Falls and Examples of EvidenceBased Programs for Falls

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Falls and Examples of Evidence-Based Programs for
Falls

• Angela Deokar, MPH, CHES
• Kentucky Department for Public Health
• Osteoporosis Prevention and Education Program

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Topics to Cover

• Define accidental fall
• Discuss falls in community-dwelling older adults
  and associated complications
• Provide an overview of multi-factorial risk and
  prevention components
• Discuss fear of falling and how it relates to
  falls
• Provide examples of two evidence-based falls
  programs
• Matter of Balance offered in Kentucky
• Stepping On being researched in Wisconsin

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Definition of a Fall

• An accidental fall is defined as an event which
  results in a person coming to rest inadvertently
  on the ground or other lower levels, and other
  than as a consequence of the following
  sustaining a violent blow loss of consciousness
  sudden onset of paralysis, as in a stroke an
  epileptic seizure. (Kellogg 1987)

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Falls

• Leading cause of injury and death for older
  adults
• Up to 30 of community dwelling adults fall each
  year
• Of those who fall, as many as half may suffer
  moderate to severe injuries that reduce mobility
  and independence
• About 50 percent of older adults hospitalized for
  hip fracture never regain their previous level of
  function
• Falls or fear of falling may contribute other
  complications and perpetuates a vicious cycle

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Vicious Cycle
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Falls

• Falls are
• Common
• Predictable
• Preventable
• Falls are not a natural part of aging!

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Falls

• 1/2 to 2/3 of falls occur around the home
• A majority of falls occur during routine
  activities
• Falls usually are not caused by just one issue.
  Its a combination of things coming together -
  multifactorial
• A large portion of falls are preventable!

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Falls are Multi-Factorial

• Behavioral
• Biological
• Environmental
• Prevention usually emphasizes
• Participating in a regular exercise program
• Making home safety improvements
• Reviewing medications
• Checking vision

Risk Factors
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CDCs Building Blocks for Falls Prevention
Programs

• Education about falls and risk factors
• Exercises that improve balance, strength and
  mobility
• Medication review and management
• Vision exam
• Home safety assessment and modifications

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Protect Your BonesWays to Make Your Home Safer
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Protect Your Bones Ways to Make Your Home Safer
Remove all small rugs. They can make you trip.
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Use non-slip mats in the bathtub or shower. Have
grab bars put in next to your toilet and in the
bathtub or shower.
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Fear of Falling

• 1/3 to 1/2 of older adults acknowledge fear of
  falling
• It is reasonable to be concerned about falls -
  safety is important
• Fear of falling is associated with
• decreased satisfaction with life
• increased frailty
• depression
• decreased mobility and social activity
  (inactivity)
• Fear of falling is a risk factor for falls

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Matter of Balance

• Designed to reduce the fear of falling and
  increase the activity levels of older adults who
  have concerns about falls.
• Research by the Roybal Center for Enhancement of
  Late-Life Function at Boston University.
• Studied effect of program on fear of falling and
  associated activity restriction in older adults
• Based on Cognitive Restructuring (Bandura and
  Lachman, 1997)
• Tennsdedt, S., Howland, J., Lachman, M.,
  Peterson, E., Kasten, L. Jette, A. (1998). A
  randomized, controlled trail of a group
  intervention to reduce fear of falling and
  associated activity restriction in older adults.
  Journal of Gerontology, Psychological Sciences,
  54B (6), P384-P392.

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Cognitive Restructuring

• Method of turning negative thoughts into positive
  thoughts
• Define barriers, obstacles when engaging in a new
  behavior
• Identify strategies for overcoming the barriers
• Plan realistic/feasible experiences so one can
  experience success

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Who can benefit from A Matter of Balance?

• Designed to benefit community-dwelling older
  adults who
• Are concerned about falls
• Have sustained a fall in the past
• Restrict activities because of concerns about
  falling
• Are interested in improving flexibility, balance
  and strength
• Are age 60 or older, ambulatory and able to
  problem-solve

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A Matter of Balance Class

• During 8 two-hour sessions, participants learn
• To view falls and fear of falling as controllable
• To set realistic goals for increasing activity
• To change their environment to reduce fall risk
  factors
• To promote exercise to increase strength and
  balance

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A Matter of Balance

• What Happens During Sessions?
• Facilitated by two leaders
• Group discussion
• Problem-solving
• Skill building
• Assertiveness training
• Sharing practical solutions
• Videotapes with peers who model behaviors
• Exercise training

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Maine Partnership for Healthy Aging Project Lay
Leader Model

• Model Program Adaptations
• Classes taught by volunteer lay leaders, called
  coaches, instead of healthcare professionals
• Healthcare connection via guest therapist
• Participant workbook developed and coach manual
  modified
• Exercises modified
• Maintaining Fidelity
• Two day coach training based on original MOB
  leader manual
• Master Trainer observes coaches during training
  and while leading a MOB/VLL class
• Use of a mentor model - new volunteer is paired
  with an experienced coach
• Communication, support and sharing outcomes

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A Matter of Balance Lay Leader Model
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Outcomes of Lay Leader Model

• Participant Outcomes
• 97 - more comfortable talking about fear of
  falling
• 97 - feel comfortable
  increasing activity
• 99 - plan to continue exercising
• 98 - would recommend A Matter of Balance
• who agree to strongly agree

• Comments
• I am more aware of my surroundings. I take time
  to do things and dont hurry.
• I have begun to exercise and am looking forward
  to a walking program.
• I have more pep in not being afraid.

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Participants Report

• Increased confidence in taking a walk, climbing
  stairs, carrying bundles without falling
• More confidence that they can increase their
  strength, find ways to reduce falls, and protect
  themselves if they do fall
• An increase in the amount they exercise on a
  regular basis
• Fewer falls after taking MOB

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A Matter of Balance/Volunteer Lay LeaderOutcomes
Healy, T. C., Peng, C., Haynes, P., McMahon, E.,
Botler, J. Gross, L. (2008). The Feasibility
and Effectiveness of Translating A Matter of
Balance into a Volunteer Lay Leader Model.
Journal of Applied Gerontology, 27 (1), 34-51.
(Significant Outcomes in Bold)
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A Matter of Balance in Kentucky

• Master training held in May 2007
• Trained 21 Master Trainers in Area Agencies on
  Aging and Health Departments
• Planning another Master Training on August
  13th-14th, 2008, in Elizabethtown
• Goals Create a coordinated system of delivering
  and evaluating A Matter of Balance in KY and
  improving geographic accessibility to the courses
  
• Request for Partners coming out soon
• Emphasis on community collaboration, ability to
  implement and sustain the program

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Video

• A Matter of Balance Fear of Falling

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• Reducing Falls
• Building Confidence
• An Effective Program for Older People.

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Stepping On

• Identified as a multi-factorial program in CDC
  Compendium
• Based on research by Clemson conducted in
  Australia

The effectiveness of a community based program
for reducing the incidence of falls among the
elderly A randomized trial. Clemson, L.,
Cumming, R.G., Kendig, H., Twible, R. (1999)
Journal of American Geriatrics Society
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Outcomes

• Randomized trial in Australia
• Intervention group experienced a 31 reduction in
  falls
• Maintained confidence to avoid a fall
• Used more protective behavioral practices

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Stepping On Underlying Concepts

• Decision-making is a process (5 stages)
• Story telling to facilitate learning confidence
• Self-efficacy (Bandura 1997,1986,1997)
• Learning and older adults as learners
• Sustaining and follow-through with safety
  behaviors

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Decision-Making as a Process

• Appraising the challenge
• Surveying the alternatives
• Weighing the alternatives
• Deliberating about commitment
• Adhering despite negative feedback

Janis and Mann (1977)
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Story Telling

• Facilitate confidence and learning
• Participants
• Explore negative events
• Describe and question the struggle to make a
  change
• Reaffirm the positive and what they could do in
  the future
• Re-tell and recreate their stories with a sense
  of personal control

Fitzgerald, 2001
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Learning and Older Adults as Learners

• Think creatively about opportunities
• Learning for an older adult is best when
• It is self-paced- benefit from breaks
• Optimistic and positive feedback
• Visual aids and practical examples
• Learning builds on previous experience and
  knowledge
• Learning must go both ways and leaders must
  recognize that participants bring their own
  unique perspective, life stage and knowledge
• Review principles of adult education

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Follow-Through with Safety Behaviors

• Sustaining prevention strategies depends on
• 1. Level of support social, peer and
  organizational
• 2. Ease of complying cost, effort, complexity,
  intrusiveness. Older adults will spend if they
  view it on a path that has a link with a goal.
• 3. Technical competence and interpersonal skills
  of professional
• 4. Opportunity and willingness for personal goal
  setting Having an overarching goal and breaking
  it into smaller steps
• 5. Feedback about success reporting back on
  exercise or home safety check or how they used
  different cues to prompt exercise like the start
  of a TV show or by leaving their exercise manual
  and or weights out on the table

Cole, Berger and Garrity, 1998
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Bringing Stepping On to the U.S.

• Aging and Disability Resource Center of Kenosha
  County, WI
• Several projects, including funding from CDC in
  2007 to
• Translate the Stepping-On fall prevention
  intervention for older adults into a program
  package that can be delivered to community-based
  organizations for implementation with older
  adults
• Prepare a final program package that can be
  broadly disseminated

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Original Australian Study vs. Implementation in
Wisconsin

• Original study
• Led by OT
• No lay leader
• Home visit by OT
• Booster session 3 months after completion

• WI implementation
• Led by health professional (OT, RN, dietician,
  educator)
• Lay co-leader
• No home visit
• Booster classes 2, 4 and 6 months after
  completion

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WI Train-the-Trainer

• Lead Trainer
• Licensed health professional, trains Master
  Trainers
• Master Trainers
• Licensed health professional, trains Leaders and
  Peer Leaders
• Leader (delivers program)
• Licensed health professional or health educator
  with knowledge of fall prevention
• Peer Leader (delivers program)
• Older adult who can effectively deliver the
  program with another trained Leader

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Bringing Stepping On to the U.S.

• May be ready to disseminate beyond Wisconsin by
  end of 2008

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The Safety of Seniors Act

• The Safety of Seniors Act
• Now titled Public Law 110-202, the act will
  develop education strategies to raise awareness
  about elder falls, encourage research to identify
  at-risk populations and evaluate falls
  interventions, and support demonstration
  projects.
• Thirty national policy organizations are now
  calling on Congress to provide 20.7 million in
  FY 2009 for the Centers for Disease Control to
  fund these initiatives.

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Challenge and Opportunity for Kentucky

• evidence-based interventions are particularly
  strong when the fall prevention intervention
  includes both health care and community
  programming components working collaborativelyWha
  t we dont know is how to effectively integrate
  community interventions that link the unique fall
  prevention contributions of health care and aging
  (services)
• Testimony Lynn Beattie at the Falls Prevention
  Briefing to Congress on May 7, 2008

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Collaboration

• When spider webs unite they can tie up a lion
• Ethiopian Proverb

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Manuals

• Matter of Balance coach manual
• Matter of Balance exercises
• Stepping On leader manual

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Thank you to

• Patti League, Partnership for Healthy Aging
  (Maine)
• Sandy Cech, Kenosha County Aging and Disability
  Resource Center (Wisconsin)
• for resources used in this presentation