A Forum on Disease Management Sustaining the Shift

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A Forum on Disease ManagementSustaining the
Shift Catalyzing the ChangeSingapore, November
9 10, 2007Best Practice Programs on Falls
Prevention and Physical Activity for Older
AdultsPatrick McGowan, PhDUniversity of
VictoriaBC, Canada
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Best Practice Guidelines

• Are processes, practices, or systems widely
  recognized as improving the performance and
  efficacy of an organization in a target area,
  such as health promotion
• (US National Council on Aging)

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Facts About Senior Falls

• Older People aged 65.
• Falls are leading cause of death.
• Falls can cause fatal traumatic brain injuries.
• Risk of falling increases with age.
• Older adults who have previous falls recorded or
  who stumble frequently, are 2-3 times more likely
  to fall again within the next year.
• 2/3 to ½ occur in or around the home.
• 95 of hip fractures are caused by falls.
• Fall-related death rates and hip fracture
  hospitalization rates increasing.
• (National Center for Injury
  Prevention and Control, 2007)

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Falls as Cause of Accidental Death

• Falling is one of the major causes of death and
  injury among older adults.
• Due to societal, personal and economic costs,
  falls are a serious health problem.
• Risk factors such as muscle weakness,
  polypharmacy, poor vision and environmental
  hazards can be modified.
• (www.cdc.gov/ncipc/duip/pre
  ventadultfalls.htm.)

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Strong Evidence for Falls Prevention Programs

• Falls Prevention Programs as a group, reduced the
  risk of falls by 11 and at a monthly rate by
  23. (Shekelle et al, 2003)
• Multi-factorial falls risk assessment and
  management programs, along with exercise is a key
  component in health promotion.
• (Public Health Agency of Canada, 2001)

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GOALS - Best Practice Falls Prevention Programs

• Decrease incidence of falls.
• Decrease severity of falls.
• Increase mobility and function.
• Improve environmental safety.
• Provide comprehensive assessment.
• Have a knowledgeable staff.
• Improve the patients confidence.
• (RNAOS Best Practice Guidelines, 2007)

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Evidence Best Practice Falls Prevention Programs

• Exercise Best Practices
• Environmental Modification Best Practices
• Education Best Practices
• Medication Best Practices
• Clinical Intervention Best Practices
• Multi-Factorial Best Practices
• Health Promotion Approaches to Best Practices
• (Ontario Injury Prevention Resource Centre)

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1. Exercise Best Practices

• Exercise regimes are an effective strategy for
  reducing falls.
• Balance training reduced falls.
• More research is needed to determine which types
  of exercise programs are most effective for
  reducing falls.
• As wells as, research to determine strategies
  most effective in balance, strength or mobility
  problems.
• Careful consideration of the level of intensity
  is still unclear, but we do know is that it does
  reduce falls.
• Compliance measures are needed to help maintain a
  healthy lifestyle.
• (Ontario Injury Prevention Resource Centre)

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2. Environmental Modifications Best Practices

• Home modifications.
• Financial and/or manual assistance in completing
  the modifications.
• Occupational therapists role is to assess home
  modifications and the functional within the
  environment.

• Success/Cost effectiveness of environmental
  strategies are enhanced by those who are ready
  for change.
• (Ontario Injury Prevention Resource Centre)

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3. Education Best Practices

• Little evidence whether or not education programs
  alone are effective.
• Education strategies may play an important role
  in multi-faceted risk factors, willing to adopt
  strategies to modify fall risk factors.
• The reduction of falls in one study may have been
  due in part to the use of theoretical models for
  adult learners, such as valuing shared learning
  among peers (modeling for change).
• (Ontario Injury Prevention Resource Centre, 2001)

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4. Medication Best Practices

• Taking medications from the class of drugs known
  as benzodiazepines is shown to increase risk of
  falling.
• Evidence is an important consideration in
  psychotropic medication withdrawal as a means to
  reduce falls.
• (Ontario Injury Prevention Resource Centre)

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Medication Best Practices cont.

• Compliance to stop medications is difficult
  clinicians may need to consider alternative
  treatments to increase compliance.
• There is a possibility that medications to
  improve physical functioning may reduce falls,
  but the one study that examined hormone
  replacement therapy to enhance muscle strength
  and improve balance failed to produce a change in
  fall frequency.
• (Ontario Injury Prevention Resource Centre)

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5. Clinical Intervention Best Practices

• Clinical assessments by nurses or physicians
  appear to be an effective strategy in reducing
  falls and related injuries.
• One study found that over half the emergency room
  patients admitted for fall injuries had balance
  deficits and visual impairments.
• For seniors who have sustained a fall, a thorough
  medical assessment should be conducted for
  underlying cognitive or physical contributors to
  the fall.
• (Ontario Injury Prevention Resource Centre)

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Clinical Intervention Best Practices Cont.

• The skills of an occupational therapist, or
  nurses trained in fall risk assessment and
  prevention, followed a clinical assessment to
  determine the best supports for home and
  community modifications.
• Initial Screening for both physical and cognitive
  impairments along with intervention of behavioral
  and environmental risk.
• (Ontario Injury Prevention Resource Centre)

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6. Multi-Factorial Best Practices

• Studies have shown that indicate that multiple
  strategies directed at a wide range of factors
  are effective in reducing falls and injuries.
• Multidisciplinary teams of health practitioners
  trained in the detection and prevention of falls.
• (Ontario Injury Prevention Resource Centre)

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Multi-Factorial Best Practices cont.

• Effective outcomes may require a combination of
  strategies such as subsidies for home
  modifications and safety equipment, access to
  health and social services tailored to those at
  risk.
• Education strategies to increase awareness and
  knowledge of fall risk factors more willing to
  adopt new strategies to modify fall risk factors.
• Dissemination of information to large groups may
  be conducted through mass media, workshops,
  classes, and meetings held in local seniors
  centre's.
• (Ontario Injury Prevention Resource Centre)

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7. Health Promotion Approaches to Best Practices

• Community-based strategies allow for multifaceted
  approaches.
• Seniors are key participants in the design and
  implementation of community-based strategies.
• The involvement of multiple stakeholders has the
  potential to facilitate and significantly enhance
  the success of prevention initiatives.
• Fostering partnerships among stakeholders
  increases local acceptance and commitment, access
  local knowledge, expertise, and resource and
  increases community capacity.
• (Ontario Injury Prevention Resource Centre)

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Steps in the Implementation of a Falls Prevention
Program

• Search for the cause(s) of a persons fall
  patient risk environmental factors.
• Use trigger to implement the program and identify
  patients at risk for falls.
• Implement the program.
• Assess and release the patient.
• Report falls.
• (RNAOs Best Guidelines, 2007)

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Physical Activity and Health Facts

• The loss of strength and stamina attributed to
  aging is in part caused by reduced physical
  activity.
• By age 75, about one in three men and one in two
  women engage in no physical activity.
• Among adults aged 65 years and older, walking and
  gardening are most popular.
• Social support from family and friends has been
  consistently and positively related to regular
  physical activity.
• 
  
  
• (Centre for Disease
  Control and Prevention, 1999)

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Recommendation

• Seniors should engage in 30 minutes of
• moderate activity on most days of the
• week.
• US Surgeon General
• American College of Sports Medicine
• Centers for Disease Control and Prevention

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Best Practices in Physical Activity Programming

• Build from evidence envision community impact.
• Ensure organizational commitment of leadership,
  resources and staff.
• Engage diverse partners in delivering effective
  physical activity programming.
• Foster participant ownership.
• Establish sustainable financing.
• Be proactive in recruitment and retention of
  diverse older adult participants
• Offer a variety of safe, effective and attractive
  programs for sedentary and active older adults.
• Recruit qualified/certified instructors and
  support ongoing training.
• Routinely monitor participant progress and
  program quality.
• (Center for Healthy Aging and
  the National Council on Aging)

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Best Practice Physical Activity Programs

• Multifaceted activities.
• Behavior change principles.
• Strategies to manage risk and prevent
  activity-related injuries.
• Accessibility and cost.
• Targeting specific sub populations.
• (Journal of Aging and physical
  Activity, 2005)

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Physical Activity in Older Adults Existing
Programs

• Lifestyle
• Endurance
• Strength
• Flexibility
• Balance
• (Journal of Aging and physical Activity, 2005)

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Generations of research
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Focus of Best Practice Programming
The research most needed in the area
of implementing interventions to assist people to
deal with falls prevention and physical exercise
is at the demonstration and dissemination end of
the spectrum. Here the research questions have
more to do with adaptation, implementation,
sustainability and diffusion of innovations.
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RE-AIM Framework
This framework cites the lack of attention to
external validity and recommends focusing on
program reach, implementation and adaptation,
consideration of outcomes important for decision
makers (e.g., costs), and maintenance and program
sustainability. for evaluating both internal and
external validity. (Glasgow, Vogt, and
Boles, 1999 Glasgow, McKay, Piette, and
Reynolds, 2001)
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RE AIM Framework

• Reach
• Effectiveness
• Adoption
• Implementation
• Maintenance
• www.re-aim.org

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RE AIM Framework

• Proportion and representativeness of the target
  population willing to participate.
• Impact of the program in terms of outcomes and
  quality of life.
• Proportion and representativeness of
  organizations and staff agreeing to deliver the
  program.
• Degree to which interventions are delivered
  consistently as planned across staff, patients,
  program components, and time.
• Extent to which behaviour change is maintained
  over the longer term and, at the setting level,
  the extent to which the program is maintained by
  the organization.
• (Glasgow, Vogt, and Boles, 1999
  Glasgow, McKay, Piette, and Reynolds, 2001)

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Value using RE-AIM Framework

• Considers all program stages in the initial
  planning
• Enables the establishment of a realistic
  recruitment plan
• Makes planners anticipate challenges
• Focuses on internal and external validity
• Facilitates more efficient program planning in
  real life settings

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Best Practice Falls Prevention Program

• Falls Prevention for Older Adults
• A Matter of Balance Managing Concerns About
  Falls.
• Designed to reduce the fear of falling and to
  increase the activity levels
• of older adults who have concerns about falls.
• www.mainehealth.org/pfha
• Research by the Roybal Center for Enhancement of
  Late-Life
• Function at Boston University

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Best Practice Exercise Program

• Physical Exercise for Older Adults
• Fit and Strong
• Designed to reduce disability from arthritis, a
  significant cause of
• disability and a risk factor for other future
  disabilities.
• shughes_at_uic.edu
• Center for Research on Health and Aging
• University of Illinois at Chicago

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Contact Information
mcgowan_at_dccnet.com Toll-free line
1-866-902-3767 Web site www.coag.uvic.ca/cdsmp