How is my resident falling?

Stephen Robinovitch, Ph.D. Falls National Call March 21, 2014

How is my resident falling? Lessons from videos capture on the

cause and prevention of falls and fall-related injuries in older adults in!

long-term care.Stephen N. Robinovitch, Ph.D.!

Canada Research Chair!Dept of Biomedical Physiology and Kinesiology &!

School of Engineering Science!Simon Fraser University

tipstechnologyfor injurypreventionin seniors

www.sfu.ca/tips


Falls are energy management problems


...which become more challenging to solve with age


Incidence of fall-related injuries in older adults

wrist fractures:!• similar in frequency to hip fractures!• >90% caused by falls

hip fractures:!• ~23,000/yr in Canada, $1 billion in treatment costs!• 25% die within one year!• 50% lose independence!• >90% caused by falls

head injuries:!• ~20,000/yr in Canada!• 60% caused by falls!• 3-fold increase in past 10 years


Falls are common in older adults, but most do not cause serious injury• 30% of older adults living in the community fall

at least once per year!

• 50% of older adults in residential care fall at least once every year!

• 15% of falls cause serious injury!

• 1-2% cause hip fracture


Due to three factors:!1. declines in bone

strength!2. increase in falls!3. changes in

mechanics of falls

Hip fracture incidence increases exponentially with age

Source: Singer et al.,1998


3-fold increases in rates of fall-related head injuries in seniors

Source: Kornhonen et al., 2013


Energy(Joules)

oldfemur

youngfemur

300

Energy to Failure

Energy Availablein a Fall from Standing

0

10

20

30

290

Any fall from standing has the potential to cause hip fracture


Energy absorption mechanisms!during falls


injuryrisk

frequency of falls

severity of falls (energy absoprtion/ protective responses)

tissue strength(resistance to trauma)

tissueloading


Falls are associated with multiple risk factors, thereby difficult to prevent• impaired muscle strength, flexibility!• impaired vision, proprioception, vestibular

function, reaction time!• cognitive impairment!• medications (hypnotics, antipsychotics)!• neurological disease (e.g., stroke, Parkinson’s)!• cardiovascular disease!• fear-of-falling!• activity level


Bisphosphonates

n = 6,007!Source: McLung, 2000

Percent of

fractures

(non-

vertebral)

70

60

50

40

30

20

10

0

Women

Above -1 (Normal)

-1 to -2.5 (Osteopenia)

-2.5 or below (Osteoporosis)

Bone density based on T-score:

70

60

50

40

30

20

10

0

Men

Percent of

fractures

(non-

vertebral)

Source: Marshall, 1996


1 SD decrease in BMD*: ! 2-3x increase!falling sideways: ! ! ! 6x increase!impact to hip: ! ! ! ! 30x increase!lower limb weakness: ! ! 5x increase!impact to hand or knee: ! ! 3x decrease!upper limb weakness: ! ! 2x increase!!Sources: Greenspan et al., 1994; Schwartz et al., 1998; Nevitt and Cummings, 1993

Risk factors for hip fracture during a fall:


• few studies have directly recorded body movements during falls!

• lab studies are challenging, and may lack external validity!

• recall of fall mechanisms may be inaccurate; most falls are unwitnessed!

• we require better understanding of how and why falls and fall injuries occur; role of intrinsic, situational, and environmental factors

The missing evidence base in falls research


Technology for Injury Prevention in Seniors (www.sfu.ca/TIPS)


Video capture of real-life falls in LTC•270 digital video cameras in common areas of 2 LTC facilities!

•fall incidence report triggers video collection!

•between 2007-2013, collected and analyzed 1074 falls in 358 residents!

•3-member team used validated questionnaire to probe characteristics of fall, situational and environmental aspects


Conceptual basis for Fall Video Analysis Questionnaire

Reference: Yang, Y., et al., BMC Geriatrics, 2013 (internal validation and !downloadable questionnaire)


Consent process• protocol approved by offices of research ethics at

SFU and FHA !• each resident or proxy provides written consent for

video capture in common areas of LTC!• video footage is shared as secondary data!• additional consent from residents captured falling

for:!− access to medical records (n=108 fallers, 322 falls)!− physical/ cognitive testing (n=69 fallers, 223 falls)!− sharing of images for educational purposes (n=51

fallers, 267 falls)


52% of fallers captured have 2 or more falls per year

Num

ber o

f fal

ls/ y

ear

0

5

10

15

20

25

30

35

40

0 20 40 60 80 100

Faller ID

n = 108 fallers,322 falls(MDS database)


Number (percent) or mean ± SD Number (percent)

Gender Male 43 (40%) Female 65 (60%)Age (yrs) 81 ± 9 Number of falls per participant: 2 falls 56 (52%) 1 fall 52 (48%)Cognitive (CPS) scale (0-6) 4.0 ± 1.5ADL performance (0-6) 3.4 ± 1.6 Balance assessment Unsteady or need support 43 (40%) Unable to attempt test 27 (25%)Vision Mild impairment 22 (20%) Moderate to severe impairment 16 (15%)

Chronic disease: Diabetes 24 (22%) Hypertension 46 (43%) Parkinson’s disease 3 (3%) Stroke 16 (15%) Alzheimer’s disease (AD) 32 (30%) Dementia other than AD 66 (61%) Medications Antipsychotic 43 (51%) Antianxiety 16 (19%) Antidepressant 44 (52%) Hypnotic 11 (13%) Diuretic 21 (25%) Analgesics 48 (57%)

Number (percent) or mean ± SD Number (percent)

Gender Male 43 (40%) Female 65 (60%)Age (yrs) 81 ± 9 Number of falls per participant: 2 falls 56 (52%) 1 fall 52 (48%)Cognitive (CPS) scale (0-6) 4.0 ± 1.5ADL performance (0-6) 3.4 ± 1.6 Balance assessment Unsteady or need support 43 (40%) Unable to attempt test 27 (25%)Vision Mild impairment 22 (20%) Moderate to severe impairment 16 (15%)

Chronic disease: Diabetes 24 (22%) Hypertension 46 (43%) Parkinson’s disease 3 (3%) Stroke 16 (15%) Alzheimer’s disease (AD) 32 (30%) Dementia other than AD 66 (61%) Medications Antipsychotic 43 (51%) Antianxiety 16 (19%) Antidepressant 44 (52%) Hypnotic 11 (13%) Diuretic 21 (25%) Analgesics 48 (57%)


Loca

tion

Diningroom

Hallways

Lounge

Other

1 am - 10 am 10 am -1 pm 1 pm - 7 pm 7 pm - 1 am

Time

Location and time of falls

n = 351 falls, 148 fallers


BR

DRL DRL

BR

Mapping location of falls in frequent fallers


Activity a

t tim

e o

f fa

llin

g

Transferring

Seated

Walking

Standing

Inco

rre

ct

tra

nsfe

r

Lo

ss o

f

su

pp

or t

Hit/

bum

p

Collapse

Slip

Tri

p

Cause of imbalance

(32) (10 ) (16) (14) (3) (1)

(53) (2) (0) (5) (2) (45)

(5) (31) (3) (4) (0) (2)

(67) (39) (0) (2) (1) (1)

Combinations of cause of imbalance and activity when falling


Reference: Robinovitch et al., Lancet, 2013


Activity a

t tim

e o

f fa

llin

g

Transferring

Seated

Walking

Standing

Inco

rre

ct

tra

nsfe

r

(44%

)

Lo

ss o

f

su

pp

ort

(23%

)

Hit/b

um

p

(9%

)

Collapse

Slip

Trip

(14%

)

Cause of imbalance

Activity

Transferring (31%)

Seated (13%)

Walking (34%)

Standing (22%)

Combinations of cause of imbalance and activity when falling



Land

ing

Con

figur

atio

n

0.00

0.25

0.50

0.75

1.00

Forw

ard

(17%

)

Back

war

d(3

9%)

Side

way

s(2

8%)

Stra

ight

dow

n(1

6%)

Initial Fall Direction

Forward(11%)

Backward(57%)

Sideways(32%)

Direction of fallsn = 351 falls, 148 fallers


0

10

20

30

40

50

60

70

80

Hand/

Forearm

Knee Hip Head

frequency o

f conta

ct

site

69%

33%

43%

30%

Impact sitesn = 351 falls, !

148 fallers


Hip impact was just as likely during forward as sideways falls

n = 351 falls, !148 fallers

Freq

uenc

y of

hip

impa

ct

0.00

0.25

0.50

0.75

1.00

Forw

ard

Back

war

d

Side

wa y

s

Stra

ight

do

wn

Initial fall direction

Yes(43%)

No(57%)

351N

3DF

31.412114-LogLike

0.1311RSquare (U)

Likelihood RatioPearson

Test62.82461.247

ChiSquare<.0001*<.0001*

Prob>ChiSq


Variable Odds Ratio (95% CI)

Initial Fall direction

Sideways vs. Forward 1.7 (0.8 – 3.6)

Backward 5.3 (2.6 – 10.8)

Straight down

5.0 (1.8 – 13.3)

Forward vs. Backward 3.2 (1.6 – 6.1)

Straight down

2.9 (1.1 – 8.7)

Landing configuration

Sideways vs. Forward 12.7 (3.4 – 47.5)

Backward 38.6 (13 – 114.3)

Hip impact was just as likely during forward as sideways falls


Probability of hip impact was not reduced by hand impact


Fre

quency o

f hip

im

pa

ct

0.00

0.25

0.50

0.75

1.00

Yes

(69%)

No

Hand impact

Yes

(43%)

No

351

N1

DF12.026515

-LogLike0.0502

RSquare (U)

Likelihood Ratio

Pearson

Test24.053

23.032

ChiSquare<.0001*

<.0001*

Prob>ChiSq


Hip fracture case study


Hip fracture case study

Cause of imbalance

Activity Initial fall direction

Landing configuration

Greatest energy absorption

Other impacts

Trip/ stumble

Walking Forward Sideways Right hip/ buttock

R/L hands, right knee, head

Co-morbidities Functional status Medications Behaviour• CHF • HTN • Alzheimer's Di • Stroke, TIA hx • Renal failure • Poor vision

• No mobility aid • Unable to rise from chair

without using arms • Mild dementia • Needs supervision in

dressing and hygiene

• Number of meds: 8 • Antipsychotics • Antianxieties

Moderate fear of falling


0

10

20

30

40

50

60

70

80

Hand/

Forearm

Knee Hip Head

fre

qu

en

cy o

f co

nta

ct

site

69%

33%

43%

30%

Head impact occurs in 30% of falls

Reference: Schonnop et al., CMAJ, 2013


• Head struck the floor in 63% of cases, wall in 13% and furniture in 17%!

• 87% of floor impacts were onto vinyl or linoleum (13% carpet)!

• Head injury was documented in 34% of cases (45% lacerations or abrasions, 30% hematoma)!

• 20% of cases resulted in hospital visits!

• No concussions were noted


Variable Odds Ratio (95% CI)

Initial fall direction Forward vs. Backward 2.7 (1.3 – 5.9)

Sideways 2.8 (1.2 – 6.3)

Straight down

7.2 (1.8 – 29)

Landing configuration Forward vs. Backward 2.7 (1.2 – 6.4)

Sideways 1.2 (0.5 – 2.9)

Hand impact Yes vs. No 1.2 (0.6 – 2.4)


Predictor Variable Head Impact Head ImpactPredictor Variable

Crude Odds Ratio 95% CI

Age

Highest vs. Lowest quartile 1.0 0.4 - 2.6Gender

Female vs. Male 2.4* 1.3 - 2.6ADL performance

Dependent vs. Independent 0.7 0.3 - 1.5Standing balance

Unsteady vs. steady 1.2 0.5 - 2.7Cognitive performance 0.4 0.2 - 1.2Moderate to severe impairment vs. intactVision

Moderately impaired vs. Adequate 2.7* 1.0 - 7.7Hypertension

Yes vs. No 2.4* 1.2 - 4.8Stroke

Yes vs. No 1.9 0.8 - 4.8Dementia

Yes vs. No 0.6 0.3 - 1.4Antipsychotic

Yes vs. No 0.6 0.3 - 1.0Antidepressant

Yes vs. No 0.4* 0.2 - 0.8

Risk for head impact associated with gender, vision, and hypertension



Multivariate model of probability for head impact



Avoiding head impact

during falls

AN INSTRUCTIONAL

EXERCISE-BASED COURSE

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tipstechnologyfor injurypreventionin seniors

www.sfu.ca/tips


SmartCells: commercially available compliant floor for fall injury prevention

Installation of compliant flooring (SmartCells) in a demonstration bedroom of Delta View Rehabilitation Centre in Delta, BC

SmartCells


SmartCells provides more force attenuation than most hip protectors

SmartCellLaing et al., Accident Analysis & Prevention, 2009

34%


SmartCells reduces force to the head by 70% during simulated falls

headform

Head impact simulator

floor mounted on load cell

9543

2541 2374 2523

0

2000

4000

6000

8000

10000

Rigid Carpet Regular Vinyl

Pea

k Fo

rce

(N)

SmartCell, 50 durometer, covered by

Source: Dr. Andrew Laing


SmartCells has little effect on mobility and balance of older women

Laing et al., Accident Analysis & Prevention, 2009


FLIP Trial DesignNew Vista = 236 rooms

Exclude 86 rooms - 49 Willow Grove (non-ambulatory) - 37 floor cannot be raised 1”

150 single-occupancy rooms across 4 villages will be randomized within villages

Intervention (INT) flooring 1” SmartCells w/ vinyl cover

Control (CON) flooring 1” plywood w/ vinyl cover

Track outcomes for 4 years

Notification & Installation 16 rooms/wk for ~10 wks

CON will also be installed in adjacent hallways

Primary outcome • moderate/severe fall-related injuries Secondary outcomes • all fall-related injuries • falls

Assess baseline characteristics

ClinicalTrials.gov Identifier: NCT01618786


Fre

quency o

f head im

pact

0.00

0.25

0.50

0.75

1.00

Low

Med

(23

%)

Hig

h

(68

%)

Fall frequency category

Yes

(30%)

No

351

N2

DF3.7921337

-LogLike0.0177

RSquare (U)

Likelihood Ratio

Pearson

Test7.584

7.821

ChiSquare0.0225*

0.0200*

Prob>ChiSq

1-2

falls/yr

8+

falls/yr

3-7

falls/yr

Highest frequency fallers were least likely to experience head impact


What caused this fall?


How could this fall be prevented?


AcknowledgementsCollaborators: Fabio Feldman, PhD (Fraser Health Authority) Ming Leung, PT, MSc (Fraser Health Authority) Joanie Sims-Gould, PhD (VCHRI/CHHM) Ed Park, PhD (SFU Mechatronics) Greg Mori, PhD (SFU Computing Science) Teresa Lui-Ambrose, PT, PhD (UBC, Physical Therapy) Andrew Sixsmith, PhD (SFU Gerontology) Cathy Arnold, PT, PhD (U. Saskatchewan, Physical Therapy) Aleks Zecevic, PhD (Western U, Kinesiology) !Parters: Fraser Health Authority Deltaview Life Enrichment Centre New Vista Society Long Term Care Centre for Hip Health and Mobility

IPML Staff/ Trainees: Yijian Yang, MD Omar Aziz, MAppSc Joseph Choi, PT, MSc Alex Korall, MSc Chantelle Lachance, MSc Emily O’Hearn, BSc Shane Virani, BSc Ryan Woolrych, PhD Bobbi Symes, MA Colin Russell, MASc Rebecca Shonnop, BSc Kayla McGowan Kimberley Chong Alan Tang

How is my resident falling?

Health & Medicine

Transcript of How is my resident falling?