Preventing falls:
Evidence from ProFaNE
Chris Todd
Professor of Primary Care & Community Health
Director of Research
Director, ProFaNE
School of Nursing, Midwifery
and Social Work
Plan
• Epidemiology of falls and fractures
• What is ProFaNE?
• What works to reduce falls
– A review of reviews
Osteoporosis, falls and fractures
EVOS/EPOS Group
www.iofbonehealth.org
Falls explain betweencenter differences in
the incidence of
limb fracture across
Europe. JBMR 2002
Low BMD is less
predictive than risk
of falling for future
limb fractures in
women across
Europe. Bone 2005
• 30-40% community dwelling 65+ fall in a year
–
–
–
–
–
40-60% no injury
30-50% minor injury
5-6% major injury (excluding fracture)
5% fractures
1% hip fractures
• Falls most serious frequent home accident
• 50% hospital admissions for accidental injury
due to fall
• History of falls a major predictor future fall
Masud, Morris Age & Ageing 2001; 30-S4 3-7
Rubenstein. Age & Ageing; 2006; 35-S2; ii37-41
Risk of fall admission by age and sex
(1.5 million cases 1991-2002)
Crude Rate of Falls
0
2000
4000
6000
8000
by age and sex
50-59
60-69
70-79
Agegroup (10 yrs)
male
80-89
90+
female
person years based on 2001 Census data
Todd et al 2008 report to DH
Increasing rates over 10 year period
Mortality rates after fall admission by sex
Crude Rate of Death within 90 days of Falling
0
200
400
600
800
by age and sex
50-59
60-69
70-79
Agegroup (10 yrs)
male
person years based on 2001 Census data
Todd et al 2008 report to DH
80-89
female
90+
• Consequences
– Injury
• 4 million NHS England bed days/annum
– £2 billion/annum cost of fragility fractures
– Peripheral fractures
– Hip fractures
• 70,000/annum
• Expensive to treat
– Expensive for patients and families
» Money, morbidity, mortality and suffering
» 20% die within 90 days
» 50% survivors do not regain mobility
– Psychological and social consequences
• Disability
– Admission to long term care
– Loss of independence
• Falling most common fear of older people
– More common than fear of crime or financial fear
– Leads to activity restriction, medication use
Risk factors for falls (17 studies)
Risk factor
Muscle weakness
RR or OR
4.9
Range
1.9-10.3
Impaired balance
Gait deficit
3.2
3.0
1.6-5.4
1.7-4.8
Visual deficit
Limited mobility
Cognitive impairment
2.8
2.5
2.4
1.1-7.4
1.0-5.3
2.0-4.7
Impaired ADL
Postural hypotension
2.0
1.9
1.0-3.1
1.0-3.4
Rubenstein 1993 from WHO 2008.
Medications and falls
CNS
benzodiazepines, antidepressants,
antipsychotics (RR 0.34 [0.16, 0.73])
Antihypertensives
centrally acting, beta blockers, ACE
inhibitors, diuretics
Cardiac medications cardiac glycosides, antiarrhythmics, calcium channel
blockers
JAGS 2001 49, 664-672.
Analgesics
NSAIDs, opioids, anticonvulsants,
antihistamines gastro-intestinal
histamine antagonists
Polypharmacy
4 or more medications 9 fold risk
(GP education RR 0.61 [0.41, 0.91])
Medication review within multifactorial (RR 0.75 [0.65, 0.86])
WHO 2008
Cochrane review 2009
Plan
• Epidemiology of falls and fractures
• What is ProFaNE?
• What works to reduce falls
– A review of reviews
• The work of ProFaNE
ProFaNE
UK Manchester Warwick
Southampton London
Newcastle
D Ulm/Stuttgart Heidelberg
NL Groningen
Maastricht
FIN Kuopio
Tampere
Turku
Jyväskylä
S
Lund
Umeå
F
Lyon
I
Florence
E
Barcelona
EL Athens
DK Copenhagen
NO Bergen
Trondheim
CH Lausanne
Lausanne
PL Cracow
WP1
Taxonomy
and
classification
WP 2
Clinical
assessment
and
management
WP 3
Assessment of
balance function
WP4
Psychological
aspects of
falling
www.profane.eu.org
http://profane.co
4,500+
members
Plan
• Epidemiology of falls and fractures
• What is ProFaNE?
• What works to reduce falls
– A review of reviews
• The work of ProFaNE
2010
Barreca 2004: sit to stand exercises in groups (stroke patients)
Donald 2000: strength training 2X daily with physiotherapist in rehab
Jarvis 2007: extra physiotherapy strength and balance in rehab (stroke excluded)
Haines 2004 & Cumming 2008: multifactorial interventions
Healey 2004: fall risk assessment in fallers
Stenvall 2007: comprehensive geriatric assessment , calcium & Vit D post #NoF
Haines 2004 & Cumming 2008: multifactorial interventions
Healey 2004: fall risk assessment in fallers
Stenvall 2007: comprehensive geriatric assessment , calcium & Vit D post #NoF
Oliver et al BMJ 2006
Falls: 0.82 (0.68 to 0.997)
Fractures :0.59 (0.22 to 1.58)
Relative risk for fallers: 0.95 (0.71 to 1.27)
Included “poor quality” studies
Conclusions for hospitals
• Multi-factorial fall prevention appear
effective for patients >3 weeks LoS
• No recommendation re: specific
components of interventions
• Exercise in subacute appears
effective
Gates S, et al. Multifactorial assessment and targeted
intervention for preventing falls and injuries among older
people in community and emergency care settings:
systematic review and meta-analysis BMJ 2008
Gates S et al . BMJ 2008
Gates S, Lamb S, Fisher J, Cooke M, Carter Y. Multifactorial assessment and targeted
intervention for preventing falls and injuries among older people in community and emergency
care settings: systematic review and meta-analysis BMJ 2008
• “Evidence of benefit from multifactorial
risk assessment and targeted
interventions … was limited and
reductions in the number of fallers may
be smaller than thought.”
Falls and the
environment
Environment modification




Slippery walking surfaces
Lack of handrails
Hazards
Visual pattern
Randomised controlled trials of environmental assessment and
modification on falls in community samples. (Ballinger, Todd,
Whitehead, 2007)
AUTHORS
PARTICIPANTS
Cumming et al
(1999)
530 people aged 65+
Day et al (2002)
INTERVENTION
FINDINGS
COMMENTS
Home assessment and
supervision
Occupational therapist
Not effective for participants
who hadn’t experienced a
previous fall
Reduced falls in people who
had fallen previously
Reduction in falls outside
the home
1090 people, mean
age 76.1 (SD 5.5)
Home assessment, advice
and provision of materials
and labour
Trained assessor
Not effective in reducing falls
Significant reduction in
home hazards
Nikolaus and
Bach (2003)
360 people, mean age
81.5 (SD 6.4)
Home assessment, advice
and training in use of
devices
Occupational therapists
and physiotherapists
Effective in reducing falls
Particularly effective in
those with a history of
multiple falls
Pardessus et al
(2002)
60 people aged 65+
Home assessment, advice,
information about living
safely with hazards
Occupational therapist
Not effective in reducing falls
Underpowered for falls as
outcome measure
Stevens et al
(2001)
1737 people aged
70+
Home assessment,
education, free installation
of safety devices
Trained nurse assessor
Not effective in reducing falls
Significant reduction in
home hazards
Interventions for preventing falls in older people
living in the community (Review)
Gillespie LD, Robertson MC, Gillespie WJ, Lamb SE, Gates S,
Cumming RG, Rowe BH
2009
Interventions: Cochrane review 2009
• Exercise targets strength, balance, flexibility, endurance
– programmes with 2 or more components reduce falls & fallers
• Supervised group exercise, Tai Chi, & individual prescribed at
home can be effective
• Multifactorial assessment and referral works under certain
circumstances
– complex interventions causal mechanisms need clarification
• Appropriate medication review and withdrawal can reduce falls
• Environment
– Home safety only effective for high risk- professionally administered
• VIP
• Surgery in appropriate clinical populations can reduce falls
– Cataract surgery, pacemakers (carotid sinus hypersensitivity)
– Vitamin D does not reduce falls (except in low baseline) (?)
Rate of falls (Rate Ratios)
Group exercise: 0.78 [0.71, 0.86]
Individual exercise 0.66 [0.53, 0.82]
Group exercise: tai chi 0.63 [0.52, 0.78]
Group exercise: gait, balance or functional training 0.73 [0.54, 0.98]
Group exercise: strength/ resistance training 0.56 [0.19, 1.65]
Vitamin D meta-analysis
Bischoff-Ferrari et al BMJ 2009
High dose
– >700IU/day 19% reduction
• (RR 0.81 95% CIs 0.71-0.92)
– Serum 25 (OH)D >60nmol/l 23% reduction
• (RR 0.77 95% CIs 0.65-0.90)
Low dose no effect
Active vitamin D
reduced risk by 22%
• (RR 0.78 95% CIs 0.64-0.94)
Exercise effect RR=0.83, 95% CI=0.75-0.93, 17% reduction
Exercise and falls
Study name
Rate ratio and 95% CI
Results
Study name
Rate ratio and 95% CI
Barnett
Bunout
Buchner
Campbell, 1997
Campbell, 1999
Campbell, 2005
Carter
Cerny
Day
Ebrahim
Green
Hauer
Korpelainen
Latham
Li
Lord, 1995
Lord, 2003
Liu-Ambrose, Resistance
Liu-Ambrose, Agility
McMurdo
Means
Morgan
Mulrow
Nowalk, Resist./Endurance
Nowalk, Tai Chi
Protas
Reinsch
Resnick
Robertson
Rubenstein
Schoenfelder
Schnelle
Sihvonen
Skelton
Steinberg
Suzuki
Toulotte
Wolf, Tai Chi
Wolf, Balance
Wolf
0.01
37 studies
40 comparisons
7111 subjects
0.01
Meta Analysis
0.1
1
10
100
0.1
1
10
100
Favours Exercise
Favours Control
Sherrington et al 2006
BalanceBalance
training
intensity
exercise and falls
Group by
Highbal
Group by
Highbal
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
1.00
0.00
1.00
0.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
Low
intensity
High
intensit
High
y
intensity
Balance exercise and falls
Study name
Rate ratio and 95% CI
Study name
Rate ratio and 95% CI
Study name
Bunout
Buchner
Carter
Bunout
Cerny
Buchner
Day
Carter
Ebrahim
Cerny
Green
Day
Latham
Ebrahim
Liu-Ambrose, Resistance
Green
McMurdo
Latham
Means
Liu-Ambrose, Resistance
Mulrow
McMurdo
Nowalk, Resist./Endurance
Means
Nowalk, Tai Chi
Mulrow
Reinsch
Nowalk, Resist./Endurance
Resnick
Nowalk, Tai Chi
Rubenstein
Reinsch
Schoenfelder
Resnick
Schnelle
Rubenstein
Steinberg
Schoenfelder
Wolf, Balance
Schnelle
Steinberg
Barnett
Wolf, Balance
Campbell, 1997
Campbell, 1999
Barnett
Campbell, 2005
Campbell, 1997
Hauer
Campbell, 1999
Korpelainen
Campbell, 2005
Li
Hauer
Lord, 1995
Korpelainen
Lord, 2003
Li
Liu-Ambrose, Agility
Lord, 1995
Morgan
Lord, 2003
Protas
Liu-Ambrose, Agility
Robertson
Morgan
Sihvonen
Protas
Skelton
Robertson
Suzuki
Sihvonen
Toulotte
Skelton
Wolf, Tai Chi
Suzuki
Wolf
Toulotte
Wolf, Tai Chi
Wolf
RR= 0.98 [0.84-1.14]
RR= 0.71 [0.63-0.80]
Rate ratio and 95% CI
0.01
0.1
1
10
100
0.01
0.1
1
10
100
0.01
Favours A
0.1
1
Favours B
10
0.01
0.1
Favours A
1
10
Favours B
100
100
Risk status
Risk status, exercise and falls
Group by
High_risk
Study name
0.00
Group by
0.00
High_risk
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00
1.00
0.00
1.00
0.00
1.00
0.00
1.00
0.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
1.00
Bunout
Studyname
Carter
Cerny
Day
Korpelainen
Bunout
Li
Carter
Lord,
Cerny1995
Liu-Ambrose,
Resistance
Day
Liu-Ambrose,
Korpelainen Agility
McMurdo
Li
Means
Lord, 1995
Reinsch
Liu-Ambrose, Resistance
Steinberg
Liu-Ambrose, Agility
Suzuki
McMurdo
Wolf,
MeansTai Chi
Wolf,
Balance
Reinsch
Low risk
High risk
1.00
1.00
1.00
1.00
Studyname
Rate ratio and 95% CI
Rate ratio
95% CI
Risk status, exercise
andand
falls
RR= 0.78 [0.66-0.92]
RR= 0.84 [0.74-0.95]
Rate ratio and 95% CI
Steinberg
Barnett
Suzuki
Buchner
Wolf,
Tai Chi
Campbell,
1997
Wolf,
Balance
Campbell, 1999
Campbell, 2005
Barnett
Ebrahim
Buchner
Green
Campbell, 1997
Hauer
Campbell, 1999
Latham
Campbell, 2005
Lord, 2003
Ebrahim
Morgan
Green
Nowalk, Resist./Endurance
Hauer
Nowalk, Tai Chi
Latham
Protas
Lord, 2003
Resnick
Morgan
Robertson
Nowalk, Resist./Endurance
Rubenstein
Nowalk, Tai Chi
Skelton
Protas
Wolf
Resnick
Robertson
Rubenstein
Skelton
Wolf
0.01
0.01
Meta Analysis
1
Favours exercise
0.01
Meta Analysis
0.1
0.1
0.1
Favours exercise
10
100
Favours control
1
1
10
100
10
100
Favours control
Sherrington et al 2006
Algorithm for exercise
prescription
POPULATION
Population Low Risk
PROGRAM
60-80 Years
Tai Chi type exercises
in groups
Population at Increased
Risk 70-80 Years
Group balance and
strength training
Population at Increased
Risk 80 + Years
Otago exercise
program
Sherrington, Whitney, Close, Herbert, Cumming, Lord . Exercise for preventing falls: metaanalysis ProFaNE WP2 Australia Falls Conference Brisbane 2006
Training needs to be challenging,
progressive, regular and aimed at strength
and balance.
www.laterlifetraining.co.uk
Otago exercises
WP4: Psychological aspects of
falling
• Motivation for prevention
• Consequences
– fear of falling (efficacy)
• FES-I
– fear of falling interventions
The Problem of Interest:
Refusal, drop out & adherence
• High refusal
– 50% common
• Low adherence
• 18% dropout
average (15
weeks)
• 44% dropout
• Long term adherence
poor
• Refusal and nonadherence 50% - 90%
thus prevention may not
be effective
Exercise and falls
Study name
Rate ratio and 95% CI
Barnett
Bunout
Buchner
Campbell, 1997
Campbell, 1999
Campbell, 2005
Carter
Cerny
Day
Ebrahim
Green
Hauer
Korpelainen
Latham
Li
Lord, 1995
Lord, 2003
Liu-Ambrose, Resistance
Liu-Ambrose, Agility
McMurdo
Means
Morgan
Mulrow
Nowalk, Resist./Endurance
Nowalk, Tai Chi
Protas
Reinsch
Resnick
Robertson
Rubenstein
Schoenfelder
Schnelle
Sihvonen
Skelton
Steinberg
Suzuki
Toulotte
Wolf, Tai Chi
Wolf, Balance
Wolf
0.01
0.1
Favours Exercise
1
10
100
Favours Control
Meta Analysis
• Prevention programmes are efficacious
• Refusal/non-adherence 50% - 90% thus
prevention may not be effective
• Training needs to be challenging,
progressive and done regularly.
The studies
1.
2.
3.
UK Qualitative interviews and focus groups
UK Quantitative surveys
EU Qualitative interviews and focus groups
Yardley L, Todd C et al
Older people’s views of advice about falls prevention: A qualitative study. Health Education
Research. 2006. 21(4); 508-517.
Attitudes and beliefs that predict older people’s intention to undertake strength and balance
training. Journals of Gerontology Series B-Psychological Sciences & Social Sciences.
2007; 62(2): 119-25,
Encouraging positive attitudes to falls prevention in later life. London: Help the Aged 2005
Older people’s views of falls prevention interventions in Six European countries. The
Gerontologist. 2006. 46(5) 650-660.
Recommendations for promoting the engagement of older people in activities to prevent
falls. Quality and Safety in Health Care. 2007 16 230-234.
How likely are older people to take up different falls prevention activities? Preventive
Medicine 2008 47 554–558
Socio-demographic factors predict the likelihood of not returning home after hospital
admission following a fall Journal of Public Health 2010
Findings
Perceptions of available falls prevention
advice
• Reported none received!
– though actually mention of receiving
information)
• Perceived falls prevention in terms of
hazard reduction
– rather than balance improvement
– often through restriction of activity
Perceptions of falls prevention
messages presented
Discussion of falling prevention is beneficial
I think it would be helpful if someone knows what you should
do and what you shouldn’t do..
I think it would give me more confidence of building up your
balance if I read this [leaflet about improving balance]
now. I think it would give me more confidence when I’m
out..
(members of focus group of women aged 78 to 95 living in
sheltered accommodation)
Perceptions of falls prevention
messages presented cont.
It’s good advice BUT
- they wouldn’t necessarily act on (all of) it
It’s all good. I mean its good advice, yes, excellent, I agree. I
doesn’t mean to say I do it all but I agree.
- it may not fit with their circumstances,
lifestyle, prioritised goals
No, no, no, no, no, no ... Nobody would go around with
padding.
Perceptions of falls prevention
messages presented cont.
It’s good advice - for ‘them’
- only seen as relevant to ‘elderly’
Because we’re that much fitter -- we don’t really take too much
notice of it, only for other people, for other disabled or elderly
people that we have to watch when we’re – we always
watch older people anyway.
(man aged 79 in sheltered accommodation)
- rejected by fit, younger people, seen as humiliating
I wouldn’t go for that [advice] because it didn’t apply to me in
any shape or form. Is there a bit of pride, is there a bit of “Well,
you know, I’m not there yet”
(fit woman in 60s)
Perceptions of falls prevention
messages presented cont.
Falls prevention advice unnecessary, upsetting
It can make you feel – somebody producing the leaflets here
– that these people here are senile and they just don’t
have any common sense and they need to be told
everything.
The last thing you want as you get older is to be told that
you’ve got to be conscious every time you go out and
might fall, you don’t want that, otherwise your life’s gone.
(woman 78, who had recently fallen)
Suggestions for future advice
• Incorporate falls prevention into lifestyle and
general exercise programmes,
• Promote activities as
– enjoyable
– interesting,
– sociable
• Give suggestions in constructive manner
• Give explanations
• Recognise
– individual’s knowledge
– choice of own lifestyle
Quantitative test of conclusions from
qualitative studies
558 people aged 60-95
71% women,
mean 74.4 yrs
53% fell in past year
23% repeat fallers
1918 people aged 54+ (subgroup of 5396 surveyed)
57% women
Mean 69.7
47% fell in past year
22% repeat fallers
.09
Intention to carry
out Strength &
Balance Training
.87
Threat appraisal
Coping appraisal
Fear of falling (FES-I)
Expected benefits of
SBT
Perceived vulnerability
- risk of falling
Perceived severity consequences of falling
Perceived causes
of falling
Expected attitudes of
others
Expected ability to carry
out SBT
Identity right to do SBT
Conclusions
• Abandon efforts at ‘falls prevention’ emphasise positive benefits of exercise
• Emphasise positive benefits of measures,
phrase advice to allow recipients to
select/modify to suit goals and lifestyle
• Target advice to different groups of older
people (e.g. high/low perceived/actual
risk)
Implications for practice
Do not present initially to older people in terms of falling
prevention (since falling risk denied anyway)
Talk in terms of Activity
Emphasise/maximise immediate wider Benefits: looking and
feeling good; remaining active and independent; taking
part in an enjoyable and interesting Communal/social
activity
Most effective approach is personal invitation from health
professional explaining exactly what is involved, benefits.
Illness, evidence of increasing Disability provides good
opportunity to suggest taking this up.
Exercise in terms of everyday activities
“F” word
Groups only for some
Home based exercise preferred
Implications for practice
Do not present initially to older people in terms of falling
prevention (since falling risk denied anyway)
Talk in terms of Activity
Emphasise/maximise immediate wider Benefits: looking and
feeling good; remaining active and independent; taking
part in an enjoyable and interesting Communal/social
activity
Most effective approach is personal invitation from health
professional explaining exactly what is involved, benefits.
Illness, evidence of increasing Disability provides good
opportunity to suggest taking this up.
Exercise in terms of everyday activities
“F” word
Groups only for some
Home based exercise preferred
Exercise and falls
Study name
Rate ratio and 95% CI
Barnett
Bunout
Buchner
Campbell, 1997
Campbell, 1999
Campbell, 2005
Carter
Cerny
Day
Ebrahim
Green
Hauer
Korpelainen
Latham
Li
Lord, 1995
Lord, 2003
Liu-Ambrose, Resistance
Liu-Ambrose, Agility
McMurdo
Means
Morgan
Mulrow
Nowalk, Resist./Endurance
Nowalk, Tai Chi
Protas
Reinsch
Resnick
Robertson
Rubenstein
Schoenfelder
Schnelle
Sihvonen
Skelton
Steinberg
Suzuki
Toulotte
Wolf, Tai Chi
Wolf, Balance
Wolf
0.01
0.1
Favours Exercise
1
10
100
Favours Control
Meta Analysis
• Prevention programmes are efficacious
• We have the technology to make them
effective
www.profane.eu.org
Funders WP4
European Commission
United Kingdom
Department of Health
Danish Ministry of Social
Affairs
Help the Aged
Swiss Federal Office for
Education and Science
Maastricht University
University of Manchester
Robert-Bosch-Foundation
Lucy Yardley
University of Southampton
Nina Beyer
Copenhagen University Hospital
Klaus Hauer
University of Heidelberg
Ruud Kempen
University of Maastricht
Chantal Piot-Ziegler
University of Lausanne
www.profane.eu.org