Professor T.Masud

President, British Geriatrics Society

Nottingham University Hospitals NHS Trust University of Nottingham

University of Southern Denmark

Maintaining Mobility into Old Age and Preventing Falls

Twitter:@TashMasud

Disclosures

I have no conflict of interest or disclosure in relation to this

presentation

Statistical summaries of risk factors for fallsFrom cohort studies- Perell 2001

n Muscle weakness 4.4 (1.5-10.3)

n Falls history 3.0 (1.7-7.0)

n Gait deficit 2.9 (1.3-5.6)

n Balance deficit 2.9 (1.6-5.4)

n Use of assistive devices 2.6 (1.2-4.6)

n Visual deficit 2.5 (1.6-3.5)

n Arthritis 2.4 (1.9-2.7)

n Impaired ADLs 2.3 (1.5-3.1)

n Depression 2.2 (1.7-2.5)

n Cognitive impairment 1.8 (1.0-2.3)

n Age > 80 1.7 (1.1-2.5)

RISK FACTOR Mean RR/OR Range

Simple Model for Balance

CNS

Vision

Vestibular

Proprioception

Tactile sensation

Musculo-skeletal

Balance

Activity & environmental hazards

FALLS

INTRINSIC FACTORS EXTRINSIC FACTORSFALLS

Falls are Often Multifactorial

Co-morbidity & Frailty increase the risk of falls

CAUSES OF FALLS

Intrinsic (personal) Factors Causing Falls

& Delirium

Extrinsic (Environmental) Factors

Fall Prevention : Intervention Strategies

Population Community

Institutional

InterventionsMultiple

Single (unifactorial)

n Occupational Therapyü Functionü Physical handicap

n Medical assessmentü General medicalü Postural hypotensionü Visual acuityü Balanceü Cognition and affectü Corotid sinus synd.ü Psychological handicapü Environmental hazards

n Referral / intervention– Day hospital– GP– O/P– Optician– Social services– Supply minor equipment

Multidisciplinary assessment of fallers attending A/E (n=397): - 65+ years, medical assessment at day hospital + OT at home

PROFET – Lancet 1999- Close et al

1 year, falls â 61%, recurrent falls â 67%Failed in Holland-Hendricks 2008

• 70+ High Risk Community Dwellers, n= 1314

• Rate of Falls IRR 0.72 (95%CI 0.61-0.86) NNT= 3

• Fall related Injuries IRR 0.74 (95%CI 0.61-0.89) NNT= 5

Injury 2014

Unifactorial Interventions

n Medication Review

n Environmental Modification

n Improving Vision

n Vitamin D

n Exercise

21 3 4 5 6 7 8 92 100

Fallers OR (95%CI)

●

●

Antidepressants Overall

Tricyclics

SSRIS

Antidepresssants and Falls- the SOMA study

●

Masud T, Frost M, Ryg J, Matzen L, Ibsen M, Abrahamsen B, Brixen K. Central nervous system medications and falls risk in men aged 60-75 years: the Study on Male Osteoporosis and Aging (SOMA).Age Ageing 2013; 42: 121-4.

21 3 4 5 6 7 8 92 100

Fallers OR (95%CI)

●

●

●

Opiates Overall

Opiates ≥ 67 yrs

Opiates < 67 yrs

Opiates and Falls - The SOMA study

Masud et al 2013

Initiation of Hypertensives

Current prescribing of thiazides is associated with an increased risk of falling and that this is strongest in the 3 weeks following the first prescription(Gribbin 2010, UK, case controlled, GPRD, n= 9682)

The risk of falls on initiation of antihypertensivedrugs in the elderly

First 14 Days

(Butt 2012, population based Canadian case controlled)

EUGMS Task & Finish Group on Fall-risk increasing drugs

Seppala L, van der Velde N, Masud T et al

Drugs Aging 2019 36: 299-307

Contact l.j.seppala@amc.nl

Deprescribing Guidelines

Educational Materials

Unifactorial Interventions -RCTs

n Medication Review

n Environmental Modification

n Improving Vision

n Vitamin D

n Exercise

Environmental Modification

n Cochrane Review* 2012 (6 studies) -Home safety intervention reduced falls rate by 19%-Subgroup analysis on those at high risk showed fall rate reduction by 44%

n In the visually impairedHome safety programme reduced fall rates by 41%(Campbell 2005)

Unifactorial Interventions -RCTs

n Medication Review

n Environmental Modification

n Improving Vision

n Vitamin D

n Exercise

Vision and falls

Visual acuity Contrast sensitivity Depth perception

Nottingham expedited cataract study

days in study

390360

330300

270240

210180

150120

9060

300

Cum

ulat

ive

risk

of s

econ

d fa

ll.5

.4

.3

.2

.1

0.0

GROUP

routine

expedited

Hazard ratio = 0.60 (95% CI 0.36-0.98)

Harwood, RH, Foss AJ, Osborn F, Gregson RM, Zaman A, Masud T. BJ Opthalmol 2005

Fall rates ↓ 34% (IRR 0.66; CI 0.45-0.96)

Fractures ↓ 77% (IRR 0.33; CI 0.1-1.0, p 0.04)

Unifactorial Interventions -RCTs

n Medication Review

n Environmental Modification

n Improving Vision

n Vitamin D

n Exercise

Forest Plot Meta-analysis: Effect of vitamin D on fallsBischoff-Ferrari HA et al.; JAMA 2004

pooled corrected OR = 0.78; 95% CI [0.64, 0.92]

800 IU

800 IU

400 IU

Cochrane review on falls 2009 (13 studies)

• No significant reduction in fall rates or risk

• Subgroup analysis showed significant reduction in fall rate of 43% if

participants had low Vitamin D levels at recruitment

Recent Vitamin D Data

Unifactorial Interventions -RCTs

n Medication Review

n Environmental Modification

n Improving Vision

n Vitamin D

n ExerciseBest Evidence

Campbell et al, BMJ, 1997

Robertson et al, BMJ, 2001, 2005

17 trials, n = 4305

Falls in Dementia

• 60-80% if people with dementia fall each year

• Mean 3 falls/year

• Two-fold increased risk in Mild Cognitive Impairment

• 60% of hospital admissions for people with dementia due to falls

• 40% of hip fractures in someone with dementia

• People with dementia who fall 5 x more likely to enter care home

• Executive dysfunction associated with increased falls risk and reduced gait speed

• Future research should focus on executive dysfunction as a training target for falls prevention

• Initiation (reasoning, planning, judgement)

• Maintenance (attention)

• Set shifting (vigilance, change in light of new information)Suchy 2009; Lezak 2004; Montero Odasso 2012

Executive function and dual-task deficit

”Stops Walking and Talking” predicts falls

Effect of music-based multitask training on gait, balance, and fall risk in elderly people: a randomized controlled trial.Trombetti A1, Hars M, Herrmann FR, Kressig RW, Ferrari S, Rizzoli R.Arch Intern Med 2011

Jaques-Dalcroze eurhythmics

Dual-task cost (DTC): mean change for A) counting, B) serial 7s , C) naming animals conditions

Can Cognitive Enhancers improve Gait and Reduce Falls? Montero-Odasso et al. Eur J Neurol. 2019 (n= 60)

MCI, n= 60

Prevention of Delirium Trial

The mean fall rate before the intervention was 4.9/month (95%CI=4.5–5.7) which fell to 2.5/month (95%CI=1.5-3.4),

Component of the NHS 10 year long term plan (UK Gov 2019)

Sarcopenia (ICD 10)

• Loss of muscle mass and function (strength or performace)

• Prevalence increases with age

• Associated with disability, morbidity, frailty and mortality

Age Ageing 2019Cruz-Jentoft et al

Once Sarcopenia Identified

Resistance Exercise

Nutrition?

Therapeutic Advances ?

Protein

Vit D

Myostatin inhibitors

ACEIsSARMS

Exercises Recommended for Older Adults

Montero-Fernandez & Serra-Rexach 2013- Eur J Phys Rehabil Med

EXERCISE

Aerobic-brisk walk, -jog,-swim-cycle-dance

Progressive Resistance-weights -resistance bands-stairs-pull-ups-push-ups-heavy loads, -heavy gardening

Flexibility-yoga,-Tai Chi-pilates

Balance TrainingStatic- stand on one leg

Dynamic- (semi-) tandem- walk backwards- Tai Chi

41Image © Public Health England, Department of Health UK

42

Image (c) Public Health England, Department of Health, UK

Nutrition & Optimal Protein Intakes

(Franzke et al, Nutrients 2018)

• Old age + Inactivity → Anabolic Resistance (Impaired MPS )

• MPS rates higher after exercise (↑ Anabolic Sensitivity, timing may be important)

• WHO recommendations 2007 for all age groups: 0.8 g/kg/day

• ESPEN : Healthy adults ≥65 yrs: 1.0-1.2 g/kg/dayChronically ill or malnourished: 1.2- 1.5 g/kg/day

• 25-30 g per each meal

• Role of Essential Amino Acids + related compounds eg leucine, HMB

Protein / AA intake

Muscle contraction(Exercise – Resistance + Endurance)

Muscle Protein synthesis (MPS)

Sarcopenia Frailty

Disability

Reduced Physical Function

Reduced quality of Life

DeathProtein/Amino Acids Exercise

? treatsprevents

Systematic Review: Delaying and Reversing Frailty in Primary care(Travers et al, B J Gen Pract 2019; 46 studies)

”A combination of muscle strength training and protein supplementation was the most effective intervention to delay or reverse frailty and the easiest to implement in primary care”

Falls

“The conservation of health by exercise and various diets”Averroes (Ibn Rushd) 1126-1198 AD (Cordoba) دشر نبا