 018!! Kerse, Butler, Robinson, & Todd. Journal of the American Gerontological Society, 52: 524 -531, 2004

Finally. . . the two best studies I found – both usable! • The first is a repeat of one already presented – employs the “stepping on” program – described in the appendix of the article – for your use! • The second is for institutional settings, is well described, and mostly measures what we typically do – individual assessments and prescribed programs!

Effectiveness of a Community-Based Program for Reducing the Incidence of Falls in the Elderly: A Randomized Trial • Intervention group showed 31% reduction in falls; this was a significant difference compared to control group, p =. 025. • Intervention gp sig. > in mobility efficacy and number of protective behaviors adopted • 70% participants followed 50% of recommendations • “Stepping on” program in Appendix and a reference to its full description Clemson, Cumming, Kendig, Swann, Heard, & Taylor. Journal of the American Gerontological Society, 52: 1487 -1494, 2004

Fall Prevention in Long-Term Care: An In. House Interdisciplinary Team Approach • Pretest/Posttest design – found significantly fewer falls (3. 2 falls) after the fall prevention program compared to before (5. 52 falls; p<. 001) • Also significantly fewer injuries from falls • Study outlines the 20 most frequently given recommendations; 274 interventions given overall with range of 5 to 17 per resident Eakman et al. Topics in Geriatric Rehabilitation, 17 (3): 29 -39, 2002

Interventions Supported by Evidence • Improve mobility efficacy and protective behaviors as in the “Stepping on” program – 7 -sewssion course in hazard identification, adopting safety strategies, etc. (described in Appendix of Clemson, Cumming, Kendig, Swann, Heard, & Taylor. Journal of the American Gerontological Society, 52: 1487 -1494, 2004) • Reduce environmental hazards and behavioral hazards. There was no difference in strength in fall vs no-fall group; but no-fall group benefitted from hazard reduction, so hazard reduction seems more important than strengthening. (Diener & Mitchell, Topics in Geriatric Rehab, 21 (3): 247 -252, 2005)

Interventions Supported by Evidence • Individually prescribed multidisciplinary recommendations ( as per OT / Speech / PT / Nursing / Pharmacy / Social Services evals): scheduled toileting program, ambulate with CNA when restless, clear pathways/clutter, wc modifications and minimal unsupervised use of adaptive mobility aids, restraint-free alarms, role-relevant activities to visit/engage. (Eakman et al. Topics in Geriatric Rehabilitation, 17 (3): 2939, 2002)

Making a list: Interventions NOT! Supported by Evidence • Strengthening program • increase in safety devices and reduction in hazards (installed hand-rails, removed rugs, increased lighting, repaired floors) in a “one-time intervention • decrease in internal risk factors including improved visual acuity, improved sit-to-stand time and improved knee flexion strength • reducing risk factors: gait/balance training, medicine review, optometry and podiatry visits • “low impact” individually prescribed fall risk management (individually prescribed: strength/balance training, ADL devices, caregiver instructions for supervision, medication review, accompany resident to toilet, ID as fall risk, vision/hearing eval & tx)

Also, it’s complicated. . .

Lighting Conditions of Falls in Three Settings

Location of Falls in Three Settings

Comparing Recommendations to Falls Circumstances Recommendations Outside: sitting on fence Railings (basement, entrance, garage); grab bar (collapsed) (shower); phone; careful of dog Kitchen: standing & Railings (basement, garage); door hinges; tub weight shift bench; ice removal; phone; careful of cat Dark room: walking (2 Railings (deck, garage); light (garage); usable participants same home) shower curtain; ice removal; sturdier step stool

Recommendations and Falls cont. Outside: jogging Railing (back stairs); tape sidewalk; grab bar & backwards bench (shower); hand-held shower; ice removal Bathroom: sitting tub- Railings (entrance, garage); grab bar, mat, tub side* bench, hand-held shower; toilet railing & assistance Railings (backyard stairs-two sets); caution tape for Outside: walking & entrance stairs; grab bar, hand-held shower; light carrying switch

Solutions? : Skyhook and harness:

For men too!

Padded outfit!

Signage?

W re ell an co -m d mm ea m e nin od n g ifi da ca tio ns ns ?

CDC Resources • Publications help older adults prevent falls • CDC, in partnership with the CDC Foundation and Met. Life Foundation, has produced four posters and redesigned two of its popular brochures to help older adults— and those who care for them—prevent falls and the injuries and deaths that result. These materials are important resources to protect the health and independence of older adults.

CDC • What YOU Can Do to Prevent Falls outlines four key fall prevention strategies. Strategies include exercising regularly, having medicines reviewed to reduce side effects and interactions, having yearly eye exams, and reducing fall hazards in the home. • Check for Safety: A Home Fall Prevention Checklist for Older Adults guides readers in a room-by-room check of their home to find and fix hazards that can increase the risk of falling. • Four posters, designed for use in health care facilities, senior centers, and other community organizations, highlight the messages in the brochures.

CDC Resources • In 2003, more than 13, 700 people 65 and older died from falls; 1. 8 million older adults were treated in emergency departments for nonfatal injuries from falls, and more than 460, 000 of these patients were hospitalized. Free Resources: • www. cdc. gov/ncipc/duip/fallsmaterial. htm. • www. cdc. gov/ncipc/duip/preventadultfalls. htm.

Guidance for gathering information as we work: Development of a Common Outcome Data Set for Fall Injury Prevention Trials: The Prevention of Falls Network Europe Consensus Sarah E. Lamb, Ellen C. Jorstad-Stein, Klaus Hauer, and Clemens Becker on behalf of the Prevention of Falls Network Europe and Outcomes Consensus Group JAGS 53: 1618– 1622, 2005 © 2005 by the American Geriatrics Society

Recommendation 2: Falls 1. A fall should be defined as ‘‘an unexpected event in which the participants come to rest on the ground, floor, or lower level. ’’ 2. Ascertainment must consider the lay perspective of falls. Participants should be asked, ‘‘In the past month, have you had any fall including a slip or trip in which you lost your balance and landed on the floor or ground or lower level? ’’

3. Falls should be recorded using prospective daily recording and a notification system with a minimum of monthly reporting. Telephone or face-to-face interview should be used to rectify missing data and to ascertain further details of falls and injuries.

• 4. Fall data should be summarized as number of falls, number of fallers/ non fallers/frequent fallers, fall rate person year, and time to first fall (as a safety measure). • 5. Primary analysis of fall data should not be adjusted for physical activity, and reporting should include the absolute risk difference between groups.

Recommendation 4: Psychological Consequences of Falling 1. Psychological consequences of falls should be conceptualized in terms of fall-related selfefficacy, defined as ‘‘the degree of confidence a person has in performing common activities of daily living without falling’’ and measured using the modified Falls Efficacy Scale (m. FES). 18 2. The measure should be scored per published guidance. 18

Recommendation 5: Measure Health Related Quality of Life 1. The recommended measures of quality of life are the Short Form 12 (SF 12) version 2 and European Quality of Life Instrument (Euro. Qo. L EQ-5 D). _____________ Reference: Euro. Qol Group. Euro. Qol. Fa new facility for the measurement of health related quality of life. Health Policy 1990; 16: 199– 208.

Amazing things have been possible! • http: //video. google. com/videoplay? docid=4 776181634656145640

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