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Physical activity and the prevention of falls among older people

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Loss of mobility, independence, dignity and confidence. Fear of another fall and further loss ... Physiotherapy and occupational therapy. 60% reduction of risk ... – PowerPoint PPT presentation

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Title: Physical activity and the prevention of falls among older people


1
Active for Later Life
Physical activity and the prevention of
falls among older people
Evidence into practice
2
  • 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
  • Putting it into practice Education and training

3
Why are falls important?
4
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

5
The human costs of falls
Why are falls important?
  • A downward 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

6
90-day outcome after hip fracture
Why are falls important?
  • 24 return to pre-fracture 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)

7
Large numbers of older people are falling
Why are falls important?
  • 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)

8
Are certain groups more at risk?
Why are falls important?
  • 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

9
Estimated incidence of hip fracture in England
and Wales
Why are falls important?
  • People
  • (000)

Source Grimley-Evans et al, 1997
10
Impact on local services
Why are falls important?
  • 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-term 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)

11
Costs to the health servicesThe financial costs
of hip fractures
Why are falls important?
4,808 7,125 164 12,097
  • Estimated acute hospital costs for fractured neck
    of femur
  • Long stay/social cost
  • Primary care costs
  • Total cost

The annual cost of treatment of fractures among
women is now in excess of 1.8 billion. (Dolan
and Torgerson, 2000)
12
Physical activity in falls prevention. Does it
work?
  • Evidence of effectiveness

13
Modifying risk factors for falls
Physical activity in falls prevention. Does it
work?
  • 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 traits
  • of an individual e.g.
  • Sensory decline
  • Medical conditions
  • Strength, balance, gait and physical
    performance
  • Four or more medications
  • (More important in over-70s)

14
Intrinsic vs extrinsic risk factors We are all
trippers.
Physical activity in falls prevention. Does it
work?
  • Over half of falls experienced 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 fall.

15
Risk factors for falls that cannot be modified
Physical activity in falls prevention. Does it
work?
  • Age
  • Gender
  • Social class
  • Chronic medical conditions
  • Irreversible vision problems
  • Osteoporosis

16
Targeting the modifiable risk factors for falling
Physical activity in falls prevention. Does it
work?
  • 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

17
Improving risk factors duration vs outcome
Physical activity in falls prevention. Does it
work?
  • 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, 1996)

18
Reviews of effectiveness in falls prevention
Physical activity in falls prevention. Does it
work?
  • 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, 2001)

19
Effective interventions
Physical activity in falls prevention. Does it
work?
  • 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

20
Tinetti et al, 1994
Physical activity in falls prevention. Does it
work?
  • Community-dwelling older women 70
  • More than one risk factor
  • Multi-factorial intervention
  • Included transfer training, gait
  • 30 reduction in falls

21
FICSIT Trials (Province et al, 1995)
Physical activity in falls prevention. Does it
work?
  • 7 sites (balance, strength, endurance and 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

22
Wolf et al, 1996
Physical activity in falls prevention. Does it
work?
  • Community-dwelling population (n200) with no
    debilitating 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

23
Campbell et al, 1997
Physical activity in falls prevention. Does it
work?
  • Women aged 80, community dwelling
  • Physical activity prescribed by a physiotherapist
  • 4 home visits over 2 months
  • Strength, balance and gait training
  • 20-30 reduction in falls

24
PROFET Trial (Close et al, 1999)
Physical activity in falls prevention. Does it
work?
  • Community-dwelling, aged 65
  • Multi-factorial intervention
  • Medical assessment
  • Physiotherapy and occupational therapy
  • 60 reduction of risk

25
FaME Project (Falls Management Exercise trial)
Physical activity in falls prevention. Does it
work?
  • 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 exercise 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)

26
Day et al, 2002
Physical activity in falls prevention. Does it
work?
  • 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 in annual rate of falls.
  • Group-based exercise was the most potent single
  • intervention tested.

27
Evidence of effectiveness
Physical activity in falls prevention. Does it
work?
  • A critical review of 29 physical activity
    interventions
  • reported
  • Increased activity levels over a longer period of
    time
  • Group/class-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)

28
How active are older people?
29
Overview
How active are older people?
  • Low levels of physical activity among older
    people
  • Thresholds for quality of life and functional
    capacity
  • Physical activity and frailty
  • Environmental factors assisting the spiral of
    decline

30
Levels of sedentary behaviour among MEN aged
50, England
How active are older people?
  • participating less than once a week

(Skelton, Young et al, 1999)
31
Levels of sedentary behaviour among WOMEN aged
50, England
How active are older people?
  • participating less than once a week

(Skelton, Young et al, 1999)
32
Levels of sedentary behaviour among minority
ethnic groups aged 55, England
How active are older people?
  • Those participating less than once a week

Men Women
African-Caribbean Indian Pakistani Bangladeshi Chi
nese
57 67 73 85 68
59 78 85 92 64
(Erens et al, 2001)
33
Older people living in care and residential
settings
How active are older people?
  • 86 of women and 78 of men in care homes are
    sedentary.
  • Sedentary behaviour in care homes 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)

34
The physical activity paradox
How active are older people?
  • 39 of men and 42 of women aged 50 are
    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.

35
Thresholds for quality of life
How active are older people?
  • Exercise performance

Threshold value necessary for performance of an
everyday task
Age
Adapted from Young (1986)
36
Aerobic capacity in MEN and WOMEN aged 50-74
(mean 2sd)
How active are older people?
  • Maximum oxygen uptake (ml/kg/min)

(Skelton, Young et al, 1999)
37
Knee extension strength inMEN and WOMEN aged
50-74 (mean 2sd)
How active are older people?
  • Isometric knee extension strength (N/kg)

(Skelton, Young et al, 1999)
38
Shoulder flexibility inMEN and WOMEN aged 50
(mean 2sd)
How active are older people?
  • Shoulder abduction (degrees)

(Skelton, Young et al, 1999)
39
Functional capacity
How active are older people?
  • Even healthy 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 reaction
  • Thermo-regulation
  • Sedentary behaviour increases loss of
    performance.
  • (Skelton and Dinan, 1999)

40
Functional decline and frailty
How active are older people?
  • (Spirduso, 1995)

41
Inactivity-related disease?
How active are older people?
  • Disuse rather than disease?
  • One weeks bed rest reduces strength 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 earlier than those who maintain
    their fitness.

42
Environmental factors assisting the spiral of
decline
How active are older people?
  • Following a fall
  • Further loss of function
  • Loss of mobility and independence
  • Further loss of function
  • Increased isolation and institutionalisation
  • Loss of dignity and confidence 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

43
Putting it into practice
  • Recommendations and guidelines

44
What do we mean by physical activity?
Putting it into practice Recommendations and
guidelines
  • 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 planned and structured, and repetitive
    bodily movement undertaken to improve or maintain
    one or more components of physiological fitness.
  • (Bouchard et al, 1990)

45
Specificity of intervention older people
(Simey et al, 1999)
Putting it into practice Recommendations and
guidelines
  • To improve health and modify 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
    outlined for reducing falls.

46
Recent recommendations and guidelines
Putting it into practice 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, rehabilitative
    management of older people who have fallen
    (Simpson, 1996)
  • Summarised in Falls, Fragility and Fractures
  • (Cryer and Patel, 2001)

47
Specific recommendations multi-factorial
interventions
Putting it into practice Recommendations and
guidelines
  • Community-dwelling older people
  • Gait training and 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)

48
Specific recommendations multi-factorial
interventions
Putting it into practice Recommendations and
guidelines
  • 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 hospital settings
  • No recommendations
  • Older people who have recurrent falls
  • Long-term exercise and balance training
  • (Cryer and Patel, 2001)

49
Recommendations and guidelines for falls
prevention for those aged 65
Putting it into practice Recommendations and
guidelines
  • Individually tailored exercise programmes
    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 with 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)

50
Putting it into practice
  • Education and training

51
Professional education and training generic
areas
Putting it into practice Education and training
  • 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)

52
Training opportunities to support local programmes
Putting it into practice Education and training
  • Making activity choices Senior peer mentoring
    programme
  • Peer mentoring to motivate inactive older people
    to become active
  • Supervised targeted exercise
  • Chair-based activity and assisted walking for
    frailer older people
  • Postural stability
  • A specialist exercise falls prevention and
    management course designed for experienced
    exercise professionals including physiotherapists
  • (Department of Health, 1999)

53
Making Activity Choices Senior peer mentor
programme
Putting it into practice Education and training
  • Training senior peer mentors to promote physical
    activity
  • Flexible education and training programme with no
    formal assessment
  • Communication skills, assessing readiness to
    exercise, overcoming barriers to activity,
    posture check and initiating activities
  • Built on the experience and skills of Age
    Concerns Ageing Well programme
  • (BHF National Centre for Physical Activity and
    Health, 2002)

54
Making Activity Choices Community Healthy
Activities Model Programme for Seniors (CHAMPS)
Putting it into practice Education and training
  • Those enrolled in CHAMPS are twice as likely to
    take part in physical activity.
  • Effectiveness based on
  • - attention from CHAMPS staff (peers)
  • - belonging to a group
  • - written materials
  • - goal-setting/self-monitoring
  • - range of accessible activities.
  • (Stewart, 2001)

55
Supervised targeted exercise Chair-based
activity and assisted walking
Putting it into practice Education and training
  • Exercise leadership training for health
    professionals
  • Total of four days training (including
    assessment)
  • 17 specific and targeted exercises designed to
    improve mobility, strength, flexibility and
    co-ordination
  • Includes assisted walking and games activities
  • (Department of Health, 1999)

56
Chair-based exercise effective at targeting
risk factors
Putting it into practice Education and training
  • Improvements in
  • strength (Fiatarone et al 1990 McMurdo et al
    1993 Skelton et al 1995, 1996)
  • power (Skelton et al, 1995)
  • flexibility (McMurdo et al, 1993 Mills, 1994
    Skelton et al, 1996)
  • functional ability (McMurdo et al, 1993, 1994
    Skelton et al, 1995, 1996)
  • static balance (Skelton et al, 1996)
  • rehabilitation following hip fracture (Nicholson
    et al, 1997)
  • the performance of everyday tasks
  • (McMurdo et al, 1994 Skelton et al, 1995, 1996)

57
Chair-based exercise effective at targeting
risk factors
Putting it into practice Education and training
  • Also reductions in
  • depression (McMurdo et al, 1993)
  • arthritic pain (Hochberg et al, 1995)
  • postural hypotension (Millar et al, 1999)
  • body fat (Nicholson et al, 1997)
  • risk of future falls (Allen et al, 1999)
  • Particularly valuable for frailer older people
  • Stabilises lower spine.
  • Greater range of movement.
  • Minimises load-bearing.
  • Reduces balance problems.
  • Increases confidence.

58
Physical stability Specialist falls prevention
and management course
Putting it into practice Education and training
  • Specialist training for experienced exercise
    professionals (exercise teachers,
    physiotherapists, occupational therapists,
    rehabilitation assistants)
  • Multi-factorial nature of falls
  • Exercise and assessment in care management plans
  • Improve postural instability, functional capacity
  • Medical conditions and medication
  • (Department of Health, 1999)

59
Evidence for tailored exercise in the prevention
of falls
Putting it into practice Education and training
  • Exercise programmes can decrease the number of
  • falls and fall risk but certain conditions need
    to be met
  • including
  • Tailoring to meet the needs of vulnerable fallers
  • Static and dynamic balance, low impact aerobics
    and strength components
  • Safely adapted Tai Chi
  • Targeted home exercise
  • Education and coping strategies
  • Programme must be regular, sustained and
    progressive.
  • (Gardner et al, 2000 Skelton and Dinan, 1999)

60
Physical activity and the prevention of falls
among older people Summary
  • Qualified and experienced teachers
  • Effectiveness is achieved through appropriate
    programming which is of sufficient intensity
    and duration is specific, progressive, tailored
    and adapted to meet the needs of the
    individual participant
  • Include home-based (independent) exercise
  • Encourage socialisation
  • Build confidence
  • Fall coping strategies
  • Telephone support
  • (Skelton and Dinan, 1999)

61
Physical activity and the prevention of falls
among older people
  • Physical activity, including muscle
    strengthening (resistance) exercise, appears to
    be protective against falling and fractures among
    the elderly, probably by increasing muscle
    strength and balance.
  • From Physical Activity and Health A Report of
    the US Surgeon General
  • (US Department of Health and Human Services, 1996)

62
Physical activity and the prevention of falls
among older people
  • Additional benefits from regular exercise
    include improved bone health and, thus, reduction
    of osteoporosis improved postural stability,
    thereby reducing the risk of falling and
    associated injuries and fractures and increased
    flexibility and range of motion.
  • American College of Sports Medicine, 1998

63
Physical activity and the prevention of falls
among older people
  • Regular physical activity helps to preserve
    independent living Regular activity helps
    prevent and/or postpone the age associated
    declines in balance and co-ordination that are a
    major risk factor for falls.
  • World Health Organization, 1996
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