Exercise for Falls Prevention in Older People:

Evidence & Questions

Professor Pam Dawson

Associate Pro Vice Chancellor

Strategic Workforce Planning and Development

Northumbria University

13 March 2017

#fallsnenc

What is a fall?

A fall is defined as an unintentional or unexpected loss of balance resulting in coming to rest on the floor, the ground, or an object below knee level (NICE).

#fallsnenc

Falls: the scale of the problem

30% people >65yrs

50% people >80yrs

fall at least once per year

5% of community

dwelling fallers will experience a

fracture

Falls are the most commonly reported patient safety incident in NHS Trusts in

England

Falls affect the faller, family and carers:

Injury, pain, distress, fear, loss of

confidence and independence,

reduced quality of life, mortality

Falls cost the NHS >£2.3b per

year

#fallsnenc

Evidence for falls prevention: the problem of the scale

Huge number of individual trials

and studies globally over more than 2

decades

Individual trials inform systematic reviews, Cochrane reviews, position statements, NICE

guidelines, ptpathways …

Evidence doesn’t speak

for itself – it has to be

interpreted for the individual

and their context

Outcome measures –

Fall rates (falls per person year) or

Fall risk (number of fallers in each group of a trial)

Primary versus secondary prevention

Community versus care

settings

#fallsnenc

Most recent NICE (2017 update) guideline messages re exercise in falls

prevention

Exercise (strength and balance training) offered as a single intervention

by an appropriately trained professional

Untargeted group based exercise has not been shown to be effective in these conditions

should be offered multiple component exercise (strength and balance training) in an individual or group programme

(following a multifactorial falls risk assessment)

as a single falls prevention intervention individually prescribed and monitored

Older people living in the community

with a history of recurrent falls and/or an identified gait and balance deficit

NICE 2017

#fallsnenc

Exercise (strength and balance training) offered asa component of multidisciplinary falls prevention

should be offered individually prescribed exercise as a component of multidisciplinary falls prevention intervention

Older people > 65yrs (or 50-64 yrs judged to be at higher risk of falls) admitted to hospital

where any identified muscle weakness or gait/balance problem can be treated, improved or managed with individualised intervention during the patient's expected stay

Older people living in extended care settings (e.g. nursing homes)

who are at risk of falling

NICE 2017

and

#fallsnenc

Considerations when designing and delivering evidence based exercise for falls prevention

#fallsnenc

• Previous falls (secondary prevention) versus identified fall risk (primary prevention)

• Consider cognitive function

• Consider motivation and likely adherence

• Gender?

Target group

• Strength/resistance exercises

• Balance/gait training

• Individual or group based

• Trained professional

• Social aspect?

Type and setting

of exercise

• How many times per week

• Over how many weeks

Frequency and duration

• The right degree of challenge for the individual

• Supervision/progression over timeIntensity

How evidence-based are our exercise programmes?

Survey of 1768 patients* referred to falls prevention services in England, Wales and NI wide shows two thirds were participating in group based exercise but wide

variation in models of delivery of exercise interventions

• Most patients attended group-based classes of short duration (<12 weeks) and only once/week

Only 50% patients said their programme was progressed as they improved

Recommended exercise programmes should be

individually tailored, progressive and delivered over long periods

(Otago 1 year; FaME 35 wks)

• But lack of follow up afterwards High levels of patient

satisfaction with programme

*Buttery et al 2014

#fallsnenc

Where the evidence doesn’t help …

#fallsnenc

•Evidence inconclusive that exercise prevents falls in dementia/ cognitive impairment*•Poor adherence and loss to follow up*•Cognitive impairment frequently cited as a reason not to refer or not to offer exercise**•Recent small trial - 6 month tailored programme can improve balance, concern about falls, and planned physical activity in community-dwelling older people with dementia***

Dementia

• Exercise alone may possibly reduce fear of falls but only in the short term****

• Not all trials have fear of falling as an outcome****

Fear of falls

*Winter et al 2013 **Buttery et al 2014 ***Taylor et al 2017 ****Kendrick et al 2014

Adherence and compliance

Trials report uptake of exercise interventions can drop from as high as 80% in the first 10 weeks to 50% at one year*

In practice adherence can be much lower than 50%

Patient level barriers include transport, cost, motivation and fear of injury

50-82% community dwelling older people did not consider that participation in exercise programs would be worthwhile, even if it reduced risk of falling to 0%.**

Programme level barriersGroup – Decreased adherence with duration of 20 weeks or more, two or fewer sessions per

week, or a flexibility component***Home - Increased adherence with balance component, home visit support and

physiotherapy led****Decreased adherence with flexibility component****

* Nyman and Victor 2011 ** Franco et al 2016 ***McPhate et al 2013 ****Simek et al 2012

#fallsnenc

How can we promote and improve adherence?

Older people participate in exercise to remain

independent and they value approaches that promote

autonomy and self management

Physiotherapists are fatalistic with a ‘take it or leave it’

attitude to the exercise they prescribe and instruct

Robinson et al 2013

#fallsnenc

Barriers and facilitators in exercise for falls prevention

Barriers

Practical issues - transport

Concerns – adverse effects, too difficult

Unawareness – denial of fall risk

Reduced health status –unwell, fatigue

Lack of support – poor instructor, no support at home

Lack of interest – low motivation

Facilitators

Support – professional and family

Social interaction –relationships, social time

Perceived benefit – staying independent

Supportive exercise context –trust, individual adaptation

Feelings of commitment –structured programme

Having fun - enjoyment

Sandlund et al 2017 systematic review

#fallsnenc

Population-based interventions forprevention of fall related injuries in

older people

Systematic review to assess the effectiveness of population-based interventions, defined as coordinated, community-wide, multi-strategy initiatives, for reducing fall-related injuries among older people.

Preliminary claim that the population-based approach to the prevention of fall-related injury is effective and can form the basis of public health practice.

Randomised, multiple community trials of population-based interventions are indicated to increase the level of evidence in support of the population-based approach.

#fallsnenc

McClure et al 2008

Exercise and falls prevention:from evidence to implementation

Multiple agency

commitment and older

people involvement

Population based and

whole system

approach involving all

sectors

Evidence based

intervention applied

consistently and with training

Joined up approach with

other pathways/

services, e.g. dementia

Leadership and

continuous innovation and quality

improvement

Joint commissioning

#fallsnenc

References

Buttery AK et al (2014) Older people’s experiences of therapeutic exercise as part of a falls prevention service: survey findings from England, Wales and Northern Ireland. Age and Ageing, 43: 369–374

Franco MR et al (2016) Smallest worthwhile effect of exercise programs to prevent falls among older people: estimates from benefit–harm trade-off and discrete choice methods. Age and Ageing, 45: 806-12

Kendrick D et al (2014) Exercise for reducing fear of falling in older people living in the community (Review), Cochrane Library, Issue 11

McClure RJ (2005) Population-based interventions for the prevention of fall related injuries in older people (Review), Cochrane Library, Issue 1

McPhate L et al (2013) Program-related factors are associated with adherence to group exercise interventions for the prevention of falls: a systematic review. Journal of Physiotherapy, Australian Physiotherapy Association Vol. 59

NICE (2017 update) Falls: assessment and prevention of falls in older people, NICE clinical guideline 161.

#fallsnenc

References

Nyman S and Victor CR (2012) Older people’s participation in and engagement with falls prevention interventions in community settings: an augment to the Cochrane systematic review. Age and Ageing, 41: 16–23

Robinson L et al (2014) Self-management and adherence with exercise-based falls prevention programmes: a qualitative study to explore the views and experiences of older people and physiotherapists. Disability and Rehabilitation, 36(5): 379–386

Sandlund et al (2017) Gender perspectives on views and preferences of older people on exercise to prevent falls: a systematic mixed studies review. BMC Geriatrics (2017) 17:58

Simek EM et al (2012) Adherence to and efficacy of home exercise programs to prevent falls: A systematic review and meta-analysis of the impact of exercise program characteristics. Preventive Medicine, 55: 262-75

Taylor et al (2017) A home-based, carer-enhanced exercise program improves balance and falls efficacy in community-dwelling older people with dementia. International Psychogeriatrics, 29:1, 81–91.

Winter H et al (2013) Falls prevention interventions for community dwelling older persons with cognitive impairment: A systematic review. International Psychogeriatrics , 25(2):215–227

#fallsnenc