1、,Active for Later Life,Evidence into practice,Physical activity and the prevention of falls among older people,Why are falls important? How active are older people? Physical activity in falls prevention. Does it work? Evidence of effectiveness Putting it into practice: Recommendations and guidelines
2、 Putting it into practice: Education and training,Why are falls important?,Why are falls important?,The human costs of falls Large numbers of older people are falling Impact on local services Costs to the health services,Why are falls important?,Why are falls important?,The human costs of falls,A do
3、wnward spiral? Further loss of function Loss of mobility, independence, dignity and confidence Fear of another fall and further loss of function Increased isolation and loneliness Frequent fallers have poor outcomes,Why are falls important?,90-day outcome after hip fracture,24% return to pre-fractur
4、e level of function 42% of survivors require extra help with half their daily activities 21% require an increased level of residential or hospital care 35% receive increased community health and social service care at home (Bandolier, 1998),Why are falls important?,Large numbers of older people are
5、falling,Each year One-third of people aged 65+ and 50% of over-80s living in the community will fall. Over 60% of those living in nursing homes will fall repeatedly. 75% of falls-related deaths occur in the home. 75% of falls are not reported. (Cryer and Patel, 2001),Why are falls important?,Are cer
6、tain groups more at risk?,Men and women fall at the same rate but men are far less likely to injure themselves. There is no evidence of higher rates of falls among minority ethnic groups. Older people over 80 Older people living in nursing homes,Why are falls important?,Estimated incidence of hip fr
7、acture in England and Wales,People (000),Source: Grimley-Evans et al, 1997,Why are falls important?,Impact on local services,Over 10% of the London ambulance service workload (Halter et al, 2000) Contributes to local authority care costs of 3 billion residential and 2 billion non-residential Long-te
8、rm nursing care 19,000 per year for older person affected by a fall Social care costs caused by falls of 2.5 million per year for an urban primary care trust (population 260,000+) (Department of Health, 2001),Why are falls important?,Costs to the health services The financial costs of hip fractures,
9、Estimated acute hospital costs for fractured neck of femur Long stay/social cost Primary care costs Total cost,4,808 7,125 164 12,097,The annual cost of treatment of fractures among women is now in excess of 1.8 billion. (Dolan and Torgerson, 2000),Physical activity in falls prevention. Does it work
10、?,Evidence of effectiveness,Physical activity in falls prevention. Does it work?,Modifying risk factors for falls,Extrinsic Social or physical environment e.g. Poor housing and lighting Baths without handles Ill-fitting shoes Unsafe walking areas (More important in under-70s),Intrinsic States or tra
11、its of an individual e.g. Sensory decline Medical conditions Strength, balance, gait and physical performance Four or more medications (More important in over-70s),Physical activity in falls prevention. Does it work?,Intrinsic vs extrinsic risk factors “We are all trippers.”,Over half of falls exper
12、ienced in the home are due to environmental hazards e.g. trips, slips, unsafe or unlit stairs. A decline in a persons intrinsic risk factors (declining function and balance) means that the extrinsic risk factors (loose mat, slippery floor) no longer cause a correctable trip; they cause an injurious
13、fall.,Physical activity in falls prevention. Does it work?,Risk factors for falls that cannot be modified,Age Gender Social class Chronic medical conditions Irreversible vision problems Osteoporosis,Physical activity in falls prevention. Does it work?,Targeting the modifiable risk factors for fallin
14、g,Low strength and power Medical condition Medications Incontinence Cognitive impairment Balance/gait Postural hypotension Vision/hearing,Foot care Poor housing Depression Previous falls Fear of falling Functional capacity Poor heating Poor diet,Physical activity in falls prevention. Does it work?,I
15、mproving risk factors duration vs outcome,Gait (8 weeks) Balance (Static 8 weeks + Dynamic 8 weeks) Muscle strength (8-12 weeks) Muscle power (12 weeks) Endurance (26 weeks) Transfer (6 months) Postural hypotension (24 weeks) Bone strength (1 year for femur and lumbar spine)(Skelton and McLaughlin,
16、1996),Physical activity in falls prevention. Does it work?,Reviews of effectiveness in falls prevention,Guidelines for the prevention of falls in older people (Clinical Effectiveness Group, 1998) Gardner et al (2000) National Service Framework for Older People Standard 6: Falls (Department of Health
17、, 2001),Physical activity in falls prevention. Does it work?,Effective interventions,Tinetti et al, 1994 FICSIT Trials: Province et al, 1995 Wolf et al, 1996 Campbell et al, 1997 PROFET: Close et al, 1999 FaME Project: Skelton, 2001 Day et al, 2002,Physical activity in falls prevention. Does it work
18、?,Tinetti et al, 1994,Community-dwelling older women 70+ More than one risk factor Multi-factorial intervention Included transfer training, gait 30% reduction in falls,Physical activity in falls prevention. Does it work?,FICSIT Trials (Province et al, 1995),7 sites (balance, strength, endurance and
19、other multi-disciplinary interventions) 10% lower risk of falling 4 sites (balance training) 25% lower risk of falling 1 site (Tai Chi only 10 moves) 47% lower risk of falling,Physical activity in falls prevention. Does it work?,Wolf et al, 1996,Community-dwelling population (n=200) with no debilita
20、ting conditions Intervention based on Tai Chi A synthesis of 108 existing forms into 10 exercise moves 2 sessions a week for 15 weeks Falls rate cut by half,Physical activity in falls prevention. Does it work?,Campbell et al, 1997,Women aged 80+, community dwelling Physical activity prescribed by a
21、physiotherapist 4 home visits over 2 months Strength, balance and gait training 20%-30% reduction in falls,Physical activity in falls prevention. Does it work?,PROFET Trial (Close et al, 1999),Community-dwelling, aged 65+ Multi-factorial intervention Medical assessment Physiotherapy and occupational
22、 therapy 60% reduction of risk,Physical activity in falls prevention. Does it work?,FaME Project (Falls Management Exercise trial),Independent, community-dwelling women with history of 3 or more falls in previous year (high risk) 9-month intervention exercise only Weekly exercise class and home exer
23、cise with trained seniors exercise instructor After 3 years, 10% of those in exercise group had died or were in hospital or in a nursing home, compared with 33% of those not exercising 60% reduction in falls and 75% reduction in injuries (Skelton, 2001),Physical activity in falls prevention. Does it
24、 work?,Day et al, 2002,1,000+ aged 70 years +, living at home Interventions included group-based exercise, home hazard management and vision improvement. Exercise (including balance training) comprised a weekly supervised group session together with 2 x weekly home exercise sessions. 14% reduction i
25、n annual rate of falls. Group-based exercise was the most potent single intervention tested.,Physical activity in falls prevention. Does it work?,Evidence of effectiveness,A critical review of 29 physical activity interventions reported: Increased activity levels over a longer period of time Group/c
26、lass-based and home-based activity were effective Tailored to individual needs Cognitive-behavioural strategies and goal-setting Telephone support and continued contact (King et al, 1998),How active are older people?,How active are older people?,Overview,Low levels of physical activity among older p
27、eople Thresholds for quality of life and functional capacity Physical activity and frailty Environmental factors assisting the spiral of decline,How active are older people?,Levels of sedentary behaviour among MEN aged 50+, England,% participating less than once a week,(Skelton, Young et al, 1999),H
28、ow active are older people?,Levels of sedentary behaviour among WOMEN aged 50+, England,% participating less than once a week,(Skelton, Young et al, 1999),How active are older people?,Levels of sedentary behaviour among minority ethnic groups aged 55+, England,Those participating less than once a we
29、ek,African-Caribbean Indian Pakistani Bangladeshi Chinese,57% 67% 73% 85% 68%,59% 78% 85% 92% 64%,Men Women,(Erens et al, 2001),How active are older people?,Older people living in care and residential settings,86% of women and 78% of men in care homes are sedentary. Sedentary behaviour in care homes
30、 is double that in private households (at age 65+). Half of all men and women in local authority residential homes never or very occasionally take trips outside the home. (Department of Health, 2002),How active are older people?,The physical activity paradox,39% of men and 42% of women aged 50+ are
31、sedentary. YET over half of sedentary men and women aged 50+ believe they take part in enough activity to keep fit. 26% of men and 34% of women aged over 70 are unable to walk a quarter of a mile on their own.,How active are older people?,Thresholds for quality of life,Exercise performance,Age,Adapt
32、ed from Young (1986),Threshold value necessary for performance of an everyday task,How active are older people?,Aerobic capacity in MEN and WOMEN aged 50-74 (mean 2sd),Maximum oxygen uptake (ml/kg/min),(Skelton, Young et al, 1999),How active are older people?,Knee extension strength in MEN and WOMEN
33、 aged 50-74 (mean 2sd),Isometric knee extension strength (N/kg),(Skelton, Young et al, 1999),How active are older people?,Shoulder flexibility in MEN and WOMEN aged 50+ (mean 2sd),Shoulder abduction (degrees),(Skelton, Young et al, 1999),How active are older people?,Functional capacity,Even healthy
34、older people lose functional capacity. Muscle strength lost at 1%-2% per year Muscle power lost at 3%-4% per year Aerobic capacity lost at 1% per year Bone density lost at 1% in men and 2%-3% in women after menopause Flexibility and balance Proprioception and kinesthetic awareness Co-ordination and
35、reaction Thermo-regulationSedentary behaviour increases loss of performance. (Skelton and Dinan, 1999),How active are older people?,Functional decline and frailty,(Spirduso, 1995),How active are older people?,Inactivity-related disease?,Disuse rather than disease? One weeks bed rest reduces: strengt
36、h by up to 20% spine bone mineral content by 1%. 86% of women and 78% of men in residential homes in England are sedentary. Nursing home residents spend 80%-90% of their time seated or lying down leading to inactivity-related disability. Those who are less active and weaker will enter nursing homes
37、earlier than those who maintain their fitness.,How active are older people?,Environmental factors assisting the spiral of decline,Following a fall Further loss of function Loss of mobility and independence Further loss of function Increased isolation and institutionalisation Loss of dignity and conf
38、idence and fear of a further fall Fear of using stairs Concerns for personal safety out of the house Poorly designed pavements/kerbs Concerns of family, friends and carers,Putting it into practice,Recommendations and guidelines,Putting it into practice: Recommendations and guidelines,What do we mean
39、 by physical activity?,Physical activity “Any bodily movement produced by skeletal muscles that results in energy expenditure.” Physical activity is a broad term covering all types of movement (including leisure, work, chores and movement). Exercise “Any leisure time physical activity which is plann
40、ed and structured, and repetitive bodily movement undertaken to improve or maintain one or more components of physiological fitness.” (Bouchard et al, 1990),Putting it into practice: Recommendations and guidelines,Specificity of intervention older people (Simey et al, 1999),To improve health and mod
41、ify certain risk factors for falling (e.g. strength), moderate physical activity is appropriate. To reduce injurious falls, exercise should include training in balance, strength, co-ordination and reaction times. To reduce fractures, exercise should include bone- loading in addition to the elements
42、outlined for reducing falls.,Putting it into practice: Recommendations and guidelines,Recent recommendations and guidelines,American Geriatrics Society, British Geriatrics Society and the American Academy of Orthopaedic Surgeons Panel on Falls Prevention (2001) Guidelines for the collaborative, reha
43、bilitative management of older people who have fallen (Simpson, 1996)Summarised in Falls, Fragility and Fractures (Cryer and Patel, 2001),Putting it into practice: Recommendations and guidelines,Specific recommendations: multi-factorial interventions,Community-dwelling older people Gait training and
44、 appropriate use of assistive devices Review and modification of medication (especially psychotropics) Exercise programmes, balance training Treatment of postural hypotension Modification of environmental hazards Treatment of cardiovascular disorders (including arrhythmias) (Cryer and Patel, 2001),P
45、utting it into practice: Recommendations and guidelines,Specific recommendations: multi-factorial interventions,Long-term care and assisted living settings Staff education Gait training and appropriate use of assistive devices Review and modification of medications (especially psychotropics) Acute h
46、ospital settings No recommendations Older people who have recurrent falls Long-term exercise and balance training (Cryer and Patel, 2001),Putting it into practice: Recommendations and guidelines,Recommendations and guidelines for falls prevention for those aged 65+,Individually tailored exercise pro
47、grammes administered by a qualified professional reduce the incidence of falls in a selected high-risk group living in the community. Exercise programmes reduce the risk of falls in a selected group of older people with mild deficits of strength and balance living in the community. Tai Chi classes w
48、ith individual tuition can reduce the risk of falls in older adults. Programmes that combine interventions (multi-faceted mostly including exercise) reduce falls. (Feder et al, 2000),Putting it into practice,Education and training,Putting it into practice: Education and training,Professional educati
49、on and training generic areas,Health and physical activity needs of older people Skills of key workers Principles of health promotion Specificity of exercise recommendations Safety issues Local opportunities and expertise Policy contexts Skills in exercise and sport services (Simey et al, 1999),Putt
50、ing it into practice: Education and training,Training opportunities to support local programmes,Making activity choices Senior peer mentoring programmePeer mentoring to motivate inactive older people to become active Supervised targeted exerciseChair-based activity and assisted walking for frailer older people Postural stabilityA specialist exercise falls prevention and management course designed for experienced exercise professionals including physiotherapists (Department of Health, 1999),
