The evidence for the Otago Home Exercise Programme to reduce falls

NSF for OP: Exercise Evidence Standards 3Intermediate Care 3Intermediate Care 5Stroke 5Stroke 6Falls 6Falls 7Mental Health 7Mental Health 8Promotion of Health and active life in old age 8Promotion of Health and active life in old age

Falls – a major problem in the UK 11 million people aged > 65 yrs 11 million people aged > 65 yrs 28,000 women aged > 90 yrs 28,000 women aged > 90 yrs Fractures costs £1.6 billion pa Fractures costs £1.6 billion pa 1 Hip Fracture every 10 mins 1 Hip Fracture every 10 mins –Cost £12-15 k 1 Wrist Fracture every 9 mins 1 Wrist Fracture every 9 mins –Cost £480 1 Spine Fracture every 3 mins 1 Spine Fracture every 3 mins 500 admitted to Hospital every day 500 admitted to Hospital every day 33 never go home 33 never go home Annual European Home and Leisure Accident Surveillance Survey (EHLASS) Report UK 2000

How common are falls? In > 75s, falls are the leading cause of death resulting from injury In > 75s, falls are the leading cause of death resulting from injury 75-80% of falls are not reported 75-80% of falls are not reported 1 in 3 >65 ’ s and 1 in 2 >80 ’ s fall each year 1 in 3 >65 ’ s and 1 in 2 >80 ’ s fall each year 10% of all call-outs for UK Ambulance Service are for people aged 65+ who have ‘fallen’ but nearly half are not taken to Hospital. 10% of all call-outs for UK Ambulance Service are for people aged 65+ who have ‘fallen’ but nearly half are not taken to Hospital.

Time and Location of Reported Falls Cambridge City Over 75s Cohort Study, Fleming, 2002

Changing incidence of fractures with increasing age 50 to 65 yrs - wrist 55 to 85 yrs - spine 75 to 85 yrs - hip (because of poor reaction, coordination and reflexes)

Incidence of Fractures Compared with Other Diseases 1. National Osteoporosis Foundation, Available at: 2. American Heart Association. Heart & Stroke Facts: 1999 Statistical Supplement. 3. American Cancer Society. Breast Cancer Facts & Figures

IMPACT – Cost to the Individual Injuries include: Injuries include: –Cuts and lacerations, –Deep bruises, –Soft Tissue Injuries, –Dislocations, –Sprains –Increase in joint pain Less than 5% of all falls result in a fracture Less than 5% of all falls result in a fracture Long lie ’ s & complications Long lie ’ s & complications Post fall syndrome Post fall syndrome Avoidance of activities and social isolation Avoidance of activities and social isolation

IMPACT - Costs to the NHS Hospital spending > £10 billion. Hospital spending > £10 billion. Local authority, residential care > £3 billion Local authority, residential care > £3 billion –Non-residential care > £2 billion. –Half of L.A. social services spent on services for older people Formal and informal ‘care’ Formal and informal ‘care’ Emergency call-outs Emergency call-outs

IMPACT- Hospitalisation Age group- years Rate / 100,00 Age-specific hospital admission rates for falls [SE Thames ] Cryer et al

IMPACT - Fear and avoiding activity Present in >50% of fallers & up to 40% non- fallers Present in >50% of fallers & up to 40% non- fallers Predicts Predicts –decreases in physical and social activity –deterioration in physical functioning –higher risk of falling Particularly common in people who cannot get up from the floor Particularly common in people who cannot get up from the floor

Map of NZ Map of NZ

Dept of Health Prevention Package 2009 Hip fractures cost the NHS in England £1.8 billion a year. Hip fractures cost the NHS in England £1.8 billion a year. The direct cost to commissioners of a hip fracture is estimated to be £10,000 – plus the cost of local authority social care. The direct cost to commissioners of a hip fracture is estimated to be £10,000 – plus the cost of local authority social care. One-third of people who experience a hip fracture are unable to continue to live independently afterwards. One-third of people who experience a hip fracture are unable to continue to live independently afterwards. An effective falls and fracture prevention service can make direct savings of £263,636 over five years for a primary care trust with a population of 320,000. An effective falls and fracture prevention service can make direct savings of £263,636 over five years for a primary care trust with a population of 320,000.

Every five hours in England, an older person dies as a result of a fall. Every five hours in England, an older person dies as a result of a fall. For a primary care trust with a population of around 300,000 this means: For a primary care trust with a population of around 300,000 this means: –15,500 older people will fall each year –2,200 of those will attend an accident and emergency department or minor injuries clinic, and a similar number will call an ambulance –1,100 will sustain a fracture – 300 of which will be of the hip. Dept of Health Prevention Package 2009

An effective falls and fracture prevention service in a primary care trust with a population of around 320,000 can make NHS and social care direct savings of £263,636 over five years. An effective falls and fracture prevention service in a primary care trust with a population of around 320,000 can make NHS and social care direct savings of £263,636 over five years. OEP is an important part of an effective falls and fracture prevention service OEP is an important part of an effective falls and fracture prevention service Dept of Health Prevention Package 2009

54% of sites had PSI trained staff 41% of sites had Otago trained staff RCP Audit of exercise in falls services (2012)

OTAGO Map of NZ Map of NZ

New Zealand RCTs - OTAGO Individually tailored programme: Campbell, BMJ years, n=233, home-based, physiotherapist -1 year, falls  32%, injuries  39% Nurse delivered programme at home: Robertson, BMJ years, n= 240, home-based, district nurse -1 year, falls  46%,  serious injuries and hospital costs Nurse programme at GP centres: Robertson, BMJ years, n=450, home-based, general practice nurse -1 year, falls  30%, injuries  28% Visually Impaired Older People: Campbell, BMJ year, home-based. Only effective with full compliance, falls  28% 6 month programme: Liu-Ambrose, JAGS years, home-based, cognitive function improvements after 6 months and after 1 year falls  47%

New Zealand RCTs - OTAGO Delivering in Groups vs One to One at home: Kyrdalen, Physio Res Int, mean age 82 years, n=125, home-based vs group based, physiotherapist led -12 weeks only. Group exercise is more effective for improving functional balance, muscle strength and physical health than home based. Falls not assessed. Cost effectiveness of OEP: Davis, BJSM, meta-analysis of 9 studies, showing that OEP is cost effective in 65+ adults and cost SAVING in over 80s. OEP reduces risk of death and falls: Thomas, Age Ageing Meta-analysis of 7 trials, N=1503 participants. Mean age 82 years. OEP participants had reduced risk of death (RR 0.45) and significantly less falls (IRR 0.68)

Multicentre cluster-randomised controlled trial 1256 people aged 65 and over in primary care Randomised into: – home exercise (Otago OEP) – group exercise (FaME) or – control (usual care (UC)) Primary outcome – continuation of exercise Falls – secondary outcome OEP & Primary Falls Prevention Iliffe et al. BMJ, in press 2014.

OEP & Primary Falls Prevention 6 month intervention FaME reduced falls compared to Usual Care in the 12 months following the intervention (IRR=0.66, The reduction in falls in the OEP group did not reach significance (IRR 0.71, p=0.14) -Shorter duration (less than 12 months) -Support options not as intensive as original OEP trials -These were not fallers so perhaps strength and balance challenge not high enough?

OTAGO Exercise Programme Summary Designed to ↓ falls by ↑ strength and balance Designed to ↓ falls by ↑ strength and balance Effective in ↓ falls in community dwelling OP Effective in ↓ falls in community dwelling OP Effective when delivered by physiotherapist and trained, supervised nurses Effective when delivered by physiotherapist and trained, supervised nurses Most effective for 80+ years with previous falls history Most effective for 80+ years with previous falls history Only effective with good compliance in OP with visual impairment Only effective with good compliance in OP with visual impairment Balance improvements better when delivered in a group than in unsupervised home exercise Balance improvements better when delivered in a group than in unsupervised home exercise

What is the OEP? Components of the OEP Components of the OEP How to deliver the OEP How to deliver the OEP

Programme Essentials Delivered at home or in groups by a trained OEP leader Delivered at home or in groups by a trained OEP leader Lower limb muscle strength and balance exercises individually tailored (by an appropriate person) from a set programme Lower limb muscle strength and balance exercises individually tailored (by an appropriate person) from a set programme Frequency - 3 x p/w Frequency - 3 x p/w Intensity - Moderate Intensity - Moderate Duration - 30 mins Duration - 30 mins Progressive Progressive + Walking (30 mins x 2 p/w) + Walking (30 mins x 2 p/w)

OEP Schedule X 4 home visits in first 2 months X 4 home visits in first 2 months Booster visit at 6 months Booster visit at 6 months 1 hour first visit, 30 mins subsequent visits 1 hour first visit, 30 mins subsequent visits Telephone call x 1 p/m between visits Telephone call x 1 p/m between visits Exercises (warm up, strength, balance, flexibility, cool down) Exercises (warm up, strength, balance, flexibility, cool down)OR  Delivered x1p/w in a group plus x 2p/w at home Walking Walking

OEP Schedule Month ……………………12 Week1248 Home Exercise Visits  Telephon e follow up 

OEP Exercise Components Warm Up – 5 exercises Warm Up – 5 exercises Strength training – 5 exercises Strength training – 5 exercises Balance training (dynamic & static) – 12 exercises Balance training (dynamic & static) – 12 exercises (Cool down) (Cool down) Walking programme Walking programme

Strength, balance and walking Guidelines state addition of strength and balance on top of moderate physical activity Guidelines state addition of strength and balance on top of moderate physical activity BUT Brisk walking may increase risk of falls in those who are frail or who do not walk regularly BUT Brisk walking may increase risk of falls in those who are frail or who do not walk regularly However, brisk walking in pre-frail older people increases bone density...dilemma? However, brisk walking in pre-frail older people increases bone density...dilemma? Strength and balance exercises should be incorporated into walking programmes Strength and balance exercises should be incorporated into walking programmes (Campbell 1997; Robertson 2001; Campbell 2005; Sherrington 2011; Ebrahim 1997)

Cue cards with walking advice plus 10 Strength and Balance exercises Leaflet for older adults containing the same exercises and simplified information

Warm Up Exercises 5 exercises 5 exercises

Strength Training Exercises 5 exercises 5 exercises

Balance Training Exercises 12 exercises 12 exercises

Walking Plan Encourage person to include walking for health benefits Encourage person to include walking for health benefits Walk at usual pace with usual walking aid Walk at usual pace with usual walking aid Progress duration before intensity Progress duration before intensity Start with 10 minutes “ walk-snacks ” Start with 10 minutes “ walk-snacks ” Progress to 30 mins 2 x p/w Progress to 30 mins 2 x p/w

OEP Equipment For OEP Leader For OEP Leader –OEP Manual and LLT Teaching Supplement For OEP Participant For OEP Participant –Stable chair / furniture –Ankle cuff weights (1, 2, 3 kg) –Activity Booklet –Calendar / Diary