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 Putting it into practice: Education and training

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?

The human costs of falls 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

Why are falls important? 90-day outcome after hip fracture 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)

Why are falls important? Large numbers of older people are 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 certain 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 fracture in England and Wales People (000) Source: Grimley-Evans et al, Estimate based on population growth alone Estimate based on increased rate of hip fracture

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-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)

Why are falls important? Costs to the health services The financial costs of hip fractures 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? 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 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)

Physical activity in falls prevention. Does it work? Intrinsic vs extrinsic risk factors “We are all trippers.” 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 person’s 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.

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 falling 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? Improving 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, 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, 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? 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 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 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

Physical activity in falls prevention. Does it work? Campbell et al, 1997 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

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 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 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)

Physical activity in falls prevention. Does it work? Day et al, ,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.

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/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)

How active are older people?

Overview 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’

How active are older people? Levels of sedentary behaviour among MEN aged 50+, England % participating less than once a week Age 0% 20% 40% 60% 80% (Skelton, Young et al, 1999)  5 kcal/min including brisk/fast walks  2 miles  4 kcal/min including all walks  2 miles  4 kcal/min plus all walks  1 mile

How active are older people? Levels of sedentary behaviour among WOMEN aged 50+, England % participating less than once a week Age 0% 20% 40% 60% 80% (Skelton, Young et al, 1999)  5 kcal/min including brisk/fast walks  2 miles  4 kcal/min including all walks  2 miles  4 kcal/min plus all walks  1 mile

How active are older people? Levels of sedentary behaviour among minority ethnic groups aged 55+, England Those participating less than once a week 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 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 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 Adapted from Young (1986) ‘Threshold’ value necessary for performance of an everyday task Physically active Physically inactive

How active are older people? Aerobic capacity in MEN and WOMEN aged (mean ± 2sd) Maximum oxygen uptake (ml/kg/min) (Skelton, Young et al, 1999) Age VO 2 max to walk comfortably at 3mph Men Women

How active are older people? Knee extension strength in MEN and WOMEN aged (mean ± 2sd) Isometric knee extension strength (N/kg) (Skelton, Young et al, 1999) Age Strength to be confident of rising from low chair without using one’s arms Men Women

How active are older people? Shoulder flexibility in MEN and WOMEN aged 50+ (mean ± 2sd) Shoulder abduction (degrees) (Skelton, Young et al, 1999) Age Requirement to wash hair without difficulty Men Women

How active are older people? Functional capacity 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)

How active are older people? Functional decline and frailty (Spirduso, 1995) DiseaseDisuse Time Human frailty

How active are older people? Inactivity-related disease? Disuse rather than disease? One week’s 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.

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 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

Putting it into practice Recommendations and guidelines

Putting it into practice: Recommendations and guidelines What do we mean 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 planned 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 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.

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, rehabilitative 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 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)

Putting 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 hospital 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 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)

Putting it into practice Education and training

Putting it into practice: Education and training Professional education 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)

Putting it into practice: Education and training Training opportunities to support local programmes ‘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)

Putting it into practice: Education and training ‘Making Activity Choices’ Senior peer mentor programme 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 Concern’s Ageing Well programme (BHF National Centre for Physical Activity and Health, 2002)

Putting it into practice: Education and training ‘Making Activity Choices’ Community Healthy Activities Model Programme for Seniors (CHAMPS) 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)

Putting it into practice: Education and training ‘Supervised targeted exercise’ Chair-based activity and assisted walking 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)

Putting it into practice: Education and training Chair-based exercise – effective at targeting risk factors 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)

Putting it into practice: Education and training Chair-based exercise – effective at targeting risk factors 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.

Putting it into practice: Education and training Physical stability – Specialist falls prevention and management course 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)

Putting it into practice: Education and training Evidence for tailored exercise in the prevention of falls 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)

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)

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)

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

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