Specialist PSI Exercise Module Risk Factors for Falls (and injuries) - intrinsic - extrinsic - modifiable with exercise

Specialist PSI Exercise Module A Risk continuum ? Over 200 risk factors documented in the literature D Drugs and alcohol A Age related physiological changes M Medical conditions E Environment

Specialist PSI Exercise Module Intrinsic vs Extrinsic - we are all ‘trippers’ Over HALF the falls experienced in the home are due to environmental hazards - trips, slips, unsafe or unlit stairways A decline in a person’s intrinsic risk factors (declining function and balance) mean that the extrinsic risk factors (loose mats, slippery floors) no longer just cause a correctable trip - they cause an injurious fall

Specialist PSI Exercise Module D - Drugs and Alcohol Cumulative effect of medication / time of day Prescribed medications / multiple drug regimes –Analgesics- Antidepressants –Sedatives- Antipscyhotics –Diuretics- ANY 4 OR MORE MEDICATIONS Heavy drinkers (>7 units per week) (Campbell et al., 1989, O’Loughlin et al., 1993) Mixing medications with alcohol

Specialist PSI Exercise Module A - Age related physiological changes Deterioration in physical functions and systems (strength, power, endurance, coordination, reaction, balance, proprioception and neural control, asymmetry) Decrease in functional capacity, mobility and activity Deterioration in feet (bunions, corns, circulation, neuropathies) Increase in cognitive impairment and depression

Specialist PSI Exercise Module Psychological risk factors Fear of falling Avoidance of activity Reduced quality of life Increased anxiety

Specialist PSI Exercise Module M - Medical Acute Infections Cardiovascular control - postural hypotension, drop attacks, heart disease, stroke, tia’s Dementia, Alzheimer’s Disease Parkinson’s Disease Thyroid dysfunction  Peripheral Neuropathies or myopathies  Malignancies  Impaired hearing or vestibular function (Menieres Disease, Tinnitus)  Impaired vision (macular degeneration, glaucoma, cataracts, visual acuity, contrast sensitivity, adaptation to dark)

Specialist PSI Exercise Module M - Medical 2 Foot deformities – pain, bunions, corns, hard skin, arthritis, oedema  Urinary incontinence or urgency  Receiving community health or social services  Recent discharge from hospital  Use of assistive walking aids - cane, zimmer Malnutrition / Anaemia - Nutritional recommendations are  g rda Vitamin D and 1,000mg rda calcium, Vit B12 deficiency leads to sensory abnormalities

Specialist PSI Exercise Module E - Environment Personal risk factors: glasses (bifocals and varifocals) footwear and clothing Outdoors: Poorly lit pathways Uneven pavements Slippery leaves Rubbish, building materials, obstacles Bus drivers! Indoors: Loose carpets Wires and cables Unstable furniture Change of level Poor lighting Cold rooms Sentimentality or “never been a problem before”

Specialist PSI Exercise Module Not modifiable with tailored exercise vision problems gender multiple medications social class chronic medical conditions poor housing hypothermia poor heating malnutrition poor footwear age exercise may not have a major effect

Specialist PSI Exercise Module Modifiable with tailored exercise low strength depression low power postural hypotension poor gait cognitive impairment poor mobility urinary urgency poor balance fear of falling arthritis exercise is likely to have a major positive effect

Specialist PSI Exercise Module How can we identify older people at high risk of falling? AGS/BGS guidelines - “get up and go” test as a filter for a full assessment by a specialist clinician for people who have fallen at least once. J Am Geriatr Soc 2001; 49: 664 – 672. Falls Risk Assessment Tool (FRAT) – 5 questions to assess risk. J Public Health 2004; 26: ?? Usefulness in residential/nursing settings

Specialist PSI Exercise Module Is there a history of any fall in the previous year? How assessed? Ask the person. Is the patient / client on four or more medications per day? How assessed? Identify number of prescribed medications. Does the patient / client have a diagnosis of stroke or Parkinson's Disease? How assessed? Ask the person. Does the patient / client report any problems with their balance? How assessed? Ask the person. Is the patient/client unable to rise from a chair of knee height? How assessed? Ask the person to stand up from a chair of knee height without using their arms. FRAT - Assessment of falls risk in older people

Specialist PSI Exercise Module PROFET: targeting risk factors (Close et al. Lancet 1999) Medical assessment General medical Postural hypotension Visual acuity Balance Cognition and affect Corotid sinus syndrome Occupational Therapy Function Physical handicap Psychological handicap Environmental hazards Referral / intervention –Day hospital –GP –O/P –Optician –Social services –Supply minor equipment The rate of falls was reduced by 60%

Specialist PSI Exercise Module Tinetti (1994) - Multifactorial The rate of falls was reduced by 30%