Maintaining Mobility into Old Age and Preventing Falls · President, British Geriatrics Society...
Transcript of Maintaining Mobility into Old Age and Preventing Falls · President, British Geriatrics Society...
Professor T.Masud
President, British Geriatrics Society
Nottingham University Hospitals NHS Trust University of Nottingham
University of Southern Denmark
Maintaining Mobility into Old Age and Preventing Falls
Twitter:@TashMasud
Disclosures
I have no conflict of interest or disclosure in relation to this
presentation
Statistical summaries of risk factors for fallsFrom cohort studies- Perell 2001
n Muscle weakness 4.4 (1.5-10.3)
n Falls history 3.0 (1.7-7.0)
n Gait deficit 2.9 (1.3-5.6)
n Balance deficit 2.9 (1.6-5.4)
n Use of assistive devices 2.6 (1.2-4.6)
n Visual deficit 2.5 (1.6-3.5)
n Arthritis 2.4 (1.9-2.7)
n Impaired ADLs 2.3 (1.5-3.1)
n Depression 2.2 (1.7-2.5)
n Cognitive impairment 1.8 (1.0-2.3)
n Age > 80 1.7 (1.1-2.5)
RISK FACTOR Mean RR/OR Range
Simple Model for Balance
CNS
Vision
Vestibular
Proprioception
Tactile sensation
Musculo-skeletal
Balance
Activity & environmental hazards
FALLS
INTRINSIC FACTORS EXTRINSIC FACTORSFALLS
Falls are Often Multifactorial
Co-morbidity & Frailty increase the risk of falls
CAUSES OF FALLS
Intrinsic (personal) Factors Causing Falls
& Delirium
Extrinsic (Environmental) Factors
Fall Prevention : Intervention Strategies
Population Community
Institutional
InterventionsMultiple
Single (unifactorial)
n Occupational Therapyü Functionü Physical handicap
n Medical assessmentü General medicalü Postural hypotensionü Visual acuityü Balanceü Cognition and affectü Corotid sinus synd.ü Psychological handicapü Environmental hazards
n Referral / intervention– Day hospital– GP– O/P– Optician– Social services– Supply minor equipment
Multidisciplinary assessment of fallers attending A/E (n=397): - 65+ years, medical assessment at day hospital + OT at home
PROFET – Lancet 1999- Close et al
1 year, falls â 61%, recurrent falls â 67%Failed in Holland-Hendricks 2008
• 70+ High Risk Community Dwellers, n= 1314
• Rate of Falls IRR 0.72 (95%CI 0.61-0.86) NNT= 3
• Fall related Injuries IRR 0.74 (95%CI 0.61-0.89) NNT= 5
Injury 2014
Unifactorial Interventions
n Medication Review
n Environmental Modification
n Improving Vision
n Vitamin D
n Exercise
21 3 4 5 6 7 8 92 100
Fallers OR (95%CI)
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Antidepressants Overall
Tricyclics
SSRIS
Antidepresssants and Falls- the SOMA study
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Masud T, Frost M, Ryg J, Matzen L, Ibsen M, Abrahamsen B, Brixen K. Central nervous system medications and falls risk in men aged 60-75 years: the Study on Male Osteoporosis and Aging (SOMA).Age Ageing 2013; 42: 121-4.
21 3 4 5 6 7 8 92 100
Fallers OR (95%CI)
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Opiates Overall
Opiates ≥ 67 yrs
Opiates < 67 yrs
Opiates and Falls - The SOMA study
Masud et al 2013
Initiation of Hypertensives
Current prescribing of thiazides is associated with an increased risk of falling and that this is strongest in the 3 weeks following the first prescription(Gribbin 2010, UK, case controlled, GPRD, n= 9682)
The risk of falls on initiation of antihypertensivedrugs in the elderly
First 14 Days
(Butt 2012, population based Canadian case controlled)
EUGMS Task & Finish Group on Fall-risk increasing drugs
Seppala L, van der Velde N, Masud T et al
Drugs Aging 2019 36: 299-307
Contact [email protected]
Deprescribing Guidelines
Educational Materials
Unifactorial Interventions -RCTs
n Medication Review
n Environmental Modification
n Improving Vision
n Vitamin D
n Exercise
Environmental Modification
n Cochrane Review* 2012 (6 studies) -Home safety intervention reduced falls rate by 19%-Subgroup analysis on those at high risk showed fall rate reduction by 44%
n In the visually impairedHome safety programme reduced fall rates by 41%(Campbell 2005)
Unifactorial Interventions -RCTs
n Medication Review
n Environmental Modification
n Improving Vision
n Vitamin D
n Exercise
Vision and falls
Visual acuity Contrast sensitivity Depth perception
Nottingham expedited cataract study
days in study
390360
330300
270240
210180
150120
9060
300
Cum
ulat
ive
risk
of s
econ
d fa
ll.5
.4
.3
.2
.1
0.0
GROUP
routine
expedited
Hazard ratio = 0.60 (95% CI 0.36-0.98)
Harwood, RH, Foss AJ, Osborn F, Gregson RM, Zaman A, Masud T. BJ Opthalmol 2005
Fall rates ↓ 34% (IRR 0.66; CI 0.45-0.96)
Fractures ↓ 77% (IRR 0.33; CI 0.1-1.0, p 0.04)
Unifactorial Interventions -RCTs
n Medication Review
n Environmental Modification
n Improving Vision
n Vitamin D
n Exercise
Forest Plot Meta-analysis: Effect of vitamin D on fallsBischoff-Ferrari HA et al.; JAMA 2004
pooled corrected OR = 0.78; 95% CI [0.64, 0.92]
800 IU
800 IU
400 IU
Cochrane review on falls 2009 (13 studies)
• No significant reduction in fall rates or risk
• Subgroup analysis showed significant reduction in fall rate of 43% if
participants had low Vitamin D levels at recruitment
Recent Vitamin D Data
Unifactorial Interventions -RCTs
n Medication Review
n Environmental Modification
n Improving Vision
n Vitamin D
n ExerciseBest Evidence
Campbell et al, BMJ, 1997
Robertson et al, BMJ, 2001, 2005
17 trials, n = 4305
Falls in Dementia
• 60-80% if people with dementia fall each year
• Mean 3 falls/year
• Two-fold increased risk in Mild Cognitive Impairment
• 60% of hospital admissions for people with dementia due to falls
• 40% of hip fractures in someone with dementia
• People with dementia who fall 5 x more likely to enter care home
• Executive dysfunction associated with increased falls risk and reduced gait speed
• Future research should focus on executive dysfunction as a training target for falls prevention
• Initiation (reasoning, planning, judgement)
• Maintenance (attention)
• Set shifting (vigilance, change in light of new information)Suchy 2009; Lezak 2004; Montero Odasso 2012
Executive function and dual-task deficit
”Stops Walking and Talking” predicts falls
Effect of music-based multitask training on gait, balance, and fall risk in elderly people: a randomized controlled trial.Trombetti A1, Hars M, Herrmann FR, Kressig RW, Ferrari S, Rizzoli R.Arch Intern Med 2011
Jaques-Dalcroze eurhythmics
Dual-task cost (DTC): mean change for A) counting, B) serial 7s , C) naming animals conditions
Can Cognitive Enhancers improve Gait and Reduce Falls? Montero-Odasso et al. Eur J Neurol. 2019 (n= 60)
MCI, n= 60
Prevention of Delirium Trial
The mean fall rate before the intervention was 4.9/month (95%CI=4.5–5.7) which fell to 2.5/month (95%CI=1.5-3.4),
Component of the NHS 10 year long term plan (UK Gov 2019)
Sarcopenia (ICD 10)
• Loss of muscle mass and function (strength or performace)
• Prevalence increases with age
• Associated with disability, morbidity, frailty and mortality
Age Ageing 2019Cruz-Jentoft et al
Once Sarcopenia Identified
Resistance Exercise
Nutrition?
Therapeutic Advances ?
Protein
Vit D
Myostatin inhibitors
ACEIsSARMS
Exercises Recommended for Older Adults
Montero-Fernandez & Serra-Rexach 2013- Eur J Phys Rehabil Med
EXERCISE
Aerobic-brisk walk, -jog,-swim-cycle-dance
Progressive Resistance-weights -resistance bands-stairs-pull-ups-push-ups-heavy loads, -heavy gardening
Flexibility-yoga,-Tai Chi-pilates
Balance TrainingStatic- stand on one leg
Dynamic- (semi-) tandem- walk backwards- Tai Chi
41Image © Public Health England, Department of Health UK
42
Image (c) Public Health England, Department of Health, UK
Nutrition & Optimal Protein Intakes
(Franzke et al, Nutrients 2018)
• Old age + Inactivity → Anabolic Resistance (Impaired MPS )
• MPS rates higher after exercise (↑ Anabolic Sensitivity, timing may be important)
• WHO recommendations 2007 for all age groups: 0.8 g/kg/day
• ESPEN : Healthy adults ≥65 yrs: 1.0-1.2 g/kg/dayChronically ill or malnourished: 1.2- 1.5 g/kg/day
• 25-30 g per each meal
• Role of Essential Amino Acids + related compounds eg leucine, HMB
Protein / AA intake
Muscle contraction(Exercise – Resistance + Endurance)
Muscle Protein synthesis (MPS)
Sarcopenia Frailty
Disability
Reduced Physical Function
Reduced quality of Life
DeathProtein/Amino Acids Exercise
? treatsprevents
Systematic Review: Delaying and Reversing Frailty in Primary care(Travers et al, B J Gen Pract 2019; 46 studies)
”A combination of muscle strength training and protein supplementation was the most effective intervention to delay or reverse frailty and the easiest to implement in primary care”
Falls
“The conservation of health by exercise and various diets”Averroes (Ibn Rushd) 1126-1198 AD (Cordoba) دشر نبا