Preventing Falls in Older People
Preventing falls in older people
Associate Professor Clare Robertson
Clare is a Research Associate Professor at the Dunedin School of Medicine. She was a key investigator in the studies that developed and tested the Otago Exercise Programme (OEP) and has worked with health organisations to promote the OEP and other effective falls prevention programmes in the community. Her research interests include investigating which falls prevention strategies provide best value for money.
Falls become a problem as we age because they are a common event and result in serious consequences for the older person, the family and carers, and to the health system. Around one third of all New Zealanders aged 65 years and older living independently in their own homes will fall in any one year, and this increases to one half of those over 80. Falls are even more frequent in residential care facilities.
Falls can be prevented
There is now a wealth of evidence showing that falls in older people can be prevented. The strongest evidence concerns exercise programmes.
It is now well established that certain exercise programmes are effective in preventing falls in older people living in the community. We know that:
· Poor muscle strength and impaired balance contribute to most falls in older people.
· Programmes that include muscle strengthening and balance training exercises, either delivered one-on-one at home or in exercise classes, reduce falls and injuries.
· Tai Chi classes are also effective in preventing falls.
· People well into their nineties can improve their strength and balance.
Successful interventions in residential care facilities include programmes addressing a combination of personal and environmental safety factors, review of medications, and vitamin D supplementation. Exercise interventions used alone have not reduced falls in this setting.
New Zealand research
John Campbell, a geriatrician and Clare Robertson, a researcher at the Dunedin School of Medicine, University of Otago have been designing and testing strategies to prevent falls since the mid 1990s.
The group has conducted clinical trials to determine the effectiveness of a number of interventions in specific populations. These include the Otago Exercise Programme for strength and balance retraining, home safety and behaviour modification for elderly people registered blind, and psychotropic (sleeping) medication withdrawal for those 65 years and over who are regularly taking these medications. The research has also shown a number of strategies, including resource intensive interventions with multiple components, do not work in certain populations.
This work highlights the effectiveness of single interventions such as exercise for preventing falls and the fact that falls prevention strategies can be cost saving to the health system.
Otago Exercise Programme
This exercise programme, designed specifically to prevent falls, is now used throughout the world. Main features are:
· The Otago Exercise Programme consists of a set of leg muscle strengthening and balance retraining exercises progressing in difficulty and a walking plan.
· The exercises are individually prescribed and increase in difficulty during a series of five home visits by a trained instructor.
· A physiotherapist, and nurses trained and supervised by an experienced physiotherapist, are equally effective in delivering the progamme.
· Each person receives a booklet with instructions for each exercise prescribed and ankle cuff weights (starting at 1 kg) to provide resistance for the strengthening exercises.
· The exercises take about 30 minutes to complete and participants are expected to exercise three times a week and to go for a walk at least twice a week.
· To maintain adherence the person records the days he or she completes the programme and the instructor telephones the person each month in between home visits. Follow up home visits are recommended every six months.
An instructor’s manual published by
ACC contains the exercise sheets for participants (www.acc.co.nz/oep)
Evaluation of the Otago Exercise Programme
The Otago Exercise Programme has been evaluated in both research and routine health care services in 1,016 people aged 65 to 97 living at home in the community.
Overall the exercise programme was effective in reducing both the number of falls and the number of injuries resulting from falls by 35%. It was equally effective in men and women.
The programme improved participants’ strength and balance and maintained their confidence in carrying out everyday activities without falling.
In terms of the number of fall injuries prevented, the programme had the greatest effect in high risk groups: those over 80 years of age and those with a recent fall. When 100 people in this group received the programme, over 50 falls (around 30 injurious falls) were prevented in one year.
Economic evaluations established the cost effectiveness of the programme.
A group of researchers in Norway modelled the costs for delivering the Otago Exercise Programme and found it to be cost saving. Their study demonstrated that there would be a return of almost 2 Euros for every Euro spent on delivering the programme.
A study from the University of British Columbia, Vancouver, Canada systematically reviewed all the published economic evaluations of successful falls prevention interventions tested in randomised trials. It concluded that the Otago Exercise Programme provides the best value for money compared with other effective falls prevention strategies.
The Otago Exercise Programme is
delivered at home by a trained instructor
Regular exercise classes with the appropriate
type and intensity of exercises will prevent falls
Role of ACC in falls prevention
The introduction of a nationwide approach to falls prevention has been made possible in New Zealand after an invaluable 15-year investment by ACC. In addition to funding falls prevention research, ACC has implemented national fall and fracture prevention strategies for older people. ACC is also the lead organisation for implementing the national Preventing Injury from Falls Strategy.
The Injury Prevention, Rehabilitation and Compensation Act 2001 states that the primary function of ACC is to promote measures to reduce the incidence and severity of personal injury.
ACC published a manual for instructors and launched national delivery of the Otago Exercise Programme in 2003. National tenders for contracts to deliver the Otago Exercise Programme and Tai Chi classes began in 2007. Over 12,000 people aged 65 years and older participated in the 2008/2009 financial year; 30,000 since commencement.
Feedback after Professor John Campbell, Professor Ngaire Kerse of The University of Auckland and Clare described this national approach at an international gerontology conference in Paris last year, was that New Zealand’s falls prevention strategies were the envy of the world.
However late last year, ACC announced a funding cut—no new Otago Exercise Programme participants to enter the scheme from January 1 this year. Tai Chi classes will still be funded until December 2010 when a decision about continuation of funding will be made.
The Minister of ACC stated that the decision was made based on estimated return on investment to ACC. The message was that ACC invests in injury prevention programmes where the corporation is satisfied that such measures are likely to result in a cost effective reduction in actual or projected levy rates. It seems ironic that ACC funded research showed that the Otago Exercise Programme produced a cost saving to the overall health system—through a reduction in fall-related hospital admissions.
About 5300 people aged 80 years and older nationwide received the Otago Exercise Programme in 2009 at a cost to ACC of $3.1 million ($550-$600 per person). In the 2009/2010 year, ACC will invest about $1.5 million in the modified Tai Chi programme and $150,000 in encouraging the provision of vitamin D supplements to residents of residential aged-care facilities.
Providers of the Otago Exercise Programme are working hard to find alternative funding. An instruction manual is available for health professionals to download from the ACC website (www.acc.co.nz/oep). No further training is required for a physiotherapist to deliver the programme, but nurses delivering the programme need training and close supervision by an experienced physiotherapist.
Individual assessment by a GP or geriatrician is important for older people at high risk of falls. A recent fall means you are three times more likely to fall again in the coming year.
Treatment can then be targeted at the falls and fracture risk factors that can be improved, for example muscle weakness, poor balance and gait (walking) impairments as discussed above. Maintaining strength, good balance and mobility has benefits in addition to fall prevention: independence, cardiovascular fitness, cognitive function and social interaction.
Older people with arthritis, dementia, Parkinson’s disease, depression or a stroke are also at higher risk of falling. Taking sleeping medication presents a high risk of falls and should be avoided if possible.
Vision should be tested regularly since poor vision means hazards may not be seen. Extreme care should be taken while getting used to new glasses, as wearing multifocal glasses, in particular, results in significantly more falls. Single focus distance glasses with transition lenses to decrease glare, are recommended for wearing outside. Removing cataracts results in a significant reduction of falls.
Taking vitamin D supplements and wearing hip protectors are recommended for nursing home residents. A new technology—safety flooring has been developed in New Zealand as a long term approach to injury prevention in residential care facilities and hospitals (www.acma.co.nz). This flooring is designed to absorb energy on impact, thus reducing fall injuries such as a hip fracture. Field trials are required to investigate this further.
— Clare Robertson, PhD
Research Associate Professor