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Recent developments in falls prevention research
Falls Clinic Coalition
March 2006
Associate Professor Keith Hill,
Physiotherapist & Researcher,
National Ageing Research Institute
Research review: what works?
• Funded by Commonwealth Dept Health & Aged Care
• Randomised controlled trials
• Community, residential aged care, and hospital settings
• Published in 2000, updated by NARI and re-published in 2004
Cochrane Systematic reviews
2000 2004
Falls Falls
Hip protectors Hip protectors
Vitamin D
Environmental mods
Evidence of intervention effectiveness: Community (2000)
Risk factorChronic medical conditionsEnvironmental hazardsReduced activityReduced balanceReduced strengthPoor visionCognitive impairmentPolypharmacyOsteoporosisLow body mass index DepressionOther
Education
Multiple strat
Injury min
Sensory
Environment
Medication
Medical screen
Exercise-gen
Exercise-bal
Exercise-str
Level II
Evidence of intervention effectiveness: Community (2004)
Risk factorChronic medical conditionsEnvironmental hazardsReduced activityReduced balanceReduced strengthPoor visionCognitive impairmentPolypharmacyOsteoporosisLow body mass index DepressionOther
Education
Multiple strat
Injury min
Sensory
Environment
Medication
Medical screen
Exercise-gen
Exercise-bal
Exercise-str
Level II (2000)
Post-hosp
Level II (2004)
Randomised controlled trials with significant outcomes
1314
0
4
8
12
16
2000 2004
num
ber
of publis
hed
stu
die
s
commonly used
One RCT identifying significant reduction in falls rates for an OT home visit / environmental assessment / behaviour risk modification IN AT RISK GROUP ONLY (Cumming et al, 1999)NB: equally as effective at home and away
from home : issues of compliance
Environmental safety: Home falls risk assessment & modification
Post hospitalisation
15% of older people fall at least once within 1 month of discharge home from hospital, with 11% experiencing serious injuries (Mahoney et al, 2000)
Nikolaus and Bach 2003 older people admitted to hospital with functional
decline post discharge, usual care vs additional home
intervention including follow-up visits, instructions on use of aids and home modifications, support for compliance
significant reduction in falls at 12 months differential outcome based on compliance
various forms of exercise balance strength cardiovascular fitness flexibility
specificity of training
other health benefits of exercise programs
strong evidence of effectiveness
of training in older people to
improve specific risk factor
Exercise
Exercise
tai chi (Wolf et al, 1996; Li et al, 2005)physiotherapy prescribed home program
(Campbell et al, 1997; Robertson et al, 2001)
group exercise program (Day et al, 2002, Barnett et al, 2003; Lord et al, 2003)
no published RCT’s evaluating medical screen with falls rate as an outcome
Campbell et al (1999) - RCT - psychotropic medication withdrawal 66% reduction in falls rates in intervention group 47% had resumed psychotropics after one month
Clinical screen: Medical (including medication)
Critical role of vision in balance and obstacle avoidance
Melbourne study identified identified that a third of people over 65 have inadequate visual correction
Cataract surgery has been shown to reduce falls (RCT – Harwood et al, 2004)
?? Effectiveness of visual assessment and correction
?? Effectiveness of changing bifocals to separate distance and reading glasses (current Sydney study)
Vision correction
Tinetti et al (1994) - RCT - subjects with one or more falls risk factors, all provided with 3 interventions (home mods, home exercise, medication review)sig difference in time to first fall, number of falls
and fear of fallingRizzo et al (1996) - cost benefit analysis of
Tinetti’s program
Clinical screen: Multiple strategy (restricted)
incorporates assessment and tailored management
Close et al (1999) - RCT - assessment by medical and occupational therapy staff significant reduction in falls rates
Cochrane meta-analysis (Gillespie et al, 2004)
Current NARI study nearing completion (700 older fallers presenting to Emergency Departments after a fall)
Clinical screen: Multiple strategy (unrestricted)
Injury minimisation
Alternative strategies may be indicated if: falls risk is high intervention has not been successfulother factors limit likelihood of successful
intervention (eg poor cognition)Osteoporotic / high fracture risk
Hip protectors
Limited studies in community settingshown to be effective in residential care
settings (though less so with recent studies) issues of limited compliance
Injury minimisation
Vitamin D & calcium supplementation RCT of older people in community / residential
aged care settings identified significant reduction in falls fracture rates (Chapuy et al, 1992)
Mechanism of slowing normal bone loss
Recent evidence of effect on reducing falls
Research gaps: Community setting
Some risk factors poorly understood and managed dizziness
Some interventions have good clinical basis, but limited research evidence use of walking aids footwear
Effect of early identification of falls risk All interventions are only as good as the adherence to the
intervention regime - issues to improve uptake and compliance need further exploration
Almost all interventions that have been shown to be effective have not included subjects with an important falls risk factor - cognitive impairment (NB- Shaw et al 2003)
Falls prevention for people presenting to Emergency Departments after a fall
Large study, in its 4th year Recruited 700 participants Evaluating effectiveness of a
comprehensive assessment (using a NARI developed tool-the FROP-Com) in reducing falls and falls injuries
Also evaluating cost effectiveness Will be one of the few studies to
evaluate outcomes on injuries and costs
Melissa Russell undertaking her PhD
Dr Irene Blackberry
Early balance screening & exercise
Using Neurocom force platform to detect mild levels of balance dysfunction
Participants with mild balance dysfunction will be randomised to receive Otago home exercise program or info booklet
12 month followup, to determine effectiveness in improving balance and mobility
2.5 year project
Funded by the Dept Veterans’ Affairs; Xaio Jing Yang undertaking her PhD
Keith Hill, Kirsten Black, Xiao Jing Yang, Sarah Tarquinio
Falls prevention for stroke patients after in-patient discharge
High falls risk stroke patients recruited at discharge
Randomised to information booklet, or risk assessment and targeted management program
12 month follow-up (falls, balance, QoL, etc)
Sub-studies: Temporal changes in fear of falling after a fall Obstacle negotiation skills at 12 months, and
association with falls
Funded by NHMRC; Frances Batchelor commencing her PhD
Keith Hill, Cathy Said, Shylie Mackintosh, Craig Whitehead, Sarah Tarquinio, Frances Batchelor
Balance problems and exercise response in clinical populations
Neurocom and clinical measures of balance in OA and RA patients
Identify any differences in balance abilities
Determine responsiveness to Otago home exercise program
Funded by JO & JR Wicking Trust
Keith Hill, Sue Williams, Sue Hunt, Caroline Brand
Funded by Haemophilia Foundation (Aust)
Keith Hill, Marcia Fearn
Neurocom and clinical measures of balance in patients with haemophilia
Identify falls history, level of balance dysfunction (relative to joint pathology)
Determine responsiveness to Otago home exercise program